Hand hygiene policy

HAND HYGIENE POLICY

(EFFECTIVE HAND
DECONTAMINATION)

Barking Havering & Redbridge Hospitals NHS Trust aims to design and implement
services, policies and measures that meet the diverse needs of our service,
population and workforce, ensuring that none are placed at a disadvantage over
others.

Policy No: 2009/PC/28
        Infection Control Committee
Review Frequency:  3 Yearly
THIS POLICY IS VERSION 3
      Chair’s approval – June 2009
Next review due: June 2012
Responsible Officer: Director of Infection Prevention & Control
Advice: Head of Infection Prevention & Control
Core Infection Control Policy: Yes
Applicable to Clinical and Non-Clinical Areas: Yes

CONTENTS


Page
1.0
EXECUTIVE SUMMARY ……………………………………………
4
2.0
SCOPE OF POLICY …………………………………………………
4
3.0 BACKGROUND
……………………………………………………...  4
4.0 BEHAVIOUR.
…………………………………………………………  4
5.0 RESPONSIBILITIES
…………………………………………………  5

5.1
The Chief Executive and Trust Board………………………
5

5.2
Director of Infection Prevention & Control …………………
5
5.3
Matrons………………………………………………………..
5

5.4
Senior Sisters/Departmental Managers……………………
5

5.5
Director of Education…………………………………………
6

5.6
Head of Prevention & Infection Control……………………
6

5.7
Infection Prevention & Control Team ………………………
6
5.8
Purchasing
Team.
……………………………………………
6

5.9
Fire, Health & Safety Adviser. ………………………………
6

5.10  All Clinical Staff……………………………………………….
6

5.11  All Trust Staff …………………………………………………
7
6.0
THE EXPECTED STANDARD……………………………………
7
7.0
TYPES OF HAND DECONTAMINATION …………………………
7
8.0
GUIDANCE ON WHEN HANDS MUST BE
7
DECONTAMINATED…………………………………………………
9.0 RISK
ASSESSMENT……………………………………………….  8
10.0
HANDWASHING TECHNIQUE. ……………………………………
9/10
11.0
ALCOHOL HAND RUB TECHNIQUE. ……………………………
10
12.0
HAND CARE …………………………………………………………
11
13.0 FACILITIES………………………………………………………….
11

13.1  Hand Wash Basins…………………………………………..
11

13.2  Alcohol Hand Rub (Placement). ……………………………
12
Barking, Havering & Redbridge Hospitals NHS Trust
2
Hand Hygiene Policy (Policy on Effective Hand Decontamination) / June 2009/IC/

14.0 HAND
WASHING
AGENTS.
12

14.1  Soap and Water ………………………………………………
12

14.2  Alcohol Hand Rub. ……………………………………………
12

14.3  Antiseptic Agent ………………………………………………
12
14.4
Approved
Agents……………………………………………..
13
15.0
HAND CREAM. ………………………………………………………
13
16.0 SKIN
LESIONS
………………………………………………………  13
17.0 POLICY
DEVELOPMENT.
…………………………………………  13
18.0
APPROVAL PROCESS. ……………………………………………
14
19.0
DISTRIBUTION AND TRAINING PLAN…………………………
14
20.0
AUDIT AND REVIEW PLAN. ………………………………………
14
21.0 AMENDMENTS
………………………………………………………  14
22.0 REFERENCES.
………………………………………………………  15
23.0 GLOSSARY………………………………………………………….
15
24.0
EQUALITY IMPACT ASSESSMENT……………………………..
16

Barking, Havering & Redbridge Hospitals NHS Trust
3
Hand Hygiene Policy (Policy on Effective Hand Decontamination) / June 2009/IC/

1.0 EXECUTIVE
SUMMARY

Barking, Havering & Redbridge Hospitals NHS Trust places the utmost importance
on minimising the risks to patients and staff from poor infection control practices.
The aim of this policy on hand hygiene is to prevent cross-infection by removing
transient organisms from hands, or reducing them to a level where they no longer
pose a threat to the next person.

