Stopping infection in its tracks

Transcription

1 National Patient Safety Agency The NPSA is an Arm s Length Body of the Department of Health. Through our three divisions we lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare: National Reporting and Learning Service Aims to reduce risks to patients receiving NHS care and improve safety. National Clinical Assessment Service Works with health organisations and practitioners to help manage concerns about performance. National Research Ethics Service Protects the rights, safety, dignity and well-being of research participants. Stopping infection in its tracks The story of the cleanyourhands campaign March 2010 National Patient Safety Agency 4-8 Maple Street London W1T 5HD T F Ref: 1158 February 2010 National Patient Safety Agency Copyright and other intellectual property rights in this material belong to the NPSA and all rights are reserved. The NPSA authorises UK healthcare organisations to reproduce this material for educational and non-commercial use.

2 Contents The cleanyourhands campaign A national initiative in England and Wales to improve the hand hygiene of healthcare staff and help reduce the spread of preventable healthcare associated infections. The campaign uses a multimodal approach to educate, prompt and enable healthcare staff to clean their hands at the right time every time. Introduction 04 Background 06 Piloting the cleanyourhands campaign 08 Patient Safety Alert 04: Clean hands help to save lives 10 Case study: York Hospitals NHS Foundation Trust 11 Year one: Ready, steady, go 12 cleanyourhands campaign National Patient Safety Agency 4-8 Maple Street London W1T 5HD T E handhygiene@npsa.nhs.uk Case study: Nottingham University Hospitals NHS Trust 14 Year two: Flowing with the go 16 Year three: Back to black 18 Case study: Cardiff and Vale University Health Board 19 All hands to the pump: Clean hands save lives 20 To the community and beyond 22 Case study: NHS Gloucestershire 24 Developing a consistent approach across the NHS 25 Your Five Moments for hand hygiene 26 Independent evaluation 28 It s OK to ask: Involving patients in improving practice 30 Global perspective 32 Looking ahead 33 References 34 Acknowledgements 35 0/

3 Introduction The cleanyourhands campaign, one of the National Patient Safety Agency s (NPSA) most high profile initiatives, has made an unprecedented contribution to improving the safety and quality of care of NHS patients in England and Wales. Its precise contribution to improved patient safety has been the subject of a fouryear independent evaluation. The results of this demonstrated cleanyourhands to be associated with a sustained change in the hand hygiene behaviour of hospital staff. This is considered to have made a significant contribution to reductions in healthcare associated infection and has helped prevent unnecessary suffering and harm to patients. At the heart of the campaign s success has been the engagement of NHS trusts in changing practice at the point of patient care. A total of 387 trusts have signed up to the initiative; representing 98 per cent of acute, integrated, primary care, mental health, ambulance and care trusts in England and Wales. Infection control teams have been at the centre of this activity taking responsibility and coordinating implementation of the campaign locally but support has come from across all levels of staff, both frontline and senior management. Since work began to develop cleanyourhands seven years ago, it has become a highly recognisable and respected brand within the NHS. As the first national campaign to target the hand hygiene of healthcare staff, it has also attracted global interest and the NPSA is proud to be working with the World Health Organization as part of their Global Patient Safety Challenge: Clean Care is Safer Care. Within the UK, cleanyourhands has received strong endorsement from key partner organisations such as the Department of Health, Welsh Assembly Government, NHS Supply Chain, Welsh Health Supplies, the Care Quality Commission, Infection Prevention Society, Royal College of Nursing and the Health Protection Agency. Their support has been crucial in the ongoing work to embed improvements in hand hygiene practice. Recognition of cleanyourhands achievements has also come from the wider marketing and communications community. The National Social Marketing Centre has highlighted cleanyourhands as an example of best practice and the campaign has received a number of industry awards, including the prominent Grand Prix Award at the Design Business Association s Design Effectiveness Awards in At the NPSA we are immensely proud of cleanyourhands and the improvements the NHS has made, however we cannot afford to be complacent. As we look forward to 2010 and beyond, we must focus on sustaining these improvements. We must make correct hand hygiene at the point of care an integral and intrinsic part of patient care. Preventive measures will also become increasingly important as the NHS strives to work more efficiently. The economic case for improved hand hygiene remains as relevant today as it was in 2002; as demonstrated with the inclusion of cleanyourhands in NHS Evidence s central resource on how to improve quality and productivity in the NHS, published December Since better hand hygiene contributes significantly to averting infection, it makes economic sense to continue to keep improved hand hygiene at the heart of the NHS agenda. Thank you to everyone who has helped make cleanyourhands the success that it has been so far. We look forward to continuing to work with, and supporting, the NHS in its efforts to reduce healthcare associated infection and making a tangible difference to the lives, and experience, of the most important dimension in all of this, our patients. Sarndrah Horsfall Chief Executive (Acting) /04 05 /

