NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST Documentation Control Reference CL/CGP/039 Approving Body Chief Nurse Date Approved 2 Implementation Date 2 Summary of Changes from Previous Version Updated in line with DH guidance Reflects wording in NUH Infection Prevention and Control Policy Supersedes NUH Version 4 (November 203) Consultation Undertaken Date of Completion of Equality Impact Assessment Date of Completion of We Are Here for You Assessment Date of Environmental Impact Assessment (if applicable) Legal and/or Accreditation Implications Infection Prevention and Control Team, Infection Prevention and Control Committee, Clinical Risk Committee, Human Resources, Occupational Health, SMT 04/09/206 04/09/206 04/09/206 Target Audience Review Date November 209 Lead Executive Author/Lead Manager Accreditation with CQC and NHSLA The Health and Social Care Act 2008, Code of Practice on the prevention and control of infections and related guidance Targets as part of NHS Outcomes Framework 206-7 All Clinical Wards and Departments Chief Nurse Mitch Clarke, Infection Prevention and Control Matron
Further Guidance/Information Infection Prevention and Control Team Ext 63866 (QMC) 55578 (City) 2
CONTENTS Paragraph Title Page. Introduction 4 2. Executive Summary 4 3. Policy Statement 5 4. Definitions 5 5. Roles and Responsibilities 5 6. Policy and/or Procedural Requirements 7 7. Training, Implementation and Resources 2 8. Impact Assessments 3 9. Monitoring Matrix 4 0. Relevant Legislation, National Guidance 6 and Associated NUH Documents Appendix Equality Impact Assessment 7 Appendix 2 Environmental Impact Assessment 20 Appendix 3 Here For You Assessment 22 Appendix 4 Certification Of Employee Awareness 24 3
.0 Introduction..2.3 Hand hygiene is the single most important factor in reducing the spread of healthcare associated infection (HCAI) (World Health Organisation (WHO) 2009, Loveday et al, 204). Hand hygiene decreases the colonisation of transient bacteria and can be achieved by either handwashing or hand disinfection (Loveday et al, 204, WHO 2009). A systematic and expert review of scientific evidence, titled epic3: National Evidence-Based Guidelines for Preventing Healthcare- Associated Infections in NHS Hospitals in England (Loveday et al, 204) and World Health Organisation (WHO) Guidelines on Hand Hygiene (2009) inform much of this policy. 2.0 Executive Summary 2. 2.2 This policy describes the infection prevention and control best practice for hand hygiene for all staff working at NUH. All staff working clinically must be aware of their responsibilities regarding hand hygiene. Do: follow the hand hygiene policy clean your hands in line with the WHO 5 moments for hand hygiene challenge staff that do not clean their hands correctly in line with this policy Don t: wear gloves as a replacement for hand hygiene. 4
3.0 Policy Statement 3. 3.2 Nottingham University Hospitals NHS Trust (NUH) is committed to reducing the risk of HCAI in line with NHS Outcomes Framework 206-7 (Department of Health, (DH), 206) This policy aims: (i) to achieve and sutain high standards of hand hygiene compliance throughout the Trust, (ii) to prevent and reduce the risk of HCAI caused by poor hand hygiene. 3.3 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. 4.0 Definitions 4. DH Department of Health HCAI Healthcare Associated Infection ICOG Infection Control Operational Group IPCT - Infection Prevention and Control Team ICLP Infection Control Link Professional TNA - Trust s Training Needs Analysis WHO World Health Organisation 5.0 Roles and Responsibilities 5. 5.. Committees The Trust board has responsibility for ratifying the Trust Hand 5
Hygiene Policy and for seeking assurance that hand hygiene is an integral part of all clinical activities. 5..2 5..3 5..4 5..5 5..6 The Infection Prevention and Control Committee (IPCC) is responsible for the on-going development of this policy. The Infection Control Operational Group (ICOG) has responsibility for monitoring Trust wide compliance with hand hygiene. Divisions have responsibility for reporting hand hygiene compliance audit data to ICOG. Where there is poor compliance the divisions via ICOG have responsibility for monitoring improvement. Divisions have a responsibility for ensuring that relevant infection data, including hand hygiene compliance is discussed at Divisional Governance forums and any other appropriate meetings. Divisions must ensure that staff attend an annual infection prevention and control mandatory update [which includes hand hygiene]. 5.2 5.2. 5.2.2 5.2.3 5.2.4 5.2.5 Individual Officers Each member of staff is responsible for ensuring that they have read and adhere to the hand hygiene policy. Named staff members, usually Infection Control Link Professionals (ICLPs) are responsible for auditing compliance of hand hygiene and staff hand hygiene assessments. All staff have responsibility for accessing the NUH mandatory training [which includes hand hygiene]. All staff that work clinically have a responsibility for ensuring that they have an annual hand hygiene assessment. The IPCT is responsible for the provision of specialist advice to clinical areas in relation to those areas covered in this policy. 6