The document provides clear guidance on the various methods available to
decontaminate hands, stressing the importance of following the guidance when
entering and leaving all clinical areas. It clearly identifies where responsibilities lie
emphasising that clinical staff play the principal role in reducing cross-infection and
the numbers of health care associated infections occurring in this Trust.

2.0
SCOPE OF POLICY

All hospital staff and visitors MUST decontaminate their hands on entering and
leaving a clinical area within the hospital setting. This policy describes the guidance
on when and how hands must be decontaminated.

3.0 BACKGROUND

In 2003, the Chief Medical Officer published an ‘Infectious Disease Strategy’
highlighting the need for intensified control measures to control infectious diseases,
an areas which had had a relatively low profile until then. In subsequent years there
have been many documents from the Department of Health on related infection
control topics such as decontamination of medical devices, MRSA, surveillance
schemes and the spread of anti-microbial resistance. In parallel, the National Audit
Office also published a report on The Management and Control of Hospital Acquired
Infections in Acute Trusts in England (2000) which highlighted the importance and
cost of such infections to patients and the NHS as a whole.

From April 2009, certain NHS organisations will be legally required to register with
the Care Quality Commission under the Health and Social Care Act 2008 and, as a
legal requirement of their registration, must protect patients, workers and others who
may be at risk of acquiring HCAI.

People’s hands are the most common way in which microorganisms, particularly
bacteria, might be transported and cause infection, especially to those who are most
susceptible to infection. In order to prevent the spread of micro-organisms to those
who might develop serious infections through this route while receiving care, hand
hygiene must be performed adequately and consistently. The evidence shows
clearly that hand hygiene remains the SINGLE MOST IMPORTANT AND
ECONOMICAL  MEANS OF PREVENTING AND CONTROLLING THE SPREAD
OF INFECTIONS (‘Pratt R J, Pell owe C, 2001’).

4.0 BEHAVIOUR

All staff must consider the hand hygiene procedure being undertaken, they should
think about the actual hazards that have, or might be encountered; the subsequent
Barking, Havering & Redbridge Hospitals NHS Trust
4
Hand Hygiene Policy (Policy on Effective Hand Decontamination) / June 2009/IC/

potential and/or actual contamination of hands; and the risks that may present as a
result. The nature of the clinician / patient interaction will often determine this.

Staff must however, always be aware that every person they encounter could be
carrying potentially harmful micro-organisms that could be transmitted and cause
harm to others. For this reason, hand hygiene is one precaution that must be
applied as standard. We all have a responsibility to prevent and control infections
but the responsibility to decontaminate your hands effectively lies with the individual.

All clinical areas should have sufficient hand washbasins to enable hand washing
with water and soap. In the absence of such, the alcohol hand rub can be used as
long as hands are socially clean. Alcohol hand rub is not a substitute for routine
hand decontamination / hygiene. More significant methods of hand hygiene are
described in the policy.

5.0 RESPONSIBILITIES

5.1   The  Chief  Executive, as Accountable Officer, and Trust Board members
have overall responsibility for the safety of patients and staff. That
responsibility extends to ensuring infection control procedures are robust and
are effective for minimising the spread of transient organisms and the
acquisition of healthcare associated infections. The Trust Board has
responsibility for monitoring infection control data and ensuring reporting
requirements are met and any actions to address shortfalls, are implemented.

5.2
The  Director of Infection Prevention and Control (DIPC) within BHRT is
the Medical Director. Their role is to oversee local control of infection policies
and their implementation, the organisation and management of the Infection
Prevention & Control Team and to provide a direct reporting line to the Chief
Executive and the Trust Board on all infection control issues.

The DIPC, and Infection Prevention & Control Team, have the authority to
challenge inappropriate clinical hygiene practice and antibiotic prescribing.
They will assess the impact of all existing and new policies and plans on
infection within the Trust and make recommendations for change. The DIPC
links closely with clinical governance and patient safety teams to ensure
consistency and continuity of care.

5.3   Matrons will be responsible to ensure all staff attend relevant training
(undertaken on induction and/or mandatory training programmes including
Passport). Dates and booking instructions are available on the BHRT
intranet. Matrons will be responsible for weekly/monthly hand hygiene audits
in their areas. Additionally, they will investigate and manage non-attendees
as and when notified.

