Hand Hygiene VISN by alicejenny


									                             DEPARTMENT OF VETERANS AFFAIRS
                                 HEALTH CARE SYSTEM
                                   EL PASO, TEXAS

Center Policy Memorandum 00Q-06                                                May 13, 2010

                                           HAND HYGIENE

1. Scope/Effect:
   Hand Hygiene is the most important single measure to reduce the transmission of health care
   associated infections. The hands of health care personnel are believed to be the mode of transmission
   for most preventable health care associated infections. This Hand Hygiene policy promotes hand
   hygiene as a top priority of the El Paso VA Health Care Center (EPVAHCC).

2. Purpose: To give employees guidelines and recommendations per CDC, JC, and EPVAHCC for
   hand hygiene practices through out the facility.

3. Policy: The El Paso VA Health Care Center will implement Veterans Health Administration (VHA)
Directive 2005-002, Required Hand Hygiene Practices, noting the following:
   a. Adequate performance of hand hygiene is the single most important means of preventing the spread
      of germs.
   b. The El Paso VA Health Care Center will addresses hand hygiene for patient care and non-patient
      care Healthcare Workers (HCW) and complies with all Category I recommendations in the Center
      for Disease Control’s (CDC) Guideline for Hand Hygiene in Health-Care Settings.
   c. Proper performance of hand hygiene is also part of the Occupational Safety and Health
      Administration (OSHA) Blood-Borne Pathogens Standard (see Blood-borne Pathogen Exposure
      Control Plan).

4. Definitions:
   a. EPVAHCS - El Paso VA Health Care System
   b. CDC – Center for Disease Control
   c. HCW - Health Care Worker
   d. JC - Joint Commission
   e. VHA - Veterans Health Administration
   f. OSHA - Occupational Safety and Health Administration
   g. EMSS - Environmental Management Services

5. Responsibility:
   a. All HCWs who deliver direct patient care, work in the patient care environment, prepare or handle
      patient care equipment, supplies, medications or food and/or handle potentially contaminated
      equipment/items must adhere to the hand hygiene practices outlined below and to any related
      department specific policies. It is essential that these employees are capable of complying with the
      hand hygiene practices outlined.
   b. All employees are encouraged to follow basic hand hygiene principles by cleaning hands before and
      after eating, after using the toilet, after using tissues, etc.
   c. All HCWs are responsible for teaching patients about the importance of hand hygiene including
      hand hygiene by patients and visitors.
   d. All HCWs are responsible for monitoring hand hygiene of other HCWs, visitors and patients and
      intervening as necessary. Supervisors are ultimately responsible for monitoring compliance in their
      employees and including this in their performance evaluation.
   e. Administration will support efforts to improve compliance with hand hygiene including helping to
      set expectations, participating in performance improvement campaigns and ensuring that hand
      hygiene supplies and lotions are available system-wide.
   f. Infection Control will provide training on hand hygiene, post signage on hand hygiene, coordinate
      compliance monitoring and participate in the evaluation/selection of hand hygiene products in all
   g. Employee Health Services is responsible for evaluating employees who are unable to perform hand
      hygiene including those unable temporarily (e.g. casts, bandages) and employees who do not
      tolerate the products available (e.g allergy).
  h. Environmental Management Services (EMS) is responsible to ensure appropriate product
       availability for general hand hygiene according to the Infection Control recommendations outlined
       below. Safety Section and EMS are responsible to ensure that EPVAHCC complies with all
       current fire code regulations related to alcohol hand gel placement and storage.

