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Policy/Guideline title: Hand Hygiene Policy

Author/Lead Infection Control Committee

Prepared by Rachel Ben Salem Team Leader Infection Control

Consultation: Infection Control Committee

Clinical Policies and Practices Committee

Nursing and midwifery Committee

Date of Last Review

(if applicable)

November 2006

Next Formal Review Date: November 2009

Approval Date December 2007-CPPC

Distribution: Trust wide available on datix.

Document Revision Record (if applicable)

Description of Change(s) Reason for Change Author & Group(s)

Date:

Duties- Description of roles and responsibilities

To comply with NHSLA Risk Management Standards

Rachel Ben Salem

November 2008

Process for checking that all relevant permanent staff groups, as identified in the training needs analysis, complete hand hygiene training with flow chart

To comply with NHSLA Risk Management Standards

Rachel Ben Salem

November 2008

Process for following those who fail to attend hand hygiene training

To comply with NHSLA Risk Management Standards

Rachel Ben Salem

November 2008

Process for monitoring compliance with all of the above

To comply with NHSLA Risk Management Standards

Rachel Ben Salem

November 2008

Synopsis: This policy has been developed to give clear guidance to staff in relation to the hand hygiene standard set by NUHT. It describes the process for ensuring the delivery of effective hand hygiene training for all relevant staff groups (clinical and non clinical) and is compliant with the NHSLA Standards for Hand Hygiene

Direction is given on:

Routine hand decontamination (cleaning)

Aseptic hand disinfection

Usage of alcohol hand rub/gel

Surgical hand disinfection (scrub)

Patient hand hygiene

Trust training programme for hand hygiene

This policy describes the procedures which are in place to ensure effective infection control with regard to hand hygiene and details the roles and responsibilities of key individuals. The purpose of this policy is to ensure that the appropriate clinical governance arrangements are in place to minimise the risk of transmission of organisms within the Trust. It forms part of the Trust’s obligations under the Health Act 2006. The needs of children and young people have been considered in relation to this policy and its principles apply equally to them.

What it means for staff All staff are required to comply with the hand hygiene standard set by the Trust. Staff are also required to support and encourage visitors and patients to comply with the standard. Ward and Department Managers – are responsible for ensuring adequate dissemination and implementation of policies as well as adopting the standard of practice for themselves. Training in relation to hand hygiene is provided by Infection Control Team and their deputies through the Induction and mandatory training programmes and other initiatives that include additional training sessions. All ward and department managers are responsible for ensuring that staff meet their training requirements for hand hygiene which are to be taught and checked in hand hygiene technique once (theory and practice). Observations of Hand hygiene compliance is required to be undertaken in all wards and departments through a peer review system and as part of DOH observational audit tools. Any failure to comply with the hand hygiene standard or poor or incorrect technique observed, must be flagged up by the manager and reported to the Infection control team and the person resent on hand hygiene training. Observational compliance audits are also conducted weekly and entered into the infection control sharepoint by ward/department managers or designated persons. This is summarised monthly and reported to Information and Performance and is reported to Trust Board and Integrated Governance Committee and Management Executive Group.

All Trust Employees – are responsible for reading the new/revised policies to maintain current awareness of changes which impact on their roles. All staff have a duty to comply with the policy and undertake training on hand hygiene as above.

Aim: The purpose of this policy is to promote hand hygiene as evidence-based practice and to define responsibilities and actions required for compliance with good hand hygiene practice throughout the organisation in conjunction with the cleanyourhands campaign Objectives • To identify the importance of hand hygiene in the prevention of healthcare associated infections. • To describe the key elements of good hand hygiene practice. • To identify strategies to implement the policy and improve compliance with good hand hygiene practice

The following general (statutory) duties apply: All Staff are responsible for co-operating with the development and implementation of Trust policies as part of their normal duties and responsibilities. In addition, it is the responsibility of all clinical staff to;

Complete effective hand decontamination, when indicated, in order to reduce the risk of infection transmission;

Receive training in the correct hand decontamination techniques

Who the policy/guideline applies to/is relevant to: All staff are required to comply with the hand hygiene standard set by the Trust. Staff are also required to support and encourage visitors and patients to comply with the standard

General and Business Managers/Ward Managers and Matrons are responsible for ensuring adequate dissemination and implementation of policies as well as adopting the standard of practice for themselves. Infection control training in relation to hand hygiene is provided by the Infection control team through training programmes and other initiatives. Clinical directorates are responsible for ensuring that staff meet their training requirements for hand hygiene.

