1.1 This report outlines how the Stoke on Trent Community Health Service (PCT) developed the Hand Hygiene Policy (2008). In this report there will be an explanation of the history of the guideline, its rationale and the evidence sources that supported its implementation. There will also be a reflective account of using the guideline in practice and how the guideline helps to further develop the student nurse’s learning.
1.2 This policy was located on the PCT website and was easy to access. The ward manager could also obtain a copy on request. Ward policies could be viewed by patients and their families on request also.
2.0 Rationale for the guideline being written
2.1 The Hand Hygiene policy was published by the PCT in November 2008. This policy provides instruction to all trust staff on how to minimize the spread of infection to patients, themselves and others.
2.2 The executive committee, clinical governors, the infection control team, ward department managers as well as all trust staff have the responsibility to ensure the policy is implemented and adhered to. The policy was ratified by the Stoke on Trent trust board in November 2009 and is due to be reviewed in November 2011.
2.3 In the policy it states that the trust will be responsible for delivering an induction for all new employees, as well as providing an ongoing programme of updates for trust staff. The trust will also monitor staff by conducting regular audits on the ward. These will be conducting by the infection prevention and control nurses (IPCN’s). The audits will be undertaken on a random basis. It is also the trusts responsibility to ensure that there adequate, suitable and well maintained hand hygiene facilities and equipment in all areas.
2.4 In 2003, the Department of Health (DH) published the document; Winning Ways: working together to reduce healthcare associated infection in England. In this document it states that hand washing is vitally important in the control of infection. It also states that problems can arise from healthcare professional’s poor knowledge of guidelines and lack of education regarding correct hand washing, as well as inadequate facilities and a lack of time to wash hands correctly. In this document there are seven action areas all relating to identifying and reducing infections in healthcare settings. Action area four in particular refers to hand hygiene practice. It states that all clinical teams must demonstrate high levels of compliance with hand washing and hand disinfection protocols.
2.5 More recently in 2008, the National Patient Safety Agency (NSPA) published The Clean Hands Save Lives Patient Safety Alert. The NSPA believe that improving the hand hygiene of healthcare staff at the point of patient care will significantly reduce healthcare associated infections. The document states that up to eight per cent of inpatients in England at any one time have a healthcare associated infection.
2.6 The World Health Organisation (WHO) have also published the WHO Guidelines on Hand Hygiene in Healthcare settings. Outlined in this publication are the ‘five moments for hand hygiene’ training exercise. Its aim is to educate health care professionals on when and where hand hygiene should be most prevalent these are;
Before patient contact
Before an aseptic technique
After body fluid exposure risk
After patient contact
After contact with patient surroundings
2.7 Alcohol rub can also be used in between patients. In most cases this is the preferred method to use for cleaning non soiled hands because it is more effective, quicker to use, better tolerated by the hands and can be provided at the patient’s point of care (NPSA 2008). However the PCT’s policy states that alcohol hand rub should not be used
When hands are visibly or potentially soiled
The patient is experiencing vomiting and/or diarrhoea
There is direct hand contact with bodily fluids i.e. if gloves have not been worn
The patient has diarrhoeal illness attributed to an infectious cause.
However alcohol rub is ineffective against clostridium difficile spores. Soap and water is the most effective form of hand hygiene in this case.
2.8 The procedure for effective hand decontamination is a six stage technique using soap and water;
Wet hands under running warm water, apply soap then rub hands palm to palm
Rub the back of both hands (right palm over left back and vice versa)
Rub palm to palm interlacing the fingers
Rub the backs of fingers by interlocking the hands
Rub the thumbs (rotational rubbing of right thumb, clasped in left palm, and then vice versa)
Rub palms with fingertips (rotational rubbing of right fingers on left palm, and then vice versa, finish by rinsing hands under running water and dry thoroughly.
How Healthcare Associated Infections (HCAI) affect the NHS
2.9 The World Health Organisation state that HCAI’s affect between 5% to 15% of hospitalized patients and 9% to 37% of intensive care patients. Also figures from the National Audit Office show that HCAI’s are responsible for approximately 5000 deaths a year (2004). This puts a great financial burden on the NHS. The cost of HCAIs to the NHS is high, at around ?1 billion per year (Parliamentary Office of Science and Technology 2005). Although research shows that an estimated ?150 million could be saved through the implementation of good clinical practice including correct hand washing practice. However there still seems to be an increase in infections such as methicillin-resistant Staphylococcus aureus (MRSA) and clostridium difficile. These infections can be carried on the skin and can spread through a lack of hand hygiene (Bissett 2005). This in turn will increase patients stay in hospitals as well as increasing the need for ‘deep cleaning’ of the wards (Cunningham, Kernohan & Rush 2006). Although Eaton (2005) states that hand washing is more important than cleaner wards in controlling MRSA. Compliance is another issue that is sometimes found within the NHS, some healthcare workers have been shown failing to follow the guidelines, thus not washing hands as they should. Conley et al argue that education and training do not normally lead to a sustained improvement in hand washing (1989). However having the correct equipment such as sinks and alcohol gels in a clear and appropriate place seems to prompt healthcare workers to wash hands more often (Parker 1999).
3.0 Sources of evidence
3.1 The policy was developed using a wide range of materials. Nine different sources were referenced, these included department of health evidence sources, national patient safety agency documents as well as two guidelines, one from the centre for disease control and one from the infection control nurses association. There is also one journal.
3.2 The most recent document that is referenced is the National Patient Safety Agency Clean Hands Save Lives campaign. This was released in September 2008. The oldest source of evidence was the Department of Health 2003 Winning Ways- Working together to reduce Healthcare Associated Infections in England.
4.0 Experiences of using the guideline
4.0 Whilst on placement, I have encountered many situations which require me to maintain a standard of cleanliness with regards to my hand hygiene. I came to realise that the six stage hand washing technique is the most thorough way to wash my hands. This policy has helped me to identify how the technique should be done and also why using the correct procedure of hand washing helps to prevent healthcare associated infections.
4.1 All staff at my placement followed and adhered to the guidelines that the policy set out. Also when visitors came to the ward, alcohol gel was visible, as well as signs encouraging visitors to make sure their hands were cleansed.
4.2 At my placement staff were also issued with alcohol hand-rub bottles to clip onto their uniforms. I was also given a leaflet on hand washing and the six stage technique to keep as a reference.
5.0 Placement Learning
5.1 Whilst I have been on placement, I have seen numerous infection control nurses on the ward. I have also seen and taken part when audits have been undertaken by the infection control nurse (ICN). These audits are also referenced in the PCT’s policy.
5.2 The infection control nurse (ICN) uses two types on audit. The first is known as the Hand Hygiene Audit Tool. This consists of sixteen checks that must be made when auditing the wards and is mainly about the equipment that is used to maintain hand hygiene. The ICN checks that equipment is available and in good working order. The other audit tool the ICN can use is the Hand Hygiene Observation Tool. This tool is used to identify compliance amongst healthcare professionals.