Hand Hygiene Policy Who Should Read This Policy Target Audience All Trust Staff Version 1.2 June 2018
Ref. Contents Page 1.0 Introduction 4 2.0 Purpose 4 3.0 Objectives 4 4.0 Process 4 4.1 Microbiology of the Hands 4 4.2 Skin Problems 5 4.3 Bare Below the Elbows Preparation for Hand Hygiene 6 4.4 Risk Assessment in Hand Hygiene 6 4.5 Your 5 Moments for Hand Hygiene 6 4.6 Hand Washing/Drying 7 4.7 Levels of Hand Hygiene 9 4.8 Use, Installation and Provision of Alcohol Hand Gel (Hand Sanitiser) 10 4.9 Installation and Risk Assessment 10 4.10 Hand Washing/Drying Facilities 11 4.11 Hand Hygiene Facilities in the Patient/Clients own Home 12 4.12 Patients, Clients and Visitors 12 4.13 Adherence to Policy 13 5.0 Procedures Connected to this Policy 13 6.0 Links to Relevant Legislation 14 6.1 Links to Relevant National Standards 14 6.2 Links to Other Key Policy/s 14 6.3 References 15 7.0 Roles and Responsibilities for this Policy 16 8.0 Training 17 9.0 Equality Impact Assessment 18 10.0 Data Protection and Freedom of Information 18 11.0 Monitoring this policy is working in Practice 18 Appendices 1.0 Ayliffe Technique- Soap and Water 20 2.0 Ayliffe Technique- Alcohol Hand Gel 21 3.0 Approved Hand Hygiene Products 22 Version No June 2018 2
Explanation of terms used in this policy Alcohol gel (Hand sanitiser)- A sanitising gel containing alcohol and emollients. Dispensed in a measured dose from a wall mounted or stand-alone dispenser. The alcohol gel disinfects/sanitises physically clean hands and destroys transient micro-organisms but not spores Antibacterial- A combination of a detergent and a micro-biocide such as chlorhexidine or povidone iodine. Resident micro-organisms can only be inhibited by the use of antiseptic solutions and therefore should be used when undertaking aseptic procedures including insertion of medical devices. These solutions should not be used for routine hand washing as frequent hand washing with antiseptics can damage the skin Bar Soap- Bar soaps must not be used by clinical staff these are for use by patients and must be kept solely for their use and not used communally Emollient- A non-perfumed hand cream that is compatible with the soap/alcohol gel in use Hand antisepsis- Reducing or inhibiting the growth of micro-organisms by the application of an antiseptic hand rub or performing an antiseptic hand wash Hand cleansing or hand hygiene- Action of performing hand hygiene for the purpose of physically or mechanically removing dirt, organic material or micro-organisms Hand drying- Drying the hands thoroughly with disposable paper towels paying particular attention to the inter-digital spaces Hand hygiene- A general term referring to any action of hand cleansing (hand washing, antiseptic hand wash, antiseptic hand rub etc.) Hand rubbing- Action of applying an alcohol based (waterless) hand hygiene product Hand soap- A non-perfumed gentle liquid soap that does not contain anti-bacterial agents. Dispensed from wall-mounted dispensers in a measured dose. Hand soap contains surfactants that provide cleaning properties to remove organic matter Hand washing- Washing hands with plain or anti-microbial liquid soap & water 5 Moments- An approach to hand hygiene developed by the World Health Organisation which aims to: Ensure hand hygiene is geographically appropriate Ensure hand hygiene is temporally appropriate To reduce unnecessary hand hygiene To ensure the chain of transmission is broken by hand hygiene Spore- A dormant non-reproductive body formed by certain bacteria in response to adverse environmental conditions and is highly resistant to desiccation and heat Version No June 2018 3
1.0 Introduction Health care-associated infections affect hundreds of millions of patients worldwide every year. Infections can: lead to more serious illness; prolong hospital stays; induce long-term disabilities; add high costs to patients and their families; contribute to additional financial burden on the health-care system and result in tragic loss of life. Hand hygiene is the primary measure to reduce infections. Although this is a simple action, the lack of compliance among health-care providers is problematic worldwide (Pittet, 2009). The hands of the healthcare worker so frequently used to giving comfort and care can become a lethal weapon, transferring pathogens to susceptible patients/clients. This policy supports the importance of adhering to hand hygiene procedures to help in the reduction of healthcare associated infections and applies to all Black Country Partnership NHS Foundation Trust (BCPFT) staff, allied health professionals and support workers. Routine hand washing will remove 90-95% of transient microorganisms acquired from normal patient contact. 2.0 Purpose The aim of hand hygiene is to prevent the spread of infection via the hands by removing transient organisms, or reducing them to a level where they no longer pose a threat to the next person or surfaces touched. 3.0 Objectives The key objectives of this policy are: to ensure all staff employed by the Trust and those working in a contracted capacity for them, are aware of the importance of effective hand hygiene to describe the key elements of good hand hygiene practice to identify strategies to implement the policy and improve compliance with good hand hygiene 4.0 Process 4.1 Microbiology of the Hands There are two groups of micro-organisms on the hands the transient microorganisms that are carried temporarily on the surface of the skin and the resident micro-organisms that colonise or live on the skin. 4.1.1 Transient Skin Flora Micro-organisms, which are acquired on the hands through contact with a person s own body sites, from other people or from the environment These micro-organisms are very superficial, easily acquired by touch and are readily transferred to the next person or surface touched A major cause of cross infection Removal of transient micro-organisms is therefore essential in preventing cross infection, and their removal is easily achieved by washing with liquid soap and water Version No June 2018 4
