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Infection Prevention and Control
Hand Hygiene Policy
For staff and patients in
Lambeth Primary Care Trust
LAMBETH PRIMARY CARE NHS TRUST
1 LOWER MARSH
LONDON SE1 7NT
Policy Classification: CLINICAL
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Policy Issue: 1
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Date issued: September 2005
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Review Date: September 2007
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Acknowledgement:
I would like to acknowledge and thank all staff and colleagues who contributed to the development of this document.
Contents Page
1. Introduction 2
2. Background 2
3. Policy Statement 2
4. When to wash your hands 3
5. The 3 types of hand washing
5.1. Social Hand Washing 4
5.2. Antiseptic Hand Washing 5 5.3. Surgical Hand Washing
6. Additional general information 6
7. Hand washing facilities - the requirements 7
8. Barriers to hand hygiene compliance 8
9. What if? 8
10. How to improve Hand Hygiene compliance 9
11. On-going monitoring - key indicators 9
12. References 10
13. Appendices
Appendix 1. Hand Washing - Six Stage Technique 11
Appendix 2. Hand Hygiene Audit Tool 12 Appendix 3. Patient Information Leaflet 14
HAND HYGIENE
1. Introduction
Hand hygiene is the single most important measure in the prevention of transmission of infection.
The aim of hand decontamination is to effectively remove potentially harmful organisms from the skin which have been acquired in the course of daily interaction with patients, staff, others and contact with the clinical environment.
The principles of hand decontamination apply equally to healthcare provided in hospitals as they do to care provided in the community, but may need to be adapted to suit local circumstances (ICNA 2002).
2. Background
The National Audit Office (2002) highlighted that a third of healthcare associated infections could easily be prevented by simple measures; one of which being hand hygiene. Studies have shown that poor hand hygiene or the lack of this is the main cause of cross infection. A recent observational study (Saba et al. 2005) found that poor compliance with hand hygiene, particularly before patient care and suggested targeted education programmes and feedback may be useful.
Many health care workers do not wash their hands adequately, even when using the Six Stage Technique unless they taught to do so correctly, practised and monitored regularly. This recalcitrant issue is being addressed nationally through the National Patient Safety Agency (2004) and is a high priority for Lambeth Primary Care Trust (LPCT).
3. Policy Statement
Lambeth Primary Care Trust is committed to providing high quality health services. A core aspect of this is to ensure that the risk of infections to patients, staff, visitors and the public is minimised.
Therefore, all staff providing services within LPCT, who have patient contact, is required to attend hand hygiene training within 3-6 months of employment, dependent on the risk associated with their individual roles.
Patients, clients, their relatives and visitors are encouraged to actively participate to ensure the success of this policy.
4. When to wash your hands - some examples
4.1. Health care workers must wash their hands before and after all patient
contact and as well as:
Before a meal, after using the toilets, after smoking
At the beginning and end of a span of duty
Before entering and leaving a clinical area or isolation room
Before and after aseptic procedures e.g. dressings, urinary catheter/intravenous/central line insertion or manipulation, tracheal suction and other procedures such as PEG feeding
After handling bodily fluid/specimens
After handling soiled or infected linen
Before and after removal of protective clothing e.g. gloves
When hands are visibly soiled
After cleaning of the environment or equipment
In instances of outbreaks, more frequent hand washing may be required
In addition, health care workers should:
Keep nails short and clean
Keep skin moisturised to avoid cracks and breaches in the skin
Avoid hand jewellery
Wear appropriate clothing for work - short sleeves to facilitate hand washing
Patients and their relatives/visitors are encouraged support the PCT Hand Hygiene Policy to reduce the transmission of infection. They should be encouraged to play their part in infection prevention and control by hand washing at appropriate times. Patient information leaflet on hand washing should be readily available (Appendix 3).
Patients should wash their hands as per 5.1. below, when hands are visibly soiled, after toileting, before eating, after touching any bodily fluid e.g. strike-through dressing. Alcohol hand rubs can be used for visibly clean hands.
Visitors are encouraged to use alcohol hand rub on visibly clean hands before and after visiting patients in a care facility.
Patients may remind staff to wash their hands if staff forgets to wash their hands between patients.
Patients should bring issues of concern regarding hygiene standards to the attention of staff as soon as possible
5. The 3 Types of hand washing - Social, Antiseptic and Surgical:
Social hand washing
All staff with patient contact should wash their hands regularly e.g. before and after duty, before handling food/eating/smoking, after using the toilet, after contact with patient, before giving medications, after bed making, and when they appear visibly dirty.