6. Procedure:
   a. Indications for hand hygiene:
      (1) Before and after any direct contact with patients including before donning clean gloves (e.g.
           isolation) or sterile gloves (e.g. invasive procedure).
      (2) Before and after contact with the patient’s environment (e.g. on room entry and exit)
      (3) After contact with any body fluid (e.g. specimen).
      (4) When moving from a contaminated body site to a clean body site during patient care.
      (5) Before any “clean” activity like preparing medications or supplies.
      (6) After contact with contaminated surfaces or waste (“dirty” activity).
      (7) Before eating, preparing or serving food
      (8) After using the toilet
             Note that a single act of hand hygiene after one patient and before the next is acceptable
               unless hands are contaminated in-between (contact with objects such as keyboards,
               telephones, doorknobs, etc.).
   b. Techniques for Hand Hygiene:
       (1) Alcohol-based hand rub is preferred except when hands are visibly dirty or otherwise soiled
            with body fluid or potentially contaminated with a spore forming organism (e.g. Clostridium
       (2) Waterless hand rub is very effective against transient microorganisms which colonize the
           superficial layers of the skin and are easily transmitted from patient to patient on the hands of
           HCWs. The hand rub is effective against most bacteria, including multi-drug-resistant
           organisms, viruses, fungi and mycobacteria.
       (3) Consistent use of alcohol hand disinfection causes less irritant dermatitis on the hands of
            HCWs than use of soap, water and paper towels.
             Note that the emollient in the hand rub product may leave a residue causing the
               hands to feel tacky. Healthcare workers may choose to perform traditional hand
               washing occasionally to remove the residue.
             Note that alcohol products are flammable; to reduce risk let it dry when applying to
               hands and do not use during any spark generating activity.
        (4) CDC recommends that alcohol-based hand rub be used 8-10 times, then wash hands with soap
             and water, start cycle again to prevent build up on hands.
                       Hand Rub                                                KEY POINTS
     1. Dispense small amount of alcohol based            Do not mix with water or wash off after use.
        hand rub onto hands (about 3-5ml).
     2. Rub product over all surfaces of hands until      Be sure to distribute solution to all surfaces of the
        dry.                                              hands and fingers.

                                                          Rubbing hands together until dry reduces any fire
                                                          hazard, especially if next activity is spark generating.
     3. When using a pocket size container. Close         The outside of the bottle may be contaminated;
        the bottle and return to pocket before            returning the bottle to the pocket before rubbing hand
        rubbing into hands.                               together will prevent recontamination of hands.
     4. Wash hands with soap and water after 8-10         Perform traditional hand washing to remove residue
         time of using alcohol based hand rub.             and tacky feeling.

c. Traditional hand washing is required when hands are visibly dirty or contaminated with blood
     and other body fluids, and after potential contact with spore forming organisms like Clostridium
     difficile (C diff.). Hand washing is also preferred after using the toilet, before and after eating or
     preparing/handling food, and after using a handkerchief or tissue.
     (1) Use of antimicrobial soap is recommended for patient care areas. If a non-antimicrobial soap is
          used (e.g. HCW allergy), the hand wash must be followed by use of the alcohol hand rub prior
          to patient contact.
     (2) In areas where soap and running water are not readily accessible, toweling in conjunction with
          a waterless alcohol based hand rub or antiseptic towelettes will be used to remove gross
          contamination and to decontaminate hands.

                             Traditional Hand Washing                                    KEY POINTS
                      ESSENTIAL STEPS IN PROCEDURE
       1.   Turn on water to comfortable temperature.                        Cool or lukewarm water is less drying.
       2.   Moisten hands with water and apply heavy lather of soap.
       3.   Use mechanical friction, vigorously rubbing hands together for   Friction helps to loosen and remove
            at least 15 seconds.                                             microorganisms.
       4.   Cover all surfaces of the hands and fingers; pay particular      These areas are frequently missed
            attention to areas between fingers, around nail beds and under
            finger nails.
       6.   Rinse well under running water.

       7. Dry hands with paper towel. Avoid contact with faucet (e.g.        To prevent recontamination of hands
          hands-free sink or use paper towel to turn off faucet).

       d. Surgical Scrub Hand Hygiene/Antisepsis is required before donning sterile gloves for surgical
      (1) The purpose of surgical hand hygiene is to remove debris and transient microorganisms, reduce
          resident flora (microorganisms that normally live in the deeper layers of skin and are more
          difficult to remove) and inhibit rapid rebound growth.
      (2) A Food and Drug Administration (FDA) compliant surgical antisepsis product with persistent
          and cumulative activity (an antimicrobial soap or an alcohol based hand-rub) will be used.
(3) Surgical scrub hand hygiene is always completed at a hands-free sink. General hand hygiene
    via traditional hand washing or hand rub will be completed after surgical gloves are removed as
    organisms can proliferate in the moist environment underneath gloves.