4.1.2 Resident Skin Flora These micro-organisms live in deep crevices and hair follicles and are known as skin flora and form part of the body s natural defence mechanism Most are bacteria of low pathogenicity such as staphylococci They are not readily transferred to other people and most are not easily removed by washing with liquid soap and water They do not need to be removed from the hands during routine clinical care During invasive procedures e.g. insertion of a urinary catheter, there is a risk that resident micro-organisms may enter the patient s tissues and cause infection 4.2 Skin Problems If you are experiencing skin problems or you have a lesion, cut or graze etc. that cannot be adequately covered you can self-refer by contacting Occupational Health on 0121 5073306. You can also be referred by your manager who will require you to complete a consent form to release your information. Your manager may need to be informed of the outcome where changes in work practice are required in line with health & safety requirements. If a particular liquid soap, antimicrobial hand wash or alcohol product causes skin irritation, seek occupational health advice. 4.2.1 Skin Care The skin provides a waterproof barrier against micro-organisms, including blood borne viruses, provided it is healthy and intact. Healthcare staffs are at increased risk of developing irritant contact dermatitis and eczema due to frequent hand washing. Hand washing agents causing irritation and dryness to skin has been highlighted as a reason healthcare workers fail to wash their hands (WHO, 2009). To minimise the risk of skin damage the golden rules of caring for your hands are: Always wet hands thoroughly before applying liquid soap to minimise the risk of dry skin Always dry hands thoroughly on disposable paper towels Apply an emollient hand cream regularly to protect skin from the drying effects of regular hand hygiene, aim to apply cream before breaks and at the end of your shift Avoid oil-based emollients if latex gloves are worn latex disintegrates within minutes of contact with petroleum Do not use communal pots of hand cream as these may become contaminated Cover cuts and abrasions with waterproof dressings. These should be replaced when wet Wear gloves when cleaning equipment or handling chemicals (See Section 1 of the Infection Prevention and Control Manual) Ensure all hand hygiene products e.g. liquid soap, paper towels, alcohol gels/rubs, hand creams etc. have been approved by infection prevention & control Don t use bar soap cartridge liquid soap dispensers reduce risk of cross infection Version No June 2018 5
4.3 Bare Below the Elbows Preparation for Hand Hygiene All healthcare workers involved in direct patient contact/care must ensure they comply with the following Department of Health Guidance: Hand Hygiene Policy Before commencing a clinical shift, all wrist and hand jewellery like watches rings and bracelets must be removed. Item Rings Bracelets Sleeves Wrist watches Nails Nail varnish False nails, nail extensions, gel fillers etc. Action Remove rings - no rings other than a plain wedding band allowed. (Bacterial counts are higher on hands when rings are worn). Remove - no bracelets to be worn. Long sleeves should be avoided, but if worn must be rolled up. Remove wristwatches - these should be avoided and always removed prior to providing direct care and performing hand hygiene. Keep nails clean and short. Remove - no nail varnish or nail art permitted. Remove - no nail extensions, false nails or nail jewellery etc. to be worn, as they harbour micro-organisms. Employees whose religion requires them to wear a religious symbol or who wish to cover their forearms should refer to the Uniform and Appearance at Work policy section 4.4 and also can seek advice from their line manager/infection prevention and control team. 4.4 Risk Assessment in Hand Hygiene A risk assessment of the activity intended or performed will determine the appropriate level of hygiene (see 4.7) and the choice of product e.g. liquid soap, alcohol or antiseptic preparation (ICNA, 2002). Consider: Do you need to decontaminate your hands before this activity/contact? Do you need to decontaminate your hands after this activity/contact? Are your hands visibly soiled? Is this a high-risk procedure or a vulnerable patient? Does this patient have a known or suspected infection? Applying the 5 moments to hand hygiene will help to determine the need for hand hygiene Version No June 2018 6
