IC 003 Hand Hygiene Policy

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					                           Hand Hygiene Policy


POLICY NUMBER                                           IC/003
DATE RATIFIED                                           April 2009
NEXT REVIEW DATE                                        April 2011
POLICY AUTHOR                                           Infection Control Nurse
ACCOUNTABLE EXECUTIVE DIRECTOR                          Director of Infection, Prevention and
                                                        Control
RATIFYING COMMITTEE
VERSION NUMBER                                          4.0




Applicable Statutory, Legal or                NHSLA Risk Management Standards for PCTs.
National Best Practice                        Standards for Better Health (C09, C07a),
Requirements


NHS Warrington is committed to an environment that promotes equality and
embraces diversity both within our workforce and in service delivery. This document
should be implemented with due regard to this commitment.

This document can only be considered valid when viewed via the NHS Warrington
intranet. If this document is printed into hard copy or saved to another location, you
must check that the version number on your copy matches that of the one online.



Issue Date:         Page 1 of 18    Document Name:                                   Version No:
April 2009                          Hand Hygiene Policy                              4.0


Author:             Lead Director:
Infection Control   Director of Infection Prevention and Control
Nurse
Version Control Sheet

Version Date                 Reviewed By                     Comment
1.0           April 2004     Infection Control               New Procedural Guideline
                             Committee
2.0           April 2006     Infection Control               Reviewed and updated
                             Committee
3.0           April 2008     Clinical Policy                 Updated
                             Ratification Group
4.0           April 2009     Clinical Policy                 Changed from Procedure to
                             Ratification Group              Policy
4.0           May 2009       Jean Sampson                    PAG Approval
4.0           May 2009       Dr M Manche                     Committee Approval




Equality Impact                    By                                  Date
Assessment completed

Executive Sponsor                  Sign                                Date
approval




Issue Date:           Page 2 of 18    Document Name:                                    Version No:
April 2009                            Hand Hygiene Policy                               4.0


Author:               Lead Director:
Infection Control     Director of Infection Prevention and Control
Nurse
Contents



Section                                                                          Page

1.                  Introduction                                                 5
2.                  Roles, Responsibilities and Duties                           5
                    General managers/Business Unit Leads/Ward and Department     5
2.1
                    Managers
2.2                 All Trust Employees                                          5
2.3                 Training Department                                          6
2.4                 Infection Control Team                                       6
2.5                 Infection Control Committee                                  6
2.6                 Trust Wide Governance Committee                              6
3.                  The Importance of Hand Hygiene                               6
4.                  Improving Compliance with Good Hand Hygiene Practice         7
5.                  The Microbiology of the Hands                                8
6.                  Types of Hand Decontamination                                8
7.                  When to Decontaminate the Hands                              9
8.                  Cleansing Agents                                             9
8.1                 Liquid soap and water                                        9
8.2                 Alcohol-based preparations                                   10
8.3                 Aqueous antiseptic solutions                                 10
9.                  Facilities for Hand Hygiene                                  11
10.                 Hand Decontamination Technique                               11
11.                 Skin Care                                                    12
12.                 Occupational Health                                          13
13                  Consultation Process                                         13
14.                 Dissemination and Implementation                             13
15.                 Process for Monitoring Compliance and Effectiveness.         13
16.                 Standards/Key Performance Indicators                         13
17.                 References                                                   13

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April 2009                                Hand Hygiene Policy                  4.0


Author:                   Lead Director:
Infection Control         Director of Infection Prevention and Control
Nurse
Section                                                                        Page

Appendices

1                   Hand Hygiene Audit Tool                                    15
2.                  Areas Most Commonly Missed During Hand Decontamination     17
3.                  Hand-Washing Technique with Soap and Water                 18




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April 2009                               Hand Hygiene Policy                 4.0


Author:                  Lead Director:
Infection Control        Director of Infection Prevention and Control
Nurse
1        Introduction

         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).     Hand hygiene is therefore an important component of risk
         management and clinical governance and should become part of a culture of
         patient safety.

         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 for all clinical and non-clinical staff.

         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.

2        Roles, Responsibilities and Duties
         Duties and process to ensure compliance:
         All individual staff are responsible for the adherence to this policy.

2.1      General Managers/Business Unit Leads/Ward and Department Managers

         Responsible for ensuring adequate dissemination and implementation of the
         Policy as well as adopting the standard of practice for themselves. Training in
         relation to hand hygiene is provided by Infection Control staff and their
         deputies through the mandatory training programme and other initiatives.
         General Managers are responsible for ensuring clinical and non-clinical staffs
         attend mandatory training/hand hygiene training every two years.

2.2      All Trust Employees

         All Trust employees are responsible for reading the new/revised Policy to
         maintain current awareness of changes which impact on their roles. All staff
         have a duty to comply with the Policy and undertake training on hand hygiene
         every two years.




