reference no: sg 34/09 - queen's university...

Standards and Guidelines Committee_Hand Hygiene Policy_V3_2014 of 16

Title: Hand Hygiene Policy

Author(s)

Irene Thompson, Lead Nurse Infection Prevention and Control Healthcare Associated Infection Improvement team

Ownership: Miss Brenda Creaney, Director of Nursing and User Experience/ Executive Lead Infection Prevention and Control

Approval by: Safety and Quality Steering Group Standards and Guidelines Policy Committee Executive Team Meeting

Approval date:

30/6/14 31/7/14 18/8/14 20/8/14

Operational Date:

September 2014 Next Review:

September 2016

Version No. V3 Supercedes V2 2011-2014

Key words: Hand Hygiene, Healthcare Associated Infections, Patient Safety, Compliance, Hand Sanitiser, Hand Washing, Alcohol Hand Rub

Links to other policies

All clinical policies

Date Version Author Comments

09/10/13 2.1 I Thompson Revision to compliance template and to reflect work in primary care

30/03/14 2.2 I Thompson Update references and compliance monitoring

30/06/14 2.3 I Thompson Review of content from feedback

11/09/14 2.4 J.Buchanan Minor amendments to incorporate community issues following review at standards and guidelines committee

Reference No: SG 34/09


1.0 INTRODUCTION / PURPOSE OF POLICY 1.1 Background

The Trust is committed to reducing the risk of Healthcare-associated infections (HCAIs). Hand Hygiene is the single most important factor in reducing the spread of HCAIs, decreasing the risk of colonisation of transient bacteria on the hands of healthcare staff and reducing the risk of cross contamination of potentially pathogenic pathogens (Pittet and Boyce, 2001). This policy provides staff with clear guidance on the actions they must take in order to comply with this policy and the Trust requires a standard of at least 90% Hand Hygiene compliance. All staff are responsible for their own compliance, for encouraging others to do so and for challenging those who don’t. Staff must ensure that hand hygiene is carried out at the correct time using the correct technique on every occasion. (See Appendices 1- 4) Staff must also adhere to the Trust and Regional Dress Code Policy (DHSSPS, 2008). Two documents offering a systematic and expert view of scientific evidence have informed this policy:-

Epic 3: National Evidence-based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England (Loveday, 2014)) http://www.epic.tvu.ac.uk/PDF%20Files/epic2/epic2-final.pdf

WHO Guidelines on hand Hygiene in Health Care (WHO, May 2009) http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf

1.2 Purpose This policy is intended to ensure that all members of clinical and non-clinical staff including students on placement working within the Belfast Trust adhere to and practice good hand hygiene principles.

1.3 Objectives

To ensure a safe environment for patients/clients, staff, carers and public in the Trust.

To reduce the risk of Healthcare Associated Infections (HCAIs) caused by poor hand hygiene.

To achieve and sustain a minimum 90% compliance with hand hygiene standards (5 moments, 7 steps and bare below the elbow).

To ensure that all staff receive hand hygiene training as part of the mandatory infection prevention and control training.

2.0 SCOPE OF THE POLICY

This Policy applies to all staff employed or contracted by Belfast Trust and also to all visiting staff including tutors, students and agency/locum staff.

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

http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf


3.0 ROLES/RESPONSIBILITIES

Every member of staff has personal responsibility to ensure they comply with this policy. It is the responsibility of all ward sisters/charge nurses/midwifery sisters/department managers/clinical leads to ensure that their staff are aware of this policy and that they have met their training requirements. All registered Medical, Nursing, Midwifery, Allied Healthcare Professionals and Social Workers are governed by their individual professional codes of conduct, and as such are personally accountable for their practice (HPC, 2007; GMC, 2006 & NMC, 2008). All members of staff are bound by a personal and contractual responsibility to comply with Trust policy. Directors have responsibility and accountability to ensure that all staff (new and existing) in their area of responsibility are aware of all Infection Prevention and Control policies and that they understand their individual responsibility to follow them at all times.

4.0 KEY POLICY PRINCIPLES

Definitions Hand hygiene is a term that incorporates the decontamination of the hands by methods including routine hand washing and hand disinfection which includes the use of alcohol hand sanitisers (Appendices 1, 2 & 4).

