Section 6
Guidelines for
Hand Hygiene
Issue No 4, April 2011, Section 6
On behalf of Infection Control Policy Review Group
© NHS Ayrshire and Arran
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Check local intranet site for current version
Guidelines for Hand Hygiene
Issue No 4, April 2011 - Section 6
Page 1 of 13
TITLE: Guidelines for Hand Hygiene
Policy
Reference:
Issue No 4, April 2011, Section 6
Scope:
Organisation Wide
Controlled
Document:
This document shall not be copied in part or whole without the express
permission of the author or the author's representative.
Expiry Date:
April 2014
Authors:
Mrs Barbara Dyet, Infection Control Clinical Trainer
Policy
Application:
Throughout NHS Ayrshire and Arran
Responsibilities for Implementation
Organisation:
Senior Management Team and Chief Executive
Directorate:
Directors
Corporate:
Senior Managers
Departmental:
Heads of Wards or Departments
Local:
All relevant staff
Policy
Statement:
It is the responsibility of all staff to ensure that they consistently maintain a high
standard of hand hygiene in accordance with this guidance.
Review Date:
October 2013
Agreed by:
Infection Control Policy Review Group
Approved by:
Signature /
Designation:
Dr R G Masterton
Executive Medical Director and
Chair – Prevention and Control of Infection Committee
Guidelines for Hand Hygiene
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Date 21/04/11
CONTENTS
PAGE
1.0
Introduction …………………………………………………………….
4
2.0
Preparation for Hand Hygiene …………………………......………..
6
3.0
Social Handwashing ………………………………………..…………
7
4.0
Hygienic Hand Hygiene ………………………………………………
8
5.0
Surgical Hand Hygiene ………………………………...………….….
10
6.0
Skin Care ……………………………………………………………….
11
7.0
Antabuse (Disulfiram) ………………………………………...……….
11
8.0
Facilities .…………………………………………..……………………
11
9.0
Risk Assessment .…………………………………………...…………
12
10.0
Hand Hygiene for Patient …………………………………………….
12
11.0
Hand Hygiene for Visitors ..………………………….……………….
12
12.0
Bibliography ……………………………………………………………
13
Guidelines for Hand Hygiene
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SECTION 6
GUIDELINES FOR HAND HYGIENE
1.0
INTRODUCTION
It is well established that inadequate hand hygiene constitutes the greatest risk
of cross-infection between staff, patients and the environment. Effective hand
decontamination is the single most important means of preventing the spread
of infection.
In January 2009 the Cabinet Secretary for Health and Wellbeing announced
that a Zero Tolerance approach to non-compliance with hand hygiene
standards be adopted across all healthcare settings CEL 5 (2009). NHS
Ayrshire & Arran has adopted the Zero Tolerance Policy and all staff have a
responsibility to ensure that they undertake adequate hand hygiene and
encourage others delivering care to do so.
All staff are strongly encouraged to undertake the NHS Ayrshire & Arran
online LearnPro Infection Control Modules. These can be accessed at
http://athena/ohrd/learndev/Pages/elearning4.aspx.
For further information please contact the Infection Control Clinical Trainer at
Crosshouse Hospital on ext 25766.
Regular local audits of hand hygiene should be performed in all clinical areas.
Further advice and support on undertaking hand hygiene audits can be
obtained from the Infection Control Clinical Trainer at Crosshouse Hospital on
ext 25766.
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NB The description given for the “Your 5 Moments for Hand hygiene” can be applied
to a range of settings and not just acute hospital wards.
Detailed guidance on the practical application of this policy in the home care
setting can be obtained in Section 7 “Infection Control Guidelines for Home
Care” in the Control of Infection Manual.
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1.1
Transient organisms
Transient organisms may include many different pathogenic organisms,
including those that commonly cause healthcare associated infections. Hands
acquire organisms from other sites on an individual’s body, from other people
and from the environment. Transient organisms do not normally survive for
long periods on the hands and therefore they either die or are passed on to
objects or individuals which are subsequently touched. The ability of transient
micro-organisms to transfer to and from the hands with ease results in hands
being extremely efficient vectors of infection.
Transient organisms are not firmly attached to the skin and can be removed
from hands by effective handwashing, or can be effectively destroyed by the
correct application of alcohol handrub on to socially clean hands.
