MEDICAL CENTER WIDE POLICY AND PROCEDURE MANUAL Fontana & Ontario Medical Centers Policies & Procedures

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Christopher Lambert Gilmore
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1 Sectin: Infectin Cntrl Medical Center Wide Departmental Subsectin(s): General Guidelines Title: Revisin Date: 4/85, 1/87, 2/88, 5/91, 4/92, 5/96, 5/98, 5/00, 6/02, 3/03, 11/03, 5/04, 11/04, 8/05, 10/05, 6/06, 9/06, 8/08, 2/09, 6/11, 2/12, 1/13, 4/13, 11/14 Accuntable Department r Cmmittee: Infectin Cntrl Cmmittee Cllabrating Department(s) r Cmmittee(s): Nursing, Hspital Administratin, Medical Grup Administratin, Infectin Cntrl REFERENCES: Review Date: 7/89, 4/90, 3/94, 12/07, 4/12, 1/15 Page Number 1 f 7 U.S Dept. f Health & Human Services, Centers fr Disease Cntrl and Preventin, Atlanta, Gergia Guidelines fr in Healthcare Settings, Internatinal Health Regulatins (2005) frm Wrld Health Organizatin (WHO); Reginal Plicy and Prcedure fr Handwashing May APIC Guidelines fr Handwashing and Hand Antiseptic in Health Care Settings. PURPOSE: 1. The purpse f hand hygiene is t remve dirt, rganic material and transient micrrganisms frm the hands t decrease the risk f crss cntaminatin. DEFINITIONS: TYPE PURPOSE METHOD Rutine Handwashing Hand rub/degerming Surgical hand scrub T remve sil and transient micrrganisms. T destry transient and resident micrrganisms n UNSOILED hands. T remve r destry transient micrrganisms and reduce resident flra. Wash hands with sap and water fr at least 15 secnds. Rub alchl-based hand degermer int hands vigrusly until dry. Wash hands and frearms with antimicrbial sap and waterwith brush t achieve frictin. Or alchlbased preparatin rubbed vigrusly until dry. 1. Red Rule is defined as: Rules cannt be brken Few in numbers, easy t remember Assciated nly with the prcesses that can cause serius harm

2 2 f 7 Any staff member is empwered t speak up when the rule is nt being fllwed POLICY STATEMENT(S): 1. Red Rule is part f the hand hygiene prgram fr Fntana / Ontari which prmtes cmpliance by the health care wrkers with hand hygiene befre and after every patient cntact and it is managed thrugh a Just Culture apprach. 2. The chice f sap and water, alchl-based hand degermer, r surgical hand scrub shuld be based n standards f care, the degree f hand cntaminatin and whether it is imprtant t reduce and maintain minimal cunts f resident flra, as well as t mechanically remve the transient flra n the hands f healthcare persnnel. Anything that precludes this is nt permitted e.g. artificial nails, rings and wrist hand splints. 3. Hand decntaminatin with alchl based degermer (gel, rinse r fam) is the recmmended methd f hand hygiene fr all situatins as defined by the Wrld Health Organizatin (WHO) 5 mments f hand hygiene, unless hands are visibly siled r patient has Clstridium difficile in which case hand hygiene with sap and water fr 15 secnds is the methd fr all patient cares areas 4. Hand washing with sap and warm water if recmmended methd prir t fd preparatin. 5. Hand decntaminatin with alchl based degermer shuld be used where n sinks are available. 6. Surgical hand scrubbing is required prir t surgical prcedures. 7. All persnnel and physicians must perfrm hand hygiene accrding t the Wrld Health Organizatin (WHO) Five Mments fr Requirements as supprted by the CDC and defined as: A. Befre having direct cntact with patients. B. Befre perfrming an aseptic task. C. After expsure t bld r bdy fluids. D. After patient cntact E. After cntact with the patient s surrundings. 8. In additin t the WHO 5 mments, all healthcare wrkers (HCW) shuld perfrm hand hygiene: A. Befre dnning sterile glves in preparatin fr perfrming invasive prcedures such as central intravascular catheter, inserting indwelling urinary catheters, r brnchscpy; B. Befre and after remving glves C. At the start f the shift