5.4   Senior Sisters/Departmental Managers will ensure hand hygiene
compliance within their areas throughout the year. Additionally, they shall
facilitate the release of staff to attend training. Senior Sisters will be
responsible for weekly/monthly hand hygiene audits in their areas.
Additionally, they will investigate and manage non-attendees as and when
Barking, Havering & Redbridge Hospitals NHS Trust
5
Hand Hygiene Policy (Policy on Effective Hand Decontamination) / June 2009/IC/

notified.

5.5 The Director of Education will be responsible to ensure that:

•  All records of attendance are maintained on the Electronic Staff Record

5.6   The  Head of Infection Control (HOIC) leads the Infection Prevention &
Control Team with regard to the review and revision of practices and
procedures that have an impact on the control of infection, and acts in an
advisory role to staff. The HOIC has responsibility for planning, implementing
and monitoring infection control programmes. This will include appropriate
recording of such and follow up of non-attendees. Individual line managers
will be informed of any non-attendance. They have responsibility for planning,
implementing and monitoring infection control training programmes.

5.7   The Infection Prevention & Control Team (IPCT) will regularly update the
hand hygiene policy and ensure that all staff has hand hygiene training as
part of the Trust’s central induction programme. Hand hygiene training will
also be incorporated into other infection control training session designed and
delivered to specific groups of staff such as the Nurse and Junior Doctor
Induction. The Team will complete a Trust annual hand hygiene programme
and promote the topic by organising hand hygiene awareness weeks.
Additionally, the IPCT will record all training undertaken.

5.4.1. The Matrons/Senior Sisters will ensure hand hygiene compliance within
their areas throughout the year.

5.8 The
Trust’s
Purchasing Team have a responsible for ensuring that
procurement and supplies provide to enable compliance with this policy are
readily within the Trust.

5.9 The
Fire, Health & Safety Adviser has responsibility for ensuring that all
hand hygiene products are stored in accordance with the COSHH regulations
to ensure staff and patient safety.

5.10 All Clinical Staff have the responsibility, under there Codes of Professional
  Conduct to maintain patient safety at all times. Abiding by the hand hygiene
guidance within this policy is crucial to prevent the spread of infection. They
have a responsibility to report to the Infection Prevention & Control Team any
occasion where hand hygiene is compromised.  Any serious breaches of
hand hygiene guidance must be reported using the Trust’s Incident Report
Form (see Incident and SUI Reporting Policy available on the Intranet).
Failure to comply with the guidance within this policy may result in
disciplinary action being taken.

Additionally, ALL Registered Nurses & Midwifery grades (AfC 5-8) including
healthcare workers (AfC 1-4), will attend the Infection Prevention Passport.

Barking, Havering & Redbridge Hospitals NHS Trust
6
Hand Hygiene Policy (Policy on Effective Hand Decontamination) / June 2009/IC/

Furthermore, Mandatory Training Programmes for Registered Nursing &
Midwifery Staff reiterates and reinforces Infection Control & Hand Hygiene
issues.

5.11   All Trust Staff, whether working in a clinical area or not, are responsible for
ensuring hand hygiene guidance is complied with at all times.

6.0
THE EXPECTED STANDARD

ALL hospital staff and visitors MUST  decontaminate their hands (either using soap
and water if available or alcohol hand rub) on ENTERING AND LEAVING a clinical
area and between all patient care contact and examinations.

KEY WORDS
KEY WORDS

  DECONTAMINATION OF HANDS
TRANSIENT ORGANISMS

  This means physically removing:
These organisms are easily acquired

by touch and easily transferred to
  • Visible
dirt
people and surfaces. They are
  •  Visible soiling (blood / bodily
effectively removed with soap and

fluids)
water or alcohol hand rubs.
  • Potentially
pathogenic

organisms (disease producing
RESIDENT ORGANISMS

bugs) which you cannot see

These organisms are permanently
All of which deem your hands to be

ingrained in the skin, and are not
contaminated. Unless removed
readily transferred during routine
  from your hands, these organisms
activities. They are not removed by
  pose a risk to the next person or
soap and water, but their numbers
  object you touch.
are greatly reduced by antiseptic

agents.

