REF: IPC 04 HAND HYGIENE P0LICY INITIATED BY: Infection Prevention & Control Team APPROVED BY: Infection Prevention & Control Strategic Group DATE APPROVED: 12 th March 2015 VERSION: 2.0 OPERATIONAL DATE: July 2011 DATE OF REVIEW: 3 years DISTRIBUTION: Infection Prevention and Control Operational and Strategic Meetings FREEDOM OF INFORMATION STATUS: Open
CONTENTS 1. Purpose...3 2. Policy Statement...3 3. Scope...3 4. Principles...3 4.1 Background...3 4.2 Standard...4 5. Legislative and NHS Requirements...4 6. Procedure...5 6.1 When To Decontaminate Hands...5 6.2 Methods For Hand Decontamination...6 6.2.1 General Hand Preparation...6 Hand Wash Techniques (refer to Appendix 2 for diagram)...7 6.3 Levels of Hand Hygiene...8 6.3.1 Level 1: Social Hand Hygiene...8 6.3.2 Level 2: Antiseptic Hand Hygiene...8 6.3.3 Level 3: Surgical Scrub...8 Surgical Scrub/Technique...9 6.4 Hand Drying & Care...9 6.5 Hand Decontamination For Visitors...9 6.6 Hand Decontamination For Patients...10 6.7 Facilities For Hand Hygiene...10 7. Training Implications...11 8. Review / Monitoring and Audit Arrangements...11 9. Managerial Responsibilities...11 10. Retention or Archiving...13 11. Non Conformance...13 12. Equality Impact Assessment...13 13. References...13 Appendix 1 Your 5 Moments for Hand Hygiene...15 Appendix 2 Hand Washing Technique...16 Appendix 3 Lewisham Hand Hygiene Observational Tool...17 Statement Many policies within Cwm Taf UHB are also relevant to the Independent Contractor Services. This policy can be adapted by them for use within their own areas of practice. 2
1. Purpose The aim of this policy is to provide a common and consistent evidence based approach to hand hygiene. Hand washing is the single most important intervention for reducing healthcare associated infections and must be applied as standard practice. The aim of the policy is to drive and support the highest standards of hand hygiene by all staff, in all situations in order to minimise harm. 2. Policy Statement The principles described here should apply to all situations and all settings. The UHB Hand Hygiene policy will be continually monitored and updated in line with current legislation and guidelines. 3. Scope This policy applies to all employees of Cwm Taf UHB including Community services, Primary care and Secondary care. This policy would also apply to people holding honorary contracts, bank and agency staff, locums, trainees and students. Each member of staff has a personal responsibility to ensure they comply with the policy. 4. Principles 4.1 Background Hands are rarely free of micro-organisms. Micro-organisms on hands can survive on skin for a length of time and may be transient or resident (normal flora). Transient microbes are organisms which are not normally part of the normal skin flora and are picked up by direct contact with contaminated materials/environment or infected/colonised patients during a work shift if appropriate hand hygiene practices are not observed. Resident microbes, such as the staphylococci form part of the normal flora of the skin. Posters on hand washing and disinfection are provided in all clinical areas and a poster is also displayed in staff and public toilets. Hand hygiene is recognised as the single most effective intervention to promote infection prevention and control and can help reduce the spread of healthcare associated infection (HCAI). It must always be assumed that every patient could be carrying potentially harmful micro-organisms and therefore hand hygiene must be applied as standard practice at all times. It is vital that all staff receive education and training on hand hygiene and that they encourage others delivering care to do so. 3
There are three levels of hand hygiene; Level 1 social hand hygiene Level 2 aseptic hand hygiene Level 3 surgical scrub. 4.2 Standard It is the responsibility of every member of staff working in the health care setting to ensure adequate hand hygiene is performed where appropriate. Managers have responsibility for clinical practices in their area and individuals are accountable for their own actions relating to hand hygiene. All health care workers will decontaminate hands as described in the 5 moments for Hand Hygiene developed by WHO (World Health Organisation) which defines the key moments (refer to 5.1 & Appendix 1). The term hand hygiene used in this policy refers to all processes, including hand washing and hand decontamination achieved by using other products, e.g. alcohol-based hand rub (ABHR s) 5. Legislative and NHS Requirements It is the policy of the UHB to comply with NHS, UK and EU statutory and other legislative requirements in relation to the prevention of healthcare associated infections. 4
