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Responsible Directorate:

Public Health

Responsible Director:

Judith Hooper

Date Approved:

10 March 2010


Governance Committee



Revision date:

March 2013

NICE GUIDANCE Once NICE guidance is published, health professionals are expected to take it fully into account when exercising their clinical judgment. However, NICE guidance does not override the individual responsibility of health professionals to make appropriate decisions according to the circumstances of the individual patient in consultation with the patient and/or their guardian or carer.

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Section 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

Introduction Associated Policies and Procedures Aims and Objectives Scope of the Policy Accountabilities and Responsibilities Routine Hand Washing Surgical Hand Washing Nailbrushes General Hand Care Advice Public Hand Hygiene Equality Impact Assessment Training Needs Analysis Monitoring Compliance with this Policy References

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Appendices A B C D E F

Definitions Key Stakeholders consulted/involved in the development of the policy/procedure Equality Impact Assessment Tool Sign off sheet Hand cleaning techniques Your 5 moments for hand hygiene at the point of care

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11 12 13 14 15 16

Policy Statement Infection prevention and control is of prime importance within NHS Kirklees and is essential to the safety and confidence of patients, families and carers. Effective hand decontamination is essential in the prevention and control of healthcare associated infection and disease.


Introduction The term ‘hand decontamination’ is utilised throughout this document and incorporates the cleaning of hands by either liquid soap or alcohol hand gel. Hand decontamination protects both the patient and health care worker. Hand hygiene is the single most important factor in the prevention of healthcare associated infections (Ayliffe et al 2000). NHS Kirklees employs a Dress Code Policy for Clinical Staff which states that “bare below the elbow” is an essential part of practice and must be engaged by all staff caring for patients. Hand hygiene using soap and water is essential before and after every patient contact. Alcohol hand rub in these instances should only be used AFTER washing with soap and water if the removal of resident bacteria is necessary, for example when carrying out an Aseptic technique. The transmission of organisms to an individual may occur through direct contact with contaminated equipment, the environment or indirectly as a result of touching by hands. Meticillin Resistant Staphylococcus Aureus (MRSA) and other pathogens have been recovered from a range of surfaces commonly touched including; door handles, computer key boards and sites where dust is allowed to settle. This supports the requirement for effective hand hygiene before and after every patient/client contact, and contact with their environment. 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”. NHS Kirklees 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 staff throughout the organisation.


Associated policies & procedures This policy should be read in accordance with the following Trust policies, procedures and guidance: ● ● ● ● ● ● ● ● ●

Infection Control Policy Incident Reporting Policy Disciplinary Policy and Procedures Diversity and Equal Opportunities in Employment Policy Health and Safety at Work Policy COSHH Policy Moving and Handling Policy Aseptic technique policy Dress code policy for clinical staff Page 3 of 16

● ● ● ● ● ● ● 3.

Decontamination of reusable medical devices Isolation Policy Waste management guidelines Incident reporting Health and safety policies Antiseptics and disinfectant use policy Clostridium difficile policy (2009)

Aims and objectives The aims and objectives of this policy are:-


To reduce the transmission of pathogenic micro-organisms between patients and healthcare worker.

To provide information to staff to ensure excellent hand hygiene practice.

Scope of the policy This policy must be followed by all NHS Kirklees employees who are developing policy and procedural documents or developing guidance for colleagues. It must be followed by all staff who work for NHS Kirklees, including those on temporary or honorary contracts, bank staff and students. Breaches of this policy may lead to disciplinary action being taken against the individual. Independent Contractors are responsible for the development and management of their own procedural documents and for ensuring compliance with relevant legislation and best practice guidelines. Independent Contractors are encouraged to seek advice and support as required.


Accountabilities and Responsibilities The Chief Executive (CE) is accountable for ensuring that effective arrangements for infection prevention and control are in place within NHS Kirklees. The Director of Infection Prevention and Control has responsibility to provide assurance to the Board that infection prevention and control policies are in place and their compliance audited. The Infection Prevention and Control Team will ensure the policy is reviewed as required and work with Heads of Service to implement necessary changes in practice.

