Page Page 1 of 16 Policy Objective To ensure that Healthcare Workers (HCWs) understand the importance of and their responsibilities in complying with this hand hygiene policy. To provide HCWs with an environment which supports and facilitates effective hand hygiene. This policy applies to all staff employed by NHS Greater Glasgow & Clyde and locum staff on fixed term contracts. Document Control Summary Approved by and date BICC 10 th November 2008 Date of Publication 10 th November 2008 Developed by Infection Control Policy Sub-Group - 0141 201 4931 Related Documents NHSGGC Standard Precautions Policy Distribution/Availability NHSGGC Infection Prevention and Control Policy Manual and the Internet Implications of Race This policy must be implemented fairly and without prejudice Equality and other diversity whether on the grounds of race, gender, sexual orientation or duties for this document religion. Equality & Diversity Impact November 2008 Assessment Completed Lead Nurse Consultant Infection Control Responsible Director/Manager Board Infection Control Manager
Page Page 2 of 16 Contents 1. Responsibilities... 3 1.1. Healthcare workers must... 3 1.2. Managers must... 3 1.3. Infection Control Team must... 3 1.4. Pharmacy, Supplies & Occupational Health Departments must... 4 1.5. Estates... 4 2. Structure... 4 2.1. Clinical settings... 4 2.2. Home Care Settings... 5 3. When to perform hand hygiene... 6 4. Types of organisms found on skin (skin flora)... 7 5. Which hand hygiene procedure to use... 7 6. Basic requirements to achieve effective hand hygiene for all healthcare workers... 8 7. Skin Care... 9 8. How to perform Hand Hygiene (not surgical scrub or surgical hand antisepsis)... 10 9. Hand Hygiene technique... 11 10. Hand Cream Products... 12 11. Audit... 12 12. Evidence Base... 12 13. Sample Audit... 13 13.1. Criteria 1: Hands should be decontaminated as per the policy... 13 13.2. Criteria 2: Alcohol hand gel should be used appropriately and effectively.... 13 13.3. Criteria 3: Hand washing should be undertaken effectively.... 14 14. Background Information... 14
Page Page 3 of 16 1. RESPONSIBILITIES 1.1. Healthcare workers must Follow this policy. Report to clinical manager or Infection Control Nurse (ICN) if the area does not have any of the structural requirements, e.g. wash hand basins, hand gel, etc., to follow this policy. Report to Occupational Health if they develop sensitivities, or are otherwise unable to use the product supplied. Ensure there is always a sufficient supply of hand hygiene sundries. Remind colleagues of the importance of hand hygiene in the clinical setting when observed hand hygiene opportunities are missed. Promote hand hygiene by patients and visitors. 1.2. Managers must Remind colleagues of the importance of hand hygiene in the clinical setting when observed hand hygiene opportunities are missed. Encourage staff to take up education programmes on hand hygiene via ICT or online at NHSGGC Training Tracker Website. Ensure all HCWs have access to this policy. Promote hand hygiene by all HCWs, patients and visitors. Ensure HCWs have access to appropriate hand hygiene sundries. 1.3. Infection Control Team must Keep this policy up to date. Provide educational opportunities on this policy.