This policy outlines the responsibility and accountability of all staff in providing a safe environment for patients through the appropriate practice of hand hygiene.

Key Policy Statement(s) All staff working in any area where a clinical intervention takes place must be

‘Bare Below the Elbows’. http://www.npsa.nhs.uk/cleanyourhands

All staff (clinical & non-clinical), volunteers & visiting staff must remove any long sleeved jackets/cardigans/jumpers/coats before commencing activities in the clinical environment.

An area where clinical intervention takes place is defined as, ‘any area where a patient is seen and/or treated – e.g. Wards; Social Care Environment; Outpatients’ Departments; Radiology; Emergency Department’.

Wristwatches, bracelets (all types), all rings (except for a plain flat band) and false or gel nails must not be worn. Wrist jewellery prevents the wearer from washing hands adequately, especially around the wrists. (WHO, 2009) Fingernails should be kept short, clean and free from nail polish, false or gel nails.

Long hair must be tied back and off the collar when delivering patient client care so that it does not need constant readjusting. This will ensure that staff do not touch their hair during a procedure and thus contaminate their hands.

Where a headscarf is worn as part of a religious observance staff must ensure that the flow of the garment does not interfere with work practice and that it does not need constant readjusting.

http://www.npsa.nhs.uk/cleanyourhands


Hands must be decontaminated before and after each and every episode of direct patient contact/care and between different care activities for the same patients.

Hands must also be decontaminated after touching any object or furniture in the patient’s immediate environment. (see Appendix 3 – WHO ‘5 Moments’)

Gloves are not a replacement for good hand hygiene. Staff must clean their hands before putting gloves on and after glove removal.

Adequate facilities will be provided to enable staff to wash and dry their hands appropriately, or to use alcohol hand sanitiser, and to protect their skin with moisturiser.

All staff should ensure that cuts and abrasions on their hands are covered with waterproof dressings.

Patients should be given instruction on hand hygiene and where necessary assisted to ensure their hand hygiene requirements are met e.g. ensuring when patients are confined to bed there is the opportunity for hand hygiene before meals and after using a commode/bedpan through the use of hand wipes

Visitors should be encouraged to undertake hand hygiene before and after they visit.

It is the responsibility of all staff to demonstrate consistently high standards of compliance with hand hygiene.

All clinical staff must achieve 90% compliance by September 2014 with hand hygiene standards i.e. bare below the elbow, following the ‘7 step’ technique and the ‘5 moments’ for hand hygiene. Continual improvement is expected to reach 100% over the next 2 years. Any member of staff not complying with the policy should have their attention drawn to Appendices 5 & 6. Serious breaches of this and the dress code policy and/or continuing non-compliance should be reported to the Directorate Senior Manager and the relevant professional lead e.g. Associate Medical Director, who are responsible for taking corrective action and who may commence disciplinary procedures. Repeated failure to follow policy may result in disciplinary action.

RELIGIOUS CONSIDERATIONS Alcohol Hand Sanitisers & Religious Considerations According to some religions, alcohol use is prohibited or considered an offence. However, in general, despite alcohol prohibition in everyday life, most religions give priority to health principles to ensure patient safety. Consequently, no objection is raised against the use of alcohol-based products for environmental cleaning, disinfection or hand hygiene by any religion (World Health Organization, 2006). Bare Below the Elbows & Religious Considerations Advice has been sought nationally on the specific issue of ‘bare below the elbows’ as some religions require that long sleeves must be worn. It has been established that all religions endorse the principle that an individual should do no harm to others. The wearing of long sleeves or the wearing of watches and bracelets prevents effective hand hygiene as it is not possible to clean the wrists fully, and hand hygiene is essential for safe patient care.


Therefore staff who are required by their religion to wear long sleeves must roll-up their sleeves and remove jewellery to ensure the wrist and forearm are exposed in the following circumstances:- 1. When undertaking direct patient contact

2. As part of standard infection control principles when particularly when patients are in source or protective isolation

3. When performing hand hygiene, using either soap & water or an alcohol hand sanitiser.

This aspect of the hand hygiene policy will be kept under regular review.

5.0 IMPLEMENTATION OF POLICY 5.1 Dissemination

All staff working in the BHSCT.

