Quality Priority:

To demonstrate that all clinical colleagues are compliant with the Infection Control practice of being "Bare Below the Elbows policy".

Current Situation:

Quarterly observed hand hygiene audits should occur in every clinical service. Each clinician should also be following Bare Below the Elbows policy and Locala should be able to demonstrate this. However, some services are not submitting audits and some that do are not demonstrating compliance with the basics of hand hygiene. 

Why is it a priority?


Patient safety has become a cornerstone of care, and preventing healthcare-associated infections remains a priority. It is estimated that 300,000 patients a year in England acquire a healthcare-associated infection as a result of care within the NHS. In 2007, Methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections and Clostridium difficile infections were recorded as the underlying cause of, or a contributory factor in, approximately 9000 deaths in hospital and primary care in England.

Healthcare-associated infections are estimated to cost the NHS approximately £1 billion a year, and £56 million of this is estimated to be incurred after patients are discharged from hospital. In addition to increased costs, each one of these infections means additional use of NHS resources, greater patient discomfort and a decrease in patient safety. A no-tolerance attitude is now prevalent in relation to avoidable healthcare-associated infections.

Observed Hand Hygiene audits are extremely difficult in the community setting as often individuals work alone.

How will we achieve it?

  • In keeping with being a technology enabled business, an intelligent IT programme will be developed which allows colleagues to input the data with minimum disruption to clinicians work.  This system will enable data to be easily retrieved so that the Infection Prevention and Control Nurse can analyse the data and support teams and individuals who are not compliant.
  • Bare below the elbows and hand hygiene will be challenged by all colleagues.
  • We will pilot the use of patients auditing compliance with hand hygiene.