HAND HYGIENE PROCEDURE Policy No If 001 Date Ratified January 2009 Next Review Date January 2012 Policy Statement/Key Objectives: This procedure describes the Trust s approach to ensure effective hand hygiene is embedded in to everyday practice Accountable Director: Director of Nursing Policy Author: Public Health Advisor Infection Prevention & Control Date of issue: March 2009
Executive Summary Hand Hygiene Subject Applicable to Key Policy Issues Date Issued February 2009 Dates Policy reviewed Next review due date February 2009 Policy written by Consultation Hand Hygiene All staff, relatives and carers Hand hygiene is the single most important means of reducing the spread of infection. This procedure describes the Trust s approach to ensure that effective hand hygiene is embedded in to every day practice. Margaret Boden, Public Health Advisor Infection Prevention and Control Infection Prevention and Control Committee Policy reviewed by: Lead responsible for policy Monitoring arrangements Approved by Authorised by Infection Prevention and Control Committee Director of Nursing The procedure will be monitored by the Infection Prevention and Control Committee via quarterly reports Infection Prevention and Control Committee Policy and Governance EMT Signature Related procedural documents P Sullivan Director of Nursing Other Associated Policies And Procedures Standard (universal) infection control precautions Aseptic technique Major outbreaks of communicable infection Isolation of patients Safe handling and disposal of sharps Prevention of occupational exposure to blood-borneviruses (BBV), including prevention of sharps injuries Management of occupational exposure to BBVs and post exposure prophylaxis. Closure of ward, departments and premises to new admissions Disinfection policy Antimicrobial prescribing Reporting HCAI to the Health Protection Agency (HPA) as directed by the Department of Health Control of infections with specific alert organisms taking account of local epidemiology and risk assessment. These must include, as a minimum, MRSA, Clostridium Difficile infection and Transmissible Spongiform Encephalopathies Control of infections with specific alert organisms taking account of local epidemiology and risk assessment. These infections must include as a minimum, MRSA, Clostridium Difficile & Spongiform Encephalopathies The Royal Marsden Hospital Manual of Clinical Nursing Procedures is available via LCFT Intranet to supplement the above policies Date of issue March 2009 2
Contents Page Number 1.0 Introduction 4 2.0 Scope 4 3.0 Policy Statement 4 4.0 Duties 4 5.0 Hand Hygiene Guidance 5 6.0 Training 7 7.0 Monitoring 8 8.0 Equality and Diversity Assessment 8 9.0 Review 9 10.0 Other Associated Policies and Procedures 9 11.0 References 9 Appendix 1 10 Appendix 2 11 Appendix 3 12 Date of issue March 2009 3
1.0 Introduction Hand Hygiene Hand hygiene is the single most important means of reducing the spread of infection. This procedure describes the Trust s approach to ensure that effective hand hygiene is embedded into every day practice. This procedure supports the implementation of the Trust s Infection Prevention and Control Policy. 2.0 Scope This procedure applies to all staff, patients, and relatives/carers 3.0 Principles This procedure has been developed to ensure all patients are cared for under circumstances, which minimise the risk of acquiring an infection while in a Healthcare setting. The Trust hand hygiene procedure recognises that hands are the principal route by which cross infection occurs in a clinical environment. Staff are required to comply with this procedure which details the occasions when hands must be cleansed and the methods to be used. The Trust recognises that all patients have a right to be cared for by staff who comply with this procedure. Monitoring of compliance with this procedure will also minimise the risk of cross infection from patients to staff 4.0 Duties 4.1 Chief Executive The Chief Executive is responsible for: Ensuring effective hand hygiene is in place across the Trust 4.2 Director of Nursing The Director of Nursing is responsible for: Providing assurances to EMT Governance and Trust Board of compliance with this procedure 4.3 Infection prevention and control team (IPCT) The IPCT is responsible for: Keeping training packages for hand hygiene up to date with NHS guidelines Providing assurance to the Infection and Prevention Control Committee of compliance with this procedure Advising Estates and Facilities on hand hygiene, facilities within refurbishments and new builds Delivering hand hygiene training Date of issue March 2009 4
4.4 All Managers All Managers are responsible for: Ensuring that staff have access to Hand Hygiene training Ensure that staff have access to soap, paper towels, moisturizer and alcohol gel Ensure that all clinical hand wash basins confirm to standards Functioning pedal bins are available 4.5 All Staff All Staff are responsible for: Following this procedure and ensuring that safe and effective hand hygiene is carried out at all times Attending training as requested by the Trust s Training Needs Analysis Participating in compliance audits 4.6 Trust Board The Trust Board is responsible for: Receiving assurance of compliance with this procedure via the Director of Nursing Governance Reports 4.7 EMT Governance The EMT Governance is responsible for: Receiving assurance of compliance with this procedure Receiving assurance from the Infection Prevention and Control Committee that actions are being monitored to address issues of non compliance 4.8 Infection Prevention and Control Committee (IPCC) The Infection Prevention and Control Committee is responsible for: Monitoring compliance with this procedure Developing and monitoring an action plan to address issues of non compliance Providing assurance to EMT Governance of compliance with this procedure 5.0 Hand Hygiene Guidance 5.1 Hand Hygiene must be carried out: Before and after every episode of direct contact/care Within an episode of care; before and after any contact with a susceptible site (e.g. wound site, urinary catheter site) After any activity or contact which might result in hands becoming heavily contaminated with bacteria (e.g. bed pan disposal, soiled linen handling, urinal disposal) Listed in Appendix 2 are examples of the occasions when hands must be washed. Choice of Methods for Hand Hygiene Hand washing with liquid soap and running water must be carried out when hands are visibly soiled or potentially heavily contaminated with bacteria Hands that are visibly clean and have not undertaken an activity likely to result in heavy bacterial contamination may be decontaminated either with an alcohol-based hand rub or washed with liquid soap and running water Date of issue March 2009 5
