Hand Hygiene Guidelines - WhatDoTheyKnow - … · Web viewWet hands under tepid running water before applying liquid soap or antiseptic preparation e.g. Hibiscrub or Povidone Iodine

HAND HYGIENE GUIDELINES

Edition No: 4 ID Number: POLCGR51-4Dated: July 2009 Review Date: July 2011

Document ID: Policy Document Type: CorporateDirectorate: Nursing Category: Governance & RiskDepartment(s): Infection Control

Author: Infection Prevention and Control Team

Sponsor: Director of Infection Prevention & Control

Policy Dissemination All staff within Medway NHS Trust

Consultation ProcessTitle of Individuals ConsultedInfection Control TeamModern MatronsWard Managers

Name of Committee / Group Consulted Date Infection Control Committee 22nd July 2009

Approval SignaturesJob Title Signature Date

1. Director of Nursing & Strategic Planning Jacqueline McKenna 1st September 2009

2. Medical Director Gulzar Mufti 3rd September 2009

3. Director of Infection Prevention & Control Rella Workman 8th September

2009 Corporate ApprovalCommittee / Job Title DateInfection Control Committee 22nd July 2009

Edition No: 4 Page 1 of 17


Document Control / HistoryEdition No Reason for Change1 Replacement for ICTAP2 Nursing Structure Review3 Reviewed

References:

Policies, Procedures, Standards for Better Health, CNST, NICE Guidelines and any other interlinking documents.

Document: Ref No:DOH (2001) The Epic Project: Developing National Evidence-based Guidelines for Preventing Healthcare Associated Infections. Journal of Hospital Infection (2001) 47 (supplement). Available online at: http://www.his.org.uk/the_journal_of_hospital_infection.cfm. ICNA (2002) Hand Decontamination Guidelines: ICNA/Regent.The Health and Social Care Act 2008NPSA (2007) Cleanyourhands Campaign available on line at www.npsa.nhs.uk/cleanyourhands


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

http://www.his.org.uk/the_journal_of_hospital_infection.cfm

http://www.his.org.uk/the_journal_of_hospital_infection.cfm


Table of Contents

Section Page

1 Introduction 4

2 Aim 4

3 Objective 4

4 Definitions 4

5 Roles & Responsibilities 5

6 Micro-organisms Found on the Hands 6

7 Routine Hand Decontamination 6

8 When Should Hands be Routinely Decontaminated? 6

9 Surgical Hand Decontamination 7

10 Choice of Cleansing Agent 7

11 The Correct Method for Clinical Hand Washing 8

12 Routine Decontamination of Hands Using Alcohol Based Hand Rubs 9

13 Prevention of Skin Damage 9

14 Hands Creams 10

15 Evidence of Training 10

16 Monitoring and Review 11

17 Equality Impact Assessment 12

18 Appendix 1 – 10 Important Points for the Use of Alcohol Hand Rub 13

19 Appendix 2 – 5 Moments for Hand Hygiene 14

20 Appendix 3 – Training Matrix 15



1 Introduction

1.1 Healthcare associated infections (HCAI) constitute one of the greatest challenges of modern medicine. HCAI affects 8% of acute admissions, delays discharge by 11 days and costs £3000 per case, on average. It leads to the death of 5,000 patients and costs the NHS £1 billion a year. The significance of healthcare associated infection has been highlighted in recent decades by the emergence of highly resistant pathogens; some of these have the capacity to spread easily from patient-to-patient and may cause infections that are very difficult to treat e.g. Glycopeptide Resistant Enterococci (GRE) and Meticillin resistant Staphylococcus aureus (MRSA).

2 Aim

2.1 Hand decontamination has a dual role to protect both the patient and the healthcare worker (HCW) from acquiring micro-organisms which may cause them harm. Hands may be contaminated by direct contact with patients, indirectly by handling equipment or through contact with the general environment. Patients with invasive devices or undergoing invasive procedures are particularly vulnerable to infection from micro-organisms transferred on hands. Hand decontamination results in significant reduction in the carriage of potential pathogens on hands.

3 Objective

3.1 To prevent transmission of infection due to poor hand hygiene compliance.

3.2 To ensure compliance with Trust standards by all staff.

4 Definitions

4.1 Hands are considered to play a major role in the transmission of infection between patients. International studies show that infection rates can be reduced by 10 – 50% when healthcare staff regularly clean their hands yet staff commonly clean their hands less than half as many times as they should, for a variety of reasons, such as inadequate facilities, sore hands, lack of time and lack of awareness. The introduction of alcohol hand rub has been instrumental in improving hand hygiene compliance in healthcare and is recommended for routine use in the clinical environment where hands are not visibly soiled. (Appendix 1)

4.2 The transmission of micro-organisms from patient to another via the hands, or from hands that have become contaminated from the environment, can result in cross infection. This can occur:

Directly:when micro-organisms are introduced into susceptible sites, such as surgical wounds and intravenous cannula sites

or

Indirectly:where micro-organisms transferred by the hands become established on a patient and subsequently cause infection at susceptible sites.



