Hand hygiene in care homes is not always what it ought to be: 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 result.
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, 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.
Providers 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.
What can be done to improve this situation?
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.
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 sanitisers 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. 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.
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. Suppliers can provide 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.
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.
Strategically placed, accessible facilities; ongoing staff education and training; and choosing the right skin care products – if all these go hand in hand care home providers can reduce the spread of germs and bacteria, raise the level of staff compliance, and improve the skin condition of employees.
 Nicolle, LE, Clinical infectious diseases, ‘Infection control in long term care facilities’, 2000. Nicolle LE, Strausbaugh LJ, Garibaldi RA, Clinical microbiological reviews, ‘Infections and antibiotic resistance in nursing homes’, 1996.
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