5.2 Agents Recommend For Routine Hand Hygiene Liquid soap from a clean soap dispenser and running water. A mild soap containing an emollient should be used An alcohol based product containing isopropyl alcohol or ethanol/mentholated spirit and an emollient should be used. All products in this category should be approved by Infection Prevention Control, Health & Safety and Occupational Health prior to initial use in the Trusts 5.3 Hand Hygiene Technique Whichever product is used a technique must be carried out which ensures that no surfaces of the hands are missed during the procedure. All wrist and hand jewellery (apart from a plain ring if worn) must be removed at the beginning of each clinical shift before regular hand decontamination begins (false nails/nail varnish must not be worn by clinical staff, nails should be clean and trimmed short). Cuts and abrasions must be covered with waterproof dressings. The recommended technique is illustrated as follows:- Date of issue March 2009 6
5.4 Skin Irritation Sore, cracked skin can be a source of infection to patients and increase the risk of cross infection to staff. If this becomes a problem seek advice from the Occupational Health Department as soon as possible. 5.5 Avoiding skin problems arising from repeated hand washing Wash hands under running water Always wet hands first before applying liquid soap Use the smallest amount of product to produce a lather on the hands Ensure the soap/antiseptic solution is rinsed off with clear water Dry hands thoroughly using disposable paper towels (do not lift the lid of a pedal bin with hands when disposing of paper towels) 5.6 Hand creams Only use hand creams with a non-ionic base that are approved by the Trust. The most effective times to use hand creams are: After hand washing before taking a break After hand washing before leaving work At night before going to sleep 5.7 Hand Hygiene using an Alcohol-based Gel The hand gel must come into contact with all surfaces of the hands. Rub hands together vigorously, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers, until the gel has evaporated and the hands are dry (following the guidance on the use of Alcohol Hand Gels produced by the Public Health Advisor Infection Prevention & Control Nurse). 5.8 Use of Protective Gloves These are recommended when direct contact with blood and body fluids/substances are anticipated. The same gloves should NOT be worn between clean and dirty procedures. If used excessively, particularly when not recommended, gloves can be a cross infection hazard and also increase the risk of allergy to constituents of the glove material. Sterile gloves are required for all invasive procedures requiring asepsis. Do not use protective gloves unless you need to do so (if not sure seek clarification from the Infection Prevention and Control Team) Powder free protective gloves should be used. Alternative gloves are available for staff identified with a latex allergy Wash hands after gloves are removed Note: Alcohol gels will NOT remove latex or other residues, which may increase risk of allergic reactions. Hands must not be washed whilst gloves are worn, neither should an alcohol hand rub be applied to gloves 5.9 Hand Washing Facilities If these are inadequate, action must be taken to rectify this. Appendix 1 lists key features required of hand washing facilities. Defects/problems must be reported to the manager of the area concerned and brought to the attention of the Estates Department. Date of issue March 2009 7
6.0 Training Hand Hygiene training will be provided in line with the Trusts Training Needs Analysis Attendance and non attendance at training will be monitored in accordance with the Trusts Statutory and mandatory training procedure. 7.0 Monitoring Monitoring and compliance Monitoring compliance with this procedure is detailed within table below: Standard Timeframe/Format How Whom Quarterly Review training IPCT Duties Inspection records Prevention and Review hand Control Reports hygiene audit Review minutes of IPCC and EMT Checking staff identified in TNA Attend training Quarterly Infection, Prevention and Control Reports Governance Review training records IPCT Following up those who fail to attend training Quarterly Infection, prevention and Control Reports Reviewing of training records IPCT The Infection Prevention and Control Committee is responsible for monitoring compliance with this procedure via quarterly reports from the IPCT. An action plan put in to place to address issues on non compliance will be monitored by the Infection Prevention and Control Committee. Assurance will be provided to EMT Governance via a report from the committee. 8.0. Equality and Diversity Impact Assessment See Appendix 3 Date of issue March 2009 8
