Hand Hygiene Policy Version 2.0 - Ipswich Hospital

Hand Hygiene Policy
Version 2.0
Purpose:
For use by:
This document is compliant with
/supports compliance with:
To advise and inform all Trust staff of the hospital’s Hand Hygiene Policy
All hospital staff
Health Act 2006
Standards for Better Health C4a
NHS Litigation Authority risk management standards for Acute Trusts, Standard 2
Criterion 8
This document supersedes: Hand Hygiene Policy 1.0
Approved by:
Hospital Infection Control Committee
Approval date: 26 January 2009
Ratified by
Trust Management Team
Date Ratified 9 February 2009
Implementation date: 25 February 2009
Review date 1 February 2012
In case of queries contact:
Responsible Officer
Directorate and Department
Head of Infection Control
Nursing and Quality, Infection Control
Archive Date ie date document no
longer in force
Date document to be destroyed:
(10 years after archive date)
To be inserted by Information Governance Department when this document is
superseded. This will be the same date as the implementation date of the new
document
To be inserted by Information Governance Department when this document is
superseded.
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Hand Hygiene Policy v2.0 Implementation Date 25 February 2009

Version and document control:
Version Date of issue Change Description
Author
number
v 0.1 First draft Lesley Taylor
v 1.0 15.1.08 Approved and ratified version including
Lesley Taylor
comments from HICC
v 1.1 7.1.09 Updated to reflect new policy template Gill Fewkes
v 1.2 9.1.09 Added para 2.6 on Education & Training and
clarified Section 6
Gill Fewkes &
Lesley Taylor
This is a Controlled Document
Printed copies of this document may not be up to date. Please check the hospital intranet for the
latest version, destroy all previous versions.
Hospital documents may be disclosed as required by the Freedom of Information Act 2000.
Details about sharing this document with third parties are contained in Section 6 of this document.
Sharing this document with third parties
As part of the hospital’s networking arrangements and sharing best practice, the hospital supports
the practice of sharing documents with other organisations. However, where the hospital holds
copyright to a document, the document or part thereof so shared must not be used by any third
party for its own commercial gain unless this hospital has given its express permission and is
entitled to charge a fee.
Release of any strategy, policy, procedure, guideline or other such material must be agreed with
the Lead Director or Deputy/Associate Director (for hospital -wide issues) or Directorate/
Departmental Management Team (for Directorate or Departmental specific issues). Any requests
to share this document must be directed in the first instance to the Head of Infection Prevention
and Control.
For further advice see the Development and Management of Strategies, Policies, Protocols,
Procedures, Guidelines and other Guidance Material Policy
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Hand Hygiene Policy v2.0 Implementation Date 25 February 2009

CONTENTS
Page No
SECTION 1 - INTRODUCTION ................................................................................................ 4
SECTION 2 – DUTIES AND RESPONSIBILITIES................................................................... 4
SECTION 3 – HAND HYGIENE ............................................................................................... 6
3.1 Hand Hygiene ............................................................................................................. 6
3.2 Hand washing facilities ............................................................................................... 6
3.3 Availability of handrub ................................................................................................. 7
3.4 Methods of effective hand hygiene .............................................................................. 7
3.5 Replenishment of supplies .......................................................................................... 8
3.6 Signage ...................................................................................................................... 8
3.7 Equality Impact Assessment ....................................................................................... 8
3.8 Dignity and Respect Charter ....................................................................................... 8
SECTION 4 – TRAINING AND EDUCATION .......................................................................... 8
4.2 Training Needs Analysis (TNA) ................................................................................... 8
4.3 Training Prospectus .................................................................................................... 9
4.4 Training ....................................................................................................................... 9
SECTION 5 – DEVELOPMENT AND IMPLEMENTATION, INCLUDING DISSEMINATION ... 9
SECTION 6 – MONITORING COMPLIANCE AND EFFECTIVENESS .................................... 9
SECTION 7 – CONTROL OF DOCUMENTS INCLUDING ARCHIVING ARRANGEMENTS 10
SECTION 8 – SUPPORTING COMPLIANCE AND REFERENCES ...................................... 11
APPENDIX 1 - HOW TO HANDWASH .................................................................................. 12
APPENDIX 2 - HOW TO HANDRUB ..................................................................................... 13
APPENDIX 3 - HAND HYGIENE OBSERVATION SHEET .................................................... 14
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SECTION 1 - INTRODUCTION
1.1 Policy Statement and Rationale
The Ipswich Hospital NHS Trust is committed to ensuring that patient safety including the
prevention and control of infection is paramount at all times. This policy describes the
precautions to be taken when caring for all patients regardless of whether they have been
diagnosed with a particular infection or carriage of a specific organism.
