Hand Hygiene Policy Version 2.0 - Ipswich Hospital

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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; Registered Document 472 Page 4 of 15 Hand Hygiene Policy v2.0 Implementation Date 25 February 2009
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 Registered Document 472 Page 5 of 15 Hand Hygiene Policy v2.0 Implementation Date 25 February 2009
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Hand Hygiene Policy Version 2.0 - Ipswich Hospital

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