Epidemiology is the study of factors affecting the health and illness of populations, and serves as the foundation and logic of interventions made in the interest of public health and preventative medicine. It is considered a cornerstone methodology of public health research, and is highly regarded in evidence-based medicine for identifying risk factors for disease and determining optimal treatment approaches to clinical practice. Surveillance is defined as the ‘ongoing systematic, collection, analysis, and interpretation of health data essential to planning, implementation and evaluation of public health practice closely integrated with timely dissemination of this data to those who need to know’. Surveillance means to watch over with great attention, authority and often with suspicion. (Shweta 2002)
Monitoring adherence with hand hygiene and providing staff with feedback on their performance is strongly recommended and frequently suggested in recent literature. There are a range of tools available for assisting staff in calculating hand hygiene compliance and a number are currently under development. The hand hygiene audit tool is the authors choice and has been successfully used at Lewisham Hospital and is adapted from the NPSA (2004) clean your hands campaign. 85% of hospital infections are caused by contamination of hands and this costs the Trusts between 1.2-1.9 billion pounds a year. (DOH 2008).
Hand washing is widely acknowledged to be the single most important activity for reducing the spread of infection, yet evidence suggests that many healthcare professionals do not use the correct technique. This means that areas of the hands can be missed. The author feels that this is crucial in preventing and controlling infection and this is why the particular audit has been used. (See appendix 1) The local Trust has implemented ‘bare below the elbows policy’ so the author has adapted the hand hygiene audit slightly to reflect this. It was implemented following recommendations from the Health Act (2006)
The hand hygiene audit examined the following referring to literature including, EPIC 2 (2006), Essential steps to clean safe care (DOH (2009), Winning Ways (DOH 2003), NICE (DOH (2003) AND RCN (2005) wipe it out campaign. Hands should be decontaminated before direct contact with patients and after every contact with patients, or potentially contaminated equipment or environment. While alcohol hand jells and rubs are a practical alternative to soap and water, alcohol is not a cleaning agent. Hands that are visibly dirty or potentially grossly contaminated must be washed with soap and water and dried thoroughly. The nails should be kept short, clean and polish free.
Wristwatches should not be used for clinical care and all jewellery should be avoided. Artificial nails must not be worn and any cuts and abrasions should be covered with a waterproof dressing. Hands should be washed using the 6 step hand washing technique commissioned by the DOH, and alcohol jel should be rubbed in for at least 15-20 seconds as it releases emollients to try to prevent dermatitis. Should the person use the hand jel 5 times or more then hands need to be washed with soap and water to avoid a sticky residue. Water should be applied before soap to avoid a contact dermatitis and elbow taps should be used to prevent recontamination of hands. All these factors where taken into account when the hand hygiene audit was performed.
The author chose to audit a number of wards and my findings were fed back to the ward managers. (See graphs appendix 2) This was very time consuming but the local trust have matrons employed in the trust to feed back information to their areas as set out in the Matrons Charter (2004). Audit results are sent via email to all departments and put on the infection control data base, this is performed by the infection control nurse. The overall compliance rate was 90% which was very disappointing as we need to strive for 100%. (DOH 2006) Each section of the audit tool was clearly identified but my only criticisms was that if 1 mark was failed in each section the ward automatically failed the whole section. The ward staff were also let down if a pharmacist for instance did not comply with the hand hygiene audit, as this still reflects on the ward as if it is the nursing staff. The tool needs to be revised as I feel it gives a false reading. My main findings from the audit were as follows:
1. Hand decontamination jel is available at every bedside and in fact every six feet as recommended by the Department of Health. 2. Health care workers hand hygiene compliance is 60% better than last years figures of 30%. 3. The worst offenders for wearing wristwatches in the clinical settings were Doctors. The author had to give a gentle reminder about the ‘bare below the elbows policy’ and it has to be said that the offenders were very gracious about it. 4. Some ward areas had no elbow taps or hot running water in the clinical area.
The author made it her business to contact facilities to deal with the situation as a matter of urgency. The author learnt that facilities are visiting all areas to change old sinks and normal taps. However, this will take some time. 5. Finally, the author found that nursing staff did have a habit of walking around with gloves and aprons on, touching and contaminating the phone and keyboard and other environmental surfaces. They failed to see that they had just been in contact with ‘hands on care’ patients. The author reminded them that gloves and aprons are single use items only.
On reflection from performing this audit, it makes me look at my clinical practice in Infection Control and will definitely be more aware of the need to decontaminate my hands at every instance. Effective hand hygiene is a central principle of infection control (Wilson 2001) and the ongoing reinforcement of its importance remains a key role of the infection control team.