The Newcastle upon Tyne Hospitals NHS Foundation Trust. Hand Hygiene Policy

Transcription

1 The Newcastle upon Tyne Hospitals NHS Foundation Trust Hand Hygiene Policy Version No.: 12.3 Effective From: 19 January 2016 Expiry Date: 23 October 2018 Date Ratified: 8 October 2015 Ratified By: Infection Prevention and Control Committee 1 Introduction The hands of health-care workers are the most common vehicle for the transmission of micro-organisms from one patient to another, from one body site to another within the same patient, and from a contaminated environment to patients. Hand hygiene is one of the most effective ways to prevent Healthcare Associated Infection (HCAI); it must be performed at the right time using the correct technique. 2 Scope This policy applies to all members of clinical and non clinical staff including students, agency workers and contractors working within the Newcastle upon Tyne Hospitals NHS Foundation Trust (NuTH). 3 Aims The aim of this policy is to promote effective hand hygiene, identifying when hands should be cleaned using the correct technique and products. The main objectives of this policy are to: ensure this policy is embedded into practice prevent transmission of micro organisms assist staff in delivering high quality safe care provide quality assurance via a robust audit and escalation process ensure all staff are aware of their responsibilities through generic and specific training programmes Achieve and sustain a minimum standard of 98% compliance with hand hygiene audit. 4 Duties (Roles and responsibilities) 4.1 The Chief Executive has overall responsibility for implementation, monitoring and review of this policy. This responsibility is delegated to the Director of Infection Prevention and Control (DIPC). Page 1 of 13

2 4.2 The Infection Prevention and Control Committee (IPCC) will review the policy and any new evidence base within the time frame set out in the policy. 4.3 The Infection Prevention and Control Team (IPCT) is responsible for providing expert advice in accordance with this policy and supporting the hand hygiene audit process. 4.4 Ward Sisters/Charge Nurses and Clinical Leads/Clinical Directors are responsible for ensuring implementation of this Hand Hygiene Policy within their area/service and all staff adhere to the principles of Hand Hygiene at all times. 4.5 Matron/Service Leads and Directorate Managers are responsible for ensuring Hand Hygiene audits are submitted at the appropriate time and non compliance is reviewed and actioned. 4.6 It is the responsibility of all staff to ensure that they understand and implement this policy and attend training sessions as specified in their role 4.7 It is the responsibility of the Trust to ensure that policies, education, training and procedures are in place to minimise the risk of infection. 4.8 It is the responsibility of the Estates Department to consult with the IPC team before any new construction or refurbishment work is planned, to advise on sink/tap type, number and location of hand washing facilities. 5 Definitions 5.1 Resident micro-organisms Normal skin flora are referred to as resident micro-organisms. These can be responsible for cross infection if a staff member fails to effectively decontaminate their hands. 5.2 Transient micro-organisms Transient micro-organisms exist on the skin surface and can be viral or bacterial. They are termed transient, as they are transferable through direct contact with equipment, the environment or individuals. These, unlike resident micro organisms, are more easily removed by hand decontamination therefore reducing the risk of transmission. 5.3 Bare Below the Elbow (BBE) All staff involved in direct patient care must be BBE; there should be no sleeves or garments below the elbow; no wrist watches or wrist jewellery and only a plain Page 2 of 13