4.5 Your 5 Moments for Hand Hygiene The 5 moments for hand hygiene approach defines the key moments when healthcare workers should perform hand hygiene (WHO 2009): Hand Hygiene Policy 4.6 Hand Washing/Drying An effective hand washing and drying technique plays a key role in standard infection control practices to prevent cross-infection. 4.6.1 Why Perform Hand Hygiene? Hand hygiene has a dual role to protect both the patient and the healthcare worker from acquiring micro-organisms, which may cause them harm. Version No June 2018 7
Hands may be contaminated by direct contact with patients, indirectly by handling equipment or through contact with the general environment. Patients with invasive devices e.g. IV lines or catheters or undergoing invasive procedures are particularly vulnerable to infection from micro-organisms transferred on hands and therefore staff must utilise Level 2 hand hygiene before commencing procedures on these patients (See 4.7 for the level of hand hygiene). 4.6.2 Areas of the Hands Frequently Missed During Hand Decontamination (Taylor 1978) 4.6.3 Why Should You Dry Your Hands? Wet hands transfer micro-organisms more effectively than dry ones. Moisture left on the hands may cause the skin to become dry and cracked. The method of hand drying is therefore very important in infection control. Where possible disposable paper hand towels should be used: Good quality paper towels can dry the hands quickly and efficiently and are convenient to use Brisk rubbing movements using the towels remembering the back of the hands and inter digital spaces Use enough paper towels for effective drying Dispose of the paper towels carefully; use the foot pedal and not your clean hands to open the bin Hot air dryers, multi-use towels off the roll or hanging type are not recommended in healthcare settings where patient care is delivered Version No June 2018 8
4.7 Levels of Hand Hygiene Why perform hand hygiene? LEVEL 1 Social Hand Hygiene LEVEL 2 Hygienic Hand Hygiene LEVEL 3 Surgical Scrub To render the hands physically clean and to remove micro-organisms picked up during activities considered social activities (transient microorganisms). Mechanical removal of micro-organisms To remove or destroy transient micro-organisms and to provide residual effect during times when hygiene is particularly important in protecting yourself and others (reduces resident microorganisms). Chemical removal of micro organisms To remove or destroy transient microorganisms and to substantially reduce those micro-organisms which normally live on the skin (resident microorganisms) during times when surgical procedures are being carried out. Which product should I use? When to perform hand hygiene? Alcohol Gel (if hands are physically clean). Gentle liquid soap applied for 20-30 seconds BEFORE: Commencing or leaving work Patient/client contact Using computer in the clinical area Eating/handling food/drink (whether own or patients/ clients) Preparing or administering medications Entering/leaving clinical areas AFTER: Patient/client contact Becoming visibly soiled Giving medications Visiting the toilet Using computer in the clinical area Handling laundry/waste or equipment, items around the patient / client environment Removing gloves or other protective equipment after blowing the nose, coughing & sneezing Liquid soap followed by alcohol gel or An aqueous antiseptic soap e.g. Aqueous Chlorhexidine 4% applied for 2-30 seconds BEFORE/BETWEEN: Aseptic procedures Contact with immuno-compromised patients AFTER: Contact with patients/ clients being cared for in isolation Being in a ward during outbreak of infection Performing invasive procedures e.g. injections, taking blood, cannulation, catheterisation etc. An aqueous antiseptic soap e.g. Aqueous Chlorhexidine 4% applied for 1 minute and procedure repeated BEFORE: Surgical or invasive procedures (Not required for current services provided by the Trust) WHAIF (2009) Version No June 2018 9
4.8 Use, Installation and Provision of Alcohol Hand Gel (Hand Sanitiser) Alcohol gel is useful for rapid disinfection of hands in both in patient areas and community settings. Alcohol gel can be used as an alternative to hand washing when hands are not visibly soiled/dirty. 4.8.1 Why Use Alcohol Based Products for Hand Hygiene? Some micro-organisms are sensitive to alcohol and its drying properties. As a result they die or are unable to multiply. These products can be useful for performing hand hygiene when sinks are not readily available. 4.8.2 When Should I use Alcohol Based Products for Hand Hygiene? Alcohol based products can also be used following hand washing, e.g. when performing aseptic techniques, to provide a further cleansing effect. 