Hand Hygiene Ref IPC-0001-006 v2 - tewv.nhs.uk · The definition of bare below the elbows is as follows: Hands and arms up to the elbows/mid forearms are free from clothing and jewellery

Hand Hygiene

Ref IPC-0001-006 v2.2

Status: Approved Document type: Procedure

IPC-0001-006 v2.2 Page 2 of 18 Approved date: April 2018 Hand Hygiene Last amended: April 2018

Contents

1. Purpose ............................................................................................................. 3

2. Related documents ........................................................................................... 3

3. Hands, Bare Below the Elbows and the hand washing process ................... 3

4. The six stage correct technique for effective hand washing ......................... 4

5. When to clean your hands – ‘my 5 moments for hand hygiene’ concept ..... 5

6. The level of hand washing required ................................................................ 6

7. Which hand wash agents should be used in which situation? ..................... 7

8. Hand Hygiene Facilities .................................................................................... 7

9. Nails and the wearing of Jewellery .................................................................. 8

10. Skin care............................................................................................................ 9

11. Patient Hand Hygiene ....................................................................................... 9

12. Audit process .................................................................................................... 9

13. Mandatory training for hand hygiene ............................................................ 10

14. References and further reading ..................................................................... 10

Appendix 1 Bare Below the Elbow Flowchart ......................................................... 12

Appendix 2 Six Stages of Hand Hygiene ................................................................. 13

15. Document Control .......................................................................................... 14


1. Purpose

Following this procedure will help the Trust to:-

• Ensure staff use recognised techniques as hand hygiene is the single most effective means of reducing the risk of infection. Healthcare Associated Infection (HCAI) are costly in both financial and human terms. The Department of Health (2007) states that hands must be decontaminated immediately before each and every episode of direct patient contact / care and after any activity that potentially results in hands becoming contaminated.

• Ensure staff undertake effective hand hygiene in order to minimise the risk of infection to patients, relatives and staff.

• Provides guidance to clinical staff in Mental Health and Learning Disability settings on compliance with the Bare Below the Elbow rule (IPS, 2017)

2. Related documents

This procedure describes what you need to do to implement the hand hygiene section of the Infection Prevention and Control Policy

The Standard (Universal) Precautions for Infection Prevention and Control defines the universal standards for IPC which you must read, understand and be trained in before carrying out the procedures described in this document.

3. Hands, Bare Below the Elbows and the hand washing process

Hands of all staff in contact with the patient environment are the most common source in transmission of infection. All staff must adopt a bare below the elbow approach when undertaking any direct and clinical contact (see Appendix 1).

In Mental Health and Learning Disability healthcare settings, direct contact includes;

• All physical (hands on) aspects of healthcare including treatments, self-care and administration of medication (NICE Clinical guidelines CG 139 2012)

• Examples of this include; performing physiological examinations, providing personal care, wound care, contact with invasive devices such as Nasogastric tubes, the insertion of urinary catheters and urine collection bags. Collecting samples for testing, contact with blood and body fluids and performing searches.

• Other activities where effective hand hygiene and bare below the elbows is required

http://intouch/Docs/Documents/Policies/TEWV/Infection%20Control/Infection%20Prevention%20and%20Control%20Policy.pdf

http://intouch/Docs/Documents/Policies/TEWV/Infection%20Control/Standard%20(Universal)%20Precautions%20for%20Infection%20Prevention%20and%20Control.pdf


include when preparing and handling food and when handling waste.

The definition of bare below the elbows is as follows:

Hands and arms up to the elbows/mid forearms are free from clothing and jewellery (including bracelets and stoned rings), wrist jewellery, nail varnish and acrylic nails.

Short sleeved garments should be worn or being able to roll or push sleeves up (NICE Clinical Guidelines CG 139 2012)

4. The six stage correct technique for effective hand washing

This technique can be used with soap and water or alcohol hand rub (see Appendix 2).

When using soap and water, hands must be wet under warm running water prior to applying liquid soap, the 6 stage technique outlined below must be followed, also paying attention to wrists and nails. This technique should take 15-30 seconds to perform.

Once washed, hands should be rinsed in warm running water, and the tap if not infrared/ automatic should be switched off with your elbow or a clean paper towel so as to not re -contaminate your hands.

