HAND HYGIENE Quality improvement toolkit for Infection Prevention & Control in General Practice

HAND HYGIENE Quality improvement toolkit for Infection Prevention & Control in General Practice : : October 2008 Version: Wales (Intranet) / NPHS (Intranet) / LHB /General Practice Purpose and Summary of Document: This simple hand hygiene audit is for use by all staff working in general practice that have patient or specimen contact.the purpose of this observational audit is to support practices in assessing the quality of hand hygiene technique performed by staff and in working with staff to improve their hand hygiene technique. Completion of this audit would constitute a suitable piece of Continuing Professional Development that could be included within the GP appraisal process or Personal Practice Development. This straight forward audit is designed to prompt reflection Publication and Distribution: Publication in NPHS Document Database (Consultant infection control nurse) Link from NPHS e-bulletin Version 0e Page 1 of 16

Preface Quality improvement toolkits The Primary Care Quality and Information Service (PCQIS) have developed quality improvement toolkits to assist practices in collating and auditing information. The quality improvement toolkits produced support the specification requirements of the latest evidence based practice. They should be seen as good practice and cover areas that some or even all practices may not be achieving at this stage. It is not expected that all the criteria within this audit will be in year one therefore the PCQIS suggests that the toolkits should be used to aid development within the practice. You can access other quality improvement toolkits that support enhanced services and National Service Frameworks from the National Public Health Service (NPHS) website: Intranet http://nww2.nphs.wales.nhs.uk/page.cfm?pid=1267 Internet http://www.wales.nhs.uk/sites3/page.cfm?orgid=719&pid=23548 Version 0e Page 2 of 16

CONTENTS Page Preface 2 1 Introduction and background 4 2 Aim of the quality improvement toolkit 4 3 Methodology 5 4 Data entry template 6 Appendix 1-10 steps to effective hand hygiene 7 Appendix 2 - Effective hand hygiene information 9 Appendix 3- Quality improvement toolkit evaluation form 11 Appendix 4- Summary collection sheet 12 Appendix 5- WHO Five moments for hand hygiene 15 References 16 Version 0e Page 3 of 16

1 Introduction and background Hand hygiene is the entrance door to better infection control and safer patient care 4 Health care-associated infections (HCAIs) remain a major cause of morbidity, mortality, and excess health care cost despite concerted infection control efforts over nearly a half-century. Patients in Wales should expect to receive care and treatment in a way that does not pose a greater risk to their health 3 A key objective of the Healthcare Associated Infections Community strategy for Wales - (2007) is to introduce a clean culture throughout the healthcare system and to ensure that hygiene and infection prevention and control are embedded in the management agenda and the accountability of all staff. 3 The importance of hand hygiene in the healthcare environment is considered a priority and the need for its emphasis in the primary care setting is recognised 7. Hand hygiene is the most effective measure to prevent transmission of microorganisms. Adequate hand hygiene can be by hand washing with soap and water--or by the use of an alcoholbased hand-rub solution 9. It is an infection control practice with a clearly demonstrated efficacy, and remains the cornerstone of efforts to reduce the spread of infection 4,8. Technique is of crucial importance in all hand hygiene 12. All Primary care staff Involvement It is important that all staff develop awareness and knowledge of infection control processes and procedures. The practice could undertake a baseline audit to identify if practice staff have received training in hand hygiene procedures. This simple audit will help gain a baseline understanding of whether staffs are performing effective hand hygiene techniques. The audit will also provide an opportunity for staff to reflect on their own hand hygiene practices, improving their technique where required. Nominated lead for infection control The practice must nominate a lead for Infection Prevention and Control, someone who must have received training in infection prevention and control to achieve competence. Central to the role of the nominated lead will be to ensure compliance with standard infection control precautions (SICP s), direct an ongoing audit programme and guarantee that improvements in practice, where identified are implemented. The nominated lead will be a role model who can influence the culture in their workplace to encourage behaviour change in the prevention and control of infection 2 Aim To identify effective hand preparation and hand decontamination of all staff within General Practice to minimise the risk of transmission of infection. Version 0e Page 4 of 16