2012 NICE Guidance states healthcare workers should decontaminate hands preferably with hand rub (conforming to current British Standards) except in the following circumstances, when liquid soap and water must be used: When hands are visibly soiled In clinical situations where there is potential for the spread of alcohol resistant organisms such as Norovirus, Clostridium difficile or organisms that cause diarrhoeal illness 4.8.3 How should I use Alcohol Based Products to Perform Hand Hygiene? Alcohol based products with a concentration of 70% are generally used as they cause less skin drying dermatitis and are less costly The amount/volume used to provide adequate coverage of the hands is usually automatically dispensed by machine and pumps, and is normally around 3-5 mls The steps to perform hand hygiene using alcohol based products are the same as when performing hand washing (See Appendix 2) Allow the alcohol based product used on the hands to dry fully before any patient/client procedures are undertaken (do not use towels to do this) Alcohol gel must be made available at the entrances/exits to all in-patient clinical areas. However, the dispensers must be visible to enable its use to be monitored (NPSA, 2008b) Currently, no scientific evidence is available to advise staff regarding the maximum number of applications of alcohol gel before hands need to be washed. Hands must be washed with soap and water if following several applications of alcohol gel hands becomes sticky 4.9 Installation and Risk Assessment Alcohol gel should be made available at key locations within wards and departments for use by staff, patients and visitors as appropriate to include entrances to clinical areas following a risk assessment. Prior to installing alcohol hand gels in areas where patients and public have access, risk assessments must be undertaken to comply with Health & Safety and COSHH related policies to ensure that the alcohol gel has not been placed where: It may cause harm to patients Version 1. 2 June 2018 10
There is a risk of ingestion the sighting of dispensers may need to be reviewed at regular intervals to assess ingestion risks for individual clients. Where a risk of ingestion has been identified the gel dispenser should be removed or re-located until the risk has been resolved or the patient has been discharged There is a risk of splashing dispensers must not point in the direction of an individual It can be misused by patients and the public Children can gain access There are electrical switches nearby Ideally wall mounted alcohol gel dispensers should be fitted with a drip tray to reduce risk of slip hazards. Alcohol gel dispensers should be sited in a secure and safe position to reduce risk of injury to patients, staff and visitors. There should be a system in place to ensure dispensers and nozzles are kept clean and cartridges replaced when empty. The ward/department manager has overall responsibility for this. Once empty the cartridges/pumps/toggles should be discarded in accordance with waste management policy and replaced. Where wall mounted dispensers are not available either individual tottles or a large bottle with integral pump should be made available. These can be used but not left at the bedside or left unattended in the patient areas. 4.10 Hand Washing/Drying Facilities All hand-wash basins and taps in clinical areas should conform to the requirements of HBN 00-10 Part C: Sanitary Assemblies (Department of Health 2013), which provides best practice guidance on the design and planning of new healthcare buildings and on the adaption/extension of existing facilities. Key points are: All installations must comply with the Water Fittings Regulations Taps should not be aligned to run directly into the drain aperture Easy accessible, dedicated hand-wash basin without plugs or overflows as these constitute a constant infection prevention and control risk more significant than the risk of damage due to water overflowing Water temperature at point of delivery should be controlled at either manual control or by individual thermostatic control For mental health facilities that have specific design requirements separate guidance is available in the guidance HBN 03-01 Adult Acute Mental Health Units (Department of Health 2013). This guidance states that mental health facilities take into consideration that sanitary facilities be: Robust in construction Ligature-free Have facilities/measures to prevent flooding Have sensors and timer controls to facilitate flushing or to isolate the water supply in the case of emergency Version 1. 2 June 2018 11
The following basic principles also apply: A separate designated hand-wash basin i.e. not used to wash instruments, cups etc., should be available wherever clinical activity takes place Each hand-wash basin must be equipped with warm running water from a mixer tap Hand-wash basins in clinical areas should be equipped with lever (wrist or elbow operated) or automatic sensor taps Wall mounted disposable paper hand towels and liquid soap dispensers must be available at each hand-wash basin Foot-only operated bins should be available at each hand-wash basin for the hygienic disposal of used paper towels A hand wash poster demonstrating an effective hand washing technique should be displayed near to each hand-wash basin Alcohol hand gel should also be available in wall mounted dispensers and/or individual staff tottles 4.11 Hand Hygiene Facilities in the Patient/Clients own Home Hand hygiene practices in the patient/clients own home should follow the same general principles outlined previously. However, it is accepted that hand wash facilities may not be of an acceptable standard in the patient/clients own home. To minimise risks, the following principles should apply: All community health care workers must have access to liquid soap, moisturising cream, alcohol gel and have access to paper towels to dry hands It is the responsibility of managers to ensure this is available It is not acceptable for staff to use soap and/or cotton towels provided by patients as they may not be adequate or appropriate Hand washing should be undertaken using a liquid soap in a sink that is clean and free from items (if a clean/ appropriate sink is not available then alcohol hand rub may be used and hands to be washed at the next available suitable facility) Health care workers should be encouraged to take alcohol hand gel with them on visits to ensure adequate decontamination between tasks. However, alcohol products must not be seen as a direct substitute for hand washing and should be provided in addition to, not instead of liquid soap, water and paper towels. 