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INFECTION PREVENTION AND CONTROL POLICY
Hand Hygiene and Gloves
|POLICY NO. |POL/001/042/016 |
|DATE RATIFIED |February 2009 |
|DATE IMPLEMENTED |February 2009 |
|NEXT REVIEW DATE |February 2011 |
POLICY STATEMENT / KEY OBJECTIVE:
To ensure hands are decontaminated and the correct gloves are used in clinical practice
ACCOUNTABLE DIRECTOR: Phil Robertson – Director of Nursing and Director of
Infection Prevention and Control
POLICY AUTHOR: Meryl Lawrenson – Head of Nursing and Infection
Prevention and Control
POLICY DOCUMENT CONTROL SHEET
|Title |Title: |Hand Hygiene and Gloves |
| |Version: | |
|Supersedes |Supersedes: |Infection Prevention and Control Policy 001/042 |
| |Description of amendments: |Stand Alone Policy |
|Accountable Director |Lead: |Phil Robertson |
| |Designation: |Director of Nursing and Director of Infection Prevention and Control |
|Policy Author |Lead: |Meryl Lawrenson |
| |Designation: |Head of Nursing , Infection Prevention and Control |
|Consultation Circulation: |Circulation List: |All ward areas and Professional Management leads for distribution |
|Approval by |Committees / Groups Consulted: Date |Trust Infection Control Group. None Acute Infection Control Committee |
| | |January 2009 |
| |Executive Director: |Phil Robertson |
| |Name / Date |4th February 2009 |
| |Policy Monitoring Group: Date |Ratified |
| | |4th February 2009 |
| |Trust Board: Date (if applicable) |N/A |
|Circulation: |Issue Date: |February 2009 |
| |Circulated by: |Corporate Administration Team |
| |Issued to: |As per policy distribution list |
|Review |Review date: |February 2011 |
| |Responsibility of: |Meryl Lawrenson, Head of Nursing, Infection Prevention and Control |
|Link Reference Documents |1) |Infection Control Policies Acute Trust and PCT in Cumbria |
| |2) |All other related Infection Prevention Control Policies |
|Service User / Carer |1) |N/A |
|Information e.g. leaflets | | |
|for service users | | |
| |2) |N/A |
|Further Advice |Contact No. |Infection Control Department |
|Glossary of Terms – |Provide definitions of technical or |Completed Yes |
|Appendix 1 |specialised terminology used within the | |
| |policy. | |
|Terms of Reference – |Attach terms of reference of group |Completed Yes |
|Appendix 2 |relevant to the policy. | |
|Monitoring Audit Tool – |Use standard template within the policy.|Completed Yes |
|Appendix 3 | | |
|Training Requirements – |(Please state category A, B or C) |Completed Yes |
|Appendix 4 | | |
|Equality Impact Assessment |Refer to further guidance in Policy on |Completed Yes. |
|– Appendix 5 |the Development of Policies |Please return this sheet separate to Liba Stones, Equality and Diversity Project|
| |(POL/002/001). |Lead, Carleton Clinic. |
TABLE OF CONTENTS
1. INTRODUCTION 6
2. ROLES AND RESPONSIBILITIES 6
3. IMPROVING COMPLIANCE WITH GOOD HAND HYGIENE PRACTICE 6
3.1 Reasons Cited For Poor Compliance With Good Hand Hygiene Practice Include: 6
3.2 Factors Associated With Improved Compliance With Hand Hygiene Practice Include: 7
4 THE MICROBIOLOGY OF THE HANDS 7
4.1 Transient Skin Flora 7
4.2 Resident Skin Flora 7
5 TYPES OF HAND DECONTAMINATION 7
5.1 Routine Hand Decontamination 7
5.2 Aseptic Technique Hand Decontamination 8
6 WHEN TO DECONTAMINATE THE HANDS 8
7 CLEANSING AGENTS 8
7.1 Liquid Soap and Water 8
7.2 Alcohol Hand Rubs 8
7.3 Hand Lotion 9
8 FACILITIES FOR HAND HYGIENE 9
9 HAND DECONTAMINATION TECHNIQUES 9
9.1 Preparation of the Hands 9
9.2 Routine Hand Decontamination 9
9.3 Hand Decontamination for Aseptic Technique 10
9.4 Hand Drying 10
10 SKIN CARE 10
11 MONITORING 10
12 OCCUPATIONAL HEALTH 11
13.1 Statement of Good Practice: 11
13.2 Risk Assessment and Glove Selection (refer to (see appendix 4 & 5) 11
13.3 Double Gloving 12
13.4 Sizing of Gloves 12
13.5 Storage 12
13.6 Glove Disposal 12
13.7 Glove Inspection 13
13.8 Hand washing (refer to section 6) 13
14 GUIDANCE FOR THE PREVENTION AND MANAGEMENT OF GLOVE RELATED REACTIONS 13
14.1 The Occupational Health (ATOS Healthcare) 13
14.2 Suspected Glove Related Reaction 13
15. TRAINING 14
16. EQUALITY AND DIVERSITY 14
17. POLICY DESTRUCTION 15
APPENDIX 1 – HAND WASHING LEAFLET 18
APPENDIX 2 – HAND HYGIENE AUDIT TOOL 19
APPENDIX 3 – DECISION TREE FOR GLOVE SELECTION 24
APPENDIX 4 - APPROPRIATE GLOVE SELECTION FOR CLINICAL TASKS 25
APPENDIX 5 – NON-STERILE GLOVE DONNING GUIDE 26
APPENDIX 6 – STERILE GLOVE DONNING GUIDE 27
APPENDIX 7 - GLOSSARY OF TERMS 28
APPENDIX 8 - COMMITTEE / BOARD / GROUP TERMS OF REFERENCE 29
APPENDIX 10 - AUDIT TOOL GUIDANCE 31
APPENDIX 11 – EDUCATION AND TRAINING 32
APPENDIX 12 - EQUALITY IMPACT ASSESSMENT FORM 35
APPENDIX 13 - SIGNATURE RECORD 38
1. INTRODUCTION
Hand hygiene is the simplest, most effective measure for preventing healthcare associated infection. However, many studies show that adherence to recommended hand hygiene practice has been unacceptably low in healthcare workers, presenting a risk to user/clients (Ward et al, 1997; Pittet et al, 1999). Hand hygiene is therefore an important component of risk management and clinical governance and should become part of a culture of user/client safety. This policy aims to promote hand hygiene as evidence-based practice and to define responsibilities and actions required for compliance with good hand hygiene practice throughout the organisation. Whilst hand hygiene is most critical in staff involved in clinical activities, user/clients and visitors to wards/departments have an important role to play (see appendix 1). The recognition of increased risks to healthcare workers from blood borne viruses (BBVs) and the introduction of ‘Standard Precautions’ in order to prevent transmission of these viruses has resulted in a significant increase in the use of gloves. In the past gloves used in clinical practice contained latex which is known to cause hypersensitivity reactions in people. Changes in health and safety legislation have renewed focus on the issue of glove selection and use, which is clearly described within the policy.
