This document may be made available to the public and persons outside of the Trust as part of the Trust's compliance with the Freedom of Information Act 2000.

In the case of hard copies of this policy the content can only be assured to be accurate on the date of issue marked on the document. The most up to date policy will always be available on the ²gether intranet site.

CONTENTS

GENERAL GUIDELINES FOR THE SUCCESFUL DECONTAMINATION OF HANDS

1.0 INTRODUCTION

1.1 Keeping the patient free from infection is an ever-increasing challenge considering new technology, increased use of immune-suppressive drugs and the increased use of invasive devices. The cost benefits from a good infection control programme are well documented & recognised. Early discharge from an acute hospital moves infection control from secondary care into the wider community and into a number of different settings.

Hand decontamination is not an innate skill. There is a wide-spread but incorrect belief that we know how to do it. Furthermore, we tend to believe that hand decontamination is such a simple activity that we need give no conscious thought to the process. Although we have been told to wash hands from a very early age we have not been actually shown “how” to do it. This has resulted in campaigns such as the National Patient Safety Agency (NPSA) Hand Hygiene Project. The core message of the campaign is “clean your hands”. ²gether has adopted the CleanYourHands campaign as well as Essential Steps to safe, clean care to maintain a high practice rate as well as an excellent standard of hand decontamination with all of its staff across every aspect of ²gether.

The lynchpin of the campaign is the availability of approved hand wash facilities and the use of alcohol hand rubs at the point of care when the availability of suitable hand wash facilities and the use of soap and water do not exist. The availability of near patient alcohol hand rubs is now wide spread at patients beds or have them available in a patients home. All other services e.g. Dental, School Nurse, District Nurse, Practice Nurse etc. are all advised to use these rubs when appropriate. Alcohol hand rub must be made available at the entry point of each and every clinical area so that patient visitors and all visiting staff can decontaminate their hands on entry and exit of the clinical environment. Management need to be made aware of these recommendations to ensure plentiful supplies.

Lord Darzi's interim report into the future of the NHS, published in October 2007 conducted one of the biggest public engagement exercises in NHS history on the issues that matter to staff, patients and the public.

The new package includes the following measures:

1. Matrons and clinical directors will report quarterly directly to trust boards on infection control and cleanliness. These reports will focus on compliance with statutory obligations and will increase the ability of senior clinical staff to raise concerns over infection control with trust boards directly.

2. New guidance on clothing will mean that ²gether will adopt a new "barebelow the elbows" dress code i.e. short sleeves, no wrist watch, no jewellery and allied to this the avoidance of ties when carrying out clinical activity. The traditional doctors' white coat will not be allowed. The new clothing guidance will ensure good hand & wrist washing.

3. New clinical guidance to increase the use of isolation for those patients who are infected with MRSA or Clostridium difficile. Although the best trusts will already be meeting this standard, for the majority of trusts this will mean greater use of single rooms, cohort nursing and better management of isolated patients.

4. The National Patient Safety Agency will extend its sccessful cleanyourhands campaign to care settings outside hospitals. The campaign, designed to improve hand hygiene among healthcare workers in order to combat healthcare associated infections, will be rolled out to primary care, ambulance, mental health and care trusts as well as to care homes and hospices.

2.0 STATEMENT OF POLICY

2.1 To reduce the transmission of pathogenic micro organisms between patients and health care workers.

3.1 This policy is an organisational, professional and/or clinical statement of intent, explicitly stating medical, nursing and/or midwifery and/or allied healthcare professional (AHP) responsibility and accountability. It is not open to interpretation or professional judgment, and is non negotiable. It is a documented framework enabling individuals or specific groups of staff to carry out interventions or plans of care.

4.0 POLICY DETAILS

4.1 Objectives

Hand decontamination is the single most important measure in reducing the spread of disease. Hands are a recognised principle route of cross infection. Hand washing is an infection control practice with a clearly demonstrated efficacy, and remains the cornerstone of efforts to reduce the spread of infection, but studies have shown that it is rarely carried out in a satisfactory manner. This reluctance to wash hands has become a major concern. The ability of transient micro organisms to transfer to, and from, hands with ease results in hands being extremely efficient vectors of infection. Thorough hand washing will reduce the risk of cross infection immediately.

