Hand Hygiene Policy - NHS Gateshead€¦ · 6.3 Good hand wash technique An effective hand washing...

Hand Hygiene Policy V6

Policy No: IC04

Version: 6.0

Name of Policy: Hand Hygiene Policy

Effective From: 01/03/2018

Date Ratified 23/01/2018

Ratified Infection Prevention & Control Committee

Review Date 01/01/2020

Sponsor Joint Director of Infection Prevention & Control

Expiry Date 22/01/2021

Withdrawn Date

Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no

assurance that this is the most up to date version.

This policy supersedes all previous issues.

Hand Hygiene Policy V6 2

Version Control

Version Release Author/Reviewer Ratified

by/Authorised

by

Date Changes

(Please identify page

no.)

1.0

19/08/2004 K Melling TPF

CIC

14/07/2004

23/07/2004

2.0

26/10/2006 K Melling /

L Flude

IPCC 28/07/2006 Summary sheet

circulated with policy

3.0

30/10/2008 L Flude IPC Policy

Approval

Meeting

29/10/2008

4.0

23/04/2012 A Cobb/

E Murdoch/

IPCC

24/11/2011 Summary sheet

circulated

New format in line

with Trust Policy

5.0

19/03/2015 E Flude IPCC 10/02/2015

6.0 01/03/2018 P.Pugh IPCC 23/01/2018 Updated evidence

and refrences,

terminology and

Trust logos


Contents

Section Page

1 Introduction ...................................................................................................................... 4

2 Policy scope ....................................................................................................................... 4

3 Aim of policy...................................................................................................................... 5

4 Duties (Roles and responsibilities) .................................................................................... 5

5 Definitions ......................................................................................................................... 6

6 Main Body of the policy .................................................................................................... 7

6.1 Hand hygiene facilities .......................................................................................... 7

6.2 When to wash/decontaminate your hands .......................................................... 8

6.3 Good hand wash technique .................................................................................. 8

6.4 Types of hand hygiene .......................................................................................... 10

6.5 Techniques, methods and agents ......................................................................... 11

6.6 Looking after your hands ...................................................................................... 13

6.7 Patient hand hygiene ............................................................................................ 13

6.8 Visitors hand hygiene ............................................................................................ 13

7 Hand Hygiene Training ...................................................................................................... 14

8 Equality and diversity ........................................................................................................ 14

9 Monitoring compliance with the policy ............................................................................ 14

10 Consultation and review .................................................................................................. 15

11 Implementation of policy (including raising awareness) .................................................. 15

12 References......................................................................................................................... 15

13 Associated documentation (policies) ................................................................................ 15

Appendices

Appendix 1 WHO 5 Moments for Hand Hygiene ......................................................................... 16

Appendix 2 Good Hand Wash Technique .................................................................................... 17

Appendix 3 Fequently Missed Areas Poster ................................................................................ 18

Appendix 4 Hand Hygiene WQM Weekly Audit Form ................................................................. 19

Appendix 5 Patient & Visitor Information Leaflet........................................................................ 20-24


Hand Hygiene Policy

1 Introduction

This policy is developed around best available current evidence.

Hand cleansing is the single most important procedure in the prevention of healthcare-

associated infection (HCAI) and of enhancing patient safety. The Epic3 guidelines (2013)

state that 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.

It is important to remember that ALL Trust personnel working and visiting within the

clinical environment should maintain the highest standards of hand hygiene. A minimum

requirement should be, washing or decontaminating hands on entering and leaving a

healthcare facility.

The World Health Organisation (WHO, 2009) promotes the 5 moments for hand hygiene

(Appendix 1):

1. Before patient contact

2. Before aseptic procedure

3. After exposure to bodily fluids

4. After patient contact

5. After contact with patient’s environment

2 Policy scope

This policy applies to all healthcare workers within Gateshead Health NHS Foundation

Trust.


3 Aim of policy

To enable healthcare workers to identify opportunities for hand washing/decontamination

and to use the correct techniques in order to reduce the risk of cross infection and

healthcare associated infections.

