Infection Prevention & Control HAND HYGIENE POLICY Policy No IC06 This Policy/Guideline can only be considered valid when viewed via the NBT intranet Document Management System (DMS). If this policy is printed into hard copy or saved to another location, you must check that the version number on your copy matches that on the one online. Specific staff groups to whom this policy/guideline directly applies All staff who undertake, clinical practice, enter clinical areas and handle specimens Other staff who may need to be familiar with the policy/guideline All staff who manage, teach or supervise staff in clinical areas / handle specimens Version Number 4 Original Version Developed and Approved by Original Date of Issue April 2002 Current Version Reviewed by Date of Equality Impact Screening Assessment Date of EIA (if necessary) Infection Prevention & Control Team Control of Infection Committee Clinical Governance Committee and Trust board Jane Searle, Elizabeth Darley, Fiona Wilkes & Enfys Mercieca 10 th March 2011 Ratified by and Date Control of Infection Committee 23 March 2011 Review Date This policy will be reviewed within a maximum of 3 years of its introduction or sooner if circumstances change or required by local or national policy. Hand Hygiene Policy IC06 Page 1
Contents 1. Executive Summary 3 2. Flowchart guide for using this policy 3 3. Policy statement 4 4. Purpose of the document 4 5. Scope of policy & responsibilities 4 6. Other relevant policies and guidelines 4 7. Staff roles and responsibilities 4 8. Policy details 6 8.1 Definition of Terms 6 8.2 Specific Staff duties 7 8.3 When to decontaminate hands at the point of care using the 5 moments for hand hygiene 8 8.4 Diagram Your 5 moments for Hand Hygiene 9/10 8.5 Social Hand Hygiene (Routine) 11 8.6 Hygienic Handwash (Aseptic) 12 8.7 The procedure for performing hand hygiene (hand washing) 13 8.8 Facilities required to perform hand hygiene 14 8.9 Hand drying 15 8.10 Surgical hand antisepsis (Surgical Scrub) 16 8.11 Procedure Surgical Hand Antisepsis Technique (Surgical Scrub) 17 8.12 Alcohol based hand rub 17 8.13 Nail Care 19 8.14 Hand Hygiene and Jewellery 19 8.15 Naked from the Elbow 19 8.16 Hand Care 20 8.17 Patients Hand Hygiene 20 9. Methods of Monitoring & Auditing 21 10. Reference and Bibliography 23 Appendix 1 5 Moments for Hand Hygiene 24 Appendix 2 Hand Washing Technique Soap & Water 25 Alcohol Gel Appendix 3 Hand Hygiene Competency Framework 27 EIA 30 Hand Hygiene Policy IC06 Page 2
1. Executive Summary Overall Statement about what the policy is designed to do: Key features: Hand hygiene is considered to be the single most important practice in reducing the transmission of infectious agents including Healthcare Associated Infections (HAI), during delivery of care. All staff have a responsibility to ensure that all students, volunteers, temporary staff, visiting contractors are aware and comply with the Trust s hand hygiene standards. All staff must attend mandatory or update infection prevention & control education sessions. Consider the elements of Standard Infection Prevention & Control Practices such as hand hygiene as an objective within staff s continuing professional development and appraisal. The patient and their immediate environment is defined as the patient zone and staff must deliver good hand hygiene at the point of care the crucial moment for hand hygiene. o Before every episode of patient care or contact o Before a clean / aseptic procedure o After body fluid exposure risk o After patient contact o After contact with patient surroundings The type of hand hygiene procedure is determined by a risk assessment of the following four key factors: o The level of the anticipated contact with patients or any equipment/surfaces o The extent of contamination that may occur with that contact o Care activities being performed o The susceptibility of the patient All patients must be provided with facilities for hand washing prior to eating and after using toilet facilities. Doctors, nurses, clinical and non clinical staff must be naked to the elbow while on the wards or in other clinical areas, to enable thorough hand hygiene, long sleeves if worn rolled up, allowing for wrists and forearms to be exposed No wrist watches, no other wrist jewellery / bands, no rings, other than a plain metal band, to be worn when performing hand decontamination. All training is recorded on the trust s managed learning environment (MLE) training records non-attendance is communicated from the learning and research directorate to line managers. Hand Hygiene compliance will be audited weekly, results collated by the Audit department and fed back to the Directorate to develop an action plan to address any area of noncompliance. 2. Flowchart guide for using this policy Hand Hygiene Policy Do you have direct contact with patients or will you be visiting clinical areas? Or manage staff that has direct contact Yes No Need to read the full policy and apply in Need to be aware the policy exists, and required to read practice section 7 as a minimum Hand Hygiene Policy IC06 Page 3
3 Policy Statement Hand hygiene is considered to be the single most important practice in reducing the transmission of infectious agents including Healthcare Associated Infections (HAI), during delivery of care. Hands are a common way by which microorganisms, particularly bacteria, can be transported and subsequently cause infection, especially to those who are most susceptible to infection. In order to prevent the spread of microorganisms to those who might develop serious infections by this route while receiving care, hand hygiene must be performed effectively. The term hand hygiene used in this document refers to all of the processes, including hand washing and hand decontamination achieved using other solutions. 4 Purpose of the Policy This policy defines the standard for hand hygiene practice and the systems for ensuring that there is a minimum of 95% compliance with requirements. 5 Scope of policy & responsibilities This policy applies to all employees of the Trust and all students, volunteers, temporary staff and visiting contractors. All staff providing direct care in a health or social care setting including a patient s/client s own home and or entering the patient s /clients care environment. 