4.12 Patients, Clients and Visitors Following initial risk assessments alcohol gel will be located in key entrance areas within the clinical areas when deemed safe to do so. Patients/clients need to be advised of their role in preventing the spread of infection and the necessity for regular hand washing. Adequate facilities must be provided by the Trust to encourage social hand washing. Social hand washing must be offered to patients when needed i.e. after using the toilet, changing pads, before meals etc. Patients and clients (when able) are to be encouraged to ask healthcare workers if their hands are clean before they provide any personal care. Version 1. 2 June 2018 12
Carers must also follow hand hygiene guidelines before assisting with the care of their relatives. 4.13 Adherence to Policy If you see a member of staff in contravention of this policy you should remind them of their responsibility for compliance. A Datix entry / incident form should be completed if: Having been asked to decontaminate their hands they refuse to do so An individual or group of individuals repeatedly infringe this policy The Datix entry/incident form should be sent to the appropriate manager for investigation and consideration of appropriate disciplinary procedures 5.0 Procedures Connected to this Policy There are no standard operating procedures connected to this policy. Version 1. 2 June 2018 13
6.0 Links to Relevant Legislation Health and Social Care Act 2008 (revised 2015) The primary focus of the Health and Social Care Act 2008 was to create a new regulator whose purpose was to provide registration and inspection of health and adult social care services together for the first time, with the aim of ensuring safety and quality of care for service users. The Care Quality Commission was established by statute, with enhanced powers to regulate primary care services, including hospitals, GP practices, dental practices, ambulance services and care homes. These powers include failing registration, fines and even closing practices down which do not adhere to the Fundamental Standards in Quality and Safety. This cohesive approach has led to the CQC becoming one of the most powerful regulatory bodies in the UK. Health and Safety at Work Act 1974 The Act sets out the general duties of employers to ensure the health, safety and welfare of employees and members of the public as far as is reasonably practicable. It also details the duties that employees have to themselves and to each other. The law requires employers to look at what the risks are and take sensible measures to tackle them. 6.1 Links to Relevant National Standards CQC Regulation 12: Safe Care and Treatment The intention of this regulation is to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. Providers must assess the risks to people's health and safety during any care or treatment and make sure that staffs have the qualifications, competence, skills and experience to keep people safe. Providers must make sure that the premises and any equipment used is safe and where applicable, available in sufficient quantities. Providers must also prevent and control the spread of infection. NICE Clinical Guideline QS61 Service providers ensure that healthcare workers are trained in effective hand decontamination techniques, and that hand rub and hand washing facilities are available so that healthcare workers can decontaminate their hands immediately before and after every episode of direct contact or care. 6.2 Links to Other Key Policy/s Health and Safety Policy The policy aims to promote and enable an organisational and systematic approach to the development of Health and Safety procedures and protocols throughout the Trust and to set out the requirements of the Trust to demonstrate and achieve legislative compliance. Risk Management Strategy Policy and Process The purpose of the Risk Management Strategy/Policy is to provide the Trust with a framework for the development of robust risk management processes throughout the organisation. Version 1.2 June 2018
