SH CP 12 Hand Hygiene Procedure (Infection Prevention and Control Policy: Appendix 6) This Hand Hygiene Appendix must be read in conjunction with the Infection Prevention and Control Policy. Summary: Target Audience: This Hand Hygiene Appendix advises staff of the actions they must take in order to prevent cross infection via contaminated hands. All staff of all disciplines, Non-Executive Directors, Volunteers, Governors and Contractors Next Review Date: November 2018 Approved by: IP&C & Decontamination Group Date of meeting: 4 th November 2014 Date issued: November 2014 Author: Sponsor: Theresa Lewis Lead Nurse Infection Prevention and Control Della Warren Executive Director of Nursing and Allied Health Professions and DIPC Author: Theresa Lewis Lead Nurse IP&C. 1
Version Control Change Record Date Author Version Page Reason for Change 05.10.12 Theresa Lewis (Lead Nurse Infection Prevention and Control) 2 Throughout Acquisition of Ridgeway to Southern Health NHS Foundation Trust. 04.11.14 Theresa Lewis 3 Throughout Policy review 7.3.18 Review date extended from October to November 2018 Reviewers/contributors Name Position Version Reviewed & Date Angela Roberts IP&C Team Jacky Hunt As above Louise Piper As above IP&C Group Members All Divisions Represented V3 21.10.14 IP&C Consultation Group V3 21.10.14 Author: Theresa Lewis Lead Nurse IP&C. 2
Contents Page 1. Introduction 4 2. Definitions 4 3. Process Hand Care Bare Below the Elbows Facilities Required When to Perform Hand Hygiene How to Perform Hand Hygiene Choice of Cleansing Agent 5 4. Training 11 5. Audit 11 6. References 11 Appendices 6.1 Hand Hygiene Outside of the Healthcare Environment 6.2 WHO 5 Moments for Hand Hygiene 6.3 Hand Washing Technique 6.4 Hand Hygiene Poster s 6.5 Hand Hygiene Technique for Alcohol Gel use 13 14 15 16 18 Author: Theresa Lewis Lead Nurse IP&C. 3
Hand Hygiene Procedure 1. Introduction: 1.1 Hand hygiene is a term that incorporates the decontamination of the hands by methods including routine hand washing, surgical hand washing and the use of alcohol hand rubs and gels (Uniform and Workwear Guidance, DH 2010). Contaminated or dirty hands are closely associated with the transmission of Healthcare Associated Infections. This contamination can be as a result of an occupational exposure to microorganisms but importantly it should be understood that a significant amount of hand contamination is from the individual themselves e.g. touching own face or sneezing into own hand. 1.2 Hand hygiene is the most important measures to protect patients, healthcare workers and the environment from microbial contamination (WHO 2009). Failure to perform appropriate hand hygiene is considered the leading cause of healthcare associated infections (HCAI) and spread of multi-resistant organisms, and has been recognised as a significant contributor of outbreaks (WHO 2009). 1.3 This Hand Hygiene Appendix advises staff of the actions they must take in order to prevent cross infection via contaminated hands. This does not cover surgical hand preparation as this is covered in LNFH Theatre Policy. 2. Definitions: Alcohol Gel - A sanitising gel containing approx. 60% isopropanol alcohol and emollients (skin softeners). Dispensed in a measured dose from a wall mounted /stand alone dispenser or carried by staff. The alcohol gel disinfects / sanitises physically clean hands. These agents have disinfectant activity, and destroy most transient microorganisms. If applied for an extended length of time, they will also destroy some resident flora. Alcohol gel does not contain soap and is therefore ineffective in the presence of physical soiling. Please note alcohol gel is not suitable for environmental cleaning. Bare Below the Elbow The term used to describe the removal of all jewellery, (except a plain wedding ring), watches, nail varnish and false nails. Where sleeves are worn, these must be rolled up when having close contact with service users and remained rolled up until an appropriate hand washing technique has been performed. Emollient - A non-perfumed hand cream / skin moisturising agent that must be compatible with the soap and gel in use. Emollient should be applied when hands are at rest i.e. during coffee break, lunch break or at the end of the working day. Hand soap A non-perfumed gentle liquid soap that does not contain anti-bacterial agents. Dispensed from a well maintained, wall mounted or stand alone dispenser in a measured dose. Handwashing Washing hands with plain / antimicrobial soap and warm water Author: Theresa Lewis Lead Nurse IP&C. 4
