MSc PhD RN RNT
Faculty of Medicine & Health Sciences
Healthcare-associated infections (HAIs) are those infections that are acquired as a consequence of healthcare treatment, investigation or rehabilitation. They pose an international challenge to healthcare providers. The most effective strategy to reduce the spread of HAIs is effective hand hygiene and recent developments have emphasised hand hygiene as an international priority and a priority that is central to patient safety.(2) Discrepancies exist between healthcare providers where hand hygiene compliance is good and those healthcare providers where it is poor, with the latter having dramatic negative effects on the provision of healthcare. This is because the lack of hand hygiene contributes to patient deaths, to illness and to the transmission of HAIs that negatively affect millions of patients worldwide.
Healthcare workers’ (HCWs) compliance with hand hygiene remains low. Factors associated with poor compliance include heavy workloads, performing activities with cross-transmission, inappropriate glove use and involvement in technical specialities. The emphasis on hand hygiene as the single most efficient preventative measure against HAIs is warranted; however, it still needs to work alongside other standard infection prevention and control precautions.
The CleanYourHands campaign
Pittet and colleagues’ work has been fundamental in changing hand hygiene compliance rates,(3) with the implementation of a multimodal campaign resulting in a sustained increase in compliance. In their three-year study, HCWs’ compliance rose from 48% to 66% and at the same time there was a highly statistically significant decrease in HAIs. This multimodal approach was highly significant, as previous strategies had largely failed to produce a sustained compliance.
Healthcare organisations have seen this earlier work as an example of “best practice” and have emulated its components. In England this resulted in the introduction and evaluation of a multimodal campaign known as the CleanYourHands campaign. At a pilot stage the campaign was introduced into hospitals in different geographical areas in England. Due to the success of this pilot campaign, it was introduced throughout England and Wales. Six hospital healthcare trusts were involved in the piloting of the campaign, which was coordinated by the National Patient Safety Agency. The multimodal nature of the campaign meant that a variety of strategies were incorporated. These included:
- The introduction of near-patient alcohol handrubs (NPAHs).
- Measurement of NPAH product usage.
- A series of posters, aprons, badges and leaflets all aimed at HCWs and patients identifying the importance of hand hygiene.
- Observational reporting and feedback audits conducted at the start, middle and end of the campaign.
- A HCW survey examining their perceptions of their own compliance and the campaign, which was completed at the start and end of the campaign.
- A patient-and-carers’ survey examining perceptions of HCWs’ hand hygiene.
- Interviews with onsite leads.
During the pilot (six months) we saw compliance increase from 32% to 63%. Over these six months NPAH product usage increased by 184%, with over 70% of nurses and 60% of doctors agreeing that its presence encouraged them to clean their hands. HCWs were generally positive about the campaign and agreed that it reiterated the importance of hand hygiene. An important development was the involvement of patients and carers, who felt they should be involved in encouraging HCWs to clean their hands. Factors contributing to the campaign’s success also included active support from an influential individual in the organisation, such as the chief executive or director of nursing.
The evidence from this pilot campaign supports previous work indicating that it is the multimodal nature of strategies that is crucial to success in increasing and sustaining hand hygiene compliance. The interplay of all related facets of the campaign resulted in a change in which staff practised their hand hygiene. The assumption from previous research studies is that HAI rates should fall and, subsequently, there should be fewer deaths, illnesses and financial strain on healthcare providers. Following the introduction of the campaign in England and Wales, research is now being undertaken to assess its impact in the long term.
The work of Pittet and the success of the CleanYourHands campaign have been influential in the implementation of other campaigns, both in Europe and internationally. It is important to remember that, although the use of NPAH was fundamental to the increase in compliance, it is not as effective as soap and water against certain organisms such as Clostridium difficile. For this reason HCWs must be aware that, in certain circumstances, soap and water should be used in preference. Similarly, NPAH should comply with European standards for surgical hand disinfection (EN12791). We recommend that hand hygiene continue to be an integral part of the fight against the predicted rise in HAIs but be seen as a part of a coherent strategy, which should see HCWs’ compliance to effective infection prevention and control improve and be sustained.
- Randle J, et al. Hand hygiene compliance in healthcare workers. J Hosp Infect 2006;64:205-9.
- World Health Organization. World Health Organiation guidelines on hand hygine in healthcare (advanced draft). A summary. Geneva: WHO; 2005.
- Pittet D, Huggonet S, Harbarth S. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000;356:1307-12.