SECTION: 18 INFECTION CONTROL POLICY AND PROCEDURE: 18.04 NATURE AND SCOPE: SUBJECT: POLICY & PROCEDURE TRUSTWIDE HAND HYGIENE This policy/procedure outlines recommendations concerning hand hygiene practices employed to reduce the risk of infection to patients, carers, volunteers, staff, contractors and visitors. The principles are underpinned by recent National evidence-based guidelines for preventing Healthcare Associated Infections. In Forensic areas individual alcohol gel dispensers carried by staff members should not be used. DATE OF LATEST RATIFICATION: JUNE 2014 RATIFIED BY: TRUSTWIDE INFECTION CONTROL COMMITTEE IMPLEMENTATION DATE: JULY 2014 REVIEW DATE: JUNE 2017 ASSOCIATED TRUST POLICIES AND PROCEDURES: Health, Safety & Welfare 16.01 Meticillin-Resistant Staphylococcus Aureus (MRSA) 18.07 Dress Code & Staff Identification Badge 11.04 ISSUE 6 JULY 2014
NOTTINGHAMSHIRE HEALTHCARE NHS TRUST HAND HYGIENE POLICY AND PROCEDURE CONTENTS 1.0 Policy Statement 2.0 Introduction 3.0 Aim of Policy and Procedure 4.0 Duties 5.0 Hand Hygiene 5.1 Micro-Organisms 5.2 Routine Hand Hygiene 5.3 Aseptic Hand Hygiene 5.4 Pre Surgical Hand Hygiene 5.5 Indications 6.0 Hand Hygiene Products 7.0 Bare Below the Elbows 8.0 Domiciliary Visits 9.0 Training 9.3 Forensic & Local Services Division 9.4 Health Partnerships Division 10.0 Target Audience 11.0 Service User Involvement 12.0 Consultation 13.0 Legislation Compliance 14.0 Review Date 15.0 Implementation 16.0 Relevant Trust Policies 17.0 Monitoring Compliance 17.1 Forensic & Local Services Division 17.2 Health Partnerships Division 18.0 Equality Impact Assessment 19.0 Champion and Expert Writer 20.0 Source Documents Appendix 1a NPSA your 5 moments hand hygiene at the point of care (bed) Appendix 1b NPSA your 5 moments hand hygiene at the point of care (chair) Appendix 2 NPSA Hand cleaning techniques Appendix 3 Religious Considerations Appendix 4 Record of Changes Appendix 5 Employee Record of Having Read the Policy ISSUE 6 JULY 2014 2
1.0 POLICY STATEMENT NOTTINGHAMSHIRE HEALTHCARE NHS TRUST HAND HYGIENE POLICY AND PROCEDURE 1.1 Nottinghamshire Healthcare NHS Trust (NHCT) recognises its duty of ensuring an effective system is in place to prevent and control healthcare associated infections (HCAI s). The business of the Trust will be conducted in such a way as to ensure those patients, carers, volunteers, staff, contractors, visitors and members of the public, who may be affected by the activities of the Trust, are not exposed to avoidable risk. 1.2 The Trust also accepts that in order to prevent and control HCAIs, there will be funding implications, which will need resourcing. 1.3 The Trust recognises that successful risk management is brought about through good management and effective communication with staff. The Trust considers that high quality management processes will greatly assist in preventing and controlling HCAI s 2.0 INTRODUCTION 2.1 Under the terms of The Health and Social Care Act 2008 (DH 2010) NHCT has a duty to ensure that the risk of healthcare associated infection (HCAI) is kept as low as possible. The National Patient Safety Agency (NPSA) recognises that improving the hand hygiene of healthcare staff at the point of patient care will reduce the risk of HCAI. Not all infections are preventable but evidence shows that improving hand hygiene contributes significantly to the reduction of HCAI (NPSA 08) 2.2 The importance of Hand Hygiene is reinforced in The Winning Ways report which states that hand washing by healthcare staff is vitally important in the control of infection and that each clinical team should demonstrate consistently high levels of compliance with hand washing and hand disinfection protocols. (DH 2003) 2.3 This policy has been written for all healthcare staff within NHCT in order to: Promote the optimal techniques for decontaminating hands. Help staff to understand the precise moments when they need to clean their hands and why Protect patients and staff from cross infection and therefore reduce incidents of HCAI 3.0 AIM OF THE POLICY AND PROCEDURE 3.1 The aim of this policy and procedure is to ensure that recommendations concerning hand hygiene practices are employed to reduce the risk of infection to patients, carers, volunteers, staff, contractors and visitors. The principles are underpinned by recent National evidencebased guidelines for preventing HCAI s. 4.0 DUTIES 4.1 The Trust has a responsibility to provide adequate and appropriate hand hygiene facilities and products. This extends to ensuring that this is included in all new builds and refurbishments. 4.2 It is the responsibility of each employee of the Trust to maintain the highest standard of hand hygiene by continually challenging their own and their colleagues hand hygiene practice. 4.3 All of the professional regulatory bodies include, as part of their core standards, a requirement for individual practitioners to be aware that there is a potential risk to patients and to take all necessary steps to ensure that their practice is such that it minimizes or removes risk. ISSUE 6 JULY 2014 3