6 Other relevant policies and guidelines Links with other Trust policies 1. IC 01 Overarching Infection Control Policy 2. IC 04 Disease specific precautions A-Z 3. IC 05 Standard Infection Control Precautions 4. IC 07 Isolation 5. IC 12 Standard of Dress Policy 6. IC 13 Clostridium difficile Policy 7. IC 16 Management of Ward Department Outbreaks of Diarrhoea and Vomiting 8. IC 20 MRSA Policy 9. IC 26 Prevention of Infection in Operating Theatres 10. HS 06 Policy for the prevention and management of natural rubber Latex allery 11. HS 14 Policy for the prevention and control of Legionella (including water hygiene) 12. HS 29 Policy for Waste Management and the Safe Handling of Waste 13. Induction Policy 14. Mandatory Training Policy This list is not exhaustive and may alter with policy requirements. 7 Staff roles and Responsibilities 7.1 Director of Infection Prevention and Control (DIPC) Has corporate responsibility for infection, prevention and control throughout the Trust as delegated by the Chief Executive, and to report directly to the Chief Executive and assure the Trust Board on the organisations performance in relation to hand hygiene and HCAIs providing regular reports The DIPC is responsible for the development of strategies on infection, prevention and control and oversees implementation. They will act on legislation and national guidance and ensure that effective policies are in place and audited. Oversee local infection control policies and their implementation and assess the impact of all plans/policies on infection prevention control and make recommendations for change Is influential in the development and provision of education and training in relation to infection, prevention and control and oversees the audit of its uptake by staff. Hand Hygiene Policy IC06 Page 4
Challenges inappropriate hygiene practice Contributies to patient safety as a member of the Quality Committee. 7.2 Infection Prevention & Control Lead Nurse / Deputy DIPC Is responsible for the strategic and operational management of the IPCT and the operational management of infection prevention and control across the Trust in ensuring awareness to this key issue. Ensure national evidence based guidance is adopted in order to ensure that patients are treated according to best practice. These are developed from gap analysis undertaken to ensure compliance with the Healthcare standards and incorporate a forward looking programme of audit activity relating to Infection Prevention & Control Policies, supported by Audit department To ensure staff are trained in appropriate infection control measures including hand hygiene and updates and ensure records of such training are kept in conjunction with Trust central recording of training. To bring to the attention of the infection prevention & control directorate management team and leads and the infection prevention & control team practice developments to enable sharing of good hand hygiene practice 7.3 The Infection Control Doctor Provide specialist expert advice of the prevention and control of infection for the Trust and on their site. Ensure national evidence based guidance is adopted in order to ensure that patients are treated according to best practice. Ensure the Trust has robust Trust wide policies for all clinical and non-clinical elements of infection prevention and control including decontamination Review surveillance requirements and data for all Healthcare Associated Infections Liaise daily with the infection prevention & control team 7.4 Infection Prevention and Control Nurses (IPCNs) Support the Director of Infection Prevention & Control & Deputy DIPC in delivering their responsibilities Develop, deliver, evaluate and review hand hygiene training at NBT in line with National guidance and Trust audit results Maintain accurate records of training attendance as required by NBT Induction, Mandatory Training Policies and utilise the Infection Prevention Society (lps) Hand Hygiene audit tool (as part of an annual audit programme) so as to ensure consistency of practice throughout NBT To develop and disseminate hand hygiene information for patients and visitors across NBT 7.5 Director of Nursing Provide strategic leadership for the effective delivery and management of patient safety in relation to infection prevention and control and decontamination To provide visible clinical leadership Ensure that the IPCT is appropriately resourced and fit for purpose Ensures nursing workforce attend Induction and Mandatory Training Programme Is informed of and ensures non-compliance is challenged and managed appropriately e.g. via Disciplinary Process 7.6 Medical Director Ensures medical staff attend Induction and Mandatory Training Programme Is informed of and ensures non-compliance is challenged and managed appropriately e.g. via Disciplinary Process 7.8 Clinical Directors, Heads of Nursing & Midwifery & General Managers Support the Clinical Matrons and Heads of other Professionals in undertaking the Hand Hygiene Audits and in challenging any non compliance Ensure non-compliance is challenged and managed appropriately e.g. using the Disciplinary Process if required Hand Hygiene Policy IC06 Page 5
7.9 Clinical Matrons & Senior Medical Clinician Ensure that the NBT Hand Hygiene Audits are conducted weekly and acted upon. Ensure that areas of concern identified in hand hygiene audits are addressed, with actions planned, and completion monitored and signed off Ensure that infection control initiatives are implemented as directed by the senior directorate management team: Clinical Director, Senior Manager and Head of Nursing & in conjunction with the Infection Control Directorate Lead Are responsible for setting and monitoring standards of infection prevention & control within their clinical teams, supporting and driving a culture of patient safety and infection control practice within clinical areas. Challenge non- compliant practice and support employees in addressing any non compliance by reminding staff, when needed, to perform hand hygiene and escalate ongoing non-compliance 7.10 Ward & Department Managers Ensure all staff are up to date with mandatory training for infection control and follow up with individual staff if they fail to attend in accordance with NBT Induction and Mandatory