Peninsula Dental Social Enterprise (PDSE) Hand Hygiene Policy Version 2.0 Date approved: August 2017 Approved by: The Board Review due: August 2019 Policy will be updated as required in response to a change in national policy or evidence-based guideline. Page 1 of 5
Contents Section Topic Page No 1 Introduction 3 2 Purpose 3 3 Duties and Responsibilities 4 4 Hand Hygiene 4-5 5 Training, assessment and audit of technique 5 Page 2 of 5
Hand hygiene policy and procedure 1. Introduction 1.1 Hand washing is widely acknowledged to be the single most effective activity in reducing the spread of infection. Hands must be washed immediately before and after each episode of direct patient contact/care and other activities that potentially result in the hands becoming contaminated. The point of care is the crucial moment for hand hygiene. The World Health Organization (WHO 2009) guidelines state most health-care associated infections are preventable through good hand hygiene. In a health care setting the importance of hand hygiene should be stressed to all levels of staff and service users. 2. Purpose 2.1 The objectives of this policy are: To improve quantitative and qualitative standards of hand hygiene across all PDSE facilities. To reduce the number of hospital acquired infections associated with poor hand hygiene. 2.2 Bare Below the Elbow 2.2.1 PDSE has a zero tolerance to healthcare associated infection. To help achieve this standard and comply, all healthcare workers carrying out a clinical activity for patients must follow the Bare Below the Elbow recommendation to ensure they can decontaminate their hands effectively and reduce the risk of harbouring microorganisms. Clinical activity is defined as any activity involving direct patient care, their medical equipment or their immediate environment where the clinical activity has taken place. Page 3 of 5
3. Duties and responsibilities 3.1 All staff, clinical and non, has a responsibility for ensuring they have read, understood and adheres to local Protocols and Policies. 3.2 The Infection Prevention and Control Team are responsible for ensuring that the latest guidance is available and included in training programmes and audits. 3.3 Clinical Managers are responsible for ensuring that current good practice routines are embedded into their clinical areas. 4. Hand Hygiene 4.1. Health care workers 4.1.1 Healthcare workers should ensure that their hands can be decontaminated throughout the duration of clinical work by: Hands and arms up to the elbow/mid forearm are exposed from clothing and jewellery. Removing wrist and hand jewellery except a wedding band. Making sure that fingernails are short, clean, and free from nail polish and no artificial nails (nails should not be visible from the palm). Covering cuts and abrasions with waterproof dressings. Hands should be washed with soap and water at the start and end of clinical duties, when hands are visibly soiled or potentially contaminated and following the removal of PPE. Routine hand decontamination with alcohol-based rub should be performed between every patient contact or each activity for the same patient when hands are not visibly soiled. This should be performed at the point of care. If a person s cultural or religious belief prevents them from using alcohol hand rub, they should wash their hands with soap and water. Gloves are not a replacement for good hand hygiene. Hand hygiene and PPE products are readily available within the DEF S and their use is not restricted. Page 4 of 5
Staff found to have allergies to the commonly available products are provided with alternatives to ensure they can follow hand hygiene procedures as recommend by Occupational Health. 4.2. Patients and visitors 4.2.1 Patients and visitors may challenge staff about decontamination. They should be able to do this without concern that it will adversely affect their clinical management or relationships with staff. 4.3. Hand wash techniques 4.3.1 Staff, patients and visitors should follow the hand cleaning techniques to achieve good hand hygiene. Posters displaying hand hygiene procedures are placed in all clinical areas where hand washing takes place and patient/visitors bathrooms. Example of a hand hygiene poster. 5 Training, assessment and audit of technique 5.1 All staff receive infection control training at induction and throughout their employment. 5.2 Infection Prevention and Control Co-ordinators play an important role in hand hygiene education at a local level and perform qualitative and quantitative audits on a regular basis for all healthcare workers at PDSE. Audit results are used for the purpose of training and the audit results are displayed on the notice board in the Patient waiting area. 5.3 All managers must ensure that new buildings or changes to existing buildings comply with infection control regulations including the provision of hand washing facilities. Page 5 of 5