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Code Ref: IC2
Issue number: 1
Hand Hygiene Policy and
Procedure
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Lead Executive Director of Nursing, Therapies, and Patient Partnership
Author with contact Infection Prevention and Control Nurses
details 01244 364085
Responsible Clinical Risk Review Sub-Committee
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Committee/Sub
Committee
Document approved by & Clinical Risk Review Sub-Committee
date: 9th November 2007
Document consultation: T
Local Infection Prevention and Control Teams
Infection Prevention and Control Group
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Governance Support Team
Patient and Public To provide service users, carers and the wider public with
Involvement (outline any assurance that the Trust is managing the risks associated with
PPI input into policy and infection prevention and control
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associated impact on
service users and carers)
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What type of document is Infection Prevention & Control Policy
this (delete as
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appropriate)
Document applicable to All Trust Staff
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(Identify by location and
staff groups):
If new document, reason Developed to provide Trustwide policy and to reduce risk by
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for development: replacing existing local policies
Synopsis outlining This hand hygiene policy has been devised for all healthcare
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document aims: professionals to able to refer to regarding all aspects of hand
hygiene. Evidence clearly demonstrates that cross infection
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can, and does occur on the hands of healthcare workers and
the hands of staff are the most common vehicle by which
micro-organisms are transmitted between patients (Ayliffe,
2000).Good hand hygiene is the cornerstone of all infection
control practice (Wilson, 2001 and Department of Health,
2003) and it is therefore imperative that all Trust employees
are familiar with, understand and practice the principles set
out in this policy.
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Implementation Date: 14th November 2007
How will the The Infection Prevention and Control Team will monitor and
implementation of this evaluate the implementation of this policy via infection control
document be monitored audits. Hand hygiene will be an integral part of Infection
and reviewed Control.
Audits will include observation of handwashing techniques
and the Infection Control Work Programme.
Review Date (default 2 November 2009
years 1 ):
Document to be read In MRSA Policy
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conjunction with: Universal Precautions Policy;
Clostridium Difficile Policy;
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Infection Prevention and Control Operational Policy
Financial resource No new resources required
implications of this
document and how these
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are going to be
addressed:
Is this document carried No
out wholly or in part by
contractors, or
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organisations with which
the Trust has a service
level agreement, and if so
state the relevant
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contractor
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Document Change History (changes from previous issues of policy (if appropriate) :
Issue Number Page Changes made with rationale and impact on Date
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practice
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1
Check with Clinical Governance/Risk Manager to ensure that there is not an external requirement that
determines review date
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CONTENTS
PG
Section SECTION HEADING
1 INTRODUCTION 4
2 BACKGROUND MICROBIOLOGY OF THE HANDS 4
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3 PRINCIPLES AND PROCEDURES 4
3.1 When must hands be washed
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4
3.2 Correct technique for handwashing 5
3.3 Alcohol hand gel 6
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4 DUTIES AND RESPONSIBILITIES 6
4.1 All Trust Staff 6
4.2 Line Managers/Senior Managers 6
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5 REFERENCES 7
6 APPENDICES 8
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1. Hand Washing Poster 8
2. Training Needs Analysis 9
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3. Equality and Diversity/ Human Rights Impact 11
Assessment
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1.0 INTRODUCTION
This policy has been devised for all healthcare professionals to able to refer to
regarding all aspects of hand hygiene. Evidence clearly demonstrates that
cross infection can, and does occur on the hands of healthcare workers and
the hands of staff are the most common vehicle by which micro-organisms
are transmitted between patients (Ayliffe, 2000).Good hand hygiene is the
cornerstone of all infection prevention and control practice (Wilson, 2001 and
Department of Health, 2003) and it is therefore imperative that all Trust
employees are familiar with, understand and practice the principles set out in
this policy.
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By reinforcing good hand hygiene practice and therefore promoting
understanding, all Trust staff will become educated in this important area of
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infection prevention and control and therefore complying with guidance such
as “Winning Ways” (Chief Medical Officer, 2003) and “Essential Steps to
safe, clean care” (Chief Medical Officer, 2006) and The Health Act (2006).
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2. 0 BACKGROUND MICROBIOLOGY OF THE HANDS
Micro-organisms found on the hands are either resident or transient. Resident
micro-organisms are deep seated and difficult to remove, however transient
organisms are more superficial and can transfer easily from the hands to
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vulnerable patients. Examples of such organisms include Staphylococcus
aureus and Klebsiella.However, good handwashing can easily remove such
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organisms from the skin and prevent such cross infection occurring.
3.0 PRINCIPLES AND PROCEDURE
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3.1 When Must Hands Be Washed?
There is not a set frequency for when hands should be decontaminated –
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this is dependant on what the duties the healthcare worker has been
carrying out. However, “it is essential that hands are washed /
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decontaminated before and after every patient care episode”. It has
been demonstrated that staff can over-estimate how often they
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decontaminate their hands and a study by Pilley, (1999) established the
level of contamination on healthcare workers hands as they entered a
staff restaurant for their lunch. Examples of when hands should be
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washed / decontaminated include:
• After using the toilet
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• After removing personal protective clothing such as gloves and
aprons
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• Before and after the administration of medication
• Before and after handling invasive devices such as urinary
catheters or dressing wounds.