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Routine Hand Washing Be bare below the elbow at all times when having direct contact with patients / clients and / or the health care environment Despite the simplicity of handwashing, many studies have shown that healthcare workers do not frequently decontaminate their hands after contact with patients. Routine hand decontamination removes transient micro-organisms acquired on the hands before they can be transferred. Handwashing with soap suspends transient organisms and allows them to be rinsed off. The correct technique for routine hand washing involves: ●

All wrist watches, bracelets and hand jewellery should be removed.

Cuts covered with waterproof dressings. Finger nails must be kept short, clean and free from nail polish / false nails.

Wet hands under running water.

Applying the soap covering all surfaces of the hand.

Vigorously rubbing the hands without adding more water.

Rinse hands thoroughly under running water to remove residual soap.

If elbow/wrist operated taps are not fitted use a paper towel to turn tap off.

Dry hands with disposable paper towels.

Dispose of hand towels safely into the domestic waste disposal bin, using a foot operated pedal bin.

Appendix E details the correct Hand Hygiene Technique to be followed 6.1

When to decontaminate In accordance with the World Health Organisation the “Five moments to hand hygiene” should be followed to ensure hands are decontaminated at appropriate times when providing care to patients; Appendix F identifies these. They are as follows: ● ● ● ● ●

Before patient contact Before an aseptic task After body fluid exposure risk After patient contact After contact with patient surroundings

Appendices E and F details the correct Hand Hygiene Technique to be followed using the National Patient Safety Agency (NPSA) and World Health Organisation (WHO) approaches to hand hygiene.

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Facilities required This policy aims to promote hand hygiene at the point of care. This refers to the patients’ immediate environment in which staff have patient contact (NPSA 2008) PEAT Assessments 2010). 6.2.1

Hand wash basin A designated hand washbasin that ideally complies with HTM 64 should be available. However, all basins for clinical use must have mixer taps, liquid soap and paper towels. This includes all patient care/clinical areas and decontamination areas. If facilities are to be upgraded/refurbished hand wash basins MUST be compliant with HTM 64 (Health Technical Memorandum 64 - sanitary assemblies).

6.2.2 Hand hygiene facilities in the patient’s home • •

All health care workers must have access to adequate equipment that allows them to decontaminate their hands when required. Health care workers must take alcohol hand gel with them on visits as a minimum to ensure adequate decontamination. Healthcare workers must take liquid soap and paper towels from the hand hygiene kits provided if hand washing with soap and water is required. If hand washing is required, then a liquid soap should be used in a sink that is clean and free from articles.

6.2.3 Liquid soap Liquid soap is the preferred solution for hand washing, for most care settings. Emollients are now standard in the majority of hand wash detergents which will prevent hands becoming dry and sore. 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 due to refillable containers having a greater risk of contamination by Gram-negative bacteria as they can multiply in the liquid soap. Bar soap can become contaminated with skin bacteria as well as Gram-negative bacilli and must, therefore, be avoided when possible. Bar soap is definitely not recommended for clinical staff. 6.3

Use of alcohol hand rub/limitations of alcohol hand rubs Alcohol hand rubs are not effective when used against spore forming pathogens such as Clostridium difficile. Alcohol solutions are not effective against some viruses as there is insufficient contact time. The method of application is illustrated in Appendices E and F.

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Dispense one application of alcohol handrub to clean dry hands (free of dirt and organic material).

Ensure solution covers all hand surfaces

Rub hands together vigorously, paying particular attention to the tips of the fingers, wrists, the thumbs and areas between fingers.

Rub hands together until the alcohol handrub has evaporated and the hands are dry. Do not use paper towels to remove residual gel.

Alcohol gel can be applied on 4 consecutive occasions before hand washing, unless they appear physically soiled

The risks associated with the use of alcohol handrub were highlighted in a national safety alert by the NPSA in 2008. This highlighted the need for a risk assessment to be undertaken when using alcohol handrub. The risks related to public access; the appropriate placement of alcohol handrub products the potential for misuse. Clinicians using alcohol handrub must therefore ensure that the risks are appropriately assessed to ensure alcohol handrub is safely stored and the potential for skin irritation or ingestion is managed. (DoH: Patient Safety Alert; 2008).