All Trust employees are responsible for reading the new and revised policies to maintain current awareness of changes which impact on their roles. All staff including contracted and other service providers have a duty to comply with the policy and undertake training on hand hygiene.

Training implications: Process for enabling all relevant staff groups to complete hand hygiene training Planned induction and mandatory training as identified in the training needs analysis (Appendix 5) is required to implement this policy for clinical staff and non-clinical staff. Additional mandatory group session training may be provided by Infection Control and can be booked by line managers through Oracle Learning management (OLM) on ESR. a) New staff- All new staff receive the theory and practice of hand hygiene training at corporate induction. This member of staff is then signed off as competent and receives a certificate of competence. Any issues that may arise with compliance of the staff member to this policy at a later date will be managed locally in the ward area or department and dealt with as above (under Synopsis- ‘Ward and Department Managers’. b) Existing staff-All existing clinical staff are required to receive the theory and practice of hand hygiene training once and demonstrate hand hygiene competency as above. They need to book onto the mandatory sessions. All staff must have hand hygiene training checked at the person’s individual appraisal by the line manager. If they have not been trained in hand hygiene then the manager will need to arrange to get them assessed and signed off. Existing Non clinical staff are required to undertake hand hygiene training as above i.e. receive the training once. This training remains the responsibility of the directorates themselves to book their staff as required. All training records of all staff will be kept in Oracle Learning Management. In addition to this Infection Control will support the Directorates to run Hand Hygiene Initiatives during the period of this policy to ensure hand hygiene remains aTrust priority. All attendance records should be entered into Oracle Learning Management (OLM) and reported to the Infection Control Committee (ICC) quarterly. A summary should be included in the Director of Infection Prevention and Control (DIPC)’s annual report. Hand Hygiene Training for Volunteers, Contractors, and Others

Hand Hygiene training is available to anyone working in the Trust, paid or unpaid and it is the responsibility of the individual manager for such workers to be trained and checked once in the theory and practice of hand hygiene. Managers must book staff onto courses through the OLM system as above.

Equipment: Dedicated hand wash basin with no plug or overflow that is easily

accessible (separate to a dedicated sink for cleaning equipment, etc);

Each hand wash sink must be equipped with warm running water ideally from a biflow mixer tap or an infrared not-touch tap

Disposable paper hand towels and approved liquid soap should be available in approved wall-mounted dispensers at each hand wash sink. A poster demonstrating an effective hand washing technique displayed over hand washing sinks in clinical areas.

A foot operated pedal bin should be available at each hand wash sink for the hygienic disposal of paper towels (used towels should not be disposed of as clinical waste unless contaminated with blood or body fluids or inside a barrier nursing room).

Washing the hands with approved liquid soap and water is adequate for most routine activities

Alcohol rub/gel (with emollients) in either a wall mounted dispenser or a pump action bottle available at every bed space except for child and mental health.

Alcohol hand rub/gel is available outside every bay and at the entrance and exit to every ward and department in a wall dispenser

Alcohol hand rub should be available on every notes trolley Each clinical area must also have access to approved dispensers of emollients for staff use to

help maintain skin patency. This should be supplied in wall-mounted dispensers, located in suitable

positions. Staff should not share tubes of handcream Aqueous antiseptic solutions (surgical scrubs). The most commonly used of these are products

based upon chlorhexidine gluconate and povidone-iodine. These should be used when a reduction in numbers of resident flora are required for invasive procedures e.g. central line insertion, surgery etc and should be in approved wallmounted dispensers in theatres and one dispenser wall mounted on one clinical hand wash basin in each ward.

