Infection prevention and control (IPC) is the name commonly given to the practice of implementing strategies to keep the risk to patients entering clinics as low as possible, by preventing them from acquiring an infection during their stay (Ruple et al, 2011).
The foundation of any good IPC system in practice must include a hand hygiene strategy as, without it, all other parts of the system will fail. Infection can be defined as the entry and multiplication of microorganisms to cause clinical, subclinical, colonising or latent infection (Ruple et al, 2011). Urinary tract infections, pneumonia, bloodstream infections, surgical site infections, and gastrointestinal infection are among the most commonly identified infections that can occur in the veterinary setting (Stull and Weese, 2015). While the environmental area that a patient is housed within or operated on must be kept as clean as possible to reduce the risk, the real prevention mechanism to stop the microorganisms being transferred from surface to patient, equipment to patient or patient to patient, is appropriate hand hygiene.
The World Health Organization (WHO) is a specialised agency of the United Nations that was founded in 1948 and is responsible for establishing and governing principles that contribute to maintaining world health (Lee, 2014). Many of the tools and guidelines that the WHO release for human IPC methods can be transferred to the veterinary sector to ensure that patients are safeguarded to the highest standard possible while in the practice.
Considerations for hand hygiene
Veterinary nurses will commonly encounter patients that are suffering from an identified active infection and are carrying organisms that the practice has been made aware of. Active measures are usually undertaken for these patients, such as barrier nursing or increased environmental cleaning and disinfection, to reduce to risk associated with the care of these patients. Unfortunately, there seems to be a common misunderstanding (personal experience) among veterinary workers that a patient must have an open wound, or an area susceptible to infection for there to be any risk. It is now know that colonisation of healthy or intact skin is completely possible and that patients that are handled by the veterinary team could be on the receiving end of workers that are colonised themselves with many different pathogens including Staphylococcus aureus, Klebsiella spp. and Acinetobacter spp. (Casewell, 1981; Bhalla et al, 2007). This fact, compounded by the increased microorganism level of the hospital environment, makes a hospital acquired infection seem like a much greater risk than previously understood.
To consider an effective hand hygiene strategy that will reduce the risks of infecting patients with either organisms from veterinary staff, or passing on another patient's infection, it is useful to first understand the steps that take place in order for a hospital acquired infection to occur in a human setting. It is surprising to note that transfer of microorganisms from environment to patient, or healthcare worker to patient includes no fewer than five steps (WHO, 2009).
- Organisms must be present on the skin or the surrounding area of the patient
- Organisms must be transferred to the hands of the carer
- Organisms must be capable of surviving on the carer's hands for several minutes
- Handwashing of the worker must be inappropriate or absent, or the product is inappropriately used
- The contaminated hands must come into direct contact with the next patient's skin or surrounding environment.
When these steps are applied to a veterinary clinical setting, it is possible to identify that canine and feline patients may be at higher risk of introducing infectious organisms to themselves. Veterinary patients have increased contact with the environment as they are known to transfer organisms through communal contact such as toileting areas and cleaning and grooming in a way that humans do not. The steps outlined above, however, do highlight that simply ensuring a good hand hygiene strategy in the practice will prevent the full five steps being able to occur, and therefore greatly reduce the ability for any hospital acquired infections to occur as a result of veterinary workers passing organisms from themselves or other patients to the next patient.
Once the importance of hand hygiene in the practice is understood, then it is useful to consider how best to implement a working strategy. Appropriate hand hygiene considerations to improve the standards in practice could include the following steps as a guideline.
Step 1: raise awareness
All team members should be made aware that good hand hygiene is a proven and successful way to safeguard patients in the hospital, and should be involved in the attempts to improve the successful implementation of the strategy in order to improve compliance. Clients may also like to be made aware that the practice is improving their standards and that their pets are going to be looked after by a team that take this part of their care seriously. Hand hygiene ‘campaigns’ or active ‘pushes’ to encourage increased uptake are the best method to instigate a change (Randle et al, 2006). Posters, toolkits, statistics and advertising competence in the area of hand hygiene can comfort clients that may be concerned about the risks prior to arrival at the practice.
Step 2: increase opportunity
Following on from a hand hygiene campaign or period of increased awareness, it is pertinent to ensure that there is increased opportunity to perform hand hygiene in the practice. For team members to want to take up increased opportunity using new hand hygiene stations, the selection of products available should include ones that have good skin tolerance and are acceptable for team members in the practice to use (Kampf, 2004). The WHO First Global Patient Safety Challenge ‘Clean Care is Safer Care’ has developed useful tools for worldwide use. Research looking at human behaviours, cognitive science and social marketing resulted in a model named ‘My five moments for hand hygiene’ (Figure 1) that targets key elements in the action and time points in the patient's care that when performing hand hygiene will prevent the spread of organisms (Sax et al, 2007).
