Ratified by: East Sussex Community Health
Services Infection Control Committee
Name of originator/author: Infection Control Team
Name of responsible East Sussex Community Health
committee/individual: Services Infection Control Committee
Date issued: October 07
Review date: August 09
Next review August 10
Target audience: All ESCHS staff
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POLICY VALIDITY STATEMENT
THIS DOCUMENT IS DUE FOR REVIEW ON 01/08/10
After this date, the Organisation-wide Policy for the Development and Management
of Procedural Documents may become invalid.
Users should ensure they are consulting the current, valid version of the
Change Control Details: Record any changes to this document in the table below to
provide a documentation audit trail:
Date Version Reason for changes
April 08 2 Updated post NHS LA 1b inspection
August 09 3 Update to reflect recent guidance
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1. Scope 4
2. Purpose 4
3. Links to other polices 4
4. Monitoring Compliance 4
5. Duties 4-5
6. Microbiology of the hands 6
7. Hand hygiene techniques 7- 8- 9
8. Skin care 10
9. Frequency of hand hygiene 10
10. Patient’s home 10
Appendix 1 (hand hygiene technique) 12
Appendix 2 (5 moments for hand hygiene ‘chair’) 13
Appendix 3 (5 moments for hand hygiene ‘bed’) 14
Appendix 4 (hand hygiene audit tool) 15
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HAND HYGIENE POLICY
This policy applies to all staff employed by East Sussex Community Health Services
Hand washing is the single most important measure for preventing the spread of
Without hand hygiene micro-organisms that are acquired during healthcare activity
can be deposited directly onto vulnerable patients and present a direct clinical threat.
(Pratt et al, 2007)
2.1 The purpose of the policy is to ensure that all health care workers understand the
importance of hand hygiene in preventing the transmission of infection and carryout
the correct technique at the correct time.
2.2 The Trust needs to demonstrate its commitment to hand hygiene through compliance
with the Core standards C4a; and Health and Social Care Act (2009) (Hygiene Code)
3. LINK TO OTHER POLICES
Infection control policies (available on the Trusts Extranet)
Learning and Development policy (available on the Trust Extranet)
Human Resources Disciplinary Procedure Policy and Dress Code policy
4. MONITORING COMPLIANCE
4.1 The Infection control hand hygiene audits use the Infection Prevention Society’s
(formally known as Infection Control Nurses Association) audit tool. These audits are
undertaken by the infection control team as part of the schedule of audit
4.2 ESCHS will be monitoring compliance with hand hygiene through the
‘Cleanyourhands Campaign’. This Campaign incorporates raising awareness to staff
and visitors of the importance of hand hygiene as well as auditing staff groups.
Infection control links and associate links in all inpatient units are responsible for
supply monthly audits of hand hygiene. This data is collated and reported on the Trust
Performance dash board. See (Appendix 4) for copy of hand hygiene audit tool.
4.3 Staff compliance will be monitored using the processes above and non compliance
will be dealt with by the Locality Manager /Service Head who have access to utilising
the HR disciplinary policies.
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4.4 Reports will go to the Community Services Directorate Governance Committee, East
Sussex Community Services Committee and the Joint Clinical Governance
4.5 Training records for infection control mandatory training will be monitored and
reported by the Learning and Development Department
5.1 Organisational duties
5.1.1. The Chief Executive of the PCTs is ultimately accountable and responsible followed
by the DIPC, Infection Control Operational Manager, Infection Control Nurses / Team.
Accountability and responsibility are with the following committees: Infection Control
Countywide Committee and Joint Clinical Governance Committee.
5.1.2 ESCHS will provide mandatory hand hygiene training for all staff as an integral part of
mandatory training on induction and ongoing throughout employment.
5.2 Staff duties
5.2.1 All staff have a clinical and ethical responsibility to carry out effective hand hygiene
and to act in a way, which minimises risk to the patient.
5.2.1 All ESCHS staff have a responsibility to ensure that they attend mandatory Infection
Control training which incorporates hand hygiene training. Mandatory training is to be
accessed through the Learning and Development Department. The Locality /Service
head will receive reports via e-mail from Learning and Development so that they can
monitor attendance and identify any staff not attending and to follow up. Learning and
Development to monitor the effectiveness of this process. Refer to Learning and
5.3 Managers duties
5.3.1 Managers / Heads of Service / Clinical leads will ensure that all staff in their sphere of
management receives appropriate training and understand the importance of hand
5.3.2 Managers / Heads of Service / Clinical lead should ensure that all patients and visitors
in the hospital setting have access to products and facilities to perform effective hand
hygiene. NB. Alcohol gel can be placed on entry/exit to wards/clinics after
undertaking risk assessment to ensure that it is not miss used or risk to public.
5.3.3 It is the responsibility of Managers / Heads of Service / Clinical lead in conjunction
with Estates and Facilities to ensure that adequate facilities and resources are
available and safely maintained in every clinical area to enable staff to undertake hand
hygiene at the point of care.