5.2 Resources

The Infection Control section of intranet. The Regional Infection Control Manual. Ward/Department Link personnel. Ward/Department posters and leaflets.

5.3 Exceptions None.

6.0 MONITORING Compliance audits will be carried out as prescribed in Appendix 5 and will

be monitored/managed by the Service Manager/Co-Director. The IPCNs will carry out independent hand hygiene audits in response to increased incidents or outbreaks or as part of Primary Focus Ward work.

Results of the audits will be presented to the Healthcare Associate Infection Improvement Team (HCAIIT). Directorates will produce action plans to address non-compliance.

7.0 EVIDENCE BASE / REFERENCES

DHSSPS (2008) Regional Dress Code Policy & Recommendations on Staff Changing Facilities for Northern Ireland. DHSSPS, 19 February 2008. Water sources and potential Pseudomonas aeruginosa contamination of taps and water systems – advice for augmented care units - published on the Department of Health (DH) website on 30 March 2012. H.P. Loveday, J.A. Wilson, R.J. Pratt, M. Golsorkhi, A. Tingle, A. Bak, J. Brown, J. Prieto, M. Wilcox (2014) epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection 86S1 (2014) S1–S70 Hand Hygiene Task Force (2002) Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices

Infection Control Nurses Association (2002) Hand Decontamination Guidelines. Bathgate. ICNA

National Patient Safety Agency (2004) Business Plan 2003-2004. NPSA.

WHO Guidelines on hand Hygiene in Health Care (WHO, May 2009)

The Standards and Recommendations for Safe Perioperative Practice (AFPP 2007)


Northern Ireland Regional Infection Prevention and Control Manual.

BMA, Dress Codes at Work - http://bma.org.uk/practical-support-at-work/contracts/consultant-contracts/dress-codes

BMA, Board of Science, (February 2006), Healthcare associated infections: A guide for healthcare professionals.

BMA, (June 2009) Tackling healthcare associated infections through effective policy action.

Belfast Trust, Dress Code Policy. March 2011.

Department of Health (England) (2007) Clean, safe care: Reducing MRSA and other healthcare associated infections.

General Medical Council (2006) Good Medical Practice. London. GMC

Hand Hygiene Liaison Group (1999) Handwashing. A modest measure - with big effects. British Medical Journal. 318: 686

Health Professions Council (2007) Standards of conduct, performance and ethics. London. HPC

Nursing & Midwifery Council (2008) Code of Professional Conduct. London. N&MC Pittet D, Boyce J.M. (2001) Hand Hygiene in Clinical care: pursuing the Semmelweis legacy. The Lancet, Infectious Disease. April 2001, 9-20.

Parienti J, Thibon P, Heller R et al (2002) Hand-rubbing with an aqueous alcoholic solution vs. traditional surgical hand-scrubbing and 30-day surgical site infection rates: a randomized equivalence study. Journal of the American Medical Association. 288(6), 722-727

Pittet D, Dharan S, Touveneau S et al (1999) Bacterial contamination of the hands of hospital staff during routine patient care. Archives of Internal Medicine. 159:821-826

H. Sax, B. Allegranzi, I. Uçkay, E. Larson, J. Boyce, D. Pittet, (2007) My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene. Journal of Hospital Infection Volume 67, Issue 1, September 2007, Pages 9–21

8.0 CONSULTATION PROCESS

Trust Directors IPCT Healthcare Associate Infection Improvement team Safety and Quality Steering Group Infection Prevention and Control Committee AMDs ADNs Executive Team Human Resources Staff Side Standards & Guidelines Committee

9.0 APPENDICES / ATTACHMENTS Appendix 1 = Types of hand hygiene and solutions used Appendix 2 = Hand hygiene methods and skin care. Appendix 3 = NPSA/WHO ‘5 moments’ for hand hygiene

