Hand Hygiene Policy. Policy PH 06. Date June Page 1 of 19

Hand Hygiene Policy Policy PH 06 Date June 2007 Page 1 of 19

Document Management Title document Type document Description of of Hand Hygiene Policy Policy PH 06 Hand decontamination is the single most important activity for preventing infection and its transmission to others. Adherence to hand hygiene practice rarely exceeds 60% and is often much lower (10% in one study) (CMO 2007) Target audience All staff Author Department Directorate Infection Control Team Infection Control Public Health Approved by Governance Committee Date approval of 15 August 2007 Version Number 2 Next date review June 2008 - reviewed and contact details updated. June 2010 Related documents Superseded documents NICE Guidelines (2003) The Health Act 2006: Code of Practice for the prevention and control of health care associated infections Essential Steps to Safe Clean Care (2006) Standards for Better Health (2004) Winning Ways (2003) Essence of Care (2001) Infection Control Policy and Guidelines for Northampton Primary Care Trust (2005) Infection Control Policy and Guidelines for Page 2 of 19

Northamptonshire Heartlands Primary Care Trust (2003) Infection Control Policy and Guidelines for Daventry and South Northants Primary Care Trust (2005) Internal distribution External distribution Availability All staff Health Protection Agency Northampton General Hospital Kettering General Hospital All ratified policies, strategies, procedures and protocols are published on the Trust Intranet and Public Website. Contact details (of main contact for this document) Name: Infection Control Team Address: Nene House, Isebrook Hospital, Irthlingborough Road, Wellingborough, NN8 1LP Tel: 01536 494001 E-mail: jenny.boyce@northants.nhs.uk lin.marlow@northants.nhs.uk susan.wood@northants.nhs.uk Page 3 of 19

CONTENTS Section Number Page Number 1.0 Introduction 5 2.0 Organisational Responsibilities 5 3.0 Skin Integrity 7 4.0 Hand Decontamination Facilities 7 5.0 Indications for Hand Washing 8 6.0 Surgical Decontamination 9 7.0 Type of Product/agent 9 8.0 Hand Hygiene Technique 9 9.0 Promoting Hand Washing 10 10.0 Hand Drying 11 11.0 Disinfectant Hand Rub 10 12.0 Hand Creams 12 13.0 General Hand Care 12 14.0 Training 13 15.0 Audit and Monitoring 13 16.0 References 14 Appendix 1 15 Appendix 2 16 Appendix 3 17 Page 4 of 19

1.0 Introduction 1.1 Hand decontamination is the single most important activity for preventing infection and its transmission to others. Adherence to hand hygiene practice rarely exceeds 60% and is often much lower (10% in one study) (CMO 2007) 1.2 The frequency of hand decontamination is determined by assessing the risks of the procedures that have been, and are about to be, undertaken. The aim of routine hand decontamination is to remove dirt, organic material and transient micro-organisms, rendering the hands socially clean. Routine hand decontamination is sufficient before and after most activities carried out in clinical practice. Prior to minor surgery and invasive procedures, a more intensive technique would be required to reduce the number of resident organisms. (Table 1) Contaminated hands most commonly spread cross infection in a healthcare setting. Skin is not sterile. Some bacteria will inhabit and multiply on skin; these are known as resident flora or commensals. Others will be picked up by contact and passed on by contact; these are known as transient micro-organisms. 1.3 The wearing of gloves is not an alternative to hand decontamination. Resident and Transient Microorganisms (Table 1). Transient micro-organisms Do not normally colonise the skin. They are acquired on hands through contact with other sites on the same individual, other people or the environment (crossinfection). Easy to remove by hand washing. Resident micro-organisms Deep seated (in skin folds and follicles) difficult to remove associated with surgical wound infection, and following invasive procedures and manipulations, reduced by a surgical hand wash 1.4 Handwashing has been shown to reduce the spread of infection. 1.5 The potential for cross-infection exists not only in the acute hospital setting but also in community care settings. Increasingly healthcare workers are undertaking a variety of care activities and procedures in the community setting. Hand washing, as an effective means of infection control is no less important in such setting. However, it is recognised that sometimes facilities for hand washing in a patient s home may be limited. Page 5 of 19

