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Clean hands: how to encourage good hygiene by patients

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VOL: 96, ISSUE: 46, PAGE NO: 37

Jackie Whiller, NVQ III, is nursing auxiliary, St Mary's Hospital, Newport, Isle of Wight

Tracey Cooper, RGN, DipN, is infection control nurse specialist, St Mary's Hospital, Newport, Isle of Wight

The importance of hand-washing by health care staff has been recognised for many years (Reybrouck, 1983). It is the single most important measure in the prevention of cross-infection and infection control teams are working hard to raise awareness of the issue (Gallagher, 1999). As a result, a great deal of literature has been published on hand-washing for health care staff (Gould, 2000). However, little has been published on the importance of hand-washing by patients (Meyers and King, 2000).

The importance of hand-washing by health care staff has been recognised for many years (Reybrouck, 1983). It is the single most important measure in the prevention of cross-infection and infection control teams are working hard to raise awareness of the issue (Gallagher, 1999). As a result, a great deal of literature has been published on hand-washing for health care staff (Gould, 2000). However, little has been published on the importance of hand-washing by patients (Meyers and King, 2000).

It is vital that patients wash their hands after using the toilet or commode because of the risk of their hands becoming contaminated by faecal organisms (Sanderson and Weissler, 1992). Hand-washing before eating and drinking can also reduce the spread of pathogens via the faecal-oral route.

Maintaining hand hygiene in immobile patients who are unable to access sinks is a challenge. Time constraints and workload are often the excuses offered for failing to offer patients such alternatives as a bowl of hot water and soap. However, patient hand wipes are a good solution to the problem. These moist, ethanol-impregnated disposable tissues are easy to use and are acceptable to clients as well as staff.

The Isle of Wight Healthcare NHS Trust introduced patient hand wipes several years ago to enable immobile patients to wash their hands. However, anecdotal evidence suggested that they were not routinely being offered to all patients who might need them. As a result, one of the authors decided to investigate the situation on her ward as part of an NVQ III course.

Hand-washing audit
The aim of the audit was to identify whether clients on the ward were being offered hand-cleansing facilities after using the commode. Twenty clients with significant mobility difficulties were selected and asked three questions (See box, below).

Audit results
Of the 20 patients selected, 16 had used a commode. Only eight (50%) of these patients had always been offered hand-washing facilities, three (19%) had sometimes been offered them, and five (31%) had never been offered them. Of the eight patients who had only sometimes been offered hand-washing facilities, seven would have liked to have been offered them every time.

It is possible that these results were skewed by the fact that the staff on the ward were aware that the audit was taking place and might have altered their practice as a result. However, even allowing for this, the results still demonstrated a need for a change in practice.

Changing practice
The next phase of the project was to implement improvements in practice. Discussion with colleagues and personal reflection suggested that there were two reasons for low compliance. First, there was a lack of awareness, resulting in staff forgetting the importance of hand-washing by clients, particularly when they were busy. Second, staff reported that they often forgot to take hand wipes to the patient along with the commode, and then they could not find them quickly when needed. Consequently, they were not always offered.

To counter these oversights, laminated, multi-coloured signs were produced and attached to the back of each commode to remind staff to offer hand wipes. Lamination made the signs easy to clean, and they were attached using elastic bands that were also easy to clean or replace when needed.

Net bags that were the correct size to hold the containers of hand wipes were attached to the side of the commode using a washable tie. These bags were made of a fine plastic net that could easily be washed in detergent and dried if contamination occurred or when replacing the container of hand wipes. The net bags cover the sides and base of the hand-wipe container but leave the top open. This means they are rarely handled by staff and not at all by patients.

These two measures have ensured that wipes are always available with the commode and act as a reminder to busy staff to offer them to patients.

A follow-up audit
Audit is a cyclical activity, requiring re-audit to complete the cycle and ensure practice has changed. Therefore a re-audit was performed using the same criteria as the initial audit. Twenty patients who had all used the commode during their admission were selected.

We found that all 20 patients were offered hand-washing facilities at least some of the time, compared with 69% in the first audit. The number who were always offered hand-washing facilities rose from 50% to 85%. This demonstrates a very positive improvement in practice that should lead to a reduction in the risk of cross-infection.

Sharing good practice
The NVQ student and the infection control nurse specialist decided that the results of this research should be shared with staff elsewhere in the trust. A presentation of the audit was made to the infection control link nurse group, and it was agreed to mass-produce laminated signs and net bags for distribution across the trust.

The infection control link nurses are to ensure these measures are implemented in their practice areas and a re-audit will be performed across the trust later in the year to confirm that good practice is maintained.

Conclusion
This project began as a small-scale investigation followed by local practice changes on one ward. Good communication and liaison within the trust has ensured that the work has been used to benefit patients in all areas. This is in line with clinical governance and the National Audit Office report on hospital infection control (National Audit Office, 2000). All staff should be encouraged to investigate infection control issues at clinical level, supported by their infection control teams.

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