Hand Hygiene Policy

HAND HYGIENE POLICY

Version 10

Name of responsible (ratifying) committee Infection Prevention Management Committee

Date ratified 02 October 2014 Document Manager (job title) Consultant in Infection Prevention Date issued 04 December 2014

Review date 03 December 2016

Electronic location Infection Control Policies

Related Procedural Documents Infection Control Policy Essential Training Policy. Hand hygiene; hand soap; alcohol hand gel/rub; 5 key moments for hand hygiene; Contamination; Dirty hands; Hygiene; Cross infection; Hospital acquired Key Words (to aid with searching) infection; Infection control; Clinical hand washing; Religious beliefs; Occupational health and safety; Clinical guidelines

Version Tracking Version Date Ratified Brief Summary of Changes Author 10 October 2014 Minor revision and review IPCT

Hand Hygiene Policy: Issue Number: 10, Issue Date: 04 December 2014 Page 1 of 14 (Review date: 03 December 2016 (unless requirements change)) CONTENTS

QUICK REFERENCE GUIDE...... 3 1. INTRODUCTION...... 4 2. PURPOSE...... 4 3. SCOPE...... 4 4. DEFINITIONS...... 4 5. DUTIES AND RESPONSIBILITIES...... 4 6. PROCESS...... 5 7. TRAINING REQUIREMENTS...... 9 8. REFERENCES AND ASSOCIATED DOCUMENTATION...... 9 9. EQUALITY IMPACT STATEMENT...... 11 10. MONITORING COMPLIANCE...... 12 APPENDIX A...... 13

Hand Hygiene Policy: Issue Number: 10, Issue Date: 04 December 2014 Page 2 of 14 (Review date: 03 December 2016 (unless requirements change)) QUICK REFERENCE GUIDE

For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.

1. Hands must be decontaminated when the hands are visibly dirty / contaminated and at the 5 key moments and immediately after the removal of gloves (Pgs 5/6):

2. All staff must be ‘naked below the elbow’ before entering a clinical area and for the duration of their work (Pg 8).

Compliant Non-Compliant

3. The two main products for hand decontamination are; alcohol-based hand rub for clean hands or liquid soap and water for visibly dirty hands or when caring for patients with vomiting or diarrhoeal illness (Pg 6).

4. All clinical staff must use a seven-step technique to systematically decontaminate hands (Pg 7).

5. Aseptic hand hygiene must be performed prior to invasive procedures e.g. central line insertion, dressing etc (Pg 6).

6. Staff should follow recommended hand hygiene techniques to prevent damage or cracking to hands and regularly use emollient hand cream to maintain skin patency when hands are at rest (Pgs 7/8).

7. All clinical staff are responsible for completing, and remaining up to date with annual hand hygiene training (pg 9).

Hand Hygiene Policy: Issue Number: 10, Issue Date: 04 December 2014 Page 3 of 14 (Review date: 03 December 2016 (unless requirements change)) 1. INTRODUCTION The decontamination of hands is shown to significantly reduce the carriage of potential pathogens and decrease the risk and occurrence of Healthcare Associated Infections1,2. The purpose of this Policy is to reduce the risk of cross-infection to staff, patients and the general public3.

2. PURPOSE The purpose of this policy is to provide staff with clear guidelines on the actions they must take in order to prevent cross-infection due to contamination of their own hands

3. SCOPE This Policy applies to all staff employed by Portsmouth Hospitals NHS Trust (the Trust), and also to all visiting staff including staff from external agencies (e.g. CCG or other Trusts), tutors, students, agency/locum staff and contractors.

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

4. DEFINITIONS Alcohol Hand Rub: A sanitising gel containing alcohol and emollients which sanitizes physically clean hands and destroys transient micro-organisms. If applied for an extended length of time, they will also destroy some resident flora. Alcohol Hand Rub does not contain surfactant or soap so does not have any cleaning properties

Hand Decontamination or Hygiene: The use of soap and water or an antiseptic solution to reduce the number of microorganisms on the hands

Hand soap: a non-perfumed gentle liquid or foaming soap that contains surfactants to remove organic matter but no anti-bacterial agents

Organic matter: Any derivative of a living or once-living organism

Resident (hand) flora: Microorganisms that live in the deeper crevices of skin and hair follicles. These form part of the normal flora of the body and are not readily transferred to other people or objects, or removed by the mechanical action of soap and water. They can be reduced in number with the use of antiseptic soap.

Transient (hand) flora: Microorganisms acquired on the skin through contact with surfaces. The hostile environment of skin means that they can usually only survive for a short time, but they are readily transferred to other surfaces touched. Can be removed by washing with soap and water, and most are destroyed by alcohol-based hand rubs.

