Download Wider rollout of cleanyourhands campaign

Supporting resource 26 - frequently asked questions about the campaign
The campaign may raise some questions from staff within and beyond your trust. Here, we list some
of the common (and not so common) queries and provide some answers which will help you respond.
The answers are taken from the available evidence, where available, and expert opinion. They are
intended as a guide only. See resource 27 for frequently asked questions about hand hygiene
generally.
_________________________________________________________________________________
Q. Is hand cleaning as important as this campaign suggests?
A. Hand hygiene is one important component in the battle against cross-infection. Minimising risks of
infection to patients depends on a range of factors. However, just by increasing hand hygiene alone
you can dramatically reduce the risk of a patient acquiring an infection. This is supported by scientific
evidence, not just opinion, which demonstrates that the bacteria that cause healthcare associated
infections (HCAI) are most frequently spread from one patient to another on the hands of healthcare
workers.
Q. What is the extent of the problem of infection?
A. HCAI are estimated to cost 5000 patients their lives and the NHS £1 billion a year. They cause
unnecessary suffering and anxiety, and may cause disability or death. Although not all of these
infections are preventable, many are.
Patients can acquire bloodstream infections, surgical site infections, urinary tract infections or chest
infections. Once patients acquire an infection, there is a possibility of the microbes which cause the
infection being passed on to other patients and this is heightened by the frequency and extent of
contact which staff have with patients.
Even patients who are not known to have an infection may be carrying transmissible (spreadable)
microbes which can be carried on the hands of staff from one patient to another.
Q. What does ‘near-patient alcohol handrub’ mean in practice?
A. Hand disinfectants such as alcohol are most effective when they are made available where busy
staff can clean their hands without leaving the patient. Near-patient alcohol can mean locating the
disinfectant at each bedside or by the examination couch in a treatment room. Where this is not
possible (for example, due to the risk associated with its placement) staff can be issued with personal
dispensers which can be carried in the pocket or clipped onto clothing. The term ‘at the point of care’
also describes what we mean by ‘near-patient alcohol’.
Q. Does handwashing or using the handrubs really make a difference?
A. The evidence has been described as ‘completely overpowering’. There are studies dating back to
the 1950s and 60s which found hand hygiene to be critical in the spread of microbes in hospitals.
Page 1 of 5
It is crucial to be aware that alcohol (or indeed handwashing at the sink) in isolation, is not the sole
answer to the problem of infections caused by poor compliance with hand hygiene. What is needed is
a multifaceted approach underpinned by strong management commitment.
Q. Is the NPSA saying that conventional handwashing at the sink is no longer important?
A. Not at all. There will always be a place for what some are calling ‘conventional hand washing’. In
particular, handwashing at the sink is always recommended if your hands are physically soiled and
dirty or if treating a patient with diarrhoea or vomiting.
The campaign advocates providing alcohol handrub as all the evidence suggests that washing hands
frequently with soap and water:

is inconvenient;

time consuming;

often causes skin irritation; and

often causes dryness.
The alcohol handrubs are designed to make it easier for staff to clean their hands quickly with a
minimum amount of effort and skin irritation. Alcohol handrubs can be used ‘on the move’.
Q. How can you convince people that alcohol is effective?
A. There are some staff who think that alcohol handrubs are less effective than soap and water and a
lazy way to clean the hands. Some staff will have been exposed to the view that hands should be
washed with soap and water prior to applying alcohol. The history behind this should not be dismissed
lightly. In the early days of alcohol handrubs many infection control nurses espoused the views just
described. It is important to be aware of this, and feel comfortable explaining to those of this view that
there has been a huge amount of work undertaken in the last ten years which has turned a lot of our
thinking about these products on its head. Today, the evidence very clearly supports the view that it is
perfectly acceptable to use alcohol on its own (without a prior handwash) as long as the hands are
clean to the naked eye.
In summary – there are a large number of studies which have looked at alcohol and antibacterial soap
and water and compared the two. In 90% of the studies, alcohol handrubs reduced bacterial counts on
the hands to a greater degree than the antimicrobial soaps.
All handrubs on the NHS Supply Chain contract have been rigorously and independently tested to
ensure that they meet the very latest in international microbiology standards. The efficacy test
programme was developed by leading microbiologists, including those who wrote the European test
standards for these products.
Q. What about the possible dangers of patients drinking the handrubs?
A. Concerns about alcohol handrub being ingested are real and are based on some reported cases
where this has happened. It is of the utmost importance that a thorough local risk assessment is
undertaken prior to deciding on placement of handrubs. In reality this means that a number of clinical
areas (e.g. areas for caring for and treating patients with confusion; alcohol related clinical conditions’
very young children) may decide to issue staff-carried dispenser of alcohol handrub. This enables the
unit or service to adhere to the principle of point of care availability whilst at the same time minimizing
any risk of ingestion.
Supporting resource 26 – frequently asked questions about the campaign
Page 2 of 5
It is important to assess the extent of staff-patient contact and the types of risks of transmission in that
area. Risk of spread differs across the healthcare community. The local infection control team, if your
trust has one, can assist.
Q. How exactly do healthcare staff play a part in the spread of microbes?
A. It is necessary to understand the complexity of clinical and patient care. In an average day
healthcare staff undertake a range of tasks. Some essential yet simple tasks like helping patients
become comfortable in bed can result in thousands of microbes being transferred onto the hands of
staff. Taking a pulse or blood pressure results in transfer of equally large numbers of microbes. A
quick squirt of alcohol handrub will destroy almost all of these potentially harmful microbes in a short
time (15-30 seconds). An absence of hand hygiene at this point would mean that whichever patient
the member of staff touches next would receive these microbes.
Sometimes the microbes from patients will be transferred by staff onto the furniture or equipment in
the immediate vicinity. This should not be a problem if there is good cleaning. However, the microbes
can contaminate the hands of staff and then be spread to other patients if staff don’t clean their hands.
Q. Does alcohol work against Clostridium difficile?
A. Clostridium difficile (C. diff) is a spore forming bacteria. When looking after a patient with diarrhoea
or vomiting including C. diff, the use of soap and water is advocated along with appropriate glove use.
Q. What sort of microbes does hand cleaning stop from spreading?
The type of microbes which can be spread by the hands of staff are:

