Trust Policy and Procedure Document Ref PP(15)225 For use in (clinical areas): All clinical areas For use by (staff groups): All clinicians For use for (patients): All patients and staff Document owner: Infection Prevention Strategy Group Status: Approved 2015 1. Purpose of the Policy The spread of infection via hands is a well-established fact. This policy highlights the importance of adhering to hand hygiene procedures to help in the reduction of Healthcare Associated infections. 2. Duties and responsibilities Chief Executive To ensure that infection prevention is a core part of clinical governance and patients safety programme. Promote compliance with infection prevention guidelines/policies in order to ensure low levels of HCAI. Awareness of legal responsibilities to identify, assess and control risk of infection. Appoint Director of Infection prevention and control ( DIPC) DIPC Over see infection prevention guidelines and policies and their implementation Responsible for the Infection prevention team ( IPT) Report directly to the CE and Trust board Challenge inappropriate hygiene practices Assess impact of guidelines/ policies on infection prevention Member of patients safety group Infection Prevention Team Promote good practice acting as an excellent role model at all times. Challenge poor practice and escalate any breaches of policy if seen Include hand hygiene in all induction and updates of training of staff. Give additional advice and training on hand decontamination as needed Source: Infection Control Committee Issue date: April 2015 Page 1 of 15
Regularly audit hand decontamination facilities and escalate or resolve any deficits Review and update hand hygiene policy Work closely with Purchasing and Occupational Health on products in use within the Trust for hand hygiene Microbiologists Provide additional advice outside office hours. Matrons Must establish a cleanliness culture across their units and promote compliance with infection prevention guidelines and policies. Act as role model for hand hygiene practice Promote good practice and challenge poor practice, escalate any breaches and ensure remedial training is given if necessary. Ensure all of their areas of responsibility have adequate/sufficient hand hygiene facilities. Medical staff Ensure compliance with infection prevention practice and policies Adhere to hand hygiene policy All healthcare staff Must be familiar with and adhere to the relevant infection prevention guidelines to reduce the risk of cross infection of patients Refer to the IPT if unable to follow the guidelines. Escalate to Occupational health if necessary. Contents 1. Hand Hygiene 1.1. Microbiology of the Hands 1.2 Solutions for hand decontamination 1.3 Hand Hygiene Procedure 1.3.1 Preparation Bare Below the elbows 1.3.2 When to use hand hygiene 5 Moments for hand hygiene 1.3.3 Six-step hand washing technique 1.3.4 Hand Hygiene Methods Source: Infection Control Committee Issue date: April 2015 Page 2 of 15
1.3.6. Skin Care 1.3.7 Skin Problems 1.4 Hand washing facilities 2. Training 2.1 Adherence to the Policy and Associated Sanctions 2.2 Governance 2.3 Monitoring 3. Development of the guideline 3.1 Changes compared to previous document 3.2 Statement of clinical evidence 3.3 Contributors and peer review 3.4 Distribution List / Dissemination method 3.5 Document configuration information 1. Hand Hygiene 1.1 Microbiology of the Hands Skin provides an environment that is acidic, dry, limited in nutrients and that is constantly shed and renewed. Microorganisms on the skin can be classified as resident or transient. Resident microorganisms are commonly termed normal flora. They live deeply seated within the epidermis in skin crevices, hair follicles, and sweat glands and beneath fingernails. Their function is to protect the skin from invasion from more harmful microorganisms. These organisms do not readily cause infection and are not easily removed. They may however establish infection following surgery or invasive procedures. Transient microorganisms are located on the surface of the skin and beneath the superficial layers of the skin. They are termed transient because direct contact with people, equipment and other body sites all result in the transfer of these microorganisms to and from the hands. Any damaged skin, moisture or wearing of rings, false nails or nail polish will increase the possibility of colonisation. The ability of transient microorganisms to transfer to and from hands easily results in hands being ideal vectors of infection. Transient microorganisms can be easily removed by washing the hands with soap and water or using an alcohol hand gel. Therefore good hand hygiene is the most important method of preventing cross infection with these organisms. Source: Infection Control Committee Issue date: April 2015 Page 3 of 15