Paper towels should be discarded as household waste. If the bin has a lid then this should be foot operated to avoid recontamination of hands.

Hands should be thoroughly dried to reduce the risk of any remaining micro-organisms from recolonizing in moist areas.

This method will remove transient organisms and is adequate for most tasks.

NB. There is no set frequency for hand washing, it is determined by actions – those completed and those intended to be performed.

When using Alcohol hand gel, apply enough gel (usually 3mls) to ensure the gel is wet when it comes into contact with all hand surfaces.

Apply enough hand gel into the palm of one hand and clean the finger tips and nails of the opposite hand first, then pour the gel into the other hand and clean the finger tips and nails of the other hand. Continue to rub wet alcohol gel into all of the hand surfaces including wrists and thumbs following the 6 stage technique outlined below.

For alcohol gel to be effective this technique should take 30 seconds to perform.

IPC-0001-006 v2 Page 5 of 18 Approved date: April 2016 Hand Hygiene Last amended: April 2016

5. When to clean your hands – ‘my 5 moments for hand hygiene’ concept

In 2009 The World Health Organisation (WHO) published guidelines on hand hygiene in healthcare incorporating the ‘my 5 moments for hand hygiene’ concept. This approach to hand hygiene encourages all healthcare workers to clean their hands at specific moments when transmission of micro-organisms is most likely to occur. These are; before touching a patient, before undertaking a clean/aseptic procedure, after contact/exposure to bodily fluids, after touching a patient and after contact with the patient’s surroundings.

1 Before

patient contact

When: clean your hands before touching a patient.

Why: to protect the patient from harmful bacteria carried on your hands

Examples: performing a search, physiological observations, patient assessments, assisting with personal cares

2 Before a clean/aseptic procedure

When: clean your hands immediately before performing any clean /aseptic procedure

Why: to protect the patient from harmful germs including their own from entering from entering his/her body

Examples: venepuncture, emptying a urinary catheter, IM injections

3 After body fluid exposure risk

When: clean your hands immediately after an exposure risk to body fluids and after glove removal

Why: to protect yourself and the healthcare environment from potentially harmful patient germs

Examples: assisting with toileting, after venepuncture, cleaning up body fluid spillages

4 After patient contact

When: clean your hands after touching a patient and his/her immediate surroundings


Examples: shaking a patients hand, performing a search, physiological observations, patient assessments

5 After contact When: clean your hands after touching any object or furniture in


with patient surroundings

the patients immediate surroundings when leaving even if you have not touched the patient


Examples: making a patients bed, cleaning a patients room

http://www.npsa.nhs.uk/cleanyourhands/resource-area/nhs-resources/education/five-moments/

6. The level of hand washing required

Liquid soap and water is the preferred option and in most situations is adequate for routine hand washing;

Alcohol hand gels give rapid decontamination, but must only be used if the hands are visibly clean;

Alcohol hand gels are useful for community staff, when hand washing facilities are not readily available.

The outside of the alcohol gel container should be kept clean and when empty should be discarded.

Alcohol hand gels should not be used when caring for patients with suspected/confirmed infectious diarrhoea or clostridium difficile

NB. Topping up of liquid soap and alcohol gel dispensers is not acceptable.

The wearing of gloves is not a substitute for hand washing. Hands should be decontaminated before donning gloves and washed after their removal.

This is not an exhaustive list of situations, but should be taken as general guidance.

http://www.npsa.nhs.uk/cleanyourhands/resource-area/nhs-resources/education/five-moments/


7. Which hand wash agents should be used in which situation?

Indications Liquid soap Alcohol Hand Gel

Gloves

At the beginning and end of a clinical procedure

When hands are visibly soiled

If contamination with body fluids is possible Non sterile

Between physical contact with patient / or

Aseptic techniques + Sterile

Before serving food, beverages

Social activities e.g. before starting work. Eating and drinking, toilet etc

Outbreak

Management of C Difficile patient Non sterile

NB. If in doubt, consult the Infection Prevention and Control Nurses.

