Hand Hygiene Policy Policy: R11 Policy Descriptor The policy sets out duties and responsibilities of various groups and individuals with regards to hand hygiene. The policy sets out the training required and how the effectiveness of the policy is monitored. Do you need this document in a different format? Contact PALS 0800 0730741 or email dpn-tr.pals@nhs.net Document Control Policy Ref No & Title: R11 Hand Hygiene Policy Version: V7.1 Replaces / dated: Previous R11 Hand Hygiene Policy dated April 16 Author(s) Names / Job Title responsible / email: Ratifying committee: Director / Sponsor: Primary Readers: Additional Readers Penny Criddle, Senior Infection Prevention and Control Nurse penelope.criddle@nhs.net Infection Prevention and Control Committee Paul Keedwell, Director of Infection Prevention and Control. All staff employed by the Devon Partnership Trust Visitors and contractors to Trust premises Date ratified: 24 th April 2018 Date issued: May 2018 Date for review: April 2020 Date archived: Relevant Standards met The Health and Social Care Act 2008: Code of practice for health and adult social care on the prevention and control of infections and related guidance. (DH 2015)
Contents 1. Introduction... 3 2. Purpose... 3 3. Duties... 3 4. Training... 5 5. Hand Hygiene Awareness For Those Who Use The Service And Visitors. 6 6. Monitoring The Effectiveness Of The Policy... 6 7. References... 6 Appendix 1 Management of All Staff Who Are Non Compliant With Infection Control Precautions... 8 2
1. Introduction 1.1. Effective hand hygiene is a critical component of infection prevention and control, and, when used as part of a bundle of measures, correctly implemented, will minimise the spread of infectious organisms and reduce healthcare acquired infection. 1.2. To be effective high levels of compliance must be achieved by all healthcare staff involved in the care of those who use the service. Experience shows that achieving high levels of appropriate hand hygiene use can be difficult. Continuous commitment is required throughout the Devon Partnership Trust (hereafter referred to as the Trust). 2. Purpose 2.1. The aims of this policy are: To demonstrate that the Trust has a strong commitment to effective hand hygiene To provide a framework through which a high level of hand hygiene is achieved (minimum of 85% using a validated observational tool). 3. Duties 3.1. Corporate responsibility The Trust has a responsibility to promote a high level of compliance with best practice in hand hygiene. The Trust will support and encourage compliance by: Adopting the practice of routine hand decontamination as set out in Section 1 of the Trust guidance document Standard Infection Control Precautions, especially: Complying with the WHO 5 moments for hand hygiene using correct technique using alcohol hand gel or hand washing with soap and water as defined in the guidance Supporting national and local initiatives to embed routine hand hygiene as an integral part of Trust culture, i.e. something that is expected of all staff who work within the Trust as a matter of clinical governance. Supporting mandatory hand hygiene education at induction for all staff and appropriate updates for staff involved in direct clinical contact. Ensuring all new Trust employees are provided with written information on hand hygiene on employment. Ensuring all necessary facilities and products are provided throughout the Trust, e.g. suitable hand washbasins, soaps, quality paper towels and alcohol hand gel available at the point of care. Involving the Infection Prevention and Control Team in the planning process for new construction and refurbishment work so that advice can be given on 3
appropriate hand hygiene facilities as emphasised by Infection Control in the Built Environment and the Health Act 2008. Regard lapses in hand hygiene practice as a serious clinical issue. 3.2. Clinical Directorate responsibilities - Each clinical directorate has a responsibility to actively encourage compliance with the Hand Hygiene Policy by all staff groups. Senior staff, e.g. Clinical Director, Consultants, Matrons and Unit managers must act as role models of good hand hygiene practice and encourage better compliance by example. Managers will be responsible for ensuring that all staff undertake and complete infection control training and annual updates for in-patient services. Managers have a responsibility to monitor hand hygiene and take appropriate action when non compliance occurs (see Appendix 1). Each in-patient unit must ensure audits of compliance with the hand hygiene policy are undertaken by appropriate staff, such as infection control link practitioners. Managers must ensure that results of audits are shared with staff teams on a regular basis and issues that are identified should be addressed accordingly through education or supervision. Managers must ensure the facilities and equipment for hand hygiene are in place so that staff have convenient access, and can comply with the guidance in the Standard Infection Control Precautions policy. Managers will be responsible for referring staff that develop allergy or intolerance to specific hand hygiene products to Occupational Health to seek advice on the alternatives available, in cooperation with the Infection Prevention and Control Department. 3.3. Infection Prevention and Control Team responsibilities - An important element in the role of the Infection Control Team (IPCT) is to promote good hand hygiene practice in all staff but particularly for those involved in providing significant care or undertaking clinical procedures delivering direct care. The IPCT will: Advise the Trust on current best practice in hand hygiene policy. Advise the Trust on current best practice in planning hand hygiene facilities for new construction and refurbishment work. Plan and facilitate delivery of a programme of hand hygiene education to be included in all induction sessions and annual updates, including e-learning. Support the infection control link practitioners in developing a programme of hand hygiene audit carried out throughout the year. The IPCT will assist with audit design, collation of results and feedback to wards/departments/senior Nurses and managers where indicated. Audit results to be presented to the Board of Directors via the performance scorecard, the Infection Prevention and Control Committee and included in the Infection Prevention and Control Annual Report. 4
