5th May - Clean Hands Save Lives
World Health Organisation Annual Hand Hygiene Day
Patient and healthcare workers form an alliance for hand hygiene at the Royal College of Nursing, London

On the 5th May MRSA Action UK met with colleagues from across healthcare at the Royal College of Nursing where we formed a patient and healthcare worker alliance focussing on hand hygiene and the next steps to keep the focus and build on the success of the cleanyourhands campaign.  Work will take place in two strands, the main theme being in health and social care.  A sub-group will look at the wider community and hand hygiene, Derek Butler will be working with Karen Shaw and Barry Cookson on the wider community, including education and schools. Maria Cann will be focussing on the health and social care main group. Details of the alliance are outlined below.


Attendees at the inaugural meeting: Karen Shaw, Sheldon Stone, Graziella Kontkowski, Louise Teare (Chair), Nigel Watson, Peter Wilson, Maria Cann, Esther Dias, Annette Jeanes, Rose Gallagher, Derek Butler, Barry Cookson, Nick Hutton, Julie Storr

INDEPENDENT ALLIANCE OF PATIENTS AND HEALTH CARE WORKERS FOR HAND HYGIENE
We are an alliance of patients and their families concerned about healthcare associated infection, healthcare professionals and research workers. We span hospital and community, laboratory and bedside, and include infection control nurses and doctors, public health nurses and doctors, behavioural scientists, health care regulators, suppliers and developers of hand hygiene products. Many of us were in the first multidisciplinary group, the Hand Hygiene Liaison Group, which first made hand hygiene a national clinical governance issue back in 1999. Many of us were in the National Patient Safety Agency's Expert Reference Group that advised the agency on this highly successful national cleanyourhands campaign, which was rolled out to all acute trusts in 2005 and then into the community in July 2008.

Following the decision to close that campaign in December 2010, we are concerned that the gains of the cleanyourhands campaign run the risk of not be maintained.   We have come together to reflect on the campaign's achievements, how to maintain them and to consider which further improvements are needed and how to achieve these within the context of the major changes proposed to the NHS.

Our membership is evolving but currently consists of 
- Adam Fraise (Healthcare Infection Society-President)
- Annette Jeanes (Infection Control Consultant Nurse, ex Hand Hygiene Liaison Group)
- Barry Cookson* (Health Protection Agency, ex Hand Hygiene Liaison Group)
- Chris Gush* (Rapid Review Panel)
- Claire Kilpatrick* (World Health Organisation Representative)
- Derek Butler (MRSA Action UK)
- Esther Dias* (Infection Prevention Society- Community Representative)
- Graham Tanner (National Concern for Healthcare Infection)
- Graziella Kontkowski (Clostridium difficile Support)
- Julie Storr* (Infection Prevention Society-vice president)
- Karen Shaw* (HPA)
- Louise Teare (ex Chair Hand Hygiene Liaison Group)
- Maria Cann (MRSA Action UK)
- Nick Hutton (NHS Supply Chain)
- Nigel Watson* (NHS Supply Chain)
- Paula Mansell (Care Quality Commission)
- Rose Gallagher* (Royal College of Nursing)
- Sheldon Stone* (Royal Free Campus, UCL)
- Susan Michie (Univeristy College London, Health Psychology)
- Tracey Cooper (Infection Prevention Society - President)
    *member Expert Reference Group
 
Our aim is to ensure a high standard of hand hygiene by every healthcare worker and personal carer.   This will be based on the best available evidence, throughout health and social care, as a pre-requisite of good safe care.

"Hand Hygiene for Every Person" means hand hygiene by every health care worker for every patient, and by every personal carer for every client, in hospitals, clinics, health centres, care homes and peoples' own homes.    "At the right time, every time"

It is essential to grasp and sustain the benefits from the recent national cleanyourhands campaign.   Gains should be maintained and improved upon, so that hand hygiene continues to be seen as the front line of defence of Patient Safety on the Public Health Agenda.