                 Surgical Scrub                                        KEY POINTS
 1. Remove rings, watches and bracelets before       Rings, watches and bracelets may harbor
    beginning the surgical hand scrub.               microorganisms or inhibit their removal during
                                                     surgical scrub.
 2. Wash hands and forearms with soap and            To remove gross soil and transient microorganisms.
     running water.
 3. Remove debris from underneath fingernails        Subungual areas that are not cleaned properly can
    using a disposable nail cleaner under            harbor microorganisms.
    running water.
 4. Rinse hands and forearms under running
 5. Choose the scrub product desired.                A variety of products will be available to
                                                     accommodate persons with product sensitivities.
 6. Follow manufacturer guidelines to
    vigorously scrub hands and forearms.
    Most recommend use of a soft nonabrasive         Using a sponge may increase mechanical friction.
                                                     Use of a brush on the skin is not necessary to reduce
    If a brush is included, use the brush to clean   bacterial counts, can cause skin damage that can
    nails and cuticles only.                         lead to increased numbers of microorganisms and
                                                     can increase skin shedding.
                                                     Extended scrub times are not necessary and may be
                                                     harmful to the skin.
    Wash all four sides of each finger, hand and
    arm for the length of time recommended by
    the manufacturer, (usually 2-6 minutes)
    repeat process for opposite fingers, hand and
 7. Repeat Step 6 if recommended by
 8. Avoid splashing surgical attire               A sterile gown over wet or damp surgical attire
                                                  increases risk of contamination by strike-through
 9. Rinse well under running water, holding       Prevent contamination of hands by allowing water
    hands higher than elbows.                     to run from clean to less clean.

 10. Dry hands with sterile towel in OR before
     donning sterile gown and gloves
                Surgical Hand rub                                       KEY POINTS
    1. Remove rings, watches and bracelets.           Rings, watches and bracelets may harbor
                                                      microorganisms or inhibit their removal.
    2. Wash hands and forearms with soap and          To remove gross soil and transient microorganisms.
       running water.
    3. Remove debris from underneath                  Subungual areas that are not cleaned properly can
       fingernails using a disposable nail cleaner    harbor microorganisms.
       under running water.
    4. Rinse hands and forearms under running
    5. Dry thoroughly with a paper towel.             Products are less effective if mixed with water.
    6. Apply product to the hands and forearms,       The alcohol provides rapid kill of organisms,
       following the manufacturer’s directions for    generally products add other active ingredients to
       use including the amount of product to be      achieve the persistence and cumulative effect
       used.                                          required.
       Generally product is spread on both hands,
       paying particular attention to the nails,
       cuticles, inter-digital spaces and forearms.
       Some manufacturers may require the use of
       water as part of the process.
       Rub thoroughly until dry.
    7. Repeat application if recommended by the
    8. In the OR, don sterile gown and gloves.

