Hand_Hygiene_Policy by ashrafp


									 Title: Hand Hygiene Policy
 Scope: Trust Wide                             Classification: Policy
 Identification No: ICM 5                      Version No: 2
 Hand Hygiene Policy v1
 Name of Author/Originator: Martin Jones Infection Control Nurse
 In consultation with: Health Protection Committee
 Accountable Director: Director of Infection Prevention & Control, Director of Provider
 Authorised by:                                          Date:
 Governance Committee                                          12 March 2009
 To be read in conjunction with: Infection Control Policies
 Issue Date:                     Review Date:
 March 2009                      March 2011
 Equality Impact Assessment       January 2009
 carried out

In considering the application of this policy, procedure or function the PCT will
ensure that staff or patients will not be discriminated against or treated differently on
account of any subjective bias in relation to the six pillars of equality and diversity:
race, disability, gender, age, sexual orientation, religion/belief.

This document can only be considered valid when viewed via the NHS Sefton website
or Department Policy Folder. 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.

This document is available in other formats on request
Hand Hygiene Policy


Section               Title                                               Page
1.                    Introduction                                           3

2.                    Principles                                             3

3.                    Indications of Hand Washing                            3

4.                    Type of Cleaning Agent                                 4

5.                    Hand Washing Technique                                 4

6.                    Hand Cream, Skin Care                                  4

7.                    Levels of Hand Contamination                           5

8.                    Hand Hygiene Training                                  5

9.                    Governance                                             5

10.                   Monitoring of Training and Compliance with Policy      6

11.                   References                                             7

12.                   Appendix 1                                             8

                                       Page 2 of 8
Hand Hygiene Policy

Trust Statement

1.     Introduction

       1.1    The aim of the policy is to prevent the spread of infection by contamination
              from health workers hands.

       1.2    Hand washing is the single most important procedure for preventing
              infections. Body secretions surfaces and hands of all healthcare workers can
              carry bacteria, viruses and fungi, that are potentially infections to them and
              others. Handwashing is known to reduce patient morbidity and mortality from
              Community Infections.

2.     Principles

       There are three principal reasons for removing or reducing the number of micro
       organisms present on healthcare workers hands.

       2.1    To reduce the number of micro-organisms present prior to an invasive

       2.2    To remove or destroy potentially pathogenic micro-organisms present on the
              hands of staff.

       2.3    To treat a carrier or dispenser of a resistant virulent or highly communicable
              strain of bacteria.

3.     Indications of Hand Washing

       The decision to wash hands must be based on assessment of the risk that microbes
       have been acquired or may be transmitted.

       Hand washing is essential in the following situations:

       Hands must be decontaminated immediately before each and every episode of direct
       patient contact/care and after any activity or contact that potentially results in hands
       becoming contaminated.

             before contact with susceptible sites eg. wounds, burns, intravascular sites.
             before performing invasive procedures, ie. Where natural defences against
              infection are breached eg. catheterisation
             before contact with susceptible patients eg. Immunosuppressed, older
              people, neonates.
             before handling food or medicines
             after contamination with bodily fluids
             prior to and after gloves have been removed
             after contact with an infectious patient
             after using toilet or when assisting others
             at the beginning and end of a shift

                                      Page 3 of 8
Hand Hygiene Policy

4.     Type of Cleaning Agent

       4.1    Soap and water should be used for handwashing and must be provided as
              liquid soap in sealed units.

       4.2    Alcohol hand gels are an excellent substitute for the community setting,
              especially where there is no access to suitable soap and water. Bar soap and
              nailbrushes must be avoided. When using alcohol gel alone, hands must be
              visibly clean, as alcohol hand gels do not remove dirt or organic material.
              The gel must come into contact with all surfaces of the hand. The hands
              must be rubbed together vigorously, paying particular attention to the tops of
              fingers, the thumbs and the areas between the fingers, until the gel has
              evaporated and the hands are dry.