• Before preparing, handling or eating food.
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3.2 Correct Technique for Hand Washing and Applying Alcohol
Hand Gel
3.2.1 Ensure warm running water is available and wet hands thoroughly prior
to applying soap. The correct technique is demonstrated in a poster
which can be downloaded from the Trust’s intranet by using the
following link: http://nww.cwp.nhs.uk/NR/rdonlyres/979C5C1F-246E-
402C-83D6-FE8087673CFA/41870/Handwashingtechniqueposter.pdf .
Also found in Appendix 1.
3.2.2 Alcohol hand gel must be applied using the same method, ensuring the
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product covers all surfaces of the hands.
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3.2.3 Nails should be kept short and clean and preferably free of nail varnish.
Rings - with the exception of a plain band wedding ring – bracelets and
watches should not be worn whilst on duty as such items hinder a
thorough hand washing technique (Taylor, 1978). For the same reason
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false nails and acrylic overlays are not acceptable in clinical practice.
3.2.4 Whilst the process of hand washing is extremely important so is
ensuring that hands are dried adequately once the procedure has been
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completed. Good quality paper hand towels are essential for this to
occur. Healthcare workers should use as many towels as necessary to
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ensure that their hands are thoroughly dried. Wet hands provide a
breeding ground for bacterial growth and subsequent cross – infection
(Ansari et al 1991). All staff should use the moisturising cream that is
supplied on a regular basis to ensure that skin remains in good
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condition. Staff may also use their own hand cream if necessary.
Communal tubs of hand cream are not advised.
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3.2.5 When hands are visibly soiled they should be washed with soap and
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water. If this is not immediately possible e.g. if the healthcare worker is
in a patient/ service users home where hand washing facilities may not
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be available then alcohol hand gel may be used until such facilities can
be accessed.
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3.2.6 In inpatient / service user areas alcohol hand gel is available at most
clinical hand wash basins (in areas that service users do not have
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unsupervised access to), at ward entrances and can also be carried by
staff on their person.
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3.2.7 It is important to emphasise that unless it is an emergency situation as
outlined previously in 3.2.5, that alcohol hand gel should only be
used on physically clean hands where no organic matter is
present. The gel should be applied onto the skin as per a routine hand
washing technique. It should be rubbed in until all traces of it have
evaporated. The alcohol contained in the product will sting cuts and
abrasions present on the skin so these must be protected with an
appropriate waterproof dressing.
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If the healthcare worker has any cuts/abrasions on their hands that
cannot be covered by such a dressing or if hands are becoming sore and
chapped then advice from the relevant Occupational Health Department
should be sought re.safety to carry out clinical duties.
3.3 Alcohol hand gel – patient / service user safety
Alcohol hand gel dispensers should only be situated where they cannot
be accessed by unsupervised patients / service users who may use the
gel to cause themselves or others physical harm. The gel can be
purchased in bottles that can be carried on the healthcare workers
person. If any further assistance is required on this issue then please
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contact the infection prevention and control team on 01244 364085
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4.0 Duties and Responsibilities
For general duties and responsibilities in Infection Prevention and Control
please refer to the Infection Prevention and control Policy (ICP) 1. For
additional and specific duties and responsibilities relating to this policy please
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see below
4.1 All Trust Employees
It is the responsibility of all Trust employees to follow this policy and
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procedure and ensure safe and effective practice in hand hygiene is
carried out in the work place.
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4.2 Line Managers/Senior Managers
Managers are responsible for ensuring staff have access to learning in
hand hygiene. They will also ensure that staff have access to hand
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decontamination and moisturising products.
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5.0 REFERENCES
Ansari SA, Springthorpe US and Sattar SA (1991). Comparison of cloth, paper
and warm air drying in eliminating viruses and bacteria from washed
hands.American Journal of Infection Control. 9. 243-9.
Ayliffe GAJ, Fraise AP, Geddes AM and Mitchell k. (2000). Control of Hospital
Infection. 4th ed. London : Arnold.
Chief Medical Officer (2003). Winning Ways. Department of Health.
London.
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Chief Medical Officer (2006). Essential Steps to safe, clean care. Department
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of Health. London.
Pilley HS, (1999) An evaluation of the level of contamination of healthcare
workers hands. Printed but unpublished.
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Taylor L.(1978). An evaluation of handwashing techniques.Nursing Times.74.
108-110.
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Wilson, J (2001).Infection Control in Clinical Practice. 2nd ed. London: Baillere
Tindall.
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APPENDIX 1 - Hand washing poster
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APPENDIX 2
Training Needs Analysis for the approved document
Please tick as appropriate
There is no specific training requirements- awareness for relevant staff required, disseminated
via appropriate channels
(Do not continue to complete this form-no formal training needs analysis required)
There is specific training requirements for staff groups
(Please complete the remainder of the form-formal training needs analysis required- link with
learning and development department.
