Hand Hygiene Policy. Paper Copies of this Document

Transcription

1 Hand Hygiene Policy This policy aims to ensure that all staff are aware of their responsibilities in relation to hand hygiene by outlining the principles behind hand hygiene, the appropriate methods, products and procedures required to carry out effective hand decontamination. Ratified Date: January 2011 Ratified By: Trust Infection Prevention Committee Review Date: January 2013 Accountable Directorate: Laboratory Medicine Corresponding Author: Trust Lead Infection Prevention Nurse Paper Copies of this Document If you are reading a printed copy of this document you should check the Trust s Policy website ( to ensure that you are using the most current version. Heart of England NHS Foundation Trust View/Print date 02 January 2012 Page 1 of 15

2 Table of Contents 1. Circulation 4 2. Scope 4 3. Definitions 4 4. Reasons for Development 4 5. Aims and Objectives 4 6. Standards in Hand Hygiene 5 7. Responsibilities Individual Responsibilities 7.2 Ratifying Board and Committee Responsibilities 8. Training Requirements 7 9. Monitoring and Compliance References and related documents 9 Attachment 1: Consultation and Ratification Attachment 2: Equality Impact Assessment (EIA) Attachment 3: Launch and Implementation Plan Heart of England NHS Foundation Trust View/Print date 02 January 2012 Page 2 of 15

3 Meta Data Document Title: Status Hand Hygiene Policy Active Document Author: Lead Infection Prevention Nurse/ Senior Infection Prevention Nurse Source Directorate: Infection Prevention Team Date Of Release: January 2011 Ratification Date January 2011 Ratified by: Trust Infection Prevention Committee (TIPC) Review Date: January 2013 Related documents Infection Control Strategy Mandatory Training Policy Infection Control Training Needs Analysis Superseded Hand Hygiene Policy 2008 documents Relevant Eternal Care Quality Commission Regulation 12 Outcome 8 Standards/ Legislation NHS Litigation Authority 2.8 Key Words Hand Hygiene, Alcohol Gel, Hand Washing, Revision History Version Status Date Consultee Comments 2.1 Draft July 2010 Infection Control Team and Safety and Governance Action from Comment Heart of England NHS Foundation Trust View/Print date 02 January 2012 Page 3 of 15

4 1 Circulation The document applies to and should be read by all staff employed by the Trust. 2 Scope This policy covers hand hygiene procedures for all types of practice from routine to surgical scrub; types of products and when they should be used; skin care for the individuals hands including where and when to seek help with regard to hand conditions; the Cleanyourhands Campaign; audit and Training and Facilities available for good Hand Hygiene. 3 Definitions 3.1 Wherever the word Trust appears in this document it refers to Heart of England NHS Foundation Trust. 3.2 Where IPT is used this refers to the Trust Infection Prevention Team 3.3 DIPC refers to the Trust Director of Infection Prevention and control 4 Reason for development 4.1 To give staff clear guidance in hand hygiene. 4.2 The Trust is using this policy review to simplify the guidance to improve compliance. 5 Aims and Objectives 5.1 This policy aims to ensure that all staff are aware of their responsibilities in relation to Hand Hygiene by outlining: The principles behind Hand Hygiene; The appropriate methods, products and procedures required to carry out effective Hand Hygiene. 5.2 Continue implementation of the Cleanyourhands campaign. This includes Include hand gels at the point of patient care(gel should be within arm reach when staff are caring for a patient). Patient and public involvement Staff encouragement of patients to enable them to feel confident to ask about Hand Hygiene. Encouraging Hand Hygiene of patients and visitors. Heart of England NHS Foundation Trust View/Print date 02 January 2012 Page 4 of 15