1.2
Resident organisms
Resident organisms are mainly harmless and are not frequently implicated as
the cause of infections. However, some of these micro-organisms may cause
infection in patients e.g. when surgery or other invasive procedures allow them
to enter deep tissues, or when a patient is severely immunocompromised.
Most transient organisms can be removed by thorough washing of hands with
soap and water. The resident organisms, however, are mostly left on the skin
after washing with soap and water but can be greatly reduced in number by
washing with an antiseptic detergent preparation. The agent used for
handwashing is determined by the degree of antisepsis required. There are
three levels of hand hygiene:▪
▪
▪
2.0
Social Handwashing
Hygienic Hand Hygiene
Surgical Hand Hygiene
PREPARATION FOR HAND HYGIENE
To perform effective hand and wrist decontamination, as wrists are deemed
part of the hand, staffs are required to be “Bare below the Elbow” the only
exception being a plain finger ring band which should be moved / removed
when performing hand hygiene in order to reach the bacteria which can
harbour underneath.
Cover cuts and abrasions with waterproof dressing which can be
decontaminated appropriately.
Keep nails short and pay particular attention to them when washing your
hands.
Do not wear artificial nails or any nail products.
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3.0
SOCIAL HANDWASHING (using liquid soap and running water)
Routine hand washing using liquid soap and running water using a good
technique removes most transient micro-organisms from soiled hands. It is
essential that a social handwash is performed:▪
▪
▪
▪
▪
▪
3.1
Start/Leaving work
After personal use of the toilet
After blowing or wiping your nose
After sneezing or coughing into hands
Before eating, drinking, preparing or handling food
When hands are visibly soiled
(This list is not exhaustive)
Technique for social handwashing
A liquid soap and warm running water should be used
i)
Turn the water to a temperature comfortable to the hands
ii)
Wet both hands under running water before applying liquid soap
iii)
Using vigorous friction to produce a lather, wash the hands and wrists for
a minimum of 15 seconds covering all surfaces, as per the WHO “How
to wash your hands and wrists” process
iv)
Rinse all areas of the hands thoroughly under running water, holding
elbows higher than hands allowing water to flow from fingertips
v)
Dry hands and wrists thoroughly using a disposable paper towel
vi)
Turn off taps using elbow, if lever operated. Where lever or motion sensor
taps are not available turn off taps with a clean paper towel
vii) Carefully dispose of paper towel into a pedal operated waste bin
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4.0
4.1
HYGIENIC HAND HYGIENE
Hygienic hand hygiene – alcohol handrub
An alcohol handrub, correctly applied to socially clean hands is an acceptable
and very effective method of hand decontamination. The use of alcohol
handrub on socially clean hands is now the preferred method of hygienic
hand hygiene in most clinical situations.
Alcohol handrub should be applied to socially clean hands as per the WHO
“Your 5 Moments for Hand Hygiene”.
Thorough hand washing with liquid soap and running water must always be
undertaken before using alcohol handrub in the following situations:▪
When hands are soiled.
▪
Following direct hand contact with any body substance e.g. if gloves have
not been worn.
▪
After contact with patients, or their immediate environment, with confirmed
or suspected Clostridium Difficile Infection (CDI). Alcohol hand rub is not
effective against CDI spores; these must be removed by the physical
action of hand washing.
▪
After contact with patients, or their immediate environment, with confirmed
or suspected of having Norovirus.
▪
Following the removal of latex gloves. Restricted use of latex gloves is
advised. Please use Nitrile gloves routinely.
N.B. Gloves do not replace the need to perform hand hygiene.
4.2
Method of application (alcohol handrub)
In accordance with the Manufacturer’s instructions, dispense the required
amount of alcohol handrub and vigorously rub hands together for 30 seconds
until dry, ensuring that all areas of the hands and wrists are covered as per the
WHO “How to handrub” process.
Alcohol handrubs are only effective when used on socially clean hands and
when allowed to dry.
Alternatively - antiseptic soap.
A hand wash using an antiseptic detergent e.g. Hibiscrub/Hydrex, may be
used as an alternative to the above method.