4 Background The National Patient Safety Agency (NPSA) initially highlighted healthcare associated infection (HCAI) as a patient safety problem in 2002, not long after the NPSA came into existence. HCAI were estimated to contribute to the deaths of 5,000 patients a year, costing the NHS 1 billion a year. 1 Yet approximately a third of these infections were considered to be preventable. 2 One of the main ways in which HCAI is spread is on the hands of healthcare staff. Due to the nature of their work, staff have the greatest potential to spread infection-causing microbes as they move between patients, or undertake different care activities with the same patient. At the outset of the campaign, the global average rate of compliance with hand hygiene was estimated to be around 40 per cent; this meant that, on average, staff were cleaning their hands less than half the number of times that they should and therefore placing patients in danger. 3 Low compliance with hand hygiene was described as a routine violation; a regularly performed shortcut between care activities that has, over time, become accepted by both frontline staff and managers. 4 Such violations can be due to the system, procedure or task being poorly described or managed. Of particular influence to the project was the work led by Professor Didier Pittet at the University Hospital Geneva in Switzerland. Professor Pittet had formulated an alcohol handrub for local use and devised and implemented a long-term awareness campaign called Hopisafe using the innovative concept of talking walls. This groundbreaking work demonstrated the value of addressing hand hygiene through a long-term, multimodal, system-wide approach that achieved successful outcomes with regard to improved compliance. The project was also underpinned by practice and research information from the Oxford Radcliffe Hospitals NHS Trust 6 and University Hospitals Lewisham 7 both of whom focused on making alcohol handrub available to staff close to the point of patient care in combination with a range of multimodal behaviour change strategies. The evidence gained from these studies suggested that a sustained improvement in hand hygiene would be best achieved through a range of methods thereby leading to long-term behavioural change. With this in mind, the cleanyourhands campaign approach was developed. This consisted of separate but interrelated strategies: alcohol handrub at the point of patient care; posters and supporting marketing materials; patient information and empowerment; audit and feedback. This was underpinned by implementation guidance based upon the current implementation science evidence. 8 Better application of infection prevention procedures, including improved adherence to local and national hand hygiene guidelines, had been shown to reduce the spread of HCAI. 5 Therefore, the NPSA began a project to assess the barriers to compliance with these guidelines and to learn from good practice and innovation in this area both within the UK and internationally with the aim of addressing both the system and behavioural factors that contributed to low compliance with hand hygiene, whilst developing a solution that could be implemented on a national basis. /06 07 /

5 Piloting the cleanyourhands campaign Prior to national implementation, the cleanyourhands campaign approach was piloted for seven months from July 2003 to January The pilot aimed to evaluate the effectiveness of the campaign in changing behaviour (of staff and patients); improvements in hand hygiene compliance; and determine the suitability of each component of the project for inclusion in a national campaign. Out of over 60 applicants, six acute trusts were selected on the basis of quality of application; evidence of top level management support and commitment; size of trust; and geographical location. The pilot was carried out in two wards of each of the participating trusts. A further three trusts were recruited to assist with work relating to patient involvement only. Evaluation consisted of: a staff survey; patient survey and interviews; interviews with onsite leads; diary and activities log; records of local hand hygiene working group meetings; observation of hand hygiene; and usage of alcohol handrub before and after the pilot. The acute trusts involved reported that the pilot had exceeded their initial expectations and had changed both practice and behaviour of stakeholders across, and sometimes beyond, the pilot wards. The changes described were overwhelmingly positive. There were also quantifiable improvements in, for example, the increase in use of alcohol handrubs and an average increase in staff hand cleaning between each patient contact from 28 per cent to 76 per cent of the time. The results of the pilot and its evaluation led to improvements to the campaign and toolkit. Economic evaluation Prior to national rollout, an economic evaluation of the cleanyourhands campaign was undertaken to consider the cost implications for the NHS. The evaluation found that if the toolkit was implemented successfully, the increased hand hygiene compliance would save the NHS 140 million per year and save 450 lives once target compliance rates had been reached. For a trust with 500 beds and 20,000 inpatient admissions, this would result in a net saving of around 460,000 or reduction in 1,540 bed days by year five of implementation. Overall the campaign was found to be cost-effective, with an estimate that it would result in a cost saving even if the reduction in rates of HCAI was as low as 0.1 per cent. The core pilot sites Aintree University Hospitals NHS Foundation Trust Northern Lincolnshire and Goole Hospitals NHS Foundation Trust Nottingham University Hospitals NHS Trust Royal Devon and Exeter NHS Foundation Trust St George s Healthcare NHS Trust York Hospitals NHS Foundation Trust The patient involvement only pilot sites Aneurin Bevan Health Board (previously Gwent Healthcare NHS Trust) East Kent Hospitals University NHS Foundation Trust University Hospitals of Morecambe Bay NHS Trust /08 09 /

