Document Details Title Trust Ref No 1517-40655 Local Ref (optional) Main points the document covers Who is the document aimed at? Author Approval process Who has been consulted in the development of this policy? Approved by (Committee/Director) Approval Date 27 Initial Equality Impact Screening Full Equality Impact Assessment Lead Director Category Sub Category This policy details guidance and technique used to undertake effective hand hygiene All staff who undertake direct and indirect patient care within Shropshire Community Health Trust Head of Infection Prevention and Control This policy has been developed by the IPC team in consultation with appropriate clinical services managers, link staff, advisors/specialists (e.g., Medical Advisor, Specialist Nurses, Medicine Management, Bridgnorth Day Surgery Unit Manager), PHE and IPC Governance Meeting members. Infection Prevention and Control Governance Meeting notified to Quality and Safety Operational Group Yes N/A Executive Director of Nursing and Operations, DIPC Clinical Infection Prevention and Control Review date 27 February 2021 Distribution Who the policy will be distributed to Method Document Links Required by CQC Other Key Words Amendments History IPC Governance Meeting Members Electronically to IPC Governance Meeting Members and available to all staff via the Trust website Yes No Date Amendment Hand hygiene; hand washing, 1 Review of revised guidance, insertion of World Health Organisation 5 moments image-appendix 1. Appendix 2 updated hand hygiene technique image. 2 February 2015 General update and review following publication of revised guidance
Contents 1 Introduction... 1 2 Purpose... 1 3 Definitions... 1 4 Duties... 1 4.1 The Chief Executive... 1 4.2 Director of Infection Prevention and Control... 1 4.3 Infection Prevention and Control Team... 2 4.4 Managers and Service Leads... 2 4.5 Staff... 2 4.6 Estates Department... 2 4.7 Domestic Team... 2 4.8 Committees and Groups... 2 4.8.1 Board... 2 4.8.2 Quality and Safety Committee... 3 4.8.3 Infection Prevention and Control Governance Meeting... 3 5 Micro-organisms Found on the Skin... 3 5.1 Resident Flora... 3 5.2 Transient Flora... 3 6 Hand Preparation Prior to Decontamination... 3 6.1 Hand Care... 3 6.2 Hand Washing Assessments... 4 6.3 Hand Hygiene Observations... 4 7 Facilities Required for Effective Hand Hygiene within Clinical Facilities... 5 7.1 Positioning of Alcohol Hand Gel... 5 8 When to Perform Hand Hygiene... 5 8.1 Which Hand Hygiene Product to use... 6 8.2 Respiratory Hygiene/ Cough Etiquette... 7 8.3 Patient, Visitor and Volunteer Hand Hygiene... 7 8.4 Community Based/Domiciliary Healthcare Workers... 7 9 Hand Washing Technique... 7 9.1 Alcohol Based Hand Rub Technique... 7 9.2 Surgical Hand Scrub... 8 10 Consultation... 8 10.1 Approval Process... 8 11 Dissemination and Implementation... 8 11.1 Advice... 8 11.2 Training... 8 12 Monitoring Compliance... 9 Datix Ref: 1517-40655
13 References... 9 14 Associated Documents... 10 15 Appendices... 10 Appendix 1 World Health Organisation 5 moments for hand hygiene... 11 Appendix 2 Effective Hand Wash Technique... 12 Datix Ref: 1517-40655
1 Introduction Healthcare related infections are costly in both human and financial terms. Body secretions and skin can carry bacteria, viruses and fungi that are potentially infectious. Effective hand hygiene is the single most important procedure for significantly reducing and preventing the spread of infection. It is an essential practice for patient safety and it is paramount that it is carried out due to rise of multi-drug-resistant organisms. 2 Purpose The policy is intended to provide guidance and techniques on effective hand hygiene to minimise the risk of cross infection to patients, staff, and all other service users. 3 Definitions Term / Abbreviation CHWB DH DIPC HBN HCAI HHOT IPC MRSA NICE NPSA PIR RCA SCHT SIP WHO Explanation / Definition Clinical Hand Wash Basin Department of Health Director of Infection Prevention and Control Health Building Note Healthcare Associated Infection Hand Hygiene Assessment Tool Infection Prevention and Control Meticillin Resistant Staphylococcus aureus National Institute for Health and Clinical Excellence National Patient Safety Agency Post Infection Review Root Cause Analysis Shropshire Community Health NHS Trust Service Improvement Plan World Health Organisation 4 Duties 4.1 4.2 The Chief Executive The Chief Executive has overall responsibility for ensuring infection prevention and control is a core part of Trust governance and patient safety programmes. Director of Infection Prevention and Control The Director of Infection Prevention and Control (DIPC) is responsible for overseeing the implementation and impact of this policy, make recommendations for change and challenge inappropriate infection prevention and control practice. Page 1 of 12