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April 2009                             Hand Hygiene Policy                        4.0


Author:                Lead Director:
Infection Control      Director of Infection Prevention and Control
Nurse
2.3      Training Department

         The Training Department is responsible for the facilitation of the mandatory
         training programme which includes hand hygiene.

2.4      Infection Control Team

         The Infection Control Team is responsible for facilitating the delivery of hand
         hygiene initiatives. The Infection Control Team is responsible for the
         provision of a representative to deliver hand hygiene training on the
         mandatory training programme.

2.5      Infection Control Committee

         Minutes of the Infection Control Committee meetings will reflect the progress
         of the Trust’s delivery against target and the minutes will be reviewed at Trust
         wide Governance and areas of non compliance will be highlighted and action
         plan developed to ensure compliance is achieved.

2.6      Trust wide Governance Committee

         Areas/departments at risk of non compliance to the Policy will be highlighted
         at Clinical Governance meetings.

3        The Importance of Hand Hygiene

         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
         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 at 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

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April 2009                           Hand Hygiene Policy                       4.0


Author:              Lead Director:
Infection Control    Director of Infection Prevention and Control
Nurse
         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.

4        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.

         (Hand Hygiene Task Force, 2001)

         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.
              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.

         (Hand Hygiene Task Force, 2001)

         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 the PCT 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.
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April 2009                             Hand Hygiene Policy                        4.0


Author:                Lead Director:
Infection Control      Director of Infection Prevention and Control
Nurse
         An Audit Tool for hand hygiene is available in the Essential Steps to Safe
         Clean Care pack. This can be found on www.clean-safe-care.nhs.uk (on the
         top line choose’ Essential Steps’.

5        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 routing 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.

6.       Types of Hand Decontamination

         Social Hand Decontamination

               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. (Alcohol hand rub).

         Surgical hand decontamination

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April 2009                             Hand Hygiene Policy                       4.0


Author:                Lead Director:
Infection Control      Director of Infection Prevention and Control
Nurse
                This is a higher level of decontamination which should be carried out
                prior to invasive procedures, where extra care must be taken to prevent
                micro-organisms on hands from being introduced into the patient’s
                tissues if gloves are damaged.
                Surgical hand decontamination aims to substantially reduce resident
                micro-organisms and to remove transient micro-organisms.
                The process is achieved by using an antiseptic hand washing solution or
                an alcohol-based preparation (if the hands are visibly clean).

         Examples of situations where surgical hand decontamination will be
         required:

                Before putting on sterile gloves prior to minor surgery, insertion of
                indwelling urinary catheter, or insertion of intra-uterine contraceptive
                device.
                Before caring for a severely immunosuppressed patient.
                After caring for a patient with a highly transmissible micro-organism.

7.       When to Decontaminate the Hands

         Hands should be decontaminated immediately before and after 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.

8.       Cleansing Agents
         8.1        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.

         Staff should be directed to use the hand hygiene packs which have been
         provided. (Order Code MRB 251)


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April 2009                               Hand Hygiene Policy                  4.0


Author:                  Lead Director:
Infection Control        Director of Infection Prevention and Control
Nurse
         N.B. Bar soaps are not appropriate for any clinical setting as they easily
         become contaminated with bacteria.

         8.2        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.
         If there are handwashing facilities available these should be used rather
         than the alcohol gel. As the facilities in clients’ homes may not always be
         suitable the hand hygiene pack should be used. Please note, alcohol hand
         gel is not effective against Clostridium Difficile.

         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.

         8.3        Aqueous antiseptic solutions

         Antiseptic solutions used with water will both remove and destroy micro-
         organisms (chemical removal). Hand disinfection will reduce counts of
         colonising resident, as well as transient, micro-organisms. Some antiseptic
         solutions have a residual activity so provide continued anti-microbial activity.
         Antiseptic solutions should be kept in wall-mounted elbow or wrist-operated
         dispensers.

         Key characteristics of aqueous antiseptic solutions (adapted from Larson,
         1995, in ICNA, 2002):


Chlorhexidine gluconate         Iodophors e.g. Betadine      Triclosan e.g. Aquasept
e.g. Hibiscrub
   Intermediate range of           Wide range of anti-          Intermediate range of
   anti-microbial activity         microbial activity           anti-microbial activity
   Initially slow-acting           Persistent       chemical    Persistent      chemical
   Persistent          chemical    activity                     activity
   activity (up to 6 hours)        Neutralised by organic       Minimally affected by
   Minimally affected by           matter                       organic matter
   organic matter                  Can cause skin irritation    Further         research
   Less       irritating  than                                  needed
   iodophors

         Any plans to introduce new brands of cleansing agents to clinical areas
         should be fully discussed with the Infection Control Team.
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Author:                  Lead Director:
Infection Control        Director of Infection Prevention and Control
Nurse
9.       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 if limited access to sinks.