Point of Care - The place where the healthcare worker provides care or treatment to the service user Resident Flora Normal flora or commensal organisms, forming part of the body s normal defence mechanisms, and protecting the skin from invasion by more harmful micro-organisms. They rarely cause disease and are of minor significance in routine clinical situations. However, during surgery or other invasive procedures, resident flora may enter deep tissues and establish infections. Removal of these organisms is essential in these situations, by following the surgical scrub technique (please refer to the LNFH policy) Transient Flora - Microorganisms that colonise the superficial layers of the skin. They are also acquired by touch e.g. from the environment, touching patients, laundry, equipment etc. Transient flora are readily transmitted to the next thing touched, and are responsible for the majority of healthcare associated infections. They are easily removed by hand decontamination. Visibly Soiled Hands - Hands on which dirt or body fluids are readily visible. 3. Process: 3.1 Hand Care: The frequent use of hand hygiene agents may cause damage to the skin and alter normal hand flora. Excoriated hands are associated with increased colonisation of potentially pathogenic microorganisms such as Meticillin-resistant Staphylococcus Aureus (MRSA), and increase the risk of infection. In order to achieve effective hand hygiene, it is therefore important to look after the skin and fingernails. Continuing damage to the skin may result in cracking and weeping, exposing the care worker to increased infection risk, and can lead to sick leave. Cover cuts and abrasions with a water-impermeable dressing, prior to contact with service users. Staff with skin lesions on their hands eg eczema or psoriasis, that cannot be adequately covered (wearing gloves to protect open lesions on hands is not acceptable) must not work until they have received advice from the Occupational Health Department. Skin damage and dryness often results from frequent use of harsh soap products, application of soap to dry hands, or inadequate rinsing of soap from the hands. It is therefore essential that only approved liquid soap products are used, and that staff carefully follow correct hand hygiene techniques. Emollient creams alone e.g. Diprobase, are insufficient to provide clinical hand hygiene. Please contact the Occupational Health Dept if you need further advice. All care areas should ensure adequate supplies of moisturiser (wall mounted where appropriate) are available for staff use, as this is more cost-effective than sicknessabsence due to damaged skin. Several controlled trials have shown that regular use of such products can help prevent and treat irritant contact dermatitis caused by hand hygiene products (WHO 2009). Moisturiser available from the NHS Supply Chain is free from perfumes to reduce the risk of reaction with other products. Therefore ideally only moisturisers purchased via the NHS Supply Chain should be used. Staff should regularly use moisturiser to maintain skin patency when hands are at rest. Communal tubs of moisturiser are not recommended Author: Theresa Lewis Lead Nurse IP&C. 5
Natural fingernails harbour micro-organisms (Larson 1995). Fingernails should be kept short, clean and free from nail varnish. 3.2 Bare Below the Elbows The Trust has adopted the Department of Health Bare Below the Elbows Strategy. This includes: Clothing - Remove long sleeved clothing or roll up long sleeves before undertaking any direct hands on care. Long sleeves prevent thorough hand hygiene procedures and are more likely to become contaminated during work activities Nails - Fingernails should be short, clean and free from false nails or nail polish when having direct contact with services users at work (EPIC 3, 2014). Artificial nails and nail extensions harbour higher levels of micro-organisms than natural fingernails, and these micro-organisms are not removed easily during hand hygiene (DH 2010). Artificial fingernails can also fall off when caring for service users. Long nails can puncture gloves and are harder to keep clean. Jewellery - Remove rings (except wedding band), wristwatches, bracelets and all other wrist and hand jewellery when having any contact with service users (EPIC 3, 2014). Rings, wristwatches and other jewellery worn on the hands and wrists become contaminated during work activities and in