- Bedside - Chair

Appendix 4 = Hand hygiene technique posters – Hand washing & Hand sanitiser Appendix 5 = Monitoring, audit and Standard Achievement Appendix 6 = Performance Management of Individual Staff member

http://bma.org.uk/practical-support-at-work/contracts/consultant-contracts/dress-codes

http://bma.org.uk/practical-support-at-work/contracts/consultant-contracts/dress-codes

http://www.bma.org.uk/health_promotion_ethics/diseases/HealthcareAssocInfect.jsp

http://www.bma.org.uk/health_promotion_ethics/diseases/HealthcareAssocInfect.jsp


10.0 EQUALITY STATEMENT

In line with duties under the equality legislation (Section 75 of the Northern Ireland Act 1998), Targeting Social Need Initiative, Disability discrimination and the Human Rights Act 1998, an initial screening exercise to ascertain if this policy should be subject to a full impact assessment has been carried out. The outcome of the Equality screening for this policy is: Major impact Minor impact No impact. X

SIGNATORIES (Policy – Guidance should be signed off by the author of the policy and the identified responsible director).

Date: 17/0914 Author

Date: 17/09/14 Director


Appendix 1

TYPES OF HAND HYGIENE AND SOLUTIONS USED Routine Hand Hygiene: The aim is to remove dirt and transient microorganisms. This is undertaken by using liquid soap and running water for 15 – 20 seconds or by rubbing an application of alcohol hand sanitiser into the hands until dry. Hand Disinfection:

Aim is the destruction of transient microorganisms and a reduction in resident microorganisms. This is used prior to an aseptic technique, invasive procedures, manipulation of lines etc. Wash hands with soap and water followed by an application of alcohol hand sanitiser or wash hands with an approved antimicrobial liquid soap. Surgical Hand Hygiene: This is undertaken by applying an approved antimicrobial agent to the hands and wrists for at least two minutes. A sterile disposable nail brush may be used for the first surgical hand wash of the day, however continued use is not advisable as damage to the skin may occur, which could increase the level of microbial colonization. If an antimicrobial agent is inappropriate for staff, a surgical hand wash with soap and water followed by two or more applications of an approved alcohol hand sanitiser may be used as an alternative (Appendix 2).

Product Where to use When to use

Liquid soap NB-In augmented care settings a hand sanitiser must be used after handwashing

All clinical and non-clinical areas *

When hands are visibly soiled, before and after each and every patient contact (see - Your 5 moments for hand hygiene)

When nursing patients with diarrhoea.

Alcohol Hand sanitiser

All areas where clinical interventions take place

(NB: Not suitable if hands are visibly contaminated)

When hands are not visibly soiled.

Before and after patient contact, and between each patient.

When entering and leaving a clinical area.

Prior to an aseptic procedure.

Prior to an invasive procedure following the prescribed method.

After removing gloves

Alcohol Hand sanitiser is not effective against Norovirus and Clostridium difficile.

Alcohol hand sanitiser approved for surgical procedures

Surgical hand disinfection in accordance with the manufactures instructions on volume of product and time of application

Prior to a surgical procedure and following the prescribed method.

*In the event that hand washing facilities are not available (eg some community settings), alcohol

sanitiser may be used and hands must be washed at the next available opportunity.


Appendix 2

HAND HYGIENE METHODS

Solution How to use

Liquid soap NB- In augmented care settings a hand sanitiser must be used after handwashing

Wet hands under warm running water. Dispense one dose of soap into a cupped hand. Wash hands for 15-20 seconds, vigorously and thoroughly, without

adding more water using the ‘7 step’ technique. Rinse hands thoroughly under warm running water.

Dry hands well with a disposable paper towel and place towel into a foot operated pedal bin.

Use elbows or the paper towel to turn tap off.

Alcohol hand sanitiser (NB: Not suitable if hands are visibly contaminated or patient has diarrhoea)

Very effective alternative when liquid soap and water is not available. It is also useful when rapid hand decontamination is required.

When decontaminating hands using a hand sanitiser, hands should be free of dirt and organic material.

Dispense one application of solution onto the hands. The hand sanitiser solution must come into contact with all surfaces of

each hand for at least 15-20 seconds. Using the ‘7 step’ technique.

Alcohol hand sanitiser approved for surgical procedures

Remove all jewellery including wedding bands. For the first surgical hand hygiene of the day wash hands and arms

with soap and warm running water. Clean nails gently using a sterile plain disposable nail brush or nail

pick. Rinse hands thoroughly. Dry hands thoroughly with paper towel. Only wash again if more than one hour between cases or hands

are visibly dirty. If the time between cases is less than one hour then hand washing is not required before application of alcohol sanitiser.

