Patient Safety Solutions | volume 1, solution 9 | …

1 WHO Collaborating Centre for Patient Safety Solutions Aide Memoire Improved hand hygiene to Prevent Health Care-Associated Infections Patient Safety Solutions | volume 1, solution 9 | May 2007. Statement of the Problem and Impact: It is estimated that at any one time, more than million Published research suggests that multimodal, multidisciplinary people worldwide are suffering from infections acquired in strategies that focus on system change (11,14,18,20 25), offer hospitals (1,2). Health care-associated infections (HAI) oc- the greatest chance of success in terms of hand hygiene im- cur worldwide and affect both developed and developing provement and infection reduction.

2 Countries. In developed countries, between 5% and 10% of The objective of any hand hygiene solution is therefore to patients acquire one or more infections and 15% 40% of pa- build or strengthen capacity so that hand hygiene improve- tients admitted to critical care are thought to be affected (3). ment is seen as and becomes an integrated component of a In resource-poor settings, rates of infection can exceed 20% broader HAI prevention strategy. (4), but available data are scanty and more research is urgently needed to assess the burden of disease in developing and tran- sitional countries. Suggested Actions: The following strategies should be considered by WHO.

3 In the United States of America (USA), one in every 136 pa- Member States. tients becomes severely ill as a result of acquiring an infection in hospital (5). This is equivalent to 2 million cases per year, 1. Promote hand hygiene adherence as a health care facility incurring additional costs of US$ billion and about 90 priority; this requires leadership and administrative sup- 000 deaths. In England, 100 000 cases of HAI are estimated port and financial resources. to cost the NHS a minimum of 1 billion per year (6) with 2. Adopt at country, region, and facility levels the nine rec- more than 5000 attributable deaths annually (7). In Mexico, ommendations of the WHO Guidelines on hand hygiene the estimate is 450 000 infections, causing 35 deaths per 100.

4 In Health Care (Advanced Draft), in particular the im- 000 neonatal admissions, with a fatality rate of between 4%. plementation of multidisciplinary, multimodal hand hy- and 56% (8). giene improvement strategies within health care facilities that incorporate: Background and Issues: a. Provision of readily accessible alcohol-based handrubs There is substantial evidence that hand antisepsis reduces the at the point of Patient care . incidence of HAI (9 24). hand hygiene is therefore a funda- b. Access to a safe continuous water supply at all taps/. mental action for ensuring Patient Safety , which should oc- faucets and the necessary facilities to perform hand cur in a timely and effective manner in the process of care.

5 hygiene . However, unacceptably low compliance with hand hygiene is c. Education of health-care workers on correct hand universal in health care (25). This contributes to the transmis- hygiene techniques. sion of microbes capable of causing avoidable HAIs. Better d. Display of promotional hand hygiene reminders in adherence to hand hygiene guidelines and policies has been the workplace. shown to reduce the spread of HAI (26 32). The key targets for e. Measurement of hand hygiene compliance action are not only health-care workers but also policy-makers through observational monitoring and feed- and organizational leaders and managers (33).

6 Back of performance to health-care workers. 3. Where alcohol-based handrubs are not avail- Opportunities for Patient and able or are too costly, consider local production of handrubs using the formula described in the Family Involvement: WHO Recommended Hand Antisepsis Formulation: Raise the awareness of patients and their families/visitors Guide to Local Production. of the risks to health when lapses in timely and appropri- Definition: Point of care - refers to a hand hygiene product ( alcohol- ate hand hygiene occur. based handrub) which is easily accessible to staff by being as close as pos- sible (as resources permit) to where Patient contact is taking place.

7 Produce information for patients and their families that Point of care products should be within an arms reach of care/treatment highlights the importance of better hand hygiene . delivery. This enables staff to quickly and easily fulfil the five moments for hand hygiene Encourage staff to clean their hands in the presence of which have been developed from the WHO Guidelines on hand hygiene the Patient prior to touching the Patient , invite patients in Health Care (Advanced Draft) ( ). The product must be capable of being used at the required moment, with- to ask staff if they have cleaned their hands prior to treat- out leaving the zone of activity.

8 Ment, if culturally appropriate. Point of care is usually achieved through staff-carried handrubs (pocket bot- tles) or handrubs fixed to the patients bed or bedside table (or around this Educate patients on correct hand hygiene technique and area). Handrubs affixed to trolleys or placed on a dressing or medicine tray indications to ensure they are aware of the correct mo- which are then taken into the zone of activity also fulfil this definition. ments for hand hygiene . Looking forward: Strength of Evidence: 1. Consider measuring the financial and economic as- Based on experimental, clinical, and epidemiological pects of health care associated infections to assist in studies, theoretical rationale, and a consensus of experts.

9 Demonstrating their impacts. 2. Inform and educate patients about the impor- Potential Barriers to tance of hand hygiene and their role in supporting improvements. Implementation: Barriers exist on a number of levels from national political commitment through to the individual health-care worker. Applicability: Implementation is also influenced by levels of resources, All healthcare facilities, where Patient care and/or general approaches to quality, and perception. The poten- treatment is provided. tial barriers are outlined in the Table 1: Table 1 Potential Barriers to Implementation Political Institutional/managerial Individual/behavioural Costs of infrastructure Competing health priorities Costs of alcohol-based handrub Failure to convince managers and Financial leaders of (micro-) economic benefits No financial incentive to modify Failure to develop a business case Inability to manufacture alcohol- performance (continuous education).

10 To demonstrate (macro-) economic based handrub benefits Staffing shortages Facility design Lack of commitment Lack of health-care worker buy-in Lack of commitment Existing culture not supportive Campaigns are not at right target Quality Failure to convince managers and Lack of infrastructure leaders of health benefits Lack of Patient participation No commitment to education Time for staff training and empowerment (pre-service and in-service) Lack of time for compliance monitoring Existing culture is not supportive Lack of institutional leaders buy-in Lack of awareness of the burden Lack of awareness of the issues Perception of disease Perception that hand hygiene is no Existing organizational culture longer a problem not supportive Perception that hand hygiene is no Low belief in the value of hand longer a problem hygiene in terms of impacting on Patient outcome Risks for Unintended 13.