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

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<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 108
PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE preference for one of the two <strong>WHO</strong> alcohol-based handrub formulations in use, although some considered it to have an unpleasant odour. All 41 Hong Kong SAR public hospitals are currently purchasing the <strong>WHO</strong> formulations from the selected local company at the price of US$ 0.50 for the 100 ml bottle and US$ 1.60 for the 500 ml dispenser. Compliance at baseline (April–October 2006) was 20.7% and 22.2% in study and control wards, respectively. Such low rates are surprising in Hong Kong SAR, when considering the major achievements with hand hygiene compliance only a few years previously at the time of the severe acute respiratory syndrome (SARS) outbreak. Implementation in the test wards of the Hong Kong SAR pilot hospitals involved original aspects of adaptation of the <strong>WHO</strong> strategy and tools. Education was carried out by presentations targeted to the different professional categories. Different scenarios simulating real care situations were presented to staff, and solutions and explanations were given. All possible efforts were made to enhance HCWs access to alcohol-based handrubs by increasing the number of dispensers at the point of care in test wards, distributing the new products in pocket bottles as well with special belts and clip holders, and making powder-free gloves available in test wards. A question and answer (Q&A) leaflet was prepared, responding to all HCWs’ concerns about the use of alcohol-based handrubs (e.g. skin damage, fire safety, bottle contamination), and topics were discussed with HCWs according to the needs. Feedback about hand hygiene performance was given to HCWs individually and immediately after observation. A competition was announced to identify the best slogan to promote “Clean Care is Safer Care” in Chinese. To boost implementation, emphasis was placed on role modelling after the first and the second follow-up periods. Three periods of follow-up observations were carried out every 3-4 months. In the first period (October 2006–March 2007), overall compliance rates were 56.6% and 18.3% in the test and control wards, respectively. In test wards, compliance improved in all professional categories apart from doctors (15.5% compliance at baseline) who showed no improvement and a significantly lower compliance at all follow-up measurements (mean 23.4%). Between July 2007 and January 2008, the hand hygiene campaign was announced hospitalwide in all pilot hospitals, with an official launch ceremony. All the abovementioned actions were extended to all wards and no longer limited to test wards only. After the hospitalwide roll-out, compliance rates in test wards remained 52.4%, whereas it increased to 43.8% in the control wards. On 21 January 2008, following the success of the <strong>WHO</strong> strategy implementation in the pilot hospitals, the Hospital Authority, Hong Kong SAR, launched a national campaign aiming to create an institutional safety climate and improving hand hygiene in 38 public hospitals. At that time a big banner (15 m wide and 9 m hight) was posted up outside the Hospital Authority Head Office for increasing public awareness of the importance of hand hygiene. Most of these hospitals are currently displaying a giant banner on hand hygiene at their entrance to show their participation and using the <strong>WHO</strong> Implementation Strategy, toolkit, and methodology. It is also of note that the strategy was adapted and successfully implemented in seven home-care facilities in Hong Kong SAR. 21.5.2 Lessons learnt from complementary test sites Since the start of the testing phase of the <strong>WHO</strong> Multimodal Hand Hygiene Implementation Strategy, complementary test sites (CTS) were able to access the entire range of tools included in the Pilot Implementation Pack following registration through an interactive web platform created for this purpose. Although CTS did not receive direct monitoring by the First Global Patient Safety Challenge team, a process of evaluation has been undertaken when the implementation phase reached an advanced stage. A structured framework was developed including three levels: level I, the mapping exercise; level II, quantitative evaluation; and level III, qualitative evaluation. The mapping exercise was conducted with the use of an online form and allowed to collect general information about the healthcare settings, their progress in the implementation of the <strong>WHO</strong> Strategy and which tools had been adopted or adapted. Sites at advanced/semi-advanced stages of implementation and which had used most of the <strong>WHO</strong> tools underwent evaluation levels II and III through a semi-structured telephone interview with the coordinators. The interview included both open and ranking questions (7-point Likert scale) on different components of the <strong>WHO</strong> Strategy and the Pilot Implementation Pack. The objective was to receive feedback on the drawbacks and advantages of the implementation of the strategy, feasibility of alcohol-based handrub local production, and the validity and obstacles encountered in the use of the tools. For the purpose of quantitative evaluation, the coordinators were requested to send the available data on key indicators e.g. hand hygiene compliance, alcohol-based handrub and soap consumption, as well as the results of the knowledge/perception/structure surveys. Level II evaluation is ongoing. A total of 114 complete responses were received for the level I survey and concerned both single sites and networks of healthcare settings. Forty-seven coordinators from the advanced and semi-advanced sites, representing 230 health-care settings from Egypt, France, Italy, Malta, Malaysia, Mongolia, Spain, and Viet Nam, participated in the level II and III evaluation. 21.5.2.1 Comments on the <strong>WHO</strong> Multimodal Hand Hygiene Improvement Strategy and the Guide to Implementation General comments by most coordinators on the <strong>WHO</strong> Multimodal Hand Hygiene Improvement Strategy indicate that it is comprehensive and detailed, and its action plan very helpful to guide practically the local implementation. For these reasons, it was considered to be a successful model suitable to be used also for other infection control interventions. However, there is a strong need for a summarized/simplified version. Some coordinators raised concerns about the complexity of the strategy and the Pilot Implementation Pack, especially in contexts with limited human resources, while others requested more details on implementation in poorly-resourced countries. As the main focus of the strategy is on hospitals, adaptation to other types of health-care settings was strongly suggested. The overall median score attributed to the usefulness of the Guide to Implementation to help understand the rationale behind the strategy, the step-wise approach to implementation, the objectives and application of the tools was 6 (range 4-7). The section on sustainability was considered worthy of expansion with more detail by some individuals. 109
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