Effective hand decontamination is essential in the prevention of infection and this can only be achieved when hands are washed following the ²gether 6 stages as illustrated (in appendix 3).

Hand washing is the single most affective action that can be taken to prevent the spread of infection.

4.2 Definitions

Hand decontamination can take place with a number of different decontamination agents;

When to decontaminate hands

Hand decontaminations should take place whenever a hand hygiene opportunity presents itself. This can most easily be represented in the `Your Five Opportunities For hand Hygiene' poster (see appendix 1) as well as those listed under When to wash hands below.

When to wash hands

There is no set frequency for washing hands; it is determined by actions - those completed and those about to be performed. Examples of some of the reasons are outlined below.

Routine washing

4.3 Routine (Social) hand wash for all patient contact:-

Wet hands and wrists, apply sufficient liquid soap to create a lather and wash hands for a minimum of 15 seconds using the recommended Ayliffe procedure, clean, rinse and dry hands thoroughly with soft white paper towels - correct hand drying is as important as hand washing.

Patient and Visitors hand washing

There are certain circumstances when visitors will be required to wash their hands before and after visiting patients. Visitors should be shown to the nearest hand wash basin and encouraged to follow the ²gether hand hygiene poster indicating the correct hand wash process.

4.4 Hygienic or Disinfection Hand Wash

Prior to undertaking invasive procedures or when caring for patients with known infections:-

Following Ayliffe's recognised hand wash procedure and dry hands as described above, then apply alcohol hand rub to the cupped hands and rub until dry using the procedure described for hand washing to insure the hands are covered with the alcohol hand rub.

4.5 Antiseptic Hand Wash (Chlorhexidine/Iodine)

Prior to undertaking invasive procedures or when caring for patients with known infections:-

Wet hands and wrists; apply 3-5mls of solution into cupped hands and wash for 15-30 seconds using procedure described (see Appendix 1). Rinse hands and dry thoroughly with paper towels.

4.6 Surgical hand washing

This type of hand washing is intended to remove or destroy the transient micro-organisms and reduce detachable resident organisms. This requires the use of an antiseptic hand wash solution. The process aims to decrease the resident organisms to prevent wound contamination should gloves become damaged. A defined washing technique is more important than the type of antiseptic solution that is being used. This process is essential before all surgical or any invasive procedure.

Surgical Hand Scrub/Disinfection - Prior to surgical procedures:-

Removal of transient & resident micro-organisms, using the technique described to include forearms, for a period of approximately 2 minutes with an antiseptic solution (Chlorhexidine recommended) with single use nail brush.

All surfaces of the hands must be washed by the technique described.

4.7 Soap or antiseptic solution?

In reality, cosmetically pleasing and a `kind' to skin solution will be far more acceptable. Therefore, the supply of a cleansing agent that will improve compliance to the washing of hands will outweigh the benefits of small cost savings, when compared to the costs of cross infection and human suffering resulting from non-compliance. Rinsing the hands before and following the application of the cleansing agent will reduce the risk of sensitisation to the agent.

Liquid soap

Liquid soap is the preferred option, in the main, for most care settings. Emollients are now standard in the majority of hand wash detergents. Soap physically removes microorganisms from the skin. It is all that is necessary to remove the transient organisms acquired from contact with patients. Disposable cartridge type liquid soap dispensers are preferable to the refillable models. This is because refillable containers have a greater risk of contamination by Gram-negative bacteria; they can multiply in the liquid soap. Bar soap can become contaminated with skin bacteria and Gram-negative bacilli and should, therefore, be avoided when possible. It is definitely not recommended for staff.

