Review
The CleanYourHandsCampaign: critiquing policy and evidence base

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Summary

Handwashing is considered to be the most effective way of reducing cross-infection. Rates of healthcare-associated infection and the incidence of meticillin-resistant Staphylococcus aureus are higher in the UK than in many other European countries. The government has responded by introducing the ‘CleanYourHandsCampaign’ throughout England and Wales, based on the success of the approach employed in Geneva. Alcohol hand rub is placed at every bedside in acute hospitals, ward housekeepers should replenish supplies and feedback on compliance is provided to health workers. Posters and other promotional materials are used to remind health workers and visitors to use the hand rub. Patients are encouraged to ask health workers if they have cleaned their hands before contact. In this paper we argue that the evidence base underpinning the CleanYourHandsCampaign is incomplete. Alcohol hand rub is acknowledged as a useful adjunct to hand hygiene but it is not effective in all circumstances. There is some evidence to support the use of feedback on performance to encourage compliance but no evidence that promotional materials such as posters or patient reminders are effective. The ethics of encouraging hospital patients to take responsibility for their own safety is questioned. Much of the success in Geneva must be attributed to the attention given to contextual factors within the organization that encouraged hand rub use, especially hospital-wide ‘ownership’ of the initiative by managers and senior health professionals. A customized intervention from another country that fails to consider local organizational factors likely to influence the implementation of the campaign is unlikely to be effective. It is concluded that although hand hygiene is of undoubted importance, undue emphasis should not be placed on it as a ‘quick fix’ to solve the unacceptably high rates of healthcare-associated infection in National Health Service hospitals.

Introduction

Healthcare-associated infection (HAI) is a concern to health workers and the public. The most troublesome infections and those most difficult to treat are caused by antibiotic-resistant (including multiply-resistant) bacterial strains such as meticillin-resistant Staphylococcus aureus (MRSA), gentamicin-resistant Gram-negative bacilli, and glycopeptide-resistant Enterococcus. Mortality from MRSA has increased 15-fold over the last 10 years in the UK where the incidence of HAI is higher than in other European countries.1 Elsewhere more aggressive approaches are employed to tackle HAI, apparently with greater success. In the Netherlands a ‘search and destroy’ policy at national level has reduced the incidence of MRSA.2 Increased compliance with handwashing protocols and reduction in HAI in the University Hospitals Geneva has been achieved through a multifaceted approach employing a raft of interventions intended to ensure that health workers do not forget about hand hygiene.3 Continuing high levels of compliance are being achieved by combining use of alcohol products with intensive feedback on performance to health workers, resulting in a ‘continuous Hawthorne effect’.4 Over a period of six years HAI was reduced by 44%. MRSA colonization rates fell by 50%. The effect of reduced HAI rates on the community served by the hospital has not been reported.

The high incidence of HAI in British hospitals and media reports of ‘superbugs’ have captured public interest. In response the government has funded research to document the extent of the problem and explore methods of control. Patients with HAI are three times more expensive to treat than uninfected patients, stay in hospital three times longer, and more often require medical and domiciliary nursing care afterwards than patients who have not developed infection.5 A survey to explore how effectively acute NHS trusts manage HAI estimated that at least 100 000 cases were documented annually, causing 5000 deaths and costing £1 billion. Infection control guidance was being poorly implemented. The National Audit Office6 concluded that it would be possible to reduce HAI by 15%, saving £150 million through better application of existing polices and procedures.

This work has been followed by a flurry of legislation and action to improve the control of HAI. Evidence-based guidelines for infection control have been commissioned and kept updated.7, 8 Improved surveillance has been introduced to control the spread of specific infectious diseases, as well as HAI, after the publication of ‘Getting ahead of the curve’, including mandatory reporting of MRSA bacteraemias.9, 10 ‘Winning ways: working together to reduce healthcare-associated infection’ has increased the profile of infection control throughout the National Health Service (NHS) and has raised the authority of infection control teams.11 Numerous other measures have been introduced to improve standards of hospital cleanliness. One of the key functions of senior nurses (‘modern matrons’) is to support ward sisters and infection control nurses.12

Section snippets

The CleanYourHandsCampaign (CYHC)

The CYHC was launched by the National Patient Safety Agency in April 2005. All acute NHS Trusts in England and Wales have been supplied with a toolkit derived from the work of Pittet et al. in Geneva.3 The toolkit comprises selected interventions drawn from the literature, which are considered by policy makers to have the potential to promote handwashing and which might feasibly be introduced in all clinical settings where acute care is delivered.13 Alcohol-based products should now be placed

Conclusion

Lip service to infection control persisted throughout the NHS until clinical governance ushered in emphasis on clinical standards with systems to monitor risk.87 HAI and its prevention, especially hand hygiene, have since become hot political topics in the UK. With such a major problem it has been necessary to take swift action, and handwashing has been singled out for particular emphasis. Although published studies seeking to increase compliance with hand hygiene and reduce rates of HAI have

References (89)

  • C.A. Muto et al.

