Hand hygiene.pdf

18.2 DEVELOPING A STRATEGY FOR GUIDELINE IMPLEMENTATION
Most guidelines, including these, contain a relatively large number of recommendations
which vary in their degree of supporting evidence and importance in preventing infection.
Moreover, some recommendations focus on interrupting the transmission of pathogens from
patient to patient, while others focus on preventing contamination of intravenous catheters
and other devices with the patient’s own microbial flora. Because of the complexity and
scope of these recommendations, prioritization is critical to achieve rapid improvement.
These strategic priorities should guide education and guideline implementation.
The first step is to choose the specific recommendations that are most likely to result in
fundamental change if practised reliably (in other words, performed correctly almost all the
time). Consideration should be given to the specific site and complexity of local health-care
delivery, as well as the cultural norms that are in play. These guidelines provide recommendations
on a package (so-called ‘bundle’) of interventions that are most likely to have
the largest impact on preventing infection in a wide variety of health-care delivery settings.
These recommendations balance formal evidence with consensus regarding each specific
intervention.
The second step is to perform an assessment (see also Part III, Section 1) to determine
whether these practices are indeed being performed. This assessment need not be exhaustive.
Sampling strategies should be employed. For example, was hand hygiene practised
after the next 10 patient contacts in the dispensary or ward when monitored one day a
week over a one-month period? What percentage of bedsides had a filled, operative alcohol
dispenser present at 07:00 on one day, 12:00 on another day, and 18:00 on a third? For each
recommended high-priority intervention, determine whether:
• the practice is being performed rarely, or not at all;
• the practice is being performed, but not reliably (for example, hand hygiene is
performed on leaving a patient’s bedside less than 90% of the time);
• the practice is well established and is performed reliably (for example, at least
90% of the time).
Clearly, if a practice is being performed reliably, it is not necessary to have a major education
campaign or quality improvement intervention. Simple continuing education and
reinforcement, along with monitoring to ensure that performance has not deteriorated,
should suffice. For practices that are not being performed at all, or should be performed
more reliably, consider the following factors in deciding how to prioritize and focus education
and improvement work:
• Do we agree and can we convince others that the practice really is important and
is supported by sufficient evidence or consensus?
• Is implementation likely to be easy and timely (for example, will HCWs resist, are
there key opinion leaders who will object, will a long period of culture change
be required, etc.)?
• Do we have the resources to implement the practice now, and if not, are we likely
to obtain the resources (for example, a reliable supply of alcohol at a price we
can afford)?
• Is change within our own power, and if not, what would be required to be successful
(for example, will success require a change in policy by the government,
or the development of a reliable, high-quality source for required materials)?
If possible, try to implement the high priority practices as a bundle, emphasizing that the
greatest impact can be expected if ALL of the practices are performed reliably. Experience