Hand hygiene: even 100% compliance scores may be concealing hospitals’ dirty secrets

Audit is often flawed and is no substitute for examining prevalence of acquired infections

Audit is often flawed and is no substitute for examining prevalence of acquired infections

  • Measuring compliance with hand hygiene policy can lead to complacency, making it harder to change habits 
  • There is a danger hand hygiene could slip down the healthcare agenda, despite its pivotal role in patient safety
  • Fresh guidance from NHS Improvement aims to make it easier for nurses in all settings to adhere to best practice

Picture: iStock

It was Craig Bradley’s own experiences as a patient and a father that helped solidify his views that the way we measure hand hygiene has to change.

As an associate chief nurse and deputy director of infection control, Mr Bradley is accustomed to seeing documents that chart compliance with hand hygiene policies. But he is hugely sceptical about what they actually demonstrate.

His own employer, Gloucestershire Hospitals NHS Foundation Trust, has now ditched the traditional hand hygiene audit report, and he is keen for other organisations to do the same.

When audit reports don’t reflect reality

‘I was in hospital with viral meningitis a year ago and hand hygiene was 0%,’ he says. ‘I also have a picture of a ward with a poster showing [hand hygiene compliance at] 100%. That was a children’s ward where my daughter was admitted with sepsis, and although hand hygiene was better than zero, it certainly was nowhere near 100%.

‘Trust boards across the country are getting these reports that show a sea of green [implying good hand hygiene levels] and think the problem has been solved, but this simply isn’t the case.’

Formal requirements for hand hygiene audit vary depending on where you are, says Mr Bradley. He points out that in England, providers are often required to submit monthly hand hygiene returns to CCGs showing compliance of 95% or more. Providers vary in how they do this, and how frequently they conduct audits, so while one clinical area might be basing its results on 10,000 observations, another might be looking at just 100.

Similarly, one trust might use people trained in audit who really look at everything that is going on, while others might use untrained staff to note whether they see people washing their hands or not. Ironically, Mr Bradley says, those who are trained in audit – and who are doing it more accurately – are more likely to report lower levels of compliance although the actual hand hygiene in that particular ward or unit could well be much better than one showing 100% compliance.

There are a variety of tools for monitoring hand hygiene based on the World Health Organization’s  key 5 Moments (before touching a patient, before clean/aseptic procedures, after body fluid exposure/risk, after touching a patient, and after touching patient surroundings).

Mr Bradley’s trust has decided to focus on the first (before touching a patient) as it is the most critical point, he adds.

Hand hygiene is recognised as one of the best things that healthcare staff can do to ensure patient safety, and there is ample evidence that doing it well improves patient outcomes.

Successive initiatives since the end of the last century have sought to keep good hand hygiene on the agenda of both NHS providers and public health bodies.

Healthcare environments have changed: today it is common for visitors to hospitals to be urged to clean their hands as they enter clinical areas, and alcohol-based hand rub dispensers (ABHRs) are ubiquitous.

An issue in danger of losing impetus

But as the UK health and care environment continues to fragment, particularly in England, there is a risk that hand hygiene might not be receiving the amount of attention it deserves, given its relevance for patient safety and outcomes.

This is something clearly recognised by NHS Improvement, which recently published a national policy on this area of care for staff of all disciplines in all settings (see box below).

Focusing on hand hygiene and personal protective equipment policy, the document is based on a similar strategy developed by Health Protection Scotland, and was unveiled in March at the chief nursing officer for England’s summit in Birmingham.

The policy is important because it supports a common understanding, making the right thing easy to do with every patient every time, says Linda Dempster, head of infection control at NHS Improvement. She adds that it aims to reduce variation in practice, and should also help nurses and infection control teams on the ground.

‘People wash their hands when it’s something they perceive as dirty, so they might not wash them after holding a baby – but nappies are full of C. diff’

Jennie Wilson, professor of healthcare epidemiology, University of West London

‘It makes sense to have a consistent approach across England, rather than having each individual organisation revising policies,’ Ms Dempster says.

Importantly, however, although the policy says that organisations must have systems and resources to implement and monitor compliance with infection prevention and control, it does not specify how they should do this.

What NHS Improvement says

The latest guidance from NHS Improvement says that alcohol-based hand rubs (ABHRs) must be available for staff as near to the point of care as possible and where this is not possible, personal ABHRs can be used.  It says staff should perform hand hygiene:

  • Before touching a patient
  • Before clean or aseptic procedures
  • After body fluid risk
  • After touching a patient
  • After touching a patient’s immediate surroundings

Picture: Solent News Agency

It says hand hygiene should be performed before putting on and after removing gloves.