Increasing the number of hand rub bottles that are placed around the clinic may act as a visual prompt and therefore could improve compliance (Cure and Van Enk, 2015).
Practice team members may become frustrated if there are no hand hygiene stations, hand rub bottles or hand washing sinks available in the area that they are working in after they have been asked to improve hand hygiene or try to adhere to the five moments. Adaptations to the five moments can be made to allow the tools to be applied to a veterinary setting, which may further act as a prompt to encourage team members to take up opportunities as shown in Figure 2.
Step 3: train and retrain
Training is important to further increase awareness and educate team members that are resistant to improving hand hygiene. More importantly, once the clinic has increased the opportunity for team members to perform hand hygiene, then training should be given to ensure that those occurrences are likely to be effective at removing or inactivating microorganisms through the appropriate technique. The WHO steps for hand hygiene are possibly the most well-known, and resources are available online to improve technique (Figure 3).
Further training can include fun activities to highlight how effective team members are at performing hand hygiene. The use of products that glow under ultra violet (UV) light that can be applied to the hands and then washed off, before checking with a UV lamp to highlight areas that have been missed, can be used as a way to show team members that they may be able to improve their technique. The measurement of organic adenosine triphosphate (ATP) on surfaces has been used to test how clean a surface may be in the food industry for some time, and can be a useful indicator of whether mechanical removal of material has occurred on team members' hands, to help with training and awareness (Carling and Bartley, 2010). A swab of a worker's hand is taken and the swab is placed into a machine that gives out a reading of organic matter at point of care (POC). A high reading of organic matter could show that the person has not washed their hands recently.
Understanding the correct types of hand products available, as well as the correct use of the type of products that the hospital requires, can make a difference to the ability to correctly perform hand hygiene (Table 1). Once products have been purchased to be used within the clinic, training on the correct method of use should be given to include quantity of the product required and time taken for the product to be in contact with skin, as many products require a contact time of longer than 30 seconds (Kampf et al, 2008).
Table 1. The types of products for hand hygiene
| Product | Use |
|---|---|
| Alcohol-based hand rub | Preparation of foam, gel or liquid that contains alcohol and can suppress growth of or inactivate microorganisms |
| Antiseptic agent | An antimicrobial substance that inactivates microorganisms or inhibits their growth on living tissues |
| Detergent (surfactant) | Also referred to as ‘soap’. Can improve the ability of water to mechanically remove the microorganism. Comprise hydrophilic and lipophilic parts and when referred to as ‘plain’ contain no antimicrobial agents |
| Antimicrobial Soap | Soap containing an antiseptic agent (above) at a concentration high enough to inactivate microorganisms or temporarily suppress their growth |
Step 4: auditing
The final consideration for effective hand hygiene in practice includes the assessment of whether effective hand hygiene is taking place in order to allow improvement and appropriate clinical governance. In order for training to be effective, it should be assessed and improved where required with the use of audits and retraining, but also any time that evidence suggests a procedure should be updated.
An audit that highlights poor compliance, poor technique, or lack of efficacy of products will allow a gold standard practice to then address any problems with the previous steps 1–3, and show up any areas of weakness within the system for addressing. Auditing can be done from the simplest format of just quantifying the number of people using hand rub or hand wash at the correct time in the practice and then reviewing how to improve it, to using more advanced auditing software, external auditors and more complex approaches that will equally provide the information needed but may be of increased quantity or value. Auditing may also include keeping a record of infection rates in the clinic that can be investigated or allow pattern recognition when infection rates or infection types increase.
Conclusion
Correct hand hygiene measures implemented as part of an effective patient safety framework that include evidence-based practice, measurement and transparency of clinical outcomes using clinical auditing, allows veterinary professionals to safeguard their patients to the highest standard.
This standard is set by the Royal College of Veterinary Surgeons (RCVS) and these are the standards that veterinary nurses should set for themselves by ensuring careful consideration of hand hygiene protocols in their clinic and encouraging everyone to think about how much they can contribute to the spread of disease if they do not follow guidelines with care. So….. when did you last clean your hands?
KEY POINTS
- Hand hygiene plays a key role in reducing the spread of infection by veterinary workers.
- Every practice should carefully consider how to implement good hand hygiene strategies to safeguard patients in line with the Royal College of Veterinary Surgeons (RCVS) standards.
- Consider the correct use and type of product available for hand hygiene in your practice.
- Appropriate training, education and auditing will help to improve practice protocols.
- Consider the five moments of hand hygiene in your practice.