3 Methodology Observational audit Compile a list of all staff trained and untrained in effective safe hand hygiene procedures Identify a practice lead for infection prevention and control to carry out an observational audit or encourage staff to buddy with another colleague to perform the audit Observe one staff member at a time, Collect relevant data for each individual staff and record using the data collection sheet provided ( page 6) Feedback the results immediately to the staff member Where 100% is not by an individual they should be advised/encouraged to reflect on their practice. The audit should be repeated at an agreed time until 100% is Aggregate data from completed audits for analysis using the summary sheet (Page 12) The Audit Lead / Team should reflect on the overall results of the audit, review themes identified from the analysis and recommend any changes to practice considered appropriate A repeat of the overall audit within the practice should be undertaken as part of the practices infection control audit programme Version 0e Page 5 of 16

4 Hand hygiene Quality Improvement Audit for Primary Care Individual staff data entry template checklist Staff.. Practice Infection control lead. The practice lead is an individual who /is undertaking or has completed the healthcare associated infection (HCAI) champion E-learning programme and who should be the person observing hand hygiene technique. Criteria All criteria are essential Hand washing Hand Preparation Hands and wrists are free from watches and jewellery (non stoned wedding rings are acceptable) Nails are short and without nail extensions and varnish Sleeves are short or rolled up during hand washing Cuts are covered with a waterproof dressing Hand washing technique CCCC1. Hands are wet under continuously running water 2. Warm Water is used to wash hands 3. Dispensed liquid soap is used 4. Liquid soap is applied to wet hands 5. Hands are rubbed to create a lather 6..A copy of the 10 steps to effective hand hygiene wall chart is prominently displayed at each wash basin (See appendix 1) 7.The lather is rubbed over all surfaces of the hands for 10-15 seconds, including the thumbs, between the fingers, fingertips and the wrist (demonstrating the 10 steps to effective hand hygiene technique (See appendix 1) 8. Hand are rinsed thoroughly under running water Drying of Hands 9.Taps are turned off using wrist/elbow levers or using a clean paper towel 10. Hands are dried using paper towels Alternative Hand Hygiene using Alcohol based hand rubs/ Hand Preparation Hands and wrists are free from watches and jewellery (non stoned wedding rings are acceptable) Nails are short and without nail extensions and varnish Sleeves are short or rolled up during hand hygiene Cuts are covered with a waterproof dressing Hands are visibly clean Alcohol based hand rub is dispensed onto the hands Alcohol hand rub is rubbed onto the hands ensuring all surfaces are covered by the alcohol Hands are rubbed until the alcohol has evaporated Definition of : criteria met in full: : criteria not met Version 0e Page 6 of 16

Appendix 1 The following guide has been adapted from the RCN and Kimberly-Clark hand washing Guide (RCN Good Practice in Infection Prevention and Control 2005) 10 steps to effective hand hygiene To ensure that all parts of the hands are cleaned properly the following technique should be followed. The same principles can be applied when using alcohol hand rubs 1 2 3 4 Wet hands and forearms Soap up and rubbing palm to palm Rub with fingers interlaced Massage between fingers. Right palm over back of Left hand, left palm over back of right hand Version 0e Page 7 of 16

5 6 7 Scrub with fingers locked Rub rotationally with thumb Rinse thoroughly Including finger tips locked 8 9 10 Dry palms using paper towels Work towel between fingers Dry around and under nails Version 0e Page 8 of 16