Staphylococcus aureus (including MRSA)

Streptococcus pyogenes (Group A Strep)

VRE

Klebsiella

Enterobacter

Pseudomonas

Clostridium difficile
Wounds will contain large numbers of microbes. Areas around the perineum can be heavily loaded
with microbes, but even the armpit, trunk and hands can be frequently covered in huge numbers.
Numbers of microbes such as Staphylococcus aureus and Klebsiella can be present on intact skin in
huge numbers ranging from 100 to 1000,000 per square cm.
It is easy to understand that the hands of staff can become contaminated even after seemingly ‘clean’
procedures such as;

taking a pulse;

taking blood pressure readings;

taking a temperature; and

touching a patient’s hand.
Q. Providing alcohol handrub will cost trusts more money up-front – how can you justify this?
Supporting resource 26 – frequently asked questions about the campaign
Page 3 of 5
A. If a trust has not yet implemented near-patient alcohol, there will of course be an initial sum of
money required to supply all areas with alcohol handrubs. As part of the development for the original
campaign in hospitals, the NPSA commissioned an economic evaluation to help NHS trusts in
estimating the likely costs and benefits of successful implementation, which might be useful to those
providing inpatient services, available from www.npsa.nhs.uk/cleanyourhands/resources. There is also
the cost tool (resource 19) to assist trusts with identifying the value of providing near-patient alcohol
handrub to staff.
Outside hospitals it is much harder to demonstrate the financial benefits for introducing near-patient
alcohol handrub, however there are other reasons that compensate for doing so:

Making it easier for staff to clean their hands can prevent infections spreading.

Seeing staff clean their hands can improve peoples’ confidence in the quality of care they are
receiving.

The risks of cross infection, both to staff and to those receiving care, are reduced.

Fewer patients with infections means that staff have more time to care for other patients and
undertake other tasks.

Reducing infection may lead to less staff absence due to sickness.

Fewer infections means less burden on the whole health economy.
The introduction of near-patient alcohol handrub can help trusts meet their obligations under the
Health and Safety at Work Act and the Control of Substances Hazardous to Health Regulations (2002)
to minimize the risk of exposure to infectious microorganisms in the workplace.
Q. Why is it important to clean hands after contact with the patient’s immediate environment?
A. The ‘average’ person sheds around one million skin squames (skin flakes) per day into their
environment. Each skin squame (flake) can contain microbes capable of causing harm. Microbes such
as Staphylococcus aureus and Enterococci can be shed in this way.
These squames will settle down onto the patient’s immediate environment (their bedside furniture and
other objects). It is easy to see how patient’s clothing and bedlinen can become contaminated with
these microbes.
Therefore hand cleaning before and after patient contact is not always enough. It is important before
and after touching things in the patient’s immediate vicinity.
Q. Surely encouraging patients to ask staff to clean their hands can’t be right? Patients will
think we should already be doing it?
A. This is not what we found in the evaluation of the original pilot for the campaign in hospitals.
Patients were interested in being involved with hand hygiene improvement. Patients will be invited
rather than obliged to ask about hand hygiene.
Q. Can patients and their relatives use the handrubs?
A. Patient can play a unique and important role as partner in hand hygiene improvement. They should
be invited rather than obliged to ask about hand hygiene. This is supported by the original pilot for the
campaign in hospitals, which found that 71 per cent of patients were interested in being involved with
hand hygiene improvement.
Supporting resource 26 – frequently asked questions about the campaign
Page 4 of 5
Q. Is hand hygiene really that important?
A. Yes. It is a simple concept, but ultimately improving hand hygiene compliance will help to save
lives.
For more details of the NPSA campaign visit: www.npsa.nhs.uk/cleanyourhands
Supporting resource 26 – frequently asked questions about the campaign
Page 5 of 5