e. Other aspects of hand hygiene:
   (1) Glove use. Gloves must be worn when contact with body fluids (including but limited to
       blood or other potentially infectious material (OPIM)), mucous membranes, non-intact skin
       and/or surfaces/items potentially contaminated via contact with body fluids, mucous
       membranes or non-intact skin is anticipated.
   (2) Remove gloves after caring from one patient or after finishing the task. Do not wear the same
       gloves for the care of more than one patient or from one patient’s environment to the next
       patient’s environment. Gloves will be changed during the care of one patient if moving from a
       contaminated body site (e.g. groin) to a clean one (e.g. Intravenous (IV) site).
   (3) Occupational Safety and Health Administration requires that all Personal Protective Equipment
       (PPE), including gloves be removed prior to leaving the work area to minimize the migration of
       contamination. Wearing gloves, even if they are clean in the hall, elevators, etc. gives the
       wrong impression to other staff, patients and visitors. There are a few times when it is
       considered permissible for staff members to wear gloves into the hallway. For example if a
       HCW needs to bring something soiled into the hallway.
   (4) Patients, contaminated items or specimens that need to be transported must be contained or
       covered in a way to protect the person transporting so that gloves are not required.
    (5) Gloves do not provide complete protection against hand contamination, pathogens may gain
         access to hands via small defects in gloves or hands may be contaminated during removal of
         gloves. Hand Hygiene is required on removal of gloves.
    (6) Gloves must be worn upon entering the room of a patient in Contact Precautions.
f. Hand Skin Health:
    (1) The skin of the hands, including the nails and surrounding tissue, must be intact and free of
         dermatitis, inflammation and any active infection. The rationale for this is as follows:
         (a) Irritated or chapped hands may be a deterrent to performing proper hand hygiene. Non-
             intact skin, hand dermatitis and nail infections increase bacterial carriage on the hands and
         (b) Non-intact skin and hand dermatitis put HCWs at risk of exposure to blood-borne
         (c) Active infections on hands and nails may be spread to patients.
  (2) Employees with dermatitis or symptoms of active infection on hands or nails or who are unable
       to perform hand hygiene, such as with temporary conditions (e.g. casts, bandages) and
       employees who do not tolerate the products provided (e.g. allergy) will be referred to Employee
       Health by their supervisor.
        (a) In the case of allergy, alternate products of the HCWs choice may be permitted after review
             by Infection Control.
        (b) Work restriction or reassignment to non-clinical duties will be considered on a case-by-case
g. Moisturizing lotions.
    (1) The use of emollient lotions is encouraged to reduce irritant dermatitis and chapping.
    (2) Only lotions provided by the institution may be used:
    (3) Other lotions may contain petroleum-based ingredients, which interfere with the integrity of
         latex gloves and are therefore not permitted under the OSHA Blood-borne Pathogens Standard.
    (4) The institutional lotion is designed to complement the other hand hygiene products
          (antimicrobial soap, alcohol product) used by the institution.
    (5) The institutional lotion uses non-refillable dispensers which are less likely to become colonized
         with bacteria.
h. Fingernails: artificial nails, nail length, nail polish: Studies have documented that subungual areas
    of the hand harbor high concentrations of bacteria. Artificial nails and long natural nails are more
    likely to harbor substantial numbers of potential pathogens even after careful hand hygiene. Long
    nails also increase the HCWs risk of exposure to pathogens, including blood-borne pathogens due
    to an increased risk of glove tears.
    (1) Health Care Workers who provide or sometimes provide direct, hands-on, patient care have
         contact with medications, handle or prepare sterile supplies, work in food service or work in
         any capacity in the Operating Room:
    (2) Are NOT allowed artificial nails, nail extenders, nail acrylic overlay, gels, wraps or any other
         modification that could promote bacterial growth and persistence, including nail studs, nail
         appliqués or nail rings.
    (3) Natural nail tips will be limited to ¼ inch in length.
    (4) Intact nail polish is permitted. Chipped nail polish may support the growth of organisms and
         should be removed.
i. Hand Hygiene Facilities / Product Availability. Alcohol hand hygiene product (hand rub) will be
   available to all clinical HCW, non-clinical HCW that perform “clean” or “dirty” activities, non-
   clinical HCWs that interact with patients on a regular basis and to patients and visitors (as
    (1) Hand rub will be available via wall mounted dispensers, counter-top bottles and/or pocket-sized
        bottles as appropriate for the environment.
    (2) Hand gel will be available in the following locations:
         (a) At the entrance to the patient’s environment (in-patient room, exam or treatment rooms,
               including operating rooms).
        (b) Inside the room/bay/cubicle where patient care takes place,
         (c) At the counter/desk where patients or visitors check in or wait,
         (d) At the counter/desk in non-clinical departments that interact with patients on a regular
         (e) In areas where “clean” activities are performed (medication rooms, medication carts,
               charting areas and clinical computers with shared keyboards),
         (f) Utility rooms, equipment and supply processing rooms,
         (g) Other convenient locations.
         (h) Pocket-sized bottles will be available to all HCWs with direct patient contact and in other
               areas deemed appropriate. In areas with patients where free access to hand rub may present
               an abuse risk (e.g. in-patient psychiatric or substance use treatment units) pocket-sized
               bottles carried by staff will be the preferred delivery method except in staff only rooms.
         (i) Environmental Management Service (EMS) is responsible for providing adequate numbers
              of dispensers and product following Infection Control recommendations and will monitor
              usage, re-stocking as necessary to prevent empty containers.
         (j) Placement of alcohol containers will comply with current National Fire Codes (National
              Fire Protection Association (NFPA)), local fire code regulations and/or VHA Directives.
              The 2006 guidelines include:
              i. Wall-mounted dispensers are permitted in exam rooms, suites and corridors.
             ii. Each smoke compartment may contain a maximum of 10 gallons in dispensers and a
                 maximum of 5 gallons in storage.
            iii. Dispensers must not be located over, or adjacent to ignition sources (including electrical
                 receptacles and switches). Consult Safety or Infection Control for specific information.
            iv. Dispensers may be mounted in egress corridors with at least 6 feet of clear width with
                 dispensers placed at least 4 feet apart.
             v. Dispensers may be placed in carpeted corridors if the corridor is sprinkler protected.
            vi. Countertop bottles may be placed on movable carts, however, do not mount dispensers
                 on carts. Hand gel should not be placed or mounted on electrical equipment.
    (3) Soaps and lotions:
        (a) All sinks used or potentially used by HCW for clinical hand washing will be stocked with
              antimicrobial soap. This includes but is not limited to in-patient units, ambulatory care
              areas, and all diagnostic, procedure and treatment areas. Sinks inside in-patient rooms are
              included as they are also used by staff.
        (b) If desired, sinks in public restrooms and patient showers may be stocked with a non-
              antimicrobial lotion soap.
         (c) Partially empty soap dispensers will not be “topped off” as this can lead to bacterial
              contamination of the soap.
        (d) Lotion dispensers will be provided in all areas where hand hygiene is required in quantities
              and in locations that promote use.
j. Hand hygiene promotion and monitoring:
    (1) Posters promoting hand hygiene will be selected by Infection Control and placed in staff-only
        areas, patient-care areas and waiting areas as appropriate, with periodic rotation of posters.
    (2) Environmental Management Services (EMS) will provide the number of alcohol rub containers
         ordered and distributed on a systematic basis.
     (3) Infection Control (IC) will coordinate a Hand Hygiene Compliance Monitoring Program with
         feedback to staff.
     (4) Infection Control will update annual training to reflect changes in policy and hand hygiene
     (5) The local web will provide a direct link to the national Hand Hygiene website and local data
         for employee education.