        4.3   As hands can only be washed on up to 8 consecutive occasions using
              alcohol hand rub, then staff have to wash their hands with hot soapy
              water. As this is potentially difficult for staff carrying out domiciliary
              visits, there is an alternative – hand wipes (available via NHS Logistics).
              These can clean hands after the 8th application of alcohol gel, after the
              hand wipe has been used staff can then resort back to using their
              alcohol gel.

5.     Hand Washing Technique

             The use of vigorous rubbing to create friction, thorough rinsing, and ensuring
              that the hands are completely dry are key factors in effective hand hygiene,
              and the maintenance of skin integrity. Effective handwashing technique
              involves four stages – preparation, washing, rinsing and drying.

              NB Remove all wrist and hand jewellery at the beginning of each shift before
              hand decontamination begins. Fingernails must be kept short and free from
              varnish. False nails must not be worn in the clinical setting. Please refer to
              PCT uniform policy. Cuts and abrasions must be covered with waterproof

              Preparation requires wetting hands under tepid running water before applying
              liquid soap.

             Hand washing solution must come into contact with all the surfaces of the

             Hands must be rubbed together vigorously for a minimum of 10-15 seconds
              paying particular attention to the tips of fingers, the thumbs and the creases
              between the fingers. Hands should be rinsed thoroughly prior to drying with
              paper towels. (Appendix 1)

6.     Hand Cream, Skin Care

       6.1    Apply an emollients handcream regularly to protect skin from drying effects of
              regular hand decontamination. Hand cream that contains emollients are
              important factors in maintaining skin integrity.

                                     Page 4 of 8
Hand Hygiene Policy

       6.2       Hands can become dry and sore; this has been shown to increase the
                 potential for cross contamination of micro organisms. If you encounter skin
                 problems, please contact the Occupational Health Department University
                 Hospital Aintree.

       6.3       Avoid abrasive products/solutions when performing routine or social hand
                 washing. Assess what you have just done, what you are going to do, the level
                 of possible contamination and then, what level of decontamination, is
                 required. This assessment, will determine the appropriate solution to use.

7.     Levels of Hand Decontamination

        Method            Solution                                Task

        Social            Liquid soap                             for all routine tasks

        Hygienic          Antiseptic, eg. Chlorhexidine or        In high risk areas and
        hand              alcohol hand-gel.                       during outbreaks
        Surgical          Antiseptic, eg. Chlorhexidine,          Prior to surgical and
        scrub             provide iodine, thorough and            other invasive
                          careful cleaning for a minimum of 2     procedures
                          min, dry on sterile towels.

8.     Hand Hygiene Training

       8.1       The spread of infection via hands is a well-established fact. This policy
                 highlights the importance of staff attending hand hygiene training in the
                 reduction of health care acquired infections.

       8.2       All healthcare staff will adhere to the Trust hand hygiene policy found within
                 the Infection Control Manual and on the Trust’s intranet site.

       8.3       Hand Hygiene training will be carried out by the Infection Control team
                 through Mandatory training, the ‘Clean Your Hands’ campaign will further
                 raise awareness of this activity in clinical areas. The hand hygiene training
                 programmes will address the standards expected as outlined in this policy.

       8.4        All healthcare workers with patient contact must have annual training in hand
                 hygiene as part of the Trust’s mandatory training programme, for non –
                 clinically based staff this is two yearly.

9.     Governance

       9.1       The Infection Control Committee is responsible for ensuring appropriate
                 policies and procedures are in place to support hand hygiene practices.

       9.2       Staff are expected to follow Trust policies and procedures; professional codes
                 of conduct/practice; accepted standards, statutory requirements and

                                        Page 5 of 8
Hand Hygiene Policy

10.    Monitoring of Training & Compliance with Policy

       10.1   Compliance with the policy shall be monitored via an annual audit for health
              clinics and a two yearly audit for GP surgeries with results submitted to the
              Infection Control and health Protection Committee’s. This shall be the
              responsibility of the infection control team who will also be responsible for
              ensuring that any issues of non-compliance identified are addressed via an
              appropriate action plan. The combined audit report and associated action
              plans shall be received and monitored by the Infection Control and Health
              Protection Committee’s. Any issues raised from the audit relating to patient
              safety will be reported to the Patient Safety Group.

