Breaking the chain of infection

Quality, innovation, productivity and prevention are the current buzz words in the NHS as we search for ways to use resources more effectively and improve the patient experience.
    
The National Patient Safety Agency (NPSA), as coordinator of the national cleanyourhands campaign in England and Wales, would argue that reducing healthcare associated infection (HCAI) through improved hand hygiene by staff would fulfil these criteria. Plus, whilst significant progress has been made, there is still more that can be done.
    
HCAI has a devastating effect on patients, affecting an estimated 5,000 patients each year1. It often means a longer stay in hospital; for example, a patient with an MRSA bacteraemia will, on average, stay in hospital for an additional 10 days. Financially, HCAI also makes a big impact on the NHS with the additional cost of treatment ranging from £4,000 to £10,000 per patient2. The overall cost to the NHS in England is estimated to be in excess of £1 billion a year3.

Preventing infections
Hand hygiene is considered one of the most cost effective interventions to reduce HCAI. Prior to national rollout of the cleanyourhands campaign back in 2004, a formal economic evaluation estimated that even a reduction of 0.01 per cent in infection rates would make the campaign worthwhile. While a nine per cent reduction on infection rates (a conservative estimate according to the academic literature) as a result of improved hand hygiene by staff could save the NHS £140 million per annum and, most importantly, 450 lives4.
    
An independent assessment of the campaign has concluded that it is has been successful in changing the hand hygiene behaviour of staff working in those organisations.
    
The National Observational Study to evaluate the effectiveness of the cleanyourhands campaign (NOSEC) surveyed infection control teams in acute trusts across England and Wales every six months from July 2004 (pre-launch) to June 2008 and collected data on bed occupancy, product consumption and infection rates. The Study found that the campaign remained a top priority for NHS trust management even 30 months after implementation with widespread uptake of the campaign materials. Importantly, virtually all acute trusts had alcohol handrub at the point of care in at least three-quarters of their inpatient wards with a threefold increase in the procurement of alcohol handrub and soap5. 
    
The campaign has engaged NHS trusts across England and Wales and from April 2008 was extended to primary care, mental health, ambulance and care trusts with over 97 per cent now signed up. From June 2008 it was also launched to hospitals in Northern Ireland and a Memorandum of Understanding was signed with the Independent Healthcare Advisory Service in December 2008; giving their members access to the campaign materials.

Changing behaviour
So what makes cleanyourhands effective? Well, the campaign approach and resources target the different reasons behind why staff don’t clean their hands as often as they should and support NHS trusts to take an organisational-wide approach to improvement. The approach is multimodel with a range of different elements working together to support behaviour change including:

• provision of alcohol handrub to make hand hygiene at the point of care a realistic possibility
• posters and other materials to act as prompts for hand hygiene and reinforce positive behaviour 
• supporting the involvement of patients, with some materials featuring the message “It’s OK to ask” 
• audit and feedback to enable the measurement and feedback of compliance 
• tools and resources to support hand hygiene awareness and education.

Two key fundamental principles underpin the campaign approach. Firstly, the focus on the hand hygiene of healthcare staff. Due to the nature of their work – moving between different patients and different care activities with the same patient – healthcare staff have the greatest potential to spread the microbes that cause infection.
    
Secondly, and even more significantly, is the focus on staff hand hygiene at the point of patient care. The point of care consititutes the time and place where there is the greatest risk of transferring those infection-causing microbes; the point of care can be defined as the patient’s immediate vicinity in which healthcare staff-to-patient contact or treatment is taking place.
    
This is not intended to lessen the value of hand hygiene at other times. In the current pandemic circumstances, good personal hand hygiene is more important than ever; however, the cleanyourhands campaign is specifically concerned with preventing HCAI and the hand hygiene behaviour of staff at the point of patient care is critical to this.

Five moments for hand hygiene
To help healthcare staff better understand when they need to clean their hands during patient care, the cleanyourhands campaign has embraced the World Health Organization’s (WHO) Five Moments for Hand Hygiene. The Five Moments approach aims to take the emphasis off the ‘how’ and focus on the ‘when’ and ‘why’ of hand hygiene so that staff apprecriate when they need to clean their hands in order to keep themselves and their patients safe.
    
The Five Moments are based on risk minimisation, with each Moment incorporating a variety of different indicators for hand hygiene. This approach rationalises when hand hygiene needs to occur, eliminating unnecessary hand hygiene and ensuring that staff clean their hands at the critical points for preventing the transmission of infection-causing microbes.
    
Each one of the Five Moments is aimed at protecting the patient and/or the healthcare worker from harmful microbes. The key principle behind the approach is the concept of ‘zones’ and preventing these harmful microbes from crossing from one zone to another. The ‘patient zone’ is the patient’s immediate environment whilst the ‘healthcare zone’ is the wider healthcare environment. The approach acknowledges that the patient zone will be colonised with that patient’s flora and fauna whilst the healthcare zone will be contaminated with lots of different microbes. The aim of the Five Moments is prevent the microbes from the healthcare zone being moved into the patient zone and vice versa.
    
Once inside the patient zone, providing Moment One (before patient contact) has been complied with, the healthcare worker can care for their patient without needing to clean their hands again unless they have contact with body fluids (Moment Three) or perform an aseptic task (Moment Two).

Supporting the NHS
The Five Moments link hand hygiene to the evidence-base about the breaking the chain of infection and was originally developed by the University Hospital Geneva as part of the Swiss national hand hygiene campaign. The cleanyourhands campaign acknowledges the challenges that this could present – being developed in different health economy for an inpatient environment – but believes that the potential benefits of this approach outweigh these challenges and, as such, is working with NHS trusts to support them in working through its application.
    
In the first instance, this has involved rolling out a programme of regional workshops aimed at infection control teams so that they are equipped and able to train frontline staff in their trusts. A number of resources were provided to support local education and training including a film that illustrates the application of the Five Moments in different care settings during one patient’s journey through the NHS from ambulance to hospital and back home. We have also facilitated a dedicated workshop for infection control and training representatives from the ambulance service to help them work through some of the issues specific to their organisations and care settings.
    
Over 286 infection control staff with a specific remit to deliver training attended the regional workshops, representing 239 trusts from across England and Wales with a good mix of all trust types. The feedback from the event was overwhelmingly positive with 95 per cent of respondents considering them excellent or good.
    
This is just the start, however, as we work to embed the Five Moments for hand hygiene as an integral element of patient care.
    
Finally, a simple online game has been created to raise awareness of the Five Moments and support the WHO initiative, Save Lives: Clean Your Hands on the 5 May. If you fancy giving it a try, visit the cleanyourhands website: www.npsa.nhs.uk/cleanyourhands

Five moments for hand hygiene

• before touching a patient,
• before clean/aseptic procedures,
• after body fluid exposure/risk,
• after touching a patient, and
• after touching patient surroundings.

References:
1 Improving patient care by reducing the risk of Hospital Acquired Infection, National Audit Office, 2004
2 Clean Safe Care: Reducing infections and saving lives, Department of Health, 9 January 2008
3 Improving patient care by reducing the risk of Hospital Acquired Infection, National Audit Office, 2004
4 The economic case: Implementing near-patient alcohol handrub in your trust, NPSA 2004
5 www.idrn.org/nosec.php