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4.3
Technique for hygienic handwash
An antiseptic detergent preparation and warm running water should be used
i)
Turn the water to a temperature comfortable to the hands
ii)
Wet both hands under running water before applying antiseptic detergent
iii)
Using vigorous friction to produce a lather, wash the hands and wrists for
a minimum of 15 seconds covering all surfaces, as per the WHO “How
to wash your hands and wrists” process
iv)
Rinse all areas of the hands thoroughly under running water, holding
elbows higher than hands allowing water to flow from fingertips
v)
Dry hands and wrists thoroughly using a disposable paper towel
vi)
Turn off taps using elbow, if lever operated. Where lever or motion sensor
taps are not available turn off taps with a clean paper towel
vii) Carefully dispose of paper towel into a pedal operated waste bin
The use of Alcohol Handrub on socially clean hands is the preferred method of
Hygienic Hand hygiene
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5.0
SURGICAL HAND HYGIENE
Please note:▪ Surgical scrubbing / rubbing must be undertaken before donning sterile
theatre garments
▪ All hand / wrist jewellery must be removed
Surgical hand hygiene is intended to remove or destroy transient microorganisms and substantially reduce the numbers of detachable resident microorganisms and is achieved by using an antiseptic hand hygiene solution.
Surgical hand decontamination is essential prior to all surgical procedures.
Surgical Hand Hygiene may be achieved by:
▪
▪
5.1
Washing with a liquid antiseptic soap
Washing with a liquid non-antiseptic soap followed by application of alcohol
hand rub
Technique for surgical hand hygiene – antiseptic soap
Staff should refer to Theatre protocols for surgical scrubbing for detailed
technique.
A three minute hand wash using a detergent based antiseptic preparation is
recommended for the first operation on a list e.g. 4% chlorhexidine gluconate,
7.5% povidone iodine. Sterile brushes and nail picks should only be used for
fingernails, and not skin, as their use is likely to increase the number of
organisms on the skin surface.
The hand wash must be systematic and cover all areas of the forearms, wrists
and hands. After washing, rinse the forearms, wrists, and hands thoroughly
and dry using a sterile disposable hand towel.
Alternatively - technique for surgical hand hygiene using alcohol
handrub (Softalind Pure (BBraun))
i)
Wash hands with liquid soap for 1 minute.
ii)
Rinse hands carefully.
iii)
Dry thoroughly with a sterile disposable towel.
iv)
Dispense the alcohol hand rub into the dry hollow of your hand.
v)
Massage the alcohol hand rub into your skin in separate portions, for a
period of no less than 90 seconds. If another product is being used,
please refer to manufacturer’s instructions with regard to time.
vi)
In the first stage, disinfect your hands and forearms, up to and including
your elbows.
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vii) Disinfect the lower half of your forearm and your hands.
viii) Finally disinfect your hands by themselves. Your hands must stay wet
throughout the whole time of application. Rub in the last portion until it
dries.
ix)
6.0
Do not dry your hands or forearms again after you have carried out the
disinfection procedure.
SKIN CARE
It is extremely important that staff take steps to prevent damage to the skin on
their hands. Staff should develop a good hand hygiene technique when
performing hand decontamination. Hand products should be used in
accordance with manufacturers' instructions. Hands can also be protected by
applying a good quality emollient hand cream. Hand cream should be applied
2-3 times a day. In order that the hand cream is able to be absorbed by the
skin it is recommended that hand cream be applied at times when no
handwashing is likely to take place following application e.g. before going for
breaks, before going off duty.
Staff members developing skin irritation associated with hand hygiene should
seek advice from the Occupational Health Department.
7.0
ANTABUSE (DISULFIRAM)
Any member of staff who has been prescribed Antabuse (Disulfiram) must not
use alcohol handrubs. Alternative hand hygiene products may require to be
used. Staff should discuss this in strict confidence with the Occupational
Health Service.
8.0
FACILITIES
Every clinical area must provide appropriate hand washing facilities.
This includes an adequate number of suitably positioned hand wash basins
with warm water by means of either mixer taps or temperature controlled
water.
Access to hand wash basins must be free from obstacles which may impede
access by staff.
All hand wash basins must be stocked with liquid soap, paper towels and a
pedal operated bin.
Alcohol handrub must be widely available in all clinical areas and should be at
or near to every bed in acute areas.
Local risk assessments should be
undertaken to determine how this is implemented in each clinical environment.
