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

<strong>WHO</strong> GUIDELINES ON HAND HYGIENE IN HEALTH CARE
consists generally of a list of recommendations on appropriate
patient-care practices. In the education programme, instead
of covering all the recommendations in a similar fashion for all
categories of HCWs, a better strategy is to focus on patientcare
practices that require adaptations, particularly those
that would meet resistance from HCWs. The review scheme
seeks to anticipate the educational needs so that the infection
control team can plan accordingly. This might highlight some
of the recommendations that are deemed to be critically
important for success or, on the other hand, choose to exclude
recommendations that are not relevant for the institution. The
document should provide specific information such as the
actual person to contact for queries and the precise location
of the supply of hand antisepsis products. A final draft of the
guideline will often require endorsement for implementation
from the management of the institution or from the infection
control committee. Importantly, institutional experts need to be
knowledgeable about evidence-based information regarding
hand hygiene.
2. Categorize all recommendations into the four types of
practice described below in Section 19.1.1. This task should
be performed with the help of a panel of experienced HCWs in
the institution. It is recommended that a senior infection control
professional in the hospital conducts the initial review. 837 Other
senior nurses in the institution should also be coopted for this
exercise. Using this scheme, studies have shown that front-line
senior nurses in the hospital are accurate in predicting actual
practices on the wards. A survey comparing their predictions
with practices reported on the wards showed a significant
correlation. 837
(a) work with the institution to provide the necessary
resources for non-established practices detailed in the
recommendations (lack of resources). The infection control
team must ensure that these resources are actually
available for the wards when the guideline is introduced.
(b) identify reasons for HCW resistance to non-established
practice (HCW resistance). The easiest method will be
to convene a focus group consisting of HCWs from the
relevant wards. Discussions can be followed, if necessary,
by a simple survey of the key issues identified by the
focus group. It is also worth while to gather information on
the determinants of good adherence to hand hygiene so
that these points can be emphasized in the educational
programme. A good example of such research is reported
by Sax and colleagues. 732
3. Measure baseline rates before the introduction of the new
guideline. The infection rate may be included, but by itself it may
be difficult to document improvement because large numbers
are usually needed. Other structural, process or outcome
indicators may be measured, and it is also pragmatic to obtain
the compliance rate or evidence of behavioural change. This
involves assessing the level of several key practices before
introduction of the guideline, e.g. observations for hand hygiene
compliance rates before and after patient contact, or the
amount of antisepsis product used in the institution.
4. Formulate and execute an educational programme focusing
on the resistance factors of non-established practice (HCW
resistance). Presenting a standardized technique for hand
hygiene such as the “five moments” will be an advantage. 1
Many techniques 788,839 for persuasion, such as the use of
opinion leaders 758 and participatory decision-making have been
described, and successful application in the health-care facility
context has been reported. 788,839 The use of these persuasion
interventions could be time-consuming and should be reserved
only for programmes requiring attitude change, i.e. the nonestablished
practice (HCW resistance) recommendations.
19.1.1 Categorization of recommendations in the guidelines
in order to identify educational needs
(i)
(ii)
Established practice. A policy for the practice is already
present in the institution or is already standard practice.
An example is the washing of hands that are visibly dirty
or contaminated with proteinaceous material, or are
visibly soiled with blood or other body fluids. Even without
an official guideline for hand hygiene, many health-care
facilities will usually already have such a practice in place.
Non-established practice (easy implementation). It is
expected that HCWs would agree with the rationale
of the recommendation and also that resources for
implementation, if needed, are already in place. Therefore,
the practice should be easily implemented by the usual
educational programme of in-service lectures or posters.
An example is hand antisepsis before inserting peripheral
vascular catheters or other invasive devices, as most
HCWs will not object to such a reasonable practice. Azjen
& Fishbein have shown that, under such circumstances,
the desired behaviour will often follow the intent. 840 Studies
have shown that where there is agreement for a patientcare
practice, a standard educational programme of
lectures or posters will be effective. 793
(iii) Non-established practice (difficult implementation: lack
of resources). For this category, it is anticipated that
implementation would be difficult mainly because of the
lack of resources. An example is the need to provide a
sufficient supply of alcohol-based handrub for use in
areas of high workload and high-intensity patient care so
that it is available at the entrance to the patient’s room or
at the bedside and other convenient locations. A list of
such resources should be compiled for the new guideline,
and the infection control team must ensure that these
materials are in place before launching the implementation
programme.
(iv) Non-established practice (difficult implementation: HCW
resistance). Implementation is difficult in this category
because HCW resistance is expected to be high. An
example is the recommendation for hand antisepsis after
glove removal as many HCWs may consider their hands to
be clean, having been protected by the wearing of gloves.
The successful implementation of the new guideline usually
hinges on this category of non-established practices (HCW
resistance). Disagreement from HCWs is anticipated, and a
programme of persuasion is needed to institute the required
change. It will be worth while for the infection control
team to understand the reasons for resistance, and both
quantitative and qualitative studies may be required to elicit
these factors. Special studies or surveys may be carried
out on the various barriers to hand hygiene that have been
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