4.4 It is the responsibility of those staff in managerial and leadership positions, in conjunction with local Infection Prevention and Control Teams, to teach and promote good hand hygiene practice. 4.5 It is the responsibility of all staff to promote and maintain good hygiene practice. 5.0 HAND HYGIENE 5.1 Micro-Organisms 5.1.1 Micro-organisms on the skin can be classified into two groups resident and transient. Resident micro-organisms are part of the normal human flora and live deep-seated within the epidermis. They protect the skin from invasion by more harmful organisms. They do not easily cause infections and are not easily removed. Transient micro-organisms are located on the surface of the skin. They are described as transient because they are easily transferred to other people, equipment and the environment, via the hands following direct contact. They have the potential to cause infections and can be easily removed or destroyed by good hand hygiene techniques. 5.2 Routine Hand Hygiene This is achieved using liquid soap and running water following the NPSA hand washing technique (Refer to Appendix 2). This method is sufficient to remove visible dirt and most transient micro-organisms. Visibly clean hands can be decontaminated with an application of alcohol hand rub following the NPSA recommended technique (Refer to appendix 2) 5.3 Aseptic Hand Hygiene This should be carried out prior to undertaking any procedure requiring an aseptic technique. It is achieved by washing with soap and water prior to preparation of equipment, following the NPSA recommended technique (refer to appendix 2) Subsequent hand decontamination, during the procedure, can then be achieved by the application of alcohol hand rub, using the NPSA recommended technique (refer to appendix 2) 5.4 Pre Surgical Hand Hygiene Surgical hand washing is intended to remove or destroy transient micro-organisms and to significantly reduce the level of detachable resident micro-organisms. It is essential to the maintenance of asepsis within the theatre environment. It is achieved by using an antimicrobial solution, which should be applied for two minutes using the hand hygiene technique included in this policy and should also include washing and rinsing up to the elbows. A sterile, disposable nail brush can be used for the first surgical hand wash of the day, but it is not advisable to use on consecutive hand washes as damage to the skin may occur, leading to an increased likelihood of microbial colonisation. A sterile towel should be used for drying. 5.5 Indications All healthcare staff have an individual responsibility to assess the need for hand hygiene in their daily practice. The point of care refers to the patient s immediate environment in which staff to patient contact or treatment is taking place (NPSA 2008) ISSUE 6 JULY 2014 4
There are 5 recognised crucial points of care for hand hygiene, representing the time and place at which there is the highest likelihood of transmission of infection via the hands of healthcare staff (World Health Organisation 2006). o o o o o Before patient contact Before an aseptic task After body fluid exposure risk After patient contact After contact with patient surroundings Refer to Appendices 1a and 1b for a detailed rationale of the 5 Moments 6.0 HAND HYGIENE PRODUCTS 6.1 All clinical environments should provide adequate hand hygiene facilities, with designated hand washbasins, as well as liquid soap, paper towels, alcohol hand rub and hand cream. 6.2 Alcohol handrub, where available, should be used before and after every patient contact when hands are visibly clean 6.3 It must be remembered that alcohol-based products are flammable, and care must be taken when storing reserve stock, and if planning to install the hand rub into new areas. (see NHS Estates alert NHSE (2005) 07 16 TH June 2005 Gateway Ref:5084). 