Using the elbow to activate the lever, pump the alcohol sanitiser into the cupped dry hand. Each portion should consist of 1.5 – 3 ml. of alcohol sanitiser preparation.

Rub in the alcohol preparation in portions over a period of 1.5 minutes (90 seconds).

1st stage - disinfect the hands/fingertips and forearms up to the elbows x 30 seconds.

2nd stage – disinfect the hands/fingertips and up to the mid arm x 30 seconds

3rd stage - disinfect hands/fingertips/wrists only x final 30 seconds. Allow hands and arms to dry by evaporation.

Ensure that hands remain moist during the entire 90 seconds. Keep the hands above elbow level at all times. After the disinfection process, do not dry hands again. Allow alcohol preparation to dry before donning gloves.

Antimicrobial liquid soap e.g. 2-4% Chlorhexidine 5-7.5%Povidone iodine 1% Triclosan

Wet hands under warm running water and apply one measure to wet hands and wrists.

Wash for two minutes using ‘7 step’ technique and forearms. For surgical procedures, dry hands with a sterile soft paper towel and

dispose off into a foot operated pedal bin. A single use sterile nailbrush may be used only for the nails. Not on

skin areas as damage to the skin may result in increased levels of micro-organisms.

Use elbows to turn taps off.


Hand Drying: Hand drying after washing is important as microorganisms will multiply more rapidly and transfer more readily on wet hands. Paper towels must be within easy reach of a sink but beyond risk of contamination from splashing. Use as many paper towels as required to ensure that hands are fully dry before continuing activities.

Always use a foot operated pedal bin to dispose of towels. Do not use clean hands to lift the lid of the bin! Hands must also be decontaminated: -

1. Before commencing work/after leaving a work area.

2. Before preparing or eating food.

3. Before handling medicines.

4. Before wearing and after removing gloves (gloves are not a substitute for

effective hand washing – they can develop holes whilst in use and hands can

become contaminated on glove removal).

5. After handling contaminated laundry and waste.

6. After using the toilet; assisting others with toileting or personal hygiene, before

and after emptying urine bags etc.

Skin Care

It is important to protect the skin on hands from drying and cracking. Skin that

is dry and broken increases the risk of carrying microorganisms.

Cover all cuts and abrasions with a waterproof dressing.

Hand creams can be applied to care for the skin on hands. Only approved

individual tubes of hand cream or hand cream from wall mounted dispensers

should be used.

Hand creams should be applied at suitable times to allow the cream to take effect

e.g. before going to lunch and before going home. Any skin sensitivity problems

must be reported immediately to the Occupational Health Department.

Creams used should not affect the action of hand cleaning solutions being

used or the integrity of gloves.

Communal tubs should be avoided as microorganisms can grow in these over

time.

Soaps or other solutions may cause skin problems for some if used frequently

therefore, this should be discussed with Occupational Health and alternatives

sought and made available

It is your responsibility to 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.

See BHSCT Skin Care Policy


Appendix 3


Appendix 4


Appendix 5

MONITORING, AUDIT AND STANDARD ACHIEVEMENT Hand Hygiene Audit All areas to achieve a minimum standard of 90% or above by September 2014. See flowchart below for frequency of audits. Monitoring Compliance will be monitored/managed by the Service Manager/Co-Director. Results of the audits will be presented to the Healthcare Associate Infection Improvement Team. Directorates will produce action plans to address non-compliance.


Appendix 6

PERFORMANCE MANAGEMENT OF INDIVIDUAL STAFF MEMBER

Member of staff observed as being non-compliant either through audit and/or practice

Is the member of staff who is observing non-compliance able to address the issue

with non-compliant member of staff?

Yes

Is this the first time non-

compliance has been observed? Report to Line Manager

Situation

Rectified

Situation

rectified

Consider whether behaviour constitutes professional

misconduct and, if so, take appropriate action

No

No Yes

Ascertain reason for non-

compliance e.g. lack of

knowledge, inadequate

equipment and rectify

Further

non-compliance

Report to identified leads* who are

responsible for taking corrective action

and may commence disciplinary

procedures.

*Medical staff – Assoc Med Dir

*All other staff –Directorate Mgrs.

Non-compliance

continues

reference no: sg 34/09 - queen's university...

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