Where elbow mixer taps are fitted, use elbows, to turn on the taps to reduce the risk of contamination. (Where elbow taps are not fitted, refer to point 7 below.)
Wet hands with running warm water before applying liquid soap as per instructions on the dispenser. (Bar soap is not recommended as it can be a vehicle to cross infection)
Avoid splashing of clothing, surfaces or floors
Rub hands together vigorously using friction to all surfaces of hands and wrists - at least 5 times to each of the surfaces for a total of 30 seconds. Pay particular attention to fingertips, cuticles and nails and the web areas between fingers and thumb - refer to the Appendix 1, Six Stage technique
Rinse hands and wrists thoroughly under running warm water - position fingers lower than the forearm to encourage water to drain away from the forearm to avoid contamination
Dry your hands thoroughly, using a disposable paper towel; preferably from finger tips to forearm
Use the paper towel to turn taps off if they are not elbow operated
Dispose used paper towels as domestic waste (black sack) into a foot-operated pedal bin, using the pedals, to avoid re-contaminating the hands.
Antiseptic Hand Washing
Antiseptic hand washing is recommended when
undertaking clinical tasks for those known to be positive for MRSA
other infected wounds
before and after aseptic procedures
after handling contaminated material
on entering and leaving all high risk areas
Use elbow to turn on the mixer taps to reduce the risk of contamination
Wet hands with warm running water before applying approximately 5 mls antiseptic soap solution - 4% w/v chlorhexidine gluconate or Betadine scrub as per instructions on dispenser
3. Avoid splashing of clothing, surfaces or floors
Rub hands together vigorously using friction to all surfaces of hands and wrists - at least 5 times to each of the surfaces for a total of 30 seconds. Pay attention to fingertips, cuticles and nails and the web areas between fingers and thumb - refer to the Appendix 1, Six Stage technique
Rinse hands and wrists thoroughly under warm
running water - position fingers lower than the forearm to encourage water to drain away from the forearm to avoid contamination.
Dry your hands thoroughly, using a disposable
absorbent paper towel
Turn tap off with elbows
Dispose used paper towels, as domestic waste (black sack), into a foot-operated pedal bin to avoid hand re-contamination
As an alternative to antiseptic soap solution, an alcohol rub may be used after social hand washing as in 5.1. above. An appropriate amount (see manufacturer's recommendations) should be rubbed vigorously to all surfaces as in Appendix 1 until completely dry.
Alcohol hand rubs are particularly appropriate for rapid disinfection of visibly clean hands where hand washing facilities are inadequate, absent, and in certain circumstances e.g. Mass vaccination clinics, phlebotomy, ward rounds, and in some patients' homes.
Surgical Hand Washing (surgical scrub)
This is performed prior to sterile invasive procedures e.g. minor surgery and podiatric surgery.
Use elbow taps to turn on the taps to reduce the risk of contamination
Wet hands with warm running water before applying
approximately 5 mls antiseptic soap solution - 4% w/v
chlorhexidine gluconate or Betadine scrub
Position hands higher than elbows, wash hands
methodically from fingertips to elbow
Lather and rub all surfaces for a minimum of 2 minutes. Single-use sterile soft nail brush may be used - discard after use. Pay particular attention to fingertips, cuticles and nails and the web areas between fingers and thumb - refer to the Appendix 1, Six Stage technique
Rinse hands and wrists thoroughly under running warm water - Position hands higher than elbows, to encourage water to drain away from the forearm to avoid re-contamination of hands
Dry your hands thoroughly, using sterile towels; discard appropriately in order to avoid hand contamination. Please note: Air dryers must not be used in a clinical environment.
As an alternative to antiseptic soap, an alcohol rub may be used after social hand washing (5.1. above) for the follow-on cases/patients. An appropriate amount as instructed by the manufacturers should be rub vigorously to all surfaces as in Appendix 1 until completely dry.
6. Additional general information
Air dryers if fitted, are an acceptable alternative in certain situatuins. However, they must not be used in a clinical environment, e.g. treatment room, minor surgery room, podiatry room, dental surgery, optometry or operating theatre etc. Furthermore, they are not recommended for catering or staff toilet areas. They must be regularly maintained and the filters checked and cleaned as necessary.
In the absence of adequate washing facilities, socially clean hands can be achieved by the use of an Alcohol hand rub. Hands should be visibly clean. Hands decontaminated in such circumstances should be washed with soap and warm water at the next available opportunity.
Alcohol rubs such as Spirigel, Sofablind, Purell are approved by PASA, are therefore available through NHS Logistics. Others available independently are Cutan Gel, Manugel, Lever Med and so on.