Training Policies Ensure hand hygiene training is monitored within individual appraisal documentation and ward/department held training records Ensure that unmet training needs are resolved and documented on completion Ensure the weekly audit on hand hygiene is conducted in their area Review practice with the Clinical Matron or Directorate IPCN Promptly report any estates problems with hand wash facilities and ensure speedy repair is carried out Challenge non- compliant practice and support employees in addressing any non compliance by reminding staff, when needed, to perform hand hygiene and escalate ongoing non-compliance Ensure that any resource issues affecting hand hygiene are escalated promptly within the directorate Ensure that appropriate hand hygiene information is available at all times to both patients and visitors Refer any staff with conditions that may affect their hand decontamination to Occupational Health and or GP 7.11 Infection Prevention & Control Link Practitioners (IPCLP) Assist in carrying out the weekly NBT hand hygiene audits Act as a ward-based resource person for hand hygiene related queries, e.g materials and consumables/facilities Assist with the hand hygiene education of staff within their clinical area Challenge non- compliant practice and support employees in addressing any non compliance by reminding staff, when needed, to perform hand hygiene and escalate ongoing non-compliance 8. Policy Details 8.1 Definition of Terms Hand hygiene A general term referring to any recognised method of hand cleansing Handwashing (Appendix 2) Washing hands with neutral or antimicrobial soap and water. Social Hand Wash (Routine) Washing the hands with unmedicated detergent and water to remove dirt and loose transient flora in order to prevent cross infection. Hygienic Handwash (Aseptic) Treatment of hands with an antiseptic handwash and water to reduce the transient flora Hand Hygiene Policy IC06 Page 6
without necessarily affecting the resident skin flora prior to clean / aseptic procedures. Surgical Hand Antisepsis (Surgical scrub) Antiseptic handwash or antiseptic handrub performed preoperatively by the surgical team to eliminate transient flora and reduce resident skin flora prior to gowning and gloving in ultra clean environments (e.g. theatres). Surgical handrub Refers to surgical hand preparation with a waterless, alcohol-based handrub used between surgical cases within e.g. Theatres, Day Surgery. Alcohol-based (hand) rub (Appendix 2) An alcohol-containing preparation (liquid, gel or foam) designed for application to the hands to inactivate microorganisms and/or temporarily suppress their growth. Such preparations may contain one or more types of alcohol, other active ingredients and humectants (Ingredient(s) added to hand hygiene products to moisturize the skin). Clinical Area Any area where there are patients, including wards, clinics, endoscopy suites, theatre suites Enteric Infection Gastro - intestinal infections spread by the faecal / oral route Pathogen A microbe capable of causing disease Patient Contact Contact with the patient, or their direct care environment, e.g. bed frames, clothing worn by the patient Point of care The NPSA cleanyourhands campaign promotes the good hand hygiene at the point of care in line with WHO guidelines. The point of care represents the time and place at which there is the highest likelihood of transmission of infection via healthcare staff whose hands act as mediators in the transfer of microbes Patient Zone The concept of the Five Moments is that the patient and their immediate environment becomes what is defined as the patient zone. Visibly soiled hands. Hands on which dirt or body fluids are readily visible. 8.2 Specific Staff duties All Staff must: Ensure that they undertake adequate hand hygiene and encourage others delivering care to do so Have a responsibility to ensure that all students, volunteers, temporary staff, visiting contractors are aware and comply with the Trust s hand hygiene standards. Attend any mandatory or update infection prevention & control education sessions. Hand Hygiene Policy IC06 Page 7
Advise the patients/clients, carers or visitors of any infection control requirements such as hand hygiene and reassurance to patients/clients and visitors/carers on precautions being taken Professionally challenge any member of staff, students, volunteers, temporary staff, visiting contractors seen not to be complying with the policy and remind them of the Trust s Hand Hygiene requirements. (If on being reminded of the requirements of this policy a staff member refuses to comply, their name will be forwarded to the Medical Director or relevant Head of Profession, General Manager for the appropriate disciplinary process.) Report to line managers any deficits in knowledge or other factors in relation to hand hygiene in particular including facilities/equipment or incidents that may result in cross contamination Ensure supplies of hand hygiene solutions and other materials, such as paper towels are readily available for all to use, including visitors. Action is to be taken promptly if shortage of supplies necessary for hand hygiene is identified. e.g. empty hand gel/soap dispensers, hand towels etc. Report any condition that might affect compliance with hand hygiene which may be as a result of occupational exposure to the line manager and the Occupational Health Department (if applicable) Report to Occupational Health and/or GP recurrent skin problems following use of soap and water and/or alcohol gel. Refrain from providing direct patient/client care while infectious potentially or actually as this could cause harm to the patient/client/others. If in any doubt consult with your manager, General Practitioner, Occupational Health Department or the IPCT. Consider the elements of Standard Infection Control Practices such as hand hygiene as an objective within staff s continuing professional development and appraisal. 8.3 WHEN to decontaminate hands at the point of care using the Five moments for hand hygiene The NPSA cleanyourhands campaign promotes the concept of the Five Moments for hand hygiene and in line with the WHO guidelines. The patient and their immediate environment is defined as the patient zone and staff must deliver of good hand hygiene at the point of care. The point of care represents the time and place at which there is the highest likelihood of transmission of infection via healthcare staff whose hands act as mediators in the transfer of microbes. Before every episode of patient care or contact Before a clean / aseptic procedure After body fluid exposure risk After patient contact After contact with patient surroundings HOW to decontaminate hands: The type of hand hygiene procedure is determined by a risk assessment of the Hand Hygiene Policy IC06 Page 8