9.0 Review Hand Hygiene This policy will be reviewed every 3 years unless there is change in guidance. 10.0 Other Associated Policies and Procedures Standard (universal) infection control precautions Aseptic technique Major outbreaks of communicable infection Isolation of patients Safe handling and disposal of sharps Prevention of occupational exposure to blood-borne-viruses (BBV), including prevention of sharps injuries Management of occupational exposure to BBVs and post exposure prophylaxis. Closure of ward, departments and premises to new admissions Disinfection policy Antimicrobial prescribing Reporting HCAI to the Health Protection Agency (HPA) as directed by the Department of Health Control of infections with specific alert organisms taking account of local epidemiology and risk assessment. These must include, as a minimum, MRSA, Clostridium Difficile infection and Transmissible Spongiform Encephalopathies Control of infections with specific alert organisms taking account of local epidemiology and risk assessment. These infections must include as a minimum, MRSA, Clostridium Difficile & Spongiform Encephalopathies The Royal Marsden Hospital Manual of Clinical Nursing Procedures is available via LCFT Intranet to supplement the above policies 11.0 References Pratt, RJ. et al (2001) The Epic Project Journal of Hospital Infection 47 (Suppl.) S1-S8 Pittet, D et al. (2000) Effectiveness of a Hospital Wide Programme to Improve Compliance with Hand Hygiene Lancet 356 (92) 1307-1312 Jeanes, A., Gauci, T., Sarosi, L. (2002) A Comprehensive Glove Choice Published by ICNA/Regent ISBN 0 9 541962 048 ICNA Hand Decontamination Guidelines (2002) ISBN 0-9541962-03 Larson, E.L. (1995) Guidelines for Hand Washing and Hand Antisepsis in Healthcare settings American Journal Infection Control 23 (4) 251-269 Hoffman P.N., Wilson, J. (1994) Hands, Hygiene and Hospitals PHLS Microbiology Digest 11(9) 211-216 Date of issue March 2009 9
Appendix 1 Key Features Required of Hand Washing Facilities in Clinical Areas A mixer tap is required so that staff can wash their hands under warm running water A mild liquid soap containing an emollient must be available from a clean soap dispenser Disposable paper towels for hand drying A pedal bin (one which does not allow lid to be lifted by hand) for disposal of paper towels The mixer tap should be correctly aligned so that water flows directly into the hand wash basin without splashing over adjacent surfaces Elbow operated handles should be accessible so that they can be used correctly Appropriate hand cream must be available for use after hand washing at locations convenient for staff to use before going for breaks/leaving the ward Alcohol gel must be provided in suitably sized/designed containers to allow use where access to hand washbasins is difficult or inconvenient. Date of issue March 2009 10
Appendix 2 Occasions When Hand Hygiene Must Be Carried Out (This List Is Not Exhaustive) Occasions when hands must be washed with soap and water include: Before wearing sterile gloves Whenever hands are visibly dirty or soiled After removing gloves After using the toilet After disposal of bedpans/urinals After handling grossly contaminated laundry and waste Before and after handling wound dressings and urinary catheters Before and after emptying urine drainage bags After removing protective clothing inside a source isolation room Smoking Occasions when alcohol gel may be used on visibly clean hands instead of washing include: Before preparing or handling food for patients or self Before and after bed making Before and after administering medication Before and after any situation which involves direct patient/client contact e.g. bathing patient, assisting patients to move After leaving source isolation Before commencing work and after leaving a work area NB Alcohol Gel MUST NOT BE USED when delivering care for a patient known to have Clostridium Difficile or any Diarrhoeal illness. Hands must be washed with soap and water Date of issue March 2009 11
Lancashire Care Trust Initial Equality Impact Assessment Appendix 3 Department/Function Infection Prevention and Control Person Responsible Margaret Boden Contact details 01772 695372 Name of Policy/procedure/service to be assessed Hand Hygiene Date of assessment 27/01/09 Is this a new or existing Policy/procedure/service? Existing 1. Briefly describe the aims, objectives and purpose of the policy/procedure/service? To ensure that all Trust staff/patient/cares adhere to good hand hygiene procedures 2. Who is intended to benefit? All staff, patient/carers 3. What outcomes are wanted? The spread of infection is reduced 4. Who are the main stakeholders? 5. Who is responsible for implementation? All staff Date of issue March 2009 12
6. Are there concerns that there could be differential impact on the following groups and what existing evidence to you have for this? People from a Black or minority ethnic background Women or men including trans people People with disabilities or long tern health conditions People with or without a religion or beliefs Lesbian, gay, bisexual or heterosexual people Older or young people 7. Could any differential impact identified above be potentially adverse? 8. Can any adverse impact be justified on the grounds of promoting equality of opportunity? 9. Have you consulted with those who are likely to be affected? Hand Hygiene Y N NO Y N NO Y N Staff, with skin problems are directed to Occupational Health/patients and carers for advice from staff Hand wipes are available for patients unable to get to a wash basin Y N Consideration has been taken in the use of alcohol gel Staff, patient/carers are not required to use this, they can wash hands with soap and water if preferred) Y N NO Y N SEE ABOVE Y N NO Y N NO Y N YES The option, re above is always given to different faith communities re the use of alcohol gel Y N NO 10. Should the policy/procedure/service proceed to full impact assessment> I understand the impact assessment of this policy/procedure/service is a statutory obligation and take responsibility for the completion of this process. Date of issue March 2009 13
Names of Assessors Margaret A. Boden Date of Assessment 27.01.09. Date of next Review January 2012. Date of issue March 2009 14