3 wedding band (i.e. without inset stone(s)) is acceptable in clinical areas and when undertaking clinical practice. False nails/nail varnish must not be worn. Where for religious requirement, staff wish to cover their forearms the use of disposable oversleeves, which are elasticated at the elbow and wrist, may be used but must be put on and discarded in exactly the same way as disposable gloves. Strict procedures for washing hands and wrists must still be observed. 5.4 Clinical Assurance Tool (CAT) An audit framework to identify, measure and demonstrate compliance with national and local requirements; e.g. Savings Lives and assurance to regulatory bodies such as the Care Quality Commission. 5.5 Essential Steps A programme which provides an audit framework for non-acute/community settings to reduce the risk of HCAI in every day practice and to ensure there is a managed environment that minimises the risk of infection to patients, client s staff and visitors. 6 Hand Hygiene 6.1 Facilities All clinical areas should have: Appropriate number and type of hand washing facilities Clear unobstructed access to all hand wash basins designated for hand washing only, which are free of inappropriate items and fitted with elbow or wrist lever armed taps Wall mounted liquid soap and/or antiseptic solution available at every sink Paper towels available at every sink Alcohol based hand sanitiser at the point of patient care and designated ward entrances To facilitate effective hand hygiene in the community healthcare workers must be provided with appropriate hand hygiene products and paper hand towels. 6.2 Hand Decontamination Agents There are three liquid types of agent that can be used to remove microorganisms from hands: liquid soap, antimicrobial solution and alcohol based hand sanitiser. Page 3 of 13

4 6.2.1 Liquid Soap Liquid soap will mechanically remove transient micro-organisms but has little effect on resident micro-organisms. However, hand washing with soap is usually all that is necessary to prevent cross infection during social contact. It can be used before all routine tasks within community settings and the clinical area. The IPC team recommend the use of liquid soap in containers which supply a measured dose Antimicrobial Solutions Antimicrobial solutions will remove transient and reduce resident skin microorganisms. Chlorhexidine based preparations have been found to be more effective than iodine-based solutions as they have a residual effect which influences the survival times of many organisms on hand surfaces. Antimicrobial solutions should be used in situations when there is a need to reduce resident microbial flora, e.g. in operating theatres and before performing an Aseptic Non Touch Technique (ANTT). In the community environment for example, patients homes, where antiseptic solutions may not be available staff must decontaminate their hands with soap and water followed by alcohol hand sanitiser prior to undertaking ANTT Alcohol-Based Hand Sanitiser Alcohol based hand sanitiser can be applied quickly and offers a practical and acceptable method of hand decontamination. In addition this product can be used as an alternative when hand washing and drying facilities are inadequate or not available. However it is not effective in removing spores or soiling and must only be used if hands are visibly clean. Alcohol based hand sanitiser must not be used with patients identified/suspected as Clostridium difficile positive. All containers must be discarded when empty. Under no circumstances should they be refilled or solutions decanted. 6.3 Hand Drying Agents In clinical areas wall mounted paper towels must be used to dry hands. A high absorbency paper towel will remove some of the transient organisms that remain after hand washing. In the community environment drying hands with disposable paper towels is advocated. The use of hot air dryers should not be used in clinical areas as these spread airborne bacteria by re-circulating the surrounding environmental air. Page 4 of 13

5 6.4 Hand Hygiene Opportunity Each hand hygiene opportunity corresponds to precise moments in patient care based on the WHO s 5 Moments for Hand Hygiene. All health-care workers must integrate hand hygiene in to all activities across the Trust. These are Your 5 Moments for hand hygiene. 6.5 Hand Hygiene Technique It is essential all areas of the hands, including wrists, are effectively decontaminated as part of the hand hygiene process. The stages identified below highlight the appropriate technique for staff to follow. Page 5 of 13

6 6.6 Hand Hygiene Process Hands must be decontaminated in accordance with the WHO s 5 moments for hand hygiene Hand Hygiene may be performed using liquid soap, an antimicrobial solution or an alcohol based hand sanitiser. The choice of solution is dependent upon the activity performed All staff must be compliant with BBE before clinical contact within the patient zone Cuts and abrasions must be covered with waterproof dressings Effective hand washing technique involves three stages: preparation, washing/rinsing, and drying (this should take seconds). Preparation requires wetting hands under tepid running water before applying liquid soap or an antimicrobial solution. The liquid hand wash must come into contact with all surfaces of the hand refer to 6.5 for Hand Hygiene images demonstrating the correct technique. The hands must be rubbed together vigorously for a minimum of seconds paying particular attention to the tips of the fingers, the thumbs, areas between the fingers and wrists. Hands should be rinsed thoroughly prior to drying with paper towels When decontaminating hands using an alcohol based hand sanitiser, hands should be free of dirt and organic material. The hand sanitiser must come into contact with all surfaces of the hand refer to 6.5 for Hand Hygiene images demonstrating the correct technique. The hands must be rubbed together Page 6 of 13