Antiseptic solution

These are soap solutions with an antiseptic added. They will significantly reduce the microorganisms that normally live on the skin as well as completely remove the transient ones. Antiseptic soap is only necessary prior to invasive procedures or after handling infectious material. The user must make the decision on which variety to choose after taking all aspects of the procedure into consideration.

Surgical hand wash solution

Agents for surgical hand washing are essentially the same as for those with aqueous antiseptic solutions, some being more commonly used than others. The user, again, should make the choice of which should be supplied.

Nailbrushes

Nailbrushes should not be generally used because they become heavily contaminated. If they are required, they should be single use items that are disposed of post single use.

4.8 Hand Drying

Thorough hand drying is an essential part of successful hand decontamination. Good quality soft paper towels with effective drying properties will work well in this role and also improve compliance to the washing of hands. Communal towels must not be used; they are a cross infection hazard. Evidence about the use and efficacy of warm air hand dryers is conflicting but they are noisy, can only be used by one person at a time and it takes longer to dry hands.

4.9 Alcohol Rubs

Alcohol-based products contain emollients designed to help prevent the drying out of the hands. Alcohol is an effective alternative when water and towels are not available such as when in the community. It is also useful when there is a need for rapid hand disinfection. Alcohol is more effective than aqueous antiseptic solutions but a preliminary wash is always needed for physically soiled hands.

Limitations of alcohol hand rubs

Alcohol hand rubs are not effective when used against spore forming pathogens. This means that alcohol hand rub does not kill Clostridium difficile, a spore forming bacterium or Rota viruses, Noro, Norwalk or winter vomiting virus which are spore forming viruses. Alcohol solutions are not effective against some viruses as there is insufficient contact time. The method of application has been described in the `Guidelines for Hand Hygiene' published by the Infection Control Nurses Association (ICNA):

Dispense the required amount of solution onto the hands

Ensure solution covers all hand surfaces

Rub vigorously, using hand washing technique, until dry.

4.10 Biocidal Hand Wipes

A relatively new innovation in hand decontamination is the biocidal wipe. This wipe contains a detergent to cleanse the skin, emollients to moisturise the hands and a biocidal action to disinfect the skin. The wipe contains only a small amount of alcohol (approx. 5%) which acts as a drying agent so that the hands do not remain moist with the wipe fluid. Early indications are that these wipes are ideal for situations where there is concern that soiling of the hands has taken place and so the use of an alcohol hand rub is unsuitable. The wipes can be used when no satisfactory hand washing facilities are available. For further information on these wipes please contact the Infection Prevention & Control Team.

4.11 Key points

4.12 Hand Care

During a working day a member of staff will decontaminate their hands on numerous occasions. This constant washing, exposure to alcohol hand rubs or biocidal wipes takes its toll on the integrity of our skin. It is therefore important that staff look after their hands by applying moisturiser at the beginning of a shift, when there is a break in hands on practice i.e. at lunch and at the end of the working day. Moisturisers should be freely available in the work place to promote usage and protect the hand health. If staff suffer with any type of issue or reaction to their hands they must contact Occupational Health in an attempt to resolve the matter.

5.0 CONSULTATION

5.1 Consultation on this policy included the following ²gether Committees and Specialist Groups

5.2 Consultation on this policy included the following Countywide Committee or Specialist Groups

6.0 TARGET AUDIENCE

6.1 This document describes the method and responsibilities for infection control for nursing, midwifery and all allied health professionals (AHP) as well as staff under temporary contract or working in contracted services within ²gether.

7.0 COMMUNICATION OF THE POLICY

7.1 The Policy will be communicated to staff in paper format via line managers following the approved process.

See the Policy Protocol for more details.

7.2 The policy will be made available on the Trust Intranet and Website and (unless after discussion with FOI lead it will not be made public) it will also be highlighted in the staff newsletter.

8.0 TRAINING

8.1 Hand hygiene decontamination practice is covered in theory at the ²gether annual mandatory training that all staff attend. There are also observational hand hygiene audits conducted on a monthly basis testing the compliance of successful and appropriate hand decontamination where education is provided if hand decontamination is not correctly implemented.

