The spread of infections represents a serious risk for any care home. Rigorous hand hygiene is crucial. But with institutions trying to do ever more with ever fewer resources, keeping up with compliance can be a struggle. Paul Jakeway, Marketing Director at skin care specialist Deb, explains how strategically placed facilities, ongoing staff education, and the right skin care products can help.
Care homes unite large numbers of people in one place with many of these people highly susceptible to catching infections. Furthermore, the fact that carers frequently move between rooms – looking after residents in quick succession, often with little or no time in between – further increases the chance of germs and bacteria travelling, with serious implications for residents, relatives, and carers alike.
Residents can be at considerable risk. As the UK’s Department of Health warns, infections caught in care homes can worsen underlying health conditions in residents. The recovery of patients could be adversely affected. Hospitalisation is a potential consequence. In some cases, infections may be life-threatening. It should be in the interest of everyone involved to keep the risk of a spread of infections to an absolute minimum.
There is more than one way to achieve this, and all of them have a role to play – but it is widely acknowledged that there is no other single activity that can do more to control the spread of infections than hand hygiene. Health care professionals, government departments, and international organisations all agree that a rigorous hand hygiene regime is crucial for every care home.
According to the Department of Health, hand hygiene should happen after each and every “episode” of caring – immediately before and after there has been direct contact with a person, as well as after any other activity that might have contaminated hands. It should be an integrated part of the everyday running of a care home.
In practice, things are not always this easy. The problem is not that care home providers or care professionals are not aware of the problem; in most cases, the opposite is the case. But it can sometimes be difficult to integrate a hand hygiene regime in a way that does not hinder the every-day business of running a care home.
Care homes are under considerable pressure to deliver ever more – in many cases with limited resources. Providers are expected to meet the complex needs of an ageing population, on budgets that are often under enormous strain. Increasingly, staff are asked to deliver significant efficiency saving. The financial and time pressures they operate under can have a negative impact on many aspects of their business – including their hand hygiene regimes.
It should come as no surprise, then, that evidence cited by the Department of Health suggests that many care workers do not always decontaminate their hands when required – or that they do not always use the correct technique. According to the Care Quality Commission, some studies now suggest that the number of infections in care homes may be comparable to those in hospitals as a result1.
What can be done to improve this situation?
Every care home’s requirements and challenges are unique – and so should be the response, with tailor-made solutions that take into account local realities as much as possible. The implementation of a hand hygiene programme should be a cooperation – with care home providers, skin care suppliers, and organisations offering help and guidance all working together.
There have been huge advances in recent times – in the design of hand hygiene dispensers and facilities as well as the range of skin care products available. All this should make it easier for care home providers to find a solution that is right for them.
THE RIGHT FACILITIES
As the Department of Health stresses: accessible hand hygiene facilities are a crucial first step in any effort to increase hand hygiene compliance. If they do not exist, staff should bring this to the attention of the care home management immediately. If they do, care home providers should ask themselves: are our facilities at their most effective? Does their location make sense? How accessible are they? What stands in the way of staff using them as frequently as they should to assure maximum compliance?
Modern dispenser design allows for much more flexibility when it comes to the location of hand hygiene opportunities. Rather than to have one centrally located facility, which might require staff to walk through the building to have access, dispensers can be strategically placed throughout a care home, for instance at the exit or entry point to a resident’s room. This makes it much more likely for staff to use them regularly.
Design advances also mean that – rather than being eye sores – dispensers can easily blend into their surroundings. This way, hand hygiene stops being an add-on – and becomes a much more integrated element of the care home environment.
There are options now that allow care homes to customise the look of their dispensers in terms of the colour and the text that appears on them. They can for instance choose to have their logo displayed on the equipment.
Alternatively, hand hygiene equipment could carry instructions on the correct hand washing technique, or prominent slogans that encourage hand washing. Such reminders are especially helpful because they are delivered exactly where the hand washing opportunity exists: all you have to do is make use of it.
The Front of House – the publically accessible areas of a care home – should be taken as seriously as the Back of House – which is reserved for staff and includes kitchen areas.
To be effective in controlling the spread of infections, it is vital that visitors (who are usually far less aware of the need for hand hygiene than staff or residents) also regularly clean their hands while on site. For this, hand hygiene facilities should not only be easily accessible; they should also be pleasant to use.
Well-designed and equipped washroom facilities have two advantages: they do not only make visitor hand hygiene more likely, they also present the care home in a good light to visitors and relatives, who might easily be put off if the opposite is the case, and think negatively of the home (even if it provides high-quality care).
ONGOING EDUCATION AND TRAINING
Properly placed dispensers and accessible facilities are not enough to increase compliance. The Department of Health, the Care Quality Commission and the WHO all agree that ongoing staff education and training are absolutely crucial.
Care home staff need to be educated about the risks of neglecting their hand hygiene. They need to know not only when or how often to wash their hands – but how. When are alcohol rubs appropriate, and when not? When should a soap product be used?
Alcohol sanitisers, for example, are not suitable for use on hands that are dirty, contaminated and soiled (e.g. faeces, bodily fluids) or during outbreaks of diarrhoeal illness (e.g. norovirus or Clostridium difficile). In such cases, washing hands with soap and water is necessary. The WHO says that quite often techniques are inappropriate even where compliance is high. Lack of knowledge, says the organisation, is one of the greatest barriers to better hand hygiene practices.