4.3 4.4 4.5 4.6 4.7 4.8 Infection Prevention and Control Team The Infection Prevention and Control (IPC) team is responsible for providing specialist advice in accordance with this policy, for supporting staff in its implementation, and assisting with risk assessment where complex decisions are required. The IPC team will ensure this policy remains consistent with the evidence-base for safe practice, and review in line with the review date or prior to this in light of new developments. Managers and Service Leads Managers and Service Leads have the responsibility to ensure that their staff including bank and locum staff etc. are aware of this policy, adhere to it at all times and have access to the appropriate resources in order to carry out the necessary procedures. Managers and Service Leads will ensure compliance with this policy is monitored locally and ensure their staff fulfil their IPC mandatory training requirements in accordance with the Trust Training Needs Analysis. Managers need to ensure assessment data is recorded on InPhase for monitoring purposes. For recording figures on InPhase, you will need to record the following: Total number of Clinical Staff Total number who have completed and who are in date for the previous 12 months. (This is a rolling 12 month total). For example, if someone last completed in November 2016 then they would expire in November 2017 so you should not count them in the Total number who have completed hand washing assessments November 2017 figures, unless they have renewed their competence. The data then gets presented to the Quality and Safety Committee for review and discussion. Staff All staff have a personal and corporate responsibility for ensuring their practice and that of staff they manage or supervise comply with this policy. Estates Department The risk of infection can be minimised through the application of evidence based design and the provision of facilities which support good infection control practice. Minimising the risk of infection should be considered at all stages of refurbishment, redevelopment and new build projects. The project lead should ensure that the IPC Team are involved at all stages of the process. The Estates Department must ensure that hand washing basins are of the correct specification for the service provided and conform to current guidance. Domestic Team To reduce the risk of infection including pseudomonas contamination of hand wash basins and taps domestic staff must ensure that hand washing facilities are cleaned in accordance with the Trust Cleaning and Disinfection Policy. Committees and Groups 4.8.1 Board The Board has collective responsibility for ensuring assurance that appropriate and effective policies are in place to minimise the risks of healthcare associated infections. Page 2 of 12
4.8.2 Quality and Safety Committee Is responsible for: Shropshire Community Health NHS Trust Reviewing individual serious incidents/near misses and trends/patterns of all incidents, claims and complaints and share outcomes and lessons learnt Agreeing and escalating key risks/items of concern to the appropriate Directors and/or the Trust Board 4.8.3 Infection Prevention and Control Governance Meeting Is responsible for: Advising and supporting the IPC team Reviewing and monitoring individual serious incidents, claims, complaints, reports, trends and audit programmes Sharing learning and lessons learnt from infection incidents and audit findings Agreeing and escalating key risks/items of concern to the appropriate Directors and/or the Quality and Safety Committee Approval of IPC related policies and guidelines 5 Micro-organisms Found on the Skin 5.1 5.2 Resident Flora Normal flora forms part of the body s normal defence mechanisms and protects the skin from invasion by more harmful micro-organisms. They rarely cause disease and are of minor significance in routine clinical situations. Transient Flora Flora acquired by touch e.g. from the environment, touching patients, laundry, equipment etc. They are located superficially on the skin, readily transmitted to the next item touched, and are responsible for the majority of healthcare-associated infections. They are easily removed by hand decontamination. 