5 Roles, Responsibilities and Duties

IT IS THE RESPONSIBILITY OF ALL TRUST PERSONNEL TO COMPLY WITH HAND HYGIENE POLICY AND PROCEDURES. Non Compliance will be addressed via the performance management framework.

5.1 Infection Prevention and Control Team

Development of policies. Education and training. Specialist advice Patient information Audit and surveillance. Compliance with this policy Co-ordination of cleanyourhands campaign Provision of performance data to Trust management and Trust Board.

5.2 Heads of Nursing/Matrons

Compliance with Infection Control training (including hand hygiene). Performance management of clinical teams. Reporting via Nursing and Midwifery Accountably system. Promotion of hand hygiene champions in accordance with the cleanyourhands

campaign

5.3 Clinical Directors

Compliance with Infection Control training. Performance management of clinical teams. Promotion of hand hygiene champions in accordance with the cleanyourhands

campaign

5.4 Director of Human Resources

The Director of Human Resources is to ensure that 100% of staff have mandatory IC training.

5.5 Ward/Department Managers

Allocation of resources (soap and alcohol gel/cleanyourhands posters and leaflets) to aid compliance with policy.

Education and training.

Audit of compliance and performance management of team members

Patient/visitor information to include hand hygiene advice and the cleanyourhands campaign to be readily available within their clinical area.



5.6 Link Nurses

Education and training of all staff in hand hygiene (annual and on induction). Audit of compliance. Patient/visitor information provision to patients and visitors.

5.7 Housekeeping To ensure ward facilities are cleaned to a satisfactory standard and provision of

supplies and sundries to the wash hand facilities.

6 Micro-organisms Found on the Hand

6.1 There are two populations of microbes present on the hands; the resident micro-organisms that normally colonise the skin and the transient micro-organisms that temporarily lodge on the surface.

6.2 Resident micro-organisms live in deeper skin layers. They play an important role in protecting the skin from invasion by other harmful species. They are not readily transferable to other people or surfaces and are not easily removed by washing with liquid soap.

In most situations resident micro-organisms are unable to cause infection and therefore it is unnecessary to remove them from the hands during routine clinical care. However, during highly invasive procedures e.g. surgery, there is a risk that resident micro-organisms may enter the patients body and cause infection.

6.3 Transient micro-organisms do not normally live on the skin but are readily acquired and transferred by touch, either through contact with other body sites on the same individual e.g. the nose, other people or the environment.

In the clinical setting there is considerable opportunity for the hands to transfer micro-organisms between patients or their environment in this way. Most transient micro-organisms are likely to be acquired from contact with heavily contaminated material such as body fluids, but can still be acquired from contact with apparently clean objects or surfaces such as patients’ skin, bed linen and work surfaces.

7 Routine Hand Decontamination

7.1 The aim of routine hand decontamination is to remove transient micro-organisms acquired on the hands before they can be transferred. This is readily achieved using alcohol hand rub on visibly clean hands or by using liquid soap and water using an effective technique.

8 When Should Hands be routinely Decontaminated?

8.1 There are 5 key moments during patient care when hand hygiene is crucial (Appendix 2). The 5 moments are:

a) Before patient contactb) Before an aseptic taskc) After body fluid exposure



d) After patient contacte) After contact with patient surrounding

8.2 It is also important, even when not involved in patient care to clean your hands:

a) After using the toilet or assisting someone elseb) Before and after using PPEc) Before doing anything with foodd) Before leaving worke) On entrance and exiting Wards and Departments

9 Surgical Hand Decontamination

9.1 Surgical hand decontamination is used prior to surgical or other highly invasive procedures where extra care must be taken to prevent micro-organisms on the hands becoming introduced into tissues should gloves be damaged. Surgical hand decontamination aims to substantially reduce resident micro-organisms and remove or destroy transient micro-organisms. This process is achieved by using an antiseptic hand cleansing preparation or an alcohol rub.

10 Choice of Cleansing Agents

10.1 There are a range of cleansing products available for hand decontamination and the selection of the correct agent will depend on whether the removal of transient or resident micro-organisms is required. It is also important that the product does not cause adverse reactions to the skin.