7.0   TYPES OF HAND DECONTAMINATION

Routine hand decontamination using:
• Soap
and
water
•  Alcohol hand rub
• Both

Surgical hand decontamination using:
• Antiseptic
agent

8.0
GUIDANCE ON WHEN HANDS MUST BE DECONTAMINATED

ALL hospital staff and visitors must decontaminate their hands on entering and
leaving a clinical area. Consider all surfaces touched to be contaminated.

Apart from the above, there is no set frequency for hand decontamination. The
decision to decontaminate hands will be based on the risk assessment (below).
Barking, Havering & Redbridge Hospitals NHS Trust
7
Hand Hygiene Policy (Policy on Effective Hand Decontamination) / June 2009/IC/

Healthcare workers must consider the level of contamination on their hands following
any task, and the risk they pose to the next person touched – or the environment.
Remember, transient organisms are readily acquired during daily activities and
contact with skin, and transferred by unwashed hands.

Therefore, hand decontamination should occur between any activities, which results
in more than superficial skin contact.

9.0 RISK
ASSESSMENT

Consider the following when assessing the risks YOUR hands pose, and whether
decontamination is necessary:

•  The task just completed and the level of contamination on your hands
•  Are your hands visibly soiled?
•  Length of time in direct contact with patient’s skin or object
•  The next task – is it a high-risk procedure, i.e. drawing up IV drugs, inserting
urethral catheters, venepuncture and cannulation?
•  Vulnerability of the next patient, i.e. immuno-compromised, neonate, ITU
patient

You must decontaminate your hands in the following instances:

•  On entering and leaving a clinical area
•  Immediately before and after each direct patient contact / care (taking
observations, manual handling, bathing, etc)
•  After any activity or contact that potentially results in hands becoming
contaminated (i.e. contact with blood and bodily fluids, skin, wounds, dust,
linen, waste, making beds, coughing or sneezing into hand)
•  Before and after carrying out a clinical procedure (i.e. aspirating NG tube,
mouth care)
•  Before and after manipulating any invasive device (e.g. IV line, urethral
catheter)
•  Before and after handling food
•  Before preparing / dispensing medications
• Before
and
AFTER wearing gloves (to remove glove product residue and
reduce risk of allergy developing)
•  Between different procedures for the same patient (i.e. mouth care, catheter
care, tracheal suction)
•  After visiting the toilet
•  Before and after smoking
Barking, Havering & Redbridge Hospitals NHS Trust
8
Hand Hygiene Policy (Policy on Effective Hand Decontamination) / June 2009/IC/

•  When hands feel unclean or are visibly dirty

Remember  PATIENTS’ HANDS may also pose a risk of cross-infection to health
care workers and the environment. Therefore, they need to be offered hand-
washing facilities. If the patient is bed bound and cannot get to a sink, a bowl of
water or moist hand wipes should be offered.  An information leaflet is available to
patients on hand hygiene.

10.0 HANDWASHING
TECHNIQUE

An effective hand washing and drying technique plays a key role in the standard
infection control practice (SICP) to prevent cross-infection, and is described below:

a)  Firstly, REMOVE ALL JEWELLERY (plain wedding band excepted), and ROLL
UP SLEEVES:
b)  Wet hands first using warm water
c)  Apply soap and rub hands together vigorously for a minimum of 10-15 seconds,
ensuring contact with all areas of the hands and wrists. Pay particular attention
to thumbs, fingertips between fingers, and under wedding ring, as these are the
areas most commonly missed
d)  Rinse hands thoroughly under warm running water removing all lather
e)  Dry thoroughly with paper towels
f)  Use elbow to turn off if elbow-operated mixer taps are available. If not, use a
paper towel
g)  Dispose of paper towels in domestic waste bin
h)  Use foot pedal of waste bin to lift the bin, NOT YOUR CLEAN HANDS!
i)  Use a paper towel if the foot pedal is not working
Barking, Havering & Redbridge Hospitals NHS Trust
9
Hand Hygiene Policy (Policy on Effective Hand Decontamination) / June 2009/IC/

11.0 ALCOHOL HAND RUB TECHNIQUE

Use one application of 70% alcohol hand rub and vigorously rub hands together until
the alcohol dries, ensuring that all areas of the hand are covered including fingertips

Use exactly the same technique for applying alcohol gel as for hand washing

Alcohol is only effective on visibly clean hands and when allowed to dry thoroughly

Hands should be washed with soap and water after every five or so applications of
alcohol rub

Alcohol is not effective against bacterial spores, e.g. Clostridium Difficile or certain
viruses, e.g. Norovirus (D&V).

