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

<strong>WHO</strong> GUIDELINES ON HAND HYGIENE IN HEALTH CARE
to be consistent with <strong>WHO</strong> requirements for the final
concentrations of the ingredients. Following the reception
of these results, the test of acceptability and tolerability of
these products among HCWs was carried out according to
the <strong>WHO</strong> method. The best tolerated and most appreciated
product was selected and distributed in wall dispensers at
the point of care.
Hand hygiene observations were conducted monthly and
during the baseline period. KSMC overall hand hygiene
compliance was 56%. Feedback of results of the surveys
conducted during the baseline period, in particular hand
hygiene compliance, was given to all decision-makers on 19
May 2008.
Great emphasis was placed on education at this pilot site.
From September 2007 to October 2008, the members of
the hand hygiene committee managed to lead 56 sessions
during which 998 HCWs were trained in the concepts
promoted by the First Global Patient Safety Challenge, in
particular, “My five moments for hand hygiene”. In addition,
a weekly training session was scheduled every Sunday
and attendance was a contract requirement for new staff
and for staff renewing their contracts. In 2008, 1297 HCWs
participated in these sessions. Much effort was dedicated
to producing a large range of new posters on hand hygiene
with more visual impact and adapted to the local culture.
These were distributed in large quantities across all wards.
Monthly observations during the implementation period
(from May to September 2008) documented an increase
of the average compliance rate to 75%, with specific
departments reaching rates as high as 88.8%.
Pakistan, Institute of Medical Sciences (PIMS)
Three ICUs – medical (9 beds), surgical (14 beds), and neonatal
(17 beds) – were selected for pilot testing the <strong>WHO</strong> Hand
Hygiene Improvement Strategy at PIMS, a tertiary referral
hospital with 1055 beds. Alcohol-based handrubs have been
in use at PIMS since the emergency situation following the
2005 earthquake. In keeping with the <strong>WHO</strong> project, the <strong>WHO</strong>recommended
formulation based on isopropanol was produced
at PIMS where it replaced the alcohol-based handrub previously
purchased from a commercial source at a much higher price
(US$ 3.00 per 500 ml vs US$ 1.85 per 500 ml).
Baseline structure evaluation pointed out no relevant deficiency
related to handwashing: sink-to-patient ratio was about 1:3,
and clean, running water was regularly available. In contrast,
alcohol-based handrubs were available (intermittently) in only
one of the three ICUs. A high level of awareness of the impact of
HCAI and of the importance of hand hygiene was demonstrated
by the 123 HCWs responding to the perception survey. It is
widely reported that most HCWs believe that compliance in their
hospital is higher than 50%. At PIMS, among 755 observed
opportunities, the overall hand hygiene compliance at baseline
was 34.7% with no significant differences between the major
professional categories. Compliance was highest with Moment
1, before touching a patient (60.0% by nurses and 55.5%
by doctors), and there was a remarkable difference in the
compliance with Moment 4, after touching a patient, between
nurses (48.8%) and doctors (22.9%).
On 11 August 2008, a training workshop on hand hygiene was
held at PIMS to train the trainers and key individuals involved in
the project, and the implementation phase was launched. All
staff members of the pilot ICUs were subsequently trained and
the <strong>WHO</strong> hand hygiene posters were made available in Urdu
to overcome language barriers. An interesting specificity of the
promotion campaign at PIMS was that training was not limited
only to regular staff, but was simplified also and offered to the
so-called “janitors”, illiterate support employees who are in
charge of clinical and human waste disposal and the emptying
of urinary bags. The adaptation of educational messages to
their level of knowledge was a very challenging task.
The <strong>WHO</strong> project implementation in ICUs had an overall,
positive impact at PIMS because an infection control doctor
and three full-time infection control nurses were appointed, and
an infection control committee was established. For the first
time, proper surveillance of HCAI was also established in the
Neonatal ICU using <strong>WHO</strong> tools. As a result of this project, HCAI
has now become a high priority as a part of quality and patient
safety agenda of the hospital. In addition, given the substantial
cost savings and the potential availability of additional funds, it
is planned that the production of the <strong>WHO</strong> formulation will be
expanded for distribution to other wards and departments. In
addition, the previous health secretary at the federal ministry of
health has expressed an interest to train 100 000 health visitors
throughout Pakistan and distribute alcohol-based handrub
to them. It is also anticipated that by the end of the project,
the <strong>WHO</strong> representative and the federal ministry of health will
explore the feasibility of the production of the <strong>WHO</strong> formulation
on a national scale using public/private partnership.
<strong>WHO</strong> Western Pacific Region (WPR)
China, Hong Kong Special Administrative Region (SAR):
four pilot hospitals
The implementation of the <strong>WHO</strong> Hand Hygiene Improvement
Strategy started in Hong Kong SAR in 2006, a few months after
the pledge signature in October 2005. Four pilot hospitals with
20 study wards in total have progressively enrolled since April
2006. Enrolled wards were surgery, internal medicine, adult
ICUs, orthopaedics, and geriatrics. Each hospital selected a
coordinator and a team of infection control professionals to
carry out the project. Aspects specific to the study design for
Hong Kong SAR pilot hospitals included that each test ward
be associated with a control ward of the same type, and the
conduct of a long-term follow-up of hand hygiene compliance
measurement.
During the preparation phase, much energy was devoted to
setting up the local production of the <strong>WHO</strong> formulations in the
perspective of ensuring cost–effectiveness and large-scale
production. Production was put out to tender, and the company
proposing the lowest price (including the purchase of plastic
fixed dispensers and pocket bottles) was selected. The quality
of the final products was ascertained at Geneva’s University
Hospitals (see Part I, Section 12.2). The <strong>WHO</strong> tolerability
and acceptability survey (double-blind, randomized, crossover
design) was carried out, and 65% of HCWs indicated a
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