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

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<strong>WHO</strong> GUIDELINES ON HAND HYGIENE IN HEALTH CARE 3. Historical perspective The First Global Patient Safety Challenge of the <strong>WHO</strong> World Alliance for Patient Safety (www.who.int/ gpsc) entitled “Clean Care is Safer Care” has followed a classic approach to health improvement. It calls for a concerted global effort to effect policy and intervention strategies to enhance patient safety through implementation of a simple, low-cost health improvement (improved compliance with hand hygiene in health care) to contribute to the prevention of HCAI. Achievement of its aims has required action on a country-bycountry basis, and has involved lobbying for national political action on hand hygiene improvement. This section positions hand hygiene improvement in health care as one component of an infection control/quality and safety health improvement programme. National health improvement programmes are historically associated with numerous benefits, including the avoidance of fragmentation, cost inefficiency, and duplication of effort. 1062 Hand hygiene improvement in health care has not been seen conventionally as a public health issue, though it does concern a health issue of significance to a subset of the population, i.e. those receiving treatment in a health-care setting. With in excess of 700 million people hospitalized annually, and an overall prevalence of HCAI ranging from around 5% in the developed world up to 20% in some developing countries, the burden of associated disease is significant. 479,835 Thus, there is an argument for the application of public health strategies to change HCW behaviour to impact positively on the health of patients. Historically, public health behaviour change campaigns have focused on persuasion as a major tool. 1063 Until recently, national hand hygiene improvement programmes in health-care settings were not widely reported. With the emergence of the <strong>WHO</strong> First Global Patient Safety Challenge and its three-pronged approach of gaining political commitment, raising awareness, and offering technical support to further the improvement agenda, national campaigning has come to prominence as one inspirational component of a comprehensive infection control strategy. Ministers of health signing a statement of commitment to address HCAI as part of this Patient Safety Challenge agree specifically to “developing or enhancing ongoing campaigns at national or sub-national levels to promote and improve hand hygiene among health-care providers”. The Millennium Development Goals (MDGs), agreed to by all countries worldwide and all leading development institutions, offer a blueprint for improvement. The goals have galvanized remarkable efforts to meet the needs of the world’s poorest populations. 1064 The MDGs are time-bound, have political support, and are ambitious in their scope. These are common features of successful health improvement campaigns. 176
PART IV. TOWARDS A GENERAL MODEL OF CAMPAIGNING FOR BETTER HAND HYGIENE – A NATIONAL APPROACH TO HAND HYGIENE IMPROVEMENT 4. Public campaigning, <strong>WHO</strong>, and the mass media Public campaigning is central to a number of <strong>WHO</strong> programmes. In The World Health Report 2002, 1065 <strong>WHO</strong> reported on a series of comprehensive approaches that have been implemented at the national level to reduce specific risks in health care, taking into account a variety of interventions including the dissemination of information to the public, mainly through media outreach. The use of mass media within public health campaigns forms one component of broader health promotion programmes and can be useful in wide-scale behaviour change. 1061,1066,1067 As many international and national health campaigns have demonstrated, the media play a key role in mobilizing public support, influencing behavioural change, and setting the local political agenda. A 2001 Cochrane review 1068 showed that the use of the mass media was a way of presenting information about important health issues, targeted by those who aim to influence the behaviour of health professionals and patients. The review concluded that the mass media should be considered as one of the tools that may influence the use of healthcare interventions. Their usefulness in changing knowledge, awareness and attitudes makes mass media campaigning a potentially significant component of attempts to impact on hand hygiene behaviour change strategies, since hand hygiene compliance is predicated upon knowledge, attitudes, and beliefs of HCWs. Mass media campaigns are usually designed to generate a specific outcome in a relatively large number of individuals within a specific period of time and through an organized set of communication activities. 1066 With the growth in telecommunications, television and the Internet are increasingly used as channels for promoting behaviour change 1069 and could play a role in hand hygiene-related mass media campaigns, particularly if they target national and local opinion leaders. 4.1 National campaigns within health care National health improvement programmes are designed to mobilize action at local levels to implement accepted methods to change behaviour and improve health care. Such programmes rely on carefully constructed improvement and spread methodologies, with the prominent model of the PDSA cycle 1070 incorporating quality improvement principles as a central component. As one approach to health improvement, there is a considerable body of evidence to support the positive impact of campaigning on health-related behaviours, 1071,1072 although campaigns are not without their critics. 1066,1073 The Institute for Healthcare Improvement (IHI) in the USA turned to the campaign approach at a national, regional, and facility level to achieve a goal of transformational improvements in health care, using learning from electoral politics to reach a large number of health-care facilities across the country. 1074 In describing the subsequent IHI 100 000 Lives Campaign (Table IV.9.1), Berwick and colleagues 1075 outline a need to create a sense of urgency and pace. This campaign, one of the largest attempts to mobilize health care to focus on issues of quality and safety, holds much relevance when considering hand hygiene improvement in health care. A feature of conventional campaigns, reflected in the IHI approach, is their association with a focused and time-bound effort. 1063 The IHI campaign was constructed around specific targets and deadlines; it also won support from national professional organizations, creating what they describe as a powerful national infrastructure to drive change and transform health-care quality. IHI identified the target (described as conceptually simple interventions) and the deadline and provided tools and resources for implementation. Berwick and colleagues 1075 emphasize, however, that the ultimate results rest with the participating hospitals to reliably introduce the interventions and engage boards, executives, frontline clinicians, patients, and families. National-level campaigns to improve antibiotic use in Europe and the USA have been reported in the literature. 1076 Such campaigns have targeted the population level and employed techniques of mass media distribution. Similar to hand hygiene improvement campaigns in health care, antibiotic campaigns are multifaceted and are concerned with cost–effectiveness. According to Goossens and colleagues, only two countries in Europe have undertaken and evaluated national antibioticuse campaigns and reported demonstrable success. 1076 The USA has seen a dramatic reduction in the use of antibiotics by paediatricians. 1077 In conclusion, these authors call for a wider use of the campaign approach and the incorporation of social marketing, together with cultural adaptation and population targeting. Campaigns are likely to be more successful when they are accompanied by concomitant structural changes that provide the opportunity structure for the target audience to act on the recommended message. 1063 These authors also suggest that accompanying campaigns with reinforcing “legislation and regulation” can influence the campaign impact and sustainability. An illustration of the impact of legislation and regulation can be seen in England and Wales where the national cleanyourhands campaign (Table IV.9.1) received considerable leverage with a parallel national target to reduce MRSA rates by 50%. 1078 177
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