2. ROLES AND RESPONSIBILITIES
Refer to POL/001/042, Infection Prevention and Control Policy, Overview
3. IMPROVING COMPLIANCE WITH GOOD HAND HYGIENE PRACTICE
The change process is complex and single interventions to improve hand hygiene practice have been found to fail. Therefore a multimodal strategy is required, which recognises the interdependence of factors associated with the individual, the environment and the organisation. Active participation by staff, managers and the Trust as an organisation are required to promote good hand hygiene practice as the expected norm. In addition, facilities for hand hygiene must be considered at the design stage of all healthcare premises developments.
3.1 Reasons Cited For Poor Compliance With Good Hand Hygiene Practice Include:
• Lack of knowledge / scepticism about the value of hand decontamination
• Perception of insufficient time or shortage of staff
• Belief that wearing gloves negates the need for hand hygiene
• Shortage of conveniently located sinks
• Lack of mixer taps to control water temperature
• Poor facilities for effective hand hygiene (especially in community settings)
• Skin irritation caused by hand decontamination agents
• Inaccessible supplies
• Interference with worker-user/client relationship; user/client needs perceived as priority
• Lack of encouragement / role modelling from key staff (Hand Hygiene Task Force, 2001)
3.2 Factors Associated With Improved Compliance With Hand Hygiene Practice Include:
• Education – continuous and innovative
• Written guidelines and reminders in the workplace
• Routine observation and performance feedback audit
• Engineering controls, e.g. conveniently sited sinks, mixer taps
• Acceptable hand hygiene and skin care agents
• Making alcohol hand rubs available
• User/client education
• Active participation and support from all levels of the organisation
• Addressing understaffing issues (Hand Hygiene Task Force, 2001)
4 THE MICROBIOLOGY OF THE HANDS
There are two groups of micro-organisms on the hands: the transient micro-organisms that are carried temporarily on the surface of the skin, and the resident micro organisms that colonise (or live on) the skin.
4.1 Transient Skin Flora
• Micro-organisms which are acquired on the hands through contact with other sites on the same individual, from other people, or from the environment.
• Easily acquired by touch and readily transferred to the next person or surface touched, so may be responsible for the transmission of infection.
• Removal of transient micro-organisms is therefore essential in preventing cross infection, and their removal is easily achieved by washing with soap and water.
4.2 Resident Skin Flora
• Micro-organisms which live in deep crevices and hair follicles, known as skin flora.
• Most are bacteria of low pathogenicity, such as coagulase-negative staphylococci.
• They are not readily transferred to other people and most are not easily removed by washing with soap.
• They do not need to be removed from the hands during routine clinical care.
• During invasive procedures, e.g. minor surgery, there is a risk that resident microorganisms may enter the user/client’s tissues and cause an infection.
5. TYPES OF HAND DECONTAMINATION
(Decontamination techniques are displayed in appendix 2)
5.1 Routine Hand Decontamination
The aim of routine hand decontamination is to remove transient micro-organisms before they can be transferred. Hands that are visibly soiled with dirt or body fluids should be washed using liquid soap and water. Hands that are potentially contaminated but visibly clean can be decontaminated using an alcohol-based preparation.
5.2 Aseptic Technique Hand Decontamination
This is a higher level of decontamination which should be carried out prior to invasive procedures, where extra care must be taken to prevent micro-organisms on hands from being introduced into the user/client’s tissues if gloves are damaged. Hand decontamination aims to remove transient micro-organisms and to substantially reduce resident micro-organisms. The process is achieved by using an antiseptic hand washing solution or an alcohol based preparation (if the hands are visibly clean).
Examples of situations where hand decontamination will be required:
• Before putting on sterile gloves prior to insertion of indwelling urinary catheter, or during an aseptic technique.
• Before caring for a severely immunosuppressed user/client.
• After caring for a User/client with a highly transmissible micro-organism.
6 WHEN TO DECONTAMINATE THE HANDS
Hands should be decontaminated immediately before every episode of direct user/client care, before handling food, and after any activity that potentially results in the hands becoming contaminated. Hands should always be decontaminated after gloves are removed. It is also important to ensure consideration is given to user/clients hand hygiene needs, providing them with the opportunity to decontaminate their hands following toileting and prior to meals.
