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Hand Hygiene Policy

Document Reference:

Author:

Lisa Henderson

Version.Issue:

Version 3

Status:

Ratified
Approved by:

Infection Control Executive Committee
Version date:

July 2009
Review date:

July 2011
Hand Hygiene Policy V3 September 2009 ICE  Risk Committee approved
Review date September 2011
BCFH Trust
Page 1 of 17

BARNET AND CHASE FARM HOSPITALS NHS TRUST

Title of policy
Hand Hygiene Policy
Policy version number
Version 3
Status
Ratified
Policy author
Lisa Henderson
Policy consultees
Infection Control Team
Negotiated through

Accountable director
Terina Riches DON,DIPC
Approved by:
Infection Control Executive Committee
Ratified by
Risk Committee
Date of ratification and
15th September 2009
implementation:
Review date:
September 2011
Equality impact assessment
Yes – No impact
completed and impact
Document location
Intranet and Green Infection Control Folder
Distribution and dissemination
All staff via intranet, BCF News and IC
Operational Group meetings
Principal target audience
All Healthcare Staff
Responsibility for dissemination of
Ward/Department Leaders/ICT
policy to new staff
NHSLA/Healthcare

Commission/ALE impact

LITERATURE SEARCH AND EVALUATION

REVISION HISTORY
Version

Date

Summary of Changes
01
1998

02
2004

03
2009
Cleanyourhands campaign,
WHO 5 moments, audit
process, individual staff non
compliance process.

RATIFICATION HISTORY
Ratifying body

Date
of  Version
ratification
Risk Committee
15.9.09
V3
This policy has been ratified by Risk Committee.  Circumstances may arise or there
may be a change in guidance or legislation that requires the policy to be updated
between now and the review date. The responsibility to ensure the policy review
process is activated lies with the Infection Control Team.  All policies remain in force
until notification of an amended policy is circulated and posted on the Trust intranet.

MONITORING THE EFFECTIVENESS OF POLICY IMPLEMENTATION
Key Performance Indicators:  Weekly Hand Hygiene Audit programme

Date of Audit Report:
Quarterly report to IPPC

Location of Audit Report:    S Drive Cleanyourhands folder;
Hand Hygiene Policy V3 September 2009 ICE  Risk Committee approved
Review date September 2011
BCFH Trust
Page 2 of 17

HAND HYGIENE POLICY

KEY POLICY POINTS

Effective hand hygiene is the single most important measure in reducing the spread of
infection

All staff must comply with this policy

All staff working in or entering a clinical area MUST be 'bare below the elbow' to ensure an
effective hand hygiene technque

Hands must be decontaminated before and after every contact with a patient or their
immediate environment

Hands must be decontaminated between 'clean' and 'dirty' tasks on the same patient

Gloves are not a substitute for hand hygiene

All staff must challenge poor hand hygiene behaviour in other staff members

Hand Hygiene Policy V3 September 2009 ICE  Risk Committee approved
Review date: September 2011
BCFH Trust
Page 3 of 17

1
POLICY STATEMENT

1.1
Hand hygiene is the single most effective measure in reducing the spread of infection
including healthcare associated infection. Healthcare associated infection (HAI) is
estimated to cost the NHS in England £1 billion per annum with 5000 deaths directly
attributable. 1 in 9 patients acquire HAI. HAI results in increased length of stay and
further care and treatment is an adverse outcome for the patient.

1.2
There is extensive evidence that clearly demonstrates that contaminated hands
are responsible for transmitting infections. Effective hand decontamination has
been proved to significantly reduce infection rates, and compliance is crucially
important for all clinical staff and for all staff across the Trust.

2.
SCOPE

2.1
This policy sets out the standard for hand hygiene and decontamination for all
healthcare personnel, including Trust employees, contractors, students and
locum / agency staff.

