The WHO Multimodal Hand Hygiene Improvement Strategy

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WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care. Geneva: World Health Organization; 2009.

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WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care.

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21The WHO Multimodal Hand Hygiene Improvement Strategy

21.1. Key elements for a successful strategy

The successful implementation of guidelines into practice continues to elude health improvement efforts globally.⁸⁷⁶ The Replicating Effective Programs (REP) framework is one example of a successful approach, although largely within the context of HIV prevention interventions.⁸⁷⁷ Recent work has also focused on knowledge transfer, often incorporating learning from the body of knowledge on diffusion of innovation.⁸⁶⁹ The literature confirms that there is no magic solution to guarantee uptake and assimilation of guidelines into clinical practice.

Against this background, the WHO Guidelines on Hand Hygiene in Health Care have been developed with the ultimate objective of changing the behaviour of individual HCWs to optimize compliance with hand hygiene at the recommended moments and to improve patient safety. For this objective to be fulfilled, a successful dissemination and implementation strategy is required to ensure that practitioners are aware of the guidelines and their use.⁷²⁸^,⁸⁷⁸

Ensuring that guidelines are transformed from a static document into a living and influential tool that impacts on the target practice requires a carefully constructed strategy to maximize dissemination and diffusion.⁸⁶⁸ Fraser describes implementation as being concerned with the movement of an idea that works across a large number of people (the target population). Based on the best available scientific evidence and underpinned by both the long-standing expertise of Geneva’s University Hospitals to promote multimodal hand hygiene promotion campaigns⁶⁰ and learning from the England & Wales National Patient Safety Agency (NPSA) cleanyourhands campaign, the WHO Hand Hygiene Implementation Strategy has been constructed to provide users with a ready-to-go approach to translate the WHO Guidelines on Hand Hygiene in Health Care into practice at facility level.

The WHO Multimodal Hand Hygiene Improvement Strategy consists of a Guide to Implementation and a range of tools constructed to facilitate implementation of each component. The Guide to Implementation accompanies the WHO Guidelines on Hand Hygiene in Health Care and outlines a process for fostering hand hygiene improvement in a health-care facility. The implementation strategy has been informed by the literature on implementation science, behavioural change, spread methodology, diffusion of innovation, and impact evaluation. At its core is a multimodal strategy consisting of five components to be implemented in parallel; the implementation strategy itself is designed to be adaptable without jeopardizing its fidelity and is intended therefore for use not only in virgin sites, but also within facilities with existing action on hand hygiene. The five essential elements are: system change, including availability of alcohol-based handrub at the point of patient care and/or access to a safe, continuous water supply and soap and towels; training and education of health-care professionals; monitoring of hand hygiene practices and performance feedback; reminders in the workplace; and the creation of a hand hygiene safety culture with the participation of both individual HCWs and senior hospital managers. Depending on local resources and culture, additional actions can be added, in particular patient involvement (see Part V).

21.2. Essential steps for implementation at heath-care setting level

The Guide to Implementation details the actions and resources necessary to ensure each component of the multimodal strategy can become assimilated into existing infection control and safety programmes. The Guide is structured around five sequential steps which are recommended to reflect an action plan at facility level (Figure I.21.1). The target for this approach is a facility where a hand hygiene improvement programme has to be initiated from scratch.

Figure I.21.1

Visual representation of the 5-Step Implementation Strategy.

Step 1.: Facility preparedness – readiness for action
Step 2.: Baseline evaluation – establishing the current situation
Step 3.: Implementation – introducing the improvement activities
Step 4.: Follow-up evaluation – evaluating the implementation impact
Step 5.: Action planning and review cycle – developing a plan for the next 5 years (minimum)

Step 1 is to ensure the preparedness of the institution. This includes getting the necessary resources in place and the key leadership to head the programme, including a coordinator and his/her deputy. Proper planning must be done to map out a clear strategy for the entire programme.

Step 2 is to conduct baseline evaluation of hand hygiene practice, perception, knowledge, and infrastructure available.

Step 3 is to implement the improvement programme: availability of an alcohol-based handrub at the point of care and staff education and training are vitally important. Well-publicized events involving endorsement and/or signatures of commitment of leaders and individual HCWs will draw great dividends.

Follow-up evaluation to assess the effectiveness of the programme naturally comes next as Step 4.

Finally, Step 5 is to develop an ongoing action plan and review cycle. The overall aim is to inculcate hand hygiene as an integral part of the hospital culture. A more comprehensive outline of activity within each step is presented in Figure I.21.2.