7. References:
   a. Association Operating Room Nurses (AORN), Standards, Recommended Practices, and Guidelines
      2007, AORN pg 565-574.
   b. Centers for Disease Control and Prevention, Guideline for Hand Hygiene in Health-Care Settings:
      Recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC) and
      the HICPAC/Society for Healthcare Epidemiology of America (SHEA)/Association for
      Professionals in Infection Control and Epidemiology (APIC) /Infectious Diseases Society of
      America (IDSA) Hand Hygiene Task Force, Morbidity and Mortality Weekly Report (MMWR),
      2002;51 (RR-16).
   c. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices
      Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of
      Infectious Agents in Healthcare Settings, June 2007.
   d. Occupational Safety and Health Administration (OSHA), Blood-Borne Pathogens Standard, OSHA
      Regulations 29 CFR-1910, revised 2000.
   e. VHA Directive 2005-002, Required Hand Hygiene Practices, January 13, 2005.

8. Rescission: Hand Hygiene dated April 12, 2010


10. Expiration Date: May 13, 2012

11. Distribution:

Josephina Olivar RN, MSN
Interim Director Patient Care Services/Nurse Executive

Cynthia D. Rivera, MD
Chief of Staff

Maria Andrews, FACHE
Associate Director

Joan Ricard, FACHE

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