8. Hand Hygiene Facilities

• TEWV NHS Foundation Trust has a duty of care to provide adequate hand hygiene facilities for all trust staff and therefore only hand hygiene products supplied by the trust should be used for hand hygiene purposes this includes; hand soap, paper towels/hand dryers, alcohol gel and hand wipes. Any exceptions to this must be agreed by the Infection Prevention & Control and Occupational Health teams.

• Adequate hand washing facilities must be available and easily accessible in all clinical areas. Hand washing sinks must be provided with liquid soap dispensers, paper hand towels and foot lidded waste bins (RCN 2017).

• Clinic room hand washing sinks must be free from extraneous items, always accessible and must not be used for any other purpose other than hand hygiene.

• In areas where paper towels and soap dispensers are not routinely supplied due to individual patient risks. Alternative patient hand hygiene arrangements (eg patient hand wipes) must be documented, in particular following the use of the toilet and before meals. All staff involved in care for those individuals should be briefed.


• Hotel services staff are predominantly responsible for ensuring that soap and paper towels are available and that these are replenished regularly. Clinical staff are also responsible for informing hotel services when dispensers are empty to ensure refilled immediately. Cleaning of dispensers is included within Hotel Services staff daily work schedules. Further cleaning as and when required will be undertaken by clinical / nursing staff.

• Health care staff working in community settings, such as patients own homes should have access to Trust supplied hand hygiene products including soap, alcohol gel or individual hand wipes to ensure routine hand hygiene is carried out where facilities do not exist or may not be suitable to use.

9. Nails and the wearing of Jewellery

You must have short natural nails which are clean and free from nail polish no false nails. False nails encourage the growth of bacteria and fungi around the nail bed, mainly because they severely limit the effectiveness of hand hygiene Long nails are easily contaminated and harder to keep clean. Nail varnish hides were nails are dirty underneath and when it becomes chipped provides a surface where microorganisms thrive. Wrist watches must be removed prior to hand washing and clinical procedures. Wrist watches can become heavily contaminated with skin flora from the wearer and as they also impede thorough hand hygiene can provide an ideal breeding ground for some microorganisms.

You must not wear rings (with exception of a plain wedding band), and jewellery as they harbor micro-organisms. Jewelled rings collect dirt and grime in the stoned settings that also provides a breeding ground for microorganisms (they also pose a risk to fragile skin of vulnerable patients).

Permissible Jewellery Unacceptable Jewellery Plain band It is the employee’s responsibility to ensure that all other rings are removed prior to commencing their shift or direct patient care.

Rings other than a plain band ‣ Engagement rings

‣ Eternity rings Ridges, stones or grooves harbour higher levels of micro-organisms & could potentially damage the integrity of a patient’s skin

Kara bracelet A steel bracelet (usually worn on the right wrist) by members of the Sikh faith

Bracelets other than a Kara • Charity bracelets • Friendship bands • Silks loosely tied around the wrists by Hindus are not acceptable and must be removed. • Woven silk or cotton bracelets such as the Rakhis worn by Hindus and Jains for the festival of Raksha Bandhan will need to be removed for compliance with this policy.

Medic-Alert Bracelets- May be worn after consultation with Occupational Health. These must be non-fabric.

• Fitness Trackers • Dermal piercings of the hands and arms


10. Skin care

You must apply liquid soap to wet hands to prevent drying effects on the skin:

Dry hands thoroughly to prevent drying effects of the skin;

Regularly apply emollient hand cream to protect skin from the drying effect of regular hand decontamination;

Any cuts and abrasions must be covered with an appropriate water-proof dressing;

Consult Occupational Health if any hand hygiene product provided by the trust causes skin irritation to you or any member of the team

11. Patient Hand Hygiene

All patients should be encouraged to wash their hands regularly, especially

• After using the toilet facilities;

• Before and after they eat.

• Where patients are unable to clean their hands independently staff are responsible for offering and providing if appropriate assistance to patients to clean their hands with soap and water or individually wrapped patient hand wipes.

12. Audit process

• The Essential Steps audit tool is to be completed by clinical teams on a monthly basis, this ideally should be coordinated by the IPC, Physical Health and Back Care Champions;

• In the instance of non-compliance with the audit regime an escalation process has been agreed by the Infection Prevention and Control Committee. Any non-returns will be reported directly to the Ward Manager and Modern Matron;

• A yearly Hand Hygiene audit is undertaken in all In-patient services and is co-ordinated by the Modern Matron for each area

• Annual environmental audits are undertaken in all in-patient areas, the IPC team also carries out validation audits in each quarter.

