Hand Hygiene Policy and Procedures

Trust Reference B32/2003

Approved By Policy and Guideline Committee

Date Approved August 2003 Most recent review 22 July 2011 – Policy and Guideline Committee

25 June 2010 – Policy & Guideline Committee 12 November 2007 – Policy & Guideline Committee

Version July 2011

Author / Originator(s) Matt Hull Infection Prevention Nurse Islwyn Jones Senior Nurse Infection Prevention

Name of Responsible Committee / Individual

Infection Prevention Committee

Next Review Date July 2014

CONTENTS –

Section Page

1. Introduction and Background 3

2. Policy Aims and Scope 3

3. Definitions 3

4. Roles and Responsibilities 4

5. Education and Training 5

6. Policy Statements 5

7. Processes for Monitoring Compliance 9

8. Evidence Base 10

9. Development and Consultation Review Process

10

10. Legal Liability 10

11. Appendices Appendix 1 – Procedure for Cleaning Hands with Soap and Water Appendix 2 – Procedure for Cleaning Hands with Alcohol Hand Sanitiser

12 13

V CHANGES

July 2011 – Amended audit and compliance monitoring section

June 2010 - Incorporation of the 5 Moments for Hand Hygiene Guidance from the World Health Organisation

Criteria of when soap and water must be used changed based on latest national guidance. Hands must be washed with soap and water • If hands are visibly dirty or visibly soiled with blood or bodily fluids • If the hands have been in contact with blood or bodily fluids • If the person they are caring for is having diarrhoea and /or vomiting • Before leaving a patient in source/strict isolation (this is then followed by using alcohol

hand sanitizer on leaving the room) • Before preparing food Alcohol hand sanitiser can be used in all other instances

1 INTRODUCTION

1.1 Cross infection in a healthcare setting is most commonly spread by contaminated hands. Skin is not sterile. Some bacteria will inhabit and multiply on skin; these are known as resident flora or commensals. Others will be picked up by contact and passed on by contact; these are known as transient micro-organisms. Appropriate hand hygiene has been shown to reduce the spread of infection.

1.2 Effective Hand hygiene is the single most important factor in the prevention of

cross infection.

2 POLICY AIMS AND SCOPE

2.1 Aim 2.1.1 The aim of this policy is to provide anyone working in and entering University Hospitals

of Leicester NHS Trust premises with evidence based information on effective hand decontamination to reduce/eliminate healthcare acquired infection which resulted from poor hand hygiene.

2.2 Scope 2.2.1 This policy details the responsibilities of staff groups or departments towards facilitating

best hand hygiene practice in the Trust. It will describe the products that are available for use within UHL for hand hygiene; the different methods of hand hygiene and circumstances to use each method and elements of good practice used to prevent the spread of infection via contact transmission.

2.2.2 This policy provides additional guidance on aspects of hand hygiene requirements in

addition to the UHL uniform and dress code (DMS No 58473). 2.2.3 The policy and attached guidelines are intended for use by anyone employed within

UHL delivering health care, either on a permanent or temporary contract, volunteers and anyone in a training capacity.

3 DEFINITIONS

3.1 Patient zone is the area in the immediate vicinity of the patient where care is provided or there is staff to patient contact. The zone can differ according to where the patient is being treated and needs to be agreed by the staff working within that environment. In the hospital environment it is usually at the patient’s bed, but in other contexts it could be for example a treatment room, cot, chair, ambulance or a patient’s home. This can also be termed the Point of Care

3.2 Commensals Micro-organisms that live on or in the body that do not cause harm to the individual

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4 ROLES AND RESPONSIBILITIES

4.1 All Staff 4.1.1 It is the responsibility of all the staff to ensure that they adhere to evidence based best

practice. All staff must take responsibility for their own hand decontamination and should act as an advocate for all their patients/clients and others to ensure that everyone decontaminates their hands appropriately. They must inform the Infection Prevention Team and facilities if hand hygiene facilities are inadequate or absent.

4.1.2 Ensuring that staff have access to hand hygiene products at the point of care is perhaps

the most critical factor in improving the hand hygiene of healthcare workers. 4.2 Facilities 4.2.1 Adequate facilities must be provided by the Trust to encourage staff to clean their hands

regularly and appropriately. This includes accessible handwash basins, soap, alcohol hand rubs, and disposable paper towels.