10.2 Soap and Water

Hand washing with soap suspends transient micro-organisms in solution and allows them to be rinsed off; this process is referred to as mechanical removal of micro-organisms. Soap and water is not suitable for hand decontamination where a higher level of skin disinfection is required i.e. prior to surgery or other highly invasive procedures. Liquid soap dispensers with individual replacement cartridges are the preferred option in clinical settings.

Bar soap is not recommended in healthcare as it frequently grows micro-organisms.

10.3 Advantages of soap and water:

a) Cheap and readily availableb) Effectively removes transient micro-organismsc) Readily removes Clostridium spores

10.4 Disadvantages of soap and water:

a) Time consumingb) Requires facilities for washing and dryingc) Can damage skin

10.5 Alcohol-based Preparations



Alcohol hand rubs/gel offer a practical and acceptable alternative to hand washing in most situations, provided hands are not visibly soiled (alcohol is not a cleansing agent). Alcohol hand rubs achieving the European Standards 12791 are suitable for surgical hand decontamination.

Alcohol hand rub should be used routinely when hands are not visibly soiled (the majority of the time).

10.6 Advantages of alcohol:

a) Alcohol-based hand rubs/gels are more effective in destroying transient micro-organisms than antiseptic hand washing agents or soap and water.

b) Active immediately against a wide range of micro-organisms.c) Requires no facilities.d) Kinder to the skin due to added emollients.e) Can be packaged into bag/pocket sized containers.f) Useful for rapid bedside hand decontamination between patients or procedures.g) Useful for community-based HCWs where access to adequate hand washing facilities

may be lacking.

10.7 Disadvantages of alcohol

a) Not a cleansing agent.b) Astringent, making hands sting if minor skin abrasions are present.c) Flammable – requires correct storage.d) Limited activity against bacterial spores e.g. Clostridium difficile, anthrax.

10.8 Aqueous antiseptic solutions

Antiseptic hand washing solutions used with water will both remove and destroy micro-organisms on the hands. This process is referred to as chemical removal of micro-organisms.

Some antiseptic agents have a residual activity so provide continued anti-microbial activity. This on-going activity is of benefit during surgical procedures and helps to minimise the risk of contaminating the surgical field if glove punctures occur.

A range of aqueous antiseptic solutions are available but only a few are routinely used in the UK. These include:

a) Chlorhexidineb) Iodophorsc) Triclosan

11 The Correct Method for Clinical Hand Washing (Appendix 2)

11.1 A good technique covering all surfaces of the hands at the right time is more important than the agent used or the length of time taken to perform it.

11.1.1 Remove all wrist and hand jewellery at the beginning of each clinical shift 11.1.2 Wet hands under tepid running water before applying liquid soap or antiseptic

preparation e.g. Hibiscrub or Povidone Iodine.



11.1.3 The hand washing solution must come into contact with all surfaces of the hand.

11.1.4 Rub the hands together vigorously for a minimum of 10-15 seconds, pay particular attention to the tips of the fingers, the thumbs and areas between the fingers.

11.1.5 Dry hands thoroughly using paper towels.

11.2 Apply hand cream regularly to protect skin from the drying effects of regular hand washing.

11.3 Nail varnish(including colourless) or nail decorations are not permitted and nails should be kept short when entering clinical areas, and particular attention should be paid to them when washing hands (most micro organisms on the hands come from beneath the nails).

11.4 False nails, veneers, acrylic coatings, extensions or any other artificial materials are not permitted when in clinical areas as these are sources of fungal and bacterial infection.

11.5 The wearing of rings with ridges or stones is not permitted. (Total bacterial counts on the hands are higher when rings are worn.)

11.6 When entering the clinical environment, such as a ward or outpatient areas ALL staff must follow the rule of ‘bare below the elbow’ i.e. short or rolled up sleeves, no wrist watches or jewellery. A plain wedding ring is permissible. The practice of hand hygiene is repeated several times in the course of duty in a clinical environment. This practical dress code is designed to make repeated wrist and hand hygiene effective and easy to practice.

12 Routine Decontamination of Hands Using Alcohol Based Hand Rubs

12.1 Hands should be from dirt and organic matter (visibly clean) – if not they should be washed using liquid soap and water.

12.2 The hand rub solution must come into contact with all surfaces of the hands.

12.3 The hands must be rubbed together vigorously, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers.

12.4 Continue to rub hands until the solution has evaporated and the hands are dry.

12.5 Apply hand cream regularly to protect skin.

13 Prevention of Skin Damage

13.1 Skin damage is generally associated with the detergent base of the preparation and/or poor hand washing technique. To minimise the risk of skin damage, hands should always be wetted under running water before applying any soap or antiseptic detergent. After washing, the hands should be thoroughly rinsed to remove residual soap and then dried carefully, paying particular attention to drying the area between the finger webs. If a particular hand hygiene preparation causes skin irritation, advice should be sought from Occupational Health. When the hands are not visibly soiled, alcohol gel can be used instead of soap and water as it is associated with less skin damage.