4 Duties - roles and responsibilities

Trust Board - The Trust Board has a responsibility to ensure that the risk of infection to

patients, staff and visitors is minimised to its lowest potential and therefore supports the

full implementation of this policy.

The Chief Executive Officer (CEO) - The CEO has ultimate responsibility for ensuring that

effective systems and processes are in place to minimise the risk of infection to patients,

staff and visitors.

The Executive Directors have specific responsibilities are delegated to members as follows:

• The Director of Nursing & Midwifery and Quality (DN) and the Medical Director (MD)

Joint Director of Infection Prevention & Control (DIPC) - The DN in conjunction with

the MD as joint DIPC has delegated responsibility and oversight for ensuring effective

systems and processes are in place to minimise the risk of infection across the Trust.

• The Deputy Chief Executive/ Director of QE Facilities - Leads on Decontamination for

the Trust, Provide an annual report against the Disinfection and Sterilisation (DAS)

Programme to the Trust board.

• The Director of Human Resources

Will ensure that all staff job descriptions contain explicit reference to infection

prevention and control and where appropriate Occupational Health policies and

procedures support minimisation of HCAI.

• The Finance Director and other Executive Director roles Will ensure that resources are

available centrally to finance the management and control of outbreaks of infection.

They will share in the overall corporate responsibility to support the implementation

and further development of the Trust’s HCAI Strategy and programme.

Business Unit Associate Directors, Heads of Service and Service Line Managers are

responsible for

• Ensuring all staff are aware of relevant HCAI policies; are up to date with attendance of

Trust’s Mandatory Training Programme, acting on non-compliance/attendance.

• Ensuring that there are effective IPC processes in place in accordance with the Trust’s

IPC strategy and annual programme and that the appropriate level of local

management action is initiated and completed as required.

• Responsible for disseminating lessons learned to all levels of staff in their Business Unit.

Chief Matrons/Matrons/Ward Clinical Managers, in addition to contributing to the

responsibilities as outlined above, have responsibility for:


• Providing visible strong leadership for IPC and driving a culture of cleanliness in clinical

areas and participating in regular monitoring of standards.

• Ensure staff attendance at mandatory training and act on non-attendances.

• Ensure clinical staff have access to, and read, infection prevention and control policies.

• Promote the standard principles of infection prevention and control, awareness and

responsibilities amongst employees, service users, contractors and partners to ensure

that patients and visitors are managed safely.

All staff

Attend Induction and annual Mandatory Hand Hygiene Training. Know how to access the

Hand Hygiene policy and to read Hand Hygiene policy as part of their induction process.

Raise awareness of effective Hand Hygiene practice and principles with colleagues, patients

and visitors. Follow the guidance within the Hand Hygiene policy and decontaminate

hands before and after every episode of patient care/contact with patient bed

space/equipment.

Infection Prevention & Control Team

Provide awareness, training and support regarding Hand Hygiene and Trust. Manage

implementation of hand hygiene programme and support the Matrons and

Ward/Department managers in implementation of weekly hand hygiene audit

incorporated in the Trust weekly ward quality measures. Ensure Hand Hygiene Policy

version is up to date with evidence based practice.

OD & Training

Hold training records for mandatory and induction training including e learning. Review

attendance at Mandatory Training. Alert Service Managers of non-attendees.

5 Definitions

Hand washing is the act of cleaning one's hands with the use of soap & water for the

purpose of removing soil, dirt, and/or microorganisms.

Hand decontamination refers to the use of alcohol hand sanitisers and is a supplement to

hand washing with soap and water. Many preparations are available, including gel, foam,

and liquid solutions. Alcohol-based hand sanitisers are more effective at killing

microorganisms than soaps but do not remove soil/dirt.

Healthcare associated infection (HCAI) – These are infections that occur in a healthcare

setting that were not present before the patient entered the care setting. Patients are

more likely to be vulnerable to infection due to their illness, their age, or the treatment for

their condition.


6 Hand Hygiene Policy

6.1 Hand Hygiene Facilities

• Hand wash sinks should only be used for hand washing.

• Hand wash sinks are available at the entrance to all in patient wards and at

the point of care within clinical patient care areas.

