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admissions in 1994 to 9.5 per 100 admissions in 2001. Total costs of HCAIs were estimated to be CHF 132.6 million for the entire study period. The authors concluded that the hand hygiene programme was cost-saving if less than 1% of the reduction in HCAIs observed was due to improved hand hygiene practices. An economic analysis of the United Kingdom’s “cleanyourhands” hand hygiene promotional campaign concluded that the programme would be cost beneficial if HCAI rates were decreased by as little as 0.1% 691 . The impact of the “cleanyourhands” campaign is the subject of a four-year research programme which will look at the effectiveness of the various components of the multimodal approach. Despite the fact that the above-mentioned studies strongly suggest a clear benefit of hand hygiene promotion, budget constraints are a fact, particularly in developing countries, and cost–effectiveness analysis might be used to identify the most efficient strategies. To achieve this goal, data on the incidence of HCAI and the resulting opportunity costs, as well as on the cost and effectiveness of competing infection control strategies, are required 704 . Since these variables may vary by and large according to the region and institution, local studies may be necessary to help choose best strategies 704 . Well-conducted local studies may suggest other infection control interventions of even greater cost–benefit, depending on the socioeconomic and cultural environments of the health-care system. Taking into account the many financial constraints in resource-poor countries and the considerably high cost investment required (e.g. secure water supply and sinks), the investment in programmes using alcohol-based handrubs as the primary or sole means of hand hygiene seems to be an obvious solution. It should nevertheless be taken into account that investment in the infrastructure of health-care facilities, such as secure water supply and sinks, is necessary in the long run to improve the quality of health-care delivery as a whole. This investment can show benefits other than an improvement in hand hygiene practices. 3.1 FINANCIAL STRATEGIES TO SUPPORT NATIONAL PROGRAMMES Interventions designed to improve hand hygiene across a country may require significant financial and human resources, particularly multifaceted campaigns. Costs must be balanced in terms of anticipated reduction in HCAI. The economies of scale achieved by centralized design and production of supporting materials will logically result in less cost to the overall health economy. This approach was used in the United Kingdom’s “cleanyourhands” campaign (see the box below). Countries without centralized distribution networks might not achieve sufficient economies of scale to make such an approach feasible without additional massive investment from the commercial sector.
PART IV. PROMOTING HAND HYGIENE ON A LARGE SCALE 1. COUNTRYWIDE ISSUES Countrywide or national hand hygiene improvement programmes in health-care settings have not been widely reported in the literature. However, infection control itself has emerged in recent years across the developed world as a national priority in health care 705 . The United Kingdom’s National Audit Office 705 commissioned a comparative review of international practices in the management of HCAI in developed countries, to determine whether there were international lessons that could be learnt. All of the countries reviewed (Australia, Belgium, Denmark, France, Germany, New Zealand, Spain, the Netherlands and the USA) had a national strategy in place for preventing HCAI. More recent strategies in Australia, France, New Zealand and the USA had been influenced by patient safety and risk management agendas and were linked to the accreditation of services. All of these national strategies universally promote the necessity for local systems and processes to improve hand hygiene guidelines and policies. There was, however, no reference to nationally driven programmes of improvement. There are a number of examples of national improvement programmes relating to specific aspects of HCAI prevention and/or patient safety enhancement. The recent “100 000 Lives” campaign 598 in the USA is being coordinated by the Institute for Healthcare Improvement (www.ihi.org), and health-care organizations are invited to join the campaign and commit to implementing changes associated with six interventions. The campaign is free to participating hospitals who must commit to making changes in the way in which the interventions are managed. Participants are provided with a range of tools and materials. The “Speak Up” campaign in the USA (2002), where patient pressure is engaged to encourage patients to observe whether HCWs have cleaned their hands and to remind them to do so when necessary, is sponsored by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). In the USA, research has been conducted in elementary schools across a number of states to determine the effectiveness of the introduction of hand hygiene products, including alcohol-based handrubs 706 . Large-scale programmes of this nature are described as beneficial in terms of the reduction of common community infections such as colds, but even in industrialized countries resources to implement such programmes remain an issue. JCAHO has included the risk of HCAI in its 2005 National Patient Safety Goals. Organizations are required to fulfil these goals to improve safety and quality. One of the requirements of the safety goals is that health-care organizations must comply with the current CDC hand hygiene guidelines 7 .
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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
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particularly when resources are lim
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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
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Page 96 and 97: Figure l.20.2: Blood safety: crucia
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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 and 110: 2. HAND HYGIENE AS A QUALITY INDICA
Page 111 and 112: can be seen during routine work. Da
Page 113: Case study: United Kingdom national
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
Page 161 and 162: Table I.8.1: Basic experimental des
Page 163 and 164: 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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