7 vigorously for a minimum of seconds, again paying particular attention to the tips of the fingers, the thumbs, areas between the fingers, wrists and until the solution has evaporated and the hands are left dry. 6.7 Hand Hygiene Audit Process Hand Hygiene opportunity, technique and BBE compliance is monitored by the CAT and Essential steps. Where the required standard of 98% with hand hygiene is not achieved, the hand hygiene escalation process will be implemented see Appendix 1 and Appendix 2. In conjunction with the hand hygiene audits undertaken via CAT and Essential steps the IPC team undertake hand hygiene validation audits. 6.8 Hand Care Frequent hand hygiene may cause skin problems for some health care workers, therefore to reduce the risk of damage to the skin hands must be wet prior to application of liquid soap or antimicrobial solution then rinsed and dried thoroughly. The use of an appropriate hand moisturiser which is compatible with hand hygiene agents may help overcome some of these adverse effects. Compatible hand moisturisers are provided in measured-dose pump dispensers. If you experience any of the following symptoms associated with hand hygiene; Red, itchy or chapped hands Your hands are burning or stinging Your hands feel excessively dry, are flaky or cracked you must complete a Datix Incident Form, and inform your manager. Your manager should then complete a referral to Occupational Health for assessment and work place advice. This may include advice on the use of appropriate hand moisturiser. 6.9 Patients and Visitors All patients and visitors must be encouraged to perform good hand hygiene to prevent transmission of infection. Staff must ensure that patients and visitors are offered the correct product and the opportunity to clean hands at the appropriate time, taking into account any communication support or disabled access needs. Page 7 of 13

8 7 Training All staff working on Trust premises, including Trust employed staff, agency and locum staff are responsible for accessing IPC Policies via the intranet in order to assist in the management of their patients. Guidance on hand hygiene is incorporated in to all mandatory IPC E-learning programmes. Where required additional hand hygiene training can be delivered by the IPCT or an IPC link person who has been trained to deliver the session. 8 Equality and diversity The Trust is committed to ensuring that, as far as is 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. This policy has been appropriately assessed. 9 Monitoring compliance Standard / process / issue Continuous monitoring of standards Monitoring and audit Method By Committee Frequency Clinical Matron/Clinical IPCC Monthly Assurance Tool Lead Essential Steps Clinical Lead IPCC Quarterly Validation audit IPC Team IPCC Quarterly 10 Consultation and review This policy has being reviewed by the members of the IPCT and IPCC, it will be reviewed every two years or when significant changes make earlier review necessary. 11 Implementation and review Clinical Directors / Matrons / Sisters / Charge Nurses and Clinical Service Leads should ensure that staff are aware of this policy. Infection Prevention and Control information is available via the Trust Intranet and Internet. Patients information leaflets are produced via the Patient & Public Involvement Committee and are available across the organisation. Page 8 of 13

9 This policy is available for staff to access via NUTH intranet. 12 References Loveday HP, Wilson JA, Pratt RJ, Golsorkhi M, Tingle A, Bak A, Browne J, Prieto J, Wilcox M (2014) Epic 3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. The Journal of Hospital Infection, Vol 86, Supp1, Pages S1-S70. National Patient Safety Alert (2004), Alcohol based Hand Gels (Up-dated 2008). Code of Practice for the Prevention and Control of Health Care Associated Infections (Health Act 2008) Department of Health World Alliance for Patient Safety. WHO Guidelines on Hand Hygiene in Healthcare. First Global Patient Safety Challenge. Clean Care is Safer Care. World Health Organisation (2009). 13 Associated documentation Dress, Appearance and Uniform Policy Visitors Policy Work Related Health Surveillance Procedure (Skin) linked to the COSHH Policy Author: Infection, Prevention & Control Team Page 9 of 13

