Overview of Hand Hygiene Policy and Procedure - Alberta Health ...

AHS Clinical Policy
Hand Hygiene Clinical Policy & Procedure
Overview Presentation
October 14, 2011

Overview
• Purpose of Hand Hygiene Policy & Procedure
• Hand hygiene practice recommendations
• When to practice hand hygiene
• Which hand hygiene product to use
• How to use Alcohol-based Hand Rub / Plain Soap and Water
• Hand hygiene products / ABHR considerations
• Direct patient care hand hygiene considerations
• Measurement to support hand hygiene practices
• Questions and additional resources
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Purpose of the Hand Hygiene Policy & Procedure
• To set the standard for Hand Hygiene practice within
Alberta Health Services to prevent the transmission of
microorganisms, reduce the incidence of infection and
promote the health and safety of Patients, Staff and
visitors
• Complies with Accreditation Canada Infection
Prevention and Control Required Organizational
Practices – Hand Hygiene
– http://insite.albertahealthservices.ca/Accreditation/tms-acrd-rop-hand-hygiene-educationand-training.pdf
– http://insite.albertahealthservices.ca/Accreditation/tms-acrd-rop-hand-hygiene-audit.pdf
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Hand Hygiene Policy & Procedure
• Supports effective hand hygiene practices:
– enhance the health and safety of all persons
receiving care, and
– are the single most important practice in reducing
the transmission of microorganisms in health care
and community settings.
• Acknowledges that hand hygiene is a shared
responsibility with patients, staff and visitors supported
to encourage Hand Hygiene practices
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AHS Hand Hygiene Policy & Procedure
• applies to to all Alberta Health Services
– employees
– Physicians, Dentists, Oral & Maxillofacial Surgeons; Podiatrists,
or Scientist Leaders who have an Alberta Health Services
medical staff appointment **
– students
– volunteers
– and other persons acting on behalf of or in conjunction with
Alberta Health Services
** see AHS Medical Staff Bylaw (4.2.1) and Rules (4.24c) found at
http://insite.albertahealthservices.ca/3101.asp
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Hand Hygiene recommendations
• Alcohol-Based Hand Rub (ABHR) recommended for performing
Hand Hygiene for when hands are not visibly soiled.
• Plain Soap and water recommended when hands are visibly
soiled with food, dirt or blood and body fluids, and following glove
removal when caring for patients with diarrhea and/or vomiting.
• Antimicrobial Soap and water recommended only in limited
circumstances and should not be used for routine Hand Hygiene.
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Perform hand hygiene
1. Before contact with a patient or patient’s environment
including but not limited to: putting on (donning) Personal
Protective Equipment (PPE); entering a patient’s room; and
providing patient care,
2. Before a clean or aseptic procedure including but not limited to:
wound care; handling intravenous devices; handling medications
or food
3. After exposure (or risk of exposure) to blood and/or body
fluids including but not limited to: when hands are visibly soiled;
following removal of gloves; and
4. After contact with a patient or patient’s environment including
but not limited to: removing (doffing) PPE; leaving a patient’s
environment; and after handling patient care equipment.
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Which product to use?
Indication
ABHR is
appropriate
Plain Soap and
Water is
appropriate
When hands are visibly soiled No Yes*
Before and after direct contact with a Patient Yes* Yes
Before clean procedures Yes* Yes
Before aseptic procedures
Yes*
Antimicrobial
soap and water*
Before and after touching objects or equipment in the
immediate area around the Patient
After Patient care or contact with used equipment in the
Yes* Yes
Patient’s immediate environment when the Patient has
diarrhea and/or vomiting
Yes Yes*
During food handling No Yes*
* Indicates preferred method of hand hygiene
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How to use Alcohol-based Hand Rub
• Ensure hands are not visibly soiled and are dry before use
• Apply enough ABHR product to the palm of one hand to cover all hand surfaces
(e.g. 2 to 3 pumps)
• Vigorously rub product over all the surfaces of the hands and wrists, including
palms, spaces between fingers, back of hands and wrists, fingers, fingertips and
thumbs
• Hands must remain wet with the product for a minimum of 15 seconds
• Continue rubbing ABHR product over hands until hands are completely dry
• Periodically apply Alberta Health Services approved hand lotion to assist in
maintaining skin integrity
Poster available: http://www.albertahealthservices.ca/Diseases/hi-dis-flu-hand-rub-how-to.pdf
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How to use Plain Soap & Water
• Wet hands with warm water, apply enough soap to ensure all hand surfaces are
lathered thoroughly (e.g. 2 to 3 pumps)
• Vigorously rub soap product over all the surfaces of the hands and wrists, including:
palms, spaces between fingers, back of hands and wrists, fingers, fingertips and
thumbs for a minimum of 15 seconds
• Rinse hands under warm running water
• Pat hands dry with disposable paper towels
• Use paper towels to turn off faucets and to open door
• Discard towels
• Periodically apply an Alberta Health Services approved hand lotion to assist in
maintaining skin integrity
Poster available: http://www.albertahealthservices.ca/Diseases/hi-dis-flu-handwash-how-to.pdf
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Hand Hygiene products
Hand Hygiene products will be placed as close as possible
to the Point of Care.
