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Organising an awareness week to target hand hygiene practice.

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Since Ignac Semmelweis, a Hungarian obstetrician, observed in 1847 that handwashing reduced the number of deaths from puerperal fever (Semmelweis, 1983), the importance of washing hands before patient contact has been recognised by health professionals worldwide. The practice is central to efforts to reduce spread of infection and has clearly demonstrated efficacy in infection control (Infection Control Nurses Association, 1998).


VOL: 100, ISSUE: 17, PAGE NO: 36

Melanie Dentith, RN (Child), Diploma in Child Health, is infection control nurse

Tracey Shelmerdine, RN (Adult), BSc Infection Control, Diploma in Professional Studies in Nursing, is infection control nurse; both at The Hammersmith Hospitals NHS Trust, London.


Since Ignac Semmelweis, a Hungarian obstetrician, observed in 1847 that handwashing reduced the number of deaths from puerperal fever (Semmelweis, 1983), the importance of washing hands before patient contact has been recognised by health professionals worldwide. The practice is central to efforts to reduce spread of infection and has clearly demonstrated efficacy in infection control (Infection Control Nurses Association, 1998).



However, although it is generally accepted that handwashing is the single most important procedure to prevent nosocomial infection (Pratt et al, 2000), studies continue to report unacceptable compliance rates among health care workers (Thompson, 1997; Pittet, 1999). Recognising the need to achieve a sustained improvement in compliance with agreed standards, the infection control team at The Hammersmith Hospitals NHS Trust set up a hand hygiene strategy group.



The group met on a twice-monthly basis to discuss the hand hygiene audit, strategy, and eventually the awareness week. This article reports on the group’s organisation of a hand hygiene awareness week.



Hand hygiene and infection control
In the autumn of 2003 the trust ran its first hand hygiene compliance audit, which was predominantly owned by the link nurses and overseen by the infection control nurse. The link nurses audited different wards from those on which they worked in order to avoid bias.



They were asked to observe the hand hygiene habits of nurses, doctors, and allied health professionals undertaking a range of tasks (Box 1). They were asked to note whether those being observed washed their hands, used an alcohol gel, or performed no hand hygiene.



The results, although above the national average of 40 per cent (National Patient Safety Agency, 2004), were still low enough for the infection control team to decide that immediate action was necessary.



Many studies have investigated hand hygiene compliance and ways to improve this. Pittet (2001) recognised that many factors influence a lack of adherence by health care personnel and suggested methods of encouraging improvement. A number of these methods, such as education, feedback, availability of alcohol hand rubs, and reminders, have formed the basis of the trust’s hand hygiene strategy, devised by the hand hygiene strategy group (Box 2). However, all of these measures require education, motivation, or system change and the awareness week has been organised to address these issues and to launch the strategy with a big impact.



The hand hygiene strategy
Promotion of hand hygiene is a major challenge for infection control experts (Jarvis, 1994) and education, leaflet distribution, workshops, and performance feedback have been associated with transient improvement (Simmons, 1990; Tibballs, 1996). We want our strategy to result in sustained improvements.



The hand hygiene strategy will involve placing alcohol gel at each bedside, increasing patient empowerment by asking staff to wear badges inviting patients to ask if their hands are clean, and implementing a poster campaign depicting staff washing their hands.



The original audit results have been set as a baseline and will be repeated quarterly with results fed back to senior managers through clinical risk committees. The results will also be made available on the trust’s internal intranet. It is hoped that subsequent audit results will show an increase in compliance with hand hygiene and a correlating reduction in rates of methicillin-resistant Staphylococcus aureus (MRSA).



Larson (1988) examined evidence for a causal link between handwashing and risk of infection, and concluded that a continued focus on handwashing as a primary infection control measure was appropriate.



Infection control is not an issue for nurses only and it was felt that the hand hygiene awareness week would make the infection control team accessible to the multidisciplinary team, thereby raising its clinical profile. This, in turn, should make everyone aware of the importance of hand hygiene and its impact on hospital-acquired infection. The week has been planned to address infection control and hand hygiene by organising activities and education for patients, staff, and visitors.



Planning the awareness week
We chose to use the awareness week to launch our hand hygiene strategy following the success of a similar event organised by colleagues at Chelsea and Westminster Hospital. A suggestions session was held to gather ideas for innovative and unusual activities for the awareness week that would most effectively deliver the message about hand hygiene.



We agreed that sponsorship was required in order to enable us to offer prizes for quizzes and for the best example of handwashing during the practical exercises, as well as to book an entertainer for two days, one at each of the main sites (Hammersmith and Charing Cross Hospitals). Various companies with whom the team had developed positive relationships and whose products or services were appropriate to the theme of hand hygiene awareness were approached.



We also held meetings with infection control staff from the Chelsea and Westminster Hospital, and local primary care trusts that were hosting a similar event during the same period. This enabled us to share experiences and ideas in order to deliver a stronger and collaborative message. Once an action plan was agreed, each team member was allocated specific tasks, which ranged from:



- Approaching sponsors;



- Sourcing materials for hand painting supplies;



- Obtaining information regarding the use of public areas within the hospital;



- Ensuring staff were aware of our plans for the week.



Progress was discussed at weekly meetings, where problems could be highlighted and overall planning could be carried out.



Events organised
The hand hygiene awareness week is to take place from 26-30 April 2004 at all four hospital sites within the trust (Charing Cross, Hammersmith, Queen Charlotte’s and Chelsea, and Ravenscourt Park Hospitals). Our planning has incorporated the hand hygiene strategy into the week and it forms the basis of the event schedule.