Incident Reporting Policy The purpose of the policy is to make clear the system used for reporting incidents involving patients, service users, staffs and others undertaking activities on behalf of the Trust. Infection Control Assurance Policy The purpose of this policy is to explain the principles of infection prevention and control and to define the infrastructure, responsibility and accountability of each member of staff in ensuring that those principles are adhered, so that the Trust can be assured that our prevention and control measures are robust and appropriate. Uniform and Appearance at Work - Dress Code Policy The purpose of this policy is to ensure all employees are clear on the standard of appearance/dress expected while at work, whether in uniform or non-uniform and to: Ensure a consistency of approach in wearing the Trust uniforms and in portraying a corporate image Ensure high standards of personal cleanliness Inform staff and managers of the policy so that they can implement and monitor compliance The purpose of these standards of dress is to: Minimise cross infection Maintain a professional appearance Enable easy identification Protect staff from trauma/injury and promote health and safety 6.3 References Department of Health (2013) Health Building Note 00-10 Part C : Sanitary Assemblies Department of Health (2013) Health Building Note 03-01 Adult Acute Mental Health Units Infection Control Nurse Association (2002) Hand Decontamination Guidelines. Infection Control Nurses Association: Regent National Patient Safety Agency (2008a) Your 5 Moments for Hand Hygiene. NPSA National Patient Safety Agency (2008b): Patient Safety Alert 2nd Ed. Clean Hands Save Lives NICE Infection Prevention & Control in Primary & Community Care Clinical Guideline partial update March 2012 Pittet, D (2009) Cited in World Health Organization (2009) WHO Guidelines on Hand Hygiene in Healthcare: First Global patient safety Challenge Clean care is safer care Taylor LJ (1978) Evaluation of hand-washing techniques. Nursing Times 74, 54-55 Welsh Healthcare Associated Infection Programme (WHAIF) (2009) Infection Prevention Model Policy/Procedure - Hand Hygiene World Health Organization (2009) WHO Guidelines on Hand Hygiene in Healthcare Version 1. 2 June 2018 15
7.0 Roles and Responsibilities for this Policy Title Role Responsibilities Executive Director of Nursing, AHPs and Governance Trust Board Executive Lead Strategic - Responsible for ensuring the Trust s management of hand hygiene is discharged appropriately and has lead responsibility for the implementation of this policy - Ensure a systematic and consistent approach to the management of hand hygiene and that any serious concerns regarding the implementation of this policy are brought to the attention of the Board - Have a strategic overview and final responsibility for overseeing the management of hand hygiene across the Trust in accordance with its primary objective to provide high quality safe care Executive Committee Infection Prevention and Control Committee Infection Prevention and Control Team Head of Departments/Ward Managers Accountable Responsible Guidance and Support Implementation - Ensure that hand hygiene is managed efficiently and effectively in accordance with the Board s Assurance Framework and strategic priorities - Oversee the implementation of a systematic and consistent approach to the management of hand hygiene - Provide exception and progress reports to the Executive Committee - Ensure appropriate policies and procedures are in place to support hand hygiene practices - Provide education & training on hand hygiene as part of the Trust s induction and mandatory training programmes - Monitor the contamination incident report for any trends in order to target specific training requirements - Advise staff on the management of hand hygiene incidents - Ensure this policy is reviewed in line with any new evidence at least once every 3 years - Facilitate the audit of hand hygiene practice annually and present the annual audit report to the Infection Prevention & Control Committee - Ensure all staff within their area, including visitors and contactors understand and comply with the hand hygiene policy - Ensure all staff working in their area have been instructed on the correct techniques of hand hygiene (e.g. Ayliffe Technique Appendices 1 & 2) as part of their induction - Ensure compliance and adherence to practice is monitored through regular audit - Identify and support Infection Prevention Champions within their area - Ensure prompt reports to the Estates Dept. when hand hygiene facilities require maintenance, repair or installation - Ensure hand hygiene facilities are kept clean - Ensure availability of suitable products, equipment and facilities for hand hygiene within their area. Where insufficient facilities or products are identified, Managers should ensure appropriate departmental managers are notified - Risk assess the placement & Provision of alcohol gel Version 1.2 June 2018
Title Role Responsibilities Infection Prevention & Control Champions and Modern Matrons Domestics including Contracted services Estates/Maintenance Contractor Healthcare staff Support Adherence Adherence Adherence Hand Hygiene Policy - Demonstrate the highest standards of hand hygiene (washing or use of alcohol hand rubs) in clinical practice - Be bare below the elbow - Challenge staff members when poor practice/compliance is witnessed - Contact manager and or Infection Prevention & Control team if a staff member refuses to comply with this policy - Promote the aspirations of the Infection Prevention & Control team amongst peers and colleagues - Be supportive of patient/ service user involvement and encourage them to feel comfortable asking you about hand hygiene - Respond in a positive manner if a patient/ service user asks if your hands are clean. It is only right for them to be involved as it is for their safety. You can clean them again where they can see you - Disseminate any promotional materials or communicating messages