Paul Weaving describes why and how the cleanyourhands campaign is being rolled out into the community
Paul Weaving, BSc, RGN, is safer practice lead infection control, National Patient Safety Agency.
Weaving, P. (2007) Improving infection control in the community. Nursing Times; 103: 38, 42–45.
Infections associated with healthcare are a major issue in patient safety. In 2004 the National Patient Safety Agency in England and Wales published Clean Hands Help to Save Lives (NPSA, 2004a), in which it proposed a strategy to reduce the risk of acquiring a healthcare-associated infection (HCAI) by improving hand hygiene in hospital staff.
The approach used to improve hand hygiene was two-fold. Trusts were instructed to implement alcohol-based handrubs at the point of care for staff to use immediately before and after any patient care activity, and then invited to join the cleanyourhands campaign. The campaign uses posters and other environmental prompts to remind staff to carry out hand hygiene.
The cleanyourhands campaign in the community
The campaign has been adopted by all acute NHS trusts in England and Wales. Initial evaluations have been positive, with an increase in the use of alcohol handrubs and no reduction in the use of soap (Slade et al, 2007).
Healthcare is also delivered in settings outside acute hospitals, such as care homes, mental health units and hospices. Good hand hygiene to reduce the spread of infection is no less important in these settings so an extension of the campaign to these areas would appear to be a logical progression.
There are substantial challenges in extending the cleanyourhands campaign. These include the sheer range of settings in which care is provided, and the suitability and safety of some elements of the campaign with regard to some of these settings. One element that provokes a lot of discussion is the use of alcohol-based handrubs.
The World Health Organization states that: ‘At present, alcohol-based handrubs are the only products to reduce or inhibit the growth of micro-organisms with maximum efficacy’ (WHO, 2006). There are limitations to alcohol handrubs – such as their lack of sporicidal activity and their potential flammability – but these limitations can be managed.
Cultural objections to the use of alcohol exist but can sometimes be overcome by the use of propanol or iso-propanol rather than ethanol. Although some cultures may prohibit the consumption of alcohol, it is often permitted for external use for the purpose of medicine or hygiene (WHO, 2006).
It should always be remembered that, while alcohol-based handrubs are extremely useful, they can never be a complete substitute for handwashing with soap and water. As such, facilities for washing hands must always be available in healthcare premises.
Availability of alcohol-based handrubs at the point of care
When alcohol-based handrubs are made available for use at the point of care, they can be used for hand hygiene immediately before and after any care activity.
In acute hospitals this can be achieved by mounting dispensers on each bed or close to each bed space, either in brackets or on the walls. The same system can be used in community hospitals, health centres or minor-injury units, where the patient or client will normally be in a particular place for examination or treatment.
It is worth noting that placing alcohol-handrub dispensers close to a sink is rarely worthwhile. Not only does this remove the opportunity to provide two points for hand hygiene in a room, it can also lead to confusion and inappropriate use if the soap and handrub are presented in similar dispensers.
There are many settings where fixed pump-top or wall-mounted dispensers will be less appropriate, for example, where a less-clinical image is desirable such as care homes and residential units. Each situation should be assessed individually. Given the current concern around HCAIs, visible dispensers for alcohol handrubs may help to promote client confidence in the care that is being provided.
In some settings risk assessment may indicate that it is not desirable for clients to have easy access to alcohol handrubs, perhaps because they may try to consume them or set fire to them. In some cases the dispensers themselves may be a risk because they could be used as a ligature point or a weapon.
Additionally, there are some settings where it is not possible to use fixed dispensers. For example, health visitor clinics may be held in settings such as village halls and vaccination programmes are delivered in schools.
When care is delivered outside acute hospitals, the easiest and most appropriate way of achieving access to alcohol handrubs at the point of care may be individual dispensers. These can be attached to clothing or carried in a bag or pocket. Handrubs in individual dispensers are often more expensive than larger containers and, because of the risk of contamination and the importance of refilling with the same type of gel, manufacturers do not recommend refilling small containers from larger ones.
In acute care, there can be overall cost savings associated with a reduction in HCAIs from the implementation of the cleanyourhands campaign (NPSA, 2004b). The arguments in support of the campaign carry less weight in organisations that do not bear the full cost of dealing with any HCAI, for example in care homes where medical treatment is provided by a GP.
It is hoped that reducing the risk of infection to service users/patients and staff would be a sufficient incentive to improve hand hygiene.
Improving hand hygiene and implementing alcohol-based handrubs at the point of care may also help organisations to meet some legislative requirements. For example, the Health and Safety at Work Act 1974 requires organisations to do everything that is reasonable and practicable to reduce the risk of harm to all those potentially affected by their work (Health and Safety Executive, 2003). Similarly, the Control of Substances Hazardous to Health (COSHH) Regulations include the control of biological agents (Health and Safety Executive, 2005), such as organisms likely to cause an infection.
NHS organisations also have to comply with the Health Act 2006 Code of Practice for the Prevention and Control of Healthcare-associated Infection (Department of Health, 2006) and the implementation of near-patient alcohol handrubs helps fulfil the requirement of the code that: ‘So far as is reasonably practicable, patients, staff and other persons are protected against risks of acquiring HCAI[s].’
Posters and prompts
The second element of the cleanyourhands campaign comprises posters and other prompts to encourage hand hygiene. These are provided
by the NPSA to organisations participating in the campaign. Implementation of the campaign has been phased in acute NHS hospitals. This is advantageous as organisations can join when they are ready and lessons learnt from early implementers can be used to make the process easier in similar organisations.
A similar approach is being used in the roll-out into the community because of the diverse range of organisations and services involved. According to the NPSA hand-hygiene team, in July 2007 in England and Wales, there were approximately 151 PCTs, 612 hospices, 11,200 general practices, 13,157 care homes with more than 10 beds, and 14 ambulance trusts, compared with 174 acute hospital trusts.
The disadvantage of phased implementation stems from different organisations being at different stages of the campaign at the same time. This may cause difficulties with the logistics of delivering campaign materials and necessitates some adjustment at a later date to try to get everyone to the same stage. However, it does mean that problems can be identified and addressed as the campaign is rolled out.
The roll-out in community settings started in July 2007, when initial approaches were made to potential early implementers.
Extending the cleanyourhands campaign to care settings outside acute hospitals presents significant challenges and only so much can be done at a national level to address these. It has been observed that in acute hospitals, where the campaign is most successful, there were enthusiastic individuals driving the campaign and a high level of local ownership. These qualities will be just as important in the success of the campaign in the wider health economy.
Department of Health (2006) The Health Act 2006: Code of Practice for the Prevention and Control of Healthcare-associated Infection. London: DH. www.dh.gov.uk/en/
Health and Safety Executive (2005) COSHH: A Brief Guide to the Regulations. What You Need to Know About the Control of Substances Hazardous to Health Regulations 2002 (COSHH). London: HSE.www.hse.gov.uk/pubns/indg136.pdf
Health and Safety Executive (2003) Health and Safety Regulation…
A Short Guide. London: HSE.
National Patient Safety Agency (2004a) Clean Hands Help to Save Lives. London: NPSA.
National Patient Safety Agency (2004b) The Economic Case: Implementing Near-Patient Alcohol Handrub in your Trust. London: NPSA. www.npsa.nhs.uk/site/media/documents/1920_EconomicCase.pdf
Slade, R. et al (2007) Does a National Behaviour Change Campaign Work for Hand Hygiene? Initial English and Welsh Results. www.idrn.org/NOSEC figures.doc
World Health Organization (2006) Guidelines on Hand Hygiene in Healthcare (Advanced Draft). Geneva: WHO