5. DUTIES AND RESPONSIBILITIES Infection Prevention and Control Team (IPCT) is responsible for:  Providing expert proactive and reactive information and advice to all staff, patient, relatives and carers in respect of healthcare associated infections and hand hygiene  Ensuring the effective auditing of infection prevention practices, including hand hygiene  The production and review of the hand hygiene policy; in line with national guidelines  Reviewing, in collaboration with other, the status of the environment including facilities for promoting and supporting effective hand hygiene

Hand Hygiene Policy: Issue Number: 10, Issue Date: 04 December 2014 Page 4 of 14 (Review date: 03 December 2016 (unless requirements change))  Facilitating link staff, ensuring they are empowered to continually raise the standards of infection prevention and control, including hand hygiene

Infection Prevention Link Advisors are responsible for:  Continually raising the standards of infection prevention and control, including hand hygiene  Providing infection prevention and control training (including hand hygiene) to colleagues on an ad-hoc basis and at regular ward meetings  Ensuring monthly hand hygiene audits naked below the elbow compliance and bi-monthly Infection Prevention and Control audits are undertaken  Ensuring that results of all audits are fed back to the IPCT and to Matrons, through the CSC structure  Developing action plans, in conjunction with the IPCT and Matrons; to rectify any deficiencies highlighted by the audits

Matrons / Ward Managers:  Must establish a culture of compliance with infection prevention guidelines across their units  Promote good practice and challenge poor practice  Undertake peer review audits to support the Trust monitoring hand hygiene and act on audit results in their own areas

All Healthcare Staff:  Must be familiar with and adhere to the relevant infection prevention policies to reduce the risk of cross infection of patients  Must adhere to the full terms and conditions documented in this policy  Report to their managers and/or Infection Prevention Team if they are unable to follow this policy  Report to their managers and occupational health if any condition (allergy, dermatitis, eczema etc) prevents them adequately decontaminating their hands

6. PROCESS 1.1. Hand Hygiene Hand hygiene must be performed when the hands are visibly dirty or contaminated, at the 5 key moments (figure 1) 1,4 and immediately after removing gloves4,5.

Hand Hygiene Policy: Issue Number: 10, Issue Date: 04 December 2014 Page 5 of 14 (Review date: 03 December 2016 (unless requirements change)) Figure 1: The Five Moments of Hand Hygiene1 Other appropriate occasions for hand decontamination include:  Before applying and after removing personal protective equipment  Before preparing, handling or eating food  After visiting the toilet  Before and after administration of medicine  Before and after leaving an isolation cubicle  Before and after emptying urinary drainage bags  After bed-making or in between bed making if making multiple beds  After handling contaminated laundry and waste, including sluice room activities  Before commencing and after finishing work  Personal contamination e.g. blowing your nose, sneezing into your hand, after smoking

This includes the use of alcohol gel where appropriate

1.2. Cleansing Agents Hands may be decontaminated using:

Alcohol hand rub  This may be used if hands are visibly clean  Alcohol hand rub will remove transient flora from the hands and will substantially reduce resident hand flora4  Hand decontamination with Alcohol hand rub should take 20-30 seconds1  Alcohol hand rub is not effective against spore-forming bacteria like Clostridium difficile and some viruses (e.g. Norovirus) so hands must be washed using soap and water when caring for these patients4  After five consecutive uses of the Alcohol hand rub hands must be washed with soap and water to remove the protein build up on the skin

Liquid soap and water  Washing hands with liquid soap and water is adequate for most routine clinical activities where removal of transient hand flora is required4  Hand washing should take 40–60 seconds1  Soap is provided in disposable containers and should never be re-used or re-filled. Bar soap should never be used in clinical areas4  Soap and water hand hygiene must always be used when caring for patients with suspected or confirmed Clostridium difficile or diarrhoea of unknown origin4

Aseptic hand hygiene  Aseptic hand hygiene must be performed prior to invasive procedures4 e.g. central line insertion, dressing etc. to remove resident hand flora  This must be used before any aseptic procedure and involves the use of aqueous antiseptic solutions (e.g. chlorhexidine gluconate, povidone-iodine)  Alternatively a hand wash with soap and water followed by an application of alcohol gel as per policy is acceptable

1.3. Hand Decontamination Technique Hands should be decontaminated using a systematic technique to ensure exposure of the hands and wrists to the cleaning agent4. This technique should be used for washing with liquid soap and water or the application of alcohol hand rub (figure 2)

Hand Hygiene Policy: Issue Number: 10, Issue Date: 04 December 2014 Page 6 of 14 (Review date: 03 December 2016 (unless requirements change)) Figure 2: Hand decontamination technique