6 Case Study: York Hospitals NHS Foundation Trust Focusing on the point of care has raised awareness of the importance of hand hygiene and has improved compliance rates across the trust. Anne Tateson, Hand Hygiene Coordinator York Hospitals NHS Foundation Trust was one of the cleanyourhands pioneers, participating in the campaign pilot in The Trust, which employs approximately 5,000 staff, provides acute hospital services for approximately 350,000 people living in and around York, plus a range of specialist services for the wider community in North Yorkshire. Reflecting the importance the Trust places on the hand hygiene of its staff, one of the first actions taken was to appoint a dedicated Hand Hygiene Coordinator. Their role was to support the implementation of cleanyourhands and focus on improving hand hygiene practice within the Trust. Patient Safety Alert 04: Clean hands help to save lives The campaign was first rolled out to the wards and areas where patients were at most risk from HCAI. To ensure consistent standards of hand hygiene, it was then rolled out to all areas of the Trust; the aim being to increase staff s understanding of the impact of poor hand hygiene on patient safety. /10 On 2 September 2004, the NPSA issued a Patient Safety Alert that instructed acute NHS trusts in England and integrated trusts in Wales to install alcohol handrub at the point of patient care and invited them to participate in the cleanyourhands campaign. The Alert signaled the national launch of the campaign and provided the impetus for widespread adoption of alcohol handrub; the latter being the system change considered necessary to overcome many of the barriers to hand hygiene, and make it possible for healthcare staff to clean their hands quickly and effectively at the point of patient care. Prior to publication of the Alert, the NPSA worked with NHS Purchasing and Supply Agency (now NHS Supply Chain) to put a national contract for the supply of alcohol handrub in place, ensuring the NHS has consistent access to high quality products at competitive prices. The product specification was developed with international experts in hand hygiene and numerous key stakeholders throughout the NHS. Every product passed skin tests advised by dermatologists and conformed to the very latest European standards in efficacy. The contract to supply the NHS in England was awarded to GOJO (Purell), Ecolab (Spirigel), and B Braun (Softalind) in July Welsh Health Supplies undertook a similar process, awarding a contract to supply the NHS in Wales to Deb (Cutan), Johnson Diversey (Soft Care) and GOJO. The alcohol handrub suppliers, NHS Supply Chain and Welsh Heath Supplies continue to work with the NPSA to support the cleanyourhands campaign. To assist NHS trusts in determining the local economic impact of implementing the Alert s actions, a simple spreadsheet tool was provided. This enabled local data to be entered, along with a variety of other data collected from pilot sites and from other sources, in order to calculate the estimated potential costs and benefits of implementing a new hand hygiene strategy based around alcohol handrub. The drive to implement the campaign brought some challenges; there was some initial opposition from ward and medical staff who were resistant to change but the infection control team persisted, and there is now widespread appreciation amongst staff of the risks associated with low hand hygiene compliance. Through the years that the campaign has been active, there has been increasing commitment to hand hygiene from senior medical staff with them becoming role models for junior staff. Senior management within the Trust endorsed the campaign from the outset, with support from the Trust s Executive Board, Hospital Committee for Infection Control, Matrons Group, and Nursing Board. The campaign has also been incorporated into the Trust s hand hygiene policy/strategy along with other patient safety initiatives. In more recent activity, the Trust s launch of the World Health Organization s Five Moments for hand hygiene and the re-focus on the point of patient care has proved to be appealing and effective. The Five Moments have been incorporated into their hand hygiene audit tool, with weekly compliance rates published on the Trust s intranet so that they can be accessed by all staff. This open approach has increased interest and provided a morale boost to staff that they are doing better with hand hygiene compliance. It has also enabled underperforming areas to be targeted with action plans to support improvement. The cleanyourhands campaign has been credited for kick-starting the Trust s improvement journey but it is the continued effort of the infection control team to maintain momentum and deliver the campaign s key messages that has ensured that hand hygiene remains a top priority at York. Maintaining staff s focus on hand hygiene can be challenging so a refreshed campaign for 2010 will help the infection control team in achieving this. 11/

7 Year one: Ready steady go /12 National rollout of cleanyourhands to acute trusts in England and integrated trusts in Wales began in September 2004 following the publication of Patient Safety Alert 04, which invited them to participate in the campaign. The campaign was rolled out in a phased approach with five waves, starting with the trusts that participated in the pilot. This meant that the first year lasted about 18 months in practice. On your marks As a criterion for enrolling in the campaign, trusts were required to have chief executive support. Each trust also had to undertake a three-month preparation period to ensure that processes were in place to manage the campaign on a day-to-day basis and that staff were engaged throughout the trust before going live. This was supported by implementation documentation entitled Ready Steady Go! which helped guide the process and addressed necessary actions at the organisational, group and individual level. A range of additional resources supported this activity, with templates for letters, press releases, and memos for local adaptation. Key documents included: Achieving our aims: evaluating the results of the pilot cleanyourhands campaign. The economic case: implementing near-patient alcohol handrub in your trust. All hands to the pump A range of marketing materials were provided to raise awareness of the importance of hand hygiene at the point of patient care, and to help prompt behaviour change in healthcare staff. Central to this were colourful eye-catching posters featuring humorous slogans based on popular phrases, and shapes created from images of bacteria. These were designed to be changed on a monthly basis in acknowledgement of the limited life that posters have, so that they did not become part of the wallpaper. Other items such as badges and stickers were provided for promotional purposes whilst a leaflet and poster were directly aimed at engaging patients in the measures for improvement, featuring the message: It s OK to ask. So can you! Role models are important for influencing behaviour, and cleanyourhands sought to utilise this with the provision of a champion poster. Featuring the caption, I do so can you, the champion poster could be adapted to feature the photo of a local member of staff who was visibly supporting the campaign. The success of the champion poster reflected the diversity of organisational cultures across the NHS; in some, being a champion was something to aspire to, whilst in others infection control teams resorted to coercion. Doing things differently Another way in which cleanyourhands broke new ground was how it distributed the campaign materials. Following close work with the NHS Purchasing and Supply Agency (PASA) on establishing a contract for alcohol handrub, the NPSA worked with PASA to deliver the campaign marketing materials direct to the ward. The campaign posters were delivered monthly in line with the monthly changes for each phase of implementers and were included in the crates along with medical supplies. This reduced the burden on infection control teams, increased the likelihood that the posters would make it onto the wards, and enabled wards to own the campaign within their area. Campaign materials for year one included: a core series of 12 posters for monthly refreshment; a locally-adaptable staff champion poster; a patient-focused poster; leaflets for patients; badges; stickers featuring the message It s OK to ask. 13 /

