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POLICY: Hand Hygiene Policy Document Reference: Infection Control Point of Reference: Peter Walsh, Director for Infection Prevention and Control Status: Final Date of Issue: May 2006 Date of Review: October 2007 Date of next Review: October 2008 Policy Reference: IC 02 Ratified by: Clinical Governance Committee Approved at Clinical Governance Committee Meeting Signed By Chief Executive Central and North West London NHS FoundationTrust Signed By Medical Director On Behalf of Chief Executive Central and North West London NHS FoundationTrust This policy is based on previous work by the Infection Control team at Westminster and Kensington and Chelsea Primary Care Trusts. Hand Hygiene Policy ICC 02 Contents Page number 1. Rationale 3 2. Aim and objectives 3 3. Legal framework 3 4. Duties 3 5. The importance of hand hygiene 3 6. Improving compliance with good hand hygiene practice 4 7. The microbiology of the hands 5 8. Types of hand decontamination 5 9. When to decontaminate the hands 6 10. Cleansing agents 6 11. Facilities for hand hygiene 7 12. Hand decontamination technique 7 13. Skin care 8 14. Occupational Health 9 15. Training 9 16. Monitoring 9 17. References 10 Appendix 1: Six step technique for hand decontamination 11 Appendix 2: Areas most commonly missed during hand decontamination 12 Appendix 3: Hand Hygiene Audit Tool 13 2 Hand Hygiene Policy ICC 02 1. Rationale Hand hygiene is the simplest, most effective measure for preventing health care associated infection (Pittet,2001). However, many studies show that adherence to recommended hand hygiene practice is unacceptably low in health care workers, presenting a risk to patients (Ward et al, 1997; Pittet et al, 1999). 2. Aim and objectives Aim: 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. Objectives: To identify the importance of hand hygiene in the prevention of health care associated infection. To identify strategies to implement the policy and improve compliance with good hand hygiene practice. To describe the key elements of good hand hygiene practice 3. Legal Framework The Health Act (2006) ‘A Code of Practice for the Prevention and Control of Health Care Associated Infections’; 4. Duties It is the responsibility of all staff to ensure they maintain good hand hygiene. It is the responsibility of the Infection Control Team to ensure all staff are aware of the processes and means to maintain good hand hygiene. It is the responsibility the Trust to ensure that the appropriate systems are in place to enable all staff to maintain good hand hygiene. 5. The importance of hand hygiene Clean Your Hands Campaign 2007 says that there has been some decrease of Hospital Acquired Infections there are still improvements to be made. Hand hygiene is a simple but effective tool to reduce the spread of infections. Active participation by all staff, 3 Hand Hygiene Policy ICC 02 managers and CNWL as an organisation are required to promote good hand hygiene practice as the expected norm. Infection is a significant risk in the health care setting where the patient is subjected to invasive clinical procedures and may be particularly vulnerable to infection because of age or disease. Studies have shown that at least one third of health care associated infections are preventable and that transmission of micro-organisms by the hands of health care workers is the main route of spread (Haley et al, 1985 and Bauer et al, 1990, in Pittet,2001). Several studies published between 1977 and 1995 demonstrated a temporal relationship between improved hand hygiene practices and reduced infection rates. Despite this evidence, most studies show that compliance with good hand hygiene practice is poor, estimated as less than 50% (Pittet,2001). Many interventions are associated with transient improvements in hand hygiene, but Larson and Kretzer (1995) found that no single intervention had consistently improved compliance. More recently, Pittet et al (2000) reported that a hospital hand hygiene promotion campaign produced a sustained improvement in compliance, coinciding with a significant reduction in hospital-acquired infection and methicillin-resistant Staphylococcus aureus (MRSA) transmission rates over a 4-year period. The promotion of bedside alcohol-based hand rubs, through an educational programme and poster campaign, largely contributed to the increase in compliance. 