6. Procedure 6.1 When To Decontaminate Hands The 5 moments of Hand Hygiene is described and illustrated in the diagram below: The following list gives some other examples of when hands should be decontaminated: Before entering or leaving the clinical work area Whenever hands are visibly dirty Before and after handling wounds, urethral catheters, intravenous lines or any body fluid After visiting the toilet Before preparing, handling or eating food or beverages After making beds After contact with contaminated inanimate objects Before wearing sterile gloves 5
After removing gloves Before and after administering medication After any possible microbiological contamination Before leaving isolation rooms Before and after emptying drainage bags Before caring for susceptible patients (immunocompromised) After contact with respiratory secretions (i.e. after disposing of tissues used to cover nose and mouth after sneezing or coughing) After handling contaminated laundry and waste If handling contaminated equipment/surfaces Please note the use of gloves does not replace the need for hand washing and even if gloves have been worn, hand hygiene must be performed. Hands can still become contaminated whilst wearing or on removal of gloves, and so must be cleaned appropriately. 6.2 Methods For Hand Decontamination 6.2.1 General Hand Preparation Clinical staff must adopt the principle of Bare Below the Elbow (described below) to ensure adequate hand hygiene can be performed when working in clinical areas. This will allow hands to be decontaminated easily and thoroughly. o Remove all wrist watches, wrist and hand jewellery (with the exception of a plain wedding ring) at the beginning of each clinical shift before regular hand decontamination begins. Staff should not wear rings with ridges or stones as they harbour bacteria and interfere with the wearing of gloves (rings may also provide a site for contact dermatitis). If a plain metal wedding ring is worn; these must be moved/remove when performing hand hygiene in order to reach bacteria which can harbour underneath it. o Ensure nails are kept short (false nails must not be worn). o Work clothes should not go past the elbow. Coats should be removed and long sleeves should be rolled up exposing the wrists and elbows. o The wrists should be included when washing the hands; forearms should be included if they have been contaminated. O Ensure cuts and abrasions are covered with a waterproof dressing. 6
Control of Substances Hazardous to Health (COSHH) and product data sheets should be available and referred to in order to ensure the safe use of products used for hand hygiene. 6.2.2 Hand Washing Sequence using soap & water Effective hand washing techniques involves three stages: preparation, washing, rinsing and drying. O Hands should already be bare below the elbows. O Where taps are the lever type they should be turned on and off using elbows (hands-free technique). O Wet hands under running water. O Apply liquid soap to hands. The hand wash solution must come into contact with all surfaces of the hands. O Rub hands together lathering well all surfaces (see technique below) for a minimum of 15 seconds paying particular attention to the tips of the fingers, thumbs and the areas between the fingers. O Hands should be rinsed thoroughly. O Dry hands thoroughly using disposable paper towels. O Taps should be turned off using the hands-free technique. A paper towel can be used to turn off a conventional tap to avoid recontamination. O Dispose paper towel without re-contaminating hands. Hand Wash Techniques (refer to Appendix 2 for diagram) O Palm to palm O Palm over the back of the hand O Palm to palm fingers interlace O Back of fingers to opposing palms with fingers interlocked O Rotational rubbing of the thumbs in the palm O Rotational rubbing of clasped fingers in the palm 6.2.3 Hand Disinfection with Alcohol Based Hand Rubs (ABHRs) Alcohol based hand rubs can be used as an alternative to routine hand washing, before and after patient contact, for hands that are visibly clean and dry. ABHRs are not effective in removing physical dirt or soiling. Therefore, hands, which are physically dirty or contaminated with blood/body fluids must be washed with soap and water. 7
