4/13/2013 1

Implementation of the WHO

Multimodal Hand Hygiene

Improvement Strategy

Selamet Hidayat

Disease Surveillance and Epidemiology

WHO Jakarta

SAVE LIVES: Clean Your Hands

Outline

I. Background

II. WHO multimodal HH improvement strategy

III. The Step-Wise Implementation

IV. Summary

Background: Why Bother with Infection Control?

Healthcare-associated infections (HCAI) are the most frequent

adverse event affected hundreds of millions patients globally;

Of every 100 hospitalized patients at any given time, 7 in

developed and 10 in developing countries will acquire at least

one HCAI;

In low- and middle-income countries, the frequency of ICU-

acquired infection is at least 2-3 fold higher than in high-

income countries;

Emergence of antimicrobial-resistance microorganisms (Super

Bugs);

HCAI is leading to high mortality and billions of dollars of

financial losses.

Prevalence of HCAI in developed countries

Prevalence of HCAI in developing countries

HCAI data: Tip of the Iceberg

Reported HCAI

Unreported HCAI

Known and unknown

risk of HCAI

Undiagnosed/silent

HCAI

Hand Hygiene: Historical Perspectives

In 1847, Ignaz Semmelweis, a Hungarian

doctor physicians who went directly from

the autopsy suite to the obstetrics ward

related to the high number of puerperal fever

among parturient women.

Application chlorine solution reduced the

maternal mortality first scientific evidence;

In 1822, a French pharmacist chlorides to eradicate the

foul odors associated with human corpses and can be used

as disinfectant and antiseptics published in 1825;

Hand Hygiene: Historical Perspectives

In 1843, Oliver Wendell Holmes an American

doctor concluded independently that puerperal

fever was spread by the hands of health personnel;

In 1975 and 1985, CDC released guidelines on

hand washing. Use of waterless antiseptic agents

was recommended only in situations where sinks

were not available;

In 1988 and 1995, APIC released guidelines for

hand washing and hand antisepsis.

Hand Hygiene: Global Movement

First Global Patient Safety Challenge: Clean Care is

Safer Care was launched in 2005

– To ensure that infection control is acknowledged universally

as a solid and essential basis towards patient safety and

supports the reduction of HCAI;

– SAVE LIVES: Clean Your Hands is a

major component. It advocates “My 5

Moments for Hand Hygiene” to sustain

HH practices and help reduce HCAI.

– As of April 2012, 127 Ministers of Health

committed to reducing HCAI and to

support the work of WHO

Hand Hygiene: Global Movement

Registration:

http://www.who.int/gpsc/5may/register/en/index.html

Low compliance/achievement: Where are the problems?

WHO multimodal Hand Hygiene

Improvement Strategy

Successful and sustained hand hygiene improvement is achieved

by implementing multiple actions to tackle different obstacles and

behavioral barriers.

The key components of the strategy are:

1. System change

2. Training / Education

3. Evaluation and feedback

4. Reminders in the workplace

5. Institutional safety climate

Key Components: #1. System Change

Ensure that the necessary infrastructure is in place to allow

HCWs to practice hand hygiene. Includes two elements:

(1) access to a safe, continuous water supply, soap and towels;

(2) access to alcohol-based hand rub at the point of care;

Tools: (1) Ward Infrastructure Survey; (2) Alcohol-based Handrub

Planning and Costing Tool; (3) Guide to Local Production: WHO-

recommended Handrub Formulations; (4) Soap/Handrub

Consumption Survey; (5) Protocol for Evaluation of Tolerability and

Acceptability of Alcohol-based Handrub;

Actions:

• complete the ‘Ward Infrastructure Survey’ at regular intervals to

help identify potential deficiencies in infrastructure;

• tailored interventions based on actual findings;

• continue to secure an adequate annual budget.

Key Components: #2. Training/education

Education is a vital strategy element which integrates strongly

with other components:

• top-down approach which target different levels: trainers,

observers and HCWs;

• basic training focus on: (1) Rationale of program, (2) Clear

definitions, (3) HCAI transmission and prevention, (4) Clear HH

guideline;

Tools: presentation slides, films, HH manuals, brochures, leaflets,

FAQs, key scientific publications and observation tools;

Actions:

• avail trainers and observers, and develop training

materials;

• establish education program on HH and provide

regular training to all HCWs, including new starts.