Monitor compliance with Hand Hygiene Policy through infection control audit and via the link practitioners observation of practice. Ensure the implementation of national campaigns and innovations, e.g. WHO Saves Lives 2011 (WHO). Involve those who use the service and promote empowerment in respect to hand hygiene practice through information leaflets, PPI forums, and other media. Enhance awareness of hand hygiene education as above. Advise that staff members whose hands become compromised through working practices and products, report to their manager to ensure they are referred to the Occupational Health Service for assessment and advice. Liaise as necessary with Occupational Health Service regarding suitable hand hygiene products that can be offered to staff exhibiting occupational dermatitis (such as Dermol 500 ) 3.4. Individual responsibility Timely, effective hand hygiene is the personal responsibility of all individuals involved in the provision of care, as well as those working indirectly with service users e.g. Facilities assistants. 4. Training All staff have a personal and corporate obligation to comply with best practice in the prevention and control of infection and follow the hand hygiene guidelines provided in Section 1 of Standard Infection Control Precautions. All staff experiencing any skin problems including symptoms of dermatitis, must report this to their manager. All staff working with people using the service should promote or facilitate hand hygiene amongst this group when possible. In Trust premises, staff must ensure that there is access to appropriate products for that setting. 4.1. All staff working within the Trust must be trained in hand hygiene procedures. This will be delivered to all staff and volunteers, both clinical and non-clinical as part of induction training. 4.2. All staff that have direct or indirect contact with those who use the service, and/or blood and other body fluids must receive regular updates. 4.3. Completion of infection control training will be monitored by the Workforce Development Service. Regular reporting of completion will be discussed at the Infection Prevention and Control Committee. Areas of concern will be brought to the attention of the Executive team/ Senior Management Board. 4.4. Clinical Directors/Managing Partners are responsible for ensuring that any staff who fail to attend training are contacted and alternative training dates planned. 4.5. All ward areas must have access to staff hand hygiene leaflets and it is the responsibility of the manager in each area to highlight this information to any temporary staff undertaking work in that area. 4.6 Training Needs Analysis 5
All staff are required to receive hand hygiene control training. This will be delivered by e-learning via the core training programme for all staff. Staff working in in-patient services, facilities and medical staff will receive additional face-to-face training via annual updates. 5. Hand Hygiene Awareness For Those Who Use The Service And Visitors 5.1. Leaflets on reducing the risk of infection, which include advice on hand hygiene for those who use the service and visitors, will be available in in-patient units leaflet racks and other central areas. 5.2. Posters will be used to deliver key messages about hand hygiene in all ward areas throughout the Trust. 5.3. Where appropriate, the IPCT will offer educational content related to hand hygiene to service user groups in inpatient settings. 5.4. Suitable facilities must be made available where people using in-patient services do not have easy access to hand hygiene products e.g. wallgate units, hand hygiene wipes or small tablet soap where applicable. 6. Monitoring The Effectiveness Of The Policy 6.1. Compliance with this policy will be audited as part of the standing audit programme as detailed in the Annual Infection Prevention and Control Programme using a validated hand hygiene audit tool. 6.2. The audits will be undertaken by the infection control link practitioners or other auditors trained to use the tool. 6.3. Feedback to staff will be provided at the time by the auditor. An updated run chart for each area will be emailed to units, managers and matrons and should be available to all staff in the department. The outcome of hand hygiene audits is reported via the performance scorecard to the Board of Directors monthly and through the Infection Prevention and Control Committee quarterly. 6.4. A report on Trust wide training activity in relation to infection control (including hand hygiene) will be received by the Infection Prevention and Control Committee quarterly. 7. References Department of Health (2015) The Health and Social Care Act 2008: Code of practice for health and adult social care on the prevention and control of infections and related guidance. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/449049/code _of_practice_280715_acc.pdf Department of Health (2006) Essential steps to safe clean care: reducing healthcare associated infections http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidan ce/dh_4136212 Devon Partnership Trust (2018) Standard Infection Control Precautions http://daisy.exe.nhs.uk/media/1548139/standard-infection-control-precautions-approved- 2018.pdf 6
Department of Health March 2013. Infection Control in the Built Environment. Health Building note 00 09 https://www.gov.uk/government/publications/guidance-for-infectioncontrol-in-the-built-environment NICE (2017) Healthcare-associated infections: prevention and control in primary and community care. Clinical guideline 139 Pratt, RJ, Pellowe, CM, Wilson, JA et al) epic 3 National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection 8651 (2014) 5-570 7
Appendix 1 Management of All Staff Who Are Non Compliant With Infection Control Precautions Member of staff observed as being non-compliant either through audit and/or practice Is the member of staff who is observing non-compliance able to address the issue with non-compliant member of staff Yes No Is this the first time noncompliance has been observed? Report to Manager/Head of Department as appropriate Yes No Ascertain reason for noncompliance e.g. lack of knowledge, inadequate equipment and rectify Report to Clinical Director or Senior Nurse who will deal with in accordance with disciplinary procedures Situation Rectified Further non-compliance Non-compliance continues Situation rectified Consider whether behaviour constitutes professional misconduct and, if so, take appropriate action 8