6.4 Wall mounted dispensers should be used in patient areas, and then only where patients are not left unattended, because of the risk of patients ingesting the alcohol gel. There is also less risk of the container becoming contaminated due to handling if it is wall mounted. 6.5 Within Forensic Services, personal pocket sized bottles of gel with clips or elastic straps to attach to clothing or a belt should not be used. The straps are potential ligatures, and again patients may ingest the gel. 6.6 The NPSA recommend that alcohol hand gel should be used in the patients immediate care zone, this is often referred to as the point of care. In most cases this will be achieved by staff using individual dispensers or wall dispensers fitted in ward areas. The use of individual or wall dispensers should be subject to risk assessment and in Forensic areas individual dispensers should not be used. 6.7 When decontaminating hands using alcohol gel, hands should be free of visible dirt and organic material. The gel must come into contact with all surfaces of the hand. The hands must be rubbed together vigorously, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers until the solution has evaporated and dried. The gel must be applied following the NPSA recommended technique. (Appendix 2) 6.8 Alcohol hand rub is not recommended for use when patients are known to have Clostridium difficile, Norovirus, experiencing diarrhoea and/or vomiting or in the event of a known enteric outbreak. 6.9 Wet surfaces transfer micro-organisms more effectively than dry ones. Consequently hand drying is important and must be done thoroughly using good quality paper hand towels, which should be positioned within easy reach of the sink but beyond splash contamination. 6.10 Staff are encouraged to apply an emollient hand cream regularly to protect skin from the drying effect of regular hand decontamination. Staff should only use the products available in clinical areas as these have been specifically designed not to interact with soaps and alcohol gel. If a particular soap, antimicrobial hand wash, or hand product causes skin irritation or exacerbates an existing skin condition, staff should seek advice from the Occupational Health Service. ISSUE 6 JULY 2014 5
6.11 Advice from Muslim Spiritual Care Provision (MSCP) in the NHS is that use of hand disinfection gels containing synthetic alcohol does not fall within the Muslim prohibition against natural alcohol (from fermented fruit or grain). For more information see Appendix 3. 7.0 BARE BELOW THE ELBOWS 7.1 NHCT endorses the Bare Below the Elbows initiative for all staff working within a clinical area (Refer to Dress Code Policy 11.04) A clinical area is defined as any setting where healthcare professionals have contact with patients/service users. 7.2 Staff must have short sleeves or rolled up long sleeves. The exception to this is Muslim female staff who for religious reasons are permitted to wear disposable over-sleeves, elasticated at the elbow and wrist. These must be put on and discarded in exactly the same way as disposable gloves and strict procedures for washing hands and wrists must still be observed. For more information see Appendix 3. 7.3 No hand or wrist jewelry other than a plain wedding band should be worn. No bangles or woven cloth wrist bands (with the exception of the Sikh Kira a single metal or plastic bangle) should be worn. 7.4 Ties and badge lanyards should be removed or tucked into clothing. 7.5 Nails should be clean, short and free from polish. False nails, nail varnish and nail adornments must not be worn when undertaking physical healthcare interventions as these pose a risk of cross infection. The hand hygiene technique will be compromised by failing to adhere to this initiative. 8.0 DOMICILIARY VISITS 8.1 This policy acknowledges the fact that some facilities outside of NHCT premises, e.g. a patient s home, may not be conducive to effective hand hygiene practice. All staff on domiciliary visits should be supplied with liquid soap, paper towels, alcohol hand rub & hand cream. Where a practitioner assesses that hand washing facilities are inadequate, e. g in a patient s home, then hands should be decontaminated using alcohol hand rub only. If required, the practitioner should then decontaminate their hands using soap and water as soon as adequate facilities can be accessed.. 