2.2
This policy is one of the clinical care protocols required under the Hygiene Code
(2009) criterion 8a

3.
AIMS

This policy aims to ensure that:

  all staff are aware of the importance of effective hand hygiene in the
prevention of cross-infection
  all staff are aware of when and how to effectively decontaminate their hands
including which products to use
  all staff are aware that the point of care is the crucial moment for hand
hygiene

4.
RESPONSIBILITIES

The responsibility for infection control lies with all staff within the organisation.
Please refer to Infection Control Roles and Responsibilities Guidelines which is
available on the Intranet.

5.
DEFINITIONS

Infection prevention and control refers to policies, procedures and practice to
minimise the risk of spreading infection. This policy on hand hygiene sets out
Barnet and Chase Farm Hospitals Trust’s approach based on the current
evidence and best practice.

The term hand hygiene used in this policy refers to all of the processes, including
hand washing and hand decontamination achieved using other solutions, e.g.
alcohol based hand rub / gel
Hand Hygiene Policy V3 September 2009 ICE  Risk Committee approved
Review July September 2011
BCFH Trust
Page 4 of 17

6.
POLICY DEVELOPMENT

6.1
This policy was developed in partnership with

  Microbiologists
  Infection Control Nurses
  Cleanyourhands coordinators

6.2
Equality impact assessment

See page 13

7.
REQUIREMENTS FOR EFFECTIVE HAND HYGIENE

7.1
Preparation

  Nails must be short, clean and free from nail varnish or acrylic nails.
  All staff when entering or working in clinical areas must be ‘bare below the
elbow’ to facilitate an effective handwashing technique:
o  Remove all wrist and hand jewellery (apart from a plain wedding
band)
o  Wedding rings are the only acceptable jewellery to be worn on
duty.
o  Stoned rings, wrist watches and bracelets must not be worn as
these harbour dirt and moisture which provide an ideal environment
for bacterial growth, prevent thorough hand washing and may
traumatise the patient.
o  Sleeves must be rolled up to the elbow (remove jackets) or wear
short sleeves
o  Cuts and abrasions must be covered with waterproof dressing

7.2
Facilities

The Trust has a responsibility to provide optimum facilities and provisions for
hand hygiene, especially in clinical areas. If these facilities are found to be
inadequate the Estates or Facilities Department must be contacted in the first
instance.

All clinical areas must have:

  sinks with mixer or thermostatically controlled water supplied to elbow /
wrist taps.
  clear unobstructed access to all hand washing sinks
  hand washing sinks for that purpose only and clear of inappropriate items
  wall mounted liquid soap in a collapsible cartridge with a non-return valve
  wall mounted paper towels for hand drying
  hand washing posters should be placed by each sink
  alcohol hand gel must be available at the point of care
Hand Hygiene Policy V3 September 2009 ICE  Risk Committee approved
Review July September 2011
BCFH Trust
Page 5 of 17

The Infection Control Team (ICT) must be consulted before any new construction
or refurbishment work is planned to advise on sink type, number and placement
of hand washing facilities.

8
HANDWASHING TECHNIQUE

8.1
When

Hands must be decontaminated immediately before each and every episode of
patient care and after any activity or contact that potentially results in hands
becoming contaminated with micro-organisms.

Hands should be cleaned at a range of times, including on entering and leaving
any care environment however in order to prevent healthcare acquired infection
at the most fundamental times during care delivery and daily routines, the 'Your 5
moments for Hand Hygiene' should be followed (Adapted from World Health
Organisation)

.

.

It should also be noted that hand hygiene may have to be performed between
tasks on the same patient

The gloved hand

The use of gloves in addition to the process of hand washing gives added
protection, whereas the use of gloves as an alternative to hand washing may
lead to infection
Hand Hygiene Policy V3 September 2009 ICE  Risk Committee approved
Review July September 2011
BCFH Trust
Page 6 of 17


Hands should always be decontaminated before donning and after removing
gloves.

Gloves must be single-use and changed between patients and between 'dirty'
and clean procedures on the same patient.

