Bare below elbow guidance

Bare Below the Elbows: Confirmation of National Ambulance Service Infection Prevention and Control Consensus Position

Following recent concerns raised nationally by NHSE and other national organisations as well as individual trust hand hygiene observations it is considered that a reminder regarding the national consensus on Bare Below Elbow by all ambulance trusts is required. We ask that all Trusts continue to support this message and their BBE policies to protect our patients, staff and colleagues.

 

Background
Healthcare-associated infections (HCAIs) can develop in all healthcare settings. The term HCAI covers a wide range of infections. HCAIs pose a serious risk to patients and staff as a result, infection prevention and control is a key priority for the NHS.

The transmission of micro-organisms that may cause infection can occur directly via hands, or indirectly from the environment or via an environmental source (e.g., medical device). Evidence indicates that hand mediated transmission is a major contributing factor in the acquisition and spread of infection. Hands can only be decontaminated effectively by ensuring that the correct technique is used which encompasses the wrists. It is therefore imperative that staff comply with ‘Bare Below the Elbow’ in order to facilitate this.

The 'Bare Below the Elbow' (BBE) policy is a national consensus policy that applies to all UK Ambulance Services and to which all UK ambulance Infection Prevention Leads (NASIPCG) and Directors of Quality (QIGARD) are in agreement with and fully endorse. Every Ambulance Trusts IPC policy should now state that patient facing staff must be BBE. It is noted that washable watch straps are not acceptable in any patient facing circumstance and all staff must be bare below the elbows whilst in a patient facing environment (and in other settings as per local policy agreement i.e. contact centres.)

Any clinically trained staff, regardless of their duties, who are wearing operational uniform must adhere to the national policy of bare below the elbows. This includes the removal of wrist watches, stoned rings, bracelets, long sleeves, long nails, nail extensions, gel polish and nail varnish (clear or coloured).

For example, clinicians working in areas such as call centres, offices or education may, at any time, be called to provide medical assistance to staff or a member of the public.

The evidence behind this is that hands are not decontaminated adequately if there is anything to impede the process and therefore puts others at risk by transmitting infections.

 

Trust Policies
The current national Ambulance IPC Policy supports Bare below the Elbows, including the removal of wrist watches. This needs to be reflected in all trusts uniform policies to ensure consistency and compliance with legislation (Health and Social Care Act) and regulatory requirements.

Trust policies should have a ‘Bare Below the Elbow’ (BBE) policy/ section in place, clearly detailed within the Infection Prevention and Control policy and procedures document.

The IPC Policy and procedures document acknowledges the challenges faced within the ambulance environment, and has clear exceptions where health and safety requirements take precedence:
All staff must be bare below the elbows whilst in operational uniform. The only exception to this is when long sleeves are required as part of personal protective equipment (PPE), such as wearing high visibility jackets, air ambulance suit or other Trust issue PPE. Sleeve protectors should be worn as appropriate in these situations. Jacket sleeves will easily become contaminated, impede access to wrists and prevent thorough hand hygiene. Long sleeved jackets must be removed, or sleeve protectors worn and should be shortened / rolled up to mid forearm for hand hygiene.

 

Implications
A review of published ambulance service CQC reports, highlights that compliance with Bare Below the Elbow is a key issue which they expect to be enforced.

Quotes from the ambulance CQC reports include:
We observed several ambulance staff were not adhering to the principles of ‘bare below the elbow’ as a way of minimising the spread of hospital-acquired infection. For example, several kept their wrist watches on, wore rings with stones in and had nail varnish on. This was not in line with current best practice, which considers that bare below the elbows means that all staff in contact with patients could effectively decontaminate their hands and wrists between each episode of patient care or contact, which is not possible to do properly when wearing cuffs, watches and/or jewellery.

 

Applying the Policy
It is important that Trusts ensures full compliance with BBE. In addition to publicising the importance of BBE, additional management processes should be in place.

 

Thank you for your cooperation.

 

For the PDF version of this text, and references relevant to its contents, please see the link below in 'downloads'.

 

Published 21st September 2022