• Hand washing facilities are visibly clean, free from patient toiletries, used

equipment and clutter.

• Liquid/foam soap dispensers are available at ALL hand washbasins (QE

Facilities domestic staff will hold stock for replenishing and ensure the soap

dispensers are available and in working order).

• Trust staff should not use communal bars of soap. Staff members should

contact Occupational Health if they are unable to use the liquid soap

provided.

• There is clear access to hand washbasins.

• Water should be at a suitably controlled temperature for hand washing.

• Mixer taps are available for sinks in clinical areas.

• If mixer taps are not available, staff should use paper towels to turn off tap.

• Disposable paper towels are available at all hand washbasins.

• Paper towels should be disposed of in a lidded bin that is pedal operated.

NB: Bins should only be opened using the pedal and not by the hands. This

should be disposed of in a household waste bin as per policy IC09 Waste

Disposal and Recycling Policy.

• Used patient wash water should not be disposed down hand wash sinks, use

the dirty utility area.

• Alcohol hand sanitiser is available at the point of care unless risk assessment

of client group prevents this or patient is identified as Clostridium difficile or

GDH positive or suspected.


6.2 When to wash / decontaminate hands:

• Whenever hands are physically soiled

• Immediately before each episode of direct patient care or contact including

clean/aseptic procedures, feeding patients, handling or preparing food &

medications

• Immediately after each episode of direct patient care or contact

• Immediately after contact with body fluids, mucous membranes and non-

intact skin

• Immediately after removing apron and gloves

• Immediately after other activities or contact with objects and equipment in

the immediate patient environment that may result in the hands becoming

contaminated

• On entering and leaving the clinical area – ward & department

6.3 Good hand wash technique

An effective hand washing technique involves 3 stages: preparation, washing and

rinsing, and drying.

Preparation: wet hands under tepid running water before applying the

recommended amount of liquid/foam soap or an antimicrobial preparation.

Washing: the hand wash solution must come into contact with all aspects of the

hand, wrists and forearm. The hands should be rubbed together vigorously for a

minimum of 10-15 seconds, paying particular attention to the tips of the fingers, the

thumbs and the areas between the fingers. Hands should be rinsed thoroughly.

Drying: use good quality paper towels to dry the hands thoroughly.

All healthcare workers should ensure that their hands can be decontaminated

effectively by:

• Removing all jewellery from hands and wrists; (One plain wedding ring is

acceptable but must not compromise hand hygiene technique and must be

removed if set with stones.)

• Wearing short sleeved clothing when delivering patient care

• Making sure fingernails are kept short, clean, and free from nail polish &

false nails

• Covering cuts and abrasions with waterproof dressing



6.4 Types of hand hygiene

• Routine hand hygiene to remove transient micro-organisms

• Surgical hand hygiene prior to surgical or highly invasive procedure when

transient micro-organisms require removing and reduction of resident flora

The three hand washing options are:

• Soap and warm running water- mechanically removes micro-organisms and

soil, but does not kill micro-organisms. Removes transient skin flora, but only

limited resident flora.

• Alcohol hand rub – does not mechanically remove micro-organisms or soil,

but kills micro-organisms. Kills transient skin flora but only limited resident

flora.

• Aqueous antiseptic solutions – mechanically removes and kills micro-

organisms and soil. Removes and kills some resident flora.

The same good hand washing technique method is used for each level of hand

hygiene. Please refer to appendix 2 for the good hand wash technique.

The most frequently missed parts of the hands when hand washing are detailed

below:


6.5 Techniques, Methods & Agents

Choosing the method of hand decontamination will depend upon the assessment of what is appropriate for the episode of care, the availability

of resources at or near the point of care and what is practically possible.