Use only Alberta Health Services Approved Hand Hygiene
Products (e.g. ABHR, soap and hand lotion).
Hand cleaning wipes / towelettes should not be used
routinely by staff for hand hygiene. These should only be
used to removing visible soil from hands in exceptional
circumstances where Soap and Water is not available for
hand hygiene.
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ABHR considerations
Consider the following in placement of Alcohol based hand rub (ABHR) dispensers:
• Patient and visitor safety – Assess risk and take appropriate corrective action where
the placement or access to ABHR constitutes a patient and/or visitor safety risk.
• Fire safety – Dispenser placement and stock storage must align with the Alberta Fire
Code and STANDATA 97FCB026, with placement away from electrical outlets,
switches, and power sources.
• Location to align with product use guidelines – Wall mounted ABHR dispensers
are not to be located by sinks. Place at:
– Patient room entrances
– public areas (e.g. building entrances, exits)
– office areas where food is consumed
– portable medication carts; nursing stations
– cafeteria entrances; multiuse computer stations
– existing clinical areas without sinks; and existing bathrooms or toilet areas without sinks
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Hand Hygiene & Direct Patient Care
In roles that provide direct patient care, reprocess or handle surgical linens
and / or medical devices, or prepare pharmaceutical medications or
handle food you must:
• Not wear artificial nails, nail enhancements (including gel and acrylic nails), or
chipped nail polish
• Limit rings on hands to plain bands
• Have natural nails that are clean, healthy with nail tips that do not exceed 6 mm or
0.25 inches
Seek guidance from Workplace Health and Safety if you have a cast, dressing
or splint that interferes with effective hand hygiene. Continuing to provide
Direct Patient Care if you cannot perform hand hygiene effectively will put
you, your patients, and your co-workers at risk!
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Measurement to support hand hygiene
Infection Prevention and Control has launched a province-wide hand hygiene
practice review initiative to measure and support hand hygiene practices.
This includes:
• a standardized tool for measuring hand hygiene practices aligned with the
4 moments of hand hygiene articulated in the AHS Hand Hygiene policy
• trained staff conducting the reviews to support valid and reliable findings
• timely reporting of aggregate findings to programs, clinical areas and staff
with a goal of improving hand hygiene practices
Results from the 2011 Summer hand hygiene compliance reviews have been
shared at the unit and facility level across AHS.
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Remember 3 key messages …
• Hand hygiene is the single most important
factor in preventing infection and the spread of
communicable diseases
• Wash hands: remember to do it, do it often and
do it properly
• If you are unsure if you need to wash your
hands – wash your hands
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You will touch many lives today.
Hand hygiene campaign
Printed posters available from
infectionpreventioncontrol@albertahealthservices.ca
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Questions and More Information
If you have questions:
• Read the Hand Hygiene FAQ document on the Clinical Policy webpage on Insite
• Contact the IPC staff member for your facility
• Email IPC at infectionpreventioncontrol@albertahealthservcies.ca
Remember to check out the IPC website – for additional hand hygiene information and
other IPC resources to improve patient safety by preventing the transmission of
infection.
Click on the links below to access information from a variety of national and international
organizations with resources and campaigns to support hand hygiene
• Do Bugs Need Drugs? (http://www.dobugsneeddrugs.org)
• Safer Healthcare Now! (http://www.handhygiene.ca/English/Pages/default.aspx)
• CHICA-Canada (http://www.chica.org/links_handhygiene.php)
• World Health Organization (http://www.who.int/gpsc/en)
• Public Health Agency of Canada http://www.phac-aspc.gc.ca/im/iif-vcg/wh-lm-eng.php
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