7 CLEANSING AGENTS
7.1 Liquid Soap and Water
Hand washing with soap suspends transient micro-organisms in solution, allowing them to be rinsed off effectively (mechanical removal). Wall-mounted liquid soap dispensers should be used in clinical settings. They should be operated using the wrist or elbow. Dispensers should be replenished as soon as necessary and should have individual replacement containers that can be discarded when empty. Responsibility for daily checking and replenishment of liquid soap dispensers should be clearly defined in each clinical area, e.g. written into cleaning schedules and monitored by site managers.
N.B.* Bar soaps are not acceptable for any clinical setting as they easily become contaminated with bacteria, unless single person use and not left in communal areas.
7.2 Alcohol Hand Rubs
Rubs are very effective and suitable for routine hand cleansing, providing hands are not soiled or visibly dirty. They have an immediate broad spectrum activity on transient and resident micro organisms. They can be used at the point of care and provide a practical alternative in situations where access to hand wash sinks is limited. Hands must be thoroughly wet with the solution in order for it to be effective, using 2-3mls rub all aspects of hands vigorously until hands are dry, using the six step technique.
The positioning and location of alcohol hand rubs should be based on a risk assessment of the individual or client group. Always use the product recommended by the Trust and when replenishing dispensers the entire cartridge is to be replaced, do not top up.
7.3 Hand Lotion
The skin provides a waterproof barrier against micro-organisms provided it is healthy and intact. Healthcare staff are at increased risk of developing irritant contact dermatitis and eczema due to frequent hand washing. To minimise the risk of skin damage hand cream should be applied regularly, communal jars are not acceptable as the contents may become contaminated. All hand lotion is to be obtained via the supplies dept or pharmacy to ensure that the cream is compatible with other skin products and gloves in use.
Any plans to introduce new brands of cleansing agents to clinical areas should be fully discussed with the Infection Control Team.
8 FACILITIES FOR HAND HYGIENE
The following facilities are required for good hand hygiene:
• Sinks specifically allocated for hand hygiene, i.e. not also used for dirty procedures or other personal care.
• Lever-operated mixer taps with hot and cold water / light sensitive taps.
• Liquid soap in wall-mounted dispenser
• Good quality paper towels in wall-mounted dispenser
• Pedal-operated domestic waste bin (black bag) with lid
• Alcohol hand rub
These requirements should be considered when new services or premises are being developed. The Infection Prevention and Control Team must be contacted for advice, e.g. on sighting of sinks or choice of taps. When staff are working in environments which may lack good hand hygiene facilities, e.g. on community visits, they should take alcohol hand rub with them.
9 HAND DECONTAMINATION TECHNIQUES
9.1 Preparation of the Hands
• Keep nails short and clean and no artificial nails and nail polish allowed
• Do not wear rings with ridges or stones as they will increase bacterial counts and can perforate gloves
• Do not wear wrist watches and jewellery
• Bare below the elbow for clinical practice, no long sleeves
9.2 Routine Hand Decontamination
a) Soap and water (see appendix 1)
b) Alcohol hand rub (see appendix 1)
9.3 Hand Decontamination for Aseptic Technique
• Soap and water technique
• Choice of glove
• Soap and water following removal of gloves
N.B. Nail brushes should not be used for routine hand decontamination as they may damage the skin and may become contaminated.
9.4 Hand Drying
Effective drying of the hands is important as wet skin surfaces transfer micro-organisms more readily than dry ones. The method of hand drying is important in maintaining hygiene; hands can become re-contaminated by some drying methods such as fabric towels. Hands should be dried thoroughly using good quality paper towels from wall mounted dispensers close to each sink. There is conflicting evidence regarding the efficacy of hot air dryers, but they should be avoided in clinical areas due to noise, the time taken to use them, and their potential for re-circulating contaminated air.
10 SKIN CARE
The skin provides a waterproof barrier against micro-organisms, including blood-borne viruses, provided it is healthy and intact. Healthcare staff are at increased risk of developing irritant contact dermatitis and eczema due to frequent hand washing. Damaged sore skin, caused by harsh hand cleansing agents, has been cited as a reason why staff failed to decontaminate their hands (ICNA, 2002). To minimise the risk of skin damage, hands should be wet before applying any soap solution. Rinsing and drying the hands thoroughly will also help to protect the skin. Alcohol hand rubs with emollients are associated with less skin damage than soap and water (Pittet et al, 2000). Cuts or abrasions should be covered by a waterproof plaster for clinical work, which should be replaced when it becomes wet. Hand creams should be applied regularly to protect the skin from drying. Communal jars are not acceptable as the contents may become contaminated. It is recommended that clinical areas should have wall mounted hand cream dispensers.
11 MONITORING
The Trust requests that weekly hand hygiene audits are completed by the Infection Prevention and Control (IP&C) Link staff and returned to the IP&C Dept. Wards are expected to display a poster stating their weekly audit results in percentage and develop action plans to improve results. On a quarterly basis a graph is developed by the IP&C Dept to demonstrate the effectiveness of the ward at hand hygiene (see appendix 3)
12 OCCUPATIONAL HEALTH
Any member of staff experiencing a skin problem should be referred/refer themselves to the Occupational Health (ATOS Healthcare), where a full history will be taken and a discussion will take place to agree a suitable treatment. The manager may need to be informed of the outcome where changes in work practice are required, in line with health and safety requirements.
13 GLOVE USE
13.1 Statement of Good Practice:
Health care workers , whether working in inpatient or community settings are advised to regard all body fluids as potentially infectious and gloves should be worn whenever contact with body fluids is anticipated. Gloves should conform to BS EN 455 and the following taken into consideration:
• Hands should be washed before putting on gloves.
• The wearing of gloves is not a substitute for thorough hand washing.
• Gloves should only be worn when necessary.
• Gloves should be changed after contact with each user/client and between procedures.
• Hands should be washed thoroughly after gloves have been removed.
• All gloves in use should be non-powdered, non latex.