1.2 Solutions for Hand Decontamination Product Where to use When to use Liquid soap All clinical and nonclinical areas When hands are visibly soiled, immediately before each and every episode of patient contact/care the patients immediate environment and after any activity or contact that potentially results in hands becoming contaminated. When nursing patients with diarrhoea Alcohol gel All clinical areas Immediately before each and every episode of patient contact/care the patients immediate environment and after any activity or contact that potentially results in hands becoming contaminated. When entering and leaving a clinical (NB: t suitable if hands are visibly contaminated) Alcohol Gel is not effective against rovirus and Clostridium difficile Chlorhexidine/ Betadine (Hibiscrub) High risk areas and patients Surgical Preparation scrub procedure Prior to all invasive procedures. Bar soap Single patient use only (not to be used by staff) Never to be used by clinical staff Foam non alcohol hand sanitizer Clinical areas affected by diarrhoeal illness and where there are no readily available clinical basins Immediately before each and every episode of patient contact/care the patients immediate environment and after any activity or contact that potentially results in hands becoming contaminated. (NB: t suitable if hands are visibly contaminated Source: Infection Control Committee Issue date: April 2015 Page 4 of 15
1.3 Hand Hygiene Procedure 1.3.1 Preparation All staff in clinical areas must be Bare Below the elbows Hands and wrists must be free from adornment. This include wearing short sleeved shirts, or rolling up sleeves and the following. Remove rings with stones or ridges total bacterial counts, particularly of Gram-negative bacteria, are higher when rings are worn. Also rings interfere with thorough hand hygiene and make it more difficult to put on gloves. Remove watches Remove any type of bracelets most microbes on the hands, come from beneath the finger nails. not wear artificial nails or nail polish they discourage vigorous hand hygiene and harbor microorganisms. Nailbrushes must not be used for routine hand hygiene as they damage the skin and encourage shedding of cells. Nailbrushes, if used, must be sterile and used once only. 1.3.2 When to use hand hygiene WHO - 5 Moment for hand hygiene Your 5 moments for hand hygiene at the point of care* *Adapted from the WHO Alliance for Patient Safety 2006 Hands must be decontaminated immediately before each and every episode of patient contact/care the patients immediate environment and after any activity or contact that potentially results in hands becoming contaminated. This includes: Source: Infection Control Committee Issue date: April 2015 Page 5 of 15
preparing/ handling or eating food. Before entering and leaving a clinical area ng/handling a patient s locker or belongings. ound the patients bed 1.3.3 Six-step hand washing technique A six-step hand washing technique was devised by Ayliffe et al. (1978), using soap (or antiseptic solution) and running water. Each step consists of five strokes forward and five backward and should last a minimum of 15 seconds. Palm to palm. Right palm over left dorsum and left palm over right dorsum. Palm to palm fingers interlaced. Backs of fingers to opposing palms with fingers interlocked. Rotational rubbing of right thumb clasped in left palm and vice versa. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa. Source: Infection Control Committee Issue date: April 2015 Page 6 of 15
1.3.4 Hand Hygiene Methods SOLUTION HOW TO USE SOLUTION LIQUID SOAP HOW TO USE Wet hands under running water. Dispense one dose of soap into a cupped hand. Wash hands for 10-15 seconds vigorously and thoroughly, without adding more water, as shown in the picture below cover all areas. Rinse hands thoroughly under running water. Dry hands with a soft disposable paper towel and dispose into a domestic pedal bin. ALCOHOL GEL Very effective alternative when liquid soap and water is not available. It is also useful when rapid hand decontamination is required. When decontaminating hands using a hand gel, hands should be free of dirt and organic material. Dispense one application of solution onto the hands. The hand gel solution must come into contact with all surfaces of each hand. Hands must be rubbed together vigorously, using the hand washing technique (previously described under 1.3.3) until the solution has evaporated and the hands are dry. SURGICAL SCRUB Eg.Betadine / chlorhexidine This procedure must be carried out before all invasive procedures. Apply an antiseptic solution to wet hands and wrists. Wash for two minutes. A single use sterile nailbrush may be used only for the nails not on skin areas as damage to the skin may result in increased levels of micro organisms. Dry hands with a sterile soft paper towel and dispose into a domestic pedal bin. 1.3.6. Skin Care DOs wet hands prior to washing thoroughly -based emollient before refreshment breaks and at the end of your shift. This will replace essential oils to the skin g -free gloves for any activity where blood or body fluids may Source: Infection Control Committee Issue date: April 2015 Page 7 of 15
