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

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<strong>WHO</strong> GUIDELINES ON HAND HYGIENE IN HEALTH CARE 22. Impact of improved hand hygiene Evaluation of the effectiveness of hand hygiene guidelines or recommendations on the ultimate outcome, i.e. the HCAI rate, is certainly the most accurate way to measure the impact of improved hand hygiene, but it represents a very challenging activity. Indeed, guideline implementation should not be evaluated per se but in relation to the availability of clear instructions on how to translate it into practice and, ideally, the existence of related tools and impact of their implementation. As an illustration, in a sample of 40 hospitals in the USA, Larson and colleagues found that although most HCWs were aware of the hand hygiene guidelines with alcohol-based handrub available in all facilities, a multidisciplinary implementation programme was conducted in only 44.2% of the hospitals. 728 The impact was quite disappointing: mean hand hygiene compliance rates were no higher than 56.6%, and the correlation of lower infection rates with higher compliance was demonstrated only for bloodstream infections. The authors concluded that a real change following guideline dissemination is not achievable unless fostered by factual multidisciplinary efforts and explicit administrative support. Difficulties to deal with this challengig issue depend firstly on the diversity of methodologies used in available studies, and this is well reflected in the very different conclusions that can be drawn from systematic reviews on the topic. 887,888 The lack of scientific information on the definitive impact of improved hand hygiene compliance on HCAI rates has been reported as a possible barrier to appropriate adherence with hand hygiene recommendations. However, there is convincing evidence that improved hand hygiene through multimodal implementation strategies can reduce infection rates. In addition, although not reporting infection rates, several studies showed a sustained decrease of the incidence of multidrug-resistant bacterial isolates and patient colonization following the implementation of hand hygiene improvement strategies. 428,655,687,701 Failure to perform appropriate hand hygiene is considered the leading cause of HCAI and spread of multi-resistant organisms, and has been recognized as a significant contributor to outbreaks. At least 20 hospital-based studies of the impact of hand hygiene on the risk of HCAI have been published between 1977 and June 2008 (Table I.22.1). 60,61,121,181,182,195,196,489,494,645,657,659,663,667,713- 718,852 Despite study limitations, most reports showed a temporal relation between improved hand hygiene practices and reduced infection and cross-transmission rates. Maki 195 found that HCAI rates were lower when antiseptic handwash was used by HCWs. Doebbeling and colleagues 659 compared hand antisepsis using a chlorhexidine-containing detergent to a combination regimen that permitted either handwashing with plain soap or use of an alcohol-based handrub. HCAI rates were lower when the chlorhexidinecontaining product was in use. However, because relatively little of the alcohol rub was used during periods when the combination regimen was in operation and because adherence to policies was higher when chlorhexidine was available, it was difficult to determine whether the lower infection rates were attributable to the hand hygiene regimen used or to the differences in HCW compliance with policies. A study by Larson and colleagues 713 found that the frequency of VRE infections, but not MRSA, decreased as adherence of HCWs to recommended handwashing measures improved. This strategy yielded sustained improvements in hand hygiene practices. The intervention lasted eight months, and a followup survey six months after the end of the intervention showed a sustained improvement in hand hygiene practices. More recently, several studies demonstrated a clear impact of improved hand hygiene on MRSA rates. 489,494,718 In a district hospital in the United Kingdom, the incidence of hospitalacquired MRSA cases significantly decreased after a successful hand hygiene promotion programme. 489 Similarly, in Australia, a hospitalwide, multifaceted programme to change hand hygiene culture and practices led to a 57% reduction of MRSA bacteraemia episodes as well as a significant reduction of the overall number of clinical isolates of MRSA and ESBL-producing E. coli and Klebsiella spp. 494 The programme was subsequently expanded to another six health-care institutions and then to the entire state of Victoria. After 24 months and 12 months of follow-up, respectively, MRSA bacteraemia and the number of MRSA clinical isolates significantly decreased both in the 6 pilot hospital and statewide (see Table I.22.1). 719 In another study, the intervention consisted of the hospitalwide introduction of an alcohol-based gel and MRSA surveillance feedback through charts. 718 Significant reductions of MRSA bacteraemia and MRSA central line-associated bacteraemia were observed hospitalwide and in the ICU, respectively, with a follow-up of 36 months. In this study, however, it is difficult to define the actual role of hand hygiene to reduce MRSA bacteraemia, because charts were a strong component of the intervention and, at the same time general infection control measures were intensified and the use of antibiotic-coated central venous catheters was initiated in the ICU. In 2000, a landmark study by Pittet and colleagues 60 demonstrated that implementing a multidisciplinary programme to promote increased use of an alcohol-based handrub led to increased compliance of HCWs with recommended hand hygiene practices and a reduced prevalence of HCAI. Individual bottles of handrub solution were distributed in large numbers to all wards, and custom-made holders were mounted on all beds to facilitate access to hand antisepsis. HCWs were also encouraged to carry a bottle in their pocket. The promotional strategy was multimodal and involved a multidisciplinary team of HCWs, the use of wall posters, the promotion of bedside handrubs throughout the institution, and regular performance feedback to all HCWs (see http://www.hopisafe.ch for further details on methodology). HCAI rates, attack rates of MRSA 124
PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE cross-transmission, and consumption of handrub were measured in parallel. Adherence to recommended hand hygiene practices improved progressively from 48% in 1994 to 66% in 1997 (P
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