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9.0
RISK ASSESSMENT
As alcohol handrub is a flammable liquid and present an ingestion risk it is
essential that a COSHH risk assessment is carried out prior to introduction in
any clinical area.
Local risk assessments should be carried out on the location and size of
dispensers in use and on the storage and disposal of new and used stock,
giving consideration to the likelihood of ingestion, especially in high risk wards
and clinical units.
It is recommended that alcohol handrub dispensers are not placed where they
can be accessed by patients who may not appreciate the dangers associated
with alcohol hand rubs or those who may willfully misuse them e.g. children,
confused patients or have alcohol dependency.
Patients in other areas who are potentially at risk should be assessed
individually and, if necessary and practical, the risk of ingestion controlled, e.g.
by close supervision or temporary removal of dispenser cartridges in the
vicinity. Alternatives include the provision of personal dispensers for staff.
10.0
HAND HYGIENE FOR PATIENTS
Hand hygiene facilities should be offered to patients
▪
▪
11.0
Following the use of toilet facilities including bedpans and commodes
before meals
HAND HYGIENE FOR VISITORS
Visitors should be encouraged to wash their hands before and after visiting.
This can be performed using liquid soap and running water. Alternatively
alcohol handrubs may be used. Particular attention should be made when
visiting patients in Isolation or patients with suspected or known CDI/Norovirus
when a hand wash must be performed before and after visiting. Visitors
should be advised against using the alcohol hand rub if they have damaged
skin such as cuts, abrasions or other skin lesions on their hands. A risk
assessment must be carried out where alcohol hand rub is provided at the
entrance to the ward (See Section 9).
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12.0
BIBLIOGRAPHY
1. LearnPro NHS online training modules Statutory and Mandatory Training
last accessed 10/03/11
2. Health Protection Scotland (2009) Hand Hygiene Policy & Procedure
Also available at
http://www.hps.scot.nhs.uk/haiic/ic/guidelinedetail.aspx?id=31220
(last accessed 10/03/11)
3. Infection Control Nurses Association. (2002). Hand decontamination
guidelines. ICNA c/o Fitwise, Bathgate UK.
4. Safety Action Notice (SAN(SC)05/34) 07 July 2005
Alcohol-based Handrubs: Risk of Ingestion
http://www.show.scot.nhs.uk/shs/hazards_safety/sanpdf/san0534.pdf
(last accessed 10/03/11)
5. Health Protection Scotland (2007) National Hand Hygiene Campaign
Available at http://www.washyourhandsofthem.com/
(last accessed 10/03/11)
6. Fagernes, M., Lingaas, E. and Bjark, P. (2007) Impact of a single plain
finger ring on the bacterial load on the hands of healthcare workers,
Infection Control & Hospital Epidemiology, 28, 1191-5.
7. Gordin, F. M., Schultz, M. E., Huber, R., Zubairi, S., Stock, F. and Kariyil, J.
(2007) A cluster of hemodialysis-related bacteremia linked to artificial
fingernails, Infection Control and Hospital Epidemiology, 28, 743-4.
8. Sax, H., Allegranzi, B., Uckay, I., Larson, E., Boyce, J. and Pittet, D. (2007)
'My five moments for hand hygiene': a user-centred design approach to
understand, train, monitor and report hand hygiene, Journal of Hospital
Infection, 67, 9-21.
9. Siegel, J., Rhinehart, E., Jackson, M., Chiarello, L. and The Healthcare
Infection Control Practices Advisory Committee (2007) Guideline for
Isolation Precautions: Preventing Transmission of Infectious Agents in
Healthcare Settings 2007, June 2007.
Available at
http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf
(last accessed 10/03/11)
10. Stout, A., Ritchie, K. and Macpherson, K. (2007) Clinical effectiveness of
alcohol-based products in increasing hand hygiene compliance and
reducing infection rates: a systematic review, Journal of Hospital Infection,
66, 308-12.
11. Pratt, R. J., Pellowe, C. M., Wilson, J. A., Loveday, H. P., Harper, P. J.,
Jones, S. R., McDougall, C. and Wilcox, M. H. (2007) epic2: National
evidence-based guidelines for preventing healthcare-associated infections
in NHS hospitals in England, Journal of Hospital Infection, 65, S1-64.
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