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

<strong>WHO</strong> GUIDELINES ON HAND HYGIENE IN HEALTH CARE
doctors and nurses, were trained to follow the <strong>Guidelines</strong> with
refresher courses every fortnight. Some perception difficulties
emerged in the use of the <strong>WHO</strong> educational concepts and tools
(see Table I.21.5.2) and a simplified “two moments” approach
was adopted. Evaluation of the implementation impact with the
use of the <strong>WHO</strong> surveys has been undertaken (Step 4) and data
are under analysis.
The project has led to very beneficial actions beyond hand
hygiene improvement both at CMCH and at national level. The
CMCH infection control committee is well established and
meets regularly every month – or more often if necessary – and
plans to expand the <strong>WHO</strong> strategy to the entire hospital. It is
in the process of developing an antibiotic utilization policy, to
conduct a prevalence study, and has already pilot infection
registers on wards. An audit on surgical procedures is planned
to investigate the appropriateness of surgical instruments
reprocessing and of surgical hand preparation.
The Joint Secretary Hospital of the Ministry of Health and
Family Welfare (MOHFW) visited CMCH during implementation
of the pilot and has called for a national roll-out of the pilot
project without delay. The MOHFW thus expressed its strong
commitment to strengthen infection control across the country,
in particular by ensuring that each hospital has a functioning
infection control team and propoer access to handwashing
facilities by installing one washbasin per 10 beds in all hospitals.
Alcohol-based handrub will be procured on a national scale and
its use promoted as the gold standard for hand hygiene of nonsoiled
hands. The proposed timeframe is for roll-out during the
financial year 2008–2009 with consolidation during 2009–2010,
and a specific budget has already been allocated that includes
the strengthening of human resources. The <strong>WHO</strong> country office
will support the MOHFW in the adaptation and updating of
guidelines and norms required for the success of the initiative.
<strong>WHO</strong> European Region (EUR)
Italy: network of 41 ICUs
In November 2006, the Italian ministry of health decided to join
the “Clean Care is Safer Care” initiative by launching a national
campaign organized by a national coordinating centre for HCAIs
(Agenzia Sanitaria e Sociale Regionale Emilia-Romagna) and
funded by the National Centre for Disease Control (Centro
Nazionale per la Prevenzione e il Controllo delle Malattie, CCM).
Participation in the campaign was proposed to all of the 21
Italian regions and public hospitals. Overall, 190 hospitals from
16 regions joined the campaign, accounting for 315 hospital
wards, mostly ICUs and surgical and medical units. The entire
range of tools included in the <strong>WHO</strong> Pilot Implementation
Package was translated into Italian and the printed material
distributed. One national and four regional training courses for
coordinators and observers were organized; the <strong>WHO</strong> strategy
and action plan were entirely adopted (see Part I, Section 21). 886
A web platform was created on the CCM web site for tool
downloading, technical questions, and interactive discussion
among the sites. One hundred sixty one hospitals reported their
findings and experience to the national coordination centre and
sent the databases of all surveys included in the <strong>WHO</strong> strategy.
Preliminary analysis of hand hygiene observations related to 66
953 opportunities detected at baseline in 172 hospitals indicate
that overall compliance was 43% and that, in 71% of hand
hygiene actions, handwashing was the technique used.
Given the high level of data collection accuracy and adherence
to the <strong>WHO</strong> strategy in the Italian campaign, a network of
participating ICUs was selected to become the pilot site
for EUR according to pre-established criteria (Table I.21.1).
Forty-one ICUs from eight regions were eligible, and most
of them implemented hand hygiene promotion between
October 2007 and January 2008 and conducted baseline and
follow-up evaluations during 3–6 months before and after the
implementation. Thirty ICUs sent the complete set of baseline
and follow-up data of all <strong>WHO</strong> surveys.
Observations related to 9 828 and 9 302 opportunities were
carried out at baseline and follow-up, respectively, with an equal
distribution of professional categories and types of indication.
Overall, a significant improvement in hand hygiene compliance
(from 55% to 69%) was detected following implementation of
the hand hygiene strategy. Comparing baseline with followup,
use of handrubs to perform hand hygiene increased from
36.9% to 60.4% of hand hygiene actions. This is reflected in
the structure surveys results from 30 ICUs which indicate that
permanent availability of alcohol-based handrubs improved
from 70% to 100% and that pocket bottles were available to
each HCW in 92% of cases at follow-up (vs 52% at baseline).
Improvement was more striking among nurses and nursing
students (compliance increased from 58% to 73% and from
52% to 69%, respectively); compliance increased from 48%
to 59% among medical doctors and from 56% to 69% among
auxiliary nurses. A comparison of the knowledge questionnaire
results at baseline and follow-up (1238 vs 802 respondents,
respectively) identified areas that need further improvement,
e.g. the understanding of the dynamics of microrganism
transmission and the role of different sources of infection. In
contrast, there was an interesting, positive correlation between
the increase of hand hygiene compliance before patient contact
(from 49% to 65%) and before an aseptic/clean task (53% to
70%) and the improvement of knowledge at follow-up when
answering questions related to these two indications.
According to the perception questionnaire (1116 vs 902
respondents at baseline and follow-up, respectively), the
percentage of HCWs who underwent training on hand hygiene
increased from 39.7% to 86.6%, respectively. Most respondents
attributed the highest scores (6 and 7 of a 7-point Likert scale)
to every component of the <strong>WHO</strong> strategy when asked about
the importance of the strategy components in determining their
hand hygiene performance improvement.
Working group discussions with 24 pilot ICU coordinators
using the CTS evaluation interview template (see Part I,
Section 21.5.2) provided very interesting information on the
implementation strategy feasibility and invaluable suggestions
for improvement (Table I.21.5.2). The discussion was very
instructive, particularly to identify actions for securing the
sustainability of the hand hygiene promotion programme. In
most pilot hospitals, staff working on the wards not involved
in the pilot testing requested hand hygiene promotion to be
extended to their settings. The campaign is becoming hospitalwide
in many institutions and additional health-care facilities
have spontaneously joined the national campaign.
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