Sample Policy Template for Hand Hygiene - Download as DOC by oyn15613


									Policy                                                               Version: 27 October 2010

                       ………. Health Service District
                        Policy for Hand Hygiene

Review:                 This document will be reviewed annually
Last reviewed:          New Policy
Supersedes:             New Policy

1. Purpose
This policy facilitates this Health Service Districts in implementing t he Queensland Health
Clean Hands are Life S avers Program, The Clean Hands are Life S avers Program is about
improving hand hygiene complianc e in the wards and departments that provide clinical care
for patients.

2. Principles
Queensland Health is committed to providing a safe and healthy working environment for all
healthcare workers (HCW) and to ensuring health and safety of patients in health care setting.
This policy has been developed in accordance with the following principles:

   The Health Quality and Complaints Commission Act 2006
   Public Health Act (Queensland) 2005
   The Workplac e Health and Safety Act 1995 (WHS Act): Queensland Health, as an
    employer, has a legal obligation to ensure workplace health and safety of employ ees and
    visitors; and employees, have legal obligation to comply with their employer‟s reasonable
    instructions, including instructions for workplace health and safety, and not to wilfully
    place at risk the workplace health and safety of any other person.

1. Rationale
The major route of transmission of microorganisms, including multiresistant organisms (MRO)
such as methicillin resistant Staphylococcus aureus (MRSA), in healthcare facilities has been
determined as the unwashed hands of HCWs (direct contact transmission). On average,
infections affect 7% to 10% of hospital admissions.

Hand hygiene is the cornerstone of all infection prevention and control programs .

Policy                                                                  Version: 27 October 2010

2. Definitions
 Term                   Definition4,5
 Hand hygiene           A general term referring to any action of hand cleansing (handwashing,
                        antiseptic handwash, antiseptic hand rub, or surgical hand antisepsis).
 Hand cleansing         Action of performing hand hygiene for the purpose of physically or
                        mechanic ally removing dirt, organic material or microorganisms.
 Handwashing            Washing hands with plain or antimicrobial soap and water.
 Hand antisepsis        Reducing or inhibiting the growth of microorganisms by the application of an
                        antiseptic hand rub or by performing an a ntiseptic handwash.
 Hand rubbing           Action of applying an alcohol-based (waterless) hand hygiene product.
 Inherent       hand    Instinctive need to remove dirt from the skin when hands are visibly soiled,
 hygiene practice       sticky or gritty. Likely to be established in the first ten years of life and to drive
                        the majority of community and HCW hand hy giene behaviour throughout life.
                        For example, among nurses, it occurs after touching an „emotionally dirty‟
                        area (e.g. axillae, groin or genitals).
 Elective       hand    Attitude to hand cleansing in more specific opportunities not encompassed in
 hygiene practice       the inherent c ategory and more frequently corresponding to some of the
                        indications for hand hygiene during healthcare delivery. For example, among
                        HCWs, it includes touching a patient such as taking a pulse or blood
                        pressure, or having contact wit h an inanimate object in the patient
 Hand drying            Hand drying is an essential step in hand cleansing and should be done in
                        such a way that hand recontamination does not occur. Common hand drying
                        methods include paper towels, cloth towels and hot -air dryers. Warm air
                        drying is not as effective at removing bacteria from washed hands as paper
                        towels; they are also less practical bec ause of longer time needed to achie ve
                        dry hands. Paper and cloth towels should be single use.
 Hand hygiene products
 Alcohol-based hand rub. An alcohol-c ontaining preparation (lotion/rinse, gel or foam) designed for
 application to the hands t o reduce the growth of microorganisms. Such preparations may cont ain
 one or more types of alcohol with excipients (inactive substance used as a carrier for t he active
 ingredients of a medication), other active ingredients, and humectants (emollients/moisturisers e.g.
 Propylene Glycol).
 Antimicrobial soap. Soap (detergent) containing an antiseptic agent at a concentration which is
 sufficient to reduce or inhibit the growth of microorganisms.
 Anti septic agent.       An antimicrobial substance which reduces or inhibits the growth of
 microorganisms on living tissues. Examples include alcohols, chlorhexidine gluconate, chlorine
 derivatives, iodine, and triclosan.
 Detergent (surfactant). Compounds that possess a cleaning action. They are composed of a
 hydrophilic and a lipophilic part and can be divided into four groups: anionic, cationic, amphoteric,
 and non-ionic. Although products used for handwashing or antiseptic handwash in health care
 represent various types of detergents, the term “soap” will be used to refer to such detergents in this
 Plain soap. Detergents that do not contain antimicrobial agents, or that contain very low
 concentrations of antimicrobial agents effective solely as preservatives.
 Waterless anti septi c agent. An antiseptic agent that does not require the us e of ex ogenous water.
 After application, the individual rubs the hands together until the agent has dried. The term includes
 different types of hand rubs (liquid formulations, gels, foams, leaflets/towelets).