Appendix 2 Importance of Hand Hygiene Effective hand hygiene Information Hand hygiene is considered to be one of the most common ways that transmission of infection occurs. Effective, timely hand hygiene can contribute significantly to reducing the risks of transmission. The hand washing technique adopted must ensure that all areas of the hands are covered. Particular attention should be paid to the finger tips, between the fingers and to the outside and back area of the thumbs, which are often missed. Once rinsed thoroughly, hand should be dried carefully with paper towels. The use of moisturisers can prevent the skin becoming dry and sore Healthcare staffs have the greatest potential to spread micro-organisms that can cause infection. Hands can transfer the patients own micro-organisms into sterile areas of the patients own body during care or treatment transfer micro-organisms from one patient to other patients transfer micro-organisms from the environment and equipment to a patient Acquire micro-organisms as a result of their contact with patients which place healthcare staff at risk of infection. Effective hand hygiene removes all transient micro-organisms and most resident microorganisms from soiled hands 2,3,4,5,6,7,8 When to Wash Your Hands The point of care is the crucial moment for hand hygiene as this represents the time and place at which there is the highest likelihood of transmission of infection via the hands of healthcare staff. The World Health Organisation (WHO) five moments for Hand Hygiene should be used to guide staff in understanding when hand hygiene is required 14. 1 Before patient contact 2 Before aseptic techniques 3 After body fluid exposure risk 4 After patient contact 5 After contact with the patient s surroundings Version 0e Page 9 of 16

Hand Care. Fingernails should be kept short. Nail varnish and/or false nails should NOT be worn by those working in clinical areas. Remove all wrist and hand jewellery (except non stoned wedding rings) prior to performing a hand decontamination technique. Any breaks anywhere on the skin should be covered with a waterproof dressing, as damaged areas of skin are more prone to colonisation with micro-organisms, increasing the risk of cross infection 7. Method Wash hands using soap and running water for 10-15 seconds. The same time applies for washing with aqueous antiseptics solutions or when using alcohol hand rubs or gels 3,5 Hand washing technique 6,7 An effective hand washing technique involves the following three stages: Preparation, Washing and Rinsing, and Drying. Preparation This requires wetting of hands with tepid running water before applying liquid soap or an antimicrobial preparation. The hand wash solution must come into contact with all of the surfaces of the hand. Washing The hands must 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. Rinsing Hands should be rinsed thoroughly before drying with good quality paper towels. Alcohol based hand rubs/gels can be used in place of soap and water except when hands are visibly soiled or after contact with patients who have diarrhoea and or vomiting 10. Recent studies have demonstrated that the use of an alcohol based hand rub between each patient contact has reduced the rate of associated infections 11. They are especially useful in situations where hand washing and drying facilities are not in the immediate vicinity. 2, 6 Application The hands must 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 13 When using alcohol hand rub, time must be allowed for the hands to dry completely for evaporation of the alcohol to take place. Foot operated bins should be used for the disposal of towels as contact with the bin lid may cause the hands to become re-contaminated. Cloth towels should not be used in healthcare premises as they have the potential to become contaminated with microorganisms which will subsequently be transferred to the hands. Version 0e Page 10 of 16

Appendix 3 Practice review A. What lessons did the practice discover from carrying out this observational audit? B. What changes, if any have the practice agreed to implement as a result of this audit? C. What support would enable the practice to enhance the service it provides to patients? This audit was compiled by; (s) Signature(s) Practice (name and address) Version 0e Page 11 of 16

Summary Collection Sheet Appendix 4 Criteria All criteria are essential Hand washing Hand preparation Hands and wrists are free from watches and jewellery (Non stoned wedding rings are acceptable) Nails are short and without nail extension and varnish Staff 1 Staff 2 Staff 3 Staff 4 plan Sleeves are short or rolled up during hand washing Cuts are covered with a waterproof dressing Hand washing technique 1. Hands are wet under continuously running water 2.Warm water used to wash hands 3. Dispensed liquid soap is used 4.Liquid soap is applied to wet hands Version 0e Page 12 of 16