following four key factors: The level of the anticipated contact with patients or any equipment/surfaces The extent of contamination that may occur with that contact Care activities being performed The susceptibility of the patient 8.4 Your Five Moments for Hand Hygiene Hands should be cleaned at a range of times however in order to prevent HAI at the most fundamental times during care delivery and daily routines, when caring for those sick and vulnerable the 'Your moments for Hand Hygiene' must be followed (see appendix 1- Sitting) Hand Hygiene Policy IC06 Page 9
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8.5 Types of Hand Hygiene Social Hand Hygiene (Routine) Why should Social Hand Hygiene be performed? Social hand hygiene is performed to render the hands physically clean and to remove microorganisms transmitted during activities considered social activities (transient microorganisms1) When must social hand hygiene be performed? Before After starting/leaving work touching a patient/client eating/handling of food/drinks (whether hands becoming visibly soiled own or patient/clients) visiting the toilet preparing/giving medications handling laundry/equipment/waste touching a patient/client blowing/wiping/touching nose entering/leaving clinical areas touching inanimate objects (e.g. equipment, items around the patient/client) and the patient/client environment removing gloves Pet therapy What solution should be used for performing social hand hygiene? Neutral soap, liquid soap from a dispenser Alcohol based hand rub can also be used for social hand hygiene (where hands have not been soiled) for ease of use where appropriate or where no liquid soap is freely available How long should it take to perform social hand hygiene? It should take at least 15 30 seconds to perform social hand hygiene, however washing your hands for excessive lengths of time is not recommended as this may damage the skin leading to increased shedding of skin scales or increased harbouring of microorganisms Hand Hygiene Policy IC06 Page 11
8.6 Hygienic Handwash (Aseptic) Why should Hygienic Handwash (Aseptic) be performed? To remove or destroy transient microorganisms. In addition to provide residual effect during times when hygiene is particularly important in protecting yourself and others (reduces resident microorganisms) When must Hygienic Handwash (Aseptic) be performed? Before After Clean/aseptic procedures Contact with immunocompromised patients/clients Touching patients/clients (or their surroundings) being cared for in isolation or having additional (Transmission Based) precautions applied due to the potential for spread of infection to others Being in wards/departments/ units during outbreaks of infection Blood/body fluid contamination Preparing/administering IV drugs Surgical/invasive procedures What solution should be used for performing Hygienic Handwash (Aseptic)? An approved antiseptic hand cleanser, e.g. 2-4% chlorhexidine, 5-7.5% povidine iodine,1% triclosan, or antimicrobial liquid soap from a dispenser Alcohol based hand rub can also be used following hand washing or when hands are physically clean, for example when performing aseptic techniques, to provide further cleansing and residual effect How long should it take to perform Hygienic Handwash (Aseptic)? It should take at least 40-60 seconds to perform hygienic hand hygiene. Washing your hands for excessive lengths of time is not recommended as this may damage the skin leading to increased shedding of skin scales or increased harbouring of microorganisms Hand Hygiene Policy IC06 Page 12
8.7 The procedure for performing hand hygiene (hand washing) Preparation: Ensure all that is needed to perform hand hygiene is at hand Ensure the sink area is free from extraneous items. Ensure jackets/coats are removed, and wrists and forearms are exposed Jewellery should be removed Ensure nails are short (False/Gel nails/extensions or adornments must not be worn) Procedure: Ideally tap water should be warm, not cold. Hands should be wet before applying the hand wash solution Apply solution Manufacturers instructions for the solution being used should give guidance as to the volume of solution to be applied. This is usually about 3 ml e.g. one squirt A good lather should be evident for undertaking the steps to perform adequate hand hygiene All areas of the hands should be covered in these steps (see Appendix 2). Hands (and forearms) should be rinsed well under the running water The physical action of washing and rinsing hands is essential as different solutions will have different activity against microorganisms Hands should be adequately dried by patting rather than rubbing Taps should be turned off using a hands-free technique, e.g. elbows. Where handsfree tap systems are not in place, paper towels used to dry hands can be used for this Dispose of the paper towels without re-contaminating your hands e.g. use the foot pedal. Do not touch bin lids with hands. Hand hygiene needs to be performed even if gloves have been worn as hands can still become contaminated whilst wearing gloves. NB It is recommended that nailbrushes are not used to perform social or hygienic / aseptic hand hygiene routinely as scrubbing can break the skin, leading to increased risk of harbouring microorganisms or dispersing skin scales that may cause harm to others. Where nailbrushes are used for surgical scrub they should be fit for purpose and single use NB Where running water is not available, for example during water failure or in non-nhs settings, the use of other products such as alcohol based hand rub should be used. Local infection control/health protection teams should be contacted for advice Hand Hygiene Policy IC06 Page 13