6 Hand Preparation Prior to Decontamination 6.1 Hand Care In order to achieve effective hand hygiene, it is important to look after the skin and fingernails. Damaged or dry skin leads to loss of a smooth skin surface, and increases the risk of skin colonisation with resistant organisms such as Meticillin resistant Staphylococcus aureus (MRSA). Continuing damage to the skin may result in cracking and weeping, exposing the healthcare worker to increased infection risk, which can lead to sickness absence. The efficiency of hand decontamination is improved if the following principles are adhered to: Staff with acute or chronic skin lesions/conditions/reactions should seek advice from the Occupational Health Department on 01743 283280 Cover cuts and abrasions with water-impermeable dressing prior to clinical contact Skin damage and dryness often results from frequent use of harsh soap products, application of soap to dry hands, or inadequate rinsing of soap from the hands. It is therefore essential that only approved liquid soap products are used and that staff always wet hands before applying liquid soap, and rinse and dry hands thoroughly Moisturising cream should also be available to maintain skin integrity. Where possible, it should be supplied in wall-mounted dispensers located in suitable Page 3 of 12
positions such as staff rooms/changing rooms and at the nurse s station. Individual, small sized moisturising cream is also available for community based staff Communal pots/tubes of hand cream must not be used due to the potential for contamination of the hand cream and incompatibility with the soap The wearing of gloves is not a substitute for hand decontamination. Bacterial counts on hands multiply whilst gloves are worn. Gloves may be punctured during use or have integral punctures prior to use. Hands must be decontaminated prior to donning gloves and again following removal Lower forearm splints, plaster casts, supports and wound dressings can harbour harmful micro-organisms and will prevent staff performing a thorough hand wash procedure and therefore may present an infection risk. Staff and volunteers who need to wear wrist or lower forearm splints (which cannot be removed for clinical duties), and/or plaster casts or dressings, should be excluded from clinical duties. To allow effective hand hygiene to be performed all staff must adopt the bare below the elbow approach before any patient contact, this includes: Removal of jackets/cardigans/jumpers/coats Long sleeves must be rolled up to above the elbow No wrist watches, wrist jewellery, fitness trackers or charity bangles No rings (other than one smooth, plain band) No nail varnish, nail art or nail piercings No long finger nails, false nails or nail tips 6.2 6.3 Hand Washing Assessments Hand washing assessments must be undertaken by clinical staff on an annual basis. This is a peer assessed observation to assess the bare below the elbow approach and use of an effective technique. The assessment criteria are as follows: Hand washing assessments are to be undertaken by trained competent assessors Hand hygiene is included in local induction All new members of staff should be assessed within a week of commencing work in the ward/department/service (this includes students who are on placement IPC team to be notified) Existing staff to be assessed annually Healthy Hands educational leaflet to be given out at time of assessment Failed assessments must be reported to the ward manager/team leader and repeated within the week Ward manager/team leader must report second failed assessments to IPC team Hard copy of assessments to be kept locally by service manager NB: Hand washing assessment tool available to print off the Trust IPC webpage. http://www.shropscommunityhealth.nhs.uk/rte.asp?id=11072 Assessment compliance is to be recorded on InPhase. Hand Hygiene Observations The ward based IPC link nurses undertake monthly hand hygiene observational audits in all four community hospitals using a Hand Hygiene Assessment Tool (HHOT). The observations assess for the performance of hand hygiene at every appropriate opportunity. Page 4 of 12