5 6 Standards for Hand Hygiene A Frequently Asked Questions - A quick guide for clinical staff detailing the standards for Hand Hygiene can be found on the Infection Control website on the HEFT intranet under policy manual or under this policy on the sharepoint site. Alternatively, press Ctrl and click here to access this document 7 Responsibilities 7.1 Individual Responsibilities Individual Staff All staff are responsible for: Attending Mandatory infection control training, which includes Hand Hygiene. Ensuring that patient s relatives and visitors are made aware of the Cleanyourhands campaign and information is freely available in clinical areas. Ensuring that empty liquid soap/paper towel/hand gel dispensers are promptly reported to the domestic contractor and replenished. (Occasionally this may mean the member of staff refilling the container themselves); Prompt reporting of damaged liquid soap/hand gels and paper towel dispensers to the Estates department; Their own Hand Hygiene practice; Challenging the poor practice of others; Patients and Visitors Patients must be advised and encouraged to decontaminate their hands after toileting, before consumption of food or drink and before and after contact with susceptible sites (e.g. Hickman lines/wounds or urinary catheters). All staff must ensure relatives and visitors are encouraged to decontaminate their hands when entering and leaving a ward or department. This can be done by using the hand gel at the entrance to wards and departments or by washing their hands at the nearest most convenient hand wash basin. Staff must ensure that visitors are advised of the need to decontaminate their hands before and after contact with patients Managers of Clinical areas/clinical staff Managers of Clinical areas/clinical Staff are responsible for: Ensuring dissemination of this policy Enforcing this policy in their areas Participating in the trusts Hand Hygiene audit programme on a monthly basis Carrying out recommendations following audit of Hand Hygiene practice Facilitating the delivery of education provided by the infection control team Heart of England NHS Foundation Trust View/Print date 02 January 2012 Page 5 of 15

6 Ensuring Hand Hygiene is included in ward/departmental based induction programmes. Ordering batteries for automatic dispensers Domestic Contractor/Domestic Services Domestic Contractors/Domestic services are responsible for: At least daily checking and refilling of liquid soap/ hand gel/paper towel dispensers as appropriate Prompt response to requests to replenish spent liquid soap/paper towel/hand gel dispensers Ensuring that Hand Hygiene facilities are clean and fit for purpose The Estates Department The Estates Department are responsible for: The prompt repair of damaged liquid soap/hand gel and paper towel dispensers reported to them, maintenance and installation of appropriate hand wash facilities. Ensure that during refurbishment or new build programmes Hand Hygiene facilities are considered and given high priority to ensure the most appropriate facilities and numbers of and wash basins are adequate for the facility as in line with NHS Estates 2003 document Infection Control in the Built Environment The Purchasing and Supplies Department Purchasing and Supplies are responsible for: Liaison with the companies supplying Hand Hygiene products in the event of supply problems. Provide the ongoing supply of appropriate Hand Hygiene products to ensure Hand Hygiene can occur. As a minimum this will include a liquid soap, paper towel and alcohol hand gel approved for use in the NHS by the NHS Purchasing and Supplies Agency (PASA) The Infection Prevention and Control Team The Infection Prevention and Control Team are responsible for: Providing Hand Hygiene training as part of mandatory training programme in line with training needs analysis. Co-ordinating audits of Hand Hygiene practice which will be monitored by the Trust Infection Prevention Committee; Ensuring the Hand Hygiene policy is reviewed in line with new evidence or at least once every two years Advising on the positioning and prioritisation of Hand Hygiene facilities during redevelopment or the development of new clinical areas Supporting the monthly audit programme carried out by the trust nursing managerial structure, and supporting staff and teams where audit performance is poor, falling below agreed benchmarks within the audit programme. Heart of England NHS Foundation Trust View/Print date 02 January 2012 Page 6 of 15

7 7.1.8 The Infection Prevention and Control and Occupational Health Teams The Infection Prevention and Control Team and Occupational Health Teams will: Advise on the efficiency and suitability of products for Hand Hygiene Liaise with the companies supplying Hand Hygiene products in the event of a clinical problem 7.2 Ratifying Board and Committee Responsibilities Trust Infection Prevention Committee (TIPC) The purpose of the Trust Infection Prevention Committee (TIPC) is to ensure continuous improvement and reduction in rates of healthcare associated infection while proving a Trust wide operations facilitation forum for control of infection. The group consists of a membership including Nursing, Infection Control and Hotel Services. TIPC is responsible for Hand Hygiene for the Trust is carried out in accordance to current best practice guidance. TIPC have responsibility for : policy ratification Review of metrics relating to Hand Hygiene taking action where appropriate Mandatory Training Committee The Mandatory Training Committee will: Monitor attendance at Hand Hygiene training as part of the mandatory training programme and follow up those who fail to attend hand hygiene 8 Training Requirements The Trust provides specific training on Hand Hygiene which is included in the trust induction programme for clinical staff, and in the infection control mandatory update. Training is based on current understanding of best practice. All relevant Trust must attend mandatory Hand Hygiene training every two years. Further details regarding which staff receive training is included in the Infection Control Training Needs Analysis. Additional training is provided on a risk assessed basis only. Hand Hygiene training is delivered via mandatory session, cascade training from infection control link workers, or use of trust e-learning facilities. It is the responsibility of the line manager and individual to rebook missed training and attend future date. Attendance information for the Infection Control element of mandatory training is contained in registers for Corporate Induction/Corporate Mandatory Study days. Following completion of the training session, the registers are forwarded to Learner Registry for inputting on to the Trust-wide training database (OLM). The registers are stored within the offices of Learner Registry. Link Nurses retain records of attendance at cascade training. Heart of England NHS Foundation Trust View/Print date 02 January 2012 Page 7 of 15