• Community teams which undertake patient clinics complete annual environmental audits.

• Bespoke training on Infection Prevention and Control is delivered in the event of poor compliance identified from hand hygiene audits or following outbreaks/significant incidents of infection.


13. Mandatory training for hand hygiene

• This will be provided in line with organisational training needs analysis (See Learning and development policy); with attendance monitored via Human Resources and reports sent to local managers to ensure mandatory training needs are met;

• Core Skills Framework-

• For training not classified by the Trust as mandatory, managers should consider the necessary competencies for the specific work required and arrange for these needs to be met through the appraisal and personal development plan process;

• Access to support to meet these needs is outlined in the Learning and development policy and in the Training portfolio section of In Touch;

• Bespoke training on Infection Prevention and Control is delivered in the event of poor compliance

identified from hand hygiene audits or following outbreaks / significant incidents of infection.

14. References and further reading

Ayliffe GAJ, Lowbury EJL, Geddes AM, Williams JD, (1992): Control of Hospital Infection (Third Edition), Chapman & Hall Medical – London.

Department of Health (2003) Winning Ways: Working Together to Reduce Health Care Associated Infection in England. Report from the Chief Medical Officer London

Department of Health (2006) Essential steps to safe, clean care. Reducing healthcare-associated infections in Primary Care Trust; Mental Health Trusts; Learning disability organisations; Independent healthcare; Care Homes; Hospices; GP practices and Ambulance Services.

Department of Health (2007) The Epic project: Developing National evidence-based guidelines for preventing healthcare associated infections

Department of Health (2008) The Health and Social Care Act 2008 Code of Practice for the Prevention and Control Health Care Associated Infection London DH 2015

Department of Health (2008) Clean Safe Care: Reducing infections and saving lives.

Infection Control Nurses Association (2001). Guidelines for Hand Hygiene. Fitwise. Edinburgh.

Infection Prevention Society (2017) ‘Bare Below the elbow (BBE) Guidance for Mental Health and Learning Disabilities Settings.

Lawrence J & May D (2003). Infection Control in the Community. Churchill Livingstone. London

National Institute for Clinical Excellence (NICE) 2003. Infection Control: Prevention of healthcare-associated infection in primary and community care.


National Patient Safety Agency (2008) Patient Safety Alert 2nd Edition Clean Hands Save Lives

Royal College of Nursing (2017) Essential Practice for Infection Prevention & Control: guidance for nursing staff

World Health Organisation (2009) Guidelines on Hand Hygiene in Health Care: first global patient safety challenge; clean care is safe care http://www.who.int/gpsc/5may/background/5moments/en/

Worsley MA, Ward KA, Parker L, Ayliffe GAJ & Sedgwick JA (editors) (1990) Infection Control:- Guidelines for Nursing Care; ICNA & Surgicos


Appendix 1 Bare Below the Elbow Flowchart


Appendix 2 Six Stages of Hand Hygiene


15. Document Control

Next review date: 01 March 2021

This document replaces: IPC-0001-006 v2 Hand Hygiene Procedure

Lead: Name Title

Angela Ridley Head of IPC and Physical Health and Back Care (Nursing)

Members of working party: Name Title

Angela Ridley Head of IPC and Physical Health and Back Care (Nursing)

Emma Rolfe Lead Nurse IPC, Medical Devices and Physical Healthcare

Claire Foster

Joanne Dunmore

IPC, Medical Devices and PHC Nurses

Sandra Walker Senior Administrator

This document has been agreed and accepted by: (Director)

Name Title

Elizabeth Moody Director of Nursing and Governance

This document was approved by:

Date Name of committee/group

April 2016 Infection Prevention and Control Committee

An equality analysis was completed on this document on:

11 January 2017

Change record Version Date Amendment details Status 2 May 2016 “6 stages of hand hygiene” poster amended

(approved at IPC Committee 29/4/15) Withdrawn

2.1 Jan 2018 Minor amendments Withdrawn

2.2 Apr 2018 Full review Published


Equality Analysis Screening Form Please note; The Equality Analysis Policy and Equality Analysis Guidance can be found on InTouch on the policies page

Name of Service area, Directorate/Department i.e. substance misuse, corporate, finance etc.