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Staff Group if Frequency Suggested Delivery Method Is this
appropriate (traditional/ face to face / e- included
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learning/handout) in
Trustwide
essential
learning
program
me for
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this staff
group (
if yes)
Career grade doctor
Training grade doctor
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Locum medical staff
Inpatient Registered Nurse
Inpatient Non- registered Nurse
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Community Registered Nurse
Community Non Registered
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Nurses/Care Assistants
Psychologists/Pharmacists
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Therapists
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Clinical bank staff regular worker
Clinical bank staff infrequent
worker
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Non-clinical patient contact
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Non-clinical non patient contact
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Please give any additional information impacting on identified staff group training needs (if applicable)
Hand hygiene is included infection prevention and control training as part of essential
learning and as such is enabled and followed up via the Trust wide Policy on Learning &
Development requirements
Please refer to training needs analysis in Trust-wide Infection Control Operational
Policy for specific staff groups
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Please give the source that has informed the training requirement outlined within the policy
i.e. National Confidential Inquiry/NICE guidance etc.
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Winning Ways 2003
Essential Steps to Safe, Clean Care, 2006
The Health Act 2006
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ADDITIONAL INFORMATION FOR CONSIDERATION:
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NAME Infection Prevention and Control Team
DATE 4th July 2007
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APPENDIX 3
Equality and diversity/Human Rights impact assessment
IS IT RELEVANT? HOW RELEVANT IS IT?
Does the policy Is there evidence to How much Is there public
include anything that believe that groups evidence do you concern that the
… could be treated have policy is
2
Eliminates different- if so, discriminatory
discrimination and/or which groups within
Promotes equal each category(e.g.
opportunities under 16 year olds 1. None or a little (Answer yes, no or
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(Answer yes, no or in age category) 2. Some N/A for each
N/A for each category 3. Substantial category listed)
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listed)
Race NO NO 1 N/A
Gender NO NO 1 N/A
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Disability NO NO 1 N/A
Age NO NO 1 N/A
Sexual orientation NO NO
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Religion or beliefs NO NO 1 N/A
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Now evaluate your answers by using the criteria provided and underline which
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describes your policy:
Relevance Rationale Monitoring 3
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High relevance If there is substantial evidence that You need to start monitoring the
indicates that groups could be treated impact of this policy within a
differently because of the policy year of it being introduced
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Medium relevance If there is some evidence that You need to start monitoring the
indicates that groups could be treated impact of this policy within 2
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differently because of the policy years of it being introduced:
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Low relevance If there is little/no evidence that Impact monitored at least every
indicates that groups could be treated 3 years
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differently because of the policy
2
Could be gauged from surveys, audit data, complaints etc,
3
Policy Reviews Group working with Equality & Diversity/Human Rights Group must monitor the impact of policies
through the following channels: results from the national service user survey, the national mental health and ethnicity
census, complaints data, PALS feedback, individual systems within clinical services through which ward and
community staff liaise with service users and carers i.e. ward meetings, modern matron meetings
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This assent will be reviewed by the Equality and Diversity/Human Rights group
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Human Rights
When developing any policies, policy writers should ask themselves ‘does the policy
engage/restrict anyone’s Human Rights?’
What is the There are 16 basic rights in the Human Rights Act, all taken from the
Convention of European Convention on Human Rights. There are 3 types of rights detailed
Human Rights? as follows:
Absolute- cannot opt out of - Right to life
these rights under any - Prohibition of torture
circumstance- cannot be - Prohibition of slavery and forced
balanced against any public labour
interest - No punishment without law
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- Right to free elections
- Right to marry
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- Abolition of the death penalty
Limited- these rights are - Right to liberty and security
subject to predetermined - Right to a fair trial
exceptions
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Qualified- these rights can be - Respect for private and family life
challenged in order to protect - Right to Freedom of thought,
the rights of other people conscience and religion
- Freedom of expression
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- Freedom
association
of assembly and
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- Prohibition of discrimination
- Protection of property
- Right to education
Where can I get More details can be found at the Department of Constitutional Affairs (DCA)
more information http://www.dca.gov.uk/peoples-rights/human-rights/publications.htm
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about this? Publications
DCA (Oct 2006) Human rights: human lives – a handbook for public
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authorities, crown copyright
DCA (Oct 2006) Making sense of human rights – a short introduction, crown
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copyright
DCA (Oct 2006) A Guide to the Human Rights Act 1998, crown copyright
What should I do You should forward for discussion at the Trustwide Equality and Diversity
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if I suspect my and Human Rights Group within the Trust- contact John Short, Chief
policy affects Operating Officer, executive lead for Equality & Diversity and Human Rights
anyone’s Human mailto: john.short@cwp.nhs.uk
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Rights?
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Please tick one of the following:
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The above has been considered and to the best of my knowledge my policy does not affect
any of the human rights listed
The above has been considered and my policy does affect a human right article(s) but this
has been discussed and ‘qualified’ at Trust Equality and Diversity and Human Rights Group
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