       10.2   The HR - training and development will keep records of attendance for
              mandatory training and will follow up non-attendees’ via the line manager.

              Any other attendance records on hand hygiene training will be kept by the
              Infection Control team.

              Compliance with the policy will be monitored through the audit programme.

              Compliance with this will be monitored by the Infection Control Committee
              and subsequently the Board and training and development team will provide 6
              monthly reports on compliance to both the Infection Control and Health
              Protection Committees.

                                     Page 6 of 8
Hand Hygiene Policy

11.    References

       1.     Albert RK, Condie. Hand washing pattern in medical intensive care units. New
              Engl J Med 1981; 304: 1465 – 66.
       2.     Ayliffe GAJ, Babb JR, Davies JG, Lilly HA. Hand disinfection: a comparison of
              various agents in laboratory and ward studies. J Hosp Infect 1988; 11:226-43.
       3.     Casewell M, Phillips I. Jands as route of transmission for Klebsiella species.
              BMJ 1977; 2:1315-1.
       4.     Cruise PJE, Ford R. A five-year prospective study of 23,649 surgical wounds.
              Arch Surg 1973; 107: 206-09.
       5.     Glynn AA, Ward V, Wilson J, Charlett A, Cookson B, Taylor L, Cole N.
              Hospital acquired infection: surveillance, policies and practice. London: PHLS
       6.     Haley RW, Bregman DA. The role of understaffing and overcrowding in
              recurrent outbreaks of staphylococcal infections in a neonatal special care
              unit. J Infect Dis 1982; 154: 875-85.
       7.     Hoffman PN, Wilson JA. Hands, hygiene and hospitals. PHLS Microbial
              Digest 1995; (40: 211-16)
       8.     Jeanes, A. (2001). “Nail art: a review of current infection control issues. “The
              Journal of Hospital Infection 49(2) ; 139-42
       9.     Larson E, Killien M. Factor’s influencing handwashing behaviour in patient
              care personnel. Am J Infect Control 1982; 10: 93-99.
       10.    Mackintosh CA, Hoffman PN. An extended model for transfer of micro-
              organisms via the hands: differences between organisms and the effect of
              alcohol and the effect of alcohol disinfection. J Hyg (camb) 1984; 345-55
       11.    Mortimer EA, Wolinsky E, Gonzaga AJ, RammelKamp CH. Role of airborne
              transmission in staphylococcal infections. BMJ 1966; 1:319-22.
       12.    Ojajarvi J. An evaluation of antiseptics used for hand disinfection in wards. J
              Hyg (Camb) 1976; 76: 75-82.
       13.    Ojajarvi J, Makela P, Rantasalo I. Failure of hand disinfection with frequent
              hand washing: a need for prolonged field studies. J Hyg (Camb) 1977; 779:
       14.    Olsen RJ, Lynch P, Coyle MB, Cummings J, Bokete T, Stamm WE.
              Examination gloves as barriers to hand contamination in clinical practice. J
              Am Med Assoc 1933; 270: 350-53.
       15.    Rotter m, Killer W, Wewalka G. providone-iodine and chorhexidine
              gluconate-containing detergents for disinfection of hands. J Hosp Infect
              1980; 1: 149-5.
       16.    Sprunt K, Redman BA, Leidy G. Antibacterial effectiveness of routine hand
              washing. Paediatrics 1973; 52: 264-70.
       17.    The epic Project: Developing National evidence – based Guidelines for
              preventing Healthcare Associated Infections. Standard Principles for hand
              The Journal of Hospital Infection: Vol. 47 Jan 2001: 23 – 27.

                                     Page 7 of 8
Hand Hygiene Policy

12.    Appendix 1

                      NHS SEFTON

                       Page 8 of 8

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