Hand Hygiene Policy Version 2.0 - Ipswich Hospital

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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. Registered Document 472 Page 6 of 15 Hand Hygiene Policy v2.0 Implementation Date 25 February 2009
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. Registered Document 472 Page 7 of 15 Hand Hygiene Policy v2.0 Implementation Date 25 February 2009
Page 1 and 2: Hand Hygiene Policy Version 2.0 Pur
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Page 13 and 14: APPENDIX 2 - HOW TO HANDRUB Apply a
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Hand Hygiene Policy Version 2.0 - Ipswich Hospital

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