Documentation Control Reference CL/CGP/039 Approving Body Trust Board Date Approved 3 Implementation date 3 Supersedes NUH Version 2 (May 2009) Consultation undertaken Infection Prevention and Control Committee Clinical Risk Committee, Directors Group Date of Completion of 28/03/11 Equality Impact Assessment Date of Completion of We 28/03/11 Are Here for You Assessment Date of Environmental Not applicable Impact Assessment (if applicable) Target audience All Staff Supporting Documents and Infection Prevention and Control Policy References(s) Review Date November 2013 Lead Executive Author/Lead Manager Medical Director Infection Prevention and Control Team Further Guidance/Information Infection Prevention and Control Team 1
Contents Paragraph Title Page 1. Policy Statement 3 2. Background 3 3. Responsibilities 3 4. Best Practice 4 5. Types of Hand Hygiene 6 6. Hand Hygiene Technique 6 7. Skin Care 8 8. Promotion of Hand Hygiene and Audit 8 9. Training and Education 9 10. Equality and Diversity 9 11. We Are Here For You 9 12. Implementation and Monitoring 10 13. References 11 Appendix 1 Equality Impact Assessment 12 Appendix 2 Certification of Employee Awareness 14 2
1. Policy Statement 1.1 Hand hygiene is the single most important factor in reducing the spread of healthcare associated infection (HCAI) (World Health Organisation (WHO) 2009). Nottingham University Hospitals NHS Trust (NUH) is committed to reducing the risk of HCAI. This policy aims: (i) (ii) To improve and maintain high standards of hand hygiene compliance throughout the Trust. To reduce the risk of HCAI caused by poor hand hygiene. 1.2 Persistent non-compliance with any element of the hand hygiene policy by any member of staff will result in an escalation via the disciplinary process. 2. Background 2.1 Hand hygiene decreases the colonisation of transient bacteria and can be achieved by either handwashing or hand disinfection (Pratt et al, 2007, WHO 2009). 2.2 A systematic and expert review of scientific evidence, titled epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England (Pratt et al, 2007) and WHO Guidelines on Hand Hygiene (2009) have informed much of this policy. 3. Responsibilities 3.1 Managers are required to ensure that: Staff are made aware of this policy The requirements for hand hygiene are built into local induction programmes Audits of compliance with hand hygiene are conducted and reported in clinical areas Staff are released to attend a yearly update of infection prevention and control [which includes hand hygiene] 3
Staff attendance at the infection prevention and control update is monitored. Local training records must be kept up to date. Any individuals not attending the infection prevention and control update should be identified and placed on the next available update. 3.2 The Infection Prevention and Control Team (IPCT) is responsible for the ongoing development and distribution of this Policy. 3.3 The IPCT is responsible for the provision of specialist advice to clinical areas in relation to those areas covered in this policy. 3.4 The IPCT is responsible for the development and provision of training in relation to this policy and forms part of the Trusts Mandatory Programme of Education. 3.5 Each member of staff is responsible for adhering to this Policy. 4. Best Practice 4.1 It is the responsibility of all staff to demonstrate consistently high standards of compliance with hand hygiene (Department of Health (DH) 2007a, WHO 2009). 4.2 Hands must be decontaminated immediately before and after each and every episode of direct patient contact/care and between different care activities for the same patient (Pratt et al, 2007, WHO 2009). 4.3 Hands that are visibly soiled or contaminated with dirt or organic material must be washed with liquid soap and water. 4.4 When caring for patients with diarrhoea including Clostridium difficile, hands must be washed with soap and water (DH 2007a, 2009) as alcohol hand rub alone is not effective at removing the Clostridium difficile spores (Pratt et al, 2007). 4
4.5 Alcohol hand rub can be used between patients or different care activities excepting if hands are soiled or caring for patients with diarrhoea. 4.6 All wrist jewellery (including wristwatches) and stoned hand jewellery must be removed at the beginning of each clinical shift by all staff working in clinical areas in line with the Trust Dress Code and Uniform Policy. A single plain wedding band is allowed (DH, 2007b). 4.7 Cuts and abrasions on hands must be covered with waterproof dressings. 4.8 Fingernails should be kept short, clean and free from nail polish. False nails and nail extensions must not be worn by clinical staff (DH, 2007b). 4.9 Short or rolled-up-above-elbow sleeves must be worn when in clinical areas (DH, 2007b). 4.10 Gloves are not a replacement for good hand hygiene. Staff must decontaminate their hands before putting on and after glove removal (WHO, 2009). 4.11 Near patient alcohol handrub must be located at the end of each bed throughout the hospital, unless otherwise agreed with the IPCT. 4.12 Alcohol handrub must be available at all ward entrances to allow both visiting staff and visitors the opportunity to decontaminate their hands. Alcohol handrub should also be available at the outside of side rooms and above all sinks in clinical areas. 4.13 Patients that are unable to effectively decontaminate their hands, eg, after going to the toilet and before meals, should be given help to ensure that their hygiene requirements are met. 4.14 Patients, relatives and visitors have a right to ask staff if they have decontaminated their hands prior to any clinical intervention. 5