Surgical Hand Washing Surgical hand washing is intended to remove or destroy transient micro-organism and reduce detachable resident micro-organisms and is achieved by using an antiseptic hand wash. Surgical hand washing is essential before minor surgery, aseptic procedures and highly invasive procedures. Suitable antiseptic solutions are Chlorhexidine Gluconate 20% (Hibiscrub) and Povidone Iodine-odophors.


Nailbrushes Nailbrushes should not be used because they become heavily contaminated. If they are required, they must be single use items that are disposed of after each use.


General Hand Care Advice Frequent hand washing, or a poor hand washing technique, or inadequate hand drying can result in dry sore hands. Dry, cracked skin is more likely to harbour micro-organisms. ●

Ensure hands are rinsed and dried thoroughly.

An emollient hand cream should be applied regularly to protect the skin from the drying effects of regular hand decontamination (not communal jars). Hand lotions are advisable to prevent skin dryness. Oil based hand creams are not recommended as these are not compatible with latex gloves. Page 7 of 16


Keep nails short and clean.

Do not wear false nails while on duty. False finger nails are host to potential pathogens, including yeasts.

Remove all nail polish.

Avoid wearing jewellery, e.g. wristbands, bracelets and stoned rings.

Always cover cuts with a waterproof dressing

Ensure that there is an adequate supply of paper towels, soap, and antiseptic solution hand wash and alcohol handrub.

If a particular soap, antimicrobial hand wash or alcohol/product causes skin irritation avoid using and contact the occupational health department for advice as soon as possible.

Public Hand Hygiene Hand decontamination when visiting patients in hospital is encouraged on entry, after any patient/environmental contact and on leaving the area. Alcohol gel is available on the entrance to the ward at Holme Valley Community Hospital and also inside and outside of each room for all visitors to use. 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 hand hygiene poster indicating the correct hand wash procedure. Visitors should also be encouraged to wash their hands when visiting Care Homes. Visitors should be encouraged and or assisted to clean their hands before and after using the toilet and before eating. All patients must be offered hand wash facilities after using the toilet or commode and prior to eating/drinking. Within the cleanyourhands campaign, patients are encouraged to ask health care staff about their hand hygiene practice. The Trust would welcome patients asking staff these questions. This policy is available on the internet for the public to access confirming the organisations commitment and approach to hand hygiene.


Equality Impact Assessment This policy has been assessed for the potential adverse impact as set out in Appendix C. The policy has not identified an impact.


Training Needs Analysis Hand decontamination training will be delivered annually as part of the Mandatory Training sessions and included in the induction programme.

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Monitoring Compliance with this Policy Hand hygiene decontamination practice is covered in theory at the annual mandatory training that all staff must attend. There are also observational hand hygiene audits conducted by either peer or self- assessment on an annual basis using the Essential Steps assessment tool. This tests the compliance of successful and appropriate hand decontamination using the Essential Steps tool. The cleanyourhands tool will also be used where hand decontamination is not correctly implemented. The Infection Prevention and Control Senior Nurse within KCHS will work with teams to ensure these audits are conducted and action plans developed and monitored where compliance of 95% is not achieved. They will advise the commissioner of the outcomes of the audits on a monthly basis, and update the Kirklees Infection Control Committee members quarterly.