8 Case Study: Nottingham University Hospitals NHS Trust the campaign is not a quick fix and the challenge is sustaining the behaviour change achieved. Mitch Clarke, Clinical Nurse Specialist, Infection Control Nottingham University Hospitals NHS Trust is a large acute trust spread over three sites and employing 12,800 staff. The Trust has been part of cleanyourhands since the pilot in 2003, with the campaign becoming a core part of the Trust s infection control improvement work and highlighting the importance of hand hygiene and infection control as a whole to all staff. Implemented in all clinical areas, the campaign materials provided by the NPSA have been enhanced with those developed locally. These locally developed materials have reflected the look and feel of cleanyourhands, successfully enabling them to work well side-by-side. Staff particularly liked the colourful approach of the early phases of the campaign; although the recent overcrowding with similar initiatives has meant that the latest materials are not as prominent. Support for the campaign has been strong throughout the Trust, with hand hygiene being discussed from Trust board level through to clinical risk and management meetings. The campaign has triggered interest in hand hygiene and has raised its profile within the Trust, but sustaining interest has proved to be particularly challenging, as Mitch Clarke, the Trust s lead coordinator for the campaign, explains: It s about making gradual improvements over time and persevering whilst not losing sight that at the heart of what we are trying to achieve is the patient s safety. Regular audits are performed to monitor hand hygiene compliance, which have stimulated discussion amongst staff about hand hygiene practice and how to improve compliance. A new audit tool based around the Five Moments was launched by the infection control team in November Key messages about the placement of alcohol handrub at the point of patient care and references to the campaign have also been incorporated into the Trust hand hygiene policy. Looking forward, the infection control team at Nottingham would like to see the campaign s multimodal approach applied to the Five Moments, supplementing the training already undertaken at national and local level. Mitch is also keen for the campaign to be refreshed and perceives the central support provided by the NPSA as pivotal: National support is very important without the central push and guidance, the campaign will lose focus and fade. /14 15 /

9 Year two: Flowing with the go /16 The second year of the campaign in acute trusts was launched in July 2006 with two key themes for activity: the power of one and the point of care. The former was about the role that each individual can play in improvement and the power that they have to make a difference. The point of patient care, which has remained a fundamental premise of the campaign, is about hand hygiene being performed at the critical moment and place, and being seen and understood to be an integral part of care, not an interruption of it or a bolt-on. Providing staff with the means to practice hand hygiene at the point of patient care is key to the success of the campaign, and was a strong theme for year two. Year two was considered the improvement phase in which early learning from the introductory phase could be applied, the impact could be broadened, messages refined, and new and better ways of delivering to the frontline were explored. As well as continuing to increase awareness, accountability and ownership to sustain the progress in improved hand hygiene behaviour within implementing trusts, the second year aimed to build on: targeting specific clinical specialities and staff groups (doctors and occupational health teams); making patient and public confidence and risk-awareness a key feature; extending provision of marketing materials, such as posters, beyond ward areas to all departments providing patient care. shareyourstraplines The posters for year two were developed following a competition for staff in acute trusts to shareyourstraplines. This aimed to engage frontline staff and reinforce NHS trusts ownership of the campaign. The winning entries were combined with cartoon hand images, inspired by the straplines suggested. Quantities of materials were increased to provide materials for a wider range of areas where patients receive care beyond wards. The new posters were printed on both sides (i.e. with two consecutive months posters on each) to reduce the amount of deliveries required. Spread the word The year two implementation guidance, entitled Flowing with the go, aimed to provide practical support for campaign implementation, and for supporting and sustaining improvements so that implementing trusts could continue to make progress in their efforts to achieve the necessary step-change in hand hygiene behaviour. New resources for year two included: An organisational check map designed for managers, infection control staff and campaign leads, the check map was a matrix that cross referenced the campaign approach and resources with the current policy initiatives to help guide local coordinators through effective local implementation of the campaign. Point of care prompts large wipeable vinyl stickers, which were to be placed at the point of care so that they could act as a reminder to staff at the crucial times for hand hygiene. 17 /

10 Case study: Cardiff and Vale University Health Board The thrust of the campaign has been to engage staff and patients from the ground up. Sacha Coodye, Senior Nurse - Infection Prevention and Control Cardiff and Vale University Health Board (UHB) is one of the largest NHS organisations in England and Wales. It provides a wide range of integrated healthcare services to a population of approximately 500,000 people and employs over 14,500 staff. When UHB launched the cleanyourhands campaign over four years ago, in August 2005, its aim was to build on the momentum of its previous hygiene awareness campaign to reduce HCAIs. Initially rolled out in hospitals, cleanyourhands was also officially extended to community settings from In order to maintain the momentum and ensure a joined-up approach to patient safety, cleanyourhands has been supported by the all-wales Save 1,000 Lives campaign. Year three: Back to black The third year of the campaign, launched in November 2007, saw a radical overhaul with the introduction of a new, bolder and more striking design. The infection control team works closely with management teams and the Nurse Director to achieve engagement and commitment from directorates. Many actions have been completed to implement the campaign effectively and deliver the key messages including: the appointment of champions to promote hand hygiene in wards and departments; posters and materials placed in patient care areas; re-evaluation of the placement of alcohol handrub following the updated Alert: Clean hands save lives; and the introduction of a link practitioner study day focused on infection control and hand hygiene. /18 Extensive research was undertaken to inform year three of the campaign, including a survey of over 300 healthcare staff about their hand hygiene routines and behaviours; focus groups with medical and nursing staff and patients; and visual audits of a number of hospitals. As a result, a harder-hitting campaign design was developed, with bold black materials that stand out in hospital environments, and the use of images of real hands to provide immediate impact. The posters featured statements designed to challenge rather than threaten staff, with positive and negative words highlighted in red and green. Facts were used to back up messaging, and to help ensure that the importance of hand hygiene was emphasised, particularly to medical staff. The range of materials provided was widened with more educational information incorporated. New items included signs to highlight locations of alcohol handrub dispensers; leaflets for staff; and posters that could be used to highlight local information and achievements. Moving away from the monthly poster changes, which research had shown was becoming onerous, eight core posters were provided in two batches with each poster designed to work individually as well as part of a series. The first batch of posters saw the inclusion of a new larger (A2) size poster; the second batch was designed to complement and add to the first, rather than replace it. A range of electronic artwork was also provided on CD so that items such as t-shirts, mugs and mouse mats could be produced locally if required. The implementation guidance was also revised and provided in a folder so that it could be updated easily and used as a working file. The big launch Martin Fletcher, NPSA Chief Executive was joined by the Chief Medical Officer for England, Sir Liam Donaldson, the Chief Nursing Officer for England, Christine Beasley, and the Chairman of MRSA Action UK, Derek Butler to launch Year three of the campaign at St Bartholomew s Hospital on 18 October Speaking at the launch, Derek Butler said: Hand Hygiene should be a process of excellence that is the cornerstone of good infection prevention and control. Aristotle once said We are what we repeatedly do. Excellence, then, is not an act but a habit. Other activities to engage staff and inform the public have included, a Dragons Den style forum where staff pitched ideas to senior management on how to better embed hand hygiene in the organisation, infection control road-shows, poster competitions for young patients, and educational sessions for new Board members on hand hygiene procedures. The UHB hand hygiene policy has been amended to include the WHO s Five Moments for hand hygiene, and was formally launched by the Chief Executive and Medical Director. All wards are expected to carry out hand hygiene compliance audits and checks, which are also carried out by the infection control team and formally reported on a quarterly basis. The UHB is working towards strengthening its hand hygiene educational programme by ensuring that all new staff have the appropriate training during induction. A pilot study is also being undertaken with junior doctors to encourage them to align their educational requirement to include hand hygiene audit training. One of the challenges faced has been that key awareness-raising campaign materials have at times got lost among the plethora of other posters. As Joy Whitlock, Service Improvement Manager for the organisation explains: This has been a wider problem for all of the organisation s communication. The issue has been examined and as a result a standardising of ward entrances is under way, including arrangements and information for hand hygiene. 19 /