Technique When Objective Method

Hand washing with

liquid /foam soap

dispensers and

warm water

Before and after patient contact or contact

with the patient’s bed side area &

equipment;

On entering & leaving a clinical

environment;

When hands are visibly soiled;

Before handling or preparing food or

medication;

Before feeding patients;

After using the toilet;

After contact with a source of micro-

organisms: body fluids, non-intact skin or

mucous membranes, contaminated

inanimate objects;

Will remove dirt and

transient microbes and

render hands socially

clean

Soap & warm water for at least 10 -15

seconds using the Good Hand Wash

Technique (Appendix 2) ensuring

Bare Below the Elbow;

Wet hands under warm running water before

applying the liquid soap;

Rub hands vigorously together for at least 10-

15 seconds ensuring that soap comes into

contact with all surfaces including fingertips,

thumbs and web spaces, wrists and forearms;

Rinse the hands thoroughly and dry using a

good quality paper towel;


Alcohol hand

sanitiser is

available to

complement hand

hygiene practice

and can only be

used to

decontaminate

socially clean

hands.

A risk assessment

Before and after patient care activities as

above;

This is not an alternative to soap & water

hand washing and should only be used

when hands are visibly clean and free from

dirt, soil and organic material. Alcohol

sanitiser should never be used for patients

with Clostridium difficile or gastroenteritis

infections, when only soap and water

should be used.

May also be used following hand wash with

Remove or destroy

transient microbes and

substantially reduce

resident micro organisms

Alcohol hand sanitiser for at least 10 -15

seconds using the Good Hand Wash

Technique Appendix 2;

Allow at least 30 seconds for alcohol hand

sanitiser foam to fully evaporate


should be

performed before

alcohol hand rub is

introduced to a

clinical area.

soap & water (as above) before a sterile

procedure rather than using antibacterial

hand wash;


Antibacterial hand

wash

Surgical scrub

For heavy microbial soiling

Before invasive procedures i.e. Insertion of

invasive devices;

For patients with: immune deficiency, skin

damage, percutaneous devices,

antimicrobial resistant flora;

When persistent antimicrobial activity is

desired;

NB: Antibacterial hand wash should not be

used for routine hand washing;

Surgical scrub technique should be used

when an aseptic procedure in operating

conditions or an invasive procedure in an

emergency situation must be performed i.e.

insertion of a central line.

Remove or destroy

transient microbes;

For reduction of resident

flora in addition to

transient micro-

organisms;

Remove or destroy

transient microbes;

reduce resident flora

Antibacterial hand wash for at least 10-15

seconds; Using the Good Hand Hygiene

Technique Appendix 2

Antibacterial hand wash or detergent with

single use sterile brush;

Use technique for liquid soap wash but

perform the procedure for at least 2 minutes

and include forearms;

Use a sterile towel to dry hands and

forearms;


6.6 Looking After Your Hands

Healthy intact skin acts as a barrier to dirt and bacteria. The following will help

maintain healthy skin and allow hand cleansing to be carried out successfully.

• Use the Good Hand wash technique every time including correct drying with

disposable paper towels.

• Cover cuts and abrasions with an impermeable waterproof dressing.

• Remove hand jewellery before hand cleansing.

• Use an emollient hand cream to protect against the drying effects of regular

hand washing but should not be used directly before any clinical work.

• Do not use communal pots of hand cream. A pump dispenser must be used

and kept clean/well maintained.

• Inform the Occupational Health Department immediately if you have any

skin Irritation.

6.7 Patient Hand Hygiene

Hand washing by patients is equally important in the prevention of infection. Staff

must ensure that patients are educated and encouraged to wash their hands after

visiting the toilet and before meals and discouraged from touching wounds or

invasive devices. Where appropriate, hand wipes may be considered. Patients must

receive assistance where necessary.

Alcohol hand sanitisers are not appropriate for patient hand hygiene. Patients

should be encouraged to ask staff if they have cleaned their hands before receiving

any aspect of care or treatment. Information regarding hand hygiene and other

infection prevention and control issues will be made available to all patients via

leaflets, posters and verbally by Trust staff.

6.8 Visitors Hand Hygiene

Visitors to the healthcare setting should be encouraged to wash their hands on

entering and leaving the ward or department. This should be a mandatory

requirement if the patient being visited has a known or suspected infection or is

immunocompromised and should be on the advice of the healthcare workers

looking after the patient.

Visitors hand hygiene information leaflets, posters and banner stands are placed at

the hospital and ward entrances to assist in reducing HCAI.