In May 2005, the Infection Control Committee identified Eco Lab as its preferred supplier of its alcohol hand rub, Spirigel (70% alcohol content), in line with Guys and St Thomas's Hospital, in order to aid compliance regarding its use and to take advantage of associated benefits of training and audit provisions.
In line with recommendations from the National Patient Safety Agency, plans are in place to roll out the use of Spirigel alcohol hand rub across Lambeth PCT, commencing with the higher risk areas of in-patient facilities in intermediate and continuing care & day centres.
Independent contractors however, have a choice of suppliers of alcohol hand rub. It is imperative that when choosing, a good quality alcohol hand rub is used in a clinical environment - look out for a CE marking. It is preferable to aim for one that has emollients and is of at least 70% alcohol base.
Alcohol hand rubs must be used and stored according to COSSH Regulations.
7. Hand washing facilities - the requirements
A designated hand wash basin with elbow operated mixer taps for all clinical areas, kitchen, staff toilets and cleaner's room. Sensor operated taps may be considered for future new builds or for refurbishment.
Hand wash basin should not have an overflow; plugs should not be available, nor taps be positioned directly over the drainage hole in the basin.
Wall mounted liquid soap (plain and antiseptic types) is available in clinical areas
Soap dispenser must be cartridge type (not the top-up system) so that the entire inner pouch and nozzle can be changed when the dispenser is empty
Disposable paper towels should be available in wall dispensers. (Cloth towels are not recommended as they can be a vehicle for cross infection. Hand dryer are not recommended for clinical, catering, and staff toilet areas)
A foot operated pedal bin for disposal of paper towels as domestic waste (black sack)
Nail brushes when used for surgical scrub prior to minor surgery should be sterile, single-use type and disposed of when finished with the procedure
Routine use of nail brushes are not recommended:
i)They are frequently contaminated with Gram-negative bacteria
ii)They can damage the skin and in turn lead to an increased number of bacteria on the skin
8. Barriers to hand hygiene compliance
Long nails, false nails, nail varnish, nail jewellery
Hand jewellery e.g. watches, bracelets, friendship bands, stoned or ridged rings
Long sleeves or other trailing garments
Sore skin
Poor attitude
Lack of facilities for hand washing and hand drying
Lack of time
Overwhelming workload
9. What If ?
When you are in doubt about when to wash your hands - WASH them
Community staff - particularly where they may not be adequate facilities or resources, alcohol hand rub can be used on visibly clean hands, as an alternative to hand washing. Ensure that hands are washed at the next available opportunity
Intermediate Care (in-patient facility) - alcohol hand rub should be available for near each patient and at the entrance to the wards
For Operating theatre - please follow specific guidance in 5.3.
Rashes and eczema on hands and forearms must always be reported to the Occupational Health Department as this may place the individual at risk of infection or increase the potential for carriage of micro-organisms
If you have further concerns, please speak with your Lead Practitioner or contact your Infection Control Advisor on Tel: 020 7716 7147
10. How to improve compliance?
Encourage compliance by role models through hand hygiene champions
Encourage others e.g. clients, patients, visitors, doctors, other practitioners and non-clinicians to join in the Clean Your Hands Campaign
Facilitate Hand Hygiene amongst clients, patients, visitors
11. On-going monitoring - key indicators
Volume of alcohol rub usage
Hand washing audit - refer to Appendix 2 for Hand Hygiene audit tool
PEAT reviews
12. References
Ayliffe GAJ, Fraise AP, Geddes AM and Mitchell K. (2000). Control of Hospital Infection. A Practical Handbook, 4th Edition, Arnold.
Bannister G, Chesworth T, Hoffman P, Humphreys H, Taylor EW, Woodhead K. (2002) Behaviours and rituals in the Operating Theatre - a report from the Hospital Infection Society Working Group on Infection Control in the Operating Theatres. Available: www.his.org.uk/_db_documents/Rituals-02.doc
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002, vol. 51, No: RR-16
Infection Control Nurses Association. (2002) Hand Decontamination Guidelines. ICNA and Regent Medical, London.
Lawrence J, May D. (2003) Infection Control in the Community. Churchill Livingstone.
National Institute for Clinical Excellence. (2003) Infection Control - Prevention of Healthcare-associated infection in Primary and Community care. NICE, London.
National Safety Patient Agency (2004) Cleanyourhands Campaign. Website (microsite) - http://npsa.nhs.uk/cleanyourhands/campaign
Pratt RJ et al. (2001) The EPIC Project: Developing National Evidence-based Guidelines for Preventing Healthcare Associated Infections. Journal of Hospital Infection. 47 (Supplement): S3-S74.