3 3 f 7 9. Glves: D. Befre administering medicatin E. Befre eating and/r drinking, after cughing r sneezing A. Glves are NOT a substitute fr hand washing glves are micrprus which can allw fr the entry f micr rganisms. Use f glve des nt preclude hand hygiene. Glves may becme perfrated and cntaminate the hands and bacteria can multiply rapidly n glved hands. B. Always perfrm hand hygiene befre & after glves use. Please refer t In-Patient Pharmacy and Hme Health Pharmacy plicies fr glve use in medicatin preparatin areas. 10. The use f alchl rinse prducts instead f handwashing is acceptable in situatins where the hands are nt siled with physical dirt. Alchls are pr cleaning agents and hands must be free frm dirt fr the alchl t be effective. 11. Sap frm wall-munted dispensers is t be used fr rutine handwashing. Bar sap is unacceptable. 13. Hand ltin is prvided t prmte skin integrity and prevent skin dryness/ A. Ltin is a ptential media fr bacterial grwth and is prvided nly in small dispsable cntainers r cntainers that are nt refilled. B. CHG (chlrhexidine glucnate), which is a cmpnent f sme f Kaiser s standard antimicrbial sap prducts and surgical scrubs, is cmpatible with Kaiser s standard hand ltin. It is nt cmpatible with mst cmmercially available ltins, which can inactivate the CHG. Cnsequently, persnal hand ltins shuld nt be brught in fr use at wrk. 14. Rings ther than plain bands are discuraged fr health care wrkers. Bands may be left in place while washing. In the Nenatal Intensive Care Unit (NICU) hand jewelry r lng sleeve garments will nt be wrn. 15. The natural nails f health care wrkers are t be kept shrt, i.e. nt extending beynd the tips f the fingers. Any nail plish must be intact, nt chipped. 16. All artificial nail enhancements including but nt limited t: nail tips, jewelry, gels, wraps, etc. are prhibited fr all health care wrkers and prviders wh prvide direct, hands-n patient care, acrss the cntinuum f care, including but nt limited t: inpatient (including Perinatal services, Labr and Delivery, Pst-Partum, Nursery), ambulatry and hme care, invasive, r diagnstic prcedures r therapies, Labratry Services, Periperative Services, Sterile Prcessing Dept, Intensive care units (adult, pediatric, newbrn), etc. Other wrkers invlved in aseptic

4 4 f 7 prcedures r wh have cntact with the patient envirnment, etc. must als cmply e.g. pharmacy, fd handlers, Envirnmental Services (EVS), Scial Wrkers Hand / wrist splints and any type f dressing that may have direct patient cntact and may preclude handwashing and hand degerming are prhibited fr all healthcare wrkers and prviders. Cnsult with Infectin Cntrl Prfessinal and Emplyee Health Services (EHS) fr case by case assessment. 18. All members f the Surgical Team must prperly cmplete a Surgical Hand Scrub prir t beginning the prcedure. 20. Hands and frearms must be free f pen lesins and breaks in skin integrity. PROVISIONS/PROCEDURE: 1. PROCEDURE FOR HANDWASHING WITH SOAP AND WATER A. Stand near sink. Avid tuching the sink, as the sink may be a surce f cntaminatin. B. Use warm water t wet hands. Avid splashing and keep misture away frm sleeves and clthing. C. Apply amunt f sap recmmended by the manufacturer (usually ne pump f the dispenser). D. Rub hands vigrusly tgether, causing frictin, t clean between fingers, arund and under fingernails, the back f the hands, wrists, and palms fr at least 15 secnds. E. Rinse hands well under running water. F. Dry hands with paper twel. 1) Use paper twel t turn ff faucet if there is nt a ft r knee cntrl t prevent recntaminating hands. G. FMC NICU staff must finish with alchl based hand degermer after washing with sap and water. 2. PROCEDURE FOR USE OF HAND DEGERMERS (ALCOHOL BASED HAND RUBS) A. Apply prduct t palm f ne hand. B. Rub hands vigrusly tgether, causing frictin, t degerm between fingers, arund and under fingernails, the backs f the hands, wrists and palms until dry. C. Degermers are nt t be used when hands are visibly siled. D. Wash hands with sap and water when hands feel sticky r are visibly siled.