Outcome measures: Hand hygiene observational audits; Saving Lives High impact observational tools to monitor clinical processes and performances and improve the reliability of clinical practices Good hand hygiene is everyone’s business and if we are to prevent the spread of infection staff/visitors and patients must read and follow the hand hygiene procedure in this policy. There is no excuse for anyone forgetting to clean their hands and any individual or group of individuals who fail to adhere to the hand hygiene procedures may be subject to disciplinary action.

I would encourage all of you, if you see a member of staff in contravention of the Policy to:

Remind the member of staff of the Policy Make a simple diary note Report the incident to the member of staff's line manager/clinical director Complete and send off an incident form

Weekly, monthly and quarterly infection data on healthcare associated infections including MRSA , CDT data representative of each ward and clinical area

Appropriate use: All contact with patients in an inpatient or outpatient setting

Inappropriate use: There are no contra-indications to this policy

What to do if policy is not followed by others: If the policy is not followed a reporting and learning form will be filled out and sent to clinical governance

Microbiology of the Skin Micro-organisms found on the skin can be described as Resident Flora Normal flora or commensal organisms forming part of the bodys normal defense mechanisms and protecting the skin from invasion by more harmful microorganisms. Resident skin flora, are permanent flora, located in deeper skin layers, that protect the skin from other harmful bacteria. They are harmless in most situations except invasive procedures. They rarely cause disease and are of minor significance in routine clinical situations. However, during surgery or other invasive procedures, resident flora may enter deep tissues and establish infections. Removal of these organisms is desirable by following the surgical scrub technique Transient Flora Those acquired by touch i.e. from the environment, touching patients, laundry, equipment etc. Removal of transient flora is essential in preventing cross infection and transient organisms are easily removed by hand decontamination. They are located superficially on the skin and account for most healthcare associated infections including Clostridium difficile(CDT) and Methicillin resistant Staphylococcus aureus (MRSA) Duties Duties and process to ensure compliance - All individual staff are responsible for the adherence to this policy. Ward and Department Managers are - responsible for ensuring adequate dissemination and implementation of policy as well as adopting the standard of practice for themselves. Training in relation to hand hygiene is provided by Infection Control staff and their deputies through the mandatory training programme and other initiatives. This training is to be booked on request through the infection control team via oracle learning management. All ward/department and other managers are responsible for ensuring that their staff meet their training requirements for hand hygiene which are to be taught and checked in hand hygiene technique once. Observations of Hand hygiene compliance is required to be undertaken in all wards and departments through a peer review system and as part of DOH observational audit tools. Any failure to comply with the hand hygiene standard or poor or incorrect technique, must be flagged up by the manager and reported to the infection control team and the persons manager; so that the staff member can be resent on hand hygiene training. Observational compliance audits are also conducted weekly and entered into the infection control sharepoint by ward/department managers or designated persons. This is summarised monthly and reported to Information and Performance and is reported to Trust Board and integrated Governance Committee and Management Executive Group. Directorates are required to report on hand hygiene training compliance within their unit meetings and quarterly the Infection Control Committee are updated with how many staff have been trained. Observational audits of hand hygiene compliance is required and undertaken in all wards and departments and is the responsibility of each Directorate. Compliance issues in relation to this will result in the need for the staff members to receive retraining (implemented by the Ward or department managers and provided by the ICT). All Trust Employees – are responsible for reading the new/revised policy to maintain current awareness of changes which impact on their roles. All staff have a duty to comply with the policy and undertake training (theory and practice) in hand hygiene once. Infection Control Team - is responsible for facilitating the delivery of hand hygiene initiatives. The team is responsible for reporting on the progress of initiatives to the Infection Control Committee. The infection control team is responsible for the provision of a representative to deliver hand hygiene training on the mandatory training programme and respond to the request for a representative for training as necessary. Infection Control Committee - Minutes of the Infection Control Committee meetings will reflect the progress of the Trusts delivery against target and the minutes will be reviewed at Trust wide Integrated Governance Committee.

