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do not even reflect current thinking about rigorous reliability, in which the entire system either performs correctly or does not. For example, defect-free care of a central venous catheter would require perfect hand hygiene, maximal barrier precautions, optimal skin preparation, and aseptic care of connections in the administration system. Failure at any one of these steps means “no credit”. Clearly, current defect rates in the hand hygiene system are no longer tolerable. Even in a setting with severely constrained resources, basic hand hygiene can and should be performed very reliably. Although health-care providers – particularly managers in relatively complex organizations – will find it valuable to understand and apply Donabedian’s quality paradigm, hazard analysis critical control point, failure mode and effects analysis, and reliability theory, it should be relatively easy for health-care providers in virtually every setting to start evaluating, improving and monitoring the reliability of the hand hygiene infrastructure and practice immediately. Table III.2.1 provides a variety of structure and process quality indicators that are derived directly from these WHO guidelines. Health-care providers and multidisciplinary teams (in collaboration with quality improvement and infection control experts where available) may want to begin by considering some of these indicators. The emphasis is on structure and process because the ultimate outcomes – reduced infection and antibiotic resistance rates – are likely to be linked closely with improvements in structure and process, are more time-consuming to measure, and may not be immediately discernible. Many indicators in Table III.2.1 are relatively easy to measure and provide real-time feedback to caregivers and managers. For example, at the most basic level: are user-friendly, clear policies in place, and are these accessible to HCWs in the workplace? Are the design of the work space and the placement of sinks and other hand hygiene equipment and supplies conducive to compliance? Are appropriate education programmes available to all HCWs, including trainees and rotating personnel, and is continuing education provided on a regular basis? What is the actual attendance at these programmes, and is it mandated? During what percentage of shifts are nurse staffing ratios adequate? It is particularly important to verify the competency of all HCWs in performing hand hygiene procedures – a critical certification step that is applied all too rarely, especially to doctors. In addition, do surveys demonstrate that providers understand the indications for hand hygiene and important facts about hand hygiene products and performance? Are they motivated, and do they have a strong sense of self-efficacy? How do they view the unit or department’s social norms regarding hand hygiene? Can they identify an opinion leader in their unit or department who takes the lead in education and the promotion of hand hygiene? Quick, real-time checks of the health-care environment can be extremely useful for monitoring barriers to compliance. Are the alcohol dispensers conveniently placed near every bed space (or are they hiding behind the ventilator)? What percentage of the antiseptic or alcohol dispensers are full? Operational? It should be recalled that the most rigorous reliability standards will require that 100% of bed spaces have conveniently located, operational alcohol dispensers that are never empty. Are hand lotions always available to HCWs and conveniently placed? Random audits of actual practice are indispensable (see Part III, Section 1.1). While hand hygiene practice can be considered a process of care, when it is not performed appropriately it can also be viewed as an important intermediate step in the chain leading to the colonization and infection of patients. Moreover, audit and feedback of compliance data is a major component of any multifaceted behaviour change programme. Simple graphics of compliance rates (or, alternatively, defect rates) should be prominently displayed where they
can be seen during routine work. Data should be incorporated into HCW’s education and fed back in real time. The ultimate customer, or course, is the patient. Patients and their families can be given a “tip sheet” to help them understand their role as partners in patient safety. They should be encouraged to point out lapses in hand hygiene technique without fear of retribution. Surveys can help HCWs determine if patient perceptions match their own view of their performance. 3. COST–EFFECTIVENESS OF HAND HYGIENE To date, no formal prospective studies have been conducted to establish the cost–effectiveness of hand hygiene in health-care settings. In general, cost–effectiveness has been estimated by comparing the costs of hand hygiene promotion programmes versus the potential cost savings from preventing HCAIs. However, a recent report has reviewed all economic studies relating to the overall impact of alcohol-based hand hygiene products in health care 703 and concluded that, while further research is required to measure the direct impact of improved hand hygiene on infection rates, the potential benefit of providing alcohol-based handrubs is likely to outweigh costs and their wide-scale promotion should continue. The report also recommended that those planning local improvements should note that multimodal interventions are more likely to be effective and sustainable than single-component interventions, and although these are more resource-intensive, they have a greater potential to be cost effective. The costs of hand hygiene promotion programmes include the costs of hand hygiene products plus the costs associated with HCW time and the educational and promotional materials required by the programme. The costs of products needed for handwashing include soap, water and materials used for drying hands (e.g. towels), while the costs of hand antisepsis using an alcohol-based handrub include the cost of the handrub product plus dispensers and pocket-sized bottles, if made available. In general, non-antimicrobial soaps are often less expensive than antimicrobial soaps. In health-care settings, mainly in resource-poor countries, basic handwashing equipment such as sinks and running water is often not available or of limited quality. In calculating costs for hand hygiene, these substantial construction costs need also to be taken into account. In addition, overhead costs for used water and maintenance need to be added to the calculation. The cost per litre of commercially prepared alcohol-based handrubs varies considerably, depending on the formulation, the vendor and the dispensing system. Products purchased in 1.0–1.2 litre bags for use in wall-mounted dispensers are the least expensive; pump bottles and small pocket-sized bottles are more expensive; and foam products that come in pressurized cans are the most expensive. Presumably, a locally produced solution composed of only ethanol or isopropanol plus 1% or 2% glycerol would be less expensive than commercially produced formulations but may not meet quality control standards achieved by most manufacturers. Boyce estimated that a 450-bed community teaching hospital spent US$ 22 000 (US$ 0.72 per patient-day) on 2% chlorhexidine-containing preparations, plain soap, and an alcohol hand rinse 362 . When hand hygiene supplies for clinics and non-patient care areas were included, the total annual budget for soaps and hand antiseptic agents was US$ 30 000 (about US$ 1 per patient-day).