ABHRs should only be applied to dry hands and rubbed in (utilizing sequence described above, including wrists) for 15 20 seconds until dry. ABHRs must not be used as the primary hand hygiene method when caring for patients with C. difficile or diarrhoea and vomiting (D&V). It can be used following hand washing with soap & water. 6.3 Levels of Hand Hygiene 6.3.1 Level 1: Social Hand Hygiene The aim of social (routine) hand washing is to remove dirt and organic material, dead skin and most transient organism. This can be achieved using soap and warm water; or in visibly clean hands using ABHRs. This applies to visitors as well. 6.3.2 Level 2: Antiseptic Hand Hygiene An antiseptic disinfection agent should be used to decontaminate hands for at least 15 seconds which will remove and kill transient micro-organism and used: within high risk areas (e.g. isolation, ICU) prior to undertaking an invasive/aseptic procedures before wound, urethral / iv catheter care before preparing and administering intravenous drugs when hands are contaminated with blood or bodily fluids during outbreaks of infections The use of ABHRs can be used following hand washing e.g. when performing aseptic techniques. 6.3.3 Level 3: Surgical Scrub During surgery the first line of defence is breached, allowing direct access of organisms. The aim of surgical hand washing is to remove and kill the transient organisms and greatly reduce the resident flora prior to invasive procedures. A defined technique is performed where common disinfectants such as iodine and chlorhexidine based products are used during the hand washing procedure for a minimum of 2 minutes. The advantage of using a disinfectant agent is the persistent antimicrobial activity of the residue on the skin. 8
Surgical Scrub/Technique Go Bare Below the Elbows Wet hands under running tap Keep hands higher than elbows at all times An antimicrobial hand wash e.g. povidone or chlorhexidine should be applied to the hands, wrists and forearms. Scrub all surfaces of hands, wrists and forearms for a minimum of two minutes Clean nails with a disposable surgical scrub brush for the first case of every list. Scrub brushes must only be used on nails and not on the skin, as continual use on the skin may damage it, potentially increasing the carriage of pathogens. Rinse from finger tips down to elbow Dry all areas thoroughly with sterile towel. Two towel technique: Use half a towel for a hand and half a towel for forearm working towards the elbow. One towel technique: Use a quarter towel for each hand and forearm. Attempt to avoid contact with any surface. If contact does occur, the procedure must be restarted Surgical scrub technique will be taught to theatre personnel by experienced scrub nurse within the department If a particular soap, antimicrobial handwash, alcohol product or hand cream causes skin irritation seek occupational health advice 6.4 Hand Drying & Care Adequate drying with disposable absorbent paper towel removes remaining moisture that may facilitate transmission of microorganisms. A hand cream could be applied regularly to protect effects of regular hand decontamination. Always cover cuts and abrasions with an impermeable waterproof plaster. 6.5 Hand Decontamination For Visitors Visitors should be given the opportunity and be actively encouraged to decontaminate their hands, either by washing with soap and water or ABHR: o before/upon and after entering into certain units or closed wards, o before and after visiting patients in isolation o before and after participating in any form of patient care or contact 9
6.6 Hand Decontamination For Patients All patients should be encouraged to wash their hands or use hand wipes prior to their meals and after toileting. This is particularly important during outbreaks or when patients have clinical symptoms of D&V. 6.7 Facilities For Hand Hygiene The University Health Board has a responsibility to provide optimum facilities in all clinical areas. Single use disposable cartridge sets alcohol based hand rubs should be available for use by all staff in clinical areas in a dispenser with an integral pump. Alternatively a small hand held dispenser is available from Pharmacy for use particularly within the community when hand wash facilities are unavailable or inadequate. Single use disposable cartridge sets liquid soap should be available in wall mounted dispensers at all hand washing sinks. Dispenser nozzles should be visibly clean. Bars of soap are a potential source of cross infection and must not be used for hand washing in clinical areas. Elbow operated or automated taps should be available in hand wash sinks in clinical areas. Hand wash sinks are dedicated for that purpose only. Hand wash sinks should not have an overflow or plugs. Good quality disposable absorbent paper towels are wall mounted near sinks with non-touch dispensers. Hand moisturisers (where provided) must be single use disposable cartridge sets which are in wall mounted dispensers. Pedal operated domestic waste bins with lid should be close at hand. The national Patient Safety Alert (NPSA), 2 nd September 2008 Clean Hands Saves Lives provides advice and risk management for the location of ABHRs. The position of ABHR s must be risk assessed using the risk assessment form to prevent any patients from ingesting solution and in relation to flammability. 10