Saba et al. Hand Hygiene Compliance in a Hematology Unit. Acta Haematol 2005; 113 (3): 190-193
Taylor L (1978) An evaluation of handwashing techniques 21a and b. Nursing Times 74 (2), 54-55
Trick WE et al. (2003) Impact of ring wearing on hand contamination and comparison of hand hygiene agents in a hospital. Clin Infect Dis; 36: 1383-1390
Widmer AF. (2000) Replace hand washing with the use of a waterless alcohol hand rub? Clin Infect Dis 2000; 31:136-143
Prepared by
June Hitchcock MSc RN DN Dip Infection Control
Infection Control Advisor
Lambeth PCT
Approved by Infection Control Committee 26th July 2005
Appendix 1 - Staff Information Leaflet
SIX STAGE HANDWASHING TECHNIQUE
Step 1 palm to palm Step 4 fingertips
Step 2 backs of hands Step 5 thumbs and wrists
Step 3 interdigital spaces Step 6 nails
Appendix 2 - Hand Hygiene audit tool
Hand Decontamination Audit Form
Auditor? Link Champion Infection Control Advisor
Member of staff being audited?
Nurse Std Nurse Doctor
Physio OT Nurse Auxillary
Midwife Phlebotomist Radiographer
Other
Did the person wash their hands? If yes, what solution did they use?
Q1a Before patient contact? 1b? Soap Alcohol
YES NO N/A Hydrex Betadine
Q2a After Patient contact 2b? Soap Alcohol
YES NO N/A Hydrex Betadine
Q3a After glove removal: 3b? Soap Alcohol
YES NO N/A Hydrex Betadine
Q4a Before aseptic technique? 4b? Soap Alcohol
(Includes any manipulation of IV site, lines, catheter insertion?)
YES NO N/A Hydrex Betadine
Q5a After contact with blood? 5b? Soap Alcohol
YES NO N/A Chlorhexidine Iodine
Q6a After contact with body fluids? 6b? Soap Alcohol YES NO N/A Hydrex Iodine
Q7a After contact with Mucous Membranes? 7b? Soap Alcohol YES NO N/A Chlorhexidine Betadine
Did the person wash their hands? If yes, what solution did they use?
Q8a When coming on duty? 8b? Soap Alcohol YES NO N/A Hydrex Betadine
Q9a After handling equipment used on 9b: Soap Alcohol YES NO N/A Hydrex Betadine
Q10a Before meal/drink breaks? 10b? Soap Alcohol YES NO N/A Hydrex Betadine
Q11a Before emptying each catheter bag? 11b? Soap Alcohol YES NO N/A Hydrex Betadine
Q12a Before emptying drainage bags? 12b? Soap Alcohol YES NO N/A Hydrex Betadine
Q13a After removal of protective clothing? 13b? Soap Alcohol YES NO N/A Hydrex Betadine
Was the appropriate hand hygiene YES NO
Has the person attended mandatory YES NO
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Appendix 3 - Hand hygiene information for patients
HANDWASHING
Advice for Patients
Are your hands clean?
It is important to pay particular attention to the areas which have been shown to be those most commonly missed following hand washing.
Why should I wash my hands?
Hands may look clean but invisible germs are always present, some harmful, some not. Removal of germs is the most important factor in preventing them from being transferred to other people.
Hand washing is the simplest and easiest way of preventing the spread of infection and disease.
When do I wash my hands?
For example:
Before preparing food
Before meal times
After visiting the toilet or changing nappies
Whenever hands are visibly dirty
General Hand Care
Keep nails short, to prevent bacteria growing under your nails
Dry hands well to prevent chapping
Protect hands with hand cream
How do I wash my hands?
In the hospital setting, wash hands using soap under running water at a sink, and dry thoroughly using a clean disposable paper towel. The following six steps describe the best way to effectively wash your hands.
Thorough rinsing under running water is an important part of the procedure. Finally, dry the hands thoroughly using one paper towel for each hand - this also helps to prevent soreness.
Remember,
Good hand washing can prevent
the spread of infection.
Produced by the Infection Control Team
Lambeth PCT
Public Health Directorate
1 Lower Marsh, London SE1 7NT
Telephone No: 020 7716 7147
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Hand Hygiene policy - Lambeth PCT July 2005. June Hitchcock
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Hand Hygiene policy - Lambeth PCT July 2005. June Hitchcock
Ward/Dept:
Less frequently missed
Did the person use the foot pedal to open the bin?
Yes ( ) No ( )