The overall objective is to ensure that there is a Trust-wide approach to hand hygiene that
ensures that the risk of transmission of infection is minimised at all times, which is
communicated to and available to all staff, patients, their families and carers and the public.
1.2 Key Principles
Hand hygiene
Use of soap and running water
Use of alcohol hand rub
1.3 Background Information
During the past two decades, healthcare associated infections (HCAI) have become a
significant threat to patient safety. The technological advances made in the treatment of
many diseases and disorders is often undermined by the transmission of infections within
healthcare settings, particularly those caused by antimicrobial-resistant strains of diseasecausing
microorganisms that are now endemic in many healthcare environments. The
financial and personal cost of these infections, in terms of the economic consequences to
the NHS and the physical, social and psychological costs to patients and their relatives,
have increased both government and public awareness of the risks associated with
healthcare interventions, especially that of acquiring a new infection.
Although not all HCAIs can be prevented, many can. Clinical effectiveness, ie, using
prevention measures that are based on reliable evidence of efficacy, is a core component
of an effective strategy designed to protect patients from the risk of infection.
1.4 Definitions
HCAI Healthcare Associated Infection
NHS National Health Service
HICC Hospital Infection Control Committee
PASA Procurement and Supplies Agency
IPC Infection Prevention and Control
SECTION 2 – DUTIES AND RESPONSIBILITIES
2.1 Chief Executive
The Chief Executive has ultimate accountability for all aspects of infection prevention and
control and for ensuring appropriate action is taken to promote low levels of HCAI. He/she
will be responsible for ensuring that the necessary resources and management framework
are available and for managing any high level risks to achieve this policy.
2.2 Director of Infection Prevention and Control (DIPC)
DIPC is appointed by the Trust Board and reports directly to the Chief Executive and the
Board. He/she is accountable to the Board for:
overseeing local control of infection policies and their implementation;
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managing the hospital’s Infection Control Team
reporting performance in infection control directly to the Chief Executive and Board.
assessing the impact of all existing and new policies and plans on infection and
making recommendations for change;
compliance with the Health Act 2006, Standards for Better Health Core Standard
C4a and Risk Management Standard 2 Criteria 7& 8, Standard 3 Criterion 6 and
Standard 4 Criterion 9.
2.3 Infection Control Team (ICT)
The team is responsible for the following:
for review/revision of this policy in line with national guidance or new evidence.
for monitoring compliance with and the effectiveness of this policy and reporting the
outcome to HICC
surveillance of infections to identify any potential failures associated with the policy
and for reviewing audit results associated with this policy as well undertaking or coordinating
audits on specific aspects
education of all staff in the contents of the policy in liaison with clinical teams and for
reporting attendance at training in accordance with Section 4
The Head of Infection Control is the Responsible Officer for this policy.
2.4 Business Unit General Managers and Chairs, Matrons, Consultants, Heads of
Department
These managers are responsible for
monitoring audit results and for communicating these throughout all staff groups in
their directorate.
reporting results of audits to the Hospital Infection Control Committee.
ensuring all staff comply with the policy and for developing and implementing action
plans if standards are seen to be below those considered acceptable by the
Hospital Infection Control Committee.
managing the performance of any staff responsible to them who do not comply with
the policy.
2.5 Individual staff
All staff, throughout the hospital play an important part in the control of HCAI and are
responsible for
ensuring that they are aware of the contents of the policy and that they comply with
it at all times.
reporting any failure to achieve the standards identified in this policy to their line
manager.
reporting any breaches of the policy that they witness to their line manager or other
senior person.
2.6 Education and Training Department
The Education and Training Department is responsible for the inputting of training data into
the central hospital staff training database, for producing reports on attendance at training
for managers and HICC. Other duties of the department are covered in the Mandatory
Training Policy.