8.8 Facilities required to perform hand hygiene Access to appropriate hand hygiene facilities, and associated supplies, is essential to ensure adequate hand hygiene can be performed. It has been shown that inadequate facilities will lead to poor hand hygiene performance. This not only includes the type and number of facilities, but also where they are situated in relation to where work/care is carried out. Provision of hand hygiene facilities must be compliant with DOH (2010) Core Principles: Health Building Note 00-09: Infection Control in the built environment and HTM 64: Sanitary Assemblies. NB Estates/maintenance staff are important partners in ensuring that hand hygiene facilities are adequate and that supplies are mounted appropriately. Poorly maintained hand hygiene facilities, e.g. chipped/cracked enamel, should be reported / repaired as soon as practical and a risk assessment carried out. Hand wash basins must conform to standards as damaged surfaces may harbour microorganisms Taps: The use of hands free tap systems is crucial in preventing re-contamination of hands following hand hygiene performance at a sink and should be available as far as possible, particularly where personal care is delivered in clinical or communal settings. These can include: Wrist, elbow or foot operated taps Motion sensor controlled taps flows must allow adequate time to wet their hands prior to performing hand hygiene. Water temperature must be delivered in line with HS 14 Policy for the prevention and control of Legionella (including water hygiene). Hand Basins: Clinical wash / Non clinical There should be no plugs or a recess capable of taking a plug in the hand wash basins in order to avoid the filling of sinks with water Clinical hand wash basins should not have overflows as these are difficult to clean and become contaminated Mixer taps or thermostatic mixer valves are preferred to provide the correct temperature of water for performing hand hygiene The tap should not directly expel/drain water straight down the drain. It should be sited appropriately to ensure water hits the sink basin as it flows out, otherwise aerosol from the drainage system can splash back on to the user Hand Hygiene Consumables: Availability of supplies for hand hygiene is essential, including: hand hygiene solutions (soap, antiseptic hand wash solution and alcohol based handrub), at the patient point of care, in easy to use, and easy to clean, holder systems that contain single use, disposable cartridge sets, particularly in clinical or communal care areas. Nozzles of solution bottles/containers should always be clean and free of any congealed product (bottles should not be reused or topped up ) Hand Hygiene Policy IC06 Page 14
Soft, user friendly disposable paper towels for hand drying, to be stored in wall mounted, easy to use and clean holders Community Staff Should carry their own hand hygiene solutions and hand towels as facilities may not be adequate when visiting non-nhs premises. (bottles should not be reused or topped up ) 8.9 Hand drying Hand drying is a critical factor in the hand hygiene process, in particular removing any remaining residual moisture that may facilitate transmission of microorganisms Hands that are not dried properly can become dry and cracked, leading to an increased risk of harbouring microorganisms on the hands. Once the taps have been turned off using a hands-free technique, use clean, preferably disposable paper towels to dry each area of the hand thoroughly. This should be done by patting dry each part of the hand remembering all of the steps included in the hand washing process The use of soft, user-friendly, disposable paper towels is preferable to encourage compliance with the hand hygiene process. Drying following surgical scrub is recommended using a motion from the hands to the elbow Disposable paper towels should be placed immediately into appropriate waste receptacles, avoiding recontamination of hands, e.g. foot-operated bins (see Safe Disposal of Waste Policy). Recontamination of hands immediately following the hand hygiene process must be avoided, e.g. by not touching any contaminated areas in the environment or touching own hair or face Disposable paper towels should always be used in clinical settings Communal towels for hand drying should never be used in the clinical setting. If used in non-clinical settings (e.g. patient s/client s own home) they should be easily identifiable for the purpose of hand drying only and washed daily or in between times if heavily contaminated The use of air dryers are not recommended in clinical areas. Hand Hygiene Policy IC06 Page 15
8.10 Surgical hand antisepsis (Surgical Scrub) Why should Surgical hand antisepsis be performed? To remove or destroy transient microorganisms and to substantially reduce those microorganisms which normally live on the skin (resident microorganisms) during times when surgical procedures are being carried out When must Surgical hand antisepsis be performed? BEFORE All surgical/invasive procedures (major and minor) NB Specific policies and procedures on surgical preparation should be available at local level What solution should be used for performing Surgical hand antisepsis? An approved antiseptic hand cleanser, e.g. 2-4% chlorhexidine, 5-7.5% povidine iodine,1% triclosan from a dispenser NB Persons sensitive to antiseptic cleansers can wash with an approved nonmedicated liquid soap followed by two applications of alcohol based hand rub seek specialist Occupational Health / IPCT advise. How long should it take to perform Surgical hand antisepsis? Carry out surgical scrub process for 2-3 minutes, ensuring all areas of hands and forearms are covered Hand Hygiene Policy IC06 Page 16