8 The OLM reports mandatory training attendance data on a quarterly basis to all managers and alerts managers of non-attendance by their staff. It is the responsibility of the line manager to ensure that their staff attend for mandatory training. The process for following up those who fail to attend relevant training is via the escalation process - which is detailed in the Trust mandatory training policy which ensures that staff who fail to attend are followed up. This is monitored by the Trust Mandatory Training Committee and HR Committee. Further detail is included in the Trust Mandatory Training policy. 9 Monitoring and Compliance Criteria Compliance with Hand Hygiene policy standards Hand Hygiene Training process for checking relevant staff attend Hand Hygiene Training process for checking relevant staff attend Monitoring Mechanism Responsible Frequency Responsible Committee DH Hand Ward Monthly Trust Infection Hygiene Managers and Prevention observation delegated link Committee tool workers OLM Line Managers Ongoing OLM Learner Registry Monthly and Quarterly as per escalation process Mandatory Training Committee and HR Committee All clinical areas will be audited monthly using the Department of Health currently recommended Hand Hygiene observation tool. The ward Manager or delegated link worker undertakes the audits and inputs these onto a centrally held database monitored by the Trust Infection Prevention Committee. A monthly report is generated for the Infection Control Operational Group, Nursing Managers and Matrons. Results below the agreed benchmark within the annual audit programme initiate a cycle of weekly audit until practice improves to the agreed benchmark within the annual programme. The cycle of audit offers a mechanism by which staff training can be targeted to teams and individuals where support is needed and policy non-compliance can be detected. Monitoring procedures for training are listed in section 8. Heart of England NHS Foundation Trust View/Print date 02 January 2012 Page 8 of 15

9 10 References Department of Health (2007) Uniforms and workwear: an evidence base for developing local policy Department of Health (2010) The Hygiene Code 2010, Code of practice for the Prevention and Control of healthcare Associated Infections London, COI Epic2: National Evidence-Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England. Vol. 65 supplement 1 S15 Feb Pittet D, Hugonnet S et al (2000). Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. The Lancet, 356: Patient Safety Alert, Clean Hands Save Lives, NPSA 2nd edition, 2nd Sept World Health Organisiation (2009) World Alliance for Patient Safety. WHO Guidelines on Hand Hygiene in Healthcare. Heart of England NHS Foundation Trust View/Print date 02 January 2012 Page 9 of 15

10 Attachment 1: Ratification Checklist Title Hand Hygiene Policy Ratification checklist 1 Is this a: Policy Yes 2 Is this: Revised Yes 3* Format matches Policies and Procedures Template (Organisation-wide) 4* Consultation with range of internal /eternal groups/ individuals Details Yes Infection prevention team Trust Infection prevention committee 5* Equality Impact Assessment completed Yes 6 Are there any governance or risk implications? No (e.g. patient safety, clinical effectiveness, compliance with or deviation from National guidance or legislation etc) 7 Are there any operational implications? Requires full co operational from Matrons and staff at ward level. 8 Are there any educational or training implications? No 9 Are there any clinical implications? No 10 Are there any nursing implications? No 11 Does the document have financial implications? No 12 Does the document have HR implications? No 13* Is there a No launch/communication/implementation plan within the document? 14* Is there a monitoring plan within the document? No 15* Does the document have a review date in line with the Policies and Procedures Framework? Yes Heart of England NHS Foundation Trust View/Print date 02 January 2012 Page 10 of 15

11 16* Is there a named Director responsible for review of the document? 17* Is there a named committee with clearly stated responsibility for approval monitoring and review of the document? Yes Trust Infection Prevention committee Document Author / Sponsor Signed. Title Date... Ratified by (Chair of Trust Committee or Eecutive Lead) Signed. Title Date... Heart of England NHS Foundation Trust View/Print date 02 January 2012 Page 11 of 15