         These requirements should be considered when new services or premises
         are being developed. The Infection Control Team may be contacted for
         advice, e.g. on siting of sinks or choice of taps

         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.

10.      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
                          Wet the hand under tepid running water.
                          Apply soap, cover all surfaces of the hands and wrists and rub
                          vigorously for 10-15 seconds using the handwashing technique.
                          (Appendix 2).
                          Rinse hands well and dry thoroughly with paper towels.

         b)         Alcohol hand rub
                          Apply alcohol to clean, dry hands.
                          Rub hands together covering all surfaces until the solution dries
                          (approximately 15 seconds).

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Author:                  Lead Director:
Infection Control        Director of Infection Prevention and Control
Nurse
         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 re-contaminated 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 re-circulating contaminated air.

11.      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 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.

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Author:                  Lead Director:
Infection Control        Director of Infection Prevention and Control
Nurse
12.      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.

13.      Consultation Process
         PCT Infection Control Nurses and Infection Control Group have been
         consulted.

14.      Dissemination and Implementation
         All managers must ensure staff comply to policy and attend regular Infection
         Control training which includes hand hygiene training. If staff do not attend,
         Training Department will inform manager and offer new dates. Manager
         must ensure staff member attends new dates as this is Mandatory Training (2
         yearly).

         Policy available on intranet.

15.      Process for Monitoring Compliance and Effectiveness
         Managers/Link Nurses to perform regular hand hygiene audits (6 monthly)
         and feed results back to Infection Control Nurses and Action Plan agreed to
         ensure good audit results.

         Infection Control Nurses will check to ensure all audits have been performed
         in each area, any outstanding audits will be reported to the CSU Lead Nurse.

16.      Standards/Key Performance Indicators
         Maintain high standards and audit results over 85% in annual infection control
         audits.

17.      References

                    Bisset L. Can alcohol hand rubs increase compliance with hand
                    hygiene? British Journal of Nursing, 11 (16):1072, 1074-7; 2002.

                    Department of Health , Essential Steps to Safe, Clean Care, 2007

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Author:                  Lead Director:
Infection Control        Director of Infection Prevention and Control
Nurse
                    Infection Control Nurses Association.         Hand Decontamination
                    Guidelines; 2007. Available from Fitwise on 01506 811077.

                    National Patient Safety Agency, Clean Your Hands Campaign, 2007

                    Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau
                    S, Pernegar 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; March –
                    April 2001.

                    Department of Health 2009 Health and Social Care Act.




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Author:                  Lead Director:
Infection Control        Director of Infection Prevention and Control
Nurse
                                                                       APPENDIX 1

              HAND HYGIENE AUDIT TOOL

                1.   Are there adequate hand washing sinks on the            YES/NO
                     premises?

                     Wards/Nursing Homes – one sink per 4 beds in main
                     area and one in each single room.
                     Clinics/Surgeries – one sink in each clinical room.
                     Hand washing sinks are required in kitchens, utility
                     rooms and toilets.

                2.   Do sinks in clinical areas have lever-operated mixer    YES/NO
                     taps?

                3.   Are there liquid soap dispensers above each sink?       YES/NO

                     Please check the dispensers have soap in them!

                4.   Are there paper towel dispensers above each sink?       YES/NO

                     Please check the dispensers have towels in them!

                5.   Are there pedal bins with lids and black bags at each   YES/NO
                     sink?

                6.   Are there hand washing reminder posters in key          YES/NO
                     areas?

                7.   Have all staff read the Hand Hygiene Policy and         YES/NO
                     adopted its recommendations?

                8.   Is Hand Hygiene Pack used, especially for home          YES/NO
                     visits?

                9.   Have staff attended an annual infection control         YES/NO
                     training update?




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April 2009                18          Hand Hygiene Policy                     4.0


Author:               Lead Director:
Infection Control     Director of Infection Prevention and Control
Nurse
              Please list areas identified as non-compliant with the guidance:

                Area                  Problem                         Action Planned




              Form completed
              by:……………………………………………………………………


              Post and
              Department:…………………………………………………………………


              Areas
              audited:………………………………………………………………………….



              Further advice is available from the Infection Control Team,
              01925 843723.


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Author:                Lead Director:
Infection Control      Director of Infection Prevention and Control
Nurse
APPENDIX 2


 AREAS MOST COMMONLY MISSEDHand hygiene
                           DURING HAND DECONTAMINATION




     Front                                     Back




                                                      5.2




  Least frequently missed


  Less frequently missed


  Most frequently missed




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Author:             Lead Director:
Infection Control   Director of Infection Prevention and Control
Nurse
  APPENDIX 3




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April 2009              18          Hand Hygiene Policy            4.0


Author:             Lead Director:
Infection Control   Director of Infection Prevention and Control
Nurse