10 Appendix 1 CAT/Essential Steps Escalation Steps Hand Hygiene Process Failure to achieve 98% compliance will be monitored against the following escalation Process for the CAT tool. Immediate Action: Real time feedback will be provided directly to staff observed during the audit period by the auditor. If any non-compliance is identified, the auditor must inform the Nurse-in- Charge/Manager and then the Matron/Clinical Lead and IPCN for information. Nurse-in-Charge/Manager to take remedial action as necessary documenting what actions have been taken. Month 1: Where there is failure to achieve 98% compliance the Matron/Clinical Lead will investigate further documenting what actions have been taken if needed, identifying if any training requirements are required and liaising with Infection Prevention and Control Nurse (IPCN) and link personnel as necessary. Month 2: Where there is failure to achieve 98% compliance for two consecutive months, it is the responsibility of the Matron/Clinical Lead to initiate and complete an Action Plan (Appendix 2). As part of the Action Plan additional hand hygiene opportunity/technique audits will be undertaken for four consecutive weeks by a staff member nominated by the Matron/Clinical Lead. With this information the Matron/Clinical Lead will then be able to identify, target and address any education and training issues. The Matron/Clinical Lead will liaise with IPCN and IPC link personnel within their department for support if necessary. The completed Action Plans are to be submitted to the IPCN team. Month 3: The Matron/Clinical Lead will continue with the Action Plan until 98% compliance has been achieved. Month 4: Where there is failure to achieve 98% compliance for four consecutive months Matron IPC will review with the Directorate Management Team. Page 10 of 13

11 Month 5: Where there is failure to achieve 98% compliance for five consecutive months the Head of Nursing will review, with Matron Infection Prevention and Control and Directorate Management Team. The outcome of the review will be presented to the Director of Infection Prevention and Control, Medical Director and Nursing and Patient Services Director via IPCC. When the investigation has identified a system failure, support and guidance will be given to the Directorate. Where reckless behaviour/misconduct is identified, the Trust policy will be invoked. Community Essential steps Hand Hygiene Escalation Process Immediate Action: Real time feedback will be provided directly to staff observed during the audit period by the auditor. If any non-compliance is identified with an individual, the auditor must inform the Clinical Manager. The auditor will document non-compliance and feedback on the audit forms which are returned to the Community IPCT and the Clinical Manager. The Clinical Manager is to take remedial action where necessary, documenting the actions taken. Action 1: Where there is failure to achieve 98% compliance in the following quarter the Clinical Manager will be informed by the Community IPCT verbally and via the respective quarterly report. The Clinical Manager will then be able to identify, target and address any education and training issues. The IPCT and the Link Personnel for that area will offer support and advice if required. Action 2: Where there is failure to achieve 98% documented compliance for two consecutive quarters the Clinical Manager will initiate an Action Plan (Appendix 2) documenting findings and what actions have been taken. As part of the Action Plan those members of staff identified as non-compliant from Action 1 must be re-audited and additional audit forms submitted to the Community IPCT within the agreed 4 week period. This audit can be undertaken by the relevant link practitioner or a staff member nominated by the Clinical Manager. The action plan will be managed by the Clinical Manager liaising with the IPCT and IPC Link personnel as necessary. The completed action plans are to be submitted to the Service Manager and the IPCT for information. Failure to submit the re-audit data within the agreed time period will result in automatic reporting to Service Manager/Head of Nursing. Page 11 of 13

12 Action 3: Where there is failure of a member of staff to achieve 98% compliance for three consecutive quarters a review will be undertaken with the Matron IPC, Service Manager and/or Head of Nursing. The outcome of the review will be presented to the Director of Infection Prevention and Control, Medical Director and Director of Nursing and Patient Services via IPCC. Where the investigation has identified a system failure, support and guidance will be given to the Directorate. Where reckless behaviour/misconduct is identified, the Trust policy will be invoked. Failure to submit Quarterly Audit Where clinical teams fail to submit the Essential steps audit, the IPC team will highlight this to the respective Clinical Lead via the appropriate quarterly report which is also submitted to the Infection Prevention and Control Committee (IPCC). Page 12 of 13