Gloved hands must not be washed or cleaned with alcohol hand rubs, gels or
wipes

8.2
Which Product

There are three types of agent that can be used to remove microorganisms from
hands: soap, alcohol based hand gel and antimicrobial agents.

Soap - will mechanically remove transient microorganisms but has little effect on
resident microorganisms. However, hand washing with soap is usually all that is
necessary to prevent cross infection and protects staff and patients from
acquiring infection.

Antimicrobial Agents - are designed to remove transient and reduce resident
skin microorganisms. Chlorhexidine based preparations have been found to be
more effective than iodine-based solutions as they have a residual effect which
influences the survival times of many organisms on hand surfaces.
Antimicrobial agents should be used in situations when there is a need to reduce
resident microbial flora, e.g. in operating theatres or similar departments or
performing an invasive procedure e.g. central line placement

Alcohol-Based Hand Gels- can be applied quickly without access to water.
However they are not effective in removing soiling and should only be used if
hands are visibly clean.  Alcohol gels are not effective against C. difficile or
many viruses causing gastroenteritis. Washing with soap and water must be
used in these instances

8.3
How

A six-step hand washing technique was devised by Ayliffe et al. (1978), using
soap (or antiseptic solution/alcohol gel) and running water. Each step consists of
five strokes forward and five backward and should last a minimum of 15
seconds.



Hand Hygiene Policy V3 September 2009 ICE  Risk Committee approved
Review July September 2011
BCFH Trust
Page 7 of 17

Washing with soap and water

Hand Hygiene Policy V3 September 2009 ICE Risk Committee approved
Review July September 2011
BCFH Trust
Page 8 of 17

How to Apply Alcohol Gel Correctly

Surgical Scrub (also refer to local protocols)

This procedure must be carried out before all surgical procedures.
  Apply an antiseptic solution to wet hands,wrists and forearms.
  Wash for two minutes.
  A single use sterile nailbrush may be used only for the nails not on skin areas as
damage to the skin may result in increased levels of microorganisms.
  Dry hands with a sterile soft paper towel and dispose into a foot operated pedal
bin.

Hand Hygiene Policy V3 September 2009 ICE  Risk Committee approved
Review July September 2011
BCFH Trust
Page 9 of 17

9
Hand Care

Frequent use of antimicrobial and liquid soaps can cause skin damage to some
health care workers, with consequential increases in levels of bacteria on the
skin. The use of an appropriate handcream i.e. compatible with the handwashing
agent will help overcome some of these adverse effects. Compatible
handcreams should be provided in measured-dose pump dispensers.

Health care workers must consult the Occupational Health Department if they
experience any skin problems, which could be attributed to the handwashing
agent being used

10
ADHERENCE TO THE POLICY AND ASSOCIATED SANCTIONS

All staff working within the Trust must comply with this hand hygiene policy

The following will apply to staff members observed not complying with this policy:

  The member of staff will in the first instance be reminded of the hand
hygiene policy and the requirements for compliance.

  In the case of repeated non-compliance the staff member will be written to
formally regarding their behaviour. This letter should be copied to:

o  Their Line Manager
o  Their Clinical Director
o  Matron
o  The Medical Director
o  Director of Infection Prevention and Control

This letter will explain that should there be a further occurrence of non-
compliance they will be taken through the disciplinary procedure (Appendix 3)


11
EDUCATION

All healthcare workers must have induction and annual training in hand hygiene
as part of the Trust’s mandatory training programme.

Records of attendance for mandatory training will be kept by ward/department
managers who will follow up non-attendees.

Compliance with this requirement will be monitored by the Infection Control
Executive Committee (ICE)

Hand Hygiene Policy V3 September 2009 ICE  Risk Committee approved
Review July September 2011
BCFH Trust
Page 10 of 17

12
MONITORING COMPLIANCE

Compliance with the policy will be monitored through weekly ward/department
hand hygiene audits. These will be undertaken by healthcare workers from the
areas and submitted to the Cleanyourhands coordinators for collation and
analysis. (Appendix 1)

Responsibility for the weekly audit is as follows:

  Matrons – ensuring data is collected and submitted for their areas of
responsibility. Identifying learning and achieving improvement as appropriate.