2.7 Hospital Infection Control Committee
This Committee, chaired by DIPC, is responsible for providing strategic direction to the
Infection Control Team (ICT), approving infection control policies, plans and developments,
and considering the implications of any outbreaks, serious incidents and Department of
Health initiatives. It receives regular performance monitoring reports on IPC from all
directorates and is accountable for considering and approving action taken to ensure
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compliance with and the effectiveness of policies and guidelines, including the development
and implementation of any action plans.
2.8 Trust Management Team (TMT)
TMT will ratify IPC policies and have overall responsibility for the allocation of resources for
and the performance management of IPC within the hospital.
SECTION 3 – HAND HYGIENE
3.1 Hand Hygiene
Hands must be decontaminated immediately before each and every episode of patient
contact/care and after any activity or contact that potentially results in hands becoming
contaminated. These can be summarised as:
1 Before patient contact
When Clean your hands before touching a patient when approaching him or
her
Why To protect the patient against microorganisms carried on your hands
2 Before an aseptic task
When Clean your hands immediately before any aseptic task
Why To protect the patient against microorganisms including the patient’s
own, entering his or her body
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
contamination
4 After patient contact
When Clean your hands after touching a patient and his or her immediate
surroundings when leaving
Why To protect yourself and the healthcare environment from
contamination.
5 After contact with patient surroundings
When Clean your hands after touching any object or furniture in the
patient’s immediate surroundings, when leaving - even without
touching the patient
Why To protect yourself and the healthcare environment from
contamination.
3.2 Hand washing facilities
Adequate hand wash basins must be provided within each care areas. Clinical hand wash
basins must not have plugs or overflows as these can cause aerolisation of
microorganisms. The drain should be flush with the bottom of the basin to facilitate
cleaning. All clinical hand wash basins must be fitted with ‘non touch’ (sensor or foot
operated) or elbow taps.
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Hand wash basins must be cleaned regularly in line with the area’s Service Level
Agreement.
3.3 Availability of handrub
Alcohol-based handrubs must be readily available on notes trolleys and drug trolleys for
use in between patients.
Near patient alcohol hand rub should be made available in all healthcare facilities except
where it could pose a risk to patients, eg in paediatric areas or in the case of a vulnerable
adult. In each case or area, a formal risk assessment must be carried out to record the
decision to remove near patient alcohol from the area. Individually-carried dispensers
should be considered in these situations.
Staff who work in the community should be provided with individual dispensers of alcohol
gel.
Patients must be assisted and/or reminded of the importance of hand hygiene after using
the lavatory and before meals. Single use patient hand wipes or alcohol gel may be used
but washing with soap and water is vital in the presence of diarrhoea.
3.4 Methods of effective hand hygiene
Before a shift of clinical work begins, all wrist and hand jewellery must be removed (an
exception is made for a single, plain wedding band). Cuts and abrasions must be
covered with waterproof dressings. Fingernails should be kept short, clean and free
from nail polish. False nails and nail extensions must not be worn by clinical staff.
Hands that are visibly soiled or potentially grossly contaminated with dirt or organic
material (ie following the removal of gloves) must be washed with liquid soap and
running water.
Hands should be decontaminated between caring for different patients or between
different caring activities for the same patient. For convenience and efficacy an alcoholbased
handrub is preferable unless hands are visibly soiled. In some situations alcohol
based products are ineffective and hands must be washed with liquid soap and running
water (presence of Clostridium difficile or Norovirus).
Hands should be washed with liquid soap and running water after several consecutive
applications of alcohol handrub.
Effective hand washing technique involves four stages: preparation, washing, rinsing,
and drying. Preparation requires wetting hands under warm running water before
applying liquid soap. The hand wash solution must come into contact with all surfaces
of the hand. The hands must be rubbed together vigorously for a minimum of 10-15
seconds, paying particular attention to the tips of the fingers, the thumbs and the areas
between the fingers. Hands should be rinsed thoroughly prior to drying with good quality
paper towels. If a wedding band is worn ensure that the area under the ring is
decontaminated. See Appendix 1 - How to handwash.
When decontaminating hands using alcohol hand rub, hands should be free of dirt and
organic material. The handrub solution must come into contact with all surfaces of the
hand. The hands must be rubbed together vigorously, paying particular attention to the
tips of the fingers, the thumbs and the areas between the fingers, and until the solution
has evaporated and the hands are dry. See Appendix 2 – How to handrub.