14 Hand Creams



14.1 Hand cream should be applied regularly to the hands to protect the skin from the drying effects of regular hand decontamination. This should be available in all clinical areas via moisturizer dispensers utilising disposable cartridges. Communal jars of hand cream are contraindicated as the contents may become contaminated and subsequently become a source of cross-infection.

14.1.1. All staff will receive hand hygiene training on Trust Induction.

14.1.2. All staff to receive a minimum of annual updates on hand hygiene (Appendix 3).

15 Training

15.1 Input onto Trust’s central Oracle Learning Management (OLM) system:

a) Infection Control Induction/annual update training. All staff have to undertaken Infection Prevention and Control training on induction and then an annual update. This includes hand Hygiene.

b) Non attendees receive a letter, which is also copied to their managers, on first non attendance. If they do not attend for a second time, they receive a letter which is copied to their managers and the Director of HR or the Medical Director.

c) Non-Attendance: see 15.1b. Staff who do not attend mandatory training will be performance managed as per the Mandatory Training Policy.

d) Infection Control Link personnel/Ward Manager to train all new staff on hand hygiene within their first week in post.

e) Infection Control Link personnel to undertake annual practical hand hygiene training for all staff within their area. Names of those who have received training are kept at ward/department level. The Ward/Department manager is responsible for ensuring training has been undertaken annually.

f) Compliance with hand hygiene training is monitored by the Infection Prevention & Control Team via audit

g) F1 and F2 hand hygiene specific induction training. All other staff this is provided at the corporate induction.

h) All Infection Control updates include theoretical hand hygiene training.

i) All Infection Control link personal will receive practical hand hygiene training annually delivered by the Infection Prevention & Control Team.

15.2 Regular Audit:

Audit will be undertaken as assurance that robust hand hygiene systems are in place:

a) Infection Prevention & Control will undertake hand hygiene audits following all post 72 hour Clostridium difficile, post 48 hour MRSA bacteraemia, or in response to an outbreak or cluster of healthcare acquired infections.



15.3 Action Plans for any non-compliance highlighted via the audit undertaken by Infection Prevention & Control Team will be returned within the specified time frame.

15.4 Cleanyourhands Campaign requires a minimum monthly audit All Cleanyourhands audits are undertaken by ward/departmental managers, and returned to Infection Prevention & Control Team.

15.5 Training in undertaking hand hygiene audit is provided by Infection Prevention & Control Team to ward/department manager/link personnel, who will then cascade train others.

15.6 More frequent audit (weekly/bi-weekly) in areas of low compliance by ward manager/link personnel.

15.7 Peer auditing of hand hygiene is to be undertaken monthly in all clinical areas. This is escalated to weekly if the compliance is below 95% or there has been a healthcare associated infection/incident.

15.8 Clinical areas report to NMAS monthly.

15.9 Directorates report via Matrons quarterly at the Governances and Risk Committee.

16 Monitoring and Review

What will be monitored

How/Method/ Frequency Lead Reporting

toDeficiencies/ gaps Recommendations

and actions

Implementation of

any requiredchange

Minimum score of 100% attendance at Infection Control Induction and Annual Updates which includes hand hygiene training

Monthly Director of HR

Trust Board

Trust Board Required changes in practice will be identified and actioned within a specified time frame and lessons will be sharedMinimum score

of 95% required for cleanyourhands campaign/audits

Monthly ICT NMAS MatronsHeads of Nursing

Review of Policy Bi yearly or when new guidance issued

Head of Infection Control

ICC ICC



17 Equality Impact Assessment

Yes/No Comments

1 Does the policy/guidance affect one group less or more favourably than another on the basis of:

Race No

Disability No

Gender No

Religion or belief No

Sexual orientation including lesbian, gay and bisexual people

No

Age No

2 Is there any evidence that some groups are affected differently?

No

3 If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?

No

4 Is the impact of the policy/guidance likely to be negative?

No

5 If so can the impact be avoided? No

6 What alternatives are there to achieving the policy/guidance without the impact?

No

7 Can we reduce the impact by taking different action?

No



Appendix 1

10 IMPORTANT POINTS FOR THE USE OF ALCOHOL HAND RUB

1. Effective hand hygiene is the most important factor in infection prevention and control.

2. Alcohol hand rubs offer a practical and acceptable alternative to handwashing in most situations.

3. Alcohol hand rub is active immediately against a wide range of micro-organisms.

4. Alcohol hand rub is more effective at destroying bacteria and viruses than soap and water/antiseptic agents, e.g. Hibiscrub.

