Section 6. Guidelines for Hand Hygiene

Section 6 Guidelines for Hand Hygiene Issue No 4, April 2011, Section 6 On behalf of Infection Control Policy Review Group NHS Ayrshire and Arran Warning - this document is uncontrolled when printed Check local intranet site for current version Issue No 4, April 2011 - Section 6 Page 1 of 13

TITLE: Policy Reference: Issue No 4, April 2011, Section 6 Scope: Controlled Document: Organisation Wide This document shall not be copied in part or whole without the express permission of the author or the author's representative. Expiry Date: April 2014 Authors: Policy Application: Mrs Barbara Dyet, Infection Control Clinical Trainer Throughout NHS Ayrshire and Arran Responsibilities for Implementation Organisation: Directorate: Corporate: Departmental: Local: Policy Statement: Senior Management Team and Chief Executive Directors Senior Managers Heads of Wards or Departments All relevant staff It is the responsibility of all staff to ensure that they consistently maintain a high standard of hand hygiene in accordance with this guidance. Review Date: October 2013 Agreed by: Infection Control Policy Review Group Approved by: Dr R G Masterton Date 21/04/11 Signature / Designation: Executive Medical Director and Chair Prevention and Control of Infection Committee Page 2 of 13

CONTENTS PAGE 1.0 Introduction. 4 2.0 Preparation for Hand Hygiene..... 6 3.0 Social Handwashing.. 7 4.0 Hygienic Hand Hygiene 8 5.0 Surgical Hand Hygiene..... 10 6.0 Skin Care. 11 7.0 Antabuse (Disulfiram).... 11 8.0 Facilities... 11 9.0 Risk Assessment.... 12 10.0 Hand Hygiene for Patient. 12 11.0 Hand Hygiene for Visitors.... 12 12.0 Bibliography 13 Page 3 of 13

SECTION 6 GUIDELINES FOR HAND HYGIENE 1.0 INTRODUCTION It is well established that inadequate hand hygiene constitutes the greatest risk of cross-infection between staff, patients and the environment. Effective hand decontamination is the single most important means of preventing the spread of infection. In January 2009 the Cabinet Secretary for Health and Wellbeing announced that a Zero Tolerance approach to non-compliance with hand hygiene standards be adopted across all healthcare settings CEL 5 (2009). NHS Ayrshire & Arran has adopted the Zero Tolerance Policy and all staff have a responsibility to ensure that they undertake adequate hand hygiene and encourage others delivering care to do so. All staff are strongly encouraged to undertake the NHS Ayrshire & Arran online LearnPro Infection Control Modules. These can be accessed at http://athena/ohrd/learndev/pages/elearning4.aspx. For further information please contact the Infection Control Clinical Trainer at Crosshouse Hospital on ext 25766. Regular local audits of hand hygiene should be performed in all clinical areas. Further advice and support on undertaking hand hygiene audits can be obtained from the Infection Control Clinical Trainer at Crosshouse Hospital on ext 25766. Page 4 of 13

NB The description given for the Your 5 Moments for Hand hygiene can be applied to a range of settings and not just acute hospital wards. Detailed guidance on the practical application of this policy in the home care setting can be obtained in Section 7 Infection Control Guidelines for Home Care in the Control of Infection Manual. Issue No 4, April 2011 - Section 6 Page 5 of 13

