Standard Operating Procedure 1

Transcription

1 CED No Standard Operating Procedure 1 HAND HYGIENE Purpose To ensure that all healthcare workers comply with best practice in hand hygiene including, but not limited to the 5 moments for Hand Hygiene, when caring for patients in order to support the reduction of healthcare associated infections (HAI) caused by the transmission of harmful pathogens. To increase awareness and emphasise the importance of Hand Hygiene (HH) compliance to all ACT Health staff, patients, visitors and contractors in all health care settings. Hand Hygiene includes: Hand washing with liquid soap and water; Decontamination utilizing Alcohol Based Hand Rub (ABHR); and Using alcohol impregnated wipes by community based staff. Micro-organisms (transmissible agents) are spread from one patient to the other through the hands of healthcare workers, patients, their visitors and contracted workers, hence the need for good HH practices. Correct HH reduces the bio burden (the load) of micro-organisms on hands. Scope HH is the responsibility of all ACT Health staff, in all healthcare settings. This SOP will provide ACT Health staff with procedural information relating to HH best practice techniques, related products and skin care. Procedures 1. For HH to be effective clinical staff must not have clothing below the elbow covering forearms. This ensures good hand and wrist washing without impediment by shirt cuffs and jewellery: All staff must wear short sleeves or rolled up sleeves; No hand or wrist jewellery (other than a plain metal wedding ring); Clothing worn by all staff must be clean and fit for purpose; and Allied to this is the avoidance of wearing ties when carrying out clinical activities. Version Issue Review Page 1 of 9

2 CED No The designated 5 Moments for Hand Hygiene (Attachment 1) must be used by all staff when attending to patient care. The 5 Moments for Hand Hygiene can be performed with either soap or water, ABHR or alcohol impregnated wipes. Moment 1: Before touching a patient. Moment 2: Before a procedure. Moment 3: After a procedure or body fluid exposure risk. Moment 4: After touching a patient. Moment 5: After touching a patient s surroundings. 3. HH must also occur: Before: Handling contact lens; and Eating and handling food. Between: Handling different types of food raw and cooked, hot and cold, meat and vegetables. After: Any activity that results in hands becoming dirty or contaminated with blood or body substances; Removing gloves or personal protective clothing; Handling any type of waste material; Handling pets or pets waste products; After environmental / instrumental / equipment cleaning; Smoking; and Personal care / hygiene. 4. Audits of HH compliance to this policy will be conducted across ACT Health by trained auditors. 5. Gloves should not be used as a substitute for HH (refer to Standard Precautions SOP and Personal Equipment (PPE) SOP). HH should be practiced immediately before and immediately after an indication for glove use has been identified. If it is required to wear gloves during an entire episode of care for a patient who requires contact precautions, changing gloves and performing HH must occur moving between clean and dirty sites of the same patient to prevent the spread of pathogens between same patient sites. 6. Jewellery and lanyards can be a source of infections: Jewellery should not inhibit proper HH; Rings should be limited to one flat band; Version Issue Review Page 2 of 9

3 CED No No wrist watches and bracelets are to be worn in a clinical area; and Lanyards are not to be worn by clinical staff when performing procedures when contamination from lanyards is possible. 7. Fingernails: Fingernails should be kept short, clean and healthy at all times; and Nail polish and nail enhancements should not be worn by healthcare workers providing patient care. Enhancements include anything applied to natural nails i.e. artificial nails, tips, wraps, acrylics, gels and any additional item applied to the nail surface. Chipped nail polish supports the growth of micro-organisms on the fingernails. 8. To care for skin staff members should: Use only supplied ACT Health HH products; Ensure hands are wet before application of soap for hand washing; Report and seek prompt medical attention for any skin problems related to the use of HH products; Moisturise their hands at least four times a day during the shift to prevent dryness and skin abrasions; Cover cuts and abrasions with an occlusive waterproof dressing to prevent invasion of micro-organisms and replaces dressings that become dislodged or damaged; Seek professional advice for skin infections and dermalogical conditions; Use warm water for hand washing whenever possible extremes of temperature can damage skin; and Wear appropriate protective gloves to minimise risk of damage from extremes of temperature and chemicals this applies to food service staff, cleaning staff and sterilising staff. 9. Placement of HH products: ABHR is to be available at the entry to all healthcare facilities and at the entry to the ware and clinical areas; ABHR must be available at the point of care and all adult beds must have ABHR attached on the right hand side of the foot of the bed rest; In paediatric/adolescent settings placement of product is at the point of care, either on the end of the bed or as close to the end of the bed as possible, except in situations of intellectual impairment or alcohol abuse where the child could unintentionally or intentionally harm themselves. In this situation an empty bottle of product should be placed in the bracket at the end of the bed, to avoid the bracket itself becoming a source of potential harm; Placement of product should be easily accessible for staff to be able to perform HH according to the 5 Moments for HH; Version Issue Review Page 3 of 9