Page Page 4 of 16 Remind colleagues of the importance of hand hygiene in the clinical setting when observed hand hygiene opportunities are missed. Audit and assist others to audit the implementation of, and compliance with, this policy. Ensure that the products employed for hand hygiene are effective and not detrimental to the skin of the HCWs. Liaise with procurement and occupational health staff re the choice of products for hand hygiene. 1.4. Pharmacy, Supplies & Occupational Health Departments must Liaise with the Infection Control Team when choosing hand hygiene products or if problems with product use or supply develop. 1.5. Estates Liaise with the Infection Control Team at all stages of planning and upgrading all healthcare facilities. 2. STRUCTURE 2.1. Clinical settings In clinical settings there must be sufficient* accessible wash hand basins (WHBs) of a size to enable effective hand washing to take place. WHBs should have elbow, wrist, foot, or automatic mixer taps which have a combined pillar and no plug or overflow. Water should not be discarged directly into an outlet and use of swan neck taps should be avoided. Paper towels must be available and wall mounted in a dispenser. Plain liquid soap must be available and wall mounted in a dispenser.**
Page Page 5 of 16 Liquid antiseptic soap in a wall mounted dispenser.** NB bar soap must not be supplied for clinical use Alcohol hand gel must be available in a wall mounted or free standing dispenser. Risk assessment should be undertaken if there is any risk that patients might ingest alcohol hand gel. Pedal operated bins for should be available for waste disposal. Educational material illustrating the correct method of hand hygiene should be present at every sink. The dispenser nozzles must be clean and free from congealed product residue. *Sufficient is defined via the NHS building notes or to the satisfaction of the ICT. **Dispensers and plungers must be used until the dispenser is empty and then discarded. The dispenser must not be topped-up and reused. 2.2. Home Care Settings HCWs working in a home care setting should undertake a risk assessment of the hand washing facilities available to perform hand hygiene, in each home. The following options are suggested: Where running water and liquid soap are available and access to the sink is clear, the HCW can carry paper hand towels to use in the client s home. When liquid soap is not available, the HCW can carry their own supply of alcohol hand gel/ liquid soap / hand towels as recommended by the employer / infection control team. If access is difficult or limited and hands are physically clean, alcohol hand gel could be used.
Page Page 6 of 16 3. WHEN TO PERFORM Hand Hygiene is mandatory at any of the opportunities displayed by the World Health Organisation diagram below, even if gloves are worn. Hands must be decontaminated as follows (this list may not be exhaustive): Before preparing, handling or eating food. After visiting the toilet, After bed-making. After removing gloves or protective clothing. Whenever hands are visibly dirty. Before and after administering a medication. After any possible microbial contamination. Before and after any situation which involves direct patient / client contact. Before and after handling wounds, or invasive devices. Before and after emptying urine or other drainage bags. Before and after any direct patient care. Before commencing work and after leaving a work area. After handling contaminated laundry or waste. Before wearing sterile gloves. Before leaving an isolation room. If you think it may be necessary.
Page Page 7 of 16 Hand hygiene is mandatory as stated in the above procedures even if gloves are used. Glove use does not negate the need for hand hygiene. 4. TYPES OF ORGANISMS FOUND ON SKIN (SKIN FLORA) Types of hand flora Definitions Transient Organisms Organisms which colonise the superficial layers of the skin, and are more amenable to removal by routine hand hygiene. Often acquired by HCWs during direct contact with patients or contact with contaminated environmental surfaces within close proximity of the patient. Resident Organisms Organisms which are attached to deeper layers of the skin and are more resistant to removal. Resident organisms, e.g. coagulase-negative staphylococci, are less likely to be associated with health-care associated infections. NB Damaged skin is more likely to be colonised with pathogenic organisms. 5. WHICH PROCEDURE TO USE. Type of Procedure Basic Hand Wash (Level 1 Wash) Description and Rationale for use Procedure using plain liquid soap and water involving hands and wrists. See Section 8 for technique. Use for non-clinical procedures, i.e. before coming to work or leaving work, visiting the toilet, before eating or handling food and drink, or before non-surgical clinical procedures that do not require the removal of resident organisms. (Not suitable for source isolation). Antiseptic Hand Hygiene (Level 2 Wash) Procedure using anti-microbial soap, or plain liquid soap followed by an alcohol hand gel, involving hands and wrists. See Section 8 & 9 for technique. Pre and post all clinical procedures requiring the removal of
Page Page 8 of 16 resident organisms. Alcohol Hand Hygiene Alcohol hand gel involving hands and wrists can be used before and after any procedure provided HANDS ARE VISIBLY CLEAN. Alcohol hand gel should mot be used to perform hand hygiene when working with a patient who has LOOSE STOOLS. See Section 8 & 9 for technique. Surgical Scrub See Hand Hygiene for Theatre & Invasive Procedures (Traditional) (Level 3 Wash) Surgical Hand See Hand Hygiene for Theatre & Invasive Procedures Antisepsis - plain liquid soap followed by an alcohol-based product with persistent activity 6. BASIC REQUIREMENTS TO ACHIEVE EFFECTIVE FOR ALL HEALTHCARE WORKERS Cover all cuts and abrasions with water-proof dressings. HCWs must not perform surgical scrub or surgical hand antisepsis if they have cuts or abrasions. Keep nails clean. Do not wear nail varnish, artificial fingernails or extenders. Keep nail tips short. Do not wear wrist-watches, stoned jewellery, bracelets or rings (other than 1 plain band). Wear gloves when in contact with blood or other potentially infectious materials.