These guidelines must be read in conjunction with the policy on Standard Infection Prevention and Control Precautions.
13.2 Risk Assessment and Glove Selection (refer to (see appendix 4 & 5)
Following a risk assessment, an appropriate glove choice should be made for the specific task/procedure to be undertaken. Wear gloves only when necessary as the prolonged wearing of gloves can affect the skin. The following factors should be borne in mind when undertaking a risk assessment of individual procedures:
• The nature of the task
• The risk of contamination
• Sterile or non-sterile gloves required
• User/client sensitisation
• Comfort for the user
• Environmental cleaning
The choice of glove should be based on risk assessment and should not be solely as a result of personal preference or habit of the user. It is widely accepted that powdered, high latex protein gloves give rise to latex allergy. It is therefore recommended, to prevent the development of latex allergy, that healthcare workers in the Trust use Nitrile vinyl gloves.
• Vinyl examination gloves should be worn where there is a low risk of contamination, non-invasive clinical care, or environmental cleaning.
• Non-sterile nitrile gloves should be worn for procedures where there is a high risk of exposure to blood-borne viruses and high barrier protection is needed.
• Sterile nitrile gloves should be used in clinical procedures outside of the theatre setting where a sterile field and high barrier protection is required.
All gloves should be purchased through NHS Logistics via purchasing. Further guidance can be obtained from Infection Prevention and Control Department and Occupational Health. If, following risk assessment, latex gloves are the gloves of choice, a copy of the assessment is to be sent to the purchasing department and the Occupational Health (ATOS Health Care). Where latex gloves are selected they must be low protein and powder free and healthcare workers will require health surveillance.
13.3 Double Gloving
A number of studies have advocated the use of double gloving during surgery. The use of double gloving is advocated by the Expert Advisory Group on AIDS and Hepatitis (DoH, 1998), as a method reducing percutaneous exposure for surgical procedures on user/clients with blood borne infections and therefore healthcare workers in LPT should consider double gloving when undertaking Exposure Prone Procedures (EPP) on user/clients with blood borne infection when glove puncture is likely to occur, e.g. where there has been a large blood spillage, or there is likely to be contact with a large volume of blood. This will reduce the risk of infection as a result of needle stick injury but it will not prevent it.
Exposure Prone Procedures (EPP) are defined as those where there is a risk that injury to the healthcare worker may result in the exposure of the user/client’s open tissue to the blood of the healthcare worker (British Medical Association).
13.4 Sizing of Gloves
It is important to ensure that gloves fit correctly. Current health and safety legislation (Health and Safety Commission 1992), states that Personal Protective Equipment (PPE) is not suitable if it is incapable of fitting the wearer correctly. Poorly donned and/or poorly fitting gloves can interfere with dexterity and performance exposing the wearer to potential risks (refer to appendix 6&7).
13.5 Storage
In general gloves have an average shelf life of 3-5 years, however, this time frame can be affected by general storage conditions such as heat, humidity, exposure to direct sunlight or sources of ozone, e.g. X-Ray machines and other electrical generators. Gloves should be stored where the temperature does not exceed 40 degrees C, or 50% humidity and stock should be rotated avoiding storage of large quantities.
13.6 Glove Disposal
All used gloves should be disposed of as clinical waste. Gloves MUST NOT be re-used. Gloves must be disposed of after single use and hands washed and dried after removal. Gloves do not provide complete protection against hand contamination
• Hands may become contaminated when gloves are being removed
• Gloves may have become punctured
• The longer the gloves are worn the greater the risk of tearing which increases the risk of hand contamination
13.7 Glove Inspection
Staff should always inspect gloves frequently whilst in use and change them if defects occur or are suspected.
13.8 Hand washing (refer to section 6)
Hands should be washed thoroughly before the use of gloves and again after gloves have been removed as glove materials increase sweating and provide a moist, warm environment for organisms to multiply on the hands.
14 GUIDANCE FOR THE PREVENTION AND MANAGEMENT OF GLOVE RELATED REACTIONS
14.1 The Occupational Health (ATOS Healthcare)
The Occupational Health (ATOS Healthcare) will, on request:
• Undertake health screening of all staff who will be asked about allergies and advised accordingly
• Provide staff with guidance and advice of the recognised management of latex allergies or respiratory sensitization and advise staff as appropriate, (this risk is reduced by ensuring the use of nitrile gloves)
• Collate records/statistics of those affected and report occupational cases as required by RIDDOR 1995 regulations.
14.2 Suspected Glove Related Reaction
In the event of a staff member developing a suspected glove related reaction (or to skin creams or soap), they are advised to:-
• Report their suspected glove related reaction to their manager
• The staff member is then referred to the Occupational Health (ATOS Healthcare) for assessment
• The manager may be asked to carry out a risk assessment on products used in that area and liaise with Occupational Health, providing background information to identify clinical need for glove usage
• Following the Occupational Health assessment and investigation, advice will be given to the employee and manager on any temporary adjustments to working practices, or alternative glove ordering
• Following a positive latex glove reaction the manager will, in accordance with policy, complete an Incident Report, as per policy
• Occupational Health will notify the Health and Safety Executive under RIDDOR
15. TRAINING
• Training regarding Standard and Enhanced Infection Precautions will be provided as part of the induction programme for all staff, and can be accessed at other times through the Infection Prevention Department or Occupational Health (ATOS Healthcare). It is the responsibility of the manager to ensure that staff are regularly updated.
• Additional training will be provided for other specific staff groups under arrangements made by the managers
• Annual updates re infection control precautions will be provided for all staff via the identified infection control link nurses for each area / Risky Business Hand Book / Infection Prevention website.
• The infection control hand hygiene audit, carried out by the Infection Control Link Staff, will pick up whether staff are following the precautions or need updating; this will be managed by the service manager.