5.2.6 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. 6.0 Policy and/or Procedural Requirements 6. 6.. 6..2 6..3 6..4 6..5 6..6 6..7 Expected Practice It is the responsibility of all staff to demonstrate consistently high standards of compliance with hand hygiene (DH 2007, 205, WHO 2009). Hand wash basins should only be used for the purpose of hand washing and not for the disposal of any body fluids. They should be labled with handwashing only sticker. All staff must be bare below the elbows when in a clinical area, to facilitate effective hand hygiene (DH, 200) 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 located on the located on the NUH policies and Trust wide procedures intranet site. A single plain wedding band is allowed (DH, 200). Cuts or abrasions must be covered with a waterproof impermeable dressing Fingernails should be kept short, clean and free from nail polish. False nails and nail extensions must not be worn by staff working in clinical areas (DH, 200). Near patient alcohol handrub must be located at the end of each bed throughout the hospital, unless otherwise agreed with the IPCT. Alcohol handrub should also be available outside of single rooms and above all sinks in clinical areas. Compliance is monitored via the Infection Prevention and Control audit programme. 7
6..8 6..9 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 (Loveday et al, 204, WHO 2009). NUH actively supports and endorses the WHO (2009) your 5 moments for hand hygiene at the point of care. These are:. Before patient contact 2. Before a clean/aseptic procedure 3. After body fluid exposure risk 4. After patient contact 5. After contact with patient surroundings. 6..0 6.. 6..2 6..3 6..4 6..5 Hands that are visibly soiled or contaminated with dirt or organic material must be washed with liquid soap and water. It is important to wash hands with soap and water (as alcohol hand rub alone is not effective) when in contact with a patient or their immediate environment with a known or suspected gastrointestinal infection. This is especially important when caring for a patient who has Clostridium difficile diarrhoea (DH 2007, 205, Loveday et al, 204) Alcohol hand rub can be used between patients or different care activities except if hands are soiled or caring for patients with diarrhoea. Gloves are not a replacement for good hand hygiene. Staff must decontaminate their hands before putting on and after glove removal (WHO, 2009). A patient that is unable to effectively decontaminate their hands, e.g. after going to the toilet and before meals, should be given help to ensure that their hygiene requirements are met. Patients, relatives and visitors are encouraged to ask staff if they have decontaminated their hands prior to any clinical intervention. 8
6.2 6.2. Types of Hand Hygiene Routine Hand Hygiene: This is undertaken by using liquid soap and running water for 5 20 seconds or by rubbing an application of alcohol handrub into the hands until dry. 6.2.2 Hand Disinfection: Prior to an Aseptic Non-Touch Technique (ANTT), wash hands with soap and water followed by an application of alcohol handrub. 6.2.3 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). 6.3 6.3. 6.3.2 Hand Hygiene Technique An effective hand hygiene technique is essential to prevent and reduce the risk of cross infection. The following techniques should be followed depending on whether soap and water or alcohol handrub is used: Handwashing: An effective handwashing technique involves 3 stages: preparation, washing and rinsing, and drying. Preparation requires wetting hands under tepid running water before applying liquid soap. The soap solution must come into contact with all the surfaces of the hand. The hands must be rubbed together vigorously for a minimum of 5-20 seconds paying particular attention to the tips of the 9