While ABHRs should be used for routine hand hygiene during care, there are some circumstances where hands should be washed with non-antimicrobial liquid soap and water. These are:

  • If hands are visibly soiled or dirty
  • When caring for patients with vomiting or diarrhoeal illnesses
  • When caring for a patient with suspected or known gastrointestinal infection, for example norovirus, or a spore-forming organism such as Clostridium difficile


Not effective in isolation

Both Ms Dempster and Lisa Ritchie, an NHS Improvement IPC (infection prevention and control) fellow, and nurse consultant in infection control at Health Protection Scotland, say that hand hygiene data should not be used in isolation. Rather, it should be combined with other information – such as numbers of infections – to help drive improvement.

They want to see all health and care organisations taking a holistic approach to hand hygiene, which includes consistency of message, leadership and education. This should work alongside public health messages to demonstrate to everyone how important hand hygiene is, whether in a health setting or not.

‘The outcome we are actually looking for is fewer patients with infections, so what we should be recording is the number of acquired infections’

Craig Bradley, deputy director of infection control, Gloucestershire Hospitals NHS Foundation Trust

University of West London professor of healthcare epidemiology Jennie Wilson, who is also vice-president of the Infection Prevention Society, says that hand hygiene should be high on the agenda across the NHS and the wider care system, including in the community.

But she acknowledges that it’s complicated. ‘We’re asking people to do routinely what they wouldn’t necessarily have to do routinely in life,’ she says. ‘So we have to make it as easy as possible for them to do it.’

This means action on several fronts, including making resources (such as alcohol gel) available at the point of care, but also encouraging people to think about their hand hygiene and developing good habits.

Psychological factors and misperceptions 

Part of this involves looking at the psychology of why and how we wash our hands, or feel we need to. ‘People wash their hands when it’s something they perceive as dirty – so they might not wash them after holding a baby or even changing a nappy, but they will if they have been changing the bed of an older person. People – wrongly – perceive babies as clean but they’re covered in bugs and their nappies are full of C. diff.’

Similarly, she adds, people’s ideas of what is ‘dirty’ can vary: if they like dogs they might not see touching them as getting bacteria on their hands, but others might think differently.

Picture: Barney Newman

Professor Wilson cautions that use of gloves among nursing staff is also problematic. Her own research observing healthcare staff found that when staff wear gloves, around 60% of the time there is no need for it.

‘Plus, they put on gloves when they are some distance from the patient, and might touch lots of things in the environment before they touch the patient, including hospital bed curtains,’ she adds. ‘The gloved hand is just the same as the actual hand, but psychologically it feels different.’

The false assurance of the high audit score

Craig Bradley, who is a trustee of the Infection Prevention Society, says he finds it ‘frustrating’ when commissioners demand that audit results show hand hygiene compliance is 95% or more. This is partly because he says it’s impossible to achieve this – the evidence from attempting to validate hand hygiene audits suggests that the best you can expect is 57% – but also because he believes it focuses on the wrong things.

‘The outcome we are actually looking for by improving hand hygiene is fewer patients with infections,’ he says. ‘So what we should be recording is the number of acquired infections, such as MRSA, norovirus or flu.’

In his organisation, the approach to hand hygiene is changing. Rather than sending reports based on audit figures, which he would present to the trust board, individual wards and units will have to demonstrate they are taking action to ensure good hand hygiene. This could include using posters in clinical areas that are changed frequently so that people don’t get used to them, and having ABHR dispensers at the point of care, which in a hospital ward would mean at every bed. They will also have to record numbers of acquired infections.

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Audit gives a false assurance that all is well, which risks the eye being taken off the ball on hand hygiene, Mr Bradley believes. ‘100% says “there’s nothing to see here – move on”. But hand hygiene is something you have to continue all the time – it’s never going to go away.’

Audit has its role, but so does talking to staff

Professor Wilson cautions against over-reliance on one method of monitoring hand hygiene and says that while audit has been regarded as the solution, it is in fact only a part of it, and only if used correctly. ‘There’s an incentive to get it to 100%, because if you don’t you get into trouble. The focus is on the score, rather that what people are actually doing.

‘Audit works where there is a very big problem, where compliance is very poor, but [monitoring hand hygiene] should be about looking at the underlying factors, and that involves a dialogue with staff about why they don’t decontaminate their hands.’

She welcomes publication of the new policy, but adds that it is not a simple problem, and there is no simple fix: ‘The problem is translating policies into change at grassroots level. I don’t think we have the answer yet.’

Jennifer Trueland is a health journalist

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