2.0 Organisational responsibilities 2.1 Trust Board The Trust Board will ensure that the Trust s Policy is implemented. 2.2 The Chief Executive The Chief Executive will ensure that this Policy is implemented in all directorates and will ensure that the effectiveness of this Policy is continually reviewed. 2.3 Executive/Clinical Directors Executive and Clinical Directors have the responsibility for the coordination of Health and Safety activities within the directorate and for ensuring that decisions are implemented in accordance with this policy and associated guidelines. 2.4 Infection Control Committee The Infection Control Committee has a responsibility to ensure that this Policy allows the Trust to comply with advice and guidance from the Department of Health and other bodies. 2.5 The Infection Control Committee will: Develop and implement a Policy on Management of Infection Control. Review the Policy on receipt of a change in advice or guidance from the Department of Health and other bodies. These guidelines will be binding on employees under Health & Safety Legislation. 2.6 The Infection Control Team The Infection Control Team are responsible for providing advice in relation to infection control aspects of care delivery to patients. The Infection Control Team takes the key role in day-to-day infection control activities and serves as a specialist source of advice. They are an active members of the Infection Control Committee and for example, assists in drawing up infection control policies and participates in and initiates infection control audits. They also provide input in identification, prevention, monitoring and control of infection in the Trust and work with the Service leads and the Infection Control Link staff and others to improve surveillance and reporting of infections to strengthen the prevention and control of infection. The Infection Control Team are proactive in the provision of infection control education for all levels of staff and in particular the development of the Infection Control Link staff. 2.7 Managers and Supervisors Managers and supervisors have a responsibility to ensure that staff are aware of their responsibilities under this Policy and associated guidelines. Managers must inform new employees of their Page 6 of 19

responsibilities under this Policy. In addition they must ensure that all employees within their area of responsibility comply with this Policy and associated guidelines. 2.8 Employees All employees have a responsibility to abide by this Policy and associated guidelines and any decisions arising from the implementation of them. This Policy is enforceable through Health and Safety Legislation and Trust disciplinary procedures. If employees are aware that the Policy or associated guidelines are not being complied with they must first take the issue to their line manager and if the problem is not resolved they must inform the Infection Control Team. 3.0 Skin Integrity 3.1 Bacterial counts increase when skin is damaged, so maintenance of skin integrity is important for all healthcare staff. Nailbrushes should be avoided. If used, they should be single use and preferably sterile. 3.2 It is important to protect any breaks in the skin with a waterproof dressing whilst working. Kitchen staff should use blue waterproof dressing. 3.3 Although emollients are now standard ingredients in most liquid soaps and alcohol rubs, some individuals continue to experience soreness or sensitisation. Rinsing of the hands before and after washing will reduce this. If a particular soap, antimicrobial hand wash or alcohol product is thought to cause skin irritation the occupational health team should be consulted. 4.0 Hand Decontamination Facilities 4.1 Hand decontamination can be improved by the provision of adequate and conveniently located facilities. 4.2 Basins must be provided where hand washing is required and in all areas where client consultations will take place. 4.3 Clinical hand washbasins should not have a plug or overflow, and ideally should have elbow, or foot-operated mixer taps. 4.4 A separate sink should be available for other cleaning purposes, such as cleaning instruments, crockery and cutlery. 4.5 Hand washbasins should have in close proximity: Page 7 of 19

Wall mounted liquid soap dispensers with disposable soap cartridges in easy reach. They must be kept clean and replenished. Disposable paper towels must be conveniently sited next to the basins. Soft paper towels will help to avoid skin abrasions. Foot operated pedal bins must also be positioned near the hand wash basin and be of appropriate size. Ideally also a pump-dispensed alcohol hand preparation and pump dispensed moisturiser 5.0 Indications for hand washing 5.1 The decision to wash hands should be based on an assessment of the risk that micro organisms have been acquired or may be transmitted. 5.2 Hand washing is essential before and after contact with patients e.g. Before starting work Before eating or handling food Before administering medications Before contact with susceptible sites, e.g. wounds, burns, Before performing invasive procedures, i.e. where natural defences against infection are breached After hands have been contaminated, e.g. contact with body fluids, soiled linen or equipment After gloves have been removed, as hands may be contaminated on their removal After using the toilet Before going home Table 2. Levels of Hand Decontamination Method Solution Task Routine Liquid soap or alcohol gel For all routine tasks. Alcohol Gel must not be used if caring for patients with Clostridium Difficile as it does not kill the spores. Hygienic hand disinfection Surgical scrub Antiseptic, e.g. Chlorhexidine or use of alcohol hand gel after a social clean Antiseptic e.g. Chlorhexidine or povidone iodine thorough and careful washing for 2-5 minutes. Dry on sterile towels In high risk areas and during outbreaks Prior to surgical and other invasive procedures Page 8 of 19