Trust wide Governance Committee- Areas/departments at risk of non compliance to the policy will be highlighted at Clinical Governance meetings. Areas of non compliance will be identified on the appropriate risk register. Process of follow up for non attendees at training Clinical Staff – Follow-up of those who fail to attend the Hand Hygiene Mandatory Training is undertaken by the Facilitator of the training. Managers are contacted by the Infection Control Team to make managers and budget holders aware that staff have DNA’d and they need to be re-booked. Those that fail to attend will be booked onto the next available session through training department or Infection Control. Ward Managers are required to monitor this and follow up any non attendees. Failure of any individuals to attend may result in disciplinary action. Non-Clinical Staff – Follow-up of those who fail to attend Infection Control training is the responsibility of the line managers. Infection Control will provide attendance records to the line managers. Line managers are responsible for re-booking non-attendees. Monitoring and Audit Both the adherence and application of this policy will be monitored by the infection control committee. The Infection Control team will conduct hand hygiene audits x 4 yearly. All wards and departments will conduct weekly and monthly hand hygiene observational audits. Any discrepancies and non compliances will be addressed promptly with the relevant staff concerned by the managers and staff identified retrained. Attendance at training is input on to ESR by Infection Control Team and numbers reported at the Infection Control Committee. Non compliances are followed up as above. A monthly summary document will be completed to capture the hand hygiene activity and hand hygiene compliance results by all wards and departments. This is monitored by Trust Board and Integrated Governance Committee and Management Executive Group and forms part of the Infection Control Scorecard.

PROCEDURE / GUIDELINE

ACTION RATIONALE

Risk assessment and Process

•There are three levels of hand hygiene applied to healthcare delivery

•They are

•Routine hand decontamination (cleaning) (Level 1)

•Aseptic hand disinfection (Level 2)

•Surgical hand disinfection (Level 3).

•Hand disinfection using alcohol gel may be used to decontaminate hands when moving between patients or from ward to ward when hands appear to be clean. Alcohol gel is ineffective and does not kill spores e.g. Clostridium difficile and must not be used without hand washing when caring for patients with diarrhoea. This includes touching patient care equipment

•Routine hand decontamination (cleaning)level 1

When to perform

Decontamination refers to the processes used for the physical removal of transient micro-organisms from the hands. Hands should be decontaminated:-

Before and after having contact with patients (e.g. taking pulse, BP, Lifting)

Before putting on and after removing gloves

After direct contact with inanimate objects , including equipment, in the patients immediate environment

If moving from one body site to another during patient care After assisting patients with toileting or personal hygiene Before assisting patients with feeding

Before and after handling wounds, urethral catheters or Intravenous lines and devices Before and after emptying urine drainage bags Before and after performing aseptic procedures e.g. venepuncture, cannulation, catheterisation etc

Before caring for susceptible patients e.g. immunocompromised

After handling contaminated laundry and waste After contact with patients in isolation or

The method of decontamination will depend on assessment of what is appropriate for the episode of care

Effective hand hygiene will render the hands clean and will help prevent cross-infection

Expert consensus groups agree that effective hand decontamination results in significant reductions in the carriage of potential pathogens on the hands. This logically decreases the incidence of preventable Health Care Associated Infections leading to a reduction in patient morbidity and mortality.

The method of decontamination will depend on assessment of what is appropriate for the episode of care. Both the decision to decontaminate hands and what type of cleaning agent to be used should be based on a risk

during outbreaks (including those infected or colonised with resistant organisms e.g. MRSA and CDT

Before leaving source isolation

Before commencing work and after leaving a work area

Before consuming food

After using the toilet;

Correct technique for routine handwashing

Wet hands under running water

Apply one dose of liquid soap into a cupped hand ensuring all surfaces of the hands come into contact with product

Vigorously perform rotational hand rubbing on both palms and interlace fingers to cover all surfaces as per hand hygiene poster (Appendix 1) for 10-15 seconds.

