How clean are your hands?

The National Patient Safety Agency (NPSA) is home to cleanyourhands, the national hand hygiene campaign of England and Wales. cleanyourhands was the first national hand hygiene campaign in the world and has received attention globally through its continued involvement with WHO Patient Safety.

The NPSA initially highlighted healthcare associated infection (HCAI) as a patient safety issue in 2002, soon after the agency came into existence. Since then the agency has continued to work on programmes aimed at increasing patient safety by reducing the burden of HCAI. These programmes in turn have changed over time to meet the needs of a changing NHS, the move towards the quality and productivity agenda being key.

At present the agency has a number of infection prevention and control (IPC) related programs including:
• Matching Michigan, a programme of work aimed at reducing catheter related blood stream infections in critical care.
• The NHS cleaning manual, a resource for all NHS staff and contractors describing detailed minimum cleaning standards.
• Design for patient safety, a programme of working which aims to design risk out of medical devices and the wider healthcare environment.
• Root cause analysis, a vital tool in learning from IPC incidents to prevent their recurrence.
• The cleanyourhands campaign.

IMPROVING HAND HYGIENE
The aim of cleanyourhands is to contribute to a reduction of HCAI by facilitating sustained improvement in hand hygiene practice by healthcare staff. The methodology of the campaign is multimodal social marketing underpinned by clinical expertise in patient safety. The campaign utilises several methods to encourage hand hygiene awareness and compliance among staff. This multimodal approach facilitates, educates, prompts and enables healthcare workers to clean their hands at the right time, and every time during patient care.

The campaigns membership now includes 100 per cent of acute trusts and 97 per cent of all other NHS trusts. Now in the final year of its originally planned lifespan cleanyourhands reflects on its successes to date and plans for the future.

FIVE YEARS OF CLEANYOURHANDS
The cleanyourhands campaign was initiated with the issue of the NPSA patient safety alert ‘Clean hands help to save lives’ on 2 September 2004. At this time one of the main problems contributing to staff compliance with best practice in hand hygiene was its poor facilitation. The realities of the built environment and how, ergonomically, this was linked to care provision meant that compliance was suboptimal. The campaign focused on facilitating hand hygiene at the point of care. This was where, based on transmission dynamics, it was understood hand hygiene could be most impactful from a patient safety perspective, as opposed to public health or social hygiene.

The main service innovation to achieve facilitation of hand hygiene at the point of care was the introduction of alcohol based handrub. Since the beginning of the campaign the procurement levels of alcohol hand rub have continued to increase, as have the levels of soap purchased by the service. It was important for the NPSA that the increasing prevalence of alcohol based handrubs was not at the expense of a decrease in hand washing with soap and water.

INCLUDING THE INDIVIDUAL
In year two the focus continued to be placed heavily on the point of care but also the role of the individual was examined. Individual and local ownership are both vital for sustained change. During the course of the campaign the centrally supported element from NPSA became less prescriptive and more facilitative, encouraging greater degrees of local engagement along the journey. Importantly, the campaign had still not been extended at this point beyond acute trusts, which perhaps reflected the perception of risk and ownership of HCAI at the time.

In November 2007 the campaign launched a bolder and more serious range of collateral. These materials reflected the seriousness of HCAI and the strength of feeling amongst the public and healthcare professionals. At this time the media and politicians had become heavily involved in the HCAI agenda.

It was during this year that calls to extend beyond the acute trusts increased. The development work for an extension beyond acute hospitals had begun in 2005. A review of existing infection control strategies in community based care settings was undertaken. By 2008 with the research complete the campaign was launched in the community based care settings. During 2008 the initial patient safety alert was re-issued underlining the fact that there was work yet to do. Specifically the alert prompted trusts to examine the locations where they had placed hand hygiene consumables. The campaign has been successful in promoting an awareness of the importance of hand hygiene but message evolution was required as the challenges presented by the diversity of the community based care settings were significant.
    
OVERCOMING THE OBSTACLES
During 2008/9 the cleanyourhands message evolved to focus on the when of hand hygiene. Having seen alcohol hand rub proliferate beyond the point of care it was time to re-focus the service on when hand hygiene is most likely to impact patient safety. To do this cleanyourhands adopted and launched the WHO developed Five Moments for hand hygiene. This allowed cleanyourhands to differentiate itself from public health hand hygiene initiatives by linking to the prevention of negative patient outcomes. Also the Five Moments fit with the journey towards local ownership as it allows individuals, wherever they work, to decide when they need to perform hand hygiene.

It became clear to the small core team at cleanyourhands that catering for the needs of the diverse community based care and service providers would be a challenge. The campaign and the Five Moments for hand hygiene were both developed specifically for the hospital environment. A series of research events were held which aimed to ask healthcare professionals what they needed in a hand hygiene programme. Focus groups, site visits, online surveys, qualitative research, feedback forms and case studies were used. Gaining feedback from mental health, social care, general practice, PCTs, learning disabilities, dental, offender health and other settings was invaluable.

What resulted was a suite of resources that had been reduced to core transferable principles and then re-built with specific settings and needs in mind. Even so a dynamic shift was required to ensure success beyond the hospital setting. Because the NHS is so diverse it would no longer be possible for cleanyourhands to prescribe how materials should be used in each setting. Even within organisations with the same broad remit, for example mental health, the services offered and ways of working can vary enormously.

For this reason cleanyourhands changed its approach to allow members to use whichever resources, as many or as few, as they felt were appropriate to where and how their staff work. This approach has been very successful to date as demonstrated in a number of online case studies. The cleanyourhands team continued to support local adaptation of resources and implementation during this time.

NOW AND NEXT
As with many other campaigns, road safety for example, messages evolve as do methods of communicating them. cleanyourhands has moved from the “how” and “why” of hand hygiene to the “when”. We have also moved from a “do this” to a “this is what you could do, we’ll help” approach.

The campaigning aspect of cleanyourhands will end in March 2011. The four year independent evaluation of the campaigning phase of cleanyourhands has ended and will be published later this year. At the present time a strategic review is underway to examine
how we can continue to add value using a new operating model. Our website will be updated with details as this work progresses.

The current climate across the health sector has encouraged the cleanyourhands team to critically analyse its outputs based on returns from a patient outcome and economic perspective. There is a clear cost saving and quality improving potential in reducing HCAI we must however focus more tightly on what is actually achieving this reduction. It is our feeling at this early point in our strategic review that a move away from promotional collateral towards more impactful targeted intervention will yield better results from both a quality and productivity angle.

We continue to supply a wide range of resources and support to the NHS in England and Wales. These resources are available to registered cleanyourhands coordinators to order online, free of charge. In partnership with local Infection Control Teams we will hold a number of events across England and Wales this year to address a number of important issues including barriers to implementing IPC services and identifying what really adds value by improving patient care. For more details on this or other cleanyourhands events see our contact details below.

E-mail: handhygiene@npsa.nhs.uk