5.3 Rubbing hands together vigorously for 15-30 seconds using a gentle liquid soap and the recommended hand wash technique (fig 1) is adequate for this purpose. Liquid soap is preferable because bar soap can become contaminated. A disposable, cartridge-type system should be used to contain liquid soap, rather than a top-up system. 6.0 Surgical Hand Decontamination 6.1 The aim of surgical hand washing is the destruction of transient organisms and a reduction of resident flora before surgical or invasive procedures. 6.2 Surgical hand washing using an antiseptic solution (or alcohol if hands are visibly clean) aims to substantially reduce resident micro-organisms and to remove transient micro-organisms. 6.3 Surgical hand decontamination must be carried out prior to invasive procedures, where extra care must be taken to prevent microorganisms on hands from being introduced into the patient s tissues if gloves are damaged. 7.0 Type of product/agent 7.1 The soap supplied must be a liquid soap ideally in wall mounted dispensers. If a freestanding soap dispenser is used the dispensing nozzle must be integral with the reservoir and the whole unit changed when empty. In the absence of appropriate provisions alcohol hand gel should be used in place of hand washing until this can be undertaken, providing hands are visibly clean. 7.2 Disinfectant hand rubs can be used in place of soap and water, except when hands are visibly dirty. It is effective at removing 99.9% of transient bacteria from hands using the correct technique. 7.3 They are especially useful in situations where hand washing and drying facilities are inadequate, or where there is frequent need for hands to be washed. 7.4 Surgical scrubs are used in situations where a reduction in the resident flora is necessary, such as during minor surgery. 8.0 Hand Hygiene technique 8.1 A 15-30 second hand wash will remove the majority of transient micro-organisms. The technique should aim to cover all surfaces of the hands. 8.2 Where soap is used: Page 9 of 19

Wet hands prior to applying cleansing agent and ensure all surfaces of hands are in contact with the agent and then rinsed thoroughly using running water and dried. 8.3 Towels used for drying are single-use and disposable. The soap and hand towels should be of a quality acceptable to users so as not to deter hand washing. 8.4 Disinfectant hand rub can be used as an alternative to washing if no visible contamination is apparent. If the hands are visibly contaminated, they should be washed in the normal way with soap and water. 8.5 Approximately 2-3mls of the disinfectant hand rub should be dispensed into the palm of one hand, rubbed thoroughly over the surface of both hands until dry; particular care should be paid to the nails, finger tips and thumbs. 8.6 The skin should be maintained in good condition to discourage the accumulation of microorganisms. This may requires the regular application of hand creams, which should be preferably water-based and contain an effective preservative, dispensed from sealed units, and should not be re-filled. If it is not dispensed from an appropriate dispenser it should be for individual staff use. 8.7 Nail-brushes must not be used for routine hand washing. Continual use of nail-brushes damages the skin which will then harbour mare bacteria. Nail-brushes also become contaminated, and therefore act as a source of cross-infection. If used in specific circumstances, i.e. prior to minor surgery, they must be single use and sterile. See appendix 1 9.0 Promoting hand washing 9.1 Adequate facilities must be provided to encourage staff, patients and their visitors to wash their hands regularly and appropriately. This includes accessible hand washbasins, soap and disinfectant hand rubs, and disposable paper towels. 9.2 All clinical areas hand wash basins should be fitted with mixer taps, wherever possible. 9.3 Foot operated pedal bins must also be positioned near the hand washbasin. 9.4 In areas where facilities are either unavailable or inappropriate (such as a patients own home) then alternative provisions should be made/sought. Healthcare professionals working within the primary Page 10 of 19