Pay particular attention to the tops of fingers, inbetween and the thumbs. Rinse hands with water and dry thoroughly with single use towels.

Use towels to turn off taps

Dry hands with disposable paper towels

When to use alcohol hand rubs

If hands are not visibly soiled and have not been contaminated with CDT spores use an alcohol hand rub for routine hand decontamination in all clinical care situations as above; alternatively wash hands using liquid soap and water

Correct technique for hand disinfection with Alcohol gel

Hands must be free of organic matter(dirt) visibly clean and dry

Alcohol gel must be rubbed into all surfaces of the hands

Rub hands together vigorously paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers until all the solution has evaporated and the hands are completely dry

ASEPTIC HAND DISINFECTION When to perform: • Prior to an invasive or aseptic

assessment. This must include the likelihood that micro-organisms have been acquired or may be transmitted, whether the hands are visibly soiled, and what procedure is about to take place.

Hand hygiene is pivotal in the prevention of transmission of infection. Numerous studies have implicated poor hand hygiene practice in the transmission of microorganisms from patient to patient.

After contact with body fluids or excretions, mucous membranes , non intact skin or wound dressings

The individual is responsible for undertaking a risk assessment to identify which hand hygiene activity should be performed in individual circumstances

Topical alcohol is useful for rapid hand disinfection and should be made available by the ward or department manager at the point of patient care in all circumstances

Risk assess whether the procedure or type of care requires aseptic hand decontamination

procedure, such as cannula insertion or wound care. • Before caring for someone very susceptible to infection (e.g. before entering a protective isolation room). Method 1 (1) Preparation: - Roll sleeves up to elbows; remove any watches or jewellery. - Wet hands & forearms under warm running water. (2) Handwash: - Apply one or two doses of liquid soap to palm of one hand. Rub all surfaces of the lathered hands vigorously for a minimum of 10 -15 seconds, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers, and including the forearms and wrists. - Rinse well under running water until all soap removed. Turn off taps using elbows or paper towels. - Dry hands and forearms completely using paper towels. Place used towels in a foot-operated bin; do not touch the top of bin with hands. (3) Apply alcohol gel handrub: - Follow handwash by applying 1-2 measures of alcohol gel to dry hands and wrists. Rub gel into all surfaces until evaporated and hands are completely dry. Method 2 Preperation;as method 1 above Handwash with antiseptic agent:apply recommended amount of aqueous antiseptic solution such as 4% chlorhexidine gluconate in surfactant solution (Hibiscrub). Rub all surfaces of the lathered hands vigorously for 1-2 minutes including forearms and wrists (as method 1). Rinse and dry completely (method 1). If an antiseptic agent is used it is not necessary to apply alcohol gel handrub afterwards Surgical hand disinfection Level 3 Perform before any highly invasive or surgical procedure (e.g. surgical operations)

The same products as used for routine hand cleaning can be used for aseptic hand decontamination-the main differences are that you need to decontaminate wrists and forearms and increase the time taken

A higher level of decontamination than routine handwashing, hand asepsis aims to reduce resident microorganisms as well as destroying or removing transient micro-organisms.

See also Theatre infection control policy

Washing should be for a minimum of 2

Surgical scrubbing is a prolonged handwashing procedure that removes all transient micro-organisms and suppresses resident flora, providing a higher level of decontamination

Method

The following 2 methods are recommended

Wash hands and forearms with an aqueous antiseptic agent, chlorhexidine gluconate 4% or Povidine iodine 7.5% for 3-5 minutes using the technique previously described. Dry hands and forearms completely

If hands and forearms are already clean, apply alcohol gel handrub to dry hands, wrists and forearms for 2-3 minutes, ensuring all surfaces are covered, using the technique previously described. This option may be used as an alternative to antiseptic handwash in between cases