16. EQUALITY AND DIVERSITY
The Trust aims to provide high quality Mental Health and Learning Disability care, ensuring equality and valuing diversity through offering correct Infection Prevention and Control services regardless of a persons age, race, ability to speak English, religion, gender, disability, sexual orientation or culture.
Language barriers may make it difficult for service users/clients to understand the guidelines and procedures necessary to prevent and reduce healthcare associated infections or other aspects of Infection Prevention and Control. It may be necessary for service users/clients to access the relevant information in a language other than English. Therefore it is important that all staff consider race, religion and spirituality and offer advice, guidance and information to the service user/client in a format they will understand.
It may be difficult for a person with a disability to access the information and guidance e.g. visual impairment, or have difficulty comprehending e.g. learning disability. Therefore staff must consider all disabilities and offer advice, guidance and information in a format that is relevant to that particular disability.
- This link will provide detailed information on how to gain access to interpreters within the trust. The main reception at Carleton Clinic can provide access to face to face and over the phone interpreting. Sign language interpreting assistance can be provided by Cumbria Deaf Association and written translations via the Communications Department. All access to interpreters must be logged through the Equality and Diversity Lead on 07747 562650 or by emailing xxxxxxxx@xxxxxxx.xxx.xx
equip.nhs.uk - Links to information rich website with resources in all languages, lists of support groups and services related to other languages or for people from ethnic minorities.
.uk - Valuing and supporting people with a learning disability and their families/carers.
.uk – Provides health leaflets and information for patients and professionals that are easy to understand.
17. POLICY DESTRUCTION
It is the responsibility of the Policy File Holder to ensure that when a new or revised policy is ratified and distributed, the old policy is removed from the policy file and destroyed, together with the old content / index listing.
REFERENCES:
Aycliffe, G.A.J. et al (1992) Control of Hospital Infection, A Practical Handbook (3rd Edition) London: Chapman & Hall.
Bissett L, 2002), “Can alcohol hand rubs increase compliance with hand hygiene?” British Journal of Nursing,11(16): 1072,1074-7
Cole, R.P., Gault, D.T. (1989) Globe perforation during plastic surgery. British Journal of Plastic Surgery 42, 481-483
DB 9601 Latex sensitisation in the Healthcare Setting (Use of Latex Gloves) (1996)
Department of Health (1998) Guidance for clinical healthcare workers: protection against blood-borne viruses. Recommendations of the expert advisory group on AIDS and the advisory group on hepatitis. London: HMSO
Department of Health (2006) Saving Lives: a delivery programme to reduce healthcare associated infection including MRSA. London: DoH
Eckersley, J.R.T., Williamson, D.M. (1990) Glove punctures in an orthopaedic trauma unit. British Journal of Accident Surgery 2, 177-178
Hand Hygiene Task Force, (2001),”Draft guideline for hand hygiene in healthcare settings”, Hospital Infection Control Practices Advisory Committee, CDC, Atlanta, USA
Health and Safety Commission (1992) Guidance on the Personal Protective Equipment at Work Regulations (PPE) London: Health & Safety Executive
Jenson, S.L., Kristenson, B. Gabrin, K. (1997) Double gloving as self protection in abdominal surgery. European Journal of Surgery 163, (3), 163-167
Korniewicz, D.M. et al (1993) Leakage of Latex and Vinyl Examination Gloves in High and Low Risk Clinical Settings. American Industrial Hygiene Association Journal 54:122-126
Larson E. and Kretzer E. K, (1995), “Compliance with handwashing and barrier precautions”, Journal of Hospital Infection, 30: 88-106
Olsen – cited in Wilge, J. (1995) Infection Control in Clinical Practice. London: Baillaire Tindall
Zinner, N.L. (1994) how safe are your gloves? AORN Journal 59(4) 876-882
Pittet D., Dharan S., Touveneau S. et al, (1999), “Bacterial contamination of the hands of hospital staff during routine User/client care”, Arch. Int. Med. 159: 821-826
Pittet D., Hugonnet S., Harbarth S., Mourouga P., Sauvan V., Touveneau S., Perneger T. and members of the Infection Control Programme, (2002) “Effectiveness of a hospital-wide programme to improve compliance with hand hygiene”, The Lancet, 356: 1307-1312
Ward V., Wilson J., Taylor L. et al, (1997), “Preventing hospital-acquired infection”, Clinical guidelines. PHLS, London
Infection Control Nurses Association, (2002), “Hand Decontamination Guidelines”
Infection Control Nurses Association (1999) Glove Usage Guidelines
.uk
.uk/latex
Legislation and further guidance:
Health and Safety at Work Act Regulations 1974
Provision and Use of Work Equipment Regulations 1992
Control of Substances Hazardous to Health (COSHH) 2002
Reporting of Injuries, Diseases and Dangerous Occurrences (RIDDOR) 1995
Management of Health & Safety at Work Regulations 1999
Workplace Health, Safety & Welfare Regulations 1992
APPENDIX 1 – HAND WASHING LEAFLET
[pic]
|APPENDIX 2 – HAND HYGIENE AUDIT TOOL |
|AUDIT TOOL BY OBSERVATION OF SERVICE USER |
|Use the TAB key to navigate | |
|from one editable field to the next. | |
|Service User 1 | |
|Staff Member |
|Staff Member |
|Staff Member |
|Staff Member |
| | | | | | | |
|Date (week Commencing) |Results (%) |Name of Auditor |Action Plan |Actioned By: |Review Date |To Be Reviewed By |
|29/12/2008 |87.50% |Tina Jackson |Continue to discuss in Breakfast meetings |Tina Jackson |05/01/2009 |05/01/2009 |
|05/01/2009 |77.50% |Tina Jackson |Continue to discuss in Breakfast meetings |Tina Jackson |05/01/2009 |05/01/2009 |
|12/01/2009 | | | | | | |
|19/01/2009 | | | | | | |
|26/01/2009 | | | | | | |
|02/02/2009 | | | | | | |
|09/02/2009 | | | | | | |
|16/02/2009 | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
|Cumbria Partnership | | | | | | | |
|NHS Foundation Trust | | | | | | | |
| | | | | | | | |
|Hand Hygiene | |
|Audit Results for | |
| | |
| | |
|Commencing | |
|13th January '09 | |
|We Scored | |
|83% | |
| | | | |
| | | | |
| | | | |Implement action plan for improvement |
| | | | |
| | | | |Implement action plan for improvement | |
| | | | |Discuss action plan with | | |
| | | | |Hand Hygiene Co-ordinator or IPN | |
APPENDIX 3 – DECISION TREE FOR GLOVE SELECTION
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APPENDIX 4 - APPROPRIATE GLOVE SELECTION FOR CLINICAL TASKS
APPENDIX 5 – NON-STERILE GLOVE DONNING GUIDE
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APPENDIX 6 – STERILE GLOVE DONNING GUIDE
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APPENDIX 7 - GLOSSARY OF TERMS
Accountable Director
The Director accountable for the policies within a specific area of responsibility. Also the person responsible for the process or production of specific policies.