care environment should be provided with a personal provision of hand washing soap, alcohol hand gel, and hand cream with a supply of disposable paper towels/kitchen towels for hand drying. 10.0 Hand Drying 10.1 This is an essential part of hand hygiene. Disposable paper towels should be used, because communal towels have been recognised as a source of cross contamination. Paper towels must be stored in a wallmounted dispenser adjacent to the hand washbasin, and disposed of into a foot operated domestic waste bin. Hands must not be used to lift the bin lid or they will be re-contaminated. Hot air dryers are not recommended in clinical settings, because they take too long to dry the hands and may re-circulate contaminated air. 11.0 Disinfectant hand rubs 11.1 These may be used in the clinical area for the disinfection of visibly clean hands. It is now well established that the principal mechanism for cross-infection is through bacterial carriage on the hands of health care personnel. The risk to patients can therefore be greatly reduced by hand disinfection with an disinfectant hand rub. The alcoholic base achieves a very rapid and effective kill of transient flora. 11.2 Suitable hand rubs should consist of 70% ethanol or 60-70% isopropanol with or without added disinfectant and containing an emollient eg 1% glycerol. 11.3 Disinfectant hand liquids/gels/foams may be used as an alternative to soap and water if the hands are visibly clean. They are particularly useful when hand washing may be inconvenient, e.g. opening dressing packs, in the midst of routine care and when in a patients own home. However, disinfectant hand rubs are not effective against spore forming bacteria such as Clostridium difficile, therefore soap and water should always be used if patient has diarrhoea or other infection caused by a spore forming bacteria. 11.4 In some circumstances an application of disinfectant hand rub, rubbed in until evaporated, will help to remove any potential pathogens that might be left after hand washing. These include: Before carrying out aseptic technique Before giving injections After contact with known or suspected infected body fluids 11.5 However for the majority of activities either soap and water or alcohol hand preparation is sufficient and the use of both will not be necessary. Page 11 of 19

12.0 Hand Creams 12.1 Communal pots of cream must not be used because the contents may become contaminated; use a pump-action container for communal use or use your own individual tubes. Hand creams must be compatible with the hand-washing agent as hand creams with an anionic (A negative ion) emulsifying agent reduce the residual antibacterial effect of Chlorhexidine. Most companies who provide the liquid soap will also provide a moisturiser for ump dispensers. 13.0 General Hand Care 13.1 FOR ALL HEALTH CARE WORKERS WHO HAVE DIRECT HANDS ON CONTACT WITH PATIENTS. 13.2 Intact skin forms an effective barrier against many pathogenic microorganisms. The skins secretions also have some anti-bacterial properties. However, poor hand hygiene carried out on a frequent basis, removes natural skin emollients, and can result in dry and sore hands. Risks of cross-infection can therefore be increased. Good hand care is therefore essential. 13.3 Finger Nails Fingernails should be kept clean, short and smooth. When hands are viewed from palm side, no nail should be visible beyond the fingertip. Nail varnish or false nails/nail extensions should not be worn. 13.4 Jewellery Hand and wrist jewellery must be removed where possible to facilitate decontamination of the hands, wrists and forearms, and to reduce bacterial counts. Rings with raised stones should not be worn as bacteria collect in the mounts, however a wedding band or the equivalent, depending on religious beliefs, is permitted. 13.5 Skin Care Hand cream, which is appropriate, should be used to avoid chapped or cracked skin. Any member of staff who is unable to use the appropriate hand hygiene agents due to the development of a skin condition/allergy should seek advice from their General Practitioner. Cuts and abrasions must be covered with an occlusive, waterproof dressing. Page 12 of 19

13.6 Gloves Disposable, single use sterile & non-sterile latex powder-free gloves are available for use when indicated. Ensure hands are washed once gloves are removed. 13.7 NB. Staff are responsible for protecting their hands. If they are using a product that appears to be having a detrimental effect on their skin, or develop damaged broken skin, they must attend the Occupational Health Department. The relevant manager may need to be informed of the outcome of the Occupational Health Department assessment where changes in work practice or alternative hand hygiene products are required. 14.0 Training 14.1 Any infection control education and training, provided by NtPCT s Infection Control Nurses will reinforce the importance of effective hand hygiene in preventing the spread of infection while supporting good practice with research. Training needs for staff are regularly identified through the Primary Care Trusts training needs analysis. Hand Hygiene Training is mandatory for all staff who have direct hands on contact with patients. Attendance at mandatory training is monitored through the Training Department. 14.2 Infection control is also a component of the organisations corporate induction and mandatory training programmes. Every member of staff has a responsibility to attend training and to maintain their knowledge and skills in infection control. 14.3 Staff that require further training or information should contact the infection control team at Nene House, Isebrook Hospital. 15.0 Audit and Monitoring 15.1 A fundamental principle of infection prevention and control is the creation and maintenance of environments and processes that ensure safety for patients, visitors and staff. A systematic approach to this has been developed through a comprehensive programme of audit. These audits are undertaken either as a questionnaire by the Infection Control Team to the relevant clinical areas for completion by the team at a local level or the Infection Control Team visit the clinical areas and undertake an observational audit. 15.2 Hand Hygiene is audited on a rolling programme based on the Infection Control Nurses Association audit tool. This audit can be used to: Determine whether or not staff are adhering to the policy. Page 13 of 19