7. Training Implications Hand hygiene training is included in Level 2 mandatory training by Infection Prevention and Control Team (IPCT). Training records will be held with the Training and Development Department, Divisions and the IPCT. Training will be required for clinical staff in completing the hand hygiene audit tool (Appendix 3). This will be undertaken in mandatory training sessions and at ward / departmental level. 8. Review / Monitoring and Audit Arrangements Approval will take place at the Infection Prevention & Control Strategic Group Meetings for ratification and will be forwarded to the Quality and Safety Committee for endorsement. 9. Managerial Responsibilities There are detailed responsibilities in the main Infection Prevention & control Management policy (IPC 01). Managers/Heads of Nursing/Clinical Directors should: o Ensure that all staff receive adequate education on the principles of hand hygiene and standard infection control precautions (SICPs). o Promote the principle of bare below the elbow o Ensure participation in surveillance and audit programmes and provide active support for hand hygiene compliance results. o Ensure that staff are supported if interventions are required when an incident occurs that may have resulted in the transmission of infection. o Ensure that there is convenient access to hand care products and hand washing sinks. o Feedback the results of audits to the Divisional leads/ipcc. o Ensure food handlers receive appropriate training. o Ensure that all staff that have skin problems or develop any skin irritation due to occupational hand hygiene is appropriately referred to the Occupational Health. 11
Employee s should: o Attend mandatory infection prevention and control training. o Ensure that adequate hand hygiene is performed. o Apply the principles of SICPs. o Explain any infection control requirements to patients/ staff/clients/residents or carers. o Ensure up to date posters are displayed in relevant, prominent areas featuring how and when to perform hand hygiene. o Report to line managers any factors that contribute to noncompliance of hand hygiene. This may include facilities/equipment or incidents that have resulted in cross contamination. o Carry out weekly hand hygiene audits which capture 10 opportunities within a 20 minute time span using the Lewisham Hand Hygiene observational tool (Appendix 3) o Report poor levels of compliance relating to hand hygiene audits to the line manager. o Display hand hygiene compliance rates clearly and appropriately in the clinical setting. o Report any occupational exposure that has resulted in illness to both the line manager and the Occupational Health Department o Be bare below the elbow whilst providing direct patient care/ working in clinical areas Housekeeping should: o Ensure liquid soap is adequately replenished and paper towels are available and are easily dispensed. o Comply with all the other relevant principles described within this policy The IP&C Team should: o Ensure training is available for all groups of staff o Act as a contact for guidance and support when advice relating to hand hygiene is required. o Investigate incidents of non-compliance relating to hand hygiene. o Undertake regular independent hand hygiene audits within the acute and community hospital settings and feedback audit results to managers within a timely manner. o Compliance with the principle of bare below the elbow will form part of the IPC hand hygiene audit and will be included in the audit feedback. o Provide support on the wards/ departments to monitor standards, identifying areas of concern and risk, and escalating concerns so that appropriate management 12