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The WHO Guidelines on Hand Hygiene
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CONTENTS INTRODUCTION . ...........
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17. Organizing an education program
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INTRODUCTION The WHO Advanced Draft
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Handwashing. Washing hands with pla
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still considered the standard of ca
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treatment selectively removes glyce
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of the organism on their hands. Mak
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6. MODELS OF HAND TRANSMISSION 6.1
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In the 1960s, a prospective, contro
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for its ability to reduce the relea
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8.2 SHORTCOMINGS OF TRADITIONAL TES
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tions of short-chain aliphatic alco
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9.1.3 WATER QUALITY The physical, c
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Case study: experience of Egypt The
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and both reduced viral counts on ha
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activity of chlorhexidine is not se
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protein synthesis and alteration of
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in micelle structures formed by sur
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In all the studies that included pl
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isopropyl alcohol) were applied to
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3) Glycerol is added using a measur
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in 2005 the costs of an alcohol-bas
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infection, risk factors that are la
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11.4.4 SIDE-EFFECTS OF THE SURGICAL
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• Repeat the process on the other
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12.2 ALLERGIC CONTACT DERMATITIS RE
Page 60 and 61: particularly when resources are lim
Page 62 and 63: Handrubs are available as gels, sol
Page 64 and 65: 14. HAND HYGIENE PRACTICES AMONG HE
Page 66 and 67: quantified in observational studies
Page 68 and 69: According to behavioural theories (
Page 70 and 71: of water with special leaves) outsi
Page 72 and 73: Furthermore, according to Phra Depv
Page 74 and 75: 16. BEHAVIOURAL CONSIDERATIONS 16.1
Page 76 and 77: and community factors must be consi
Page 78 and 79: i. ii. iii. iv. v. vi. a) b) Educat
Page 80 and 81: tion precautions 580 . There are al
Page 82 and 83: follow the intent 588 . Studies hav
Page 84 and 85: 18. FORMULATING STRATEGIES FOR HAND
Page 86 and 87: 18.2 DEVELOPING A STRATEGY FOR GUID
Page 88 and 89: 1998 (P
Page 90 and 91: HCWs routinely to wear vinyl gloves
Page 92 and 93: quality gloves, reuse, shortage of
Page 94 and 95: • To test for holes, gloves shoul
Page 96 and 97: Figure l.20.2: Blood safety: crucia
Page 98 and 99: Consensus recommendations are that
Page 100 and 101: D. Wash hands with either plain or
Page 102 and 103: 5. SKIN CARE A. B. C. Include infor
Page 107 and 108: PART III. OUTCOME MEASUREMENTS 1. M
Page 109: 2. HAND HYGIENE AS A QUALITY INDICA
Page 113 and 114: Case study: United Kingdom national
Page 115 and 116: PART IV. PROMOTING HAND HYGIENE ON
Page 117 and 118: ated to reinforce its principles (t
Page 119: 6. PRINCIPLES OF COUNTRYWIDE HAND H
Page 122 and 123: As many international and national
Page 124: debate that resulted in increasing
Page 128 and 129: 23. Lee YL et al. Colonization by S
Page 130 and 131: Interscience Conference on Antimicr
Page 132 and 133: 122. Vicca AF. Nursing staff worklo
Page 134 and 135: 171. Kauppinen J et al. Hospital wa
Page 136 and 137: 224. Krilov LR et al. Inactivation
Page 138 and 139: 276. Thomas L et al. Development of
Page 140 and 141: 326. Johnson S et al. Prospective,
Page 142 and 143: 34th Interscience Conference on Ant
Page 144 and 145: 423. Kampf G, et al. Influence of a
Page 146 and 147: 474. West DP et al. Evaluation of a
Page 148 and 149: 524. Muto C et al. Hand hygiene rat
Page 150 and 151: 578. Babcock HM et al. An education
Page 152 and 153: Interscience Conference on Antimicr
Page 154 and 155: 679. Hirschmann H et al. The influe
Page 156: 729. Martin LS, McDougal JS, Loskos
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Table I.8.1: Basic experimental des
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Table I.9.1: Waterborne pathogens a
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Table I.9.3: Virucidal activity of
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Table I.9.4: Studies comparing the
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Table I.9.6: Studies comparing the
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Table I.14.1: Hand hygiene frequenc
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Table I.14.2: Hand hygiene adherenc
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Table I.15.1: Hand hygiene indicati
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Table I.18.1: Strategies for succes
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Table l.20.1: Possible problems and
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Table I.21.1. Hand hygiene research
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Table I.21.1: Hand hygiene research
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Table I.21.2: Unsolved issues for r
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Table III.2.1: Quality indicators r
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Table V.3.1: Examples of public inf
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Table V.4.1: Examples of national p
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Table V.5.1: The public information
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APPENDIX 1. DEFINITIONS OF HEALTH-C
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APPENDIX 2. HAND AND SKIN SELF-ASSE
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Data in coloured cells can be chang
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NHS NICU n-P NPSA NA NS OPD PACU PA
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AUTHORS: John Boyce Saint Raphael H
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Garance Upham People’s Health Mov
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