We will achieve this through working with and influencing those agencies involved in commissioning, regulation, education, professional development, research, product development and procurement.   Processes and agendas of all these agencies need to reflect the World Health Organisation's first Global Patient Safety challenge of achieving and sustaining a high standard of hand hygiene.    Our outcome will be to reduce the global burden of health care associated infection. T

The cleanyourhands campaign

The cleanyourhands campaign was achieved in the setting of a political drive to reduce HCAI, with multiple interventions such as the Saving Lives Campaign co-ordinated by the Department of Health, the publication of the Health Care Act mandating the essential processes of infection control and a centrally funded and co-ordinated campaign to improve hand hygiene, the Cleanyourhands campaign.   The campaign has been delivered by the National Patient Safety Agency and consisted of installing alcohol hand rub at the bed side, distribution of posters in hospital wards, reminding healthcare workers to clean their hands, audit and feedback of compliance, and distribution of materials empowering patients to ask healthcare workers if they had cleaned their hands.   The campaign became an important NHS success story and is regarded by the WHO as "an inspiration" to other countries.   The campaign is held up as an exemplar to other nations seeking to implement a national hand hygiene improvement strategy through the "WHO's SAVE LIVES: cleanyourhands" initiative to reduce the global burden of HCAI through sustained improvements in hand hygiene.
 
Independent Research and research carried out by the National Audit Office showed that the main components of the campaign had been widely implemented in all acute trusts, with near universal bedside alcohol hand rub, posters in nearly every ward, and audit and feedback occurring in over 80% of wards at least once a month.  At three years after completion of roll out of the campaign, over 90% of  infection control teams reported that hospital management, by their actions, had shown that the campaign, and hand hygiene in general, was a top strategic priority for their trust.  Procurement of soap and alcohol hand rub had tripled and the amounts used were directly related to reductions in both MRSA and Clostridium difficile in individual trusts.
 
The campaign started in Dec 2004 , was refreshed and relaunched in 2006 and again in 2007, won national awards for its social marketing from the marketing industry, and was extended later  into the community in Primary Care, the Ambulance Service and Care Homes. Although no formal independent evaluation of the community campaign has been undertaken, our experience as an expert reference group is that the culture in the community had begun to change with hand hygiene being regarded as an essential pre-requisite of good health and personal care.
 
The campaign has now closed in both hospital and community, although the recommendation of the expert reference group and from the NPSA itself, who commissioned outside advice, was that the campaign should continue, although in a different vein. The independent research evaluation of the campaign in acute hospitals had shown that there was still much to be done to improve the practice of hand hygiene. It recommended that the campaign continue in acute hospitals, but change from raising the awareness of the importance of hand hygiene to increasing healthcare workers' knowledge and expertise, with provision of specialist training, on and off line, for healthcare workers to learn the technique of accurate audit and ways of enhancing feedback.

It also suggested widening the campaign to include gloving practice as gloves were often worn when not indicated and vice versa, with hand hygiene less likely to occur when gloves were worn. It also called for national reporting of soap and alcohol hand rub data, as in other countries, to help with measurement of hand hygiene, and establishing independent assessors of hand hygiene compliance to provide truly objective measures.   Also, to compare hospitals, wards and units, and to establish whether hospitals own hand hygiene interventions had been effective or not.   In addition, our view as an expert group is that there is work to be done concerning the development, assessment and procurement of new hand hygiene agents for Clostridium difficile and norovirus, which are insensitive to alcohol hand rub, and for developing compounds for those healthcare workers whose skin cannot tolerate alcohol hand rub or ordinary soap. 

With regard to the campaign in the community our view is that although it had started to achieve change, it needed more time to replicate the achievements of the hospital campaign. The campaign urgently needs to be continued, but modified so that attention is paid to defining the  correct moments for hand hygiene in the social care setting, and ensuring that care workers in people's homes and in care homes know when and how they should clean their hands.

The risks of closure
Overall, the cleanyourhands campaign has been a large scale  successful intervention to change behaviour, that was driven by a political perception and understanding that hand hygiene makes a basic and important contribution to Patient Safety and Public health.

The announcement of the campaign's closure in December 2010 has been a cause for considerable concern amongst healthcare professionals, patients and their representatives. When interventions stop, behaviour usually relapses and we are concerned that the gains of the last few years will be lost and that opportunities to improve practice still further will be missed, unless there is a clear national policy and strategy for hand hygiene. We have thus come together, as an Alliance to ensure that hand hygiene compliance is kept high on the health and social care agenda.

Hand hygiene and the new NHS
The coalition government's vision for clinical ownership of healthcare delivery provides us with an opportunity to keep hand hygiene as an essential pre requisite of Patient Safety, demanded by patients and expected of healthcare workers and personal carers. We are therefore announcing this Alliance as a prelude to engaging and working with the new Department of Public Health, the new NHS Commissioning Board, as well as with local commissioners, inspectors, regulators, product developers, procurement agencies and research councils to ensure that the Health and Social Care systems provide the best standard of hand hygiene based on the best available evidence.