Hand Hygiene

1. Hand Hygiene Infection Prevention Team May 2010

2. Why Hand Hygiene? FACT: Hand Hygiene is the single most important measure for preventing the spread of infection (Pittet et al 2001) IT IS ESSENTIAL FOR PATIENT SAFETY

3. Ignaz Philip Semmelweis (1818 – 1865) • Hungarian born doctor • Worked in Vienna • Mortality rate in Doctor led ward 3 times higher than Midwife led ward • Doctors worked in autopsy room, then delivered women afterwards • Semmelweis identified link in 1846 & introduced chlorinated lime for hand washing • Mortality rate fell dramatically

4. Why carry out hand hygiene?: • To render hands socially clean and to remove transient micro-organisms. NB: Routine hand hygiene removes most transient micro-organisms from soiled hands.

5. Resident Flora: Deep seated Difficult to remove Part of body’s natural defence mechanism Associated with infection following surgery/invasive procedures. Transient Flora: Superficial Transferred with ease to and from hands Important cause of cross infection Easily removed with good hand hygiene. What are your hands carrying?

6. Hand Hygiene includes: • Routine hand washing • Surgical hand ‘scrub’ • Use of alcohol rubs/gels.

7. NOTHING BELOW THE ELBOWS (NBE) • In line with national guidance (DoH, Sept 2007), SUHT has chosen to adopt a “Nothing Below the Elbows” policy for all staff working in the clinical environment • Clinical environment to be defined as “any area where a patient is seen/treated” e.g. • Wards • OPD’s • Radiology • ED • These requirements apply even if the staff member will not be having direct clinical contact with a patient, as hand contamination & the need for hand hygiene occurs due to contact with the environment & equipment, as well as with patients.

8. NBE Cont. • On arrival in the clinical environment • ALL staff (clinical & non-clinical), volunteers & visiting staff must remove jackets/cardigans/jumpers/coats & hang them up in a designated secure area for the ward/dept they are in • Wristwatches, bracelets (except Kara) & all rings (except for a PLAIN wedding band) must be removed • Long sleeves must be rolled up to above the elbow • Hands must then be decontaminated with alcohol hand rub/gel or soap & water following the posters on display in the clinical areas.

9. NBE Cont. • Any staff member with any portion of their forearm, wrist and/or hand in a bandage, splint, plaster cast and/or sling of any description cannot be permitted to work in the clinical environment as hand contamination and the need for hand hygiene occurs due to contact with the environment and equipment, as well as with patients.

10. Fingernails • Fingernails • Short • Clean • Free from nail varnish • Free from nail art • Free from nail extensions • Free from artificial fingernails • Harbour micro organisms that are not easily removed during hand hygiene (Larson, 1989) • Documented evidence of link between artificial nails and a Pseudomonas outbreak in a neonatal intensive care unit in the USA

11. Jewellery • Jewellery worn on the hands & wrists • become contaminated during work activities • Prevent thorough hand hygiene procedures (Larson, 1985)

12. Permissible Jewellery • Plain wedding band • Ridges, stones or grooves harbour higher levels of micro organisms • Could potentially damage the integrity of a patient’s skin • Kara bracelet • A steel bracelet (usually worn on the right wrist) by members of the Sikh faith • Forms one of the five “K’s” • Fob watches or wrist watches worn through a belt loop on a waistband

13. Unacceptable Jewellery • Rings other than a plain wedding band • Engagement rings • Eternity rings • Bracelets other than a Kara • Medic-Alert (may be worn as necklace or anklet or attached to uniform, but not on the wrist) • Charity bracelets • Friendship bands • Wrist Watches

14. RELIGIOUS CONSIDERATIONS Alcohol hand rubs – most religions give priority to health principles to ensure patient safety. Consequently, no objections have been raised against the use of alcohol-based products for environmental cleaning, disinfection or hand hygiene by any religion (WHO, 2006; Allegranzi et al, 2009).