9.0 TRAINING 9.1 In order to effectively prevent and control infection the Trust will give high priority to ensuring that the level of information which is provided to staff is appropriate to the roles and responsibilities of the post in which they are employed. The Trust is committed to make available resources to support the training requirements of all employees in the prevention and control of infection. 9.2 The Directorates within Local Services, Forensic Services and the Health Partnership (HP) Division are responsible for developing a Training Needs Analysis structure which will be refreshed annually 9.3 The following sections apply to Local Services and Forensic Services Divisions only: 9.3.1 Glow and Tel Machines are available in all areas to support training and development initiatives. 9.3.2 Ongoing Hand Hygiene Training Techniques will be delivered by the relevant Line Manager, who will also ensure monitoring of performance through supervisory appraisal processes. ISSUE 6 JULY 2014 6
ISSUE 6 JULY 2014 7 Hand Hygiene 18.04 9.3.3 Hand hygiene is an integral part of all Infection Prevention and Control training, including induction. The relevant Line Manager will ensure all their staff receive a regular update in hand hygiene, and follow up non-attendees. 9.3.4 The minimum mandatory requirement for hand hygiene update training is every 3 years for clinical staff only. Additional training may be accessed if required or requested by staff 9.3.5 The relevant Line Manager will maintain staff records of annual hand hygiene training, and forward these to the central Trust training records department 9.3.6 The Infection Prevention and Control Teams will provide hand hygiene Train the Trainer training to ensure that all areas can comply with training needs in each local area. 9.4 The following Sections apply to Health Partnership Division staff only 9.4.1 All members of staff have an individual responsibility to ensure that they access mandatory training. 9.4.2 Hand Hygiene is included in the Induction training programme for all staff; this ensures compliance with the National Health Service Litigation Authority requirements. 9.4.3 The minimum mandatory requirement for hand hygiene update training is every 3 years for clinical staff only. Additional training may be accessed if required or requested by staff 9.4.4 Hand hygiene is an integral part of all Infection Prevention and Control training. The relevant Line Manager should ensure that staff attend mandatory training, according to their role and follow up any non-attendees 9.4.5 Glow and Tell machines, which are used to demonstrate the effectiveness of hand hygiene techniques, are available for loan from the IPC team, for the use of staff who wish to carry out hand hygiene training within their own teams/departments. 10.0 TARGET AUDIENCE 10.1 The target audience for this policy is all employees of the Trust and Involvement Volunteers. 11.0 SERVICE USER INVOLVEMENT 11.1 In order to comply with the Health and Social Care Act 2008(DH 2010) healthcare workers should encourage the involvement of patients and the public in Infection Prevention and Control. Hand Hygiene notices and posters should be displayed in areas that are visible to patients and hand hygiene information leaflets should be made available to all patients and visitors to healthcare facilities 11.2 Facilities should be made available in all NHCT environments for patients and visitors to carry out relevant hand hygiene. Patients should be encouraged and, where necessary, assisted to carry out hand hygiene 11.3 In line with the Cleanyourhands Campaign patients are encouraged to ask staff if they have cleaned their hands prior to any clinical contact. NHCT and the Infection Prevention and Control Team will support all patients in challenging poor practice in relation to hand hygiene. 12.0 CONSULTATION 12.1 Trust wide Infection Prevention and Control Committee 12.2 Executive Leadership Council (ELC)