6. Improving compliance with good hand hygiene practice Reasons cited for poor compliance with good hand hygiene practice include: Lack of knowledge/scepticism about the value of hand decontamination Perception of insufficient time or shortage of staff Belief that wearing gloves obviates the need for hand hygiene Shortage of conveniently located sinks Lack of mixer taps to control water temperature Poor facilities for effective hand hygiene (especially in community settings) Skin irritation caused by hand decontamination agents Inaccessible supplies Interference with worker-patient relationship/patient needs perceived as priority Lack of encouragement/role modelling from key staff Factors associated with improved compliance with hand hygiene practice include: Education – continuous and innovative Written guidelines and reminders in the workplace Routine observation and performance feedback 4 Hand Hygiene Policy ICC 02 Engineering controls, e.g. conveniently sited sinks, mixer taps Acceptable hand hygiene and skin care agents Making alcohol hand rubs available Patient education Active participation and support from all levels of the organisation Addressing understaffing issues The change process is complex and single interventions to improve hand hygiene practice have been found to fail. Therefore a multimodal strategy is required, which recognises the interdependence of factors associated with the individual, the environment and the institution. Active participation by staff, managers and CNWL as an organisation are required to promote good hand hygiene practice as the expected norm. In addition, facilities for hand hygiene must be considered at the design stage of all health care premises developments, including general practice developments. 7. The microbiology of the hands There are two groups of micro-organisms on the hands: the transient micro-organisms that are carried temporarily on the surface of the skin, and the resident micro-organisms that colonise (or live on) the skin. Transient skin flora micro-organisms acquired on the hands through contact with other sites on the same individual, from other people, or from the environment. easily acquired by touch, and readily transferred to the next person or surface touched, so may be responsible for the transmission of infection. removal of transient micro-organisms is therefore essential in preventing cross- infection, and their removal is easily achieved by washing with soap and water. Resident skin flora micro-organisms which live in deep crevices and hair follicles, known as skin flora. most are bacteria of low pathogenicity, such as coagulase-negative staphylococci. not readily transferred to other people and most are not easily removed by washing with soap. do not need to be removed from the hands during routine clinical care. during invasive procedures, e.g. minor surgery, there is a risk that resident micro- organisms may enter the patient’s tissues and cause an infection. 8. Types of hand decontamination Routine hand decontamination 5 Hand Hygiene Policy ICC 02 the aim of routine hand decontamination is to remove transient micro-organisms before they can be transferred. hands that are visibly soiled with dirt or body fluids should be washed using liquid soap and water. if hands are potentially contaminated but visibly clean, they can be decontaminated using an alcohol-based preparation. 9. When to decontaminate the hands Hands should be decontaminated immediately before every episode of direct patient care, before handling food, and after any activity that potentially results in the hands becoming contaminated. Hands should always be decontaminated after gloves are removed. 10. Cleansing agents 9.1 Liquid soap and water Hand washing with soap suspends transient micro-organisms in solution, allowing them to be rinsed off effectively (mechanical removal). Wall-mounted liquid soap dispensers should be used in clinical settings. They should be operated using the wrist or elbow. Dispensers should be replenished as soon as necessary and should have individual replacement containers that can be discarded when empty. Responsibility for daily checking and replenishment of liquid soap dispensers should be clearly defined in each clinical area, e.g. written into cleaning schedules and monitored by site managers. Bar soaps are not appropriate for any clinical setting as they easily become contaminated with bacteria. 9.2 Alcohol-based preparations Alcohol-based hand rubs or gels provide an acceptable alternative to soap and water in most situations, provided the hands are not visibly contaminated. They are available in wall-mounted dispensers, free-standing containers and in pocket-sized tubes. As the facilities in clients’ homes may not always be suitable for effective hand hygiene, alcohol hand rub should be carried by community staff on home visits. 