5. Hands are rubbed to create a lather Staff 1 Staff 2 Staff 3 Staff 4 plan 6.A copy of the 10 steps to effective hand hygiene wall chart is prominently displayed at each wash basin (See appendix 1) 7. The lather is rubbed over all surfaces of the hand for 10-15 seconds, including the thumbs, between fingers, fingertips and the wrist. Demonstrating the 10 steps to effective hand hygiene technique (See appendix 1) 8.Hands are rinsed thoroughly under running water Drying of hands 9.Taps are turned off using wrist/elbow levers or using a clean paper towel 10.Hands are dried using paper towels Version 0e Page 13 of 16

Alternative Hand hygiene using alcohol based hand rubs/gels Staff 1 Staff 2 Staff 3 Staff 4 plan Hand preparation Hands and wrists are free from watches and jewellery (Non stoned wedding rings are acceptable Nails are short and without nail extension and varnish Sleeves are short or rolled up during hand washing Cuts are covered with a waterproof dressing Hands are visibly clean Alcohol based hand rub is dispensed onto the hands Alcohol hand rub is rubbed onto the hands ensuring all surfaces are covered by the alcohol Hands are rubbed until the alcohol has evaporated Version 0e Page 14 of 16

Appendix 5 The WHO five Moments for Hand Hygiene 14 1 Before patient contact When? Clean your hands before touching a patient when approaching him/her Why? To protect the patient against harmful germs carried on your hands 2 Before an aseptic task When? Clean your hands immediately before any aseptic task Why? To protect the patient against harmful germs, including the patient s own, from entering his/her body 3 After body fluid exposure risk When? Clean your hands immediately after an exposure risk to bodily fluids (And after glove removal) Why? To protect yourself and the healthcare environment from harmful patient germs 4 After Patient contact When? Clean your hands after touching a patient and his/her immediate surroundings when leaving the patient s side Why? To protect yourself and the healthcare environment from harmful patient germs 5 After contact with patient surroundings When? Clean your hands after touching any object or furniture in the patients immediate surroundings -even if the patient has not been touched Why? To protect yourself and the healthcare environment from harmful patients germs Version 0e Page 15 of 16

References 1 Ayliffe (2000) Control of Hospital Infection A Practical Handbook 2 National Patient Safety Agency (NPSA) guidelines Clean your hands campaign 3 Healthcare Associated Infections A Community strategy Welsh Assembly Government November 2007http://howis.wales.nhs.uk 4 RCN Good Practice in Infection Prevention and Control 2005 http://www.rcn.org.uk/ 5 Welsh Healthcare Associated Infections e learning Champion Welsh Healthcare Associated Infection Programme (WHAIP) - E-Learning Programme 6 Hand Hygiene and care Bury Primary Care Trust: 2007 7 National Institute for Clinical Excellence (2003) Infection control prevention of healthcare associated infection in primary and community care http://www.org.uk/pdf/cg2fullguidelineinfectioncontrol.pdf 8 World Health Organisation (WHO): who guidelines on hand hygiene in health care summary-clean hands are safe hands. http:/www.who.int/patientsafety/events/05/hh_en.pdf 9 Hugonnet S, Pittet D. 2000. Hand hygiene revisited: Lessons from the past and present. Curr.Infect.Dis.Rep; 2(6):484-9. 10 Martin P[ Chief Nursing Officer] 2005, Alcohol based hand rubs and infection control, Scottish Executive. 11 Ojajarvi J. 2003. Alcohol hand rubs v soap. Finnish experience shows that alcohol rubs are good for hands. BMJ; 326(7379):50 12 Widmer AE, Dangel M. 2004. Alcohol-based handrub: evaluation of technique and microbiological efficacy with international infection control professionals. Infect.Control Hosp.Epidemiol; 25(3): 207-9. 13 Larson EL (1995) APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 23 (4): 251-69. 14 National Patient Safety Agency (NPSA) Patient safety alert Second Edition 2 September 2008: The WHO five moments for hand hygiene. http://www.npsa.nhs.uk/cleanyourhands/the-campaign/latest-news/ Version 0e Page 16 of 16