The HHOT observations assess staff within different groups in order to enable feedback to the specific group on their compliance. If the compliance rate achieved is below 95% the observations audits should be repeated weekly until a 95% or above compliance is achieved; they can then revert back to monthly assessments. NB: Hand hygiene observational tool available to print off the Trust IPC webpage http://www.shropscommunityhealth.nhs.uk/rte.asp?id=11072 7 Facilities Required for Effective Hand Hygiene within Clinical Facilities Adequate facilities must be provided to enable staff to wash and dry their hands regularly and appropriately, to use alcohol hand gel, and to protect their skin with moisturiser. Each clinical area must have the following equipment to ensure adequate hand washing: All clinical hand washbasins purchased and installed should meet requirements set out in Health Building Note (HBN) 00-10 guidance and used for hand washing only Wall mounted liquid soap dispenser, with an adequate supply of liquid soap Wall mounted disposable paper hand towel dispenser Foot operated waste bin located next to the hand wash basin Hand hygiene posters indicating correct hand washing technique. These are available to print from the IPC page of the Trust website http://www.shropscommunityhealth.nhs.uk/rte.asp?id=11072 Each clinical area must have easily accessible alcohol hand rubs/gels (with emollients) Each clinical area must have an easily accessible wall mounted dispenser with hand moisturiser e.g. in staff cloakroom, at nurses station Clinical hand wash basins (CHWB) should be used for hand washing only. Waste water/fluids must NOT be disposed of in CHWB as this practice poses a potential for pathogen contamination of taps and water systems For cleaning of CHWB refer to the SCHT Cleaning and Disinfection Policy 7.1 Positioning of Alcohol Hand Gel Hand gel must be positioned at the point of care including: At every ward/unit entrance and exit - in a wall mounted dispenser At the entrance to every bay - in a wall mounted dispenser At every patient s bedside (in a mounted holder on the bed or locker; please ensure a risk assessment is carried out and documented for the reason of removal) On notes and medicine trolleys Positioned by or attached to examination trolley or couch 8 When to Perform Hand Hygiene Patients are put at risk of developing a Healthcare associated infection (HCAI) when healthcare workers caring for them have contaminated hands. Decontamination refers to a process for the physical removal of dirt, blood and body fluids, and the removal or destruction of microorganisms from the hands. The World Health Organisation (WHO) developed the 'Five Moments' for hand hygiene, defining the key points for healthcare workers to clean their hands. The evidence considered by the National Institute for Health and Clinical Excellence (NICE 2012) indicated that there was an increase in the compliance of hand hygiene before and after patient contact associated with the implementation of the WHO five moments but there had not been an increase in compliance after contact with patient surroundings. Therefore the following recommendations are derived from the WHO Page 5 of 12
framework and the NICE guidelines, which include additional points of emphasis (see Appendix 1) Hands must be decontaminated: Immediately before each episode of direct patient contact or care, including clean/aseptic procedures Immediately after each episode of direct patient contact or care Immediately after contact with body fluids, mucous membranes and non-intact skin Immediately after other activities or contact with objects and equipment in the immediate patient environment that may result in the hands becoming contaminated Immediately following the removal of gloves 8.1 Which Hand Hygiene Product to use Choosing the appropriate method of hand decontamination will depend on the assessment of what is appropriate for that episode of care, patient intervention and accessibility of facilities. Below are some examples of which product to use. If you have worn gloves or your hands are visibly soiled or contaminated with body fluids: Use soap and water followed by drying with disposable paper towels. Before and after patient contact and when your hands are visibly clean: Use alcohol hand gel. If you are about to perform an aseptic technique: Use soap and water followed by drying with a disposable paper towel. OR Use alcohol hand gel if your hands are visibly clean. If you have performed any care for a patient who has vomiting or has diarrhoeal illness, including Clostridium difficile or Norovirus: Wash hands with soap and water. Alcohol is not effective against spore-bearing organisms or in the presence of diarrhoea. Hands must be decontaminated: Before commencing work/after leaving a work area Before preparing or eating food Before handling medicines After contact with any patient or contact with patients surroundings. Before contact with all patients, particularly with susceptible sites e.g. wounds, burns, intravenous lines, catheters Before performing aseptic procedures e.g. venepuncture, catheterisation Before wearing and after removing gloves (gloves are not a substitute for effective handwashing they can develop holes whilst in use and hands can become contaminated on removal of gloves) After handling contaminated laundry and waste After using the toilet, assisting others with toileting or personal hygiene, before and after emptying catheter bags/urinals, changing nappies and incontinence pads After contact with patients in isolation or during outbreaks Page 6 of 12