8.11 Procedure Surgical Hand Antisepsis Technique (Surgical Scrub) Each step of surgical scrubbing consists of five strokes rubbing backwards and forwards and adapts Ayliffe s six step technique into eight steps. Sources of evidence drawn on include AfPP s Standards and Recommendations for Safe Perioperative Practice recommended practices and Ayliffe s six step hand washing technique Step 1 (pre-scrub/pre wash) Set water temperature and flow rate. Wash hands and arms with running water and an antimicrobial solution or plain soap Remove debris from under nails using a nail pick Rinse hands and arms During each of the following steps keep hands above elbows allowing water to drain away from the elbow Avoid splashing surgical attire. Step 2 Apply an amount of surgical scrub product recommended by the manufacturer. Work into hands palm to palm and continue with rotating action down from finger tips, opposing arms working to just below the elbows. Step 3 Right hand over back of left and vice versa with fingers interlaced. Step 4 Rub palm to palm, fingers interlaced Step 5 Rotational rubbing of right thumb clasped in left hand and vice versa. Step 6 Rub left palm with clasped fingers of right hand and vice versa Step 7 Once more rotate down from finger tips to elbow, the arm with opposing hand working to just below the elbow. Rinse and repeat steps 2-7 keeping hands above elbows at all times. Step 8 Rinse hands under running water. Dry thoroughly using one (or one side of a) sterile paper hand towel for each hand, rotating down from hands to elbows before discarding. Alcohol Hand Gel Based Scrub Technique Subsequent surgical scrubs, following the first of the list, within the same operating theatre room, can be achieved by the application of a 70% alcohol solution. Provided hands have not become visibly contaminated: Apply two 5 ml amounts to clean hands and forearms using the standardised scrub technique until completely dry. A break in the theatre list by members of the operating/scrub team will mean a full surgical hand scrub prior to the commencement of the next case. The alcohol hand scrub technique can then be implemented for the subsequent cases on the list. Occupational Health may advise alternative antiseptic detergents when there is clinical evidence of allergy. 8.12 Alcohol based hand rub Alcohol gel is located throughout NBT, near all points of care, in accordance with NPSA cleanyourhands campaign based on WHO guidelines. It is an effective alternative to soap and water for use on visibly clean hands. Hand Hygiene Policy IC06 Page 17
(Appendix 2) It should be used on entrance and exit to clinical wards and departments, during clinical ward rounds and medication rounds. Unless hands are visibly soiled or outbreaks of infection occur when hand washing is then advocated. To assist point of care point application of alcohol gel dispenser should be located on the patient s bed base. Exception will be where there is a clinical risk to the patient, or where clinical equipment prevents positioning. Alcohol rubs with a concentration of 70% e.g. isopropanol, ethanol or a combination of two of these are generally used as they are effective, cause less skin drying dermatitis. Products that also contain emollients can be used to ensure the drying effects of alcohol based hand rubs are minimised Alcohol rubs / gel is not suitable if the patient has an enteric infection or when hands are visibly soiled. When attending patients with diarrhoea and/or vomiting or confirmed enteric infection including Clostridium difficile infection, it is important that staff must wash their hands with soap and water and do not use the alcohol gel. Alcohol gel is ineffective at killing non-enveloped viruses, e.g. norovirus or spores, e.g. C difficile. After three consecutive applications of alcohol hand rub/gel, hands should be washed with soap and water to prevent build up of the product and to reduce drying effects of alcohol. (Pratt et al, 2007). It has been shown that alcohol based hand rub used for the hand hygiene process can inhibit microorganisms on hands by filling the crevices in hands and evaporating as it spreads over all areas How to use alcohol based hand rub The amount/volume used to provide adequate coverage of the hands should be indicated in the manufacturers instructions. This is normally around 3 ml The steps to perform hand hygiene using alcohol based hand rub are the same as when performing hand washing (see Appendix 3) The time taken to perform hand hygiene using alcohol based hand rub is at least 20 seconds (20-30 seconds is adequate). Manufacturers instructions should be followed (a number of these recommend rubbing for 30 seconds) If the solution has not dried by the end of this process allow hands to dry fully before any patient/client procedures are undertaken (do not use towels to do this) Alcohol Rub - Good Practice Points Caution must be taken when using alcohol based hand rub in relation to flammability and ingestion. Local risk assessments should be undertaken to address each of these issues Caution should be taken to avoid drips or spills of solutions for health and safety reasons (e.g. slips or falls) Those working in areas such as patients /clients own homes should carry their own supplies of solutions Hand Hygiene Policy IC06 Page 18
NB. The use of antimicrobial impregnated wipes has been considered for use in the hand hygiene process, however, it has been shown that such wipes are not as effective as hand washing or the use of alcohol based hand rub, therefore these are not considered a substitute. For further advice contact the IPCT. 8.13 Nail Care It has been shown that nails, including chipped nail polish, can harbour potentially harmful bacteria. Caring for nails helps prevent the harbouring of microorganisms, which could then be transmitted to those who are receiving care Nails must be natural, kept short and clean Nail polish should not be worn by staff in clinical areas Artificial fingernails/extensions should not be worn when providing care. National guidance (AfPP) does not advocate the use of nail brushes, however if required should be single use and fit for purpose. Nail picks are recommended in UK theatre practice but scrubbing brushes are no longer deemed to be necessary especially for use on skin, randomized controlled trial showed no difference in the amount of colony forming units. 8.14 Hand Hygiene and Jewellery It has been shown that jewellery, particularly rings with stones and/or jewellery of intricate detail, can be contaminated with microorganisms, which could then spread via touch contact and potentially cause infection. No wrist watches, no other wrist jewellery / bands, no rings, other than a plain metal band, to be worn when performing hand decontamination. Staff providing care must therefore, remove these at the start of the working day It is acceptable to wear a plain metal band, for example wedding bands. 