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5.4 Infection Control Nurse Team duties
5.4.1 The role of the infection control nurse (ICN) is in the prevention and control of
infection. The monitoring / auditing, reporting and training of hand hygiene is an
integral part of the ICNs duties.
5.4.2 Hand hygiene compliance is facilitated through working with the infection control links
nurses audits which requires the ICN to analyse findings, implement interventions
and recommend actions where required .
5.4.3 The Infection Control Nurse provides support and advice through education and
6. MICROBIOLOGY OF THE HANDS
6.1 The purpose of hand hygiene is to remove dirt and / or reduce the levels of micro –
organisms present on the skin. Micro-organisms maybe resident or transient:
These are commonly termed ‘normal flora’ or ‘commensals’. They live deeply seated
within the epidermis in skin crevices, hair follicles, sweat glands and beneath
fingernails. Their primary function is to protect the skin from invasion by more harmful
micro-organisms. Resident micro-organisms rarely cause infections but a reduction in
counts is required with highly invasive procedures such as surgery. They are not easily
These are located on the surface of the skin and beneath the superficial cells of the
stratum corneum. They are both easily acquired by touch and readily transferred to
other people, equipment or surfaces. These are the bacteria that are most often
implicated in episodes of cross-infection. Transient micro-organisms are easily removed
by simple hand washing with soap and water or alcohol gel. However, damaged skin,
false nails or wearing rings with stones in will make them more difficult to remove,
transient organisms including, Meticillin-Sensitive and Meticillin-Resistant
Staphylococcus aureus (MSSA/MRSA).
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7. HAND HYGIENE TECHNIQUES
7.1.1 Research has shown that the most commonly missed areas during hand washing are
the backs of the hands, between the fingers and the tips of the fingers (figure 1).
Figure 1: - AREAS FREQUENTLY MISSED
Taylor. L. (1978)
7.1.2 The hand washing technique should aim to cover all surfaces of the hands from the
tips of fingers to mid-forearm.
7.2.1 The following should be undertaken prior to hand hygiene
Keep nails short.
Do not wear nail varnish or artificial nails.
Rings with ridges or stones not to be worn – Only one plain gold band ring can be
worn. (refer to Dress code Policy)
Remove wristwatches bracelets and roll up sleeves
Apply hand creams regularly to help protect hands from soreness and maintain the
integrity of the skin. This must be supplied as individual tubes or in a pump-action
container. Communal jars of hand cream must not be used.
Cover cuts and abrasions with a waterproof dressing.
7.3 Work clothing / uniform
7.3.1 In order to ensure hands can be effectively decontaminated clothing should be worn
above the elbow level. Jackets and coats should be removed and sleeves if worn
should be rolled up, allowing the forearms to be exposed. All health care staff in
clinical contact are to be ‘bare below the elbow’ (Darzi, 2007). (Refer to Dress Code
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7.4 Hand washing with soap and water
7.4.1 For most routine activities hand washing with soap and water is sufficient. It removes
the transient micro-organisms from the skin rendering them socially clean.
7.4.2 In clinical areas, liquid soap should be provided in wall-mounted dispensers with
disposable cartridges or disposable pump-action bottles. Re-fillable cartridges are not
recommended. Dispensers must be kept clean and replenished.
7.4.3 Nail brushes are not to be used for routine hand washing as brushes remain moist
and harbour bacteria
7.4.4 Hands should be washed with liquid soap:
Before and after each work shift/ break
Whenever hands are visibly dirty
Before and after handling wounds, urethral catheters, intravenous lines and any other
Before preparing, handling or eating food
After handling contaminated laundry and waste.
Before wearing gloves
After removing gloves or aprons
Before and after caring for any patients
After visiting the toilet
After blowing nose
Wet hands under running water; apply the one dose of liquid soap into cupped hand
rub hands together vigorously for 20-35 seconds to make a lather covering all
surfaces of the hands using the technique shown in (Appendix 1)
7.4.6 Rinse the hands thoroughly under running water
Turn off taps using elbow or wrist taps if available. Where wrist or elbow taps are not
available use a clean paper towels to turn off the taps to prevent recontamination.
Dry hands with a disposable paper towel. Communal towels are not recommended in
Dry all surfaces of the hands thoroughly.
Dispose of paper towel into a foot operated pedal bin; do not lift up the lid of the bin
with hands, as this will re-contaminate them.
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7.6 Hand disinfection using alcohol hand-rub
7.6.1 Alcohol hand rub may be used as an alternative to soap and water, if the hands are
7.6.2 They may also be used after hand washing if hand disinfection is needed.
7.6.3 Alcohol hand rub is not a cleansing agent and visible contaminants must be removed
with soap and water.
