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

<strong>WHO</strong> GUIDELINES ON HAND HYGIENE IN HEALTH CARE
This has provided a discussion forum exclusively for CTSs and
an opportunity for mutual support and exchange during the
implementation process.
Pilot testing has been completed in most sites and results have
been made available. Similarly, a process of evaluation has been
undertaken in some CTSs (Section 21.5.2). Data and lessons
learnt from testing have been of paramount importance to revise
the content of the present <strong>Guidelines</strong> and to confirm the validity
of the final recommendations. Furthermore, when appropriate,
they enabled modification and improvement of the suite of
implementation tools.
Sections 21.5.1 and 21.5.2 briefly summarize the experience
and lessons learnt from the official pilot sites and a number
of CTSs. In Section 21.5.1, the specificities of each pilot site
regarding implementation and impact and sustainability at
local and national/regional levels have been highlighted in brief
paragraphs and the lessons are summarized in Table I.21.5.2. A
detailed and exhaustive report will be published separately after
a careful scrutiny of all data and information available. Specific
information about critical aspects of the local production of
alcohol-based handrubs is detailed in Section 12.2.
21.5.1 Implementation in pilot sites
<strong>WHO</strong> African Region (AFR)
Mali - Hôpital du Point G
Hôpital du Point G, an acute-care, 456-bed university
health-care facility serving the population of Bamako and its
surroundings and being a referral hospital for the entire country,
was selected as the pilot site representing the African region. No
infection control expertise was available before the enrolment.
A pharmacist underwent training in infection control and learnt
how to produce the <strong>WHO</strong> formulation I at the University of
Geneva Hospitals and became the project co-ordinator.
The preparation phase was very intensive, in order to set
up the conditions for implementation. A committee was
established to advise on action plan and take decisions; the
hospital directorate showed strong leadership in the promotion
and support to the project kick off. Nine units (two surgical,
gynaecology and obstetrics, urology, nephrology, infectious
diseases, internal medicine, and accident and emergency)
representing 13 wards and 224 HCW were selected for pilot
testing. The <strong>WHO</strong> strategy was faithfully implemented fulfilling all
steps, starting from December 2006. The <strong>WHO</strong>-recommended
formulation based on ethanol, produced locally from sugar
cane and included in the hospital budget, was manufactured at
the hospital pharmacy and bottled in 100 ml pocket bottles; a
cleaning/recycling process was put in place. At very low cost,
3700 bottles were produced and quality control tests confirmed
accordance with the optimal quality parameters in all samples
(see also Part I, Section 12.2).
The baseline infrastructure survey identified severe deficiencies
in hand hygiene facilities and products. Although clean water
was permanently available, only a minority of patient rooms
was equipped with sinks (sink:bed ratio equal to 1:22) and no
soap and towel were available. This partly explains the very
low overall level of hand hygiene compliance (8.0%) among
1932 observed opportunities at baseline. Compliance markedly
differed among professional categories, ranging from an
average of 3.2% for nursing assistants to 20.3% for doctors and
an average of 4.4% for nurses. Compliance also varied among
medical specialities, with the lowest level observed in intensive
care (2.4%). The level of HCWs knowledge was also very
low, with limited understanding of the pathogen transmission
dynamics, of the concept of colonization and of the infection
risk. Interestingly, according to the baseline perception surveys,
the level awareness of the epidemiologic importance of HCAI
and of its impact was higher among senior managers than
among HCWs.
Implementation of hand hygiene promotion was launched on 2
November 2007 in an official ceremony chaired by the Minister
of Health, the <strong>WHO</strong> representative in Mali and the hospital
director, and involving all HCWs. During the event, chairs and
HCWs were invited to sign a giant bottle of alcohol-based
handrub as a symbol of their commitment, and information
leaflets and T-shirts with the project logo were distributed.
During the following months, visual posters featuring the
<strong>WHO</strong> project, hand hygiene indications and the technique for
handwashing and handrubbing were displayed in study wards.
Following the launch, five three-hour education sessions using
<strong>WHO</strong> materials and including feedback of baseline survey
results were organised for all study ward HCWs. All participants
were given a 100 ml individual pocket bottle of alcohol-based
handrub and trained to use it in practice. From this time on,
alcohol-based handrub has been regularly distributed by the
pharmacy to the study ward head nurses upon return of the
empty bottles.
Interestingly, the improvement of critical deficiencies in
infrastructure for handwashing was not considered by the
hospital directorate as a top priority for improving practices
because of resource and cultural issues. Firstly, improving
sink:bed ratio is associated with economic constraints at
UHPG. Secondly, HCWs consider that sinks in patient rooms
are for patient use and are therefore usually reluctant to use
them. Thirdly, in patient rooms, soap bars would very likely be
taken by patients and/or visitors and to install wall-mounted
liquid soap dispensers would be too expensive.
At follow-up evaluation (six months after implementation kick off)
hand hygiene compliance increased to 21.8% and handrubbing
became the quasi-exclusive hand hygiene technique (93.3%).
Improvement was observed among all professional categories
and medical specialties, especially as far as indications “after
body fluid exposure risk” and “after touching a patient” are
concerned. Knowledge scores the following educational
sessions increased significantly (p