WHO Guidelines on Hand Hygiene in Health Care - Safe Care ...

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE
its strong visual message (Figure I.21.5b). The objective is to
represent the ever-changing situations of care into pictograms
that could serve a wide array of purposes in health-care
settings. The main visual focus depicts a single patient in the
centre to represent the point of care of any type of patient.
The patient zone, health-care area, critical sites and moments
for hand hygiene action are arranged around and on this
patient to depict the infectious risks and the corresponding
moments for hand hygiene action in time and space. This visual
representation is congruent with the point of care concept.
Some limitations can be envisaged in this model and are
discussed elsewhere. 1
21.4.2.2 Training
There are important interpersonal differences when it comes
to learning styles. Some individuals respond well to conceptual
grouping and will readily understand the risk-based construct of
zones and critical sites and the five moments for hand hygiene.
The rationale of the current concept is a strong motivator.
With these trainees, it is helpful to insist on the main reason
for each of the five moments for hand hygiene. Other people
respond better to circumstantial cues. For them, it is useful
to list the most frequent examples occurring in their specific
health-care settings. The five moments’ model also offers many
possibilities for the development of training tools, including
on-site accompanied learning kits, computer-assisted learning,
and off-site simulators. It is of importance to understand that
HCWs often execute quite sophisticated medical tasks without
conscious cognitive attention. Their behaviour is triggered
by multiple cues in the environment that are unconsciously
processed. To build hand hygiene into their automatic
behaviour for these situations, they may need training in a given
environment with multiple cues for action. “My five moments
for hand hygiene” would serve as solid basic building blocks for
such training. It is crucial to determine the delimitation of patient
zones and critical sites with local staff in their unique setting,
which has the added benefit of increasing process ownership
by the concerned staff.
21.4.2.3 Monitoring
Direct observation is the gold standard to monitor compliance
with optimal hand hygiene practice. The five moments model
can be a valuable aid to observation in several ways. Many care
activities do not follow a standard operating procedure, so it is
difficult to define the crucial moment for hand hygiene. The five
moments’ concept lays a reference grid over these activities
and minimizes the opportunities for inter- observer variation.
Once HCWs are proficient in the five moments concept and its
application, they are able to become observers with minimal
additional effort, thus reducing training costs. 1 Furthermore,
the concept solves the typical problems of clearly defining the
denominator as an opportunity and the numerator as a hand
hygiene action (see Part III, Section 1.2).
21.4.2.4 Reporting
Reporting results of hand hygiene observation to HCWs is
an essential element of multimodal strategies to improve
hand hygiene practices. 58,60 Based on the five moments, it is
possible to report risk-specific hand hygiene performance in full
agreement with training and promotional material. The impact
of feedback is thus increased, as the different moments can be
individually discussed and emphasized.
21.5 Lessons learnt from the testing of the <strong>WHO</strong>
Hand Hygiene Improvement Strategy in pilot and
complementary sites
Since 2006, the <strong>WHO</strong> Hand Hygiene Improvement Strategy
(see Part I, Sections 21.1–21.4) has been tested in a number of
health-care settings around the world to generate information
on feasibility, validity, and reliability of the interventions, to
provide local data on the resources required to carry out
the recommendations, and to obtain useful information for
the revision and adaptation of the proposed implementation
strategies. 62
Before and during implementation, the Pilot Implementation
Pack tools were translated into the six official languages of
<strong>WHO</strong> (Arabic, Chinese, English, French, Russian, and Spanish)
and also into some local languages (e.g. Armenian, Bengali,
and Urdu). Eight hospitals were selected in seven countries
(Table I.21.5.1) located in the six <strong>WHO</strong> regions (Africa, the
Americas, South-East Asia, Europe, Eastern Mediterranean,
and the Western Pacific) to participate in the pilot test phase
with technical support and careful monitoring from the First
Global Patient Safety Challenge team. Field testing has been
made also possible through the support of the <strong>WHO</strong> Regional
Patient Safety Focal Points and the <strong>WHO</strong> representatives at
country level, as well as collaboration with expert technical and
academic partners and professional associations. Diversity was
built into the selection of pilot sites to ensure comparability of
the results across the six regions, and they represented a range
of facilities in developed, transitional, and developing countries.
All sites identified a project and deputy coordinator and formed
a committee mandated to give advice and take decisions on
the project plan. The instructions included in the Guide to
Implementation and the steps proposed in the action plan were
carefully followed in all sites, and all implementation tools were
used at the suggested steps (see Part I, Sections 21.1–21.3).
Therefore, hand hygiene promotion was conducted according
to the <strong>WHO</strong> strategy, and baseline and follow-up evaluation
included the detection of hand hygiene compliance, alcoholbased
handrub consumption, perception of hand hygiene by
senior managers and HCWs, HCWs’ knowledge, and structures
related to hand hygiene.
At the same time, a wide range of different health-care settings
worldwide also requested to use the <strong>WHO</strong> Hand Hygiene
Improvement Strategy and tools. For this reason, a web-based
community forum was established where any health-care
facility could enrol in order to access all the tools included in
the Pilot Implementation Pack and to ask questions related to
implementation. In this way, any health-care facility has been
able to participate in field testing as a “complementary test site”
(CTS). For logistic and economic reasons, support offered by
the <strong>WHO</strong> to a CTS is limited and mainly web-based. Through
the web community, experiences and solutions related to the
implementation have also been shared with other test sites.
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