Barking, Havering & Redbridge Hospitals NHS Trust
10
Hand Hygiene Policy (Policy on Effective Hand Decontamination) / June 2009/IC/

12.0 HAND
CARE

Regular hand washing or a poor hand washing technique can result in dry, sore
hands. In addition to discomfort, dry, cracked skin is more likely to harbour micro-
organisms. To avoid this:

•  Wet hands first before applying soap
•  Ensure hands are rinsed and dried thoroughly
•  Apply an emollient hand cream regularly to protect the skin from becoming too
dry (use individual pots, or communal if in a pump dispenser). DO NOT USE
communal pots
•  If a particular soap, antimicrobial hand wash or alcohol product causes skin
irritation, seek occupational health advice.
•  Nail brushes must not be used (except for disposable brushes for theatre use)
as they can damage the skin.
•  Cover cuts and abrasions with waterproof dressings
•  Keep nails short, clean and varnish free
•  Do Not wear false nails – these harbour micro-organisms.

13.0 FACILITIES

Within the clinical area there should be adequate hand hygiene facilities within
easy reach of each bed and patient contact area, whether it is a hand-wash basin or
alcohol hand rub

13.1   Hand Wash Basins

Hand-wash basins should be easily accessible and have the following:

•  Warm water by means of mixer taps or temperature controlled water
•  Liquid soap in a clean dispenser (no bars of soap) e.g:
Soft - in clinical areas
Mild - a detergent-based liquid soap in public toilets, non-clinical areas and
kitchens
•  No anti-microbial soap should be used within the clinical area
•  Soft disposable paper towels in a clean dispenser (check the underside)
•  Foot-operated domestic bin (clinical waste bin on advice of ICPT in certain
areas)
•  Hand wash technique poster
•  ALL HAND PAPER TOWELS CAN BE DISPOSED OF IN A BLACK
DOMESTIC WASTE BAG

Barking, Havering & Redbridge Hospitals NHS Trust
11
Hand Hygiene Policy (Policy on Effective Hand Decontamination) / June 2009/IC/

13.2  Alcohol Hand Rub (Placement)

The placement of alcohol hand rubs within the clinical area needs to be based
on a risk assessment. Suggested placements include:

•  Entrance of clinical areas
•  Each bed space (if safe to do so)
• Drugs
trolley
• Notes
trolley
• Resus
trolley
•  Individual staff bottles (e.g. Tottles)
•  Alcohol hand rub is not required at sinks

14.0  HAND WASHING AGENTS

The selection of the correct agent will depend on whether the removal of transient or
resident organisms is required. The time available to decontaminate hands will also
influence the choice.

14.1   Soap and water

•  Soap and warm water is suitable for routine hand decontamination /
hygiene
•  There is NO anti-microbial agent in liquid soap. It is the frictional
movement of vigorously rubbing your hands together using the soap and
water, which will remove transient organisms. Therefore, a good hand
wash technique is vital as illustrated above and on posters within the
clinical environment.

14.2  Alcohol Hand Rub

•  Alcohol hand rub is suitable for routine hand decontamination in most
circumstances
•  Alcohol hand rub is a quick alternative to hand washing if hands are not
visibly soiled with blood or body fluids.  It is highly effective in destroying
most transient organisms, but it has limited activity against bacterial
spores, e.g. Clostridium difficile and Noro virus. Therefore hands need to
be washed with soap and water when in contact with these organisms.

14.3 Antiseptic
Agent
  •  Antiseptic agents are suitable for more invasive tasks, i.e. central line
insertion, and surgery
Barking, Havering & Redbridge Hospitals NHS Trust
12
Hand Hygiene Policy (Policy on Effective Hand Decontamination) / June 2009/IC/

•  Aqueous antiseptic hand washing agents will both remove and destroy
transient organisms, and also reduce counts of resident organisms.
•  Some agents offer residual activity, so providing continued anti-microbial
activity for some time after its use.