Clinical staff should be aware of the potentially damaging effects of hand
decontamination products. They should be encouraged to use an emollient hand
cream regularly, for example, after washing hands before a break or going off duty and
when off duty, to maintain the integrity of the skin.
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If a particular soap or alcohol based product causes skin irritation, review methods as
described above before consulting the Occupational Health team.
3.5 Replenishment of supplies
Soap and paper hand towels will be replenished by domestic staff routinely, but supplies
must be available for replenishment if required in their absence.
Alcohol gel dispenser replenishment is the responsibility of the ward staff, including those
located at the bug stops on entry to the ward. However, all staff have a duty to bring the
ward staff’s attention containers that need replacing.
All hand hygiene products used within the hospital must be approved by the Infection
Control Team. Purchase through PASA will ensure that products have been subject to
appropriate testing.
3.6 Signage
Signs explaining the importance of hand hygiene must be visible on entry to all in-patient
healthcare facilities.
There must be clearly signposted hand hygiene facilities on entry and exit from in-patient
wards.
Visitors and patients need to be encouraged to comply with requests for hand hygiene
through the use of easily visible and clear signage, information leaflets and where possible,
automated speech systems explaining the importance of hand hygiene.
3.7 Equality Impact Assessment
An Equality Impact Assessment has been undertaken and this policy complies with current
legislation
3.8 Dignity and Respect Charter
The hospital’s Dignity and Respect Charter will be adhered to in implementing this policy.
SECTION 4 – TRAINING AND EDUCATION
4.1 The hospital places a high priority on IPC education and training which includes effective
hand hygiene and use of gloves. It forms part of the hospital’s mandatory training
programme to be completed by staff both on induction and at designated regular intervals
throughout their course of employment.
4.2 Training Needs Analysis (TNA)
The Head of Infection Control will undertake an annual training needs analysis of all IPC
training, including hand hygiene, provided by the organisation to ensure compliance with
minimum standards set by the NHS Litigation Authority and Health Act. This TNA identifies
the level of training required by each staff group which acts as a baseline for identifying
TNA for all individual members of staff.
The Head of Infection Control will agree these mandatory training requirements with HICC.
Following this, the Head of infection Control will forward the completed TNA to the
Education and Training department which will be used to inform the hospital’s TNA
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covering all areas of mandatory training. This TNA will be published on the hospital’s
intranet.
4.3 Training Prospectus
In addition the Head of Infection Control will compile information on the training to be held
each year and forward details to the Education and Training Department for inclusion with
the hospital’s training prospectus. This will also be placed on the hospital’s intranet.
4.4 Training
It is the responsibility of all line managers to ensure that their staff receive mandatory
training in line with the TNA. Each member of staff is also personally responsible for
attending training courses and for carrying out their duties in accordance with the training
given. Full information is given in the hospital’s Mandatory Training Policy including
duties and responsibilities for managers and staff
the arrangements for staff to receive training,
the recording of training received on the hospital’s electronic staff record system
and the availability of records
the process for checking that all relevant staff groups, as identified by the TNA,
complete mandatory training
the process for following up those staff who fail to attend mandatory training
linking mandatory training with annual staff appraisals.
SECTION 5 – DEVELOPMENT AND IMPLEMENTATION, INCLUDING DISSEMINATION
5.1 This policy has been developed by the Infection Control Team, with input from members of
the Hospital Infection Control Committee and infection control link nurses. The revised
policy will be submitted to the Trust Management Team following approval by the Hospital
Infection Control Committee.
5.2 This policy will be made available on the hospital’s intranet and brought to the attention of
all staff by broadcast and through mandatory training and the work of Infection Control Link
Nurses and via implementation of audits and the dissemination of results.
SECTION 6 – MONITORING COMPLIANCE AND EFFECTIVENESS
6.1 Hand hygiene resources and individual practice will be audited at regular intervals and the
results fed back to healthcare workers.
6.2 The application of the Standards Principles for Infection Control are intended to provide
consistency of audit practice of hand hygiene compliance and do not preclude departments
from continuing to audit hand hygiene facilities, competency and practice in respect of low
and medium risk hand hygiene compliance.