12.3 Equality and Diversity Steering Group 13.0 LEGISLATION COMPLIANCE 13.1 This policy has been considered in the context of the following legislation and evidence based guidance: Health and Social Care Act 2008 (Revised Edition 2010) The Health & Safety at Work etc Act 1974 The Food Standards Act 1999 Department of Health Getting Ahead of the Curve A strategy for combating infectious diseases. (DOH 02) Department of Health Winning Ways working together to reduce health association infection in England. (DOH 03) World Health Organisation 5 moments of hand hygiene (2006) National Patient Safety Agency 5 moments of hand hygiene (2006) Department of Health 2007 Essential Steps to safe, clean care Department of Health 2010 Uniforms and Workwear Equality Act 2010 Epic3:National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England (2013) 14.0 REVIEW DATE 14.1 This policy will be reviewed in 3 years or in light of organisational or legislative changes. 15.0 IMPLEMENTATION 15.1 Responsibility for assessing the implications of this policy for staff rests with the manager responsible for each individual or group of staff, for example Teams. They will be required to identify and carry out such preparation as is necessary to confirm that staff understand the expectations on them and that they are both competent and confidant to discharge these. 16.0 RELEVANT TRUST POLICIES Meticillin-Resistant Staphylococcus Aureus (MRSA) 18.07 Management of Clostridium Difficile Infection 18.13 Outbreak of Infection Procedure 18.03 Prevention & Control of Infections Standard Precautions 18.12 Health, Safety & Welfare 16.01 Dress Code & Staff Identification Badge 11.04 17.0 MONITORING COMPLIANCE 17.1 The following section applies to Local Services & Forensic Services only 17.1.1 Infection Prevention and Control Teams will undertake quarterly random compliance audits to report to the Trust Wide Infection Prevention and Control Committee. 17.1.2 The General Managers are responsible for their division s compliance with the policy and ensuring that hand hygiene training is delivered. Working with their local governance processes they will develop action plans as necessary and monitor the implications of these. 17.1.3 Records of personnel trained by other staff members to be kept centrally by the local areas and the Learning and Development Department. 17.1.4 Monthly training statistics are sent to the Executive Directors for Forensic and Local Services Divisions who will review the results and take action as necessary. ISSUE 6 JULY 2014 8
17.1.5 All General Managers and Heads of Service must have constant and immediate access to the training database and can see who requires training and up-dating. 17.1.6 In the event of persistent non attendance / non completion, General Manager and / Heads of Service will be informed in order to take this through local management performance routes. 17.2 The following section applies to Health Partnerships Staff only 17.2.1 Compliance with this policy will be monitored by the IPC team as part of the IPC audit programme and will include observations of hand hygiene practice and audit of hand hygiene facilities within HP environments. 17.2.2 Staff should self-audit hand hygiene compliance using the Essential Steps assessment tool (DH 2007) 17.2.3 All audit results and action plans should be forwarded to the IPC Group via Heads of Service. 17.2.4 Frequency of audit/ monitoring should be variable, according to the results and on advice from the IPC Team 18.0 EQUALITY IMPACT ASSESSMENT 18.1 Following the Equality Impact Assessment (EIA) screening exercise it has been concluded that a Full EIA is not needed. The purpose of this policy is to ensure that an effective system is in place to prevent and control healthcare associated infections, thereby ensuring that all individuals who come into contact with the Trust are not exposed to avoidable risk. Accordingly this policy is to the benefit of all of the diverse communities which the Trust serves. Furthermore, specific provision has been made within the policy to ensure that the religious needs of female Muslim employees are identified and met in relation to the Bare Below the Elbows requirement, thereby ensuring that the dignity and respect of individuals is maintained at all times. 19.0 CHAMPION AND EXPERT WRITERS 19.1 The champion for this policy is Dean Howells, Executive Director for Nursing and Allied Health Professionals. The expert writers are Sheila Smith Infection Prevention and Control Nurse Specialist Health Partnerships, Diane Churchill Hogg Infection Prevention & Control Nurse Specialist Health Partnerships 20.0 SOURCE DOCUMENTS Pittet D. Boyce J M. (2001). Hand hygiene and patient care: pursuing the Semmelweis legacy. The Lancet, Infectious Diseases April 2001. Emmerson AM. Enstone J.E. Griffin (1996). The Second National Prevalence Survey of Infection in Hospitals. Journal of Hospital Infection 32, 3, 175-190. Ayliffe G A J. Babb J R. Taylor L J. (2001). Hospital Acquired Infection Principles and Prevention. Third Edition, Butterworth Heinemann Infection Control Nurses Association. (1999). Guidelines for Hand Hygiene. ICNA Bathgate. Plowman, R. Graves, N. Griffin, MA. Roberts, JA. Swan,AV. Cookson,B and Taylor, L. (2001) The rate and cost of hospital-acquired infections occurring in patients admitted to select specialties of a district general hospital in England and the national burden imposed. Journal of Hospital Infection. 47(3):198-209 ISSUE 6 JULY 2014 9