Allow hands and forearms to dry completely before donning sterile gloves

Standard required of staff working and entering clinical areas

All staff who come into contact with patients must remove watches and jewellery. Any bracelet worn for religious or cultural purposes must either be removed or worn further up the arm to allow for wrist or forearm decontamination

Sleeves must be rolled up and turned back when in clinical areas with direct patient contact and during hand washing. Remove long-sleeved clothing, or roll up long sleeves, before any patient contact. Perform hand hygiene before putting long-sleeved clothing back on, or rolling sleeves back. To ensure effective communication, clothing which covers the face (veil/niqab) is not permitted for any staff in contact with patients, carers or visitors, or for staff in other roles where clear face to face communication is essential.

minutes ( studies have shown that this is effective in reducing hand bacterial colony counts; there is no evidence than more than a 2 minute wash using aqueous disinfectants is required).

The first wash of the day should include a thorough clean under the fingernails; a brush or orange stick can be used. Nailbrushes should be for single use only. A nail brush should be used for the first handwash of the day only to avoid damage to the skin Wrist and forearms need to be decontaminated as well as hands: clean each hand and forearm using rotational rubbing Hold hands and forearms higher than elbows while doing this, so that water and debris drip away from hands and into the sink

The handwash process must be thorough and systematic, covering all areas of the hands and forearms

Hands must be dried thoroughly adhering to the principle of working from the fingertips to the elbows and using one towel per hand (NATN, 2004)

Rings, wristwatches and other jewellery worn on the hands and wrists become contaminated during work activities. In addition they prevent thorough hand hygiene procedures. Long sleeves prevent thorough hand hygiene procedures, and are more likely to become contaminated during work activities

•Nails must be kept short

•No artificial nails must be worn

•Nail polish must not be worn

•Rings with the exception of plain wedding bands must not be worn Wrist watches and bracelets must not be worn

Irritations to skin on hands Staff who identify skin irritation of their hands are responsible for contacting Occupational Health. Occupational Health are required to advise the individual on actions they may take to resolve skin irritation issues. Cover cuts and abrasions with a water-impermeable dressing, prior to clinical contact. Staff with skin lesions that cannot be adequately covered must not work until they have received advice from the Occupational Health Department.

Patients/Visitors

•Patients and visitors must be encouraged to undertake hand hygiene in line with this policy when on Trust premises

Patients should wash their hands before eating food,or staff should offer or provide a handwash to patients as necessary. Information leaflets on handwashing are available to all inpatients and their relatives. Specific attention must be paid by patients and relatives if standard precautions are being applied as laid down in the Trust isolation policy

Additional information

•Ward Managers are responsible for ensuring that posters demonstrating appropriate hand hygiene technique are available and visible within their departments

Natural fingernails harbour micro-organisms (Larson 1995). Fingernails should be kept short, clean and free from nail varnish. Artificial nails and nail extensions harbour higher levels of micro-organisms than natural fingernails, and these micro-organisms are not removed easily during hand hygiene. Artificial nails and nail varnish can break and chip off, and this may pose a risk to patients especially when wounds are present

Staff with acute or chronic skin lesions/conditions/reactions should seek advice from the Occupational Health Department.

Visual reminders of handwashing can support staff, patients and visitors to carry out effective hand hygiene techniques

References:

Ayliffe, G, Babb, J, Quoraishi, H (1978) A test for hygienic hand disinfection. Journal of Clinical Pathology. 31 (10).923-928

•Department of Health (2005) Saving Lives a delivery programme to reduce healthcare associated infections including MRSA

•Pratt R; Pellowe C; Wilson J; Loveday H; Harper P; Jones S; McDougall C; Wilcox M( 2007).Epic2: National evidence base guidelines for preventing healthcare associated infections in NHS hospitals in England .Journal of Hospital Infection 65S:S1-S64 •Gould, D, (2006). Commentary on handwashing. Journal of Advanced Nursing 53 50-51.

