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

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<strong>WHO</strong> GUIDELINES ON HAND HYGIENE IN HEALTH CARE <strong>Guidelines</strong> for hand hygiene prepared by various other agencies, both prior to and after the publication of the Advanced Draft of these guidelines, are currently available. An analysis of recommendations in guidelines produced by 16 countries was published in 2001. 635 However, several guidelines included in the analysis were not formal publications agreed upon nationally or sub-nationally, and the level of details provided could be expanded more extensively. This section examines the scope, approaches, and recommendations of some national and sub-national guidelines. Different strategies were used to identify available guidelines. These included using search engines such as Google and electronic resources such as PubMed and the Guideline International Network. Keywords used in the search were “hand hygiene”, “hand washing”, “handwashing”, “hand rubbing”, “handrubbing”, “hand decontamination” and “guidelines” in various combinations. Requests for hand hygiene guidelines were also made to members of the <strong>WHO</strong> First Global Patient Safety Challenge core group of experts, national representatives of the European Union hospital infection network (Hospital in Europe Link for Infection Control through Surveillance) and <strong>WHO</strong> regional offices. Twenty-one guidelines were obtained for comparison. These included 15 national guidelines from Australia, 1146 Belgium, 1147 Canada, 1148 Egypt, 1149 England, 1150 France, 1151 Germany, 1152 Ireland, 1153 Nepal, 1154 the Russian Federation, 1155 the Netherlands, 1156 Tunisia, 1157 Scotland, 1158 Sweden, 1159 and the USA, 58 and six sub-national guidelines from Ontario 1160 and Manitoba 1161 (Canada), and Liverpool, 1162 Southampton, 1163 Mid Cheshire, 1164 and Bassetlaw 1165 NHS Trusts (England). The documents were analysed using a methodology adapted from the European HARMONY (Harmonisation of Antibiotic Resistance measurement, Methods of typing Organisms and ways of using these and other tools to increase the effectiveness of Nosocomical infection control) project approach, 1166 a tool developed originally to evaluate antibiotic policies in different hospitals and since used in several other infection controlrelated projects. 1167 The main aspects considered by this method were: information about the guideline’s title, year of publication, endorsing body, and mode of publication; aspects related to the guideline development process (e.g. national vs sub-national, developers, target population, and methods for evidence evaluation and recommendation development); type of recommendations, details about indications and technique, and products recommended for hand hygiene; and recommended strategies for hand hygiene improvement and guideline implementation. Eighteen of the 21 guidelines were available through web sites, 14 of which were in English. These documents were developed either by professional societies involved in infection prevention and in the control of antimicrobial resistance or by governmental agencies such as the ministry of health. In some cases, recommendations on hand hygiene were part of much longer infection control or antimicrobial resistance control guidelines. In the latter documents, details on important issues related to hand hygiene were generally insufficient or the information was made available in different parts of the document or allied publications, thus making difficult the analyses. The documents varied in their scope, approach to the topic, and content. Some were primarily intended as advisory directives, 58,1146,1150,1152,1153,1159 while the primary focus of others were the technical issues of why, when and how to perform hand hygiene. 1149,1154,1157,1162-1165 Developers of the advisory type of documents focused mainly on evidence-gathering and making general recommendations applicable to different settings and areas. The latter group of documents focused more on specific issues related to implementation such as technical details, popularizing practices, and logistics; they referred to documents in the advisory group for their evidence base. Some documents belonging to the advisory group mentioned and referred to companion materials, such as training guides and other national guidelines, for some details. Several documents contained a long detailed text in addition to the evidence for recommendations. The extent to which evidence was collected and assessed varied considerably. Only three guidelines described clearly the method used for collecting or selecting evidence. Seven national and two sub-national guidelines graded the evidence for recommendations. 58,1148,1150-1153,1159,1160,1162 However, they used different grading systems and definitions to indicate the strength of evidence and recommendations. The strength and quality of evidence was determined based on expert consensus in three documents. 1148,1152,1159 The evidence grading was performed using the methods adopted by the National Institute for Health and Clinical Excellence (NICE) from the Scottish Intercollegiate Guideline Network (SIGN) for the EPIC (Evidencebased Practice in Infection Control) 2 guidelines. 1150 Published guidelines used as references were assessed using the AGREE (Appraisal of <strong>Guidelines</strong>’ Research and Evaluation) instrument in one document. 1150 Table VI.1 shows some of the major aspects of the evidencegrading systems used in different documents. There were additional differences in the individual statements. For example, the CDC Category 1A is “strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies” and that of France Category 1 is “strongly supported by well-designed studies and do not pose economical or technical problems”. In EPIC 2 guidelines, evidence grades 1 and 2 were further classified into three (e.g. 1, 1 + , and 1 ++ ). In general, there were three to five grades of evidence and recommendations. The quantum of evidence and details of data from studies presented varied considerably. This probably reflects differences in the rigour in evidence-gathering and assessment. The recommendations formulated were based on expert consensus for most documents. The validation process was not clear for most guidelines. Seven described internal or external peer reviews and public consultations as the methods of validation. The guideline documents appeared to be still evolving. Several guidelines stated that they need to be revised periodically based on new evidence and some are currently being revised, e.g. the French and Belgian guidelines (personal communication). 200