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Boyce J. Pittet D. (2002) Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection control Practices Advisory Committee. Centres for Disease Control and Prevention. Morbidity and Mortality Weekly Report 51:16. Department of Health (2006) Health Technical Memorandum 64: Sanitary assemblies (HTM64). Department of Health (2007) Uniforms and Workwear - An evidence base for developing local policy, DH, London. Department of Health (2008) clean hands save lives - patient safety alert: Gateway 10468. 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. Gordin, F. M., Schultz, M. E., Huber, R., Zubairi, S., Stock, F. and Kariyil, J. (2007) A cluster of haemodialysis-related bacteraemia linked to artificial fingernails, Infection Control and Hospital Epidemiology, 28, 743-4. Infection Control Nurses Association (2002) Hand Decontamination Guidelines. Infection Control Nurses Association and Regent Medical. National Audit Office (2000) The Management and Control of Hospital Acquired Infection in Acute NHS Trusts in England. National Audit Office. National Institute for Clinical Excellence (2003) Infection Control – Prevention of healthcareassociated infection in primary and community care. NICE. NHS (2008) Cleanyourhands Campaign. National Patient Safety Agency. NHS (2008) Supporting resource 29- myths about hand hygiene. National Patient Safety Agency. National Patient Safety Agency (2009): patient Environment Action Team Assessments 2010. Pratt et al; (2007) epic2 Project: National Evidence-based Guidelines for Preventing Healthcare Associated Infections in hospitals in England. Journal of Hospital Infection supplementing volume 65. World Health Organisation, (2006), WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft) World Alliance for Patient Safety, WHO, Geneva.

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HCAI Healthcare Associated Infection. This is an infection acquired through a healthcare intervention delivered in any setting.

MRSA Meticillin-resistant Staphylococcus aureus. A micro-organism which has become resistant to some antibiotics.

Bare Below the Elbows Bare below the elbows means that all staff in contact with patients should effectively wash their hands and wrists between each patient. It is only possible to wash hands properly by removing all jewellery and wearing short sleeved clothing.

Resident flora (resident microbes) Micro-organisms residing under the superficial cells of the stratum corneum and also found on the surface of the skin.

Transient flora (transient microbes) Micro-organisms that colonise the superficial layers of the skin and are more amenable to removal by routine hand washing, but easily picked up when touching patients, equipment or their environment.

Visibly soiled hands Hands on which dirt or body fluids are readily visible.

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APPENDIX B. Key stakeholders consulted/involved in the development of the policy/procedure

Stakeholders name and designation Infection Prevention and Control Team KICC

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Key Participant Yes/No Yes Yes

Feedback requested Yes/No Yes Yes

Feedback accepted Yes/No Yes Yes


Equality Impact Assessment Tool

Insert Name of Policy / Procedure Yes/No Does the policy/guidance affect one group less or more favourably than another on the basis of:


• Race


• Ethnic origins (including gypsies and travellers)


• Nationality


• Gender


• Culture


• Religion or belief


• Sexual orientation including lesbian, gay and bisexual people


• Age


• Disability - learning disabilities, physical disability, sensory impairment and mental health problems



Is there any evidence that some groups are affected differently?



If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?



Is the impact of the policy/guidance likely to be negative?



If so can the impact be avoided?



What alternatives are there to achieving the policy/guidance without the impact?



Can we reduce the impact by taking different action?



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Appendix D Sign off Sheet regarding Dissemination of Procedural Documents To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval.

Title of Document:

Hand Decontamination

Lead Director:

Dr Judith Hooper

Date Approved: Where approved: Dissemination Lead: Placed on Website: Review Date:

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Your 5 moments for hand hygiene at the point of care*

Before patient contact WHEN? Clean your hands before touching  a patient when approaching   him/her WHY? To protect the patient against  harmful germs carried on your  hands *Adapted from the WHO Alliance for Patient Safety 2006

After body fluid  exposure risk

Before an aseptic task WHEN? Clean your hands immediately  before any aseptic task WHY? To protect the patient against  harmful germs, including the  patients own, from entering  his/her body

After patient contact

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  harmful patient germs

After contact with  patient surroundings

WHEN? Clean your hands after touching a  patient and her/his immediate  surroundings when leaving the  patient's side

WHEN? Clean your after hands after  touching any object or furniture in  the patient’s immediate  surroundings when leaving – even if  the patient has not been touched

WHY? To protect yourself and the   healthcare environment from  harmful patient germs

WHY? To protect yourself and the   healthcare environment from  harmful patient germs

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