Wexford General Hospital HAND HYGIENE Action plan

2013

Introduction

The HSE set a national target of a hand hygiene compliance rate of >90% in 2013. This action plan outlines the processes in place and further initiatives to achieve this target by May 2013. This hand hygiene action plan is endorsed by WGH Infection prevention and control committee.

The aim of this hand hygiene action plan is to create an environment and a hospital wide culture which:

·  Supports and promotes effective hand hygiene.

·  Encourages a sustainable hand hygiene culture.

·  Provides staff with hand hygiene knowledge and skills.

·  Assists and encourages healthcare workers (HCWs) to decontaminate their hands effectively and as frequently as required, as well as minimise the risk of damage to HCWs’ skin.

·  Assists and encourage patients and visitors to decontaminate their hand effectively.

·  Ensures there is effective and sufficient hand hygiene resources (equipment and materials) available

·  Assists with the reduction in the risks of healthcare associated infection (HCAI) to patients and HCWs.

·  Demonstrates a continuous quality improvement at all levels of the hospital.

Strategic Direction / Criteria / Comments
Governance, leadership & culture / Develop a sustainable hand hygiene culture which is embedded in the organization. / Walk the talk- lead by example and have visible executive leadership.
Infection Prevention and control is an agenda item at the Board of Management meeting.
Access to Hand Hygiene Facilities and Products / Physical infrastructure is a necessary pre-requisite to improve hand hygiene practice. / Hand Hygiene facilities are available in all clinical/non clinical areas:-
o  Hand washing sinks which meet the requirement under SARI guidelines.
o  Elbow/sensor operated taps
o  Liquid soap
o  Paper towels
o  Alcohol gel hand rubs strategically placed so that they are within easy reach of each clinical situation.
o  Moisturizer cream
Hygiene audits are conducted to assess the availability of hand hygiene facilities/products and report the results.
Education and Training / Hand Hygiene Education and training to improve knowledge, beliefs and attitudes on the importance of hand hygiene
To improve hand hygiene practices and compliance rates. / Comprehensive IP&C Education programme available for all healthcare workers in the hospital
Responsibility of Departmental Heads/Managers to ensure all staff receives mandatory training on hand hygiene.
Attendance records are kept
Additional hand hygiene education sessions provided as required e.g. post hand hygiene audits, Grand Rounds for medical staff etc.
Infection Prevention & Control Link Practitioner Programme- Clinical champions for hand hygiene through active participation in the IP&C Link Practitioner role. / IP&C Link Practitioners are trained in the hospital.
Strategic Direction / Criteria / Comments
Hand Hygiene Audits / Hand Hygiene Audits to monitor hand hygiene compliance rates. / National Hand hygiene audits are undertaken using the HSE national standardised audit tool.
The IPCT report findings via a hand hygiene audit report to:-
o  Clinical Nurse Managers
o  Heads of Service
o  Hospital Manager
o  Deputy Manager
o  Nurse Management
o  Clinical Director
o  Infection Prevention & Control Committee
Feedback of audit results, alcohol gel usage and any other Key performance indicators / The feedback of key performance indicators in a timely fashion / The results of key performance indicators are widely disseminated from the Infection prevention and control committee members to all heads of departments for distribution to their staff. Each department receives a copy of their individual hand hygiene audits.
Hand Hygiene Policies/
Guidelines / Hand Hygiene Policies/Guidelines / |The hand hygiene policy which was adapted from the Guidelines for Hand Hygiene in Irish Health Care Settings; Health Protection Surveillance Centre 2005 was reviewed in 2011.
The hand hygiene policy contains up to date and expert advice on hand hygiene techniques, hand hygiene products and hand hygiene importance.
Policies/guidelines are available and accessible to staff both locally and electronically.
HCWs who develop irritant dermatitis must report to the Occupational Health Department
Education and Awareness Campaigns / Promote and support multidisciplinary partnerships to deliver intervention hand hygiene programmes / The IP&CT provide regular hand hygiene initiatives that promote effective hand hygiene behaviour for staff, patients and visitors:- there are a posters available to encourage patients to ask staff to decontaminate their hands
‘World Health Organization Save Lives: Clean your hands campaign’ annually in May to highlight awareness about the importance of hand hygiene and the 5 moments for hand hygiene.
Infection Prevention & Control Awareness Campaign is a global event held every year to highlight everyone’s responsibility- staff, patients and visitors alike - in helping to prevent healthcare associated infections.
Develop Infection prevention and control hand hygiene champions to work with Infection prevention and control link nurses. We need
The IPCT in consultation will hold hand hygiene work shops in a suitable area. These workshops will focus on the 5 moments for HH and each participate will receive a certificate of attendance. This workshop must be endorsed by the BOM

References

Health Information and Quality Authority. (2009). National Standards for the Prevention and Control of Healthcare Associated Infections.

SARI (2001). A Strategy for the Control of Antimicrobial Resistance in Ireland. Report of the subgroup of the Scientific Advisory Committee of the National Disease Surveillance Centre.

Victorian Quality Council (2007) Hand hygiene sustainability. Results from the Victorian Quality Council Hand hygiene sustainability forum.