6.3 An audit framework that includes the principle of "local audit for local action" which requires
a clear escalation standard ensuring that an immediate response occurs at a local level and
a rapid improvement cycle is embarked upon when compliance drops below the expected
standards.
The audit framework is as follows:
1. The target for Hand Hygiene is set at 100%, and monitored through weekly audits
undertaken by peers.
2. If the standard is over 95% then the next audit is due the following week.
If the standard is maintained for four weeks at 95% they may step down to two weekly,
but no less than this.
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3. If the standard is over 80% then the Head Matron must be informed and the audit
repeated daily until 95% is achieved for three consecutive days.
4. If the standard is below 80% the Head Matron will ensure hand hygiene training is
provided to the local area and it is re audited daily until it reaches 95% for three
consecutive days.
5. Should an area fail to achieve 60% or fall below 80% on three of four weeks, special
measures will be enacted (these can include daily visits from the Chief Executive/
Director of Nursing & Quality, targeted training or a calling to account to the Chief
Executive.
Compliance against a target of 100% will be audited and reported on across the hospital.
6.4 An audit tool must be used to observe a minimum specified number of individual healthcare
workers opportunities for and their subsequent compliance (or not) with hand hygiene
activity over a 20 minute period (see Appendix 3)
Audits of hand hygiene compliance, using the hand hygiene observation sheet, must take
place, as a minimum, in the context of clinical procedures and at the point of care using the
WHO ‘Your 5 moments for hand hygiene’ and results provided monthly to the
Commissioning Primary Care Trust for entry on to the Strategic Health Authority balanced
score card data. This will be undertaken by The Productive Ward
Clinical champions.
6.5 The hospital’s electronic staff record system will be used to monitor compliance with
training. The Assistant Director of Education and Training will produce monthly reports to
Business Units who will be required to follow up non-attendance of staff within their areas of
responsibility. Each Business Unit will be required to report on training levels to HICC as
part of their monthly performance reports together will action taken to improve training
levels where required. Action taken will be monitored by HICC.
6.6 Monthly ICT performance data is reported to HICC by DIPC and the Head of Infection
Control. Any remedial action is identified and action plans agreed by HICC. Responsibility
for implementation is agreed and progress monitored by HICC within agreed timescales.
Each Business Unit reviews IPC as part of its own governance arrangements and submits
highlight reports on compliance to HICC in accordance with an agreed reporting schedule.
Any identified risks with IPC compliance will be reported to and considered by the Risk
Management Committee who will monitor action taken to mitigate the risk.
Performance data is reported monthly to TMT, Trust Board, Senior Managers and
Clinicians and disseminated to staff – Lead DIPC.
SECTION 7 – CONTROL OF DOCUMENTS INCLUDING ARCHIVING
ARRANGEMENTS
7.1 Once ratified by the Trust Management Team, this policy will be forwarded to the
Information Governance Department for a document index number to be assigned and
recorded onto the hospital’s master index.
7.2 The DIPC is responsible for ensuring that this policy adheres to the Trust’s Record
Management Policy, including working with the Information Governance Department on
retention and archiving arrangements.