We also aim to have alcohol hand gel dispensers at the end of every patient’s bed, so that they are available to all staff in clinical areas. All the ward managers have been given the relevant ordering information and have been informed of the importance of providing this product in their own ward areas. Personal hand alcohol gel dispensers have also been provided, which clip to staff uniforms, and the infection control team has encouraged their use.



All clinical staff are encouraged to wear badges prompting patients and other staff to ‘Ask me if my hands are clean’. These aim to empower patients, enabling them to take some responsibility for their care, and to provide a continuing means for providing handwashing education (McGuckin et al, 2001).



Work undertaken by the National Patient Safety Agency (NPSA, 2004) suggests that encouraging hospital patients to discuss hand hygiene with health care workers significantly improves compliance. A hand hygiene improvement toolkit has been piloted and is being considered for national implementation.



Posters have been designed showing senior and respected members of staff (clinical and non-clinical) washing their hands. These will be displayed in the clinical areas in which those particular people work, so that they can act as role models for their colleagues. Photographs have also been taken of senior members of staff performing hand hygiene and these will be displayed in public areas so that the staff featured can act as ambassadors for improved hand hygiene compliance. Since time has been identified as a key factor in motivating staff to undertake hand hygiene they will be encouraged to use the individual alcohol gel dispensers attached to their uniforms.



Educational leaflets on hand hygiene are to be distributed in clinical areas throughout the trust - colour-coded versions have been designed for staff, patients, and visitors. Members of the infection control team will distribute the leaflets, which will give them the opportunity to answer any questions and to further promote the awareness week.



An entertainer on stilts will be distributing the leaflets in public areas, especially to people entering through the main foyers of the hospitals.



A board will display leaflets, photographs, and hand hygiene literature in the main foyers during the awareness week, and an infection control nurse will be available throughout the day to talk to staff and the public and to answer any questions on hand hygiene. In addition, a portable hand basin will be placed in each of the main foyers to allow a practical handwashing exercise to be undertaken under the supervision of the infection control team.



An ultraviolet ‘glow and tell’ machine will be used to show participants areas of their hands that they have missed during handwashing. Free hand reflexology sessions will be available to generate interest in the hand hygiene information stand in the foyers and to encourage discussion.



Staff will be encouraged to participate in a hand-painting exercise by printing their hands on a large piece of paper and signing their names underneath. This will then be framed and hung in the cafeteria of each hospital site, providing a piece of art that we hope will act as a constant reminder of the importance of hand hygiene.



The local media have been invited to attend the awareness week to advertise the event to the local communities and to promote awareness. Internal media in the form of hospital radio, intranet, and weekly and monthly newsletters are also being used to keep staff informed of events.



Although they have already been disseminated widely, emphasis will be placed on the results of the trust-wide hand hygiene audit throughout the week. This will remind staff why the week was organised, and that the audit will be repeated regularly. All staff, visitors, and patients within the trust will be invited to enter a quiz, with prizes including a nurse’s uniform signed by the cast of Holby City.



Education and training
Education is a cornerstone for improvement in hand hygiene practices (Boyce and Pittet, 2002), so a day of education is planned at the two main hospital sites during the week. Sessions are aimed at all trust staff, and presenters include an infection control technical adviser, a decontamination coordinator, an environmental health officer, and a pharmacist.



The environmental health officer will teach all housekeeping staff on a mandatory attendance basis to ensure that the hand hygiene awareness message reaches everyone. The aim of these sessions is to highlight the different areas of infection control and to show how handwashing impacts on all areas within the hospital. It also gives staff the opportunity to meet the presenters and ask questions or raise issues.



Education will also be carried out on all the wards and in all departments by the infection control team. This will focus mainly on hand hygiene techniques, type of handwash, products to use, and when to wash hands. Practical sessions using an ultraviolet light will also be used to demonstrate areas commonly missed during handwashing and how each individual’s technique could be improved by concentrating on those areas. This training will be incorporated into the infection control team’s regular ward-based teaching programme called IC2U, which is tailor-made for each ward area to ensure appropriateness of information and subject matter and to maximise attendance at the 20-minute sessions.



The overall message of the week is that people should be more aware of hand hygiene, more thorough in their hand hygiene practice, and more conscious of when hand hygiene should take place. In addition, the consequences of poor hand hygiene will be highlighted to demonstrate the effects of non-compliance.



The results of the hand hygiene compliance audit and the associated MRSA rates will provide an invaluable insight into the success of the hand hygiene week and incorporated hand hygiene strategy.



As the audit is a continual process, we will monitor the effectiveness of the strategy on an ongoing basis in order to ensure that an optimal level of compliance is maintained. Throughout the week, we will be handing out evaluation forms, especially after the education components, and all feedback will be analysed and used to improve future events.



We hope the hand hygiene awareness week will be a regular event within the trust and that we will have new and innovative ideas to improve the delivery and content, allowing us to continually deliver a message that is fresh and unique. Although it has been shown that increased compliance with hand hygiene is not usually sustained, organisational and behavioural change is also required to achieve long-lasting results.



We recognise that the amount of work required to produce an awareness week on this scale cannot be maintained indefinitely, so we are receptive to any innovative ideas that may sustain an increase in hand hygiene compliance.



This article has been double-blind peer-reviewed.

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