5. Types of Hand Hygiene 5.1 Routine Hand Hygiene: This is undertaken by using soap and running water for 15 20 seconds or by rubbing an application of alcohol handrub into the hands until dry. 5.2 Hand Disinfection: Prior to an Aseptic Non-Touch Technique, wash hands with soap and water followed by an application of alcohol handrub. 5.3 Surgical Handwashing: This is undertaken by applying an antimicrobial agent to the hands and wrists for at least two minutes. A sterile disposable nail brush may be used for the first surgical hand wash of the day, however continued use is not advisable as damage to the skin may occur, which could increase the level of microbial colonisation. If an antimicrobial agent is inappropriate for staff, a surgical handwash with soap and water followed by two or more applications of alcohol handrub may be used as an alternative (WHO, 2009, Widmer et al 2009). 6. Hand Hygiene Technique 6.1 An effective hand hygiene technique is essential to reduce the risk of cross infection. The following techniques should be followed depending on whether soap and water or alcohol handrub is used: Handwashing: This involves several stages: Firstly hands should be wet with luke warm water before applying soap. The soap solution must come into contact with all surfaces of the hand. The hands must be rubbed together vigorously for a minimum of 15 20 seconds paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers. Hands should be rinsed thoroughly prior to drying with paper towels. Alcohol Handrub: When decontaminating using an alcohol handrub, hands should be free of dirt and organic material. The handrub must 6
come into contact with all surfaces of the hand. The hands must be rubbed together vigorously, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers, until the handrub has evaporated and the hands are dry The following technique should be undertaken for hand washing and steps 3 to 9 for applying alcohol hand rub: Adapted from WHO Guidelines on Hand Hygiene in Health Care (WHO, 2009). Hand Drying: The method of hand drying is important as micro-organisms transfer more readily on wet than dry hands. Ensuring that hands are completely dry is a key element of effective hand hygiene and maintenance of skin integrity. Paper towels must be within easy reach of a sink but beyond risk of contamination from splashing. Use as many paper towels as required to ensure that hands are fully dry before continuing activities (Pratt et al, 2007). 7
7. Skin Care 7.1 Staff are encouraged to apply an emollient hand cream to protect skin from the drying effects of regular hand decontamination. Staff should only use the products available in the clinical areas, as these have been specifically designed not to interact with the soaps and alcohol handrub. The emollient cream should be used at least 4 times per shift. 7.2 If a particular soap, antimicrobial agent or alcohol handrub causes skin irritation, this must be reported to line manager immediately and advice should be sought from Occupational Health. An incident report form must also be completed. 8. Promotion of Hand Hygiene and Audit 8.1 NUH actively supports the National Patient Safety Agency (NPSA) cleanyourhands campaign, the WHO SAVE LIVES: Clean Your Hands and other initiatives to improve and maintain standards of hand hygiene. 8.2 Promotional materials produced by the Trust and the NPSA must be visible in all clinical areas and clearly displayed. 8.3 Staff must act as role models and be able to demonstrate ongoing commitment to hand hygiene. 8.4 Regular audits of compliance utilising the WHO Your 5 moments for hand hygiene are conducted throughout NUH in all clinical areas. 8.5 Copies of the hand hygiene audit tool and other supporting information is available on the Infection Prevention and Control intranet site. 8.6 Hand hygiene audit results are reported to and are performance managed by the Infection Control Operational Group [ICOG]. Directorates have a responsibility to ensure that staff have sufficient time to conduct the audits and that they are completed, including where necessary the development of action plans. 8
9. Training and Education 9.1 Infection prevention and control training [including hand hygiene] is a mandatory requirement for all staff and is part of the corporate induction programme. 9.2 Each member of staff must have a yearly update on Infection Prevention and Control [including hand hygiene] in accordance with the Trust s Training Needs Analysis [TNA]. Please refer to the Personal Development Review Policy for details of the Trust s Training Needs Analysis. 9.3 All attendance to Infection Prevention and Control Training must be recorded centrally on the Trust OLM system. Directorates must ensure that local training records are kept up to date and that local managers follow up and address the reasons for any non attendance. Any individuals not attending the infection prevention and control update should be identified and placed on the next available update. 10. Equality and Diversity 10.1 All patients, employees and members of the public should be treated fairly and with respect, regardless of age, disability, gender, marital status, membership or non-membership of a trade union, race, religion, domestic circumstances, sexual orientation, ethnic or national origin, social & employment status, HIV status or gender re-assignment. 11. We Are Here For You 11.1 This Trust is committed to providing the highest quality of care to our patients, so we can pledge to them that we are here for you. This Trust supports a patient centred culture of continuous improvement delivered by our staff. The Trust established the Values and Behaviours programme to enable Nottingham University Hospitals to continue to improve patient safety, outcomes and experiences. The set of twelve agreed values and behaviours explicitly describe to employees the required way of working and behaving, both to patients and 9