7.6.4 Alcohol gels/rubs are particularly useful in situations where hand-washing facilities are
limited. Staff visiting clients at home should carry a supply of alcohol hand rub/gel. A
small amount of gel should be applied using the same sequence of movements as for
hand washing and rubbing until dry. Wash hands after 5 to 6 applications to remove
7.6.5 Alcohol gel is to be available at the point of care either at the end of patient’s beds and
/ or personal dispenser. Risk assessment to be carried out to ensure that alcohol gel
is positioned safely.
NB: Alcohol gel/rub is not recommended when dealing with any cases of diarrhoea
and it is not intended for use on equipment.
7.7 Hand disinfection prior to invasive procedures
7.7.1 Hand disinfection with antiseptics (Chlorhexidine, providine, iodine or triclosan) is
recommended prior to performing aseptic procedures.
7.7.2 Follow same technique as hand washing using antiseptic in place of soap (see
7.8 Surgical scrub (eg. HIBISCRUB)
7.8.1 These are only required prior to surgical and other highly invasive procedures and
should not be used for routine hand washing.
7.8.2 This removes or destroys transient micro-organisms and readily detachable resident
micro-organisms. Hands and forearms are washed thoroughly for two minutes using
an antiseptic solution containing either chlorhexidine, povidone-iodine or triclosan.
Chlorhexidine and triclosan both have a residual effect which means that they
continue to destroy bacteria for some time after application.
7.8.3 Sterile nail brushes may be used to clean the nails prior to the first operation of the
day but are rarely required between operations. Frequent use of nail brushes
damages the skin and may encourage microbial proliferation.
7.8.4 Hands should be dried using sterile towels before donning sterile gloves.
7.8.5 For theatre staff utilising scrubs - also see local theatre policy
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NB: Any member of staff that has a skin reaction to hand hygiene agents should seek
advice form the occupational health department
8. SKIN CARE
Bacterial counts increase when skin is damaged
Measures that can be taken to prevent skin damage include:
Wet hands before applying soap
Rinse hands well after washing
Dry hands thoroughly
Apply an emollient hand cream at frequent intervals
Protect any damaged skin with impermeable waterproof dressing.
9. FREQUENCY OF HAND HYGIENE
As a general guide the World Health Organisation have produced 5 moments for hand
hygiene as a guide to when healthcare workers must undertake hand hygiene. (See
Appendix 2 & 3).
10. HAND WASHING FACILITIES
10.1 CLINICAL AREAS
A separate designated hand-washing sink i.e. not used to wash instruments/cups etc,
must be available.
Each hand-washing sink must be equipped with warm running water, ideally from a
Hand washing sinks in clinical areas should be equipped with lever mixer taps, (either
wrist or elbow operated)
Disposable paper hand towels and liquid hand soap in wall-mounted dispensers must
be available at each hand washing sink.
A foot operated pedal bin should be available at each hand washing sink for the
hygienic disposal of paper hand towels. (Used towels should not be disposed of as
clinical waste unless contaminated by blood or body fluids).
A hand-washing poster demonstrating an effective hand washing technique should be
displayed over hand washing sinks in each clinical area. (Appendix 1)
11. PATEINT’S HOMES
All health care workers must have access to adequate facilities that allow them to
decontaminate their hands before and after patient contact. If the patient's own
facilities are not adequate then disposable paper hands towels, liquid soap and/or an
alcohol hand rub must be taken on each visit. Paper towels should be used to turn off
the taps after hand washing.
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Darzi. Lord. (2007) Our NHS, Our Future. Available [Online]
asset/dh_079087.pdf Accessed 20/08/09
Department of Health (2009) Health and Social Care Act: code of practice for the NHS on the
prevention and control of healthcare associated infections and related guidance [Online]
ce/DH_093762 Accessed 20/08/09
National Standards, Local Action: Health and Social Care Standards and Planning
Framework 2005/06-2007/08 [Online] Available at:
ce/DH_4086057 Accessed 28/04/08
Pratt R.J. Pellowe C.M. Wilson J.A. Loveday H.P. Harper P.J. Jones S.R.L.J. McDougall C.
Wilcox M.H. (2007), Epic 2. National Evidence-based Guidelines for Preventing Healthcare-
Associated Infections in NHS. Hospitals in England. Journal of Hospital Infection. Vol. 65
supplement 1. February
Skipper L. Philip R. White G. Rees J. Wilson J. (2002) Hand decontamination guidelines.
Infection Control Nurses Association
Taylor L. (1978) An evaluation of handwashing techniques – 1. Nursing Times. January 12th,
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East Sussex Community Health Services inpatient unit Hand
Hygiene Audit data collection tool
Guidance & definitions:
• "Hand hygiene" means every time (opportunity) when either hand gel should be used or hand washing should happen
• "Before" / "After" means prior to / following patient contact
• Opportunities for good hand hygiene may occur several times within one episode of patient care
• In Before / After column, put "Y" if staff complied, "N" if not,
If “N”, what sort of non- What action did you take with
Before After Staff Type
[Complete afterwards:] How many minutes (approx) did it take to collect your 10 observations?
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