PART VI. COMPARISON OF NATIONAL AND SUB-NATIONAL GUIDELINES FOR HAND HYGIENE Based on the original CDC evidence document, a “How-to Guide” was made by the same agencies a few years later. 1168 Four guidelines, 1148,1160-1162 one revised guideline, 1150 and the IHI “How-to Guide” document 1168 were published after the publication of the Advanced Draft of these <strong>WHO</strong> <strong>Guidelines</strong> (October 2005 onwards), although, interestingly, only three of these six documents referred to the <strong>WHO</strong> publication. 1158,1160,1168 HCWs were the main target population in all guidelines. Since all were national and sub-national documents, policy-makers (local authorities, institutional authorities, etc.) were also possible intended users, but this was specified only in nine documents. 58,1146,1150,1153,1158,1160-1162,1164 The intended settings were also not exactly specified in most documents. Seven documents mentioned health care in community settings in addition to hospitals. 1146,1158,1160-1162,1164,1165 As far as it is possible to understand, the others are intended to be used primarily for care in hospital settings. Although not clearly specified in many documents, most of the recommendations relate to inpatient care. Most documents stated that the intended outcome was to produce improvement in hand hygiene so as to contribute to the reduction in pathogen transmission and ultimately HCAIs and/or antimicrobial resistance. However, audit and measurable indicators were mentioned in only nine of them. 58,1148,1150,1151,1153, 1158,1160,1162,1164 Administrative approaches for implementation, such as the emphasis on the binding nature of the document, varied. Fourteen documents recommended the implementation of the guidelines as a priority, 58,1146,1147,1150,1151,1153,1157,1158,1160-1165 and eight stressed adherence to the guideline as a requirement. 1151,1158,1160-1165 All sub-national guidelines make this statement. Although the general concepts concerning indications and methods to perform hand hygiene practices were similar in essence in all documents, the terminology used to describe various issues differed considerably between documents, thus making exact comparisons difficult. For example, terms such as decontamination and antisepsis were used synonymously in different documents. Several documents included a list of definitions, but the number of terms for which an explanation was provided and even its details varied. Definition of terms used to classify situations where hand hygiene practices were indicated also differed between documents. For example, in some cases, “social” indications meant contacts other than patient care (between HCWs, casual social contact between patient and HCWs, etc.). In some others, the same word was used to include all situations where plain soap and water was recommended as the method, including visible soiling with blood and body fluids. Others did not classify indications, but merely provided lists. In the present evaluation, three types of indications for hand hygiene were considered: social (contacts different from patient care), patient care, and surgical hand preparation. According to this classification, most guidelines appeared to have focused on the latter two types of indication. Five guidelines, three national and two subnational, 1148,1150,1156,1161,1162 were developed primarily for routine patient care and had only social and routine patient-care indications. Although indications and methods for hand hygiene were the focus for several national and all sub-national guidelines, the level of detail described varied considerably between documents. In general, the sub-national guidelines tended to have more technical details with easier to understand illustrations than the national documents, which were more advisory in nature. In some documents, the approach was to describe the methods according to indications (for example, “before” and “after” indications and then the appropriate methods) and, in others, the indications for a given method (e.g. all indications requiring handrubbing) of hand hygiene. Most guidelines advocated hand hygiene for a variety of, but similar, “before” and “after” indications. Some documents advised that the decision for hand hygiene and choice of methods be based on risk assessment by the HCW. 1162,1165 Many guidelines also had “umbrella” indications that could include many different situations for hand hygiene. These meant that it was up to the HCW to decide whether hand hygiene was required or not for individual situations. The indications which were listed were meant to be examples and not to fulfil a complete list, at least in some. There were also differences in wording between documents which led to differences in situations included under one stated indication. Overall, there is an overlap between stated indications from different documents. An analysis of what was stated in the documents was performed (Table VI.2). Among the indications “before” an activity for routine patient care, performing invasive procedures was the most mentioned. Among indications for hand hygiene “after” procedures during routine patient care, visible soiling of hands, and contact with blood, body fluids, wounds, catheter sites or drainage sites were the most frequently mentioned. A few documents listed situations where hand decontamination was not required. 1147-1149,1151,1156 The situations included were before nursing care or the physical examination of nonimmunocompromised patients, before and after short or social contact with non-immunocompromised patients, and after contact with surfaces not suspected of being contaminated. Handwashing was the standard for routine patient care in seven documents, 1146,1148,1149,1155 ,1157 ,1164 ,1165 and alcohol-based handrub in seven others. 58,1150-1152,1156,1159,1160 Either handwashing or handrubbing were recommended in seven. 1147,1153,1154,1158,1161-1163 Most guidelines, especially sub-national, provided details of the procedures for hand hygiene and the analyses of their content in this regard are presented in Table VI.3. Handwashing was recommended in all documents for soiled hands. Handwashing with medicated soap was recommended as an alternative. Several strategies were considered for promotion and implementation of the guidelines. Here again, details were more developed in the sub-national guidelines. In most cases, strategies recommended for implementation and sustainability were based on multiple elements. Ongoing education of HCWs, making materials required for hand hygiene easily available and accessible, monitoring performance, and attention to the skin care of HCWs were stressed to be the most important aspects: at least nine documents had some reference to all of these four issues. 58,1148,1150,1151,1153,1158,1160,1162,1164 One document had only a general discussion on various issues impacting on 201
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