Key Components: #3. Evaluation and feedback

- To identify areas deserving major efforts and provide

crucial information to plan for the most appropriate

interventions;

- Key indicators:

• hand hygiene compliance through direct observation;

• ward infrastructure for HH;

• health-care worker knowledge on HCAI and HH;

• health-care worker perception of HCAI and HH;

• soap and alcohol-based handrub consumption.

Tools: HH manuals, observation tools, perception surveys,

ward infrastructure survey, soap/handrub consumption

survey, HH knowledge questionnaire, data entry and analysis

tool, data summary report framework, etc;

Key Components: #3. Evaluation and feedback

Actions:

- Conduct a baseline (may include HCAI incidence or

prevalence);

- Conduct data entry and analysis by trained and skillful person

(epidemiologist/statistician);

- Provide regular feedbacks.

For health-care facilities embarking on a new HH improvement

program:

Key Components: #4. Reminders in the Workplace

Key tools to remind HCWs, patients and visitors about HH

indications and procedures;

Tools: posters, leaflets, banners, stickers, screensavers, etc;

Actions:

– consider the adaptation of reminders to

the national/local context;

– should address health-care workers,

patients and visitors;

– reminders should be used and visibly

displayed in all clinical setting;

– strategically placed and easily

accessible.

Key Components: #5. Institutional Safety Climate

Create an environment and the perceptions that facilitate

awareness-raising about patient safety and HH improvement

issues as a high priority at all levels;

Includes:

– active participation at both the institutional and individual levels;

– awareness of individual and institutional capacity to change and

improve (self-efficacy);

– partnership with patients and patient organizations.

Tools: advocacy letters, guideline on engaging patients,

guideline for sustaining/improving HH programme, promotional

videos, etc;

Key Components: #5. Institutional Safety Climate

Actions:

– establish institutional safety climate as a priority

regardless of the level of progress in hand hygiene

improvement at the facility;

– engage of decision makers, influential HCWs and

individuals;

– engage relevant external parties such as: professional

association, patients, NGOs, etc.

Minimum Criteria for Implementation

Implementing the Step-wise Approach

Step 1: Facility preparedness–readiness for action

Develop a clear, realistic, result-oriented and measurable action plan;

Convince high level senior managers and key professionals that infection

control is a crucial issue “HH (IC) is investment !” sufficient

resource allocation;

Identify the key people (agent of change) to be involved:

– co-ordinator;

– deputy co-ordinator;

– team/committee ;

– clear individual tasks and deliverables.

Average: 2 months

Implementing the Step-wise Approach

Step 2: Baseline evaluation–establish knowledge of the current

situation

Conduct the infrastructure, perception and knowledge surveys and collecting

hand hygiene observation and soap/handrub consumption data;

Conduct the tolerability and acceptability survey for the alcohol-based handrub;

Entry, analyze and disseminate findings;

Evaluate HCAI rates in the last 6 months/1 year if surveillance system is in

place or conduct a prevalence survey;

Prepare training and promotional materials and conduct Training of Trainer;

Procurement of supporting equipments and consumables.

Average: 3 months

Implementing the Step-wise Approach

Step 3: implementation

Implement plan in step1 and use the core findings from step 2 to achieve

the objectives on the 5 key components. Key activities:

Conduct promotional events to gain support and commitment (demand);

Avail alcohol-based handrub or sinks with soap and clean towel at point of care

(supply);

Display reminders at the point of care;

Distribute guidelines and organize educational sessions for HCWs;

Monitor monthly alcohol-based handrub/soap consumption;

Conduct monthly HH observation;

Organize regular meeting HH of the team/committee.

Average: 3 months

Implementing the Step-wise Approach

Step 4: Follow-up evaluation–evaluate the impact

Carry out evaluation to compare the periods pre- and post-

implementation (surveys on infrastructure, perception and knowledge,

HH observation, and soap/handrub consumption);

Conduct data entry and analysis to assure reliability;

Provide feedback on key findings to HCWs and decision makers;

The evaluation will provide information only about the immediate

impact of the programme.

Average: 2 months

Step 5: ongoing planning and review cycle-developing

a plan for the next 5 years

To review the entire cycle of implementation to develop long-term plans to

ensure sustainability;

A hand hygiene improvement strategy cannot remain static and must be

rejuvenated at set intervals.

Summary