4 CED No Education and support regarding the importance of ABHR s must be given to the patient and their family members; All clinical areas must have adequate ABHR to allow easy access during clinical procedures; Procedure trolleys should have ABHR attached to them to allow easy access for staff to be able to perform HH; Hand washing basins should be kept clear of excess items to allow easy access for hand washing; and The staff of wards and departments should ensure adequate supplies of the products are available for use at all times. 10. Staff should not: Remove the ABHR brackets from the end of the bed; Re-use dispensing plunger; Refill containers of HH products; Top up part filled containers; Use out-of-date products; Bring commercially available products in from home as these are unsuitable for a healthcare environment and not compatible with hospital hand hygiene products and they may not be compatible with latex; or Use products provided by patients. 11. Promoting patient, visitor and volunteer HH: Staff should encourage patients to perform HH after going to the toilet, using bedpan, urinal, before eating and after sneezing or coughing into hands; HH products should be offered to bed ridden patients to promote HH; Staff should educate patients on correct HH technique; and Visitors and volunteers should be encouraged to comply with HH products before entering patient room/ward. Evaluation Outcome Measures All staff will implement appropriate, safe and effective HH and comply with best practice in skin care. HH compliance rates will be audited all year in nominated ACT Health sites and measured against the national average; and Infection will monitor the HAI rates (i.e. Staphyloccocus bacteraemia and Clostridium difficile infection. Version Issue Review Page 4 of 9

5 CED No Method Trained auditors will carry out HH compliance audits in nominated ACT Health sites, enter data and generate reports; Feedback on HH compliance rates will be provided to stakeholders including Hand Hygiene Australia, ACT Health and other health facilities involved; and HH education is delivered through in-service education sessions, staff orientation, e-learning package, and opportunistic occasions during workplace audits and in response to a compliant of broken skin integrity or excessive dryness. Related Legislation and Policies Legislation Health Act 1993 Health Practitioners Regulation National Law (ACT) Act 2010 Public Health Act 1997 Workplace Safety Act 2009 Public Service Management 1994 Policies ACT Health Policy Infection CED ACT Health Policy Dangerous Substance Management CED Standards ACHS EquIP 1.5.2; Definition of Terms Alcohol Based Hand Rub (ABHR): Alcohol containing preparation designed for application to the hands in order to reduce the number of viable micro organisms with maximum efficacy and speed. Healthcare Associated Infection (HAI): Infections that originate from, or are related to, a healthcare setting or the delivery of healthcare. Hand Hygiene (HH): A process that reduces the number of micro-organisms on hands. Hand hygiene is a general term applying to the use of soap solution (non-anti-microbial or antimicrobial) and water or water-less antimicrobial agent to the surface of the hands (e.g. alcohol based hand rub). Moment: An opportunity to perform hand hygiene where there is a risk of pathogen transmission from one surface to another via the hands. Version Issue Review Page 5 of 9

6 CED No References Barts and the London NHS Trust. (2010). Infection Control Manual Policy 22 for Hand hygiene (accessed 10 September 2010). Buffet M, Turnbull L, Spady D, Rennie, R & Forgie, S. (2009). ID Tags does the ID stand for identification or infectious Disease, American Journal of Infection Control, 37, The Canberra Hospital. (2007). Infection Control Personal Hygiene and Fingernail Enhancement Policy. Retrieved from Centre for Disease Control (CDC). (2002). Guidelines for Hand Hygiene in Health Care Settings. Retrieved from Communicable Diseases Network Australia (CDNA). (2004). Infection Control guidelines for the prevention of transmission of infectious diseases in the health care setting. Retrieved from F190003B4DA/$File/icg-rescinded.pdf Hand Hygiene Australia New South Wales Health. (2010). Hand Hygiene Policy. Retrieved from Tameside Hospital NHS Foundation Trust. (2010). Hand Hygiene Policy. Retrieved from World Health Organisation. (2009). WHO Guidelines on Hand Hygiene in Health Care. Retrieved from Attachments Attachment 1: Attachment 2: Attachment 3: 5 Moments of Hand Hygiene Product Use in the Community Setting Effective Hand Wash Procedure Disclaimer: This document has been developed by ACT Health, <Name of Division/Service/Branch> specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and ACT Health assumes no responsibility Version Issue Review Page 6 of 9

7 CED No Attachment 1: 5 Moments for Hand Hygiene 'Based on the 'My 5 moments for Hand Hygiene', URL: World Health Organization Version Issue Review Page 7 of 9

8 CED No Attachment 2: Product Use in the Community Settings Location Activity What product to use Out patient or health centre based clinic or MHACT or DACT residential unit General hand wash Liquid hand cleaner and warm water or ABHR How to use it seconds wash, clean water rinse and pat dry rub in well to all surfaces Aseptic technique Liquid hand cleaner and warm water 1 minute wash, clean water rinse and pat dry followed by ABHR Rub well into all surfaces of hands for 15 to 30 seconds before donning gloves Client s home General hand wash and *Soft pre-moistened cloth followed by Thorough wipe (use second cloth if hand visibly soiled) for 10 to 15 seconds. Aseptic technique ABHR rub in well to all surfaces before donning gloves Version Issue Review Page 8 of 9

9 CED No Attachment 3: Effective Hand Wash Procedure Apply product then: Using liquid soap and water OR antimicrobial hand gel NB: don t forget finger nails and under rings Skin that is intact and without cuts, abrasions or lesions is a natural defence against infection Version Issue Review Page 9 of 9 HINTS for effective liquid hand cleaner ('soap') and water wash 1. Wet hands before applying cleaning product it is a concentrate and may damage skin 2. Use ph neutral liquid hand/skin cleaner ('soap') 3. Use only recommended amount usually one push of pump dispenser 4. Ensure all surfaces of hands and wrists are vigorously rubbed with soapy lather for a seconds for general wash b. 60 seconds for wash prior to undertaking aseptic technique 5. Rinse hands thoroughly after washing under running water leaving a residue of liquid hand cleaner is drying to your skin 6. Pat hands dry on clean single use cloth towel or disposable paper towel avoid vigorous rubbing as friction causes heat and heat causes your skin to dry 7. Ensure finger nails are kept short, trim and clean, and without nail polish.