Policy File Holder
Person in charge of the administration systems for policies and procedures in a particular service location.
Policy Author
The person nominated by the Accountable Director to prepare the draft of a specific policy.
APPENDIX 8 - COMMITTEE / BOARD / GROUP TERMS OF REFERENCE
|1 |Name of Committee |Infection Prevention and Control Trust Group |
| | | |
|2 |Connectivity Reports to |Risk Management Committee |
| | |Committee Liaison – Acute Trust & PCT |
| | | |
| |Committees reporting to this group |Infection Prevention and Control Link Nurses Group |
| | |Infection Prevention and Control Policy Group |
| | | |
|3. |Chairman |Phil Robertson, Director of Nursing and Director of Infection Prevention |
| | |and Control. |
| | | |
| |Vice Chairman |Meryl Lawrenson, Head of Nursing, Infection Prevention and Control |
| | | |
| |Management Lead |Tim Evans |
| | | |
|4. |Members of the Committee |Phil Robertson |Director of Nursing |
| | |Meryl Lawrenson |Head of Nursing Infection Prevention and |
| | | |Control |
| | |Tim Evans |Deputy Director of Nursing |
| | |Karen Edwards |Head of Facilities |
| | |Mandy Wright |Head of Risk Management |
| | |George Hope |Locality Representative - Carlisle |
| | |Jeannie Mark |Locality Representative - Eden |
| | |Tina Jackson / Bob Treen / |Locality Representative - Furness |
| | |Cheryl Bell / Diane Spur | |
| | |(depending on rota | |
| | |availability) | |
| | |Maureen Graham / Lynnette |Locality Representative - Allerdale |
| | |Dickson (depending on rota | |
| | |availability) | |
| | |Sue Armstrong |Locality Representative – South Lakes |
| | |Hilary McKenzie |Locality Representative - Copeland |
| | |Julie Graham |Learning Disabilities Representative |
| | | |
|5. |Reference No. |INF/001/002 |
| | | |
|6. |Function of Committee |To monitor the compliance of the Trust to ensure high standards of |
| | |healthcare and infection control across the Trust. |
| | | |
| |Inputs |Cumbria wide infection prevention and control committees/groups. |
| | | |
| |Outputs |Reports to each Risk Management Committee (bi-monthly) |
| | | |
|7 |Quorum |3 members plus the chair or vice chair. |
| | | |
|8 |Review date for committee terms of |January 2009 |
| |reference / structure | |
| | | |
|9 |Frequency of meetings |Monthly (at least 11 meetings per year) |
| | | |
|10 |Purpose |To provide assurance to the Risk Management Committee that the Trust is |
| | |compliant with National and local recommendations of Infection Prevention |
| | |and Control to prevent Health Care associated infections. |
| | | |
|11 |Principal Functions |To commission work for Head of Nursing Infection Prevention and Control. |
| | | |
| | |To monitor compliance against policy and audit action plans. |
| | | |
| | |To lead on the implementation of the Health Act 2006. |
| | | |
|12 |Basis of Authority |Full Authority delegated from the Risk Management Committee. |
APPENDIX 10 - AUDIT TOOL GUIDANCE
STATEMENT
The Trust will work towards effective clinical governance and governance systems. To demonstrate effective care delivery and compliance regular audits must be carried out. Policy authors are encouraged to attach audit tools to all policies. Audits will need to question the systems in place as outlined in the policy. It is suggested that each policy will list at least ten standard statements which can then be audited in practice and across the Trust.
|Infection Prevention and Control – Hand Hygiene and Gloves |
|STANDARD STATEMENT | |Yes |No |
|Statement 1 |Are staff aware of the policy and its location. | | | |
|Statement 2 |Have all staff completed the mandatory Infection Prevention and | | | |
| |Control training (Risky Business Handbook). | | | |
|Statement 3 |Does the ward/setting have adequate hand washing basins. | | | |
|Statement 4 |Are there liquid soap and paper towel dispensors above each sink. | | | |
|Statement 5 |Does the ward/setting display hand washing technique posters in the | | | |
| |appropriate areas. | | | |
|Statement 6 |Are staff wearing or have access to alcohol hand rub at point of | | | |
| |care. | | | |
|Statement 7 |Are user/clients being offered hand hygiene opportunities prior to | | | |
| |meals, after using the toilet etc. | | | |
|Statement 8 |Are the gloves being stored in appropriate conditions (as outlined in| | | |
| |the policy). | | | |
|Statement 9 |Does the ward/setting have a supply of gloves in differing sizes and | | | |
| |materials (if required). | | | |
|Statement 10 |Can staff state 4 of the points outlined in the Statement of Good | | | |
| |Practice for Glove Use. | | | |
APPENDIX 11 – EDUCATION AND TRAINING
NEEDS ANALYSIS AND ACTION PLAN
STATEMENT
All policies will provide clear analysis of the amount of education and training required to ensure compliance. Policy authors will be asked to complete the following table to support submission to the Policy Monitoring Group.