fingers, the thumbs and the areas between the fingers. Hands should be rinsed thoroughly prior to drying with paper towels 6.3.3 Alcohol Handrub: When decontaminating using an alcohol handrub, hands should be free of dirt and organic material. The handrub must 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 6.3.4 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). 0
6.3.5 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 (Loveday et al, 204). 6.4 6.4. 6.4.2 6.5 6.5. 6.5.2 6.5.3 6.5.4 Skin Care Staff are encouraged to apply an emollient hand cream to protect skin from the drying effects of regular hand decontamination. The products available in the clinical areas should only be used, 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. If a particular soap, antimicrobial agent or alcohol handrub causes skin irritation, this must be reported to the line manager immediately and advice should be sought from Occupational Health. An incident report form must also be completed. Promotion of Hand Hygiene and Audit NUH actively supports the WHO SAVE LIVES: Clean Your Hands and other initiatives to improve and maintain standards of hand hygiene. Promotional materials produced by the Trust must be clearly visible in all clinical areas. Staff must act as role models and be able to demonstrate on-going commitment to hand hygiene. All staff that have clinical contact with patients must have a yearly hand hygiene assessment. This is generally undertaken in the clinical setting by a staff member (usually an ICLP) who has been trained by the IPCT. Staff wishing to become assessors should
contact the IPCT for further information. 6.5.5 6.5.6 6.5.7 Regular audits of compliance utilising the WHO Your 5 moments for hand hygiene are conducted throughout all clinical areas. The time table for areas completing audits is agreed by ICOG. Copies of the hand hygiene audit tool and other supporting information is available on the Infection Prevention and Control intranet site. Hand hygiene audit results are reported to and are performance managed by ICOG. Divisions have a responsibility to ensure that they are completed and sufficient time is allocated. Where appropriate the development of an action place will be required. 7.0 Training and Implementation 7. 7.. 7..2 Infection prevention and control training [including hand hygiene] is a mandatory requirement for all staff and is part of the corporate induction programme. Each member of staff must have an update on Infection Prevention and Control [including hand hygiene] in accordance with the Trust s Training Needs Analysis [TNA]. Please refer to the NUH Personal Development Review Policy for details of the Trust s Training Needs Analysis. Infection Prevention and Control Training attendence is recorded centrally on the Trust Training data base. Divisions must ensure that any local training records are submitted to Learning and Organisational Development (L&OD) as per the register. Local managers are responsible for non-attendance follow up. Managers should consult the NUH Induction and Statutory and Mandatory Training policy located on the NUH policies and Trust wide procedures intranet site for further information regarding nonattendance process. 2
7.2 7.2. 7.2.2 7.2.3 Implementation In line with all infection prevention and control policies, this policy will be available on the Trust Policy intranet site. The Hand Hygiene policy and contents form part of infection prevention and control mandatory training. Updates to infection prevention and control policies are communicated via e-mail and newsletters to clinical areas including ICLPs. 7.3 Resources No additional resources are required. 8.0 Trust Impact Assessments 8. 8.. Equality Impact Assessment An equality impact assessment has been undertaken on this document and has not indicated that any additional considerations are necessary. 8.2 8.2. Environmental Impact Assessment An environmental impact assessment has been undertaken on this document and has not indicated that any additional considerations are necessary. 8.3 Here For You Assessment A Here For You assessment has been undertaken on this document and has not indicated that any additional considerations are necessary. 3