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SECTION 8 – SUPPORTING COMPLIANCE AND REFERENCES
8.1 This policy will support the hospital’s compliance with
The Health Act 2006 including the Code of Practice for the Prevention and Control
of Healthcare associated infections (amended January 2008)
NHS Litigation Authority Risk Management Standards for Acute Trusts – Standard 2
Criteria 5, 6 and 8, and Standard 4 Criterion 9
Department of Health. (2003). Winning Ways: Working Together to Reduce
Healthcare Associated Infection in England
National Patient Safety Agency. (2004). Patient Safety Alert 4 Clean Hands Help to
Save Lives and Clean Your Hands Campaign
Healthcare Commission (2007). Healthcare associated infection: What else can the
NHS do
8.2 References
Winning Ways: working together to reduce healthcare associated infection in England
(2003), Chief Medical Officer, Department of Health.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuida
nce/DH_4064682
Epic2: National evidence based-based guidelines for preventing healthcare associated
infections in NHS hospitals in England (2007). Journal of Hospital Infection (Vol 65
supplement 1, S1-64). http://www.epic.tvu.ac.uk/PDF%20Files/epic2/epic2-final.pdf
The Health Act 2006: Code of practice for the prevention and control of healthcare
associated infections : Department of Health - Publications
World Health Organization, Clean Care is Safer Care, Five Moments for hand Hygiene,
accessed 15/01/09. http://www.who.int/gpsc/tools/Five_moments/en/index.html
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APPENDIX 1 - HOW TO HANDWASH
Wet hands with water Apply enough soap to cover Rub hands palm to palm
all hand surfaces
Right palm over left dorsum Palm to palm with fingers Backs of fingers to
with interlaced fingers and interlaced opposing palms with
vice versa
fingers interlocked
Rotational rubbing of left Rotational rubbing, backwards Rinse hands with water
thumb clasped in right palm and forwards with clasped
and vice versa
fingers of right hand in left palm
and vice versa
Dry thoroughly with a single
use towel
Use elbow taps properly or
use towel to turn off
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APPENDIX 2 - HOW TO HANDRUB
Apply a palmful of the product in a cupped
hand and cover all surfaces
Rub hands palm
to palm
Right palm over left dorsum Palm to palm with fingers Backs of fingers to
with interlaced fingers and interlaced opposing palms with
vice versa
fingers interlocked
Rotational rubbing of left Rotational rubbing, backwards Continue rubbing until
thumb clasped in right palm and forwards with clasped hands are dry
and vice versa
fingers of right hand in left palm
and vice versa
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APPENDIX 3 - HAND HYGIENE OBSERVATION SHEET
HAND HYGIENE OBSERVATION SHEET
The observation sheet is intended to look at all groups of staff. If necessary move around the ward
so you can observe all staff groups. The audit of hand hygiene compliance should be undertaken at
the point of patient care and after any activity or contact that potentially results in hands becoming
contaminated, ie if in contact with anything within the patient curtain area.
Date ..................... Time …………….. Location of audit ………………………………
Observer’s Name & Designation …………………………………………..………………
Observe for a 20 minute period or for a
minimum of 20 hand hygiene opportunities
Please complete audit tool indicating:
‘O’ for a hand hygiene opportunity
‘H’ for observed hand hygiene (unchallenged)
‘C’ for observed hand hygiene (when challenged)
If a member of staff has to be challenged to perform hand hygiene at an appropriate
opportunity, please STOP them and discuss this with them and record as ‘C’
if they then perform hand hygiene.
If a staff member has to be challenged regarding hand hygiene record
their full name and designation next to the hand hygiene opportunity.
Nurses / HCA
Allied Health
Professionals
(eg Physiotherapists /
Occupational Therapists)
Doctors
Example:
O – H
O – H
O – C (record name +
designation)
O – C (record name +
designation)
O – H
O – H
O
(record
name+designation) Others
(health care workers eg Porters /
Ward Assistants – NOT
PATIENTS / VISITORS)
Percentage compliance for both unchallenged and challenged hand hygiene will be reported:
Unchallenged:
Challenged:
Compliance = observed hand hygiene (H) x 100 = ___ % Compliance = observed hand hygiene (H+C) x 100 =___ %
hand hygiene opportunities (O)
hand hygiene opportunities
PLEASE RETURN AUDIT FORMS TO: Nursing & Quality Administrator
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Action following audit
Nominated member of staff
completes 20 min
Daily/weekly/monthly
observation
Head Matron submits
data to Nursing &
Quality Administrator
Audit data results are
submitted to Head Matron
the day of the audit
Nursing & Quality
Administrator produces
anonymised hand
hygiene report for
discussion at Clinical
Governance Meeting
Members of staff who were challenged
will be spoken to by the matron and they
will inform either AHP Leads, Clinical
Service Lead, Clinical Director or Support
Service line manager if a member of their
staff
For any members of staff who fail to demonstrate
behavioural change the Trust’s disciplinary
procedure will be followed by the Head Matron,
Clinical Service Lead, Clinical Director or their
Support Service Line manager as appropriate.
Head Matron, AHP Leads, Clinical
Service Lead, Clinical Director and
Service Manager discuss the number of
non compliances at the relevant
directorate governance
If the person remains non compliant the
Head Matron must raise this with the
service manager and clinical lead. The
AHP Lead or Clinical Service Lead and
the Head Matron will then continue to
follow the Trust’s performance
management process
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