action can be taken to maintain the highest standards via the directorate IP&C Groups, IPCOG or Strategic Group as necessary 10. Retention or Archiving The Responsible Lead Infection Prevention and Control Nurse must ensure that copies of policies and procedures are archived and stored in line with the UHB Records Management Policy and are made available for reference purposes should the situation arise supported by IP&C Co-ordinator. 11. Non Conformance All employees will follow the policy, any difficulties in undertaking the measures advised in this document must be highlighted immediately to the appropriate senior manager. Non conformance with this policy has serious implications for patient safety and management. Compliance with infection prevention & control guidance, protocols and polices is taken seriously by the organisation. 12. Equality Impact Assessment This policy or procedure has been subject to a full equality assessment and no impact has been identified. 13. References Infection Control Nurses Association. Hand Decontamination Guidelines. ICNA and Deb Ltd; 2002. Kampf G. & Loffleer H. (2003) Dermatological aspects of a successful introduction and continuation of alcohol based hand rubs for hygienic hand disinfection. Journal of Hospital Infection 55, 1-7. Pittet D. & Hugonnet S. et al (2000) Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. The Lancet Vol. 356. Pratt R, et al. Standard Principles for preventing hospitalacquired infections. Journal of Hospital Infections. 2001. 47 (SUPPLEMENT): 23-28. 13
NPSA Patient Safety Alert 04 (issued September 04) Clean hands help to save lives. NPSA (2008), Clean Hands Saves Lives 2 nd ed, Patient Safety Alert Welsh Healthcare Associated Infection Programme (WHAIP) (2009) Infection Prevention Model of Policy/ Procedure 2 & Procedure. World Health Organization (WHO), Clean Care is Safer Care, Five Moments for Hand Hygiene. http://www.who.int/gpsc/tools/five_moments/en/ 14
Appendix 1 Your 5 Moments for Hand Hygiene -15-
Appendix 2 Hand Washing Technique Hand washing/hand hygiene 1 2 3 Palm to palm. Right palm over left dorsum and left palm over right dorsum. 4 5 6 Palm to palm fingers interlaced. 5.3 Backs of fingers to opposing palms with fingers interlocked. Rotational rubbing of right thumb clasped in left palm and vice versa. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa. -16-
Appendix 3 Lewisham Hand Hygiene Observational Tool Instructions on Use All of the above should be followed by hand washing or use of alcohol rub. The observational tool compares hand hygiene opportunities (O) with actual observed hand hygiene (H). Compliance can then be expressed as a percentage. Compliance can be defined as either washing hands with soap and water or rubbing with an alcohol rub in accordance with a hand hygiene opportunity, so Compliance = observed hand hygiene (H) x 100 = compliance % Hand hygiene opportunity (O) Instructions 1. The staff member undertaking observation should undertake a number of practice observations to get familiar with the tools and to minimise the Hawthorne Effect. This also reduces staff on the wards awareness of the presence of the observer. 2. Observations can take place by just one person or with a partner. 3. Identify an area with the ward/department where you can comfortably observe staff. Stay in this place for 20 minutes and observe your window of activity. Do not move from this place during the 20 minutes. If staff walk away without you seeing whether they perform hand hygiene, do not follow them. Do not mark anything down unless you see it. 4. Position yourself so that you do not cause an obstruction but can still see what is happening. It may feel strange and you may think that you are too noticeable. This is normal and the best thing is to just carry on. 5. Observe for 20 minutes period. 6. Using the observation sheet mark a O for a hand hygiene opportunity and an H for an actual hand hygiene activity taking place. If hand hygiene does not take place leave it blank. 7. The observation sheet offers you the chance to identify opportunities as low, medium or high. Don t worry if you can t identify if the period is high, medium or low risk, use the first of the available tools which does not require you to specify. -17-
8. When you have completed 20 minutes observation, give feedback to the staff a feedback form is included in this pack. When you give verbal feedback try to stress positive findings first and if you give negative feedback give examples and suggestions for improvement. 9. Keep hold of the completed observations and hand to the ward manager. 10. While you are observing you may identify issues which are barriers to hand hygiene, e.g. no soap, obstructed sinks, no alcohol by the bed, alcohol not working, alcohol empty -include this is in your feedback. 11. If you find activities which are not identified on the chart, add them and let the infection, control team know. 12. Observe and report if staff are compliant with the principle of bare below the elbow The chart below can be used. It is a basic version. University Hospitals of Lewisham observation Date: Time: Location: 20 minute period Nurses/Stn Doctors HCA s Other OOO HH OOO H OOOOOO HHH OO H Compliance = observed hand hygiene (H s) = 7 x 100 = 50% Hand hygiene opportunities (O s) 14-18-