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

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
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