9.0 Policy / Procedure Monitoring Matrix Minimum requirement to be monitored Compliance with the Health and Social care Act 2008: Code of Practice on the prevention and control of infection and related guidance Compliance with Hand hygiene Responsible individual/ group/ committee Infection Prevention and Control Committee ICOG and divisions Process for monitoring e.g. audit Matron report, Infection Prevention and Control annual report Hand hygiene audit data Frequency of monitoring Formal review annually In line with agreed time table via ICOG (minimum of two monthly) Responsible individual/ group/ committee for review of results Infection Prevention and Control Committee and Individual Divisions ICOG Responsible individual/ group/ committee for development of action plan Infection Prevention and Control Team Infection Prevention and Control Team, ICOG Responsible individual/ group/ committee for monitoring of action plan Infection Prevention and Control Committee and Individual Divisions ICOG Mandatory Learning and Review of Monthly Trust Board Trust Board Trust Board 4
infection prevention and control training Organisational Development Managers training data 5
0.0 Relevant Legislation, National Guidance and Associated NUH Documents 0. Department of Health (2007). 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 (200). Uniforms and Workwear: Guidance on uniform and workwear policies for NHS empoyers. Department of Health. London Department of Health (205). The Health and Social Care Act 2008. Code of Practice for the NHS on the prevention and control of healthcare associated infections and related guidance. Department of Health. London. Department of Health (2009). Clostridium difficile infection: How to deal with the problem. Department of Health. London. Department of Health (206) NHS Outcomes Framework: At a Glance List of Outcomes and Indicators in the NHS Outcomes Framework 206-7, Department of Health, London Loveday, H.P, Wilson, J.A, Pratt R.J., Golsorkhi, M., Tingle, A., Bak, A, Browne, J, Prieto, J., Wilcox, M. (204). Epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. The Journal of Hospital Infection, Jan; 86, Suppl :S - 70. 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):2-22 World Health Organization (WHO) (2009) WHO Guidelines on Hand Hygiene in Health Care, WHO, Geneva. 6
Insert templates of relevant impact assessments (page break after each) APPENDIX Equality Impact Assessment (EQIA) Form (Please complete all sections) Q. Date of Assessment: Q2. For the policy and its implementation answer the questions a c below against each characteristic (if relevant consider breaking the policy or implementation down into areas) Protected Characteristic a) Using data and supporting information, what issues, needs or barriers could the protected characteristic groups experience? i.e. are there any known health inequality or access issues to consider? The area of policy or its implementation being assessed: b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics, screening Race and No known issues N/A N/A Ethnicity Gender No known issues N/A N/A Age No known issues N/A N/A Religion No Known Issues N/A N/A Disability No Known Issues N/A N/A c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality 7
Sexuality No Known Issues N/A N/A Pregnancy and No Known Issues N/A N/A Maternity Gender No Known Issues N/A N/A Reassignment Marriage and No Known Issues N/A N/A Civil Partnership Socio-Economic No Known Issues N/A N/A Factors (i.e. living in a poorer neighbour hood / social deprivation) Area of service/strategy/function Q3. What consultation with protected characteristic groups inc. patient groups have you carried out? Public Representative at IPCC that reviews all Infection Prevention and Control Policies Q4. What data or information did you use in support of this EQIA? DH equality impact assessment guidance Q.5 As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys, questionnaires, comments, concerns, complaints or compliments? No Known Issues Q.6 What future actions needed to be undertaken to meet the needs and overcome barriers of the groups identified or to create confidence that the policy and its implementation is not discriminating against any 8
groups What By Whom By When Resources required Q7. Review date 9
Environmental Impact Assessment APPENDIX 2 The purpose of an environmental impact assessment is to identify the environmental impact of policies, assess the significance of the consequences and, if required, reduce and mitigate the effect by either, a) amend the policy b) implement mitigating actions. Area of impact Environmental Risk/Impacts to consider Action Taken (where necessary) Waste and Is the policy encouraging using more materials/supplies? materials Is the policy likely to increase the waste produced? Does the policy fail to utilise opportunities for introduction/replacement of materials that can be recycled? Soil/Land Is the policy likely to promote the use of substances dangerous to the land if released (e.g. lubricants, liquid chemicals) Does the policy fail to consider the need to provide adequate containment for these substances? (e.g. bunded containers, etc.) Water Is the policy likely to result in an increase of water usage? (estimate quantities) Is the policy likely to result in water being polluted? (e.g. dangerous chemicals being introduced in the water) Does the policy fail to include a mitigating procedure? (e.g. modify procedure to prevent water from being polluted; polluted water containment for adequate disposal) Air Is the policy likely to result in the introduction of procedures No No No No No No No No No 20