1.1 Transient organisms Transient organisms may include many different pathogenic organisms, including those that commonly cause healthcare associated infections. Hands acquire organisms from other sites on an individual s body, from other people and from the environment. Transient organisms do not normally survive for long periods on the hands and therefore they either die or are passed on to objects or individuals which are subsequently touched. The ability of transient micro-organisms to transfer to and from the hands with ease results in hands being extremely efficient vectors of infection. Transient organisms are not firmly attached to the skin and can be removed from hands by effective handwashing, or can be effectively destroyed by the correct application of alcohol handrub on to socially clean hands. 1.2 Resident organisms Resident organisms are mainly harmless and are not frequently implicated as the cause of infections. However, some of these micro-organisms may cause infection in patients e.g. when surgery or other invasive procedures allow them to enter deep tissues, or when a patient is severely immunocompromised. Most transient organisms can be removed by thorough washing of hands with soap and water. The resident organisms, however, are mostly left on the skin after washing with soap and water but can be greatly reduced in number by washing with an antiseptic detergent preparation. The agent used for handwashing is determined by the degree of antisepsis required. There are three levels of hand hygiene:- Social Handwashing Hygienic Hand Hygiene Surgical Hand Hygiene 2.0 PREPARATION FOR HAND HYGIENE To perform effective hand and wrist decontamination, as wrists are deemed part of the hand, staffs are required to be Bare below the Elbow the only exception being a plain finger ring band which should be moved / removed when performing hand hygiene in order to reach the bacteria which can harbour underneath. Cover cuts and abrasions with waterproof dressing which can be decontaminated appropriately. Keep nails short and pay particular attention to them when washing your hands. Do not wear artificial nails or any nail products. Page 6 of 13

3.0 SOCIAL HANDWASHING (using liquid soap and running water) Routine hand washing using liquid soap and running water using a good technique removes most transient micro-organisms from soiled hands. It is essential that a social handwash is performed:- Start/Leaving work After personal use of the toilet After blowing or wiping your nose After sneezing or coughing into hands Before eating, drinking, preparing or handling food When hands are visibly soiled (This list is not exhaustive) 3.1 Technique for social handwashing A liquid soap and warm running water should be used i) Turn the water to a temperature comfortable to the hands ii) iii) iv) Wet both hands under running water before applying liquid soap Using vigorous friction to produce a lather, wash the hands and wrists for a minimum of 15 seconds covering all surfaces, as per the WHO How to wash your hands and wrists process Rinse all areas of the hands thoroughly under running water, holding elbows higher than hands allowing water to flow from fingertips v) Dry hands and wrists thoroughly using a disposable paper towel vi) Turn off taps using elbow, if lever operated. Where lever or motion sensor taps are not available turn off taps with a clean paper towel vii) Carefully dispose of paper towel into a pedal operated waste bin Page 7 of 13

4.0 HYGIENIC HAND HYGIENE 4.1 Hygienic hand hygiene alcohol handrub An alcohol handrub, correctly applied to socially clean hands is an acceptable and very effective method of hand decontamination. The use of alcohol handrub on socially clean hands is now the preferred method of hygienic hand hygiene in most clinical situations. Alcohol handrub should be applied to socially clean hands as per the WHO Your 5 Moments for Hand Hygiene. Thorough hand washing with liquid soap and running water must always be undertaken before using alcohol handrub in the following situations:- When hands are soiled. Following direct hand contact with any body substance e.g. if gloves have not been worn. After contact with patients, or their immediate environment, with confirmed or suspected Clostridium Difficile Infection (CDI). Alcohol hand rub is not effective against CDI spores; these must be removed by the physical action of hand washing. After contact with patients, or their immediate environment, with confirmed or suspected of having Norovirus. Following the removal of latex gloves. Restricted use of latex gloves is advised. Please use Nitrile gloves routinely. N.B. Gloves do not replace the need to perform hand hygiene. 4.2 Method of application (alcohol handrub) In accordance with the Manufacturer s instructions, dispense the required amount of alcohol handrub and vigorously rub hands together for 30 seconds until dry, ensuring that all areas of the hands and wrists are covered as per the WHO How to handrub process. Alcohol handrubs are only effective when used on socially clean hands and when allowed to dry. Alternatively - antiseptic soap. A hand wash using an antiseptic detergent e.g. Hibiscrub/Hydrex, may be used as an alternative to the above method. Page 8 of 13