4.2.2 Agents for surgical scrub procedure must be available in operating departments and

other clinical areas where invasive procedures are performed. 4.2.3 All clinical areas hand wash basins should be fitted with lever operated or sensor taps

and be installed with thermal mixer valves. 4.2.4 Facilities are responsible for the provision of and maintenance of hand washing

facilities. 4.3 Patients and Visitors 4.3.1The general public must be allowed access to appropriate facilities for cleaning their

hands. 4.3.2 Patients must be offered appropriate methods of cleaning their hands in line with their

abilities. 4.4 Divisional and Clinical Business Unit Management Structure 4.4.1 Divisional Directors, Managers and Heads of Nursing are responsible for ensuring

compliance with the hand hygiene policy within the Divisions. 4.4.2 The Clinical Business Unit medical leads, lead nurses or midwife and managers are

responsible for ensuring compliance with the policy within their respective business units.

4.5 Heads of Service 4.5.1 Heads of service have a role in ensuring that hand hygiene practice amongst medical

staff within their service meets expected standards. 4.6 Matrons 4.6.1 Matrons have a particular role in ensuring that hand hygiene meets expected standards.

They are responsible at a local level for leading and driving a culture of adherence to good hand hygiene practice in clinical areas and for monitoring, recording and reporting compliance with standards. This will be done by auditing monthly using the Trust standard and audit tool and implementing an action plan (See Section 7)

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4.7 Line Managers of Clinical and Non Clinical Areas 4.7.1 Line manager of a Clinical or non clinical area are accountable for the standards of

infection prevention and control within the area managed. The Line manager is expected to audit, observe and report compliance with infection control policies and guidelines and to personally demonstrate and promote compliance within their department.

4.7.2 Line Manager is expected to challenge and correct poor practice when observed and

identifying through appraisal and observational training to develop the needs of team members making the appropriate arrangements to have these training needs met in co-operation with the Infection Prevention Team.

4.8 Procurement 4.8.1 Procurement and purchasing are responsible for securing appropriate hand hygiene

products. 4.9 Infection Prevention Team 4.9.1 Infection Prevention Team is responsible for educating and training staff relating to hand

hygiene practice. (See Section 5) 4.9.2 The Infection Prevention Team on behalf of the Trust will ensure that new developments

in hand hygiene or new initiatives are communicated to staff, visitors and patients with the support of the clinical business units.

4.9.3 The Infection Prevention Team will also ensure that information such as leaflets and

posters are available for Clinical Business Units to use.

5 EDUCATION AND TRAINING

5.1 The Health and Social Care Act (2008) states that all staff should have training on hand hygiene.

5.2 There are a number of methods of delivering hand hygiene training available for use

within UHL including online teaching, workbooks, formal group sessions and practical demonstrations. Each Division can utilise one or more to provide a blended approach of practical and theoretical information delivery.

5.3 The Line manager of the Department is responsible for ensuring that all their staff have

completed hand hygiene training 5.4 Recording of hand hygiene training will be done using the Electronic Skills Passport.

Training provided by the Infection Prevention Team as well as any provided locally by the Divisionsor corporate directorates education teams must be recorded against an individuals account.

5.5 Failure to attend hand hygiene training will be considered a breach of the statutory and

mandatory training policy (DMS No 20229). The procedure for follow up of non-attendees is as follows

• 1st non attendance – Letter to be sent to staff member by course provider (and copy to

line manager) reminding them of obligation to attend mandatory training and asking them to rebook within 21 days.

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• 2nd non attendance – Letter to be sent to staff member (copy to line manager) by course

provider warning them that failure to attend mandatory training again within 21 days of letter (unless there are exceptional circumstances) will result in performance management procedures being commenced that may lead to disciplinary action.

• 3rd non attendance – Letter to be sent to Line manager of staff member informing them

that unless there are exceptional circumstances disciplinary procedures will be commenced. The line manager will have 7 days to provide exceptional reasons for non attendance. Should there be no exceptional circumstances then the HR representative fro the area will be informed and the issue will be progressed as a disciplinary matter. A copy of the letter will also be sent to the delegate.