addition skin underneath rings is more heavily colonised with microorganisms in comparison to other areas where rings are not worn (WHO 2009). In addition they prevent thorough hand hygiene procedures Non-Clinical Roles - Staff who work in certain non-clinical roles e.g. cleaning staff, catering or food handling staff will need to comply with being Bare Below the Elbows to facilitate effective hand hygiene Social Care - In social care settings staff should be bare below the elbows when undertaking physical care activities Staff who are unable to comply with the Bare Below the Elbow strategy may wear disposable over sleeves/gauntlets. These are single use items and must be changed between each different procedure on the same patient and between patients. They are to be removed after patient contact and before hand hygiene is performed. Disposable over sleeves should be disposed of as clinical waste and are not to be worn outside of the care area. Please contact a member of the IP&C team for further advice if required. 3.3 Facilities Required: Adequate facilities must be provided to enable staff to wash and dry their hands regularly and appropriately, to use alcohol hand gel if applicable, to use clinell wipes if applicable and to protect their skin using moisturiser. Each inpatient and non-domestic area must have the following equipment near to the service user, to ensure adequate hand washing: Dedicated hand wash basin*, that is easily accessible (separate to a dedicated sink for cleaning equipment or body fluid discharge) Ideally should have elbow operated mixer taps if elbow taps are not available disposable paper towels can be used to turn off the taps Well maintained liquid soap dispenser, with adequate supply of liquid soap Disposable paper towels Author: Theresa Lewis Lead Nurse IP&C. 6
Hand hygiene posters (laminated) indicating correct technique New builds should include hand washing sinks which conform to national standards eg they must not have a plug or overflow (HBN 00-10 DH 2013). Well maintained moisturiser dispenser with adequate supply of emollient these are usually placed in staff rest areas *Requirements for a clinical hand wash basin (HBN 00-09 DH 2012) The dimensions of the clinical hand wash basin should be large enough to contain most splashes and therefore enable the correct hand wash technique to be performed without excessive splashing of the user Clinical hand wash basins should be wall mounted using concealed brackets and fixings. They should be sealed to a waterproof splash-back to allow effective cleaning of all surfaces They should not have a plug or a recess capable of taking a plug. Clinical hand wash basins should not have overflows as these are difficult to clean and become contaminated Clinical hand wash basins should be accessible eg not situated behind curtain rails Taps should be elbow operated or sensor and be fitted with a thermostatic mixing valve Taps should not be aligned to run directly into the drain aperture as contamination from the waste outlet could be mobilised Clinical hand wash basins should not be used for other purposes eg cleaning patient equipment Each area must also have (where it is deemed safe to use following Risk Assessment) easily accessible alcohol hand rub/gels (with emollients). Suggested locations include: At every ward/unit entrance in a wall dispenser; At the entrance to service user bays in a wall dispenser; On all healthcare record trolleys and drugs trolleys and outside isolation rooms By every patient s bed / at the point of care, except in certain areas such as Child Health and Mental Health If on risk assessment alcohol gel is deemed unsafe to be located at the point of care, staff should be provided with pocket sized containers of alcohol gel which is carried on a short clip or retractable cord Community Staff: Mobile community staff should be provided with appropriately sized containers of alcohol hand-gel. When hand washing is required and mobile staff have no access to soap and water, hand wipes e.g. clinell sanitising wipes can be used. (order code VJT119 from NHS Supplies*). However these wipes should only be used as a last resort, when there is no alternative and hands should be washed with soap and water at the first available opportunity. *Please note this order code is accurate as at Oct 2014. Author: Theresa Lewis Lead Nurse IP&C. 7