4.3 Technique for hygienic handwash An antiseptic detergent preparation and warm running water should be used i) Turn the water to a temperature comfortable to the hands ii) iii) iv) Wet both hands under running water before applying antiseptic detergent Using vigorous friction to produce a lather, wash the hands and wrists for a minimum of 15 seconds covering all surfaces, as per the WHO How to wash your hands and wrists process Rinse all areas of the hands thoroughly under running water, holding elbows higher than hands allowing water to flow from fingertips v) Dry hands and wrists thoroughly using a disposable paper towel vi) Turn off taps using elbow, if lever operated. Where lever or motion sensor taps are not available turn off taps with a clean paper towel vii) Carefully dispose of paper towel into a pedal operated waste bin The use of Alcohol Handrub on socially clean hands is the preferred method of Hygienic Hand hygiene Page 9 of 13

5.0 SURGICAL HAND HYGIENE Please note:- Surgical scrubbing / rubbing must be undertaken before donning sterile theatre garments All hand / wrist jewellery must be removed Surgical hand hygiene is intended to remove or destroy transient microorganisms and substantially reduce the numbers of detachable resident microorganisms and is achieved by using an antiseptic hand hygiene solution. Surgical hand decontamination is essential prior to all surgical procedures. Surgical Hand Hygiene may be achieved by: Washing with a liquid antiseptic soap Washing with a liquid non-antiseptic soap followed by application of alcohol hand rub 5.1 Technique for surgical hand hygiene antiseptic soap Staff should refer to Theatre protocols for surgical scrubbing for detailed technique. A three minute hand wash using a detergent based antiseptic preparation is recommended for the first operation on a list e.g. 4% chlorhexidine gluconate, 7.5% povidone iodine. Sterile brushes and nail picks should only be used for fingernails, and not skin, as their use is likely to increase the number of organisms on the skin surface. The hand wash must be systematic and cover all areas of the forearms, wrists and hands. After washing, rinse the forearms, wrists, and hands thoroughly and dry using a sterile disposable hand towel. Alternatively - technique for surgical hand hygiene using alcohol handrub (Softalind Pure (BBraun)) i) Wash hands with liquid soap for 1 minute. ii) iii) iv) Rinse hands carefully. Dry thoroughly with a sterile disposable towel. Dispense the alcohol hand rub into the dry hollow of your hand. v) Massage the alcohol hand rub into your skin in separate portions, for a period of no less than 90 seconds. If another product is being used, please refer to manufacturer s instructions with regard to time. vi) In the first stage, disinfect your hands and forearms, up to and including your elbows. Page 10 of 13

vii) Disinfect the lower half of your forearm and your hands. viii) Finally disinfect your hands by themselves. Your hands must stay wet throughout the whole time of application. Rub in the last portion until it dries. ix) Do not dry your hands or forearms again after you have carried out the disinfection procedure. 6.0 SKIN CARE It is extremely important that staff take steps to prevent damage to the skin on their hands. Staff should develop a good hand hygiene technique when performing hand decontamination. Hand products should be used in accordance with manufacturers' instructions. Hands can also be protected by applying a good quality emollient hand cream. Hand cream should be applied 2-3 times a day. In order that the hand cream is able to be absorbed by the skin it is recommended that hand cream be applied at times when no handwashing is likely to take place following application e.g. before going for breaks, before going off duty. Staff members developing skin irritation associated with hand hygiene should seek advice from the Occupational Health Department. 7.0 ANTABUSE (DISULFIRAM) Any member of staff who has been prescribed Antabuse (Disulfiram) must not use alcohol handrubs. Alternative hand hygiene products may require to be used. Staff should discuss this in strict confidence with the Occupational Health Service. 8.0 FACILITIES Every clinical area must provide appropriate hand washing facilities. This includes an adequate number of suitably positioned hand wash basins with warm water by means of either mixer taps or temperature controlled water. Access to hand wash basins must be free from obstacles which may impede access by staff. All hand wash basins must be stocked with liquid soap, paper towels and a pedal operated bin. Alcohol handrub must be widely available in all clinical areas and should be at or near to every bed in acute areas. Local risk assessments should be undertaken to determine how this is implemented in each clinical environment. Page 11 of 13