and equipment with resulting emissions to air? (e.g. use of a furnaces; combustion of fuels, emission or particles to the atmosphere, etc.) Does the policy fail to include a procedure to mitigate the effects? Does the policy fail to require compliance with the limits of emission imposed by the relevant regulations? Energy Does the policy result in an increase in energy consumption levels in the Trust? (estimate quantities) Nuisances Would the policy result in the creation of nuisances such as noise or odour (for staff, patients, visitors, neighbours and other relevant stakeholders)? No No No No 2
We Are Here For You Policy and Trust-wide Procedure Compliance Toolkit The We Are Here For You service standards have been developed together with more than,000 staff and patients. They can help us to be more consistent in what we do and say to help people to feel cared for, safe and confident in their treatment. The standards apply to how we behave not only with patients and visitors, but with all of our colleagues too. They apply to all of us, every day, in everything that we do. Therefore, their inclusion in Policies and Trust-wide Procedures is essential to embed them in our organization. Please rate each value from 3 ( being not at all, 2 being affected and 3 being very affected) Value Score (- 3). Polite and Respectful Whatever our role we are polite, welcoming and positive in the face of adversity, and are always respectful of people s individuality, privacy and dignity. 2. Communicate and Listen We take the time to listen, asking open questions, to hear what people say; and keep people informed of what s happening; providing smooth handovers. 3. Helpful and Kind All of us keep our eyes open for (and don t avoid ) people who need help; we take ownership of delivering the help and can be relied on. 4. Vigilant (patients are safe) Every one of us is vigilant across all aspects of safety, practices hand hygiene & demonstrates attention to detail for a clean and tidy environment everywhere. 22
5. On Stage (patients feel safe) We imagine anywhere that patients could see or hear us as a stage. Whenever we are on stage we look and behave professionally, acting as an ambassador for the Trust, so patients, families and carers feel safe, and are never unduly worried. 6. Speak Up (patients stay safe) We are confident to speak up if colleagues don t meet these standards, we are appreciative when they do, and are open to positive challenge by colleagues 7. Informative We involve people as partners in their own care, helping them to be clear about their condition, choices, care plan and how they might feel. We answer their questions without jargon. We do the same when delivering services to colleagues. 8. Timely We appreciate that other people s time is valuable, and offer a responsive service, to keep waiting to a minimum, with convenient appointments, helping patients get better quicker and spend only appropriate time in hospital. 9. Compassionate We understand the important role that patients and family s feelings play in helping them feel better. We are considerate of patients pain, and compassionate, gentle and reassuring with patients and colleagues. 0. Accountable Take responsibility for our own actions and results. Best Use of Time and Resources Simplify processes and eliminate waste, while improving quality 2. Improve Our best gets better. Working in teams to innovate and to solve patient frustrations TOTAL 2 23
APPENDIX CERTIFICATION OF EMPLOYEE AWARENESS Document Title Version (number) 5 Version (date) 2 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/ Division 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 Division Divisional General Manager or Nominated Deputy Corporate Directorates - Deputy Director or equivalent. The manager may, at their discretion, also require that subordinate levels of their division / department utilize this form in a similar way, but this would always be an additional (not replacement) action. 24