|Training Assessed at: |For which staff |Suggested cost implications |
|Level A | | |No cost | |
|(Green) | |See training needs analysis below | | |
|Level B | | |Minimal cost | |
|(Amber) | | | | |
|Level C | | |Large costs | |
|(Red) | |Refer to Infection Prevention and Control | | |
| | |training program in the policy file. | | |
|Please refer to training matrix below | |Comments |
| | | |
| | | |
| | | |
TRAINING MATRIX
Level A (Green) - A policy will be designated for this required level of training if the policy is felt to present minimal risk to the Trust. These policies designated green would be disseminated to the local policy file holder. It is acknowledged that all staff must be aware of all new and reviewed policies. A central record of acceptance from local policy file holders will be recorded on the policy database. Local policy file holders will need to place the new/reviewed in the correct policy file, change the contents page which will be attached to the new/reviewed policy and inform all staff in their area of the new/reviewed policies.
Level B (Amber) - A policy will be designated for this required level of training if the policy is felt to present medium risk to the Trust. These policies designated amber would be disseminated to the local policy file holder. It is acknowledged that all staff would need to receive minimal training/discussion on all new and reviewed policies. A central record of acceptance from local policy file holders will be recorded on the policy database. Local policy file holders will need to place the new/reviewed in the correct policy file, change the contents page which will be attached to the new/reviewed policy and inform all staff in their area of the new/reviewed policies.
Level C (Red) - A policy will be designated for this required level of training if the policy is felt to present high risk to the Trust. These policies designated red would be disseminated to the local policy file holder. It is acknowledged that staff will require high level training. The training support will be identified and details will be sent out with individual policies. A central record of acceptance from local policy file holders will be recorded on the policy database. Local policy file holders will need to place the new/reviewed in the correct policy file, change the contents page which will be attached to the new/reviewed policy and inform all staff in their area of the new/reviewed policies.
EDUCATION AND TRAINING ISSUES ON POLICIES: ACTION PLAN
STATEMENT
All policies require an action plan to provide assurance to the Policy Monitoring Group on education and training needs to ensure compliance with the policy. Policy Authors will be asked to complete the following Action Plan to support submission to the Policy Monitoring Group. Policy Authors are also requested to provide evidence on education and training to the PA of the Director Responsible for the policy to ensure that the SharePoint document management systems is kept updated
TRAINING NEEDS ANALYSIS
|Inpatient Unit |Community and/or Directorate |Staff Group |Level of training required |How often |
|(Please specify) |(Please specify) | | | |
| | |Doctors | | |
| | |Qualified Nurses | | |
| | |HCA/Support Workers | | |
| | |Social Workers | | |
| | |Occupational Therapists | | |
| | |Psychologists | | |
| | |Psychotherapists | | |
| | |Other Non Clinical Staff | | |
| | |Admin and Clerical | | |
| | |Managers | | |
| | |Domestic Workers | | |
| | |All Staff |Refer to the Infection Prevention and Control training | |
| | | |program in the policy file. | |
APPENDIX 12 - EQUALITY IMPACT ASSESSMENT FORM
(Please refer to the Equality Impact Assessment Guidance to complete the assessment contained with the Policy for the Development, Communication & Control, Ratification, Review & Destruction of Policies and Procedures)
| |Across the Trust |
|Clinical Directorate / Area | |
| |Meryl Lawrenson |
|Name of person completing this assessment | |
| |28th January 2008 |
|Date | |
| | |
|Name of proposed policy |Infection Prevention and Control - Hand Hygiene and Glove |
| |
|Stage 1: Initial Screening |
| |To ensure hands are decontaminated and the correct gloves are used in |
|What are the main aims of the policy? |clinical practice |
| |
|What evidence is available to suggest that the proposed policy could have an impact on people from the equality groups? Document reasons, e.g. |
|research, results of consultation, monitoring data and assess relevance as: |
|Not relevant / Low / Medium / High. |
|Area |Not relevant |H/M/L |Evidence |
| | | |Language barriers and/or ethnicity may make it difficult for service |
|Race | |M |users/clients to understand or gain access to guidelines and procedures |
| | | |necessary to reduce and/or prevent the spread of infection. |
| | | |Service users/clients religion and/or belief systems may make it difficult|
|Religion / Spirituality | |M |for them to understand or gain access to guidelines and procedures |
| | | |necessary to reduce and/or prevent the spread of infection. |
| | | | |
|Gender |X | | |
| | | |Physical and/or learning disabilities may make it difficult for a |
|Disability | |M |client/service user to gain access or have understanding of the guidelines|
| | | |and procedures that are necessary to prevent and/or reduce the spread of |
| | | |infection. |
| | | | |
|Sexual Orientation |X | | |
| | | | |
|Age |X | | |
|If you assess the policy as not relevant, please proceed to Question 8. |
|If you assess the policy as relevant, continue to Stage 2, Full Equality Impact Assessment. |
|Stage 2: Full Equality Impact Assessment |
| |
|Are there service user, public or staff concerns that the proposed policy may be discriminatory, or have an adverse impact on people from the |
|equality groups? |
| | |
|Public |No |
| | |
|Staff |No |
| |
|If there are no concerns, proceed to Question 5. |
|If there are concerns, amend policy to mitigate adverse impact (Question 5), consider actions to eliminate adverse impact (Question 7), or |