6 Hand Hygiene Policy ICC 02 Alcohol-based hand rubs are more easily accessible and less time consuming than using soap and water, and are often less irritant as well. They have been found to increase compliance with hand hygiene practice by up to 25% (Bissett, 2002). Hands will need to be washed with soap and water after several applications of alcohol hand rub to prevent the build-up of emollients on the skin. Alcohol hand rubs may also be used when surgical hand decontamination is required. They are immediately active against a wide range of micro-organisms but do not have any residual activity. 11. Facilities for hand hygiene The following facilities are required for good hand hygiene: Sinks specifically allocated for hand hygiene, i.e. not also used for instrument washing or other dirty procedures Lever-operated mixer taps with hot and cold water Liquid soap in wall-mounted dispenser Good quality paper towels in wall-mounted dispenser Pedal-operated domestic waste bin (black bag) with lid Alcohol hand rub and/or antiseptic solution if indicated These requirements should be considered when new services or premises are being developed. The Infection Control Team should be contacted for advice, e.g. on siting of sinks or choice of taps for all new builds/ refurbishments. There should be a designated handwashing sink in all clinical areas. This will be audited in the Infection control audit. When staff are working in environments which may lack good hand hygiene facilities, e.g. on community visits, they should take paper towels and alcohol hand rub with them. 12. Hand decontamination technique Preparation of the hands Keep nails short and clean and avoid artificial nails or nail polish Avoid wearing rings with ridges or stones as they will increase bacterial counts Remove wrist watches and jewellery and roll up long sleeves prior to hand washing Routine hand decontamination a) Soap and water 7 Hand Hygiene Policy ICC 02 Wet the hands under tepid running water Apply soap, cover all surfaces of the hands and rub vigorously for 10-15 seconds Rinse hands well and dry thoroughly b) Alcohol hand rub Apply alcohol to clean, dry hands Rub hands together covering all surfaces until the solution dries (approximately 15 seconds). Surgical hand decontamination Wet the hands under tepid running water Wash all surfaces of hands with an aqueous antiseptic solution for 3 minutes Rinse hands well and dry thoroughly Appendices 1 and 2 provide further advice on ensuring all skin surfaces are covered during hand decontamination. N.B. Nail brushes should not be used for routine hand decontamination as they may damage the skin and may become contaminated. If used for surgical hand decontamination, they must be single-use and sterile. Hand drying Effective drying of the hands is important as wet skin surfaces transfer micro-organisms more readily than dry ones. The method of hand drying is important in maintaining hygiene; hands can become recontaminated by some drying methods such as fabric towels. Hands should be dried thoroughly using good quality paper towels from wall- mounted dispensers close to each sink. Sterile paper towels should be used after surgical hand decontamination. There is conflicting evidence regarding the efficacy of hot air dryers, but they should be avoided in clinical areas due to noise, the time taken to use them, and their potential for recirculating contaminated air. 13. Skin care The skin provides a waterproof barrier against micro-organisms, including blood-borne viruses, provided it is healthy and intact. Health care staff are at increased risk of developing irritant contact dermatitis and eczema due to frequent hand washing. Damaged sore skin, caused by harsh hand cleansing agents, has been cited as a reason why staff fail to decontaminate their hands (ICNA, 2002). To minimise the risk of skin damage, hands should be wetted before applying any soap solution. Rinsing and drying the hands thoroughly will also help to protect the skin. Alcohol hand rubs with emollients are associated with less skin damage than soap and water (Pittet et al, 2000). Cuts or abrasions should be covered by a waterproof plaster 8 Hand Hygiene Policy ICC 02 for clinical work, which should be renewed when it becomes wet. Hand creams should be applied regularly to the hands to protect against drying. Communal jars are not desirable as the contents may become contaminated. The increased use of gloves containing natural rubber latex (NRL), to comply with standard infection control precautions, has increased the incidence of latex sensitivity and irritant reactions. The risks relate to the proteins found in NRL, accelerators added during manufacture, and the addition of cornstarch powder. Therefore NRL gloves that are powder-free, with the lowest possible levels of extractable proteins (< 50 g/g) and residual accelerators (< 0.1% w/w) should be used (ICNA, 2002). Synthetic gloves should be made available for staff who are known to be sensitised to NRL proteins. 