in their clinical area - Attend Infection Prevention Champion meetings - Check and refill liquid soap dispensers daily and paper towel dispensers as appropriate - Respond promptly to requests to replenish spent liquid soap/ towel dispensers - Ensure hand-wash basins and liquid soap/alcohol (including drip trays)/ towel dispensers are regularly cleaned as per specification - Ensure that the equipment required for hand hygiene is in place, functional & clean, this includes hand-wash basins, taps, liquid soap dispensers, towel dispensers, alcohol gel dispensers and waste bins - Ensure that there is a high standard of hand hygiene in the Trust by reporting lapses in practice via incident reporting mechanisms (e.g. Datix/incident form), verbally to the person concerned - Attend infection control induction and refresher training as directed by their line manager, failure to do so may result in disciplinary action - Ensure dispensers e.g. liquid soap, alcohol gel & paper towel dispensers are promptly replenished as/when necessary - Infection Prevention & Control Policy competency check list 8.0 Training What aspect(s) of this policy will require staff training? Hand Hygiene training Which staff groups require this training? Is this training covered in the Trust s Mandatory and Risk Management Training Needs Analysis document? If no, how will the training be delivered? Who will deliver the training? All staff groups Yes Infection Prevention and Control Team/ Learning and Development How often will staff require training On induction and annually thereafter Who will ensure and monitor that staff have this training? Learning and Development Version No June 2018 17
9.0 Equality Impact Assessment Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact Assessment for this policy has been completed and is readily available on the Intranet. If you require this in a different format e.g. larger print, Braille, different languages or audio tape, please contact the Equality & Diversity Team on Ext. 8067 or email bcpft.equalityimpactassessment@nhs.net 10.0 Data Protection and Freedom of Information Data Protection Act provides controls for the way information is handled and to gives legal rights to individuals in relation to the use of their data. It sets out strict rules for people who use or store data about individuals and gives rights to those people whose data has been collected. The law applies to all personal data held including electronic and manual records. The Information Commissioner s Office has powers to enforce the Data Protection Act and can do this through the use of compulsory audits, warrants, notices and monetary penalties which can be up to 20million or 4% of the Trusts annual turnover for serious breaches of the Data Protection Act. In addition to this the Information Commissioner can limit or stop data processing activities where there has been a serious breach of the Act and there remains a risk to the data. The Freedom of Information Act provides public access to information held by public authorities. The main principle behind freedom of information legislation is that people have a right to know about the activities of public authorities, unless there is a good reason for them not to. The Freedom of Information Act applies to corporate data and personal data generally cannot be released under this Act. All staffs have a responsibility to ensure that they do not disclose information about the Trust s activities; this includes information about service users in its care, staff members and corporate documentation to unauthorised individuals. This responsibility applies whether you are currently employed or after your employment ends and in certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to ensure a high level of transparency in all its business activities but reserves the right not to disclose information where relevant legislation applies. The Information Governance Team provides a central point for release of information under Data Protection and Freedom of Information following formal requests for information; any queries about the disclosure of information can be forwarded to the Information Governance Team. 11.0 Monitoring this policy is working in Practice What key elements will be monitored? (measurable policy objectives) Where described in policy? How will they be monitored? (method + sample size) Who will undertake this monitoring? How Frequently? Group/Committee that will receive and review results Group/Committee to ensure actions are completed Evidence this has happened Staff complete hand hygiene training, in line with the training needs analysis 4.0 Process Audit Learning and Development Quarterly Workforce Development Group Workforce Development Group Completed action plan signed off / minutes of meeting Version 1.2 June 2018
Hand hygiene 95% compliant 4.0 Process In-patient settings observational hand hygiene audits Head of Departments/Ward Managers Monthly The Infection Prevention and Control Committee Hand Hygiene Policy The Infection Completed Prevention and action plan Control Committee signed off / minutes of meeting Hand hygiene practice 4.0 Process Audit Infection Prevention and Control Team/ Infection Prevention & Control Champion Annually The Infection Prevention and Control Committee The Infection Prevention and Control Committee Completed action plan signed off / minutes of meeting Version No June 2018 19
