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Policy Date: 31/08/2008 Review date: 01/09/2010Author: Sam Lonnen
CONTENTS
Section / Section Heading / Page Number1 / INTRODUCTION / 3
2 / STATEMENT OF PROTOCOL / 4
3 / DEFINITION / 4
4 / POLICY DETAILS / 4-8
5 / CONSULTATION / 8
6 / TARGET AUDIENCE / 8
7 / COMMUNICATION OF POLICY / 8
8 / TRAINING / 8
9 / COST IMPLICATIONS / 8
10 / REFERENCES / 9
SUPPORTING DOCUMENTS
Appendix 1 / Your 5 Opportunities for Hand Hygiene / 10
Appendix 2 / POLICY TEMPLATE / 11
Appendix 3 / AUTHORISATION FORM / 12-13
Appendix 4 / The ²gether 6 stages of Hand Washing / 14
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.
3.0 DEFINITION
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).
· Micro organisms on the hand are either resident or transient flora.
· Resident flora is usually of a low virulence and rarely cause infections except when introduced into the body through exposure prone procedures such as surgery or the introduction of an invasive device i.e. a urinary catheter, peripheral cannula etc.
· Transient flora may consist of many different pathogenic micro organisms. They are not firmly attached to the skin and are removed quickly and effectively with routine hand washing using soap and water or an alcohol based hand rub.
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;
· Liquid soap should be non-perfumed and non-coloured and dispensed from a clean wall mounted or free standing pump action dispenser.
· Anti-microbial action hand wash solutions i.e. Hibiscrub are not required for social hand washing and are only required prior to a minor surgery procedure.
· Alcohol hand rubs can only be used if there is no visible soiling on the hands and that the potential organism involved with the action prior to hand decontamination is not a spore forming pathogen.
· Biocide hand wipes can be used on soiled hands, as there is a detergent ingredient that will remove soiling and still disinfect the hands due to biocidal action.
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.
· Prior to and on completion of duty.
· Between any patient contact.
· Before and after all aseptic/invasive procedures.
· After removal of gloves.
· Before handling food.
· After any contact with blood/body fluids.
· Before entering and after leaving any source isolation facility.
· Before leaving work place, office, ward, clinic or patients home.
· After removal of personal protective clothing/equipment.
Routine washing
· Before preparing, eating, drinking or handling food
· Before and after smoking..
· After visiting the toilet.
· Before starting work (remove jewellery e.g. rings) and after leaving
· Before and after physical contact with each client in clinical situations e.g. bathing, assisting to move, toileting.
· After handling contaminated items such as dressings, bedpans, urinals, urine drainage bags and nappies etc.
· Before putting on sterile gloves.
· Before and after removing any protective clothing this includes sterile and non-sterile gloves
· After blowing your nose, covering a sneeze
· Whenever hands become visibly soiled
· After handling contaminated laundry and waste
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):