11 All hands to the pump: Clean hands save lives On 2 September 2008, exactly four years to the day since the original Alert that launched cleanyourhands was published, the NPSA issued an updated Patient Safety Alert, Clean Hands Save Lives, at a hand hygiene summit in London attended by over 200 trust representatives. The revised Alert re-emphasised the point of patient care as the critical time and place for healthcare staff to clean their hands and provided up-to-date guidance on hand hygiene best practice, product standards and managing the risks associated with hand hygiene products. The Alert contained a number of actions for all providers of NHS care in England and Wales: reviewing the provision, placement and suitability of all hand hygiene facilities; reviewing hand hygiene processes and policies to ensure that the point of patient care was prioritised; and developing and implementing action plans to address the issues identified through the audits. In England, the Department of Health s (DH) Central Alert System (CAS) monitored uptake and implementation by NHS trusts. Additional research was undertaken by the NPSA to gauge the extent of Alert implementation and impact in the NHS; the results of this research will be published shortly. /20 21 /

12 To the community and beyond The extension of cleanyourhands to primary care, mental health, ambulance and care trusts aimed to take a system-wide approach to hand hygiene improvement, reflecting the requirement for consistent standards of hand hygiene across the NHS and the growing appreciation that HCAI was not just an issue for the acute sector. Initially, a review of existing infection control strategies in community-based care settings was undertaken from October 2005 to February This included a risk assessment to enable the prioritising of care settings and the development of solutions to minimise the cross-transmission of infection. Given the scale and diversity of care provision in the community, a small group of organisations, representing a mix of care settings, agreed to test the campaign for a six-month period prior to national rollout. Nineteen organisations from across England and Wales provided feedback on their experiences, contributed to evaluation activities, and hosted site visits from the cleanyourhands team. The learning gathered was used to inform adaptation of the campaign for the different care settings. The initial implementers Bredoncare Foundation, Hampshire Hereford Primary Care Trust Lancashire Care NHS Foundation Trust NHS Brent NHS Leeds NHS Leicestershire County and Rutland NHS Manchester NHS Middlesbrough NHS Norfolk NHS Oxfordshire Nightingale House Hospice, Wrexham Sheffield Health and Social Care NHS Foundation Trust South East Coast Ambulance Service NHS Trust St Leonard s Hospice, North Yorkshire Surrey and Borders Partnership NHS Foundation Trust The Fountains Care House, Greater Manchester The Laurels Nursing Home, Lincolnshire Welsh Ambulance Services NHS Trust West Midlands Ambulance Service NHS Trust Going national A call to primary care, mental health, ambulance and care trusts to register for the campaign opened in January 2008, with the campaign formally launching in April The initial commitment for the campaign in community-based trusts was for a three-year programme that ran concurrent to fiscal years from April 2008 to March As with the acute sector, implementing trusts had to undertake a threemonth preparation period to ensure that the campaign had maximum impact through engagement with all relevant key and senior staff within the trust. To ensure all trusts had an opportunity to complete the preparation period and allow greater flexibility, national roll out took place in two phases. Utilising the design concept from the first year of the campaign in acute trusts, the campaign posters featured images made up of bugs with humorous captions that were changed on a monthly basis in order to keep the campaign message fresh. The design and content of the posters were reviewed to ensure they were appropriate for the different care settings; certain designs resonated with some trusts (for example, glove abuse and ambulance trusts) whilst others were considered inappropriate for some trusts given their service user/patient groups. Items that would be more appropriate for use in community-based care settings, such as the point of care stickers, were included from the outset with formats revised if necessary to ensure maximum impact and usability. /22 23 /