Loveday H.P.Wilson J.A. Pratt R.J. Golsorkhi M. Tingle A. Bak A. Browne J. Prieto J. Wilcox M. epic3: National Evidence Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals. Journal of Hospital Infection 86S1 (2014) S1-S70. Pritchard V. Hathaway C. (1988). Patient Hand-washing Practice. Nursing Times, September 7 Vol. 84, No. 36, pages 68-72. Damani N. (1997). Manual of Infection Control Procedures. Greenwich Medical Media ltd. London. National Patient Safety Agency. (2008). Clean Hands Save Lives Patient Safety Alert. Second Edition. September 2008 Boyce, J M, Pittet, D. (2002). Guidelines for Hand Hygiene in Healthcare Settings. Recommendations of the Healthcare Infection Control Practice Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hygiene Task Force ISSUE 6 JULY 2014 10
APPENDIX 1a ISSUE 6 JULY 2014 11
APPENDIX 1b ISSUE 6 JULY 2014 12
APPENDIX 2 ISSUE 6 JULY 2014 13
APPENDIX 3 ADVICE FORM MUSLIM SPIRITUAL CARE PROVISION (MSCP) IN THE NHS. Extract from:- Uniforms and Workwear: Guidance on Uniform and Workwear Policies for NHS Employers (Department of Health, 2010) Bare Below the Elbows Exposure of the forearms is not acceptable to some staff because of their Islamic faith. In response to these and other concerns, the MSCP convened a group including Islamic scholars and chaplains and multi-faith representatives as well as Department of Health policy-makers and external experts in infection prevention. Based on these group discussions, the MSCP prepared list of recommendations to ensure that local dress code policies are sensitive to the obligations of Muslims and other faith groups whilst maintaining equivalent standards of hygiene. Incorporating any of these recommendations into trust policy will have to be agreed in conjunction with clinical managers and the local infection prevention and control team: Uniforms may include provision for sleeves that can be full length when staff are not engaged in direct patient care activity. Uniforms can have three-quarter length sleeves. Any full or three-quarter length sleeves must not be loose or dangling. They must be able to be rolled or pulled back and kept securely in place during hand-washing and direct patient care activity. Disposable over-sleeves, 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. Hand Disinfection Gels Use of hand disinfection gels containing synthetic alcohol does not fall within the Muslim prohibition against natural alcohol (from fermented fruit or grain). ISSUE 6 JULY 2014 14
APPENDIX 4 POLICY/PROCEDURE FOR: HAND HYGIENE Issue: 06 Status: Author Name and Title: APPROVED Sheila Smith Infection Prevention and Control Nurse Specialist Health Partnerships Division, Diane Churchill Hogg Infection Prevention & Control Nurse Specialist Health Partnerships Division Issue Date: JULY 2014 Review Date: JUNE 2017 Approved by: Distribution/Access: TRUSTWIDE INFECTION CONTROL COMMITTEE Normal DATE AUTHOR POLICY/ PROCEDURE RECORD OF CHANGES DETAILS OF CHANGE 03/06 S Marshall HS/GS/06 HS/GS/06 & HS/GS/07 merged into one document. 10/06 S Marshall HS/GS/06 Changes to reflect requirements from NHSLA standards. 05.08 S Marshall HS/GS/6 Changes to reflect requirements from NHSLA standards. 11/11 01/14 N Murphy/ S Smith / P Strazds S Smith/ D Churchill- Hogg 18.04 18.04 (Issue 6) Changes throughout to reflect requirements Department of Health and National Patient Safety Agency and CHP division Minor amendments to reflect Organisational changes and mandatory training requirements Addition of information for Religious considerations ISSUE 6 JULY 2014 15
APPENDIX 5 EMPLOYEE RECORD OF HAVING READ THE POLICY/PROCEDURE TITLE OF POLICY/PROCEDURE: HAND HYGIENE I have read and understood the principles contained in the named policy/procedure. PRINT FULL NAME SIGNATURE DATE ISSUE 6 JULY 2014 16