    Hand hygiene rates unchanged by installation of dispensers of a rapidly acting hand antiseptic

    Am J Infect Control

    (2000)
  • W. Moongtui et al.

    Using peer feedback to improve handwashing and glove usage among Thai health care workers

    Am J Infect Control

    (2000)
  • V.D. Rosenthal et al.

    Effect of education and performance feedback on handwashing: the benefit of administrative support in Argentinean hospitals

    Am J Infect Control

    (2003)
  • M. Whitby et al.

    Handwashing in healthcare workers: accessibility of sink location does not improve compliance

    J Hosp Infect

    (2004)
  • M. Thomas et al.

    Focus group data as a tool in assessing effectiveness of a hand hygiene campaign

    Am J Infect Control

    (2005)
  • M. Graham

    Frequency and duration of hand washing in an intensive care unit

    Am J Infect Control

    (1990)
  • J. Hilburn et al.

    Use of alcohol hand sanitizer as an infection control strategy in an acute care facility

    Am J Infect Control

    (2003)
  • J. Ojajarvi

    Hand washing in Finland

    J Hosp Infect

    (1991)
  • E. Larson et al.

    Factors influencing handwashing behavior of patient care personnel

    Am J Infect Control

    (1982)
  • E. Kownatzki

    Hand hygiene and skin health

    J Hosp Infect

    (2003)
  • E. Larson et al.

    Multifaceted approach to changing hand washing behavior

    Am J Infect Control

    (1997)
  • M. Khatib et al.

    Handwashing and use of gloves while managing patients receiving mechanical ventilation in the ICU

    Chest

    (1999)
  • B.C. Camins et al.

    Reducing the risk of health care associated infections by complying with CDC hand hygiene guidelines

    Jt Comm J Qual Patient Saf

    (2005)
  • E.A. Jenner et al.

    Hand hygiene posters: selling the message

    J Hosp Infect

    (2005)
  • T. Gillespie

    Patient empowerment to improve hand washing compliance in health care workers

    J Hosp Infect

    (2001)
  • M. McGuckin et al.

    Patient education model for increasing hand washing compliance

    Am J Infect Control

    (1999)
  • M. McGuckin et al.

    Evaluation of a patient education model for increasing hand hygiene compliance in an inpatient rehabilitation unit

    Am J Infect Control

    (2004)
  • L. Silvestri et al.

    Hand washing in the intensive care unit: a big measure with modest effects

    J Hosp Infect

    (2005)
  • T. Eckmanns et al.

    Hand rub consumption and hand hygiene compliance are not indicators of pathogen transmission in intensive care units

    J Hosp Infect

    (2006)
  • G. Duckworth

    Controlling methicillin-resistant Staphylococcus aureus

    BMJ

    (2003)
  • F.J. Roethlisberger et al.

    Management and the Worker

    (1939)
  • R. Plowman et al.

    The socio-economic burden of hospital acquired infection

    (1999)
  • National Audit Office

    The management and control of hospital-acquired infection in acute NHS trusts in England

    (2000)
  • R. Pratt et al.

    The EPIC Project: developing national evidence-based guidelines for preventing health care associated infections

    J Hosp Infect

    (2001)
  • C.M. Pellowe et al.

    The epic project. Updating the evidence based guidelines for preventing healthcare associated infections in NHS hospitals in England. A report with recommendations

    Br J Infect Control

    (2004)
  • Chief Medical Officer's Report

    Getting ahead of the curve. A strategy for combating infectious diseases

    (2002)
  • Department of Health

    Surveillance of Healthcare Associated Infections

    (2003)
  • Department of Health

    Winning ways: working together to reduce healthcare associated infection in England

    (2003)
  • Department of Health

    Modern matrons in the NHS

    (2002)
  • J. Storr

    The effectiveness of the national cleanyourhandscampaign

    Nurs Times

    (2005)
  • Department of Health

    The NHS Plan: a plan for investment, a plan for reform

    (2000)
  • G. Reybrouck

    The role of hands in the spread of nosocomial infections

    J Hosp Infect;

    (1983)
  • R. Albert et al.

    Handwashing patterns in medical intensive care units

    N Engl J Med

    (1981)
  • J. Sedgewick

    Hand-washing in hospital wards

    Nurs Times

    (1984)
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