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

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<strong>WHO</strong> GUIDELINES ON HAND HYGIENE IN HEALTH CARE Some examples of the local adaptation of the strategy are the local production of posters, brochures, training films, badges and gadgets, organization of focus groups on glove use, use of the fingerprint method for educational purposes, and the involvement of patients and visitors in hand hygiene promotion. 21.5.2.2 Comments on specific elements of the <strong>WHO</strong> Strategy System change. System change was considered a very important component of the <strong>WHO</strong> Strategy (median score 7, range 4-7). As far as handwashing was concerned, in some cases where major infrastructure deficiencies were present (e.g. lack of sinks and paper towels), these could not be completely overcome, mainly due to lack of resources. Forty-six CTS adopted locally-produced <strong>WHO</strong>-recommended handrub formulations produced either at the hospital pharmacy or in a centralized facility. In the sites where handrub was already in use, the system was strengthened through the increase in the number of dispensers and the use of different types of dispensers. Reported long-term obstacles to system change included staff subconsciously resistant to using handrub (mainly for self-protection reasons), leakage problem with liquid solutions, rumours about handrubs causing skin cancer, and allergic reactions. Education. This component was considered of major importance for the success of the campaign and the <strong>WHO</strong> tools were widely used with the addition of local data in most cases. HCWs who had previously received less education expressed the most interest. In many cases, traditional educational sessions with slide-shows were used, but other methods such as interactive sessions and practical sessions on hand hygiene technique were also adopted. The “My five moments for hand hygiene” concept was perceived as the key winning message of the Strategy and the visual impact of the educational tools and the training film were highly appreciated. Feedback was noted as being very important to raise awareness and to acknowledge the results achieved. The method used most frequently was a slide presentation during educational sessions; in some cases, immediate compliance feedback and a written report were given to staff and the hospital directorate. In some facilities, the reaction of HCWs to reported low rates of compliance was not positive; in others, when data were disseminated to other units, they generated much interest to take part in the implementation. The other <strong>WHO</strong> tools for evaluation (structure, perception and knowledge surveys) were used in some sites. Although their usefulness to gather a more comprehensive understanding of hand hygiene practices was acknowledged, it was also pointed out that it was too time-consuming to perform the surveys, some questionnaires are too long, and some questions are difficult to understand. In some sites, a combined knowledge/ perception questionnaire was developed locally. Reminders in the workplace. <strong>WHO</strong> posters were used in all sites and adapted locally in some cases. They were also useful for patients and visitors and led to spontaneous patient participation. Perishability was one concern and, in some sites, posters were plasticized to overcome this problem. The median score attributed to the importance of reminders was 6 (range 3-7;) median scores attributed to the <strong>WHO</strong> posters were as follows: “5 Moments”, 7 (range 6-7); “How to Handrub”, 6 (range 5-7); and “How to Handwash”, 6 (range 5-7). Patient safety climate. Some coordinators pointed out that the implementation of the hand hygiene campaign acted as a trigger to introduce other patient safety topics. Support from top managers and the directorate varied from strong practical support to more moral and verbal support among the different sites. No active patient participation was reported. The median score attributed to the importance of the promotion of a safety culture was 6 (range 2-7); scores attributed to the usefulness of the tools to secure managerial support were: information sheets, 5 (range 3-7); advocacy sheet, 4 (range 2-6); and senior managers’ letter template, 5 (range 2-7). Major obstacles were the limited time availability of HCWs beyond the work shifts and the reluctance of doctors to attend training sessions. The median score attributed to the importance of education was 7 (range 5-7). Scores given to the usefulness of the different <strong>WHO</strong> educational tools were as follows: training film, 7 (range 5-7); slide presentation, 6 (range 5-7); hand hygiene brochure, 7 (range 5-7); pocket leaflet, 7 (range 5-7); and the 9 recommendations leaflet, 7 (range 5-7). Observation and feedback. All sites adopted the <strong>WHO</strong> observation method and found it relatively easy to apply due to the precise instructions included in the Manual for Observers. The median score attributed to both the importance of observation and feedback and the usefulness of the Manual for Observers was 7 (ranges 4-7 and 1-7, respectively). Observers were mainly infection control nurses. Nevertheless, difficulties were experienced for their validation and the time availability for this task, particularly when limited manpower was available. 110
PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE Table I.21.1 Basic requirements for implementation Multimodal strategy 1A. System change: alcohol-based handrub 1B. System change: access to safe continuous water supply and towels Minimum criteria for implementation Bottles of alcohol-based handrub positioned at the point of care in each ward, or given to staff One sink to at least every 10 beds Soap and fresh towels available at every sink 2. Training and education All staff involved in the test phase receive training during Step 3 A programme to update training over the short-, medium- and long-term is established 3. Observation and feedback Two periods of observational monitoring are undertaken during Steps 2 and 4 4. Reminders in the workplace “How to” and “5 Moments” posters are displayed in all test wards (e.g. patients’ rooms; staff areas; out-patient/ambulatory departments) 5. Institutional safety climate The chief executive, chief medical officer/medical superintendent and chief nurse all make a visible commitment to support hand hygiene improvement during Step 3 (e.g. announcements and/or formal letters to staff) Table I.21.2 Type of tools* available to implement the <strong>WHO</strong> Multimodal Hand Hygiene Improvement Strategy Type of tool Informational/technical Educational Promotional (marketing/reminder tools) Evaluation and monitoring Tool <strong>WHO</strong> <strong>Guidelines</strong> on Hand Hygiene in Health Care A summary of the <strong>Guidelines</strong> The Global Patient Safety Challenge document Information sheets <strong>WHO</strong>-recommended hand antisepsis formulation – guide to local production Alcohol-based handrub production planning and costing tool Slide presentation on HCAI and hand hygiene for HCWs and observers Training films Pocket leaflet Hand hygiene brochure Manual for observers How to handrub poster How to handwash poster “My Five Moments” poster Clean hands poster Clean environment poster Clean practices poster Clean products poster Clean equipment poster Sample letter to chief nurses/senior medical staff Facility situation analysis Country situation analysis Senior executive manager perception survey HCW perception survey Ward structure survey Soap and handrub consumption survey Hand hygiene observation survey HCW knowledge survey How to use Epi-Info Baseline and follow-up data summary report framework Alcohol-based handrub tolerability and acceptability survey * Most tools are freely available at: http://www.who.int/gpsc/en/ 111
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