6 POLICY STATEMENTS

6.1 INDICATIONS FOR HAND HYGIENE

Hands must be decontaminated using the appropriate agent (See section 6.3)

• Before starting and at the end of each work period.

• Before and after each ‘hands on’ patient contact at the point of care.

• Before and after carrying out each aseptic procedure.

• After contact with any body fluid or secretion.

• After handling soiled or contaminated equipment or linen.

• Before and after drug administration.

• Whenever skin is visibly soiled.

• Before and after glove use.

• Before performing or assisting at operative procedures, a surgical scrub for hand

decontamination should be performed.

• After using the lavatory.

• Before eating, drinking or handling food.

• After contact with the patients surroundings.

This list is not exhaustive and we expect all staff to use the five moments for hand hygiene when within the patient zone and their clinical judgement to decide appropriateness. The 5 moments can be found in section 6.2

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6.2 YOUR 5 MOMENTS FOR HAND HYGIENE 6.2.1 Hands should be cleaned at a range of times however in order to prevent HAI at the

most fundamental times during care delivery and daily routines, when caring for those sick and vulnerable the 'Your moments for Hand Hygiene' should be followed.

6.2.2 Hands should be cleaned before leaving the patient zone or at the closest hand wash

basin. Hand cleaning must be done in public view. The reason for this is two fold. Firstly observation of hand hygiene by patients and visitors improves confidence in the Trust and secondly it allows any member of staff conducting hand hygiene audits to observe correct practice.

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6.3 TYPE OF AGENT 6.3.1 Soap must be a liquid soap in sealed units. The dispensing nozzle must be integral

with the reservoir and the whole unit changed when empty. Soap and water have a key place in hand hygiene and staff will always need to use a sink and soap for handwashing in certain situations. These are:-

• If hands are visibly dirty or visibly soiled with blood or bodily fluids • If the hands have been in contact with blood or bodily fluids • If the person they are caring for is having diarrhoea and /or vomiting • Before leaving a patient in source/strict isolation (this is then followed by using alcohol

hand sanitizer on leaving the room) • Before preparing food 6.3.2 Alcohol Hand Sanitiser can enable staff to clean their hands when it really matters at

the point of care –and the sanitiser dispensers themselves can become a prompt for action. Alcohol hand rub can be used in place of soap and water, except for those situations listed above. It is effective at destroying 99.9% of transient bacteria from hands using the correct technique. It must be in sealed units. The dispensing nozzle must be integral with the reservoir and the whole unit changed when empty.

6.3.4 These may be used in the ward or department area for the disinfection of visibly

clean hands. It is now well established that the principal mechanism for cross infection is through bacterial carriage on the hands of health care personnel. The risk to patients can therefore be greatly reduced by hand disinfection with an alcohol hand rub. The alcoholic base achieves a very rapid and effective kill of transient flora.

6.3.5 They are especially useful in situations where handwashing and drying facilities are

inadequate, or where there is frequent need for hands to be washed. Ensuring that staff can clean their hands in the right way at the right time depends not only on sanitiser dispensers being where they are needed, when they are needed – but also on the dispensers being full and functional. Most importantly, if the alcohol hand sanitiser is not at the point of care then a crucial opportunity for hand hygiene is lost.

6.3.6 The use of hand sanitiser containing synthetic alcohol does not fall within the

Muslim prohibition against natural alcohol (from fermented fruit or grain) therefore there should be no concerns regarding their use on religious grounds.

6.3.7 Surgical Scrubs are used in situations where a reduction in the resident flora is

necessary, such as in operating theatres or similar departments. 6.3.8 The choice of scrub allows staff to avoid the use of agents to which they may be

sensitised. Note: All materials are supplied ready for use and must not be diluted Chlorhexidine Gluconate 4% Surgical Srub – e.g ‘Hibiscrub’ (500ML) This is an antiseptic skin cleansing solution for pre-operative hand disinfection. Chlorhexidine is active against Gram-positive organisms, and less active against Gram-negative organisms. It is inactivated by soaps and anionic agents. Povidone-Iodine 7.5% Surgical Scrub e.g ‘Betadine’ (500ML) Used for pre-operative hand disinfection. It may have a slightly wider spectrum of activity than alternative products.