Policy                                                                Version: 27 October 2010

3. Policy
CHRISP is responsible for:
 Ongoing statewide development and evaluation of HH promotional resources to assist
   HSD implement and sustain the Clean Hand are Life Savers program
 Maintaining HH network and dissemination of new initiatives, research findings and
   relevant data
 Providing statewide advic e, guidance and support to HS D regarding compliance with t he
   HQCC Standard.
 Provision of feedback to HQCC regarding the validity and reliability of data obtained from
   the collection of performance measures
 Hosting Infection Prevention Week in October each y ear in consult ation and collaboration
   with HS Ds

Health Care Facility is responsible for:
 Developing loc al policy that delegates responsibility for t he HH program to infection
   control link to ICMP
 Implementation, ongoing management and continued support of t he Clean Hand are Life
   Savers program providing regular feedback to staff
 Choic e of performance measures and the frequency at which they will be conducted and

4. Indications for Hand Hygiene: Risk Categorisation

It is recommended that Health Service Districts/facilities focus initially on achieving very high
hand hy giene compliance with high -risk activities. Once the ward/unit/department has
reached 50% compliance with high-risk hand hygiene activities (opportunities 1-6), the focus
should move to medium -risk activities (opport unities 7 & 8). Once high levels of compliance
are reached with medium-risk activities, low-risk activities (opportunities 9-11) should be
target ed.
It is acknowledged that this will be an incremental process and it may take several years to
achieve high levels of compliance with low-risk activities.
Compliance to hand hygiene should be measured using the Hand Hy giene Audit Tool.
Compliance can be defined as either washing hands with soap and running water or
decontaminating hands with an alcohol-based hand rub in accordance with a hand hygiene

   Policy                                                                 Version: 27 October 2010

Ri sk           Acti vities
Asse ssment
High Ri sk      1.   Care of indwelling devices inserted into sterile body sites e.g. manipulation of
                     indwelling devices, accessing indwelling devices i.e. administration of
                     intravenous (IV ) medication into IV lines, changing of IV and central venous
                     catheter (CV C, PICC) lines, dressings of indwelling devices e.g. CV C site.
                2.   Moving from a cont aminated body site to a clean body site on the same patient
                     e.g. moving from respiratory tract care (+/- gloves) to manipulating a CVC hub.
                3.   Care of non-int act skin e.g. routine care of surgical and other wounds (pressure
                4.  Entry into a sterile body cavity where the device is removed e.g. endo -tracheal
                    suction, in-out urinary catheter insertion.
                5. Brief invasive procedure – skin integrity or vascular system breached but no
                    devic e is left in situ e.g. blood collection (arterial and venous), intramuscular and
                    subcutaneous injection.
                6. All contact with patients known to have transmissible pathogens e.g. MRSA,
                    vancomycin resistant enterococci (VRE ), Norovirus, Respiratory Syncytial Virus
                    (RSV); including inanimate objects in the patient‟s environment.
                Alcohol-based hand rubs have no activity against bacterial spores (including
                Clostridium difficile) and parasites, and poor activity against non-enveloped viruses
Medium Risk     7.   Cont act with body fluids and muc ous membranes including entry into non-sterile
                     body sites i.e. contact with secretions, excretions, blood or any body fluids,
                     naso-gastric tube insertion and as piration, rectal tube insertion and drainage,
                     emptying urinary drainage bags, changing nappies; includes contact with
                     materials contaminated with blood or body fluids, such as linen.
                8.   Patient contact – long duration e.g. sponging/showering a patient, performing
                     full nursing care, full medical assessment/clinical examination. Includes making
                     and cleaning beds.

