Wexford General Hospital HAND HYGIENE Action plan
2013
Introduction
The HSE set a national target of a hand hygiene compliance rate of >90% in 2013. This action plan outlines the processes in
place and further initiatives to achieve this target by May 2013. This hand hygiene action plan is endorsed by WGH Infection
prevention and control committee.
The aim of this hand hygiene action plan is to create an environment and a hospital wide culture which:
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Supports and promotes effective hand hygiene.
Encourages a sustainable hand hygiene culture.
Provides staff with hand hygiene knowledge and skills.
Assists and encourages healthcare workers (HCWs) to decontaminate their hands effectively and as frequently as required,
as well as minimise the risk of damage to HCWs’ skin.
Assists and encourage patients and visitors to decontaminate their hand effectively.
Ensures there is effective and sufficient hand hygiene resources (equipment and materials) available
Assists with the reduction in the risks of healthcare associated infection (HCAI) to patients and HCWs.
Demonstrates a continuous quality improvement at all levels of the hospital.
Strategic
Direction
Criteria
Comments
Governance,
Develop a sustainable hand hygiene Walk the talk- lead by example and have visible
leadership
& culture which is embedded in the executive leadership.
culture
organization.
Infection Prevention and control is an agenda
item at the Board of Management meeting.
Access
to Physical
infrastructure
is
a Hand Hygiene facilities are available in all
Hand Hygiene necessary pre-requisite to improve clinical/non clinical areas:Facilities and hand hygiene practice.
Products
o Hand washing sinks which meet the
requirement under SARI guidelines.
o Elbow/sensor operated taps
o Liquid soap
o Paper towels
o Alcohol gel hand rubs strategically placed
so that they are within easy reach of each
clinical situation.
o Moisturizer cream
Hygiene audits are conducted to assess the
availability of hand hygiene facilities/products
and report the results.
Education and Hand Hygiene Education and Comprehensive IP&C Education programme
Training
training to improve knowledge, available for all healthcare workers in the
beliefs and attitudes on the hospital
importance of hand hygiene
Responsibility of Departmental Heads/Managers
To improve hand hygiene practices to ensure all staff receives mandatory training on
and compliance rates.
hand hygiene.
Attendance records are kept
Strategic
Direction
Hand Hygiene
Audits
Additional hand hygiene education sessions
provided as required e.g. post hand hygiene
audits, Grand Rounds for medical staff etc.
Infection Prevention & Control Link IP&C Link Practitioners are trained in the
Practitioner Programme- Clinical hospital.
champions for hand hygiene
through active participation in the
IP&C Link Practitioner role.
Criteria
Comments
Hand Hygiene Audits to National Hand hygiene audits are undertaken
monitor
hand
hygiene using the HSE national standardised audit tool.
compliance rates.
The IPCT report findings via a hand hygiene
audit report to:o
o
o
o
o
o
o
Feedback
of
audit results,
alcohol
gel
usage and any
other
Key
performance
Clinical Nurse Managers
Heads of Service
Hospital Manager
Deputy Manager
Nurse Management
Clinical Director
Infection Prevention & Control Committee
The
feedback
of
key The results of key performance indicators are
performance indicators in a widely disseminated from the Infection
timely fashion
prevention and control committee members to all
heads of departments for distribution to their
staff. Each department receives a copy of their
individual hand hygiene audits.
indicators
Hand Hygiene Hand Hygiene Policies/Guidelines
Policies/
Guidelines
|The hand hygiene policy which was adapted
from the Guidelines for Hand Hygiene in Irish
Health Care Settings; Health Protection
Surveillance Centre 2005 was reviewed in 2011.
The hand hygiene policy contains up to date and
expert advice on hand hygiene techniques, hand
hygiene products and hand hygiene importance.
Policies/guidelines are available and accessible
to staff both locally and electronically.
HCWs who develop irritant dermatitis must report
to the Occupational Health Department
Education and
Awareness
Campaigns
Promote
and
support
multidisciplinary partnerships
to deliver intervention hand
hygiene programmes
The IP&CT provide regular hand hygiene
initiatives that promote effective hand hygiene
behaviour for staff, patients and visitors:- there
are a posters available to encourage patients to
ask staff to decontaminate their hands
‘World Health Organization Save Lives: Clean
your hands campaign’ annually in May to
highlight awareness about the importance of
hand hygiene and the 5 moments for hand
hygiene.
Infection Prevention & Control Awareness
Campaign is a global event held every year to
highlight everyone’s responsibility- staff, patients
and visitors alike - in helping to prevent
healthcare associated infections.
Develop Infection prevention and control hand
hygiene champions to work with Infection
prevention and control link nurses. We need
The IPCT in consultation will hold hand hygiene
work shops in a suitable area. These workshops
will focus on the 5 moments for HH and each
participate will receive a certificate of
attendance. This workshop must be endorsed by
the BOM
References
Health Information and Quality Authority. (2009). National Standards for the Prevention and Control of Healthcare Associated
Infections.
SARI (2001). A Strategy for the Control of Antimicrobial Resistance in Ireland. Report of the subgroup of the Scientific
Advisory Committee of the National Disease Surveillance Centre.
Victorian Quality Council (2007) Hand hygiene sustainability. Results from the Victorian Quality Council Hand hygiene
sustainability forum.