8.15 Naked from the Elbow Doctors, nurses, clinical and non clinical staff must be naked to the elbow while on the wards or in other clinical areas, to enable thorough hand hygiene. Jackets, coats must be removed and long sleeves if worn rolled up, allowing for wrists and forearms to be exposed As door handles and ward equipment easily become contaminated with organisms present in the clinical environment, all NBT staff must decontaminate their hands on entry to and exit from every ward/clinical department, even if they do not intend to or have not had direct clinical patient contact. In order to facilitate this, all staff are required to be naked from the elbow whilst on wards or in other clinical areas. Any employee who wishes to wear particular types of clothes or jewellery, markings or other adornments for religious, cultural or health reasons that may mean a deviation from this policy must raise this issue formally with their line manager who will not unreasonably withhold approval but should also seek advise from IPCT. Decisions will be subject to the overriding requirements for patient and staff safety and public confidence and best practice, and all staff who are involved in direct patient care activity must be naked below the elbow. Requests to deviate from the policy will be documented in the employee s personal file and, to ensure consistency across the Trust, line managers will seek advice from the relevant HR Operations Manager/Advisor. Responses to such requests and the outcome will also be documented. Hand Hygiene Policy IC06 Page 19
8.16 Hand care Normal hand flora can be altered if skin is damaged, which may consequently lead to hands carrying increased pathogens which could be responsible for healthcare-acquired infections (Larson 1999). The provision of hand emollient ( moisturiser creams ) can assists in the maintenance of skin integrity and hydration (Pratt et. al. 2007). It is important to protect the skin on hands from drying and cracking where bacteria, in particular, may harbour, and to protect broken areas from becoming contaminated particularly when exposed to blood and body fluids Cover all cuts and abrasions with a waterproof dressing Hand creams can be applied to care for the skin on hands, however, only individual tubes of hand cream should be used or hand cream from wall mounted dispensers. Communal tubs, in particular, should be avoided as these may contain bacteria over time Creams used should not affect the action of hand cleaning solutions being used or the integrity of gloves Report any skin problems to your Manager, Occupational Health or General Practitioner in order that appropriate skin care can be undertaken and the risks of harbouring microorganisms while providing care for others can be avoided Perfumed soaps, or other solutions, might cause skin problems for some if used frequently, therefore, this should be discussed with Occupational Health services and alternatives sought and made available 8.17 Patients Hand Hygiene All patients must be provided with facilities for hand washing prior to eating and after using toilet facilities. If a hand-wash basin is not accessible, patients must be offered patient hand wipes. These are available from the clinical wards and departments, and should be offered to the patient on admission. The provision of effective hand hygiene is instrumental is the prevention of C difficile and Norovirus infection Patients are encouraged to challenge staff as to whether they have appropriately decontaminated their hands, as promoted by the NPSA cleanyourhands campaign. Information & Signage for Staff, Patients and Visitors Laminated signs regarding hand-washing technique with soap and water and alcohol hand rub/gel hand hygiene technique will be appropriately displayed throughout NBT (i.e. soap and water signs next to handwash basins, and the alcohol hand rub next to the pump dispensers). The templates and guidance on signage will be supplied by the IPCT and the Directorate responsible for ensuring posters featuring when to perform hand hygiene and the steps included in the hand hygiene process etc. are displayed in relevant, prominent areas to support infection prevention & control practice. Elective admissions will receive Infection Control information within as part the patient admission information leaflet. This outlines what patients should expect in respect of staff hand hygiene and also describes the hand hygiene requirements of the patients themselves. Emergency admissions will be able to access information at ward level, by Hand Hygiene Policy IC06 Page 20
communicating directly with the clinical teams, along with information displayed (e.g. ward/department entrance) 9 Methods of Monitoring & Auditing 9.1 Clinical Wards / Unit Hand Hygiene Audits - Safer Patient Initiative and Saving Lives All wards are required to audit hand hygiene compliance using the approved observational Hand hygiene Tool on a weekly basis. This is a 20 minute observational tool audits of the hand-washing activity of members of staff and staff undertaking these must be trained in its use. It is expected that 40 episodes of care will be observed each month on all wards. Compliance with Naked below the Elbow is also included in the audit tool All staff groups who have patient contact, either clinical or non-clinical will be included in this audit. Wards and clinical areas are required to enter hand hygiene compliance data on line via Quality Improvement and Clinical Audit Department (QICA) hand hygiene site. Additionally paper copies of audits tools can be down loaded and will need to be sent to the QICA department for collation and reporting. The results are reported monthly by the (QICA) and reports are available on line on the QICA intranet site in both the Quality Synopsis ward reports and the Full Hand Hygiene report which is also published on the same site. Clinical Directors, General Managers and Heads of Nursing are responsible for reviewing and acting on the results of the audit with the support of the directorate Infection Control Lead, Ward Managers, Department Leads, Matrons and Consultants. Hand hygiene rates must be reviewed monthly. Directorate and the directorate infection control leads will work with individual wards / units / clinical areas to develop an action plan to address any non-compliance with the support of the IPCT. COIC - is the feedback mechanism for directorate leads to report on compliance and assurance on action plan A minimum compliance level of 95% must be achieved. IPCT Audits The IPCT have an annual Audit Programme, which includes auditing clinical areas using the Hand Hygiene Tool The IPCT will be responsible for ensuring completion of the audits and development and dissemination of the action plans to directorates. Low compliance e.g. lower than 95% at ward level will require that the ward be re-audited in line with the agreed action plan. 9.2 Infection Rates Internal assurance Healthcare Associated Infection (HCAI) rates, specifically mandatory surveillance e.g. MRSA Bacteraemia, Clostridium difficile, are monitored and represent key performance indicators for this policy. Other HCAI are monitored on specific units as relevant. External assurance Hand Hygiene Policy IC06 Page 21
This will be monitored through: Patient Environment Action Team (PEAT) audits Care Quality Commission Strategic Health Authority Department of Health visits Patient Feedback / Complaints 9.3 Training Attendance Audit The IPCT will provide training and education on Hand Hygiene for: All new Trust employees attending the North Bristol Induction Programme within the infection control session All Trust employees at their mandatory infection control updates which includes reinforcing infection control responsibilities, in accordance with the Health and Social Care Act 2008 Infection prevention control link practitioners (IPCLP) Hand Hygiene Competency - Individual directorate are responsible for ensuring that each member of staff is assessed as competent as part of this process (See Appendix 5 Hand Hygiene Competency) Bespoke training sessions delivered in relation to audit findings, outbreak situations, action plans and or requests from directorates. Numbers and names of staff attending training will be recorded by the Infection Prevention & Control Team and held on the managed learning environment (MLE) Records of attendance at all Mandatory training will be recorded and names of non-attendees are sent to clinical leads to identify gaps in training of staff, in line with the Mandatory Training Policy. All training is recorded on the trust s managed learning environment (MLE) training records. Monitoring of this training including non-attendance is communicated from the learning and research directorate to individual line managers. Managers have a duty to establish reasons behind non attendance at sessions and rearrange. Courses planned by local managers require those managers to maintain responsibility for non-attendees, which should then be highlighted as part of the appraisal process in line with the individuals Knowledge Skills Framework (KSF) Training attendance data will be reviewed on an annual basis within the annual audit plan, and with reference to the Managed Learning Environment (MLE) and Training Needs Analysis. Training details collated from records of attendance from MLE will be collated by the Infection Prevention Control Team to create a Gap Analysis identifying where extra teaching/training sessions are required. 9.4 Incident Reporting Any incident where failures in hand hygiene practice/compliance has occurred or where there are product/facility deficiencies that affect adequate hand hygiene being performed should be reported in line with local reporting policies and protocals. Hand Hygiene Policy IC06 Page 22
10. References: AfPP (2007) Standards and Recommendations for safe Perioperative Practice AfPP (2010) Surgical Hand Antisepsis Ayliffe et al. (2000) Control of Hospital Infection: A practical handbook, 4 th London edition, Arnold, DOH (2002) Infection Control in the Build Environment DOH (2010) Core Principles: Health Building Note 00-09: Infection Control in the built environment Consultation Draft. Health Protection Scotland (2009) Standard Infection Control Precautions, Literature Review: Hand Hygiene. Hartley J, Mackay A & Scott G (1999) Wrist watches must be removed before washing hands. BMJ. P318. HSC (2007) Legionnaires Disease: the control of legionnella bacteria in water systems Health Technical Memorandum (2006) 64: Sanitary Assemblies, HMSO Infection Control Nurses Association (2004) Audit tools for monitoring infection control standards. Huntingdonshire. Suitable Design. Larson, E. (1999) Skin Hygiene and Infection Prevention: More of the same or Different Approaches? Clinical Infectious Diseases. Vol. 29, 1287-1294. National Patient Safety Agency (2004) Patient Safety Alert 04: Clean hands help to save lives. Pratt, R.J. Pellowe, C.M. Wilson, J.A. Loveday, H.P. Harper, P.J. Jones S.R.L.J. McDougall, C. Wilcox, M.H. (2007) epic2: National Evidence-Based Guidelines for Preventing Healthcare- Associated Infections in NHS Hospitals in England. The Journal of Hospital Infection. Vol. 65, Supplement 1. UBHT (2007) Hand Hygiene Policy WHO (2006) World Alliance for Patient Safety. WHO (2009) WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care is Safer Care Hand Hygiene Policy IC06 Page 23
Appendix 1 Your 5 moments for Hand Hygiene at the point of care (Sitting in a chair) Hand Hygiene Policy IC06 Page 24
Appendix 2 Hand Hygiene Policy IC06 Page 25
Hand Hygiene Policy IC06 Page 26
Appendix 3 Hand Hygiene competency framework Assessment of competence Name.. Training.. Date of attendance at formal Assessors must assess against the following criteria for competence. Knowledge 1 Why is hand hygiene so important? Competent YES NO Date Assessors feedback 2 What microorganisms are commonly transmitted by hands? 3 Discuss the chain of infection in relation to HCAI 4 What are resident flora and when are they a risk? 5 What are transient flora and how are they acquired? Risk Management 1 Knowledge of incident reporting policy CG01 2 Knowledge of COSH regulations in relation to hand hygiene products. 3 Identify and discuss the following in relation to hand hygiene: Skin problems acute / chronic Norovirus / C.Diff Communal items e.g. soap Competent YES NO Date Assessors feedback 4 Where are Infection Prevention & Control policies located? Procedure Competent Date Assessors feedback Hand Hygiene Policy IC06 Page 27