14. Occupational Health Any member of staff experiencing a skin problem should refer themselves to the Occupational Health Department, where a full history will be taken and a discussion will take place to agree a suitable care plan. Management may need to be informed of the outcome where changes in work practice are required, in line with health and safety requirements. 15. Training All clinical and non-clinical new starters will receive a session on hand hygiene as part as the Trust induction programme. All clinical and non-clinical staff who go into clinical areas or who have contact with service users will receive local and central updates. Please refer to the Trust’s Statutory and Mandatory Training document for details on the organisation’s expectations in relation to staff training needs in hand hygiene. This document also addresses the process for dealing with staff who fail to attend Trust Induction. This can be found in the CNWL Training, Education and Development Strategy on Trustnet. 16. Monitoring The Infection Control Team will conduct an effectiveness audit of how hand hygiene is implemented across the Trust. This will be conducted on a yearly basis. (Please see Appendix 3 for the audit tool) The Infection Control Team monitor attendance on the hand hygiene awareness sessions and focus on areas with poor attendance as appropriate. They will also run adhoc sessions if incidents data or an outbreak indicates there is a hand hygiene problem at a particular site. 17. References 9 Hand Hygiene Policy ICC 02 Bissett L. Can alcohol hand rubs increase compliance with hand hygiene? British Journal of Nursing, 11 (16): 1072, 1074-7; 2002 Hand Hygiene Task Force. Draft guideline for hand hygiene in healthcare settings. Hospital Infection Control Practices Advisory Committee, CDC, Atlanta, USA; 2001 Infection Control Nurses Association. Hand Decontamination Guidelines; 2002 Available from Fitwise on 01506-811077 Larson E and Kretzer EK. Compliance with handwashing and barrier precautions. Journal of Hospital Infection, 30: 88-106; 1995 National Patient Safety Agency. Clean Your Hands Campaign. 2007 Pittet D, Dharan S, Touveneau S et al. Bacterial contamination of the hands of hospital staff during routine patient care. Arch. Int. Med. 159: 821-826; 1999 Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, Perneger T and members of the Infection Control Programme. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. The Lancet, 356: 1307-1312; 2000 Pittet D. Improving Adherence to Hand Hygiene Practice: A Multidisciplinary Approach. Emerging Infectious Disease, 7: 2; Mar-Apr 2001 Ward V, Wilson J, Taylor L et al. Preventing hospital-acquired infection. Clinical guidelines. PHLS, London; 1997 10 Hand Hygiene Policy ICC 02 Appendix 1 Six step technique for hand decontamination 11 Hand Hygiene Policy ICC 02 Appendix 2 Areas most commonly missed during hand decontamination Hand Hygiene Policy ICC 02 Appendix 3 Hand Hygiene Audit Tool 1. Are there adequate sinks dedicated too hand washing us in the ward/ unit on the premises? YES/NO 2. Is there a handwashing basin in each clinical/ treatment area? YES/NO 3. Do sinks in clinical areas have lever-operated mixer taps? YES/NO 4. Are there functioning liquid soap dispensers above each sink? YES/NO 5. Are there paper towels and paper towel dispensers above each sink? YES/NO 6. Are handwashing sinks free from equipment and inappropriate items (Including bars of soap and nailbrushes and cotton towels)? YES/NO 7. Is there foot operated pedal bins with lids and black bags at each sink? YES/NO 8. Are there hand washing posters above all hand washing sinks? YES/NO 9. Have all staff read the Hand Hygiene Policy and adopted its recommendations? YES/NO 10. Are functioning alcohol hand rub dispensers in clinical areas? YES/NO 11. Are portable hand rub dispensers available in the ward/ unit? YES/NO 12. Are small individual dispensers available for community visits? YES/NO 13. Have staff attended an annual infection control training update? YES/NO 14. Are clinical staff nails short, lean and free from nail extensions and varnish? YES/NO 17. Are stoned rings and wrist jewellery removed during clinical procedures? YES/NO Please list areas identified as non-compliant with the guidance: Area Problem Action planned Hand Hygiene Policy ICC 02 Form completed by:______________________________ Post and department:_____________________________ Areas audited:___________________________________ Further advice is available from the Infection Control Team.
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