13 Appendix 2 Hand Hygiene Action Plan Objective Action Target Completion Date Person responsible Comments Page 13 of 13

14 The Newcastle upon Tyne Hospitals NHS Foundation Trust Equality Analysis Form A This form must be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. PART 1 1. Assessment Date: Name of policy / strategy / service: Hand Hygiene Policy 3. Name and designation of Author: Lesley Wilson -Infection Prevention and Control 4. Names & designations of those involved in the impact analysis screening process: Sheila Postlethwaite -Infection Prevention and Control; Lucy hall Equality and Diversity Lead 5. Is this a: Policy x Strategy Service Is this: New Revised x Who is affected Employees x Service Users x Wider Community 6. What are the main aims, objectives of the policy, strategy, or service and the intended outcomes? (These can be cut and pasted from your policy) The aim of this policy is to promote effective hand hygiene, identifying when hands should be cleaned using the correct technique and products.. 7. Does this policy, strategy, or service have any equality implications? Yes x No These have been taken into account in the final policy If No, state reasons and the information used to make this decision, please refer to paragraph 2.3 of the Equality Analysis Guidance before providing reasons:

15 8. Summary of evidence related to protected characteristics Protected Characteristic Race / Ethnic origin (including gypsies and travellers) Evidence, i.e. What evidence do you have that the Trust is meeting the needs of people in various protected Groups Provision of Interpreting Service E&D Training Pictorial information is used in the policy to promote understanding of hand hygeine techniques. Does evidence/engagement highlight areas of direct or indirect discrimination? If yes describe steps to be taken to address (by whom, completion date and review date) Studies show that when interpreters were provided, patients had a better understanding of their diagnoses and treatment plan than patients without interpreters. Consider use of communication support within the policy to ensure patients are aware of procedures. Action SP add to policy Sex (male/ female) None relevant to this policy No No Religion and Belief None relevant to this policy No No Sexual orientation including None relevant to this policy No No lesbian, gay and bisexual people Age Dementia strategy and support Pictorial information is used in the policy to promote understanding of hand hygiene techniques. No Does the evidence highlight any areas to advance opportunities or foster good relations. If yes what steps will be taken? (by whom, completion date and review date) No No Disability learning difficulties, physical disability, sensory impairment and mental health. Consider the needs of carers in this section Your e Welcome accreditation Low level sinks are available for children in some areas. Provision of BSL Signers and Deaf Blind Guides LD Liaison Nurse E&D Training Pictorial information is used in the policy to promote understanding of hand hygiene techniques. Low level sinks and accessible Consider use of communication support within the policy to ensure patients are aware of procedures. Action SP add to policy No

16 toilets are available for people with a physical disability. Gender Re-assignment None relevant to this policy No No Marriage and Civil Partnership None relevant to this policy No No Maternity / Pregnancy None relevant to this policy No No 9. Are there any gaps in the evidence outlined above? If yes how will these be rectified? No 10. Engagement has taken place with people who have protected characteristics and will continue through the Equality Delivery System and the Equality Diversity and Human Rights Group. Please note you may require further engagement in respect of any significant changes to policies, new developments and or changes to service delivery. In such circumstances please contact the Equality and Diversity Lead or the Involvement and Equalities Officer. Do you require further engagement? Yes No 11. Could the policy, strategy or service have a negative impact on human rights? (E.g. the right to respect for private and family life, the right to a fair hearing and the right to education? No PART 2 Name: Sheila Postlethwaite -Infection Prevention and Control Date of completion: 10 th September 2015 (If any reader of this procedural document identifies a potential discriminatory impact that has not been identified, please refer to the Policy Author identified above, together with any suggestions for action required to avoid/reduce the impact.)