Social Care: Staff working within supported living environments, where possible, should have access to dedicated hand hygiene facilities. Where liquid soap, water and disposable paper towels are not available, tottle bottles of alcohol gel and disposable hand wipes should be made available for staff use. It is not appropriate for staff to use communal bars of soap or to share a communal hand towel. Moisturising cream should also be freely available to maintain skin integrity. Where appropriate this should be supplied in wall-mounted dispensers, located in suitable positions eg staff rest room. Alternatively individual pocket sized containers can be used. Please see Appendix 6.1 for further guidance on performing hand hygiene outside of the healthcare environment. 3.4 When to Perform Hand Hygiene: Hands must be decontaminated before each episode of direct patient contact or care including clean or aseptic procedures (EPIC 3 2014). Both the decision to decontaminate hands and what type of cleaning agent to be used should be based on a risk assessment. This must include the likelihood that microorganisms have been acquired or may be transmitted, whether the hands are visibly soiled or not, and what procedure is about to take place. Hands must be decontaminated:- Before and after each episode of patient contact / care NB hand hygiene is only required once between each patient contact e.g.: Changing dressings Handling invasive devices Administrating medications or in between administrations (when assisting the service user) during a drug round. Handling food Contact with urethral catheters Bed making or in between bed making if making multiple beds Assisting service users with personal hygiene Before e.g.: Direct close contact with a service user Before performing a clean or aseptic technique Leaving source isolation Leaving the care area Before eating or serving food Commencing work After e.g.: Direct close contact with a service user Close contact with the service user s environment Author: Theresa Lewis Lead Nurse IP&C. 8
Removing personal protective clothing Sluice room activities After any exposure to body fluids After the removal of personal protective equipment e.g. gloves and aprons Personal contamination e.g. coughing or sneezing Handling surfaces that are likely to be contaminated e.g. specimen pots, suction equipment After contact with waste Using the toilet After handling soiled laundry The World Health Organisation (WHO) 5 moments for hand hygiene is a useful tool which can be used for guidance as to when hand hygiene could be performed. See Appendix 6.2 3.5 Choice of Cleansing Agent The following types of cleansing agent can be used to remove micro-organisms from hands: Liquid Soap - Washing the hands with plain liquid soap and tepid water* is adequate for most routine activities. Hand washing with soap lifts transient micro-organisms from the surface of the skin and allows them to be rinsed off. An effective hand wash technique involves three stages; preparation, washing and rinsing, and drying. In preparation for hand washing, staff must be bare below the elbows see section 3.2. *Apart from the issue of skin tolerance and level of comfort, water temperature does not appear to be a critical factor for microbial removal from hands being washed. However warmer temperatures have been shown to be very significantly associated with skin irritation and therefore the use of very hot water for hand washing should be avoided as it increases the likelihood of skin damage. (WHO 2009). The use of cold water alone may deter some from washing their hands during cold winter conditions (HSE 2014). Bars of soap should not be used for hand hygiene. Technique Routine hand washing use liquid soap and tepid water, and follow this procedure: Wet hands under running water Dispense one dose of liquid soap into the cupped hand Wash hands vigorously cover all surfaces as per 6-step hand hygiene poster Hands must be rubbed together vigorously for a minimum of 15-20 seconds, paying particular attention to the tips of fingers, the thumbs and areas between the fingers Rinse hands thoroughly under running water Turn off taps using elbows (or a paper towel if taps are not elbow operated) Pat hands dry with a disposable paper towel and discard without touching a dirty surface e.g. bin lid Author: Theresa Lewis Lead Nurse IP&C. 9