13 Case Study: NHS Gloucestershire Successes measured in the original launch of the cleanyourhands campaign were relatively small success had to be celebrated in a bid to change the mindset of some areas of care. Sam Lonnen, Infection Prevention and Control Team Lead Offering a wide breadth of healthcare services, NHS Gloucestershire covers a population of approximately 602,000 across Gloucester and employs over 3,000 staff. It is responsible for the commissioning of healthcare services and its provider arm, Gloucestershire Care Services, delivers community nursing, therapy and community hospital services. The cleanyourhands campaign was introduced to Gloucestershire Care Services in October 2005 using campaign materials purchased by the community infection prevention and control team. This demonstrated a commitment to promote successful hand decontamination across the organisation prior to the formal sign-up to the campaign when it was extended to primary care trusts in As well as the practical challenges of hand hygiene across a range of communitybased care settings, the Trust s infection control team faced an initial challenge in changing the mindset of the staff in some areas. The colourful posters provided for the start of the campaign helped with this as staff felt that an investment had been made in them and this conjured a respect for the campaign and its message. Materials, such as the WHO s Five Moments for hand hygiene, were also adapted to ensure they were relevant and applicable to local needs. As part of the second phase of the campaign, a concerted effort was made to undertake accurate observational hand hygiene audits that could be used to influence and recognise good practice. Infection control nurses with clinical responsibility for different areas of the county became responsible for conducting the monthly audits. Once the culture of ongoing audit was in place, a network of infection control link personnel was established to continue the audit process. It was also agreed that every member of the care team should conduct an audit at some time so that they are aware of what is involved in auditing, whilst at the same time improving their awareness of hand hygiene best practice. The publication of the audit scores at various meetings, such as clinical governance and infection control committee meetings, has also sparked competition and rivalry for improved scores between care facilities. The Trust has had a strong, integrated, county-wide approach to the campaign and hand hygiene improvement in general and this continues to grow. In 2008, there was even closer collaboration with stage two of the community campaign being simultaneously launched with year four of the inpatient facility campaign to both inpatient and primary care. The launch took place at a local health centre reinforcing that it is now a county/service wide approach to maintaining timely and successful hand decontamination. Developing a consistent approach across the NHS 2009 saw the fourth year of the campaign in acute trusts and the second stage of the campaign in primary care, mental health, ambulance and care trusts. It was a year of greater integration for the campaign across all trust types, with the Five Moments for hand hygiene forming the central theme for activity. One of the aims for 2009 was to provide more flexibility and scope for adaption at local level, supported by a greater focus on education and training resources. As previously, the views and ideas of local campaign coordinators was sought to inform the approach for the year ahead. A workshop with coordinators was held in December 2008 to establish needs for the next stage of the campaign in community-based trusts. This helped develop a more flexible approach that enabled coordinators to have more control in designing their individual campaign, with greater emphasis placed on the use of digital and online technology to facilitate this. For the first time the look of the campaign materials was the same across all types of trusts, but the content and format were again tailored to the needs of the different trust types. Bespoke packages of materials were developed and distributed according to the type of trust, with community-based trusts receiving more materials and support, given that the campaign was less established in these settings. A wider variety of materials was also provided, with greater emphasis on electronic resources which enabled trusts to select the most suitable materials for their care settings and permitted more scope for local adaptation. In support of the wider campaign implementation, the cleanyourhands website saw a major overhaul with a new look that reflected the design of the campaign materials being launched in April The new more user-friendly format was intended to provide greater practical support for the day-to-day implementation of cleanyourhands. A dedicated area was created for campaign coordinators to: /24 download artwork, videos and other resources; access implementation guidance and support; and order additional materials. An online forum was also provided to facilitate discussion of campaign-related issues between local coordinators. 25 /

14 Your Five Moments for hand hygiene A central focus throughout the campaign has been improving hand hygiene at the point of patient care. To help staff better understand when they need to clean their hands during patient interaction and why, the cleanyourhands campaign has embraced the Five Moments for hand hygiene, developed by the WHO. The Five Moments identifies when hand hygiene should occur during patient care to prevent the transmission of infection. In 2009, the Five Moments had already been widely adopted but the impression from anecdotal feedback was that staff did not wholly understand the approach or had the opportunity to consider it in depth. To address this, a toolkit of resources was developed to assist infection control staff in understanding the approach and applying it locally. A key component of the toolkit was film clips that illustrated the application, and sometimes incorrect application, of the Five Moments in a range of different care settings from an ambulance to a patient s home and inpatient environment. This was the first time that a training film about the Five Moments had been produced in English as the existing WHO version was in French and did not reflect healthcare settings in England and Wales. Rollout of the toolkit was supported by a programme of regional workshops across England and Wales that provided theoretical and practical applications of the approach as well as the knowledge and confidence needed to train other frontline staff. Over 286 infection control staff from 239 NHS trusts attended the workshops; feedback was overwhelmingly positive with 95 per cent of those that attended considering the workshops excellent or good. Sarah Watts, Senior Nurse - Infection Control at the Mayday Healthcare NHS Trust, was one of seven clinical leads who assisted in the delivery of the workshops. Sarah has since used the toolkit of resources in her own trust to deliver clinical training on hand hygiene and says: The workshop resources are already proving a big help in teaching the Five Moments and even making it fun to teach There is no doubt that the science behind the Five Moments helps add weight to the approach and makes it more acceptable and valid to certain groups of healthcare workers. /26 27/