9.0 COST IMPLICATIONS

9.1 While there are no additional financial implications upon implementing this policy financial implications may emerge as the policy is reviewed and updated.

10.0 REFERENCES and Further Reading

Ayliffe, G.A.J., Babb, J.R., and Quoraishi, A.H. (1978) A test for “hygienic” hand disinfection. Journal of Clinical Pathology 31: 923-8.

Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings: Available at: www.cdc.gov/handhygiene/

Cooper T (2004) `Infection Control in General Practice' Primary Health Care 14 (6) July 2004 p 15-17.

Cowling P (2003) `Hand Cleansing': `Stop spreading infection - start spreading the message' British Journal of Infection Control 4:(6) 5 December 2003.

Department of Health (2003) `Winning Ways: Working together to reduce Healthcare Associated Infection in England' Report from the Chief Medical Officer HMSO December 2003

Gould D. (2002) `Hand Decontamination' Nursing Times 98 (46) 48-49

Hartley, J.C., Mackay, A.D., and Scott, G.M. (1999) Wrist watches must be removed before washing hands. British Medical Journal 318: 328.

ICNA `Guidelines for Hand Hygiene' published by the Infection ControlNurses Association (ICNA) received 1999.

Infection Control Nurses Association (2002) `Hand Decontamination Guidelines' ICNA Bathgate, West Lothian, UK

McGinley K, Larson E, Leyden J. (1988) `Composition and density of microflora in the subungual space of the hand.' Journal of Clinical Microbiology 26 p 950 -3.

National Institute for Clinical Excellent (2003) `Infection Control: Prevention of healthcare associated infection in primary or community care 2003 available @ www.nice.org.uk

Panhotra BR, Saxena AK, al-Arabi AM (2004) `The effect of a continuous educational program on hand washing compliance among healthcare workers in an intensive care unit'. British Journal of Infection Control 5(3) 15-18 June 2004.

Rayfield J.E. Lawson J. Howard J. (2003) `Infection Control Guidance for General Practice' ICNA, Bathgate, West Lothian, UK

Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA

Hand Hygiene Task Force. (2002) Morbidity and Mortality Weekly Review 51: RR-16.

Pratt, RJ, Pellowe, C, Loveday, HP et al. (2001)

Available at: www.doh.gov.uk/hai/standardprinciples.pdf

Taylor L (1978) `An evaluation of hand washing techniques 1' Nursing Times January p 54 - 55.

The epic Project; Developing National Evidence Based Guidelines for Preventing Healthcare Associated Infections. Journal of Hospital Infection 47 (Supplement): S1.

OTHER RESOURCES

UK Hand Hygiene Liaison Group website at: www.handhygiene.co.uk/

Ayliffe GAJ, Fraise AP, Geddes AM, Mitchell K (2000) Control of Hospital infection - a Practical Handbook, 4th edition. Arnold.

OCCUPATIONAL HEALTH CONTACT NUMBERS

Cheltenham General Hospital 08454 224084

Gloucestershire Royal Hospital 08454 225564

APPENDIX 1

APPENDIX 2

2gether NHS Foundation Trust

Clinical Policy Authorisation Form

Assessment of Competence for Registered Health Care Practitioners

Clinical Skill:

1 copy for personal portfolio 1 copy to ²gether Training Dept 1 copy individuals portfolio

Acknowledgments: Sam Lonnen

The ²gether 6 stages of Hand Washing APPENDIX 4

Each step consists of five strokes backwards and forwards.

1. Wet hands, apply soap & 2. Right palm over left dorsum

palm to palm & left palm over right dorsum

3. Palm to palm fingers interlaced 4. Backs of fingers to opposing palms with fingers interlocked

5. Rotational of right thumb clasped 6. Rotational rubbing around

in left palm & vice versa palm with clasped fingers of right hand then vice versa

Rinse hands under running water & dry thoroughly

Community Infection Prevention

and Control Policy and Procedure

HAND DECONTAMINATION