14.4 Approved Agents
Liquid Soap: a) Liquid Soap (clinical areas) – improved hand protection
        b) Detergent based (non-clinical areas)

Antiseptic Soaps: a) Chlorhexidine 4% surgical scrub
        b) Chlorhexidine 4% in 70% alcohol
        c) Povidine Iodine 7.5% surgical scrub

Alcohol Hand Rub:    * 70% alcohol with emollient


Liquid Soap: a) Oil based (clinical areas) – improved hand protection
   b)
Detergent
based
(non-clinical
areas)

Antiseptic soaps:
a) Chlorhexidine 4% surgical scrub


b) Chlorhexidine 4% in 70% alcohol

c) Povidine Iodine 7.5% surgical scrub


Alcohol Hand Rub: *

70% alcohol with emollient

15.0 HAND
CREAM

It is advisable to carry one's own personal tube of hand cream. Do NOT use multi-
dose pots of cream, as these may become contaminated.

16.0 SKIN
LESIONS

If any member of staff has a hand lesion, or experiences skin problems associated
with hand-washing, he or she should consult the Occupational Health Department.

If skin problems such as eczema are present, then staff should report to the
Occupational Health Department or IPCT or manager for advice. Staff with eczema
are at high risk of acquiring resistant hospital-associated staphylococci.

Cuts and abrasions on the hands must be adequately covered with an impermeable
dressing when starting duty.

17.0 POLICY
DEVELOPMENT

This policy complements the Infection Control Policy and promotion and compliance
with this policy is supported by a poster campaign from the National Patient Safety
Agency who champion the ‘cleanyourhands’ campaign which commenced in 2005.

Barking, Havering & Redbridge Hospitals NHS Trust
13
Hand Hygiene Policy (Policy on Effective Hand Decontamination) / June 2009/IC/

18.0 APPROVAL
PROCESS

This policy has been approved at the Infection Control Committee.

19. 0 DISTRIBUTION AND TRAINING PLANS

This policy will be made available to all staff via the Trust’s intranet, and hand
hygiene issues will periodically be publicised within the in-house magazine ‘Vital
Signs’ and the weekly electronic newsletter ‘Vital Link’.

Patient information on various infection control topics including hand hygiene is
available on the wards.

The Trust’s mandatory Induction Programmes (corporate, nurse, health care worker,
and junior doctors) includes guidance on hand washing as outlined in the Training
Needs Analysis included within the Risk Management Strategy.

20.0 AUDIT AND REVIEW PLAN

The Infection Prevention & Control Team will include hand hygiene compliance
audits in their annual programme of work and feed results back to the Trust Board.
Matrons and Senior Sisters will be responsible for weekly/monthly hand hygiene
audits in their areas.

Ad hoc audits will be undertaken by the Infection Prevention & Control Team in the
event of an outbreak of infection or infection control incidents in a particular area.

The success of the Trust’s hand hygiene policy will be monitored through the
infection control surveillance data, collected and shared with the Department of
Health and reported to the Infection Control Committee, Clinical Governance
Committee and Trust Board.

Infection control practice is also included in the annual cycle of audits by the Trust’s
internal auditors, Parkhill and external auditors, The Audit Commission, to ensure
systems are robust and support good infection control performance.

Any hand hygiene related risk assessment graded ‘red’ will be included on the
Trust’s Risk Register and any hand hygiene incidents notified through the IR1
system will be monitored by the Risk Team, based within the Clinical Governance
Department.

21.0 AMENDMENTS

The clinical content of this policy has not been changed, however the document has
been broadened and reformatted to ensure it meets CNST requirements as of April
2009.