contaminate the hands Do wear gloves in cold weather DON Ts -based emollients if wearing latex gloves. Latex disintegrates within minutes of contact with petroleum. forget to wash your hands either with liquid soap and water or alcohol hand gels. 1.3.7 Skin Problems If you are experiencing skin problems or if you have a lesion, cut or graze that cannot be adequately covered, contact the Occupational Health Advisor, Ext 3103. Apply an emollient hand cream regularly to protect skin from the drying effects of regular hand decontamination. If a particular soap, anti microbial hand wash or alcohol product causes skin irritation, seek occupational health advice. 1.4 Hand washing facilities The Trust has a responsibility to provide optimum facilities and provisions for hand hygiene, especially in clinical areas. If you find these facilities inadequate please contact the Infection Prevention Team on Ext 3688/2786. Any deficits should be reported promptly so that they can be remedied in a timely manner. Mechanical problems should be reported immediately using the Smartline system (Ext 5555 or the intranet) giving as much detail as possible to ensure prompt repair. taps. -return valve. of soap dispenser in the domestic cleaning schedule. domestic pedal-operated bins. or sensor points in the clinical areas. wards and at all other strategic Foam non alcohol hand sanitizer will be supplied when areas are affected by diarrhoeal illness (such as rovirus or increased incidence of Clostridum difficile )for use where a sink is not easily accessible for prompt and timely hand decontamination. 2. Hand Hygiene Training The spread of infection via hands is a well-established fact. This policy highlights the importance of attending hand hygiene training in the reduction of Healthcare Associated infections. 2.1 Adherence to the Policy and Associated Sanctions Source: Infection Control Committee Issue date: April 2015 Page 8 of 15
Should an individual or group of individuals continue to infringe this Policy the manager will consider disciplinary procedures as a means of encouraging adherence to the Policy. (ref. Disciplinary Rules Policy PP053). If you see a member of staff in contravention of the Policy you should: In circumstances where the member of staff does not wish to directly raise the issue with the individual concerned they should invoke the Staff Concerns about Patient Care Policy PP 056. Training will be offered to staff in advising colleagues, patients, visitors etc. of the Policy. 2.2 Governance All healthcare staff will adhere to the Trust Hand Hygiene policy found within the Infection Prevention Manual and on the Trust s website. Hand Hygiene training will be carried out by the Infection Prevention Team through Mandatory training and Trust and clinical induction. Mandatory training and clinical induction processes including follow up are described in detail in the mandatory training and induction policy. (PP244 and PP076). Clean Your Hands Campaign and targeted training in clinical areas. The hand hygiene training programs will address the standards expected as outlined in section 1.3 of this policy. The Infection Prevention StratergyGroup is responsible for ensuring appropriate policies and procedures are in place to support hand hygiene practices. The Risk Management Executive Committee is responsible for monitoring compliance with mandatory training, including hand hygiene. Staff are expected to follow Trust policies and procedures; professional codes of conduct/practice; accepted standards, statutory requirements and regulations. Staff failing to adhere to the hand hygiene procedures outlined in this policy may be subject to disciplinary action. (ref. Disciplinary Rules Policy PP053). 2.3 Monitoring Training will be monitored and audited annually through the Saving Lives program High Impact Intervention 1, carried out by clinical staff, supported by Matrons and the Infection Prevention team. ( Appendix 1) Managers will keep their own staff records to include hand hygiene compliance The Nursing Directorate will keep records of attendance for Mandatory Training and will follow up non-attenders. Other attendance records on hand hygiene training will be kept by the Infection Control team. Compliance with attendance at mandatory hand hygiene training will be reported to the Risk Management Executive Committee for consideration and action to address any gaps. Source: Infection Control Committee Issue date: April 2015 Page 9 of 15