5 5 f 7 3. NICU INITIAL SCRUB: A. All NICU Staff must perfrm a ne minute hand scrub at the beginning f each shift B. Remve all hand jewelry. C. Wet hands and wrist area. D. With firm rubbing, using circular mtins, wash the palms, the back f the hands, each finger, tips f fingers, areas between the fingers, knuckles, wrists, and Frearms t the elbw. E. Using the clck abve the sink, wash fr ne minute. F. Dry hands and wrists with a clean paper twel, ging frm fingertips ending at the elbws. G. FMC NICU must fllw by rubbing with alchl based degermer until dry. 4. GENERAL PROCEDURE FOR SURGICAL SCRUB A. All Persnnel (prviders, staff, physicians, thers) scrubbing in fr surgical/invasive prcedures will adhere t the Surgical Attire Practices plicy and fllw the prvisins fr scrubbed persnnel. B. Surgical hand scrub will be perfrmed by all scrubbed persnnel, using either an antimicrbial surgical scrub agent intended fr surgical hand antisepsis r an alchl-based antiseptic surgical hand rub with dcumented persistent and cumulative activity that have been apprved by US Fd and Drug Administratin (FDA). C. All artificial nail enhancements including but nt limited t: nail tips, jewelry, gels, wraps, etc. are prhibited fr all health care wrkers and prviders in Periperative Services, Additinally, chipped fingernail plish, rings, watches, and bracelets are nt permitted t be wrn by scrubbed persnnel and must be remved prir t scrubbing. D. Cuticles are in gd cnditin and there are n cuts r skin prblems (hands and frearms) present. E. Surgical hand scrub prcedure using an a traditinal antimicrbial surgical scrub agent with a spnge r sft brush will be perfrmed in the fllwing manner: 1) Remve jewelry including rings, watches, and bracelets. 2) Dn a surgical mask. If thers are at the scrub sink, a mask will be wrn in the presence f scrub activity.

6 6 f 7 3) Wash hands and frearms if visibly siled with sap and warm, running water immediately befre the first scrub f the day and whenever hands are visibly siled. 4) Clean underneath the fingernails f bth hands under running water using a dispsable nail cleaner. 5) Rinse hands and frearms under running water. 6) Chlrhexidine Glucnate prduct: a. Apply 5ml f the prduct b. Scrub hands fr 3 minutes, paying particular attentin t the nails, cuticles, and interdigital spaces. c. Rinse thrughly with water. d. Scrub hands fr an additinal 3 minutes with 5ml f the prduct and rinse under running water. 7) Pvidne Idine prduct: a. Apply 5ml f the prduct, b. Scrub hands fr 5 minutes, paying particular attentin t the nails, cuticles, and interdigital spaces. c. Rinse thrughly with water. d. Scrub hands fr an additinal 5 minutes with 5ml f the prduct and rinse under running water. 8) Visualize each finger, hand, and arm as having fur sides. 9) Wash all fur sides effectively, keeping the hands elevated. 10) Repeat prcess with fingers, hand, and arms including elbw. 11) Avid splashing surgical attire. 12) Discard used spnge in trash receptacle. 13) Rinse hands and arms under running water in ne directin frm fingertips t elbws as ften as needed. 14) Hld hands higher than elbws and away frm surgical attire.

7 7 f 7 G. Surgical hand scrub prcedure using a water-less alchl-based surgical hand rub agent will be perfrmed in the fllwing manner: 1) Remve jewelry including rings, watches, and bracelets. 2) Dn a surgical mask. If thers are at the scrub sink, a mask will be wrn in the presence f scrub activity. 3) Wash hands and frearms if visibly siled with sap and warm, running water immediately befre beginning the surgical scrub befre the first scrub f the day and whenever hands are visibly siled. 4) Clean underneath the fingernails f bth hands under running water using a dispsable nail cleaner. 5) Rinse hands and frearms under running water. 6) Dry hands thrughly with clean paper twel. 7) 3-Pump Prcedure with Waterless Alchl-based Surgical Scrub: a. After hand hygiene, b. Use 1 metered dse pump (2 ml) f waterless prduct in palm f 1 hand c. Dip the fingertips f the ppsite hand int the scrub slutin and wrk it under the nails. d. Spread the remaining hand scrub ver the hand and wrist up t the elbw, cvering all surfaces until dry. e Repeat prcess with ther hand. f. Dispense a 3rd pump f waterless prduct int either hand; reapply t all aspects f bth hands t the wrist until dry. g. Allw prduct t dry befre dnning glves. h. Repeat prcess in between surgical prcedures.

In healthcare settings, hand hygiene is the single most important way to prevent infections.

In healthcare settings, hand hygiene is the single most important way to prevent infections. Infectin Preventin & Cntrl Manual 2. HAND HYGIENE Hand hygiene (HH) is a general term referring t any actin f hand cleaning. Hand hygiene relates t the remval f visible sil and remval r killing f transient