Implementation of the WHO Multimodal Hand Hygiene … · 2013. 4. 23. · WHO multimodal Hand Hygiene Improvement Strategy Successful and sustained hand hygiene improvement is achieved
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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
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