8.2 8.3 8.4 Respiratory Hygiene/ Cough Etiquette Hand hygiene is an important part of respiratory hygiene and cough etiquette. The following measures will assist good practice: When coughing, sneezing, wiping or blowing the nose, cover the nose and mouth with disposable single use tissues Dispose of used tissues immediately into the appropriate waste stream Wash hands after coughing, sneezing wiping or blowing the nose, or after contact with respiratory secretions Patients, particularly the immobile, confused, older person may need assistance with the disposal of used tissues and hand hygiene Patient, Visitor and Volunteer Hand Hygiene Patients, relatives and volunteers should be provided with information about the need for hand hygiene and how to keep their own hands clean. Patients should be offered the opportunity to clean their hands before meals/eating; before taking medication, after using the toilet, commode or bedpan/urinal and at other times as appropriate. Products available should be tailored to patients needs and may include alcohol-based hand rub, hand wipes and access to hand wash basins. Link for all leaflets are found below. http://www.shropscommunityhealth.nhs.uk/rte.asp?id=11072 Community Based/Domiciliary Healthcare Workers Healthcare workers visiting patients/service users in their own home should be supplied with their own hand hygiene products. These must include: Liquid soap and paper towels or moist skin cleansing wipes Alcohol hand rub Moisturiser Small size containers of products are available. An assessment must be made with regard to selection of an appropriate product and accessible facilities. 9 Hand Washing Technique Effective handwashing technique involves three stages: preparation, washing/rinsing and drying. Preparation: wet hands under running water before applying the liquid soap Washing: The hand wash product must come in contact with all surfaces of the hand. The hands should be rubbed together vigorously for 10-15 seconds, paying particular attention to the tips of the fingers, thumbs, and the areas between the fingers. Hands should then be rinsed thoroughly (see appendix 2) Drying: Effective drying of hands after washing is important because wet surfaces transfer micro-organisms more effectively than dry ones and inadequately dried hands are prone to skin damage. Use good quality paper towels to dry the hands thoroughly. (See Appendix 2) 9.1 Alcohol Based Hand Rub Technique When decontaminating hands using an alcohol based hand rub, hands should be free of dirt and organic material: Alcohol hand rub must come in contact with all surfaces of both hands Page 7 of 12
Hands should be rubbed together vigorously, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers, until the solution has evaporated and the hands are dry. (see Appendix 2) 9.2 Surgical Hand Scrub For information regarding surgical hand scrub technique refer to the Trust Standard Precautions including Surgical Hand Scrub, Gowning and Gloving Policy http://www.shropscommunityhealth.nhs.uk/policies 10 Consultation This policy has been developed by the IPC team in consultation with Infection Prevention and Control Governance Meeting members and Bridgnorth Day Surgery Unit Manager. A total of three weeks consultation period was allowed and comments incorporated as appropriate. 10.1 Approval Process The IPC Governance Meeting members will approve this policy and its approval will be notified to the Quality and Safety Committee. 11 Dissemination and Implementation This policy will be disseminated by the following methods: Managers informed via Datix who then confirm they have disseminated to staff as appropriate Staff - via Team Brief and Inform Awareness raising by the IPC team Published to the Staff Zone of the Trust website The web version of this policy is the only version that is maintained. Any printed copies should therefore be viewed as 'uncontrolled' and as such, may not necessarily contain the latest updates and amendments. When superseded by another version, it will be archived for evidence in the electronic document library. 