Please see appendix 6.3 for Hand Washing Technique Poster and Appendix 6.4 for generic Hand Hygiene posters Hand drying Because wet hands can more readily acquire and spread microorganisms, the proper drying of hands is an integral part of routine handwashing. Hands must be patted dry and not rubbed. Care must be taken to avoid recontamination of washed and dried hands. Reusing or sharing towels should be avoided because of the risk of crossinfection (WHO 2009). Alcohol hand rub/gels (with emollients). These may be used in place of soap and water if hands are visibly clean. They are especially useful if hand washing and drying facilities are inadequate, or where there is a need for rapid or frequent hand washing. These agents have disinfectant activity, and destroy transient microorganisms. If applied for an extended length of time, they will also destroy some resident flora. In some religions, alcohol use is prohibited or considered an offence. As a result the adoption of alcohol-based formulations for hand hygiene may be unsuitable or inappropriate for some HCW s either because of their reluctance to have contact with alcohol, or because of their concern about alcohol ingestion or absorption via the skin. WHO (2009) state that in general, those religions with an alcohol prohibition in everyday life demonstrate a pragmatic vision in the perspective of optimal patient-care delivery and do not object to the use of alcohol-based products for environmental cleaning, disinfection or hand hygiene. When NOT to use alcohol gel: Visibly clean hands can be decontaminated with alcohol gel for all activities with the following two exceptions when liquid soap and water must be used instead. When hands are visibly soiled or potentially contaminated with body fluids When caring for a service user with diarrhoea and/or vomiting e.g. norovirus or clostridium difficile Technique Enough alcohol gel should be dispensed to ensure all surface areas of the skin are covered. 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 solution has evaporated and the hands are dry. Please see Appendix 6.5 for poster on Hand Hygiene Technique with alcohol hand rubs Sanitising Hand Wipes. If hands are visibly dirty and soap and water is not available, a clinell sanitising wipe can be used. Care must be taken to ensure the wipe covers all surfaces of the hands. Common Examples: If your hands are visibly soiled or covered with body fluids: Author: Theresa Lewis Lead Nurse IP&C. 10
Use soap and water followed by drying with a disposable paper towel. If no access to soap and water use a clinell sanitising wipe or similar. If exposure to potential spores e.g. Clostridium difficile and viral diarrhoea & vomiting in suspected outbreaks of norovirus Use soap and water followed by drying with a disposable paper towel. If there is no access to soap and water antiviral gel can be used in suspected outbreaks of viral diarrhoea and vomiting. Antiviral gel differs from the normal alcohol gel used as this has been proven to be effective against viruses such as norovirus. Standard alcohol gel is not effective against viruses. If you are about to, or have had, contact with a servicer user and your hands are visibly clean: You can use either alcohol hand gel / soap and water followed by drying with a disposable paper towel. Clinell sanitising wipes can be used as a last resort if no other method is available. If you are about to perform an aseptic technique: Use soap and water followed by drying with a disposable paper towel if hands are visibly dirty OR Use alcohol hand gel if hands are visibly clean. 3.6 Hand Hygiene and Service Users Service users and relatives should be provided with information about the need for hand hygiene and how to keep their own hands clean. Service users should be offered the opportunity to clean their hands before meals, after using the toilet, commode or bedpan and at other times as appropriate (EPIC 3, 2014). Products available should be tailored to the needs of the service users and may include alcohol hand rub, hand wipes and access to handwash basins. HCW s should educate service users and carers about their role in maintaining standards of healthcare workers hand decontamination. (NICE 2012). 4 Training Training in hand hygiene is included as part of IP&C essential training at induction and as part of ongoing training. Practical training in hand hygiene using the light box is carried out by our IP&C link advisors or by a member of the IP&C team if hand hygiene audit scores drop or during outbreak if this is required. Refer to TNA in IP&C Policy. Author: Theresa Lewis Lead Nurse IP&C. 11