•Hand Decontamination Guidelines (2002). Infection Control Nurses Association www.icna.org.uk

•Health & Safety Executive (2002) Control of Substances Hazardous to Health Regulations. London, HSE

•Jarvis WR (1994). Handwashing- the Semmelweis lesson forgotten? Lancet.; 344:1311-2

•Larson EL. APIC Guidelines for handwashing and hand antisepsis in health care settings. Am J Infection Control 1995; 23: 251-269

•National Patient Safety Agency (NPSA) 2004 Clean your hands campaign

Standards and Recommendations for Safe Perioperative Practices

(2007).Published By NATN, Harrogate

Weblinks

http://tinyurl.com/32v2lo

http://www.epic.tvu.ac.uk/PDF%20Files/epic2/epic2-final.pdf

Appendices:

Appendix 1- Practical Procedures for Handwashing Appendix 2- Summary of key points:Hand Decontamination ‘Clean hands’

Appendix 3- Areas commonly missed during hand decontamination

Appendix 4- 6 Stage procedure for handwashing

Appendix 5- Training Needs Analysis

Appendix 2 Summary of key points:Hand Decontamination ‘Clean hands’

Hand hygiene is the single most

important method of preventing

cross-infection:

• Cleaning your hands will help

prevent cross-infection and will

decrease the risk of spreading

infection.

• You have a duty to protect

patients and yourself through

good hand hygiene practice at

all times.

There are regular teaching sessions on hand decontamination. If you have not attended one of these and would like to, please contact your manager or a member of the Infection Control team.

When should you clean your

hands?

The required standard for routine hand

decontamination is:

• After each and every direct patient

contact

• After any patient care procedure

that involves contact with the

immediate patient environment,

such as bedmaking or washing a

patient

• After handling equipment, n

otes or specimens

• After cleaning equipment

• After removing gloves

Alcohol gel hand rubs

• Should be used for routine hand

cleaning.

• Are as effective as soap and water

(assuming hands are visibly clean

to start with). For routine hand

cleaning it is not necessary to wash

hands as well as using gel.

• Are quicker than hand washing,

easy to use and convenient

• Provide patients with a visible

assurance that you have clean

hands, as you use gels by the

bedside.

Care for your hands by:

• Regular use of hand creams during

breaks and when off duty.

• Thorough drying after hand

washing helps to prevent chapping

of the skin.

• Use of products containing

emollients that reduce drying

effects.

Appendix 3-Areas commonly missed during hand decontamination

Appendix 4- 6 Stage procedure for handwashing

Appendix 5 Training Needs Analysis Hand hygiene and decontamination requirements will vary depending on the staff group and the level of patient contact. The following are the different levels of training: i Alcohol hand gel using Ayliffe technique ii Water and liquid soap using Ayliffe technique iii Clinical decontamination using Ayliffe technique, plus aseptic non-touch technique or aseptic technique iv Surgical decontamination – surgical scrub plus sterile aseptic technique. Staff group Number of Staff Level of training required Achieved/Attended Registered Nurses

i, ii, iii(iv where appropriate)

Health Care Assistants

i, ii, (iii where appropriate

Doctors

I,, ii, iii (iv where appropriate)

Phlebotomists i, ii, iii

Theatre ODPs I,, ii, iii (iv where appropriate)

Physiotherapists i, ii, iii

Radiographers i, ii, (iii where appropriate)

Occupational Therapists

i, ii,

Dietetic Department i, ii,

Medirest i, ii Porters i, ii ISS Mediclean i, ii Estates i, ii Volunteers i, ii,

Administration Staff i, ii,

REQUEST FOR POLICY REVIEW

The Trust Board/Clinical Policies & Procedure Committees is asked to approve the reviewed policy for immediate implementation. Policy title: ……………………………………………………………………………… Author/Lead Date

policy was last approved:

Name of body who originally approved Policy

Details of Trust committees who have been involved in review/consultation process:

List changes made during review: (e.g. roles & responsibilities have been re-assigned, new evidence incorporated.