Appendix 1 Ayliffe Hand Washing Technique Wash hands following the 8 steps below. Each step consists of five strokes rubbing backwards and forwards 1. Wet hands under running water. Take a measure of soap. 2. Work into hands, palm to palm. 3. Right hand over back of left and vice versa. 4. Rub palm to palm, fingers interlaced 5. Back of left fingers to right palms, fingers interlocked and vice versa. 6. Rotational rubbing of right thumb clasped in left hand and vice versa 7. Rub left palm with clasped fingers of right hand and vice versa. 8. Left wrist with right hand and vice versa. Rinse hands under running water and dry thoroughly Version 1.2 June 2018 20
Appendix 2 Ayliffe Hand Decontamination Technique using Alcohol Hand Rub Decontaminate the hands using the 8 steps below. Each step consists of five strokes rubbing backwards and forwards 1. Apply a measure of alcohol hand rub. 2. Work into hands, palm to palm. 3. Right hand over back of left and vice versa. 4. Rub palm to palm, fingers interlaced 5. Back of left fingers to right palms, fingers interlocked and vice versa. 6. Rotational rubbing of right thumb clasped in left hand and vice versa 7. Rub left palm with clasped fingers of right hand and vice versa. 8. Left wrist with right hand and vice versa. Rub in the alcohol hand rub until dry Version 1.2 June 2018 21
Appendix 3 Approved Hand Hygiene Products Product Description Order instructions Unit of issue (UOI) Gojo Purell cleanser alcohol hand rub gel (300ml) freestanding with pump (for use on trolley/desk) MRB1149 stock item NHS supply chain Order UOI in multiples of Each 1 or 12 Gojo Purell cleanser alcohol hand rub gel (118ml) staff carried Gojo dispensers and accessories non retractable clip for use with MRB153 Gojo Purell cleanser alcohol hand rub gel (1200ml) TFX wall mounted touch free dispenser. MRB153 Each 1 or 24 BCPMRB181 procurement catalogue Pack of 24 N.B. these are provided free from Gojo via infection control 1 Gojo Purell cleanser alcohol hand rub gel (1200ml) TFX refill for wall mounted touch free dispenser. MRB1139 stock item NHS supply chain Case of 2 1 Dispensers and accessories protector shield (drip tray) for use with wall mounted dispenser Gojo hand cream (moisturiser) cartridge for dispenser use fragrance free (500ml) refill Gojo hand hygiene kit community pack (contains alcohol gel, mild liquid soap and hand medic moisturiser) Gojo moisturiser cream bottle (59ml) staff carried Gojo Purell alcohol hand rub liquid bottle (60ml) staff carried Gojo Purell cleanser alcohol hand rub foam bottle (45 ml) staff carried Gojo hand wash liquid (soap) fragrance free (118 ml) staff carried MRB172 non stock item NHS supply chain MRB383 stock item NHS supply chain MRB252 non stock item NHS supply chain MRB218 stock item NHS supply chain MRB063 stock item NHS supply chain MRB512 non stock item NHS supply chain MRB212 non stock item NHS supply chain Each 1 or 6 Case of 6 1 Each 1 Each 1 or 12 Each 1 or 24 Each 1 Each 1 or 48 Version No June 2018 22
Purell wipe alcohol based hand sanitising wipe individually wrapped VJT407 non stock item NHS supply chain Box of 1000 1 or 9 Version 1.2 June 2018 23
Policy Details Title of Policy Unique Identifier for this policy State if policy is New or Revised Hand Hygiene Policy BCPFT-COI-POL-01 Revised Previous Policy Title where applicable Policy Category Clinical, HR, H&S, Infection Control etc. Executive Director whose portfolio this policy comes under Policy Lead/Author Job titles only Committee/Group responsible for the approval of this policy Month/year consultation process completed * N/A Control of Infection Executive Director of Nursing, AHPs and Governance Infection Prevention Lead Nurse Infection Prevention and Control Committee n/a Month/year policy approved July 2018 Month/year policy ratified and issued August 2018 Next review date August 2021 Implementation Plan completed * Equality Impact Assessment completed * Previous version(s) archived * Disclosure status Key Words for this policy Yes Yes Yes B can be disclosed to patients and the public Control of Infection, Microbiology of the hands, Skin Care, Bare below the elbows, Your 5 Moments for Hand Hygiene, Hand washing/drying, Levels of Hand Hygiene, Hand Sanitiser, Ayliffe technique, Approved hand hygiene products, Hand decontamination * For more information on the consultation process, implementation plan, equality impact assessment, or archiving arrangements, please contact Corporate Governance Review and Amendment History Version Date V1.2 June 2018 Details of Change Section 4.2 slight change to reflect change in referral process to Occ Health as managers now need to obtain consent from staff if they are making a referral Section 4.3 referred to the relevant section of Uniform Policy re bare below the elbows and religious requirements Section 4.10 updated legislation and added the mental health Version 1.2 June 2018 24
V1.1 Aug 2015 Hand Hygiene Policy guidance this does not change practice for clinical staff but relates to estates and installation or refurbishments. New policy format and minor amendments phone number updated for Health Duty Nurse and use of terms updated for consistency V1.0 July 2012 Alignment of policies following TCS Version 1.2 June 2018 25