7 Hand Hygiene Training

• All staff will receive information on Trust expectations for hand hygiene compliance

at induction and throughout mandatory training. The attendance records will be

kept by OD& Training Department.

• All staff will complete their mandatory infection prevention and control update,

which will reiterate the importance of good hand hygiene technique and

compliance. A member of the infection prevention & control team (IP&CT) will

provide this as required in addition to E-learning modules. The attendance records

will be kept by O D &Training Department.

• Non–attendees will be identified by O D & Training and names will be forwarded to

their Manager.

• All staff will understand how to risk assess the level of hand hygiene and

decontamination necessary.

• All staff will understand the importance of hand hygiene promotion for their patient

group and visitors.

• All staff will know how to access literature within their own areas to support hand

hygiene.

• All staff will be aware of the Trust involvement and their role in delivering the WHO

5 moments.

• All staff will be aware of the role of the Hand Hygiene Champion/IPC link person in

their own area of practice.

8 Equality and diversity

The Trust is committed to ensuring that, as far as reasonably practicable, the way we

provide services to the public and the way we treat our staff reflects their individual needs

and does not discriminate against individuals or groups on any grounds. The policy has

been appropriately assessed.

9 Process(s) for monitoring compliance with the policy

Individual Practitioners are encouraged to review and take responsibility for their hand

hygiene practice.

The IPCT will review aspects of hand hygiene practice throughout the Trust via a structured

approach and report to the Infection Prevention and Control Committee. This will involve

regular hand hygiene roadshows and awareness days.


Standard /

process / issue

Monitoring and audit

Method By Committee Frequency

Hand hygiene

audit tool based

on the NPSA

Cleanyourhands

campaign audit

tool

Completed

weekly as part

of the 7 weekly

ward quality

measure audits

and submitted

electronically;

Reports are

displayed on the

Time To Care

Boards on each

ward/

department

Ward & Dept

Managers

responsible

for

delegating to

appropriate

member of

staff;

Infection

Prevention &

Control

Committee

Weekly

submission

If results are <75%

for 2 consecutive

weeks daily audits

are required with

an action plan

instigated by the

Matron and IPC

Nurse

10 Consultation and review

Members of Infection Prevention and Control team (IPCT) and Infection Prevention and

Control Committee (IPCC)

11 Policy implementation (including awareness raising)

All members of staff will be informed via trust wide email, Mandatory Training and

Safecare Bulletins and individual team meetings.

12 References

WHO Guidelines on Hand Hygiene in Healthcare:

First Global Patient Safety Challenge Clean Care is Safer Care World Health Organisation

(2009) available at http://www.who.int/gpsc/5may/tools/9789241597906/en/

Epic3: National Evidence based Guidelines for Preventing Healthcare-Assoiciated Infections

in NHS Hospitals in England. H.P. Loveday, J.A. Wilson, R.J Pratt, M. Golsorkhi, A. Tingle, A.

Bak, J. Browne, J. Prieto, M. Wilcox. Journal of Hospital Infection 86S1 (2014) S1-S70;

available at https://www.his.org.uk/files/3113/8693/4808/epic3_National_Evidence-

Based_Guidelines_for_Preventing_HCAI_in_NHSE.pdf

Hand Hygiene Technique (2017) : D. Pittet, JM Boyce, B. Allegranzi, MN. Chraiti, AF.

Widmer

13 Associated documentation

The trust has a portfolio of Infection Prevention & Control policies which assist healthcare

workers in the reduction, prevention and control of the risks of healthcare associated

infection. This policy refers users to the following core IPC policies:

• Infection Prevention & Control Policy – Roles and responsibilities –IC01

• Personal Protective Equipment in Clinical Practice IC 02

• Standard Precautions for the Prevention & Control of Infection IC 0 3

• Waste Policy IC 0 9


Appendix 1

WHO 5 Moments for Hand Hygiene


Appendix 2

Good Hand Washing technique


Appendix 3

Frequently Missed Areas Poster


Appendix 4

Cleanyourhands Campaign Hand Hygiene audit tool


Hand Hygiene Information Leaflet Appendix 5





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