5. Alcohol hand rub should be used for routine hand decontamination, except when hands are visibly soiled when they must be washed with soap and water.

6. Hands must be decontaminated immediately before each and every episode of direct patient contact/care and after any activity or contact that potentially results in hands becoming contaminated.

7. Cup the hand, apply 1 shot of alcohol hand rub. Cover all surfaces of the hands. Rub hands together vigorously paying particular attention to the tips of the fingers, thumbs and between fingers until the solution has evaporated and the hands are dry.

8. Alcohol hand rub contains emollients (moisturisers), which prevent irritation and dryness.

9. Alcohol hand rub has limited activity against spores (C. difficile). Hand washing with liquid soap should be used in this instance or when patients have type 5-7 stools.

10. Please contact Occupational Health if you experience any skin problems when using alcohol hand rub.

11. Ref: Epic Guidelines 2001 – Journal of Hospital Infection (2001) 47 (Supplement) S3-S4



Appendix 2



Appendix 3Medway NHS Trust Training Matrix

Requirements for Trust staff’s specific Health & Safety Training

Mandatory SubjectConsultants,

Trust Drs

Doctors (Training Grades)

Other Students

Nursing & Midwifery

Staff

Admin & Clerical Roles

Allied Health Professionals

Non-Medical Support Service

Staff (i.e. Facilities)

Directors & Senior

Managers

Volunteers /Contractors

& Partner Employees

Trust/Corporate Induction Day (First month)

Infection Control Induction (including Hand Hygiene)

Infection Control Annual Update (including Hand Hygiene)

Junior Doctors Fire Induction

Fire Non-Clinical

Dependent on base/ specialty

Dependent

on base/role

Unless ward

based

Unless ward

based

Fire Clinical (Ward based)

Dependent on base/ specialty

Dependent

on base/role

If

substantively ward based

If

substantively ward based

Fire Refresher(Ward/Dept Based) Moving & Handling Introduction Moving & Handling 1-day Clinical Course (people movers)

If moving people

If moving people

If moving people

if moving people

If moving people

Moving & Handling ½-day Non-Clinical(non-people movers)

non people

movers

non people

movers

non people

movers

non people

movers

non people movers




Trust Drs


Other Students

Nursing & Midwifery Staff



Non-Medical Support

Service Staff (i.e. Facilities)

Directors & Senior

Managers

Volunteers /Contractors &

Partner Employees

Moving & Handling Annual Updates ½-day Clinical (people movers)

If moving people

If moving people

If moving people

If moving people

If moving people

Moving & Handling Annual Updates up to ½ day (non-people movers related to work area)

non people

movers

non people

movers

non people

movers

non people

movers

non people movers

Moving & Handling Manager Awareness ½ day

If in

managerial position

If in

managerial position

If in

managerial position

If in

managerial position

Moving & Handling Key Worker 5-day (people movers)

For those staff

undertaking key worker

role

For those staff


role

Moving & Handling Key Worker 3-day (non people movers)

For those staff


role

For those staff


role

Moving & Handling Competency Based Equipment Training

If using

moving and handling

equipment

If using

moving and handling

equipmentMoving & Handling Key Worker Annual Updates 1-day

Key workers

Key workers

Key workers

Key workers

Health & Safety Basic Awareness (3 hrs) Health & Safety Annual Update (1 hr)




Trust Drs


Other Students

Nursing & Midwifery Staff



Non-Medical Support

Service Staff (i.e. Facilities)

Directors & Senior

Managers

Volunteers /Contractors &

Partner Employees

COSHH 3 hr (specific to role)

* specific to role

* specific to role

* specific to role

* specific to role

* specific to role

Specifically Housekeepers,

Pathology & Facilities Staff

Display Screen Assessment (3 hrs)

Designated Assessors


Risk Assessment (3hrs) Designated Assessors






Violence & Aggression (Securicare) 1-day

*Prioritised via risk

assessment by role


assessment by role


assessment by role


assessment by role


assessment by role


assessment by role


assessment by role


assessment by role


assessment by role

Violence & Aggression Update (1/2 day)


assessment by role


assessment by role


assessment by role


assessment by role


assessment by role


assessment by role


assessment by role


assessment by role


assessment by role


Documents

Hand Hygiene Guidelines - WhatDoTheyKnow - … · Web viewWet hands under tepid running water before applying liquid soap or antiseptic preparation e.g. Hibiscrub or Povidone Iodine