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Triclosan 2% Surgical Scrub (500ML) Used for pre-operative hand disinfection. The spectrum of activity is very comparable to that of Chlorhexidine 6.4 MAINTAINING GOOD PRACTICE IN HAND HYGIENE 6.4.1 Hand Care The skin should be maintained in good condition to discourage the accumulation of micro-organisms. This may require the regular application of hand creams, which should be preferably water-based and contain an effective preservative, dispensed from sealed units, and should not be refilled. If it is not dispensed from an appropriate dispenser it should be for individual staff use. Any member of staff who is unable to use the appropriate hand hygiene agents due to the development of a skin condition/allergy must seek advice from the Occupational Health Department. Cuts and abrasions must be covered with an occlusive, waterproof dressing.

6.4.2 Finger Nails Staff working within a clinical area: Fingernails must be kept clean, short and smooth; long nails are harder to keep clean. When hands are viewed from palm side, no nail should be visible beyond the fingertip. Nail varnish or false nails must not be worn; false nails harbour micro-organisms and can reduce compliance with hand hygiene.

6.4.3 Jewellery Jewellery must not be worn when undertaking clinical practice; wearing jewellery can harbour micro-organisms and reduce compliance with hand hygiene. Stoned rings and bracelets and wristwatches must not be worn as bacteria can live in the settings, clasps or on straps. The exception to this is one plain wedding band and metal Kara. Wristwatches and the Rakhi must not be worn when undertaking clinical practice, as bacteria can live on watchstraps and fabric threads. Fob watches have been designed to negate this problem. (The Chartered Institute of Environmental Health, 1996, p25). 6.4.4 Clothing All staff who have patient contact will be bare below the elbow. Clothing must have short sleeves or long sleeves rolled up as cuffs can become heavily contaminated with micro-organisms and are more likely to come into contact with patients. 7 PROCESS FOR MONITORING COMPLIANCE WITH THE DOCUMENT

7.1 Monitoring of compliance with the hand hygiene policy will be carried out by monthly audit

within each division using a tool approved by the Trust Infection Prevention Committee. Contact Infection Prevention for the most up to date version of the audit tool.

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7.2 The responsibility for ensuring that monthly hand hygiene audits are carried within the

respective CBU’s lies with the CBU medical lead and lead nurse. In practice this may be delegated to those working at ward level.

7.3 Any person conducting hand hygiene audits must be familiar with the tool and the audit

criteria. This is available from the Infection Prevention Team 7.4 A minimum score of 98% must be achieved. If this minimum score is not achieved then

the CBU is responsible for developing and implementing an action plan to improve compliance.

7.5 Monthly hand hygiene data must be reported by the CBU to the Infection Prevention

Team who will collate the data for the Trust. 7.6 Compliance with hand hygiene is reported by the Infection Prevention Team to the Trust

Infection Prevention Committee on a monthly basis. In addition it is reported externally to the commissioners via the clinical quality review group

Figure 1 – Flow of data in relation to monitoring compliance with hand hygiene

Audit completed at ward or department level – Immediate feedback to ward or department staff of results

Result collated in CBU and entered onto CBU scorecard

Scorecard is sent to infection prevention team data administrator for collation of Trust data

Infection Prevention team feed results to Trust infection prevention committee on a monthly basis

Infection prevention team send results via clinical quality review group as assurance to commissioning PCT of compliance with hand hygiene within the Trust

8 EVIDENCE BASE

The Chartered Institute of Environmental Health (1996) Basic Food Hygiene Teaching Package. DH (2008) The Health and Social Care Act 2008 Code of Practice for health and adult social care on the prevention and control of infections and related guidance Department of health Dec 2009 p1-69 available from www.dh.gov.uk/publications DOH (2007)Uniforms and workwear: an evidence base for developing local policy: Department of Health September 2007 p1-10 http://www.dh.gov.uk/publications epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England- R.J. Pratt,C.M. Pellowe, J.A. Wilson, H.P. Loveday, P.J. Harper, S.R.L.J. Jones, C. McDougall, M.H. Wilcox Journal of Hospital Infection (2007) 65S, S1–S64 available from - www.elsevierhealth.com/journals/jhin Healthcare associated infections- A guide for healthcare professionals A publication from the BMA Science and Education Department and the Board of Science feb 2006 P1-35 ISBN: 1-905545-02-9 National patient safety agency –clean your hands campaign 2009/210 http://www.npsa.nhs.uk/cleanyourhands