Nursing and Governance/IPC and Physical Healthcare

Name of responsible person and job title Elizabeth Moody, Director of Infection Prevention and Control/Nursing & Governance

Name of working party, to include any other individuals, agencies or groups involved in this analysis

Elizabeth Moody, Dr R Bellamy, Angela Ridley, Emma Rolfe and the Infection Prevention and Control Committee

Policy (document/service) name IPC-0001-006 v1 Hand Hygiene Procedure

Is the area being assessed a; Policy/Strategy Service/Business plan Project

Procedure/Guidance √ Code of practice √

Other – Please state

Geographical area Trustwide

Aims and objectives To set standards in practice to ensure the delivery of patient care is carried out safely and effectively by the trust staff. To comply with the HCAI Code of Practice of the Health and Social Care Act 2008.

Start date of Equality Analysis Screening 11th January 2017

End date of Equality Analysis Screening

11th January 2017


You must contact the EDHR team as soon as possible where you identify a negative impact. Please ring Sarah Jay on 0191 3336267/3542

1. Who does the Policy, Service, Function, Strategy, Code of practice, Guidance, Project or Business plan benefit?

Trust staff and patients

2. Will the Policy, Service, Function, Strategy, Code of practice, Guidance, Project or Business plan impact negatively on any of the protected characteristic groups below?

Race (including Gypsy and Traveller) Yes/No

No

Disability (includes physical, learning, mental health, sensory and medical disabilities)

Yes/No

No

Gender (Men, women and gender neutral etc.)

Yes/No

No

Gender reassignment (Transgender and gender identity)

Yes/No

No

Sexual Orientation (Lesbian, Gay, Bisexual and Heterosexual etc.)

Yes/No

No

Age (includes, young people, older people – people of all ages)

Yes/No

No

Religion or Belief (includes faith groups, atheism and philosophical belief’s)

Yes/No

No

Pregnancy and Maternity (includes pregnancy, women who are breastfeeding and women on maternity leave)

Yes/No

No

Marriage and Civil Partnership (includes opposite and same sex couples who are married or civil partners)

Yes/No

No

Yes – Please describe anticipated negative impact/s No – Please describe positive impacts/s - No barriers to access or implementing this policy


3. Have you considered other sources of information such as; legislation, codes of practice, best practice, nice guidelines, CQC reports or feedback etc.? If ‘No’, why not?

Yes

No √

Sources of Information may include: • Feedback from equality bodies, Care Quality

Commission, Equality and Human Rights Commission, etc.

• Investigation findings • Trust Strategic Direction • Data collection/analysis • National Guidance/Reports

• Staff grievances • Media • Community Consultation/Consultation Groups • Internal Consultation • Research • Other (Please state below)

5. As part of this equality analysis have any training needs/service needs been identified? Not relevant to this procedure

4. Have you engaged or consulted with service users, carers, staff and other stakeholders including people from the following protected groups?: Race, Disability, Gender, Gender reassignment (Trans), Sexual Orientation (LGB), Religion or Belief, Age, Pregnancy and Maternity or Marriage and Civil Partnership

Yes – Please describe the engagement and involvement that has taken place

No – Please describe future plans that you may have to engage and involve people from different groups Not relevant to this procedure


No Please describe the identified training needs/service needs below

A training need has been identified for;

Trust staff No

Service users No Contractors or other outside agencies

No

Make sure that you have checked the information and that you are comfortable that additional evidence can provided if you are required to do so

The completed EA has been signed off by:

You the Policy owner/manager:

Type name: Angela Ridley

Date: 11/1/17

Your reporting (line) manager:

Type name: Elizabeth Moody

Date: 11/1/17

1.

2.

3.

Palm to palm Rub back of both hands Palm to palm, fingers interlaced

4.

5.

6.

Rub backs of fingers interlocked

Rub all parts of both hands, including thumbs

Rub both palms with fingertips

Correct technique for effective hand washing

Six stage hand washing technique This can be used with soap and water or alcohol hand gel