Each step in the cycle builds on the activities and actions that occurred during the previous step, and clear roles and responsibilities are outlined within the strategy. The steps are presented in a user-friendly guidebook, designed to be a working resource for implementers and leads in infection control, safety, and quality. Throughout the five steps, activities are clearly articulated and the accompanying tools to aid implementation are clearly signposted. At the end of each step, a checklist is presented and implementers are instructed to ensure all recommended activities have been completed prior to moving to the next step. Central to the implementation strategy is an action plan, recommended to be constructed within Step 1, to guide actions throughout each subsequent step.

Rather than a linear process, the five steps are intended to be dealt with in a cyclical manner, with each cycle repeated, refined, and enhanced over a minimum 5-year period. A key feature of an implementation strategy is evaluation and this is a permanent feature of the WHO multimodal strategy during Steps 2 and 4. Implementation, evaluation, and feedback activities should be periodically rejuvenated and repeated and become part of the quality improvement actions to ensure sustainability. Following the full implementation of the strategy for the first time, the plan of activities and long-term steps should be based on lessons learnt about key success factors and on areas that need further improvement. Therefore, the choice to privilege some specific activities and/or steps might be performed.

21.2.1. Basic requirements for implementation

In situations where the complete implementation strategy is not considered feasible, perhaps because of limited resources and time, implementers can focus on minimum implementation criteria to ensure essential achievement of each component of the multimodal strategy. The eight criteria are listed in Table I.21.1.

Table I.21.1

Basic requirements for implementation.

21.3. WHO tools for implementation

The Guide to Implementation is accompanied by an Implementation Toolkit (called Pilot Implementation Pack during the testing phase and illustrated in Figure I.21.3) including numerous tools (Table I.21.2) to translate promptly into practice each of the five elements of the WHO Multimodal Hand Hygiene Improvement Strategy. These tools focus on different targets: operation, advocacy, and information; monitoring; hand hygiene product procurement or local production; education; and impact evaluation. The latter is an essential activity to measure the real impact of the improvement efforts at the point of care. The same tools used for the baseline evaluation should be used to allow a comparison of standardized indicators such as hand hygiene compliance, perception and knowledge about HCAI and hand hygiene, and availability of equipment and infrastructure for hand hygiene. The Guide to Implementation includes details on each tool and instructions on how and when to use it. The practical toolkit represents a very helpful and “ready-to-go” instrument enabling facilities to start immediately their hand hygiene promotion without the need to decide upon the best scientific approach to be selected.

Figure I.21.3

The Pilot Implementation Pack (now named “Implementation Toolkit”) comprising tools corresponding to each component of the WHO Multimodal Hand Hygiene Improvement Strategy.

Table I.21.2

Type of tools available to implement the WHO Multimodal Hand Hygiene Improvement Strategy.

21.4. “My five moments for hand hygiene”

In this section, a new model intended to meet the needs for training, observation, and performance reporting across all health-care settings worldwide is described.¹ This model is also integrated in various tools included in the WHO Multimodal Hand Hygiene Improvement Strategy (see Part I, Sections 21.1–21.3).

The concept of “My five moments for hand hygiene” aims to: 1) foster positive outcome evaluation by linking specific hand hygiene actions to specific infectious outcomes in patients and HCWs (positive outcome beliefs); and 2) increase the sense of self-efficacy by giving HCWs clear advice on how to integrate hand hygiene in the complex task of care (positive control beliefs). Furthermore, it reunites several of the attributes that have been found to be associated with an increased speed of diffusion of an innovation such as relative advantage by being practical and easy to remember, compatibility with the existing perception of microbiological risk, simplicity as it is straightforward, trialability as it can be experimented with on a limited basis, and specifically tailored to be observable.⁸⁷⁹ The fact that the concept uses the number 5 like the five fingers of the hand gives it a ‘stickiness factor’, i.e. the capacity to “stick” in the minds of the target public and influence its future behaviour, that could make it a carrier of the hand hygiene message and help it to achieve the tipping point of exponential popularity.⁸⁸⁰ Since its development in the context of the Swiss National Hand Hygiene Campaign⁸⁸¹ and its integration in the WHO Multimodal Hand Hygiene Improvement Strategy, the concept of “My five moments for hand hygiene” has been widely adopted in more than 400 hospitals worldwide in 2006–2008, of which about 70 have been closely monitored to evaluate impact and lessons learnt.

21.4.1. Concept features and development

Requirement specifications for a user-centred hand hygiene concept

The main specifications for the concept are given in Table I.21.3. Importantly, it aims for minimal complexity and a harmonious integration into the natural workflow without deviation from an evidenced-based preventive effect. The resulting concept applies across a wide range of care settings and health-care professions without losing the necessary accuracy to produce meaningful data for risk analysis and feedback.

Table I.21.3

Requirement specifications for a user-centred hand hygiene application concept.