1.4. Hand Care Skin damage due to hand hygiene is generally associated with the detergent base, poor hand washing technique and frequency5. Staff should follow recommended hand hygiene techniques to prevent damage or cracking to hands and maintain skin patency when hands are at rest: This includes:

 always wetting hands under tepid running water before applying the recommended amount of liquid soap (usually a single shot)  always rinsing soap off hands thoroughly and drying hand completely  ensuring that Alcohol hand rub is completed rubbed into the hands and not left to air dry  using a good quality personal emollient hand cream during breaks and at home5. Multi-person use emollient hand cream is not provided due to the risk of contamination. Pump dispensed emollient hand cream should not be available in clinical areas

Staff with acute or chronic skin lesions/conditions/reactions on their hands (e.g. figure 3) which prevent effective hand decontamination should not perform clinical duties and should seek advice from the Occupational Health Department

Hand Hygiene Policy: Eczema Dermatitis Issue Number: 10, Issue Date: 04 December 2014 Page 7 of 14 (Review date: 03 December 2016 (unless requirements change)) Figure 3: Eczema and dermatitis preventing adequate hand decontamination All cuts and abrasions must be covered with a water-impermeable dressing, prior to clinical contact4,5. Staff requiring hand splints should not undertake direct clinical care and should seek advice from the Occupational Health Department. Hand splints which cover any key hand parts (wrists, thumbs, fingers, palms or backs) prevent adequate hand hygiene and become easily contaminated.

1.5. Naked Below the Elbow To achieve adequate hand decontamination, hands and wrists need to be fully exposed to the hand hygiene product and therefore should be free from jewellery and long-sleeved clothing4,5.

All staff must be ‘naked below the elbow’ before entering a clinical area and for the duration of their work. Clinical areas are defined as any area where patients are being cared for, including:

 Wards  Departments including outpatient clinics  Theatres and anaesthetics

Naked below the elbow means (figure 4):  Wearing short-sleeved tops or rolling long sleeves up above the elbow5. Staff who are unable to comply with this for religious reasons may wear disposable over sleeves/gauntlets when performing clinical care and must ensure they wash their hands to the wrist. Over sleeves/gauntlets are single use items and must be changed between each different procedure on the same patient and between patients.  No jewellery (i.e. bracelets, rings, wristwatches): a single, plain, smooth band may be worn  No artificial nails, nail extensions or nail polish  Finger nails should be kept short and clean

Compliant Non-Compliant

Figure 4: compliance with naked below the elbows

1.6. Facilities Adequate facilities are provided to enable staff to:

 Wash and dry their hands regularly and appropriately  Use alcohol hand rub at the point of care

Each clinical area will have the following equipment to ensure adequate hand decontamination:

 Dedicated clinical hand wash basin with no plug or overflow that is easily accessible (clinical hand wash basins are for hand hygiene only – do not dispose of body fluids or washing water at the clinical hand wash basin and do not wash or store patient equipment at the basin)6  Elbow operated or automatic mixer taps  Wall mounted liquid soap dispenser, with adequate supply of liquid soap  Disposable paper towels in wall mounted dispenser Hand Hygiene Policy: Issue Number: 10, Issue Date: 04 December 2014 Page 8 of 14 (Review date: 03 December 2016 (unless requirements change))  Easily accessible alcohol hand rub provided at point of care

Clinical hand wash basins that are inaccessible or infrequently used must be reported to the Carillion Water Safety Team on ext.6261

Mobile, community staff should be provided with appropriately sized containers of alcohol hand- gel, for use in patient’s homes (see appendix A)

1.7. Monitoring Audit

 Monthly Hand Hygiene audits are to be carried out in all clinical areas using the Portsmouth Hand Hygiene Audit Tool  Peer review Hand Hygiene audits are to be undertaken 3-monthly by Matrons  The hand hygiene performance indicators can be found at ‘Hand hygiene Performance indicators’ on the intranet site

Feedback and Learning  All monthly hand hygiene audits are to be forwarded to the Infection Prevention Data Manager who will collate the results and report to the CSC’s and Trust Board monthly, using a performance dashboard  The hand hygiene audit trend analysis report will be discussed at every Infection Prevention Management Committee who will, through the Chair, take any action as identified by the audits  The link advisors, in conjunction with the IPCT and the Matrons, will develop and implement action plans to rectify any deficiencies highlighted by the audits

7. TRAINING REQUIREMENTS Training forms part of the Trust’s Essential Skills and Training Requirements; as identified in the Training Needs Analysis. It is included in mandatory Corporate Induction (Setting Direction) and in local updates

Staff must attend classroom delivered update training every two years, including practical hand hygiene training, and undertake refresher training via the Electronic Staff Record (ESR) system in the intervening years

All training (including ad hoc sessions) is recorded on the ESR from which the Learning and Development Team provide a monthly heat map to each CSC, to enable monitoring of compliance

Compliance is further monitored through the CSC performance reviews with the Executive Team

8. REFERENCES AND ASSOCIATED DOCUMENTATION

1. World Health Organization. WHO Patient Safety. WHO guidelines on hand hygiene in health care. Geneva: World Health Organization; 2009.

2. Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000;356:1307–1312.

Hand Hygiene Policy: Issue Number: 10, Issue Date: 04 December 2014 Page 9 of 14 (Review date: 03 December 2016 (unless requirements change)) 3.Department of Health (2008) The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance. Department of Health, December 2010. London. HMSO

4. Loveday et al (2014). epic3: National Evidence-Based Guidelines for Preventing Healthcare- Associated Infections in NHS Hospitals in England. Journal of Hospital Infection 86S1 (2014) S1–S70

5. National Clinical Guideline Centre (2012). Infection: prevention and control of healthcare- associated infections in primary and secondary care. NCGC, London (partial update of NICE CG2)

6. Department of Health (2013) Water systems Health Technical Memorandum 04-01: Addendum Pseudomonas aeruginosa-advice for augmented care units. DH, London

Associated Documentation: World Health Organization (2009) Clean Care is Safer Care Campaign. www.who.int/gpsc/5may/en/

Hand Hygiene Policy: Issue Number: 10, Issue Date: 04 December 2014 Page 10 of 14 (Review date: 03 December 2016 (unless requirements change)) 9. EQUALITY IMPACT STATEMENT Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy has been assessed accordingly

All policies must include this standard equality impact statement. However, when sending for ratification and publication, this must be accompanied by the full equality screening assessment tool. The assessment tool can be found on the Trust Intranet -> Policies -> Policy Documentation

Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace. Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do. We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:

Respect and dignity Quality of care Working together No waste

This policy should be read and implemented with the Trust Values in mind at all times.

Hand Hygiene Policy: Issue Number: 10, Issue Date: 04 December 2014 Page 11 of 14 (Review date: 03 December 2016 (unless requirements change)) 10. MONITORING COMPLIANCE

As a minimum the following elements will be monitored to ensure compliance

Minimum requirement Lead Tool Frequency of Reporting Reporting arrangements Lead(s) for acting on to be monitored of Compliance recommendations 100% of staff following CSC Matron Self Assessment Monthly Policy audit report to: Infection Prevention & Control appropriate hand  Infection Prevention Team hygiene procedures Management Committee Matron Infection Prevention Link Advisors 100% of staff following CSC Matron Peer Review Quarterly Policy audit report to: Infection Prevention & Control appropriate hand  Infection Prevention Team hygiene procedures Management Committee

85% of staff complete Learning and Monthly heat map Quarterly Policy audit report to: CSC Management Team relevant hand hygiene Development  Infection Prevention training – in line with Business Management Committee Trust performance Manager indicator 100% of staff who fail to Learning and Monthly heat map Quarterly Policy audit report to: CSC Management Team attend are followed up Development  Infection Prevention Manager Management Committee

Hand Hygiene Issue 9 07 July 2011 Page 12 of 14 (Review date: June 2013 unless requirements change) Hand Hygiene Policy: Issue Number: 10, Issue Date: 04 December 2014 Page 13 of 14 (Review date: 03 December 2016 (unless requirements change)) APPENDIX A

COMMUNITY

In some circumstances employees working in the community will not have access to the equipment necessary to carry out hand hygiene such as no running warm water, no access to liquid soap and no equivalent to disposable hand towels.

Prior to visiting a client in their home the clinician should discuss with the patient what is required to carry out effective hand hygiene.

This would include providing:

 Plain liquid soap – this does not have to be for the clinician’s exclusive use.  Warm running water.  Clean towel for the clinician’s specific use. The clinician could provide disposable towels in the form of a roll of paper if necessary

There will be certain circumstances when this is not achievable and in those situations the following alternatives can be used:

ALCOHOL HAND GEL

 Before and after providing direct patient care.  After removal of gloves and before performing further patient care.  On entering and leaving the patient’s home.

DETERGENT WIPES

 Hand packs of detergent wipes  After 5 applications of alcohol hand gel or before when the hands have become tacky.  When hands are soiled with organic material such as dirt or body fluids.

SOAP & HAND TOWELS

 When running warm water is available the healthcare worker can obtain soap dispenser and paper hand towels/roll from their usual supply chain.

This is not an exhaustive list of circumstances. For further advice please contact the Infection Prevention Team, 023 92 286000 Ext 6261

Hand Hygiene Issue 9 07 July 2011 Page 14 of 14 (Review date: June 2013 unless requirements change)