12 Policies and Procedures: Hand HygieneHand Hygiene Policy Attachment 2: Equality and Diversity - Policy Screening Checklist Policy/Service Title: Hand Hygiene Policy Directorate: Laboratory Medicine Name of person/s auditing/developing/authoring a policy/service: Trust Lead Infection Prevention Nurse Aims/Objectives of policy/service: All UK healthcare regulatory bodies (Nursing and Midwifery Council, General Medical Council etc) stipulate that healthcare staff must act to identify and minimise risk to patients and clients. Many infections occur because micro-organisms are introduced to a susceptible site of individual through contaminated hands. The organism then colonises the skin and subsequently causes an infection. Policy Content: For each of the following check the policy/service is sensitive to people of different age, ethnicity, gender, disability, religion or belief, and seual orientation? The checklists below will help you to see any strengths and/or highlight improvements required to ensure that the policy/service is compliant with equality legislation. 1. Check for DIRECT discrimination against any group of SERVICE USERS: Response Question: Does your policy/service contain any statements/functions which may eclude people from using the services who otherwise meet the criteria under the grounds of: 1.1 Age? 1.2 Gender (Male, Female and Transseual)? 1.3 Disability? 1.4 Race or Ethnicity? 1.5 Religious, Spiritual belief (including other belief)? 1.6 Seual Orientation? 1.7 Human Rights: Freedom of Information/Data Protection Action required Resource implication Yes No Yes No Yes No If yes is answered to any of the above items the policy/service may be considered discriminatory and requires review and further work to ensure compliance with legislation. 2. Check for INDIRECT discrimination against any group of SERVICE USERS: Question: Does your policy/service contain any statements/functions which may eclude employees from operating the under the grounds of: Response Action required Resource implication Yes No Yes No Yes No Heart of England NHS Foundation Trust View/Print date 02 January 2012 Page 12 of 15

13 Policies and Procedures: Hand HygieneHand Hygiene Policy 2.1 Age? 2.2 Gender (Male, Female and Transseual)? 2.3 Disability? 2.4 Race or Ethnicity? 2.5 Religious, Spiritual belief (including other belief)? 2.6 Seual Orientation? 2.7 Human Rights: Freedom of Information/Data Protection If yes is answered to any of the above items the policy/service may be considered discriminatory and requires review and further work to ensure compliance with legislation. TOTAL NUMBER OF ITEMS ANSWERED YES INDICATING DIRECT DISCRIMINATION = 3. Check for DIRECT discrimination against any group relating to EMPLOYEES: Response Question: Does your policy/service contain any conditions or requirements which are applied equally to everyone, but disadvantage particular persons because they cannot comply due to: 3.1 Age? 3.2 Gender (Male, Female and Transseual)? 3.3 Disability? 3.4 Race or Ethnicity? 3.5 Religious, Spiritual belief (including other belief)? 3.6 Seual Orientation? 3.7 Human Rights: Freedom of Information/Data Protection Action required Resource implication Yes No Yes No Yes No If yes is answered to any of the above items the policy/service may be considered discriminatory and requires review and further work to ensure compliance with legislation. 4. Check for INDIRECT discrimination against any group relating to EMPLOYEES: Question: Does your policy/service contain any statements which may eclude employees from operating the under the grounds of: Response Action required Resource implication Yes No Yes No Yes No 4.1 Age? 4.2 Gender (Male, Female and Transseual)? 4.3 Disability? 4.4 Race or Ethnicity? 4.5 Religious, Spiritual belief (including other belief)? 4.6 Seual Orientation? 4.7 Human Rights: Freedom of Information/Data Protection Heart of England NHS Foundation Trust View/Print date 02 January 2012 Page 13 of 15

14 Policies and Procedures: Hand HygieneHand Hygiene Policy If yes is answered to any of the above items the policy/service may be considered discriminatory and requires review and further work to ensure compliance with legislation. TOTAL NUMBER OF ITEMS ANSWERED YES INDICATING INDIRECT DISCRIMINATION = 0 Signatures of authors / auditors: Date of signing: Heart of England NHS Foundation Trust View/Print date 02 January 2012 Page 14 of 15

15 Policies and Procedures: Hand HygieneHand Hygiene Policy Attachment 3: Launch and Implementation Plan To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval. Action Who When How Present Policy to key user groups Diane Tomlinson Trust Lead IPCN, January 2011 Trust Infection Prevention Committee Add to Policies and Procedures intranet page / document management system. Launch new Dept Health hand hygien audit tool Infection Prevention Administrator Diane Tomlinson Trust Lead IPCN, January 2011 Upload to Sharepoint and infection Prevention and Control Website On release Ward based training via ICNs Link staff training Heart of England NHS Foundation Trust View/Print date 02 January 2012 Page 15 of 15