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Infection prevention and control uniform and dress guidance: East Midlands Strategic Health Authority December 2007 WHO (2009) Guidelines on Hand Hygiene in Health Care First Global Patient Safety Challenge - Clean Care is Safer Care 2009 P1-262 Available from http://www.who.int/en ISBN 978 92 4 159790 6 9 DEVELOPMENT, CONSULTATION AND REVIEW PROCESS

9.1 This policy and associated procedures has been developed by the Infection Prevention Team using the latest guidance available.

9.2 It was consulted with all Clinical Business Units.

10 LEGAL LIABILITY

The Trust will generally assume vicarious liability for the acts of its staff, including those on honorary contract. However, it is incumbent on staff to ensure that they:

• Have undergone any suitable training identified as necessary under the terms of this policy or otherwise.

• Have been fully authorised by their line manager and their Division to undertake the activity.

• Fully comply with the terms of any relevant Trust policies and/or procedures at all times.

• Only depart from any relevant Trust guidelines providing always that such departure is confined to the specific needs of individual circumstances. In healthcare delivery such departure shall only be undertaken where, in the judgement of the responsible clinician it is fully appropriate and justifiable - such decision to be fully recorded in the patient’s notes.

It is recommended that staff have Professional Indemnity Insurance cover in place for their own protection in respect of those circumstances where the Trust does not automatically assume vicarious liability and where Trust support is not generally available. Such circumstances will include Samaritan acts and criminal investigations against the staff member concerned.

Suitable Professional Indemnity Insurance Cover is generally available from the various Royal Colleges and Professional Institutions and Bodies.

For advice please contact: Assistant Director - Head of Legal Services on Ext 8585

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Procedure for Cleaning hands with Soap and Water

Appendix 1 Hand Hygiene Policy Soap and water must be used. • If hands are visibly dirty or visibly soiled with blood or bodily fluids • If the person they are caring for is having diarrhoea and vomiting • Before leaving a patient in source/strict isolation (this is then followed by using alcohol

hand sanitizer on leaving the room) • Before preparing food When soap is mixed with water using friction, lather is created. Micro-organisms are suspended in the lather and physically removed from the skin when rinsed with clean water. It is essential to ensure that all surfaces of the hands are covered by lather. The wrists and arms can also be washed as necessary following an assessment of the task to be commenced or completed. A 15 - 30 second hand wash will remove the majority of transient micro-organisms. Wet hands prior to applying cleansing agent and ensure all surfaces of hands (and arms up to elbows if necessary as per training programme) are in contact with the agent and then rinsed thoroughly using running water and dried. Towels used for drying are single-use and disposable. The soap and hand towels should be of a quality acceptable to users so as not to deter handwashing. Towels must be disposed into ‘hands free’ waste bins.

WHO Guidelines on Hand Hygiene in Health Care 2009 -155

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Procedure for Cleaning hands with Alcohol Hand Sanitiser

Appendix 2 Hand Hygiene Policy

Handrubbing is the gold standard technique to perform hand hygiene on all occasions except for those described for handwashing with soap and water, i.e. handrubbing is the action recommended for health-care workers for the routine, day-to-day decontamination of hands (WHO 2009) Alcohol Hand Sanitiser alone cannot be used: • If hands are visibly dirty or visibly soiled with blood or bodily fluids • After using the toilet • If the person they are caring for is having diarrhoea and/or vomiting • Before leaving a patient in source/strict isolation (Handwashing is then followed by

using alcohol hand sanitiser on leaving the room) • Before preparing food hands must be cleaned with soap and water first Press pump once to apply the sanitiser and apply one to three shots depending on size of hands. Rub in well covering all surfaces of the hands for at least 20- 30 seconds ensuring hands are dry before commencing activity.

*WHO Guidelines on Hand Hygiene in Health Care 2009 p156

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