Improved hand hygiene

The accepted costs of healthcare-associated infections (HCAIs) are quoted often enough to be well known: there are an estimated 300,000 cases every year in English hospitals, with consequences for affected patients ranging from discomfort through disability to, in an estimated 5,000 cases each year, death.
    
In financial terms, HCAIs in English hospitals are estimated to cost the National Health Service (NHS) £1 billion each year. Costs are incurred because infections require treatment and often lead to more time spent in hospital. Bacterial infections are more difficult to treat and more likely to have an adverse outcome if they are caused by an organism that is resistant to antibiotics, such as meticillin-resistant Staphylococcus aureus (MRSA).
    
The proportion of patients suffering from HCAIs in the NHS is comparable with other countries, but a higher proportion of those may be caused by resistant organisms. MRSA is the example that is usually quoted: almost half of the bloodstream infections in the UK caused by Staphylococcus aureus are caused by MRSA, compared with fewer than 1 per cent in some Scandinavian countries. Additionally, problems arising from HCAIs can become compounded: For example, treatment of bacterial infections with antibiotics increases the risk of Clostridium difficile-associated disease, and the longer an individual remains in hospital, the greater the risk of further infection or of one person’s infection spreading to someone else.

Safety of patients
Longer hospital stays due to HCAI have a knock-on effect on bed availability that may in turn increase the time spent by patients on waiting lists and in emergency departments. The costs of a longer stay and for the treatment of any infection are specifically not included in the “payment by results” tariffs. It therefore follows that the financial stability of a trust and its ability to achieve targets for waiting times are adversely affected by HCAIs. While there will always be problems in juggling what may be seen as competing priorities, that may in some situations make solutions that could compromise infection prevention seem attractive, the Healthcare Commission has been explicit that the safety of patients must not be compromised by the need to meet other objectives. In fact, the experience of trusts that have given priority to infection prevention and control is that other objectives are more easily achieved when the number of HCAIs is reduced.

Worrying reports
One strategy that has been demonstrated to have a positive effect on infection rates is to improve hand hygiene. This is because the microorganisms responsible for infections are easily transferred from place to place and person to person on the hands of healthcare workers. Hand decontamination, with soap and water or alcohol-based handrub, carried out with good technique and at the right time, stops this happening. Unfortunately, the hand hygiene compliance of healthcare workers is frequently reported as being 40 per cent or less – that is, they clean their hands on fewer than half the occasions on which they should.
    
Some groups of staff are much better than this, but unfortunately some are much worse: Medical staff, for example, are often reported as having very poor hand hygiene compared with other health care workers, with studies showing their compliance to be as low as 10 per cent or less.

Available at point of care
In 2004, in order to improve the hand hygiene of healthcare workers, the National Patient Safety Agency launched the cleanyourhands campaign with the publication of Patient Safety Alert 04: Clean Hands Save Lives. This alert invited acute NHS trusts in England and Wales to join the campaign and instructed them to implement one of its key elements by installing alcohol-based handrubs so that they could be used at the point of care. Making handrub available at the point of care has several advantages: It can be used immediately before and after any care activity, thus both minimising the risk of re-contaminating the hands before contact with the patient and minimising the risk of transferring any organisms picked up from the patient elsewhere.
    
Additionally, hand hygiene at the point of care takes place in full view of the patient. This reassures them that they are not being put at risk, and should improve their confidence in the care being delivered. This opens the way to involving patients in their own care. Another element of the campaign focuses on making patients aware that they should expect to see staff clean their hands before any hands-on activity. Using the slogan “It’s OK to ask”, gives them permission to challenge staff whom they haven’t seen clean their hands. Obviously this also requires that organisations make clear to their staff that they are expected to react positively to such challenges.
    
The most visible elements of the campaign are the environmental prompts that remind staff of the importance of hand hygiene and encourage them to carry it out. Yellow triangles were provided by the NPSA, to be displayed at the point of care to remind staff that that is where they need to clean their hands.
    
Additionally, 12 different posters were produced for each of the first two years of the campaign. This was so that the posters could be changed each month, and continued to be noticed and acted upon. Displaying and changing the posters has presented challenges for some trusts, particularly those using buildings provided under a private finance initiative (PFI) where there are often restrictions on displaying posters other than on notice boards. Other difficulties have been encountered in getting the posters changed regularly, either because of logistical problems or a lack of understanding about how the materials were to be used. However, these difficulties have generally been overcome and the independent evaluation of the campaign demonstrates that it is having a positive effect: consumption of alcohol handrubs by hospital trusts has increased, and without any decrease in the amount of soap being purchased. This indicates that the overall number of occasions on which hand hygiene is being performed has gone up.

Holistic approach
Those trusts that have implemented the campaign most successfully are those that have both engaged the whole organisation, and used the campaign as a starting point on which to build their own hand hygiene improvement initiatives. For example, in one trust matrons have been given the responsibility by their directors of ensuring that observational audits of hand hygiene are carried out in their units. The results of these audits are fed back to the people concerned so that everyone is able to see how each unit is performing and to compare it with other units. This approach has resulted in reported hand hygiene compliance of more than 90 per cent.

Off-site
The cleanyourhands campaign is now being implemented by all acute NHS trusts in England and Wales. Although different trusts started at different times, all have now been harmonised in order to facilitate the logistics of the delivery of materials. The first batch of new materials for Year Three of the campaign will be available later in 2007. However a large proportion of health and social care is delivered outside hospitals, and hand hygiene is no less important in these settings than it is in hospitals. For this reason the campaign will shortly be made available to primary care and mental health and ambulance NHS trusts, and other organisations providing “non-acute” care. This extension presents many more challenges, not least because of the sheer range and number of care settings involved. However, it is important to ensure that hand hygiene is given priority across the health economy because failures of infection control in one area can easily affect other care providers: For example, a nursing home resident may be seen by a general practitioner, receive treatment from the PCT’s podiatrist, occupational therapist or district nurse, or attend a day hospital; if they become acutely ill they will be admitted to an acute hospital. Failures in hand hygiene may result potentially pathogenic microorganisms being carried from one setting to another by the patient or by carers to other people in their care. Extending the cleanyourhands campaign to non-acute care should reduce the risk of this happening.

For more information
To find out more visit the NPSA
website: www.npsa.nhs.uk