  Ward/department manager – ensuring individuals are identified and trained to
undertake the audit on a weekly basis. Identifying learning and achieving
improvement as appropriate.

  Cleanyourhands coordinators – collating, analyzing and reporting data on a
weekly/monthly basis.

The Trust target for hand hygiene compliance is 100% across all areas. Warning
letters will be sent to wards and departments that fail to reach a month score of
80% (Appendix 2). Subsequent action plans will be presented to the Infection
Control Executive Committee by the Matron and Directorate General Manager.

Monthly analysis will be reported to the Infection Control Executive Committee
and the Trust Board via the DIPC report.

The weekly/monthly audit results will be reported to the Infection Control
Operational Meetings and the Matrons who will cascade the information to
individual wards/department managers who will be responsible for
communicating to staff within the area.

Independent validation audits will be carried out by the Cleanyourhands
coordinators every six months. These results will also be reported to the Infection
Control Executive Committee and subsequently the Trust Board.

9.
REFERENCES

Ayliffe, G.A.J., Lowbury, E.J.L., Geddes, A.M., Williams, J.D. (1992) Control of
Hospital Infection - A Practical Handbook 3rd Edition. London, Chapman and
Hall Medical

Infection Control Nurses Association. (1998) Guidelines for Hand Hygiene,
Deb/ICNA, Edinburgh.

NHS Estates (2002) Infection Control in the Built Environment – design and
briefing (2002). Also available on [email address]
Hand Hygiene Policy V3 September 2009 ICE  Risk Committee approved
Review July September 2011
BCFH Trust
Page 11 of 17

Pratt RJ, Pellowe CM, Wilson J A, Loveday HP, Harper PJ, Jones SRLJ,
McDougall C Wilcox MH, (2007) Epic 2 National Evidence based Guidelines for
Preventing Healthcare Associated Infections, Journal of Hospital Infection,
February Vol 65. Supplement 1

Winning Ways: Working together to reduce healthcare associated infections in
England, A Report from the Chief Medical Officer (2003)
http://www.dh.gov.uk/com.

www.npsa.nhs.uk/cleanyourhandscampaign

APPENDICES

Appendix 1: Hand Hygiene Audit Tool

Appendix 2: Directorate Hand Hygiene Warning Letter

Appendix 3: Individual Staff Warning Letter  - Non Compliance

Hand Hygiene Policy V3 September 2009 ICE  Risk Committee approved
Review July September 2011
BCFH Trust
Page 12 of 17

Equality Impact Assessment First Stage Screening Template

The EIA Panel recommends that the Equality Screening Template (below) ) is
used to consider if equality impact assessment is necessary.

To be completed and attached to any procedural document when submitted to the
appropriate committee for consideration and approval.

EQUALITY SCREENING TOOL

Yes/No
Comments
1.
Does the policy/guidance affect one group

less or more favourably than another on the
basis of:

No

Race

No

Ethnic  origins  (including  gypsies  and

travellers)

No

Nationality

No

Gender

No

Culture

No

Religion or belief

No

Sexual  orientation  including  lesbian,

gay and bisexual people

No

Age

No

Human Rights

No

Disability

2.
Is there any evidence that some groups are
No

affected differently?
3.
If you have identified potential
NA

discrimination, are any exceptions valid,
legal and/or justifiable?
4.
Is the impact of the policy/guidance likely to  NA

be negative?
5.
If so can the impact be avoided?
NA

6.
What alternatives are there to achieving the
NA

policy/guidance without the impact?
7.
Can we reduce the impact by taking
NA

different action?