3. Development of the Policy 3.1 Changes compared to previous document This document has been taken out of the Standard Principles for Prevention Hospital Acquired Infection document and now is a stand-alone policy. Additions of Bare Below the Elbows and 5 Moments for hand hygiene. 3.2 Statement of clinical evidence See Reference above 3.3 Contributors and peer review This document was produced by the West Suffolk Hospital NHS Trust Infection Prevention Department. It was circulated for comment to all Infection Control Steering Committee members, Governance Manager, Link Nurses and ward and departmental managers. All feedback was discussed and queries resolved. 3.5 Distribution List / Dissemination method This document will be available on the West Suffolk Hospital web site in electronic form and also in paper hard copy as part of The Infection Control Manual, which will be on every ward and department in the hospital. Copies will also be sent to organisations that we share policies with i.e. St Nicholas Hospice. The Infection Prevention Team will be responsible for the distribution of this document. Document configuration information References: Department of Health (2007) The Epic Project: Developing National Evidence-based Guidelines for Preventing Healthcare Associated Infections. Journal of Hospital Infection. Vol 47 Supplement January 2007. Pittet D (2000) Effectiveness of a hospital-wide program to improve compliance with hand hygiene. Lancet 2000 356: 1307-131 Heenan ALI. (1996) Handwashing Solutions. Professional Nurse 11 (9): 615-622 Infection Control Nurses Association (1998) Guidelines for Hand Hygiene. ICNA World Health Organisation-2008. 5 Moments for hand Hygiene Department of Health 2007 Uniforms and Workwear. An evidence base for developing local policy. Bibliography: NICE Prevention and control of Healthcare-Associated Infections NICE Quality Improvement guide 2011 NICE public guidance 36 e Management and Control of Hospital Acquired Infection in Acute Trusts in England National Audit Office 2000. Patient information See: leaflet 5122-1: Hand Hygiene (7 May 2009). Source: Infection Control Committee Issue date: April 2015 Page 10 of 15
Author(s): Infection Prevention Team Other contributors: Infection Prevention Implementation group. Infection Prevention Strategy Group Approvals and endorsements: yes Consultation: yes Issue no: 5 File name: Supercedes: 4 Equality Assessed yes Implementation yes Monitoring: (give brief details how Monthly audits this will be done) Other relevant policies/documents & See Above references: Additional Information: none Appendix 1 2010 Patient Intervention Hand Hygiene Audit with Dress Code Element This tool is used by Wards/Departments to audit compliance with the patient contact aspect of the Trust Hand Hygiene policy (PP225) and record whether staff dress is bare below the elbow. To complete the audit, the assessor observes patient interventions made by West Suffolk Hospital staff. Ten occasions of actual physical contact with patients are watched and a record made of whether or not each member of staff decontaminates their hands. Observations may be either prior to or immediately after each patient intervention. For each hand hygiene observation, also record whether the dress code is being observed with respect to bare below the elbows. Please read the guidance notes on how to undertake this audit given on the reverse of this form before starting to audit. What constitutes a patient intervention? Actual physical contact with the patient. Hand decontamination? Hand decontamination is achieved by using either alcohol gel or soap & water. Ward / Department Assessment Date Assessment time Assessors name/ Designation Nurse / Doctor / HCA / AHP / Other,specify Record 10 yes or no observation marked with an X Hand Hygiene observed PRIOR to patient intervention Hand Hygiene observed AFTER patient intervention Arms bare below the elbows Record name / designation of staff not cleaning hands Doctor Trained Nurse Source: Infection Control Committee Issue date: April 2015 Page 11 of 15
HCA Housekeeper Dietitian Pharmacist Physiotherpist OT Speech Therapist Other staff(specify) Source: Infection Control Committee Issue date: April 2015 Page 12 of 15
Please return this form to Sally Smith, Governance Audit and Information Officer, Governance Support, x2752, as soon as possible. forms will be accepted after the 5 th of the month following data collection. Instructions to auditor The spread of infection via hands is a well-established fact. The purpose of the audit is to ensure that all West Suffolk Hospital healthcare staff adhere to established hand hygiene practices. The audit is an ongoing process, carried out each month in each ward/department, reviewing hand Hygiene practices by all West Suffolk Hospital staff. Ten occasions of actual physical contact should be watched and recorded. The interventions can be accumulated over the monthly period if necessary (eg in areas of low patient contacts). When it is observed that members of staff have not cleaned their hands, the auditor must write the individual s name and designation in the right hand column of the form. If you feel comfortable about making an approach, you should speak to individuals who do not follow the established hand hygiene practices. If you feel unable to do this, please contact the relevant matron or a member of the Infection Prevention team, who will follow up for you. When should hands be decontaminated? The audit assesses whether hand decontamination has been carried out at the beginning ( Prior to ) and the end of ( After ) each observed actual patient contact. If the member of staff decontaminates their hands (using either soap and water or alcohol gel) before physical contact with a patient, the auditor should mark X in the yes row of the Prior to column. If the member of staff fails to decontaminate their hands (using either soap and water or alcohol gel) after physical contact with a patient, the auditor should mark X in the no row of the After column. The entry should be made in the appropriate sector of the form according to the observed member of staff s designation. Dress Code Element bare to the elbow (Trust Policy PP(08)230) The Medical Staff Dress Code and Infection Control Policy states To improve the efficacy of hand hygiene procedures, medical staff must wear short sleeves/sleeves rolled up to the elbow and must not wear rings (other than a single simple band), bracelets, bangles or wristwatches during patient contact. From June 2009 this element is audited at the same time as hand hygiene. For each observation of patient contact, record in the next column to the right whether or not the member of staff was bare below the elbows. Do not make assumptions record only what you see. Questions and answers Where should the auditor be based on the ward/department? The auditor should be able to see the whole area under observation eg by standing outside the bay area. When I watch a member of staff finish one patient intervention and begin another, how do I record this? Source: Infection Control Committee Issue date: April 2015 Page 13 of 15
If hand decontamination occurs after physical contact with a patient and the member of staff moves directly to another patient, mark a cross in the After column and a second cross in the Prior column to record the start of a new patient intervention. If hand decontamination is not carried out, a cross should be marked in the no row for both After and Prior to patient intervention. Should the auditor stay in the same place throughout the audit period?. They should move around the ward/department to look at different bays, areas and activities and observe different staff groups. Should the auditor leave the bay/area to watch the end of an intervention?, for example if the staff member being observed goes into sluice room, the auditor should follow to watch if hand hygiene is performed. What if I missed part of a patient intervention? Do not record anything you do not see for yourself. How should I record non-west Suffolk Hospital staff such as Paramedics and Social Services staff? The purpose of the audit is to assess compliance with an aspect of the Hand Hygiene policy by Trust staff. n-wsh staff do not need to be observed. What if I only see 6 actual physical contacts with patients? You are required to observe 10 interventions during a one month period. The interventions do not need to be observed at the same time and can be spread out over the time period. The spread of infection via hands is a well-established fact. The purpose of the audit is to ensure that all West Suffolk Hospital healthcare staff adhere to established hand hygiene practices. The audit is an ongoing process, carried out each month in each ward/department, reviewing Hand Hygiene practices by all West Suffolk Hospital staff. The WHO 5 moments for Hand Hygiene identifies the opportunities when hand hygiene must be carried out to reduce the risk of transmission of micro-organisms Source: Infection Control Committee Issue date: April 2015 Page 14 of 15
1. Before patient contact For example - shaking hands helping a patient to move giving a massage taking pulse chest auscultation, abdominal palpation 2. Before an Aseptic task 3. After body fluid exposure 4. After patient contact For example - Venepuncture IV flush Eye drops Suppository Tracheotomy care Urinary catheter care Wound dressing Mouth care preparation of food After any potential body fluid exposure. For example - Oral care Eye drops Cleaning urine, faeces or vomit NB: glove use After touching a patient in any way: For example - shaking hands helping a patient to move giving a massage taking pulse chest auscultation, abdominal palpitations 5. After contact with patients surroundings After touching patients immediate surroundings when patient has not been touched: For example - Bed/linen Table Charts Locker TV remote Light switches Personal belongings Chair Bare below the elbows The Trust Dress Code and states To improve the efficacy of hand hygiene procedures, staff must wear short sleeves/sleeves rolled up to the elbow and must not wear rings (other than a single simple band), bracelets, bangles or wristwatches in a clinical area. These observations are recorded in addition to the 10 observations for the 5 moments. On auditing do not make assumptions record only what you see. All staff who come into contact with patients within the Trust will be audited. Any staff who comply with the audit on being prompted will not have their name taken. Source: Infection Control Committee Issue date: April 2015 Page 15 of 15