Help determine if staff require further education or training in the area covered by the policy. Help determine if a lack of resources is an obstacle to the correct implementation of the policy. Help determine if the policy contains recommendations, which need to be modified. 15.3 All audit reports and subsequent activity and outcomes are reported to the Infection Control Committee of the PCT. 16.0 References Ayliffe, G.A.J. et al. 1978. A test for Hygienic Hand Disinfection. Journal of Clinical Pathology. 31. 923 Ayliffe, G.A.J. et al. 1992. Control of Hospital Infection A Practical Handbook. Chapman and Hall Medical. London. Chief Medical Officer 2007 2006 Annual Report of the Chief Medical Officer Dirty hands the human cost Department of Health London Infection Control Nurse Association (2002) Guidelines for Hand Hygiene, ICNA, London Infection Control Nurse Association (2002) Audit Tools for Monitoring Infection Control Guidelines within the Community Setting National Institute for Clinical Excellence (2003) Infection Control Prevention of health care associated infection in primary and community care, NICE, London Pittet D. 2001. Improving Adherence to Hand Hygiene Practice: A Multidisciplinary Approach. Emerging Infectious Disease. 7 (2), Mar-Apr. Pittet D, Dharan S, Touveneau S et al. 1999. Bacterial contamination of the hands of hospital staff during routine patient care. Arch. Int. Med. 159. 821-826. Ward V, Wilson J, Taylor L et al. 1997. Preventing hospital-acquired infection. Clinical guidelines. PHLS, London. Page 14 of 19

Appendix 1 The Six-Step Hand Washing Technique (Ayliffe et al, 1978) Page 15 of 19

APPENDIX 2 Areas Most Frequently Missed During Hand Washing (Ayliffe et al, 1992) Page 16 of 19

Appendix 4 Policy Impact Assessment Screening Tool Name of Directorate: Public Health Date of Assessment: 28.06.07 Policy being assessed: Hand Hygiene Policy Assessment Carried out by Jenny Boyce/Keren Salt As Above POLICY TITLE Who is affected Statutory requirements Full Assessment Needed Yes / No Staff Patients Visitors Contractors Volunteers Carers Standards for Better Health (2004) Health Act (2006) NHSLA (2007) Yes Priority High / Medium / Low High Page 17 of 19

Policy Impact Assessment Full Assessment Tool Name of Directorate: Public Health Date of Assessment: 28.06.07 Policy being assessed: Hand Hygiene Policy Assessment Carried out by : Jenny Boyce/Keren Salt 1. What consultation process will be undertaken? 2. Where will records of this consultation be kept? Infection Control Committee, Governance Committee, SHA, Electronically, Infection Control Team records 1. What existing monitoring arrangements are in place? 2. Are these sufficient? 3. Are any additional arrangements required 1. How will the results of the assessment be published? Certain aspects of the policy are audited annually. Yes as a rolling programme. If particular issues arise we will audit these. Via Infection Control Committee Page 18 of 19

POLICY AIMS AND OUTCOMES See section 1.1 1.2, 3.1 and section 6.0 Evidence for assessment Statutory requirements. Policies reviewed annually or sooner if national guidance changes Difference in Outcomes The policy is seen as a useful reference tool when managing instances of infection and understanding the role of hand hygiene in the management of infection. Assessing Impact No adverse impact identified. The issue about the use of alcohol gel has been considered as some aspects of the PCT population may have concerns about using products containing alcohol. This issue has been addressed, as it is not compulsory. Hand washing with soap and water is the most important issue. Proposed action Review as necessary. Page 19 of 19