Hand hygiene on a global scale

It’s 2013, and most of us spend our time keeping up with the myriad of mandates and directives that, in the name of patient safety and standards, aim to prevent as many infections as is humanly possible during care delivery. Ensuring the hands of healthcare workers are clean, when having contact with the patients and service users who put their trust in healthcare every day, is a big part of this. How did we get here? How did we get to the point that hand hygiene is the topic of two annual, global days of action and the feature of an editorial and edition of the Journal of Infection Prevention?

Talk of the town
The topic is still being talked about in this year, this decade, still hitting the headlines; and still not occurring enough to ensure patient safety, as well as the patient confidence in healthcare that we want to see.

At the time of writing this, it took Google 0.26 seconds to retrieve 15 million entries on the term hand hygiene. There are almost 50,000 videos on YouTube and as well as hand hygiene now being a MeSH term in its own right – quite an achievement, it is also a well-used hashtag on Twitter. If “what gets talked about gets done” (Fraser 2002) is really true, then we have nothing to fear and this problem is sorted. But we know, due to many underlying reasons, that this is not the case. So do we know where to go next?

An annual global day, which is facilitated by WHO occurs every 5 May focused on hand hygiene in healthcare. However, this year has seen the topic talked about from many different angles at a national and international level. It is being talked about as a true patient safety intervention that protects patients from harm. The Agency for Healthcare Research and Quality (AHRQ) in the US (AHRQ 2013), the Chief Medical Officer’s (England) annual report volume two (Chief Medical Officer 2013) and the final Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry (Francis 2013) mention hand hygiene so many times that it’s hard to count, so why would we think we have ‘done hand hygiene’ or that it’s old news? It is clear that there continues to be an urgent need for renewed action to make hand hygiene happen more reliably. To not do this, should another incident happen, could be seen as neglectful. Therefore it is the time to be responsible and accountable for this call to action to make sure no person receives sub-optimal care due to the omission of hand hygiene.

Behaviour Change
Some say it started with Semmelweiss, but where most of us are today more or less started with Pittet et al (2000). In the first year of a new century, those who were around were inspired by this culmination of a revolutionary account of how a straightforward, multimodal behaviour change strategy could change the way we looked at a fundamental action: cleaning our hands at key times when delivering care. It injected new life into a recalcitrant problem that formed the staple diet of infection preventionists’ day-to-day activity. It re-energised and reinvigorated the issue. For some of us it changed everything.

And today, to celebrate 5 May, across the UK and Ireland we should not underestimate the role we have played in influencing the global agenda on hand hygiene and therefore ultimately influencing the safety of patients at home and around the world.

Before the cleanyourhands™ campaign for England and Wales was conceived, the work of Roa et al (2002) was published and disseminated, highlighting the application of social marketing and bedside alcohol-based handrub to impact on healthcare associated infection. It is worth remembering that it was under the strong influence of the senior ICN involved at the time that led to this groundbreaking work.

Between 2002 and 2005, the first nationally funded campaign on hand hygiene improvement in healthcare was then developed, tested, evaluated and implemented across England and Wales and became a model illustration of a multimodal approach to improvement that has been cited in the World Health Organisation’s (WHO) Guidelines on Hand Hygiene in Healthcare (2009). This, and the work of Pittet and his team in Geneva (2000) was also influenced by the work of the Oxford Radcliffe Hospitals local hand hygiene campaign that incorporated patient empowerment (McGuckin et al, 2000).

Part of the scoping of the cleanyourhands™ campaign also saw the influence of a senior Infection Control Nurse in Swindon in catalysing the adoption of the term ‘point of care’. Point of care wasn’t a new term overall, but it was in relation to thinking about vulnerable patients in their beds in particular, and the times when they most needed our protection – when they were being touched or while critical items were being inserted into them. What a great idea! A clear focus on a few critical times when this lifesaving action is vital; not an endless list of times at which a basic hygiene measure we should all expect, should happen. Unfortunately people fail to remember and acknowledge this in healthcare, still, and in turn patients get harmed: fact.

Committed to Hand Hygiene
In the early part of the last decade came the launch of other campaigns tying in with the start of WHO’s Clean Care is Safer Care programme, which at inauguration had nine leading countries, including all UK countries, pledge their commitment to take action through national hand hygiene campaigns.

Scotland then became a leader in their field, launching the Washyourhandsofthem campaign which incorporated different elements to suit the population’s needs – a methodological protocol, national public auditing and reporting and a public marketing aspect including evaluation through market research, among other things (Kilpatrick 2007).

The cleanyourhands™ campaign from England and Wales was then launched in Northern Ireland in 2008 to add to our countries’ efforts, and the Republic of Ireland is still being innovative in their national approach, working hard to spread the word of the WHO 5 Moments.

The Domino Effect
So, what has really happened during this time? We have seen a domino effect, starting with individuals, then organisations, then countries, and now we have over 15,000 healthcare facilities across the world signed up to the WHO 5 May campaign, SAVE LIVES: Clean Your Hands, including many on our doorstep.

What we don’t realise during this time is how much of the change management and human factors fields we have influenced over these years – terms that are used today and are synonymous with innovation and future thinking.

We are not good enough at celebrating success in healthcare, but perhaps on 5 May each year, while we take stock and reflect on the pressing need to maintain a strong focus on hand hygiene improvement, we should also recognise that, over the last decade, gains have been made and infections averted because we got better at hand hygiene. It is inherently difficult to determine the precise impact of single interventions like hand hygiene that take place within complex sociotechnical systems. However, it is highly likely that a significant part of the work we have all done over the last 10 years has saved lives. It’s never enough and there is always more to be done.

The bottom line is that if we continue to accept defects in compliance with hand hygiene then our patients will be harmed. Such an acceptance undoubtedly flies in the face of the IPS’s vision that no person will be harmed by a preventable infection. No infection preventionist, manager, leader or CEO should tolerate this.

As the Agency for Healthcare Research and Quality said a couple of months ago – hand hygiene works as a patient safety intervention. Let us focus on it around this time of 5 May, as well as every day. In addition let us commit to continuously revisiting, developing and designing monitoring techniques and interventions that will help to maintain and improve the behaviour of those we urgently need to influence. Let us never tolerate complacency and dismissiveness. Hand hygiene is actually a technology that works for patient safety and some of our IPS members are working hard right now to forge the right future in this regard for our patients and service users.

What will be next in hand hygiene improvement and how can we continue to contribute to this? Can you be the catalyst for the next phase of the hand hygiene improvement conundrum?

Further information
To view the original article, visit www.bji.sagepub.com/content/14/3/84.full