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

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<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
PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE of the forthcoming boostering phase of the campaign. The study successful results about the feasibility of the strategy implementation and practice improvement have motivated the Mali government to expand the production of the alcoholbasedhandrub and the dissemination of the strategy to the national level. <strong>WHO</strong> Region of the Americas (AMR)/Pan American Health Organization (PAHO) Costa Rica: Hospital Nacional de Niños (HNN) The strategy was implemented from March 2007 to September 2008 in 12 wards (290 beds) of HNN, a paediatric hospital in San José, Costa Rica. All steps of the action plan were completed and the facility is now developing a review cycle and a five-year plan to ensure sustainability. The alcohol-based handrub was produced according to the <strong>WHO</strong> recommendations by a private company, which accepted to donate the product and the dispensers. The validation of the local production of the <strong>WHO</strong>-recommended formulation took much longer than expected because of several initial failures at the quality control test level (see Part I, Section 12.2). An engineer reviewed the hospital plan to place the new dispensers at the point of care according to local safety criteria. The system change was critical to the improvement of hand hygiene practices, because alcohol-based handrubs were not previously widely available and, in some areas of the hospital, significant infrastructure deficiencies (sink to bed ratio
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