each other, which would enable patients to have clear expectations as to their experience of our services 12. Implementation and Monitoring 12.1 Each Directorate will monitor compliance with this policy through the developed Key Performance Indicators, the Infection Prevention and Control Audit Programme and the Saving Lives High Impact Interventions. 12.2 When variances are seen the Directorate Clinical Lead will be responsible for producing and ensuring compliance with exception reports that will include recommendations and action plans. 12.3 Through the weekly ICOG meetings chaired by the Chief Executive, directorates are required to present a range of performance data which includes attendance at Infection Prevention and Control updates [which includes hand hygiene]. Issues of poor performance are challenged and actions agreed. 12.4 This policy will be reviewed as a minimum every three years by the Director of Infection Prevention and Control and members of the Infection Prevention and Control Committee [IPCC]. 12.5 Compliance with this policy will be continually evaluated by the ICOG and IPCC. 12.6 The Trust board will receive quarterly updates via the Matrons report on progress detailing progress against infection prevention and control and hand hygiene practice. 12.7 The IPCC will produce an infection prevention and control annual report for the Trust Board, detailing performance against agreed targets and actions. 10
13. References Department of Health (2007a). Saving Lives: a delivery programme to reduce Healthcare Associated Infection including MRSA (Revised Edition: October 2007). High Impact Intervention No 6: Reducing the risk of infection from and the presence of Clostridium difficile. Department of Health. London Department of Health (2007b). Uniforms and Workwear: An Evidence Base for Developing Local Policy. Department of Health. London Department of Health (2009). Clostridium difficile infection: How to deal with the problem. Department of Health. London. Pratt R.J, Pellowe C.M, Wilson J.A, Loveday H.P, Harper S.R.L.J, Jones C, McDougall C, Wilcox M.H (2007). epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. The Journal of Hospital Infection, 655, Supplement 1, 1-64 Widmer, A.F., Rotter, M., Voss A, Nthumba P,. Allegranzi B, Boyce J, Pittet D.,(2009) Surgical Hand Preparation: State-of-the-Art, Journal of Hospital infection, Volume 74(2):112-22 World Health Organization (WHO) (2009) WHO Guidelines on Hand Hygiene in Health Care, WHO, Geneva. 11
Equality Impact Assessment Appendix 1 1. Name of Policy or Service 2. Responsible Manager Dr Stephen Fowlie, Medical Director 3. Name of person Completing EIA Mitch Clarke 4. Date EIA Completed 28 th March 2011 5. Description and Aims of Policy/Service (including relevance to equalities) This policy aims: (iii) (iv) To improve and maintain high standards of hand hygiene compliance throughout the Trust. To reduce the risk of HCAI caused by poor hand hygiene. 6. Brief Summary of Research and Relevant Data This policy reflects national and international guidance. 7. Methods and Outcome of Consultation Consultations have been carried out with the following: Infection Prevention and Control team Infection Prevention and Control Committee Clinical Risk Committee Directors Group 8. Results of Initial Screening or Full Equality Impact Assessment: Equality Group Age Gender Assessment of Impact 12
Race Sexual Orientation Religion or belief Disability Dignity and Human Rights Working Patterns Social Deprivation 9. Decisions and/or Recommendations (including supporting rationale) From the information contained in the policy, it my decision that a full assessment is not required at the present time. 10. Equality Action Plan (if required) N/A 11. Monitoring and Review Arrangements (including date of next full review) It is recommended that this policy and EIA be reviewed three yearly in line with the requirements in this policy. 13
Appendix 2 CERTIFICATION OF EMPLOYEE AWARENESS Document Title Version (number) 3 Version (date) 3 I hereby certify that I have: Identified (by reference to the document control sheet of the above policy/ procedure) the staff groups within my area of responsibility to whom this policy / procedure applies. Made arrangements to ensure that such members of staff have the opportunity to be aware of the existence of this document and have the means to access, read and understand it. Signature Print name Date Directorate/ Department The manager completing this certification should retain it for audit and/or other purposes for a period of six years (even if subsequent versions of the document are implemented). The suggested level of certification is; Clinical directorates - general manager Non clinical directorates - deputy director or equivalent. The manager may, at their discretion, also require that subordinate levels of their directorate / department utilize this form in a similar way, but this would always be an additional (not replacement) action. 14