11.1 11.2 Advice Individual Services IPC Link staff act as a resource, role model and are a link between the IPC team and their own clinical area and should be contacted in the first instance if appropriate. Further advice is readily available from the IPC team on 01743 277671 or the Consultant Microbiologist on 01743 261000 ask for on call Microbiologist. Training Managers and service leads must ensure that all staff are familiar with this policy through IPC induction and update undertaken in their area of practice. In accordance with the Trust s mandatory training policy and procedure the IPC team will support/deliver training associated with this policy. IPC training detailed in the core mandatory training programme includes standard precautions and details regarding key IPC policies. Other staff may require additional role specific essential IPC training, as identified between staff, their managers and / or the IPC team as appropriate. The systems for planning, advertising and ensuring staff undertake training are detailed in the Mandatory Training Policy and procedure. Staff who fail to undertake training will be followed up according to the policy. Page 8 of 12
Further training needs may be identified through other management routes, including Root Cause Analysis (RCA) and Post Infection review (PIR), following an incident/infection outbreak or following audit findings. Additional ad hoc targeted training sessions may be provided by the IPC team. 12 Monitoring Compliance Compliance with this policy will be monitored locally by managers and by the IPC team as part of the standing audit programme using adapted Department of Health and Infection Prevention Society audit tools. Monthly observational hand hygiene audits should be completed within the ward environments of the community hospitals. If the compliance rate is below 95% audits should be completed weekly until 95% compliance is achieved and frequency can revert back to monthly. The IPC team will undertake validation hand hygiene observations. Bespoke hand hygiene sessions can be arranged with the infection prevention and control team as necessary. As appropriate the IPC team will support Services Leads to undertake IPC RCA and PIRs. Managers and Services Leads will monitor subsequent service improvement plans (SIPs) and report to the IPC meeting. Knowledge gained from RCA, PIR and IPC audits will be shared with relevant staff groups using a variety of methods such as reports, posters, group sessions and individual feedback. The IPC team will monitor IPC related incidents reported on the Trust incident reporting system and liaising with the Risk Manager advice on appropriate remedial actions to be taken. 13 References Department of Health (2010) Uniforms and workwear: Guidance on uniform and workwear policies for NHS employees. 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 Fraise, A. P, & Bradley C (2009) Ayliffe s Control of Healthcare-Associated Infection (fifth edition). Arnold, London Health Building Note 00-10: Performance requirements of building elements used in healthcare facilities. DH, 2011 Infection Prevention Society (April 2017) High impact interventions care processes to prevent infection, 4 th Edition of saving lives Loveday, H.P., Wilson, J.A., Pratt, R.J., Golsorkhi, M.,Tingle, A., Bak, A., Browne, A., Prieto, J., Wilcox, M. (2014) epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection 86 (Supplement 1) (2014) S1 S70 National Institute for Clinical Excellence (2012), Infection control: Prevention of healthcare associated infection in primary and community care. London, National Clinical Guideline Centre Health Building Note 00-09 Infection control in the built environment. The Stationery Office 2013 World Health Organisation (2009) WHO Guidelines on Hand Hygiene in Healthcare: First Global Patient Safety Challenge Clean Care is Safer Care. WHO Press, Switzerland Page 9 of 12
14 Associated Documents This policy should be read in conjunction with SCHT: Cleaning and Disinfection Policy Isolation Policy Mandatory (Risk Management) Training Policy and Procedure Standard Precautions including Surgical Hand Scrub, Gowning and Gloving Policy Uniform Policy and Dress Code 15 Appendices Page 10 of 12
Appendix 1 World Health Organisation 5 moments for hand hygiene Page 11 of 12
Appendix 2 Effective Hand Wash Technique Page 12 of 12