9.0 RISK ASSESSMENT As alcohol handrub is a flammable liquid and present an ingestion risk it is essential that a COSHH risk assessment is carried out prior to introduction in any clinical area. Local risk assessments should be carried out on the location and size of dispensers in use and on the storage and disposal of new and used stock, giving consideration to the likelihood of ingestion, especially in high risk wards and clinical units. It is recommended that alcohol handrub dispensers are not placed where they can be accessed by patients who may not appreciate the dangers associated with alcohol hand rubs or those who may willfully misuse them e.g. children, confused patients or have alcohol dependency. Patients in other areas who are potentially at risk should be assessed individually and, if necessary and practical, the risk of ingestion controlled, e.g. by close supervision or temporary removal of dispenser cartridges in the vicinity. Alternatives include the provision of personal dispensers for staff. 10.0 HAND HYGIENE FOR PATIENTS Hand hygiene facilities should be offered to patients Following the use of toilet facilities including bedpans and commodes before meals 11.0 HAND HYGIENE FOR VISITORS Visitors should be encouraged to wash their hands before and after visiting. This can be performed using liquid soap and running water. Alternatively alcohol handrubs may be used. Particular attention should be made when visiting patients in Isolation or patients with suspected or known CDI/Norovirus when a hand wash must be performed before and after visiting. Visitors should be advised against using the alcohol hand rub if they have damaged skin such as cuts, abrasions or other skin lesions on their hands. A risk assessment must be carried out where alcohol hand rub is provided at the entrance to the ward (See Section 9). Page 12 of 13

12.0 BIBLIOGRAPHY 1. LearnPro NHS online training modules Statutory and Mandatory Training last accessed 10/03/11 2. Health Protection Scotland (2009) Hand Hygiene Policy & Procedure Also available at http://www.hps.scot.nhs.uk/haiic/ic/guidelinedetail.aspx?id=31220 (last accessed 10/03/11) 3. Infection Control Nurses Association. (2002). Hand decontamination guidelines. ICNA c/o Fitwise, Bathgate UK. 4. Safety Action Notice (SAN(SC)05/34) 07 July 2005 Alcohol-based Handrubs: Risk of Ingestion http://www.show.scot.nhs.uk/shs/hazards_safety/sanpdf/san0534.pdf (last accessed 10/03/11) 5. Health Protection Scotland (2007) National Hand Hygiene Campaign Available at http://www.washyourhandsofthem.com/ (last accessed 10/03/11) 6. Fagernes, M., Lingaas, E. and Bjark, P. (2007) Impact of a single plain finger ring on the bacterial load on the hands of healthcare workers, Infection Control & Hospital Epidemiology, 28, 1191-5. 7. Gordin, F. M., Schultz, M. E., Huber, R., Zubairi, S., Stock, F. and Kariyil, J. (2007) A cluster of hemodialysis-related bacteremia linked to artificial fingernails, Infection Control and Hospital Epidemiology, 28, 743-4. 8. Sax, H., Allegranzi, B., Uckay, I., Larson, E., Boyce, J. and Pittet, D. (2007) 'My five moments for hand hygiene': a user-centred design approach to understand, train, monitor and report hand hygiene, Journal of Hospital Infection, 67, 9-21. 9. Siegel, J., Rhinehart, E., Jackson, M., Chiarello, L. and The Healthcare Infection Control Practices Advisory Committee (2007) Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007, June 2007. Available at http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/isolation2007.pdf (last accessed 10/03/11) 10. Stout, A., Ritchie, K. and Macpherson, K. (2007) Clinical effectiveness of alcohol-based products in increasing hand hygiene compliance and reducing infection rates: a systematic review, Journal of Hospital Infection, 66, 308-12. 11. Pratt, R. J., Pellowe, C. M., Wilson, J. A., Loveday, H. P., Harper, P. J., Jones, S. R., McDougall, C. and Wilcox, M. H. (2007) epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England, Journal of Hospital Infection, 65, S1-64. Page 13 of 13