Furthermore, the concept is congruent in design and meaning for trainers, observers, and observed HCWs. This sharing of a unified vision has a dual purpose. First, it avoids an expert–lay person gap and leads to a stronger sense of ownership⁸⁸² and second, it reduces training time and cost for observers. Additionally, the robustness of the concept reduces inter-observer variation and guarantees intra-hospital, inter-hospital, and international comparisons and exchange.

21.4.1.1. Health care-associated colonization and infection: the prevention targets

The important concepts of colonization and infection associated with health-care practices have been discussed in depth in Part I.7.

In summary, four negative outcomes constitute the prevention targets for hand hygiene: 1) colonization and exogenous infection of patients; 2) endogenous and exogenous infection in patients; 3) infection in HCWs; and 4) colonization of the health-care environment and HCWs.

21.4.1.2. The core element of hand transmission

During daily practice, HCWs’ hands typically touch a continuous sequence of surfaces and substances including inanimate objects, patients’ intact or non-intact skin, mucous membranes, food, waste, body fluids, and the HCW’s own body. With each hand-to-surface exposure, a bidirectional exchange of microorganisms between hands and the touched object occurs and the transient hand-carried flora is thus continually changing. In this manner, microorganisms can spread throughout a health-care environment and between patients within a few hours.¹²⁶^,⁸⁸³

The core elements of hand transmission are stripped down to their simplest level in Figure I.21.4. Effective hand cleansing can prevent transmission of microorganisms from surface “A” to surface “B” if applied at any moment during hand transition between the two surfaces. Typically, surface “A” could be a door handle colonized by MRSA and surface “B” the skin of a patient. Another example would be surface “A” being the patient’s groin and surface “B” being an open vascular access hub. If transmission of microorganisms between “A” and “B” would result in one of the four negative outcomes detailed above, the corresponding hand transition time between the surfaces is usually called “hand hygiene opportunity”. It follows clearly that the necessity for hand hygiene is defined by a core element of hand transmission consisting in a donor surface, a receptor surface, and hand transition from the first to the second.

Figure I.21.4

Core elements of hand transmission. 1) Donor surface “A” contains microorganisms “a”; receptor surface “B” contains microorganisms “b”. 2) A hand picks up a microorganism “a” (more...)

21.4.1.3. Conceptualization of the risk: patient zone and critical site

To meet the objective of creating a user-centred concept for hand hygiene, the evidence-based hand transmission model (see Part I.7) was translated into a practical description of hand hygiene indications. The terms zone, area, and critical site were introduced to allow a “geographical” visualization of key moments for hand hygiene (Figure I.21.4a). Focusing on a single patient, the health-care setting is divided into two virtual geographical areas, the patient zone and the health-care area (Figures I.21.4a and I.21.4b).

The patient zone contains the patient X and his/her immediate surroundings. This typically includes the intact skin of the patient and all inanimate surfaces that are touched by or in direct physical contact with the patient such as the bed rails, bedside table, bed linen, infusion tubing and other medical equipment. It further contains surfaces frequently touched by HCWs while caring for the patient such as monitors, knobs and buttons, and other “high frequency” touch surfaces. The model assumes that the patient’s flora rapidly contaminates the entire patient zone, but that the patient zone is being cleaned between patient admissions. Importantly, the model is not limited to a bedridden patient, but applies equally to patients sitting in a chair or being received by physiotherapists in a common treatment location. The model also assumes that all objects going in or out of the patient zone are cleaned. If this is not the case, they might constitute an alternative transmission route.

The health-care area contains all surfaces in the health-care setting outside the patient zone of patient X, i.e. other patients and their patient zones and the health-care facility environment. Conceptually, the health-care area is contaminated with microorganisms that might be foreign and potentially harmful to patient X, either because they are multiresistant or because their transmission might result in exogenous infection.

Within the patient zone, critical sites are associated with infectious risks (Figure I.21.4a): critical sites can either correspond to body sites or medical devices that have to be protected against microorganisms potentially leading to HCAI (called critical sites with infectious risk for the patient), or body sites or medical devices that potentially lead to hand exposure to body fluids and bloodborne pathogens (called critical sites with body fluid exposure risk), or both precited risks simultaneously (called critical sites with combined risk). Drawing blood for example concerns a critical site with combined risk that is at the same time associated with an infectious risk for the patient and a body fluid exposure risk for the HCW.

Critical sites either 1) pre-exist as natural orifices such as the mouth and eyes, etc.; 2) occur accidentally such as wounds, pressure ulcers, etc.; 3) are care-associated such as injection sites, vascular catheter insertion sites, drainage exit sites, etc.; or 4) are device-associated such as vascular catheter hubs, drainage bags, bloody linen, etc..

The added value of critical sites lies in their potential use in visual material and training: risk-prone tasks become geographically located and hence more palpable. On the behavioural level, manipulation of