5 Audit Hand hygiene is audited regularly as part of the IP&C Annual Audit plan. Results from audits are reported via the IP&C Group and through Divisional Governance systems. Where appropriate hand hygiene compliance scores are on display in clinical areas. 6 References: Department of Health (2010) Uniform and Workwear. Guidance on Uniforms and Workwear Policies for NHS Employees London HMSO Department of Health (2010) Saving Lives: a delivery programme to reduce Healthcare Associated Infections including MRSA. London HMSO Department of Health (2012) Health Building Note 00-09: Infection Control in the built environment Department of Health (2013) Health Building Note 00-10 Part C: Sanitary assemblies Hand Hygiene Task Force (2007) Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Morbidity and Mortality Weekly Report 51(16) 1-48 Health and Safety Executive (2014) A review of the data on efficacy of handcleaning products in industrial use as alternatives to handwashing Larson E (1995) APIC guideline for handwashing and hand antisepsis in healthcare settings. American Journal of Infection Control 23(4), 251-269 Loveday J, Wilson J, Pratt R, Golsorkhi M, Tingle A, Bak A, Browne J, Prieto J, & Wilcox M. (2014) epic 3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England Journal of Hospital Infection 86S1 (S1-S70) National Patient Safety Agency (2004) Clean Your Hands Campaign. NPSA National Institute for Health and Clinical Excellence (2012) Prevention and control of healthcare associated infections in primary and community care NICE 2012 Pittet D., Dharan S., Touveneau S., et al (1999) Bacterial contamination of the hands of hospital staff during routine patient care. Archives of Internal Medicine 159: 821-826 World Health Organisation (2009) WHO Guidelines on Hand Hygiene in Healthcare First Global Patient Safety Challenge Clean Care is Safe Care Author: Theresa Lewis Lead Nurse IP&C. 12
Appendix 6.1: Hand Hygiene Outside of the Healthcare Environment In some circumstances employees working in the community will not have access to the equipment necessary to carry out hand hygiene such as no running warm water, no access to liquid soap and no equivalent to disposable hand towels. Prior to visiting a client in their home the clinician should discuss with the patient what is required to carry out effective hand hygiene. This would include providing: Plain liquid soap in a dispenser or pump (not a bar of soap) this does not have to be for the clinician s exclusive use. Warm running water. Clean towel for the clinician s specific use. Disposable paper towels in the form of a roll of paper if necessary e.g. kitchen roll HCWs can obtain supplies of liquid soap and paper towels/roll from their usual supply chain. There will be certain circumstances when this is not achievable and in those situations the following alternatives can be used: ALCOHOL HAND GEL Before and after providing direct patient care. After removal of gloves and before performing further patient care. On entering and leaving the patient s home.. DISINFECTANT WIPES e.g. Clinell (recommended only if soap and water are not available) After several applications of alcohol hand gel if hands have become tacky. When hands are soiled with organic material such as dirt or body fluids. MOISTURISERS Dispensers can be located at meeting areas, such as GP surgeries, to allow this part of the hand hygiene policy to be carried out. Individual hand moisturisers when used must be purchased through the routine supply chain to ensure it is compatible with the alcohol hand gel. This is not an exhaustive list of circumstances. For further advice contact the IP&CT. Author: Theresa Lewis Lead Nurse IP&C. 13
Appendix 6.2: WHO 5 Moments for Hand Hygiene The World Health Organisation have developed an approach called the 5 moments for hand hygiene. This supports the national Clean your Hands campaign and helps all health care professionals to decide when to clean their hands. The Five Moments of hand hygiene is based around preventing the transfer of micro-organisms between each patient zone e.g. the zone around a patients bed or chair and lists the important times during our work, where we should stop to clean our hands. The 5 moments is applicable in all healthcare environments. Author: Theresa Lewis Lead Nurse IP&C. 14
Appendix 6.3: Hand Washing Technique Author: Theresa Lewis Lead Nurse IP&C. 15
Appendix 6.4: Hand Hygiene Posters Author: Theresa Lewis Lead Nurse IP&C. 16
Author: Theresa Lewis Lead Nurse IP&C. 17
Appendix 6.5: Hand Hygiene Technique with Alcohol-Based Formulations Author: Theresa Lewis Lead Nurse IP&C. 18