The guidance the WHO publishes on this is known as the ‘Five Moments for Hand Hygiene’. It is one the highest clinical standards care providers can aspire to. The Five Moments are:
- Before patient contact
Clean your hands before touching a patient when approaching him or her.
- Before an aseptic task
Clean your hands immediately before any aseptic task.
- After body fluid exposure risk
Clean your hands immediately after an exposure risk to body fluids (and after glove removal).
- After touching a patient
Clean your hands after touching a patient and his or her immediate surroundings when leaving.
- After touching patient surroundings
Clean your hands after touching any object or furniture in the patient’s immediate surroundings, when leaving – even without touching the patient.
This approach – which was developed based on the most comprehensive evidence-based document available on hand hygiene – aims for hand hygiene to be performed at the correct moments, and at the correct location, within the flow of care delivery.
To integrate such an ambitious regime into their everyday business, care home providers need to make staff education and training a clear priority. Which approach to take will depend on the type and size of the care home, but the Care Quality Commission says that practical training, mentoring and role modelling often work better than theoretical training.
Innovative approaches might be rewarded. Easy-to-use training and educational kits are widely available these days, and they can help with demonstrations of hand washing techniques and the right use of products. E-Learning programmes are increasingly being used by hospitals, and could become popular with care home providers too. As the WHO points out, this form of distance learning can reduce the time and energy investment by the teacher and is very advantageous for easily monitoring the learning process.
Training should not be a one-off event, but an ongoing conversation between employers and employees. Regular refreshers and constant updates on infection prevention and control can help to achieve this aim, as can easily accessible information materials, such as leaflets or brochures. Large-scale posters have proven effective in keeping awareness at the level it needs to be.
Monitoring plays an important role too. The WHO recommends for healthcare providers to closely monitor their practices – as well as their infrastructure. Are we equipped to meet our challenges and meet our responsibilities? Are there problems in our infrastructure that stand in the way of better compliance? How could we make life easier for our staff?
A close monitoring of staff performance on hand hygiene should be combined with frequent performance and feedback sessions. Is our hand hygiene regime working? How can we improve compliance even further? Is there anything that does not work as well as it should?
One of the most important features of a successful hand hygiene regime is the inclusion of staff – from the beginning, and at every important point along the way. The aim should be the creation of an environment where staff do not merely feel included, but empowered. The more active a role care staff play in the implementation – and continuous improvement – of a hand hygiene regime, the more likely it is to be widely accepted and executed. The best hand hygiene regimes are the ones that are owned by an entire care home operation.
CHOOSING THE RIGHT PRODUCTS
Choosing the right hand hygiene products is important too. The WHO admits that this can be a very difficult task indeed. Cooperation between hand hygiene product suppliers and healthcare institutions has shown that an ongoing conversation can benefit both sides, with suppliers providing cutting edge innovation, while healthcare providers report back what works and what does not work for them, as well as what their needs might be in the future.
Hand washing with soap is a fundamental step in hand hygiene practice. Apart from removing any visible soilings from hands, a good hand washing technique will remove high levels of bacteria and viruses also present on the skin. Perfume-free and dye-free foam hand wash have proven to be good products for this.
Hand sanitising is very useful in reducing microbial counts on visibly clean hands when access to running water is inconvenient. In care environments, alcohol is the preferred active biocide for skin sanitising without the need for rinsing. Effective hand sanitisers can kill up to 99.999% of common germs. Sanitisers can be provided through dispensers, or in personal issue packs so staff can carry around with them.
It would be a missed opportunity not to think about the skin health of employees when implementing a hand hygiene regime. While hand washing and sanitising are the most important steps, there is a third element to a fully thought-through skin care system: restoring.
Frequent hand washing makes it necessary to regularly replenish the natural oils and secretions lost from the skin via the use of a conditioning cream. For care home employees, maintaining good skin condition is vital to both their own long term health and the health of those in their care.
In care homes where carers frequently work outdoors, UV protection could be an additional element. Prolonged unprotected exposure to the sun causes sunburn, skin damage and can lead to skin cancer. Publically available sun cream can help to drastically reduce this risk.
EVERYONE COULD BENEFIT
Strategically placed, accessible facilities; ongoing staff education and training; and choosing the right skin care products – for a hand hygiene regime to be at its most effective, all these should work hand in hand.
Smartly integrated, a hand hygiene system does not only benefit carers, residents, and relatives; care home providers could expect significant advantages as well. It goes without saying that keeping the risk of infections to a minimum reflects positively on a care home’s image. If residents feel safe, relatives at ease, and carers protected, the wider care home operation can only gain.
There could be a financial benefit too. Infections place an enormous burden on the healthcare system (it is estimated that healthcare-associated infections are currently costing the NHS up to £1 billion each year). Controlling and preventing them effectively can translate into significant cost-savings for care providers, with case studies showing that money put into the implementation of an intelligently designed hand hygiene system could provide a positive return – sometimes within less than a year.
This should put at ease care home providers who – understandably – are worried about the up-front costs or a large initial investment needed from implementing an ambitious regime.
Smart solutions could help care home operators expected to deliver ever more with ever fewer resources to fully embrace hand hygiene. Not as a necessary burden, but as a very effective way to strengthen themselves – in the service of those they care for.