Hand Hygiene Policy V3 September 2009 ICE  Risk Committee approved
Review July September 2011
BCFH Trust
Page 13 of 17

Appendix 1

BARNET & CHASE FARM NHS HOSPITALS TRUST
HAND HYGIENE AUDIT TOOL (revised April 2008)
Ward:....................................... BH/CFH

Date:...........................................Name:.................................

Opportunity
Nurses/HCAs
Doctors
Others (specify)

Before
After
Before
After
Before
After
contact  contact  contact  contact  contact  contact
Medium Risk
Leaving a Bay

Stripping a bed

Patient examination

Cleaning tasks

Observations (T,P,BP)

Bed bathing, washing

patients
Non-sterile procedure

e.g. O2, nebs
High Risk
After removal of gloves

Clean/Aseptic procedure

Dealing with body fluids

Bedpans/commodes

Tracheostomy care

Wound dressing

Phlebotomy/cannulation

Setting up IVI, giving

injections

Comments:

Hand Hygiene Policy V3 September 2009 ICE  Risk Committee approved
Review July September 2011
BCFH Trust
Page 14 of 17

Appendix 2

Trust Headquarters
Maple Block
Chase Farm Hospital
The Ridgeway
Enfield
Middlesex
EN2 8JL
Tel: 020 8375 2181
Email: [email address]

To Clinical Director
General Manager
Matron

Dear …………

Warning Notice

(Ward’s/Department) (Hospital) Hand Hygiene results for (month) were …%.  This is due to
……………………………….

The Infection Control Executive will be reviewing these results.

These  audits  assess  compliance  with  the  requirement  for  staff  to  decontaminate  hands
appropriately before and after patient contact.

A basic national standard of healthcare provision is to ensure a safe environment for patients,
staff and visitors, and this includes the prevention or minimisation of HCAI. This is now a legal
requirement of the Health and Social Care Act (2008).

Hand decontamination is the most important preventative measure for the control of healthcare
associated infections (HCAIs) and is part of good medical and nursing practice.

Compliance  with  these  legal  and  clinical  requirements  is  monitored  by  the  Healthcare
Commission. The audit data is available to the public and can be produced in court as evidence
of poor practice in medico-legal cases involving HCAIs.

As you know infection prevention and control is one of the core corporate priorities of the Trust.
Corporate action will be taken to improve departments that have persistently unacceptable audit
results.

Hand Hygiene Policy V3 September 2009 ICE  Risk Committee approved
Review July September 2011
BCFH Trust
Page 15 of 17

You are required to investigate the reasons for failure of your staff to decontaminate their hands
appropriately and to provide Lisa Henderson (DDIPC) with a copy of an action plan to remedy
the problem within seven days and give an update of the improved performance at the Hospital
Infection and Prevention Control Committee on (date).  You must achieve 100% compliance in
the next month’s hand hygiene audit.

Please contact the infection control team if you need any help or advice.
.



Richard Harrison

Terina Riches

Medical Director

Director of Infection Prevention & Control

cc:

Lisa Henderson
Deputy D.I.P.C.

Hand Hygiene Policy V3 September 2009 ICE  Risk Committee approved
Review July September 2011
BCFH Trust
Page 16 of 17

Appendix 3

Individual Staff warning letter non compliance

Ward/Department

Hospital

Date

Dear ……….

Following our conversation, I am writing to confirm that you were observed failing to
follow the Trust hand hygiene policy. As you know this has also been discussed with
you previously.

I am therefore, by copy of this letter, alerting the Director of Nursing and Infection
Prevention and Control.

I must also tell you that failure to comply again could lead to disciplinary action being
taken.

Yours sincerely

cc:
Director of Nursing/DIPC and Clinical Director

And /or



Medical Director (for medical staff)

Head of Department (for Therapies/ Allied Health Professionals)

Hand Hygiene Policy V3 September 2009 ICE  Risk Committee approved
Review July September 2011
BCFH Trust
Page 17 of 17