|justify adverse impact (Question 4). |
| |
|Can the adverse impact be justified? |
| |
|What changes were made to the policy as result of information gathering? |
|An equality and diversity statement has been added to each policy to ensure staff are aware of their responsibilities, the impact it may present|
|to service users/clients and the aim of the Trust with regard to IP&C and equality and diversity. |
|Website details and telephone number listed for translation, interpretation, information and leaflets that may be of assistance when undertaking|
|IP&C procedures. |
|What arrangements will you put in place to monitor impact of the proposed policy on individuals from the six equality groups? |
|Policy audit and review. |
|Monitoring of DoH, NICE, Epic 2 guidelines. |
|List below actions you will take to address any unjustified impact and promote equality of outcome for individuals from equality groups. |
|Consider actions for any procedures, services, training and projects related to the policy which have the potential to promote equality. |
|Action |Lead |Timescales |
|Data will be collected through the audit process and |Ward Managers and Lead Nurse of Infection|Ongoing |
|reviewed. |Prevention and Control. | |
|Any issues that have a negative impact will be addressed |Ward Managers and Lead Nurse of Infection|Ongoing |
|immediately by policy amendment or action by the relevant |Prevention and Control. | |
|staff. | | |
|Information and training to be provided to the Infection |Lead Nurse of Infection Prevention and |Ongoing |
|Prevention and Control link staff at monthly meetings when |Control. | |
|necessary. | | |
|Link staff will disseminate relevant training/learning to |Link staff and Ward Managers. |Ongoing |
|colleagues in their area. | | |
|Serious issues/unjustified impacts will be brought to the |Lead Nurse and Director of Infection |Ongoing |
|attention of the Director of Infection Prevention and |Prevention and Control. | |
|Control and the Chief Executive, by the IP&CT and be | | |
|addressed accordingly. | | |
| | | |
|Review date |February 2011 |
| |
|I am satisfied that this policy has been successfully equality impact assessed. |
| |
|Date: 29th January |
|Name of policy author: Meryl Lawrenson |
| |
|Please send the completed assessment for scrutiny to: Liba Stones, Equality and Diversity Project Lead, Cumbria Partnership NHS Foundation |
|Trust, Carleton Clinic, Cumwhinton Drive, Carlisle, CA1 35X, or xxxx.xxxxxx@xxxxxxx.xxx.xx. |
| |
|I am satisfied that this policy has been successfully equality impact assessed. |
| |
|Date: 26th March 2009 |
|Equality and Diversity Project Lead: Liba Stones |
APPENDIX 13 - SIGNATURE RECORD
Policy for Hand Hygiene and Glove Policy
This sheet should be used to record the names of staff members who have read and understood the above policy document.
By signing this document I acknowledge I have read and understood the above named policy.
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Please print this page for your records[pic]
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KEY POLICY ISSUES
• Promotion of good hand hygiene.
• Defines the responsibilities and actions for good hand hygiene practice.
• Defines when to use gloves and how to choose the correct gloves.
• Defines the audit process in monitoring
Non-theatre environment:
Sterile Nitrile
Non-sterile nitrile or synthetic glove with equivalent barrier properties
Non-sterile vinyl
Don’t wear gloves
YES
NO
YES
Is a sterile filed required?
NO
Is there a high risk of exposure to blood and body fluids
Gloves ARE required for procedures where there is a risk of cross infection between User/clients and staff and further risk assessment should be carried out.
Gloves are not required where there is a minimal risk of cross- infection between User/clients and staff, e.g.
• Basic care procedures without contact with blood or body fluids
• Transferring food from trolley to User/client bedside
• Making uncontaminated beds/changing or removing User/clients uncontaminated clothing
• Taking recordings (BP, temp, pulse)
• Closed endotracheal suction
Are Gloves Really Necessary?
Non - Sterile
nitrile
Non - Sterile
nitrile
Type of Activity
Glove Selection
ALL GLOVE SELECTION MUST BE PRECEDED BY RISK ASSESSMENT
Specific risk assessment required for handling specific chemicals
Procedures which require a sterile field and high barrier protection e.g.
• Lumbar punctures
• Liver biopsies
• Clinical care to surgical wounds and drain sites
• Procedures for neutropenic User/client s
• Insertion of urinary catheters
• Vaginal examination in obstetrics
Procedures involving high risk of exposure to BBVs and where high barrier protection is needed e.g.
• Potential exposure to blood/body fluids e.g. blood spillages, faecal incontinence, blood glucose monitoring, administering enemas/suppositories and rectal examinations
• Handling cytotoxic material
• Handling disinfectants
• Venepuncture/cannulation
• Vaginal examination in gynaecology
• Basic care and specimen collection procedures on User/clients known or suspected to be high risk of BBV
• Non surgical dentistry/podiatry
• Handling dirty/used instruments
• Processing specimens in a laboratory
Non - Sterile nitrile
Nitrile gloves
Non - sterile
nitrile
Nitrile
Non sterile nitrile
Blood –borne
Virus exposure/ spillage
Isolation room
General Cleaning
Tasks where there is a low risk of contamination, non invasive clinical care, or environmental cleaning e.g.
Oral care
Emptying catheter drainage bags
Emptying urinals/bedpans and suction jars
Handling low risk specimens
Clinical cleaning
Dressing wounds when contact with blood/body fluids is unlikely e. g. Gastrostomy dressings
Endotracheal suction
Applying creams
Touching User/clients with unknown skin
rash/scabies/shingles
Making beds/changing clothing of User/clients in isolation
Food handling preparation, serving
Cleaning by General Services staff
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