15 Trends in procurement of alcohol handrub and soap Estimated average procurement in mls per bed-day July 2004-Sept 2008 by alcohol handrub and liquid soap Independent evaluation The National Observational Study of the Effectiveness of the cleanyourhands campaign (NOSEC) is an independent assessment of the campaign in acute NHS hospitals, which was funded by the DH and commissioned by the Patient Safety Research Programme at the University of Birmingham. A four-year multidisciplinary study, NOSEC looked at the effectiveness of the campaign and implementation of its components in NHS hospitals to determine whether it is successful and sustainable over time. The study aimed to assess: How successfully cleanyourhands has been implemented across NHS acute hospitals. Whether the campaign is sustainable over the longer term. If it has increased hand hygiene compliance amongst healthcare staff. Changes in mandatory reports of meticillin-resistant Staphylococcus aureus (MRSA) and meticillin sensitive Staphylococcus aureus (MSSA) bacteraemia, and Clostridium difficile. Correlations between compliance and infection rates. Infection control teams within acute trusts in England and Wales were surveyed every six months from July 2004 (pre-launch) to June 2008 to gauge the uptake of the campaign and its materials. Response rates remained consistently good for a voluntary survey, only dipping below 50 per cent once. The final questionnaire, which was distributed in collaboration with the National Audit Office as part of their 2009 report on HCAI in English hospitals, elicited a 90 per cent response rate. Data on bed occupancy, alcohol handrub, soap procurement and infection rates was also collected along with data on potential confounding national interventions, such as the DH in England s Saving Lives programme and MRSA screening. The NOSEC Study concluded that cleanyourhands is associated with a sustained change in hand hygiene behaviour of hospital staff nationally and in particular found 9 : a threefold increase in the procurement of alcohol handrub and soap; alcohol handrub at the point of care (near the bedside) in most inpatient wards in 94 per cent of trusts; the campaign remained a top priority for 92 per cent of trusts three years after implementation; the campaign posters were displayed in most wards in 96 per cent of hospitals; audit and feedback of hand hygiene compliance being undertaken in 86 per cent of hospitals; however the patient involvement materials were less successful. The Study also found that each extra millilitre of alcohol handrub used per patient per day was strongly associated with a 1.3 per cent reduction in MRSA Bacteraemia; whilst each extra millilitre of soap was strongly associated with a 0.33 per cent reduction in Clostridium difficile infection. These associations remained after adjustment for other variables and interventions. /28 29 /

16 It s OK to ask: involving patients in improving practice /30 Involving patients in efforts to improve staff hand hygiene has been part of the cleanyourhands campaign from the outset. Their views on staff hand hygiene were assessed as part of the original campaign pilot and 71 per cent (266/374) of patients and visitors wanted to be involved in improving hand hygiene practice. As a result some specific items (for example the poster and leaflet) aimed at patients and featuring the message It s OK to ask, have been incorporated into the campaign materials. The intention is that patients are invited rather than obliged to ask staff about their hand hygiene. The concept of involving patients in improving staff hand hygiene was taken further by the Chief Medical Officer for England (CMO), Sir Liam Donaldson, in his 2006 Annual Report when he called for patient involvement in the cleanyourhands campaign to be strengthened. The CMO advocated a pilot in which hospital inpatients are given their own dispenser of alcohol handrub on admission that they can ask their healthcare staff to use before touching them. As a result of this, the NPSA initiated a three-month feasibility study (January-March 2008) to scope the project. An expert reference group was convened, chaired by Professor Didier Pittet, and five acute trusts recruited to work alongside the NPSA to explore the CMO s proposal. Research was undertaken with the public, patients, healthcare staff and local campaign coordinators to provide insight about patient involvement in hand hygiene and inform the work. The results of the feasibility study are currently being finalised for publication in a peer-reviewed journal, however the following conclusions were reached: being given permission or authorisation increased patients likelihood to ask; little was currently being done to prepare or empower staff to be asked or talk about hand hygiene; both patients and staff were not adequately aware of the important moments for hand hygiene (i.e. the Five Moments) to prevent HCAI. The NPSA subsequently received project funding from the DH, which enabled further research to be commissioned to help identify the most appropriate opportunities for communication and empowerment regarding hand hygiene during the patient s journey through healthcare. Forty in-depth interviews (including a mix of observation and interview) with patients were undertaken across three acute hospital sites between February to June The feedback reinforced the learning from the feasibility study and identified that the existing cultural norms within the hospital context put the healthcare worker in a position of authority over the patient; the greatest opportunities for interventions to inform and empower patients were pre-admission and pre-treatment; and that staff involvement is likely to be critical in converting intention into action and greater patient empowerment generally. This work to date has provided valuable insight into patient involvement in improving the hand hygiene of healthcare staff, particularly regarding the beliefs, opinions and behaviours of patients in this area. The proposed next step for taking this work forward is to undertake research with healthcare staff, mirroring the depth of information gained about the patient perspective, as their engagement is essential to achieving successful patient involvement and empowerment. Trusts involved in the feasibility study North Tees and Hartlepool NHS Foundation Trust Northern Lincolnshire and Goole Hospitals NHS Foundation Trust Southampton University Hospitals NHS Trust The Lewisham Hospital NHS Trust The Shrewsbury and Telford Hospital NHS Trust 31 /