Low Risk        9.  Patient contact – s hort duration e.g. taking vital signs (t emperature, pulse,
                    respirations, blood pressure), clinical examination – listening to heart sounds,
                    taking ECG, repositioning or lifting patient, medication round.
                10. Cont act with inanimate objects e.g. contact with medication charts, bed-end,
                    locker, infusion pumps, monitors, chairs, curtains, computer keyboards, sterile
                11. HCW personal hygiene e.g. commencement of shift, after using the toilet, after
                    blowing nose, covering mouth if coughing, contact with own body fluids.

   5. Process for managing skin reactions to hand
   There are two major types of skin reactions associated with hand hygiene: irritant contact
   dermatitis and allergic contact dermatitis. Any skin reactions relating to hand hygiene are to
   be reported using the Queensland Health Workplace Incident Report Procedures

   Incidents must be reported on the approved Queensland Health Work place Incident Report
   and entered into the Incident Management System (IMS) to facilitate review of HSD and
   statewide data. The following responses should be report ed for thes e c ategories:
           ∙   Injury/Illness = Skin disease/dermatitis
           ∙   What Happened = Chemical/substance
           ∙   Prime Cause = Chemical exposure

Policy                                                              Version: 27 October 2010

Trends in adverse effects/product complaint should also be reported via the HS D committee
structure and to Health Services Purchasing a nd Logistics (HSPL) using the
Procedure/Protocol for Complaints/Feedback which is available at

6. Measuring and reporting compliance
In order to measure compliance wit h the hand hy giene policy and t o ensure continued
reinforcement of the program and appropriate hand hygiene behaviour, CHRISP has
developed one mandatory and other performance and outcome indicators cited in t he
literature. The mandatory Outcome Indicator calls for routine auditing (percentage compliance
with hand hygiene recommendations) see CHRISP Recommended Practice 4 (link).

Performance feedback to HCW‟s on hand hygiene behaviour is critical to improve compliance
with hand hygiene. It is recommended that outcome data be provided to staff.


   MRSA isolates are dependent on the level of multiresistant organism (MRO) screening
    undertaken in a facility. Hospitals t hat have an extensive MRO screening program could
    be unfairly scrutinised when compared to hospitals with minimal screening programs;
    there is also potential for variance in screening frequencies and screening sites. More-
    over the rates of MRSA bloodstream infection (bacteraemia) are less than 25% of those
    of NHS hospitals in England and Wales where this indicator has been mandated and thus
    a significant and sustained improvement will not be readily detected for some years.
   The MRSA indicators are not suitable for small- and medium-size facilities where
    denominator data are not used. The process within small Queensland Health hospitals is
    Signal Infection Surveillanc e.
   More importantly another factor that assists with controlling MRSA is isolation and
    currently many hos pitals ability to adequately isolate MRSA is limited so inc reasing hand
    hygiene is unlikely to reflect in decreased MRSA rates.
   The number of episodes of MRSA bloodstream infections is already submitted to t he
    CHRISP Surveillance Program by 22 enrolled hospitals. The CHRISP E pidemiologist
    and Statistician use complex statistical methods to analyse and report the data including
    Bayesian shrinkage estimates and funnel plots. Outliers (>two standard deviations) are
    identified and managed by the CHRISP Statewi de Infection Prevention Service (S IPS),
    which includes review of int erventions, medical devices etc. Given the comprehensive
    Statewide surveillance system that already exists, the purpose of submitting the same
    data to the HQCC is questionable.
   The denominator us ed by CHRISP for bloodstream infections is occupied bed days (rate
    per 1, 000 bed days).
   In summary, CHRISP would not recommend these indicators.                  Instead CHRISP
    recommends individual facilities monitor and investigate all cases of healthcare
    associated intravascular device-related S. aureus bloodstream infections (BS I), which
    would include MRSA BS I and be more applicable to a broader range of healthcare
    facilities. An investigation checklist has already been developed as part of the CHRISP I-
    Care Project (refer au/chrisp/icare/about.asp)

