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follow the intent 588 . Studies have shown that where there is agreement for a patient-care practice, a standard educational programme of lectures or posters will be effective 557 . In the next category, non-established practices (no resources), the lack of resources is the limiting factor. 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. The successful implementation of the new guideline usually hinges on the last category, 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 identified in the literature. After understanding the reasons for resistance, a special behavioural change strategy might also be adopted to implement these practices 551,589 (see Part I, Sections 16 and 18). 17.3 STEPS IN GUIDELINE IMPLEMENTATION Using the scheme just described, there are seven basic steps in implementation: 1. Elaborate a final draft of the guideline for the health-care institution/centre. After obtaining various international guidelines on hand hygiene from the literature, the infection control team needs to customize the recommendations according to the requirements of its health-care facility. It 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 practices as described above, with the help of a panel of experienced HCWs in the institution. 3. Work with the institution to provide the necessary resources for the non-established practice (no resources) recommendations. The infection control team must ensure that these resources are actually available on the wards when the guideline is introduced. 4. Conduct research on reasons for resistance for the non-established practices (HCW resistance). The easiest method will be to convene a focus group consisting of HCWs from the relevant wards. This can be followed, if necessary, by a simple survey of the key issues identified by the focus group. 5. 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 usage in the institution.
6. 7. Formulate and execute an education programme focusing on the resistance factors of the non-established practices (staff resistance). Many techniques 551,589 for persuasion, such as the use of opinion leaders 556 and participatory decision-making have been described, and successful application in the health-care facility context has been reported 551,589 . The use of these persuasion interventions could be time-consuming and should be reserved only for programmes requiring attitude change, i.e. the non-established practice (HCW resistance) recommendations. Specific elements that should be considered for inclusion in educational and motivational programmes are listed in Table I.17.1. Evaluate and monitor progress. This is the last step but of no less importance. The same practices evaluated in step 5 should be re-evaluated. Even when improvement in these practices is documented, it is worth surveying HCWs for feedback on the effectiveness of the whole guideline. With this information, further improvement can be made. 17.4 THE INFECTION CONTROL LINK HEALTH-CARE WORKER Research has indicated that the effect of a formal education programme for infection control would be significantly improved when front-line ward HCWs have been recruited to participate in the education programme for the guideline 556,590 . The infection control link HCW programme is an attempt to apply this principle in practice and has been widely used to assist in the implementation of guidelines in health-care facilities. In the infection control link HCW programme, a senior member of staff would be appointed from each hospital ward from the pool of staff HCWs presently working in that clinical area. She or he would be the ward or department representative assisting the infection control team in implementing new policies in the institution. The position of the infection control link HCW is generally a voluntary assignment without monetary remuneration and the HCW is under no obligation to accept the appointment. Special training must be provided for the infection control link HCW so that she or he can be the person on the spot to enhance compliance with the guideline. The infection control link HCW could be enlisted to participate in the educational programme of the hand hygiene guideline, and could help to identify the reasons for resistance to the non-established practice (HCW resistance) recommendations. An initial educational session should be organized for the infection control link HCWs before the launch of the formal programme for the entire institution. They could then begin preparing their wards for better acceptance of the guideline. Subsequently, in the institution-wide formal educational programme, they could also be present to assist in providing comments and answering questions especially for HCWs who are from their clinical areas. Compliance with guidelines is critical for the success of the entire field of infection control, and not only for hand hygiene. Therefore, organizing an effective formal educational programme is vitally important.
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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
Page 32 and 33: 9.1.3 WATER QUALITY The physical, c
Page 34 and 35: Case study: experience of Egypt The
Page 36 and 37: and both reduced viral counts on ha
Page 38 and 39: activity of chlorhexidine is not se
Page 40 and 41: protein synthesis and alteration of
Page 42 and 43: in micelle structures formed by sur
Page 44 and 45: In all the studies that included pl
Page 46 and 47: isopropyl alcohol) were applied to
Page 48 and 49: 3) Glycerol is added using a measur
Page 50 and 51: in 2005 the costs of an alcohol-bas
Page 52 and 53: infection, risk factors that are la
Page 54 and 55: 11.4.4 SIDE-EFFECTS OF THE SURGICAL
Page 56 and 57: • Repeat the process on the other
Page 58 and 59: 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 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 and 110: 2. HAND HYGIENE AS A QUALITY INDICA
Page 111 and 112: can be seen during routine work. Da
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
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122. Vicca AF. Nursing staff worklo
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171. Kauppinen J et al. Hospital wa
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224. Krilov LR et al. Inactivation
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276. Thomas L et al. Development of
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326. Johnson S et al. Prospective,
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34th Interscience Conference on Ant
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423. Kampf G, et al. Influence of a
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474. West DP et al. Evaluation of a
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524. Muto C et al. Hand hygiene rat
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578. Babcock HM et al. An education
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Interscience Conference on Antimicr
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679. Hirschmann H et al. The influe
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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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