Page Page 9 of 16 7. SKIN CARE Provide only hand hygiene products that minimise the risk of hand irritation and contain emollients. All products for hand hygiene will be approved by the Infection Control Committees and NHSGGC. It is better for the integrity of the skin to use plain liquid soap and alcohol hand gel rather than an antimicrobial soap when Antiseptic Hand Hygiene is required. See section 5. Apply an emollient hand cream as required to protect skin from the drying effects of regular hand hygiene. If hand creams are required, use them after clinical procedures not before. Only those supplied in a pump dispenser should be used. Provide HCWs with hand creams which are sanctioned by the procurement department which do not negate the properties of antiseptics in other hand hygiene products, or the integrity of rubber gloves. Do not use communal tubs of hand cream which can become contaminated during use. If exfoliative skin conditions develop contact the Occupational Health Dept. If staff have sensitivities, the Occupational Health Dept. will liaise with the ICTs to ensure comparable alternative are supplied.
Page Page 10 of 16 8. HOW TO PERFORM (NOT SURGICAL SCRUB OR SURGICAL HAND ANTISEPSIS) Remove excess jewellery and wrist-watches. These should not be worn during clinical care. Forearms should be exposed. Procedure for Washing Hands* Turn on taps and get a comfortable water temperature. Wet hands under running water. Apply sufficient soap solution (plain liquid or anti-microbial) to form a lather that will completely cover the hands. Follow manufacturer s instructions on specific amount. To ensure that the soap lather comes into contact with all surfaces vigorously rub hands as per the technique illustrated in Section 9 for at least 15 seconds. Pay particular attention to the tips of the fingers, the thumbs and the areas between the fingers. Rinse hands thoroughly. Dry hands thoroughly. Procedure for applying Alcohol hand gel Check hands are visibly clean. If they are not, then change to a hand wash procedure. Apply one plunger full of the alcohol solution. (This is usually the pre-primed amount recommended by the manufacturer). If one plunger full is insufficient to cover all surfaces apply sufficient to do so. (Homecare settings as per manufacturer s instructions). Gently rub the solution over all surfaces of the hands as per the technique illustrated in Section 9. Pay particular attention to the tips of the fingers, the thumbs and the areas between the fingers. Ensure the alcohol has dried before touching any surface. Turn off taps with elbow/wrist or paper towels. Discard paper towels in the bin provided using the pedal, not hand, to open the lid. If plain liquid soap is used and the NB It is better for the integrity of the skin to use plain procedure requires Antiseptic Hand liquid soap and alcohol hand gel rather than an Hygiene proceed to use alcohol hand gel antimicrobial soap when Antiseptic Hand Hygiene is described in the next column. required. *The method of hand washing is the same whether plain liquid or anti-microbial soap is used. Hand Hygiene demonstration videos are available.