7. Fire Safety issues
When implementing alcoholic hand based hygiene products within the HSD Material S afety
Data Sheets (MSDS ) (Link t o CHEM watch) are to be available in all areas where alcohol-
based hand hygiene products will be provided. In addition due alcohol -based hand hygiene
products containing at least 60% ethyl, isopropyl or n -propyl alcohol the following points
relating to fire safety must be taken into consideration:

Policy                                                                  Version: 27 October 2010

   Flash-points of alcohol -based hand hygiene products range from 21 C to 24C,
    depending on the type and concentration of alcohol present.
   Alcohol-based hand hygiene products should be stored away from high temperatures or
    flames in accordance wit h rec ommendations of the Queensland Health Occupational
    Healt h and Workplace Safety Unit (24 May 2007) but can be installed in patient rooms,
    procedure areas, staff areas (e. g. staff station) and corridors of healthcare facilities.
   The maximum size of an individual alcohol-based hand hygiene product dispenser fluid
    capacity is not to exceed 500mL.
   Not more than a tot al number of 40 individual alcohol-based hand hygiene product
    dispensers (maximum capacity of 500mL) s hall be installed within a single smoke
    compartment, and the total quantity of all flammable liquids (including hand hygiene
    products) is not to exceed 10 litres per 50m² of floor space.
   When considering the requirements for minor storage, the total quantities of all flammable
    liquids (not just alcohol-based hand hygiene products) must be considered. Minor storage
    of all flammable liquids is not to exceed 10 litres per 50m² of floor space (AS 1940 -2004,
    Section 2, Table 2.1).
   Corridors must have at least 180cm of clear width with alcohol -based hand hygiene
    dispensers spaced at least 150cm apart.
   Alcohol-based hand hygiene dispensers should not be installed in carpeted corridors
    unless the corridors are sprinkler prot ected.
   Dispensers must not project more than 15cm into corridor egress width.
   In all locations, alcohol-based hand hygiene dispensers must not be located over, or
    directly adjacent to, ignition sources including electrical receptacles and switches such as
    power points, light switches, nurse call buttons, monitoring equipment and other
    electrically powered equipment or devices.
   The introduction or use of mobile electrical equipment within the immediat e location of
    alcohol-based hand hygiene dispensers should be avoided.
   Alcohol-based hand hygiene dispensers should not be indiscriminat ely placed in locations
    which the public (and children) may access/use the product, without adequate staff
    supervision and training safe guards in place. Instruction for use signage is required,
    however this alone is not considered adequate for public use.
   Supplies of alcohol -based hand hygiene products must be stored in cabinets or areas
    approved for flammable material consistent with Australian Standard AS 1940 -2004 –
    The Storage and Handling of Flammable and Combustible Liquids.
    ▪ When considering the requirements for minor storage, the total quantities of all
        flammable liquids (not just alcohol-based hand hygiene products) must be
    ▪ Minor storage of all flammable liquids is not to exceed 10 lit res per 50m² of floor
        space (AS 1940-2004, Section 2, Table 2.1).

8. Other Issues
When establishing the Clean Hands are Life Savers Program each health Service District is to
consider accidental ingestion and dermal absorption of alcohol based products (link to
Recommended P ractice XX)

9. Resource Links
        CHRISP Clean Hands are Life Savers Program Hand web page
        Hand hygiene recommended practices for improving compliance with hand hygiene in healthcare
        WHO website


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