Revisions to Policy:
Pg.4
Sections 1-4 added
Barking, Havering & Redbridge Hospitals NHS Trust
14
Hand Hygiene Policy (Policy on Effective Hand Decontamination) / June 2009/IC/

Pg.5
Section 5 added
Pg.6
Section 5 continued
Pg.12
Sections 17-19 added
Pg.13
Section 20, 21 added

22.0 REFERENCES

Department of Health. (2005). Saving Lives. A delivery programme to reduce
Healthcare Associated Infection including MRSA

Department of Health. (2003) Winning Ways. Working together to reduce Healthcare
Associated Infections in England. Report from the chief Medical Officer

Hospital Acquired Infection: Information for Chief Executives. Handwashing Liaison
Group, Department of Health. 1998

Infection Control Nurses Association Guidelines. May 2002

McCormick R, January 2002 . New Proposed CDC Hand Hygiene Guidelines. 3M
Infection Control Rounds. (Vol 5. no.1. 4-8)

Pratt RJ, Pellowe C, Loveday HP et al The Epic Project, January 2007. Developing
National Evidence-based Guidelines for Preventing Healthcare Associated Infections
Phase 1: Guidelines for Preventing Hospital Acquired Infections. .Journal of Hospital
Infection 47 (supplement)

CleanYourHands Campaign website: http://www.npsa.nhs.uk/cleanyourhands

The Health and Social Care Act 2008 (Revised January 2009)
Code of Practice for the NHS on the prevention and control of healthcare associated
infections and related guidance.

23.0 GLOSSARY

COSSH
Control of Substances Hazardous to Health
DIPC
Director of Infection Prevention & Control
D&V
Diarrhoea & Vomiting
HOIF
Head of Infection Control
IPCT
Infection Prevention and Control Team
MRSA
Meticillin Resistant Staphylococcus Aureus
NG
Naso Gastric
SICP
Standard Infection Control Precautions
SUI
Serious Untoward Incident
HCAI
Healthcare Associated Infection
Barking, Havering & Redbridge Hospitals NHS Trust
15
Hand Hygiene Policy (Policy on Effective Hand Decontamination) / June 2009/IC/

24.0 Equality Monitoring and Impact Assessment

Although certain employment Acts require policies to be assessed for their impact and that
the general duties are being adhered to, the Trust has decided to assess for impact on all
areas identified under its Equal Opportunity Policy to ensure that no group is disadvantaged
by any condition or requirement which cannot be shown to be justified.

Please complete and attach to any policy document when submitting it to the appropriate
committee for consideration and approval.

Policy Name:

HAND HYGIENE
Policy Number:
2009/IC/XXXX
Responsible Officer:
Director of Infection Prevention and Control
Approving Committee:
Infection Control Committee

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

more favourably than another on the basis
of:
Age N

Disability – learning disabilities, physical  N
disability, sensory impairment and mental health
problems.
Race N

Nationality N

Ethnic origin – including gypsies and travellers N

Gender / Gender reassignment N

Religion N

Beliefs N

Sexual orientation – including lesbian, gay and  N
bisexual people
Domestic
circumstances N

Social and employment status N

Marital/partnership
status N

HIV
status N

Political
affiliation N

Trade
Union
membership N

Barking, Havering & Redbridge Hospitals NHS Trust
16
Hand Hygiene Policy (Policy on Effective Hand Decontamination) / June 2009/IC/

2.
What is the overall purpose of this policy
That all clinical staff comply with the hand
area, function or activity?
hygiene guidance within this policy to prevent
infection.
3.
What approaches are currently used to
Audit, daily monitoring by Infection Prevention
measure progress and performance in this
and control team.
area?
4.
What counts as success in this area?
Prevention of cross infection.
5.
Are there opportunities within this policy to:

Eliminate illegal discrimination N/A

Promote equality of opportunity N/A

Promote good relations between people of  N/A
different groups?
6.
Is the impact of the policy likely to be

negative e.g. is their risk of:

Illegal discrimination N

Reducing equality of opportunity for some  N
groups?

Harming relations between different people of  N
different groups?
7.
If you have identified potential
N/A
discrimination, are any exceptions valid,
legal and/or justifiable?
8.
If so, what action could be taken to reduce
N/A
adverse effects and promote or enhance
positive effects?
9.
Please describe the options available for
N/A
incorporating equality monitoring into
routine arrangements?



Barking, Havering & Redbridge Hospitals NHS Trust
17
Hand Hygiene Policy (Policy on Effective Hand Decontamination) / June 2009/IC/