Page Page 11 of 16 9. TECHNIQUE
Page Page 12 of 16 10. HAND CREAM PRODUCTS Hand creams must be compatible with hand hygiene products and approved of by the Infection Control Committee. They should be available for staff whose hands are irritated by frequent hand hygiene. Hand cream dispensers must not be topped up and reused. 11. AUDIT Optimising hand hygiene performance is extremely challenging. It is essential that there is audit of not just structure but also of performance in terms of frequency and ongoing quality. Below are some suggested methods to audit and use as an indication of performance. Monitor the volume of alcohol based hand gel or liquid / antimicrobial soap used per 1,000 patient days. Audit of hand hygiene compliance with this policy. (Section 13 shows a sample audit). Frequent use of the Hand Hygiene Monitoring Tool developed by Health Protection Scotland and the Scottish Patient Safety Programme. 12. EVIDENCE BASE This policy is based on: Guideline for hand hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR October 2002 51. No RR-16. The Epic Project Team. The guidelines for hand hygiene. Journal of Hospital Infection Vol47. Suppl. S1-82. Infection Control Nurses Association. Guidelines for Hand hygiene. 1999 Infection Control in the Community. (2003) Lawrence J & May D. Churchill Livingstone. WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft 2008)
Page Page 13 of 16 13. SAMPLE AUDIT 13.1. Criteria 1: Hands should be decontaminated as per the policy The audits attached to this policy cover practice. Observation Observe 20 opportunities for hand hygiene and determine the proportion performed. Hand hygiene performed Hand hygiene not performed Percentage of performance 13.2. Criteria 2: Alcohol hand gel should be used appropriately and effectively. Observe 10 procedures using alcohol hand gel. Observation Number of procedures It was appropriate to use alcohol hand gel. / 10 Stoned rings or wrist-watches were not worn (for the clinical / 10 procedure or the hand rub). Forearms are exposed. /10 An appropriate amount of alcohol hand rub was used. / 10 The correct technique was followed. (Section 9) / 10 The hands were not recontaminated immediately after the / 10 procedure by touching for example the face or hair.
Page Page 14 of 16 13.3. Criteria 3: Hand washing should be undertaken effectively. Observe 10 hand washing procedures. Observation Number of procedures Was a hand wash as opposed to a hand rub appropriate? / 10 Stoned rings or wrist-watches were not worn (for the clinical / 10 procedure or the hand hygiene procedure). Forearms are exposed. /10 Hands were wet under running water prior to application of soap. /10 The appropriate solution was used. / 10 The correct technique was followed (Section 9). / 10 The technique took place for 15 seconds / 10 The soap was rinsed off under running water. / 10 Hands were dried with paper towels. / 10 Taps were turned off with paper towels, or using elbows or wrists. / 10 If necessary the procedure was followed by an alcohol hand rub / 10 procedure. The hands were not recontaminated immediately after the / 10 procedure by touching for example the face or hair. 14. BACKGROUND INFORMATION
Page Page 15 of 16 Extract from The Epic Project: why is hand hygiene crucial to the prevention of healthcare acquired infection. Evidence from reviews clearly demonstrates that in outbreak situations contaminated hands are responsible for transmitting infections. Our systematic review indicates that effective hand hygiene can significantly reduce infection rates in gastro-intestinal infections and in high-risk areas, such as intensive care units. Overviews of epidemiological evidence conclude that hand mediated transmission is a major contributing factor in the current infection threats to hospital in-patients. These include both methicillin-sensitive and methicillin-resistant Staphylococcus aureus, and multi-resistant Gramnegative aerobes and enterococci. The transmission of micro-organisms from one patient to another via the hands, or from hands that have become contaminated from the environment, can result in adverse outcomes. Primary exogenous infection is a direct clinical threat where micro-organisms are introduced into susceptible sites, such as surgical wounds, intravascular cannulation sites or catheter drainage sites. Secondary endogenous infection creates an indirect clinical threat where potential pathogens transmitted by hands establish themselves as temporary or permanent colonisers of the patient and subsequently causes infection at susceptible sites. Expert consensus groups agree that effective hand hygiene results in significant reductions in the carriage of potential pathogens on the hands and logically decreases in the incidence of preventable healthcare acquired infection leading to a reduction in patient morbidity and mortality. Website Links http://
Page Page 16 of 16 www.washyourhandsofthem.com http://www.who.int/gpsc/en/ http://www.show.scot.nhs.uk/ http://www.hps.scot.nhs.uk/haiic/ic/publicationsdetail.aspx?id=36570