15. RELIGIOUS CONSIDERATIONS CONT. • Nothing Below the Elbows – It has been established that all religions endorse the principle that an individual should do no harm to others. The wearing of long sleeves prevents effective hand hygiene as it is not possible to clean the wrists fully, and hand hygiene is essential for safe patient care. Therefore, staff who are required by their religion to wear long sleeves must roll-up their sleeves to ensure that the wrist & forearm are exposed in the following circumstances: • When undertaking direct patient contact. • As part of Infection Control “Standard”, “Contact”, or “Protective Isolation” precautions. • When performing hand hygiene, using either soap & water or alcohol hand gel.

16. WHO “My five (KEY) moments for hand hygiene” • Before touching a patient • Before clean/aseptic procedure • After body fluid exposure risk • After touching a patient • After touching patient surroundings

17. Additional Moments for Hand Hygiene • Before commencing work/after leaving work area • Before preparing or eating food • Before handling medicines • Before wearing & after removing gloves* • After handling contaminated laundry & waste • After using the toilet • After contact with patients in isolation • After cleaning equipment or the environment

18. Health-care & Patient Zones

19. Choice of cleansing agent. Risk Assessment: • Likelihood that micro-organisms have been acquired or transmitted. • Whether the hands are visibly soiled. • What procedure is about to take place. • Wash hands with soap & water following contact with Clostridium difficile diarrhoea/infective diarrhoea.

20. Alcohol rubs/gels • Use on visibly clean hands only • Rub into hands using same technique as for hand washing • Continue rubbing until dry (emollient will condition hands). • Not suitable for use following contact with Clostridium difficile or suspected infectious diarrhoea.

21. Routine Hand Washing. Duration • Routine hand wash = 40 – 60 seconds. Technique • Wash systematically, rubbing all parts of hands and wrists with soap and water – careful to include areas of hands that are most frequently missed.

22. Technique • palm to palm • backs of hands • interdigital spaces • fingertips • thumbs and wrists • nails

23. Areas most frequently missed: • Webs of fingers • Thumbs • Palms • Nails • Backs of fingers & hands • Wrists

24. Drying: • CRUCIAL – micro-organisms thrive in a warm, moist environment • Use paper hand towels • When you dry your hands: • Work from fingertips to wrists • Dispose of used towel correctly (foot operated bin) • Repeat until both hands are completely dry.

25. Tips: • Remove jewellery, roll up sleeves & remove wrist watches (should already be compliant with NBE). • Always use running water at a comfortable temperature • Wet hands thoroughly before applying any soap (forms a protective barrier) • Use enough soap to get a visible lather

26. Tips: MAKE SURE THAT YOU: • Clean all parts of both hands • Pay attention to thumbs, fingertips, palms. • Clean and dry beneath wedding rings (& Kara if worn) • Pay equal attention to dominant and non-dominant hands.

27. Tips: • Rinse your hands thoroughly under running water to ensure that all micro-organisms and soap are washed away. • Leaving soap on your hands or failing to dry properly will make them sore. • The only time you should use soap & water followed by alcohol hand gel, is when you are about to don a pair of sterile gloves prior to performing a (non-operative) aseptic technique.

28. Looking after your hands • Risk of skin problems (dermatitis) may increase with frequent hand washing. • Bacterial counts increase when skin is damaged. • Risk reduced by: • Using alcohol gel instead of washing if appropriate • Always apply soap to wet hands. • Thorough rinsing & drying • Moisturise (should be available in all clinical areas) • Only using gloves when necessary • Always cover cuts and grazes • Report any skin rashes immediately to Occupational Health (ext 4156)

29. Hand Care Important to look after the skin & fingernails Damaged skin leads to loss of a smooth skin surface & increases the risk of skin colonisation with resistant micro organisms Continuing to work with damaged, cracked or weeping skin may expose the healthcare worker to increased infection risk, which could ultimately lead to sickness absence due to dermatitis

30. Hand Care cont. • Appendix 8 (p. 24) of the Hand Hygiene Policy details the action a staff member must take if they experience • Acute skin lesions/conditions/reactions • Chronic skin lesions/conditions/reactions • Possible dermatitis • The staff member must seek advice from the Occupational Health Department (OH)

31. Action is not optional: • Professional Codes of Conduct • Clinical Negligence Scheme for Trusts (CNST) • NHSLA (NHS Litigation Authority) • Trust Policies (Terms & conditions of employment) • Standards for Better Health core standard 4a. • The Health Act 2006 (Revised 2008)

32. Any Questions?