17 Global perspective Looking ahead /32 As the first national campaign in the world to target the hand hygiene of healthcare staff, England and Wales embarked early on their improvement journey. When WHO s Patient Safety Alliance launched its First Global Patient Safety Challenge: Clean Care is Safer Care in 2005, England and Wales were amongst the first countries to pledge their commitment to implement actions to tackle HCAI within their countries and to share results and learning internationally. Since then hand hygiene improvement has become a global movement, with a network of campaigning countries established and the number of countries with national or sub-national campaigns reaching 38. The second international meeting for campaigning countries in August 2009 was attended by representatives from over 35 countries, with similar challenges being faced globally regarding sustainability, making infection control a central component of the patient safety agenda, and improving public confidence in relation to HCAI. The insight gained from the experience of the cleanyourhands campaign has been shared with healthcare facilities and systems around the world including the USA, New Zealand and Mexico. Closer to home, Northern Ireland joined the cleanyourhands campaign in November Initially launched to hospitals, the campaign will be extended to health and social care. UK Hand Hygiene Collaborative The four nations of the UK have also been collaborating to share the knowledge and experience from each of the different country s initiatives to improve hand hygiene and promote the UK as a centre for innovation in hand hygiene. The Collaborative meets two to four times a year to discuss developments in hand hygiene policy, practice and other related issues. It has also worked collectively to support the WHO initiative, Save Lives: Clean Your Hands, an annual event on 5 May (started in 2009) which acts as a focal point for activity to improve hand hygiene in healthcare. Wi-Five? Also in support of Save Lives: Clean Your Hands, the NPSA launched a simple online promotional tool based around the Five Moments. The tool takes the form of an electronic game where a healthcare worker moves around a care setting (either an inpatient or home environment) tending to patients and the player has to decide whether they have to clean their hands or not, in accordance with the Five Moments. The game has received such a positive response within the NHS and internationally that work is underway to develop it further for 2010 so Since the campaign began, infection prevention and control has increased in significance and prominence, and rightly this shows no sign of diminishing. The Operating Framework for 2010/11 continues to place preventing HCAI high on the NHS agenda. 10 This is supported by the Care Quality Commission s focus on infection prevention standards as a basic requirement of registration for healthcare providers, and the ongoing inspections against the Code of Practice for the prevention and control of HCAI, as well as the recently announced MRSA objective for PCTs. Infection prevention and control is at the heart of patient safety and as cleanyourhands moves beyond its originally intended lifespan, the emphasis will be on embedding hand hygiene as an integral and intuitive aspect of routine patient care. The Five Moments will remain a central element of the cleanyourhands approach, with a continuing focus on education and training to embed the concept at local level, link the requirement for hand hygiene with infection transmission dynamics, and demonstrate its impact through evaluation. In order to embed hand hygiene in an effective and sustainable way, hand hygiene and infection prevention need to be considered at the highest level of organisations through to the frontline of service delivery. We also need to consider how cleanyourhands needs to evolve in line with the wider changes within the NHS, to ensure that primary care trusts are supported to commission for hand hygiene. The support and resources provided need to reflect the diversity of care settings in which the NHS functions and the increasing shift towards communitybased care. From a practical point of view, cleanyourhands will continue to work with key partners to maintain the focus on hand hygiene and, wherever possible, ensure consistency of message and practice. In particular, we will be supporting the introduction of the observational tools for auditing hand hygiene compliance (according to the Five Moments) and technique being developed by the Infection Prevention Society for launch in These voluntary tools, which are part of a wider suite of Quality Improvement Tools, will provide an opportunity towards standardising how hand hygiene is measured so that NHS trusts will be able to benchmark their performance against other trusts and provide greater confidence for the public in the information that is published externally as a measure of quality. that it can have greater application and utility as a potential tool to support training. 33 /

18 References With thanks to 1. National Audit Office. Improving patient care by reducing the risk of Hospital Acquired Infection. (2004). 2. National Audit Office. The management and control of hospital acquired infection in acute trusts in England. (2000). 3. Boyce J and Pittett D. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. (2002). 4. Reason J. Human Error: models and management. BMJ. 2000; 320: Pittet D, Hugonnet S, Harbarth S et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet. 2000; 356: McGuckin M, Waterman R, Storr IJ et al. Evaluation of a patient-empowering hand hygiene programme in the UK. J Hosp Infect. 2001; 48(3): Gopal Rao G, Jeanes A, Osman M, Aylott C and Green J. Marketing hand hygiene in hospitals a case study. J Hosp Infect. 2002; 50: Fraser S W. Rolling Out Your Project: Thirty Five Tools for Health Care Improvers. Kingsham Press Ltd. (2002). 9. Stone S, Slade R, Fuller C et al. Early communication: Does a national campaign to improve hand hygiene in the NHS work? Initial English and Welsh experience from the NOSEC study (National Observational Study to Evaluate the CleanYourHands Campaign). J Hosp Infect. 2007; 66: Available at: Department of Health. The NHS operating framework for England for 2010/11. (2009). Additional photography and images courtesy of: Julie Storr, formerly Director of the cleanyourhands campaign (page 09) York Hospitals NHS Foundation Trust (page 11) Surrey and Sussex Healthcare NHS Trust (page 13) Nottingham University Hospitals NHS Trust (page 14-15) Cardiff and Vale University Health Board (page 19) NHS Gloucestershire (page 24) North Tees and Hartlepool NHS Foundation Trust (page 26) Special thanks for the hard work of the cleanyourhands campaign team through the years. In particular thanks to Dr Helen Glenister, Julie Storr and Gabrielle Teague who were responsible for the development and inception of the campaign, creating the solid foundations from which it has grown. Thank you to the six trusts that piloted the original campaign toolkit and the further three trusts involved in the patient involvement dimension of the pilot. It was their experience and feedback that turned the concept into a reality. Thanks also to the trusts that tested the extension of the campaign prior to wider rollout and those involved in the patient empowerment project. A real strength of the campaign is the insight provided by NHS trusts on which everything is based. We remain grateful for the input and support of all our national partners, in particular members of the original campaign working group, and the current expert reference groups for the campaign and the patient empowerment pilot. These include: Department of Health; Welsh Assembly Government; NHS Supply Chain; Welsh Health Supplies; Health Protection Agency; Infection Prevention Society; Royal College of Nursing; Care Quality Commission; World Health Organization; NOSEC Study; University Hospital Geneva; MRSA Action; and The Patient s Association. Finally we would like to thank all the NHS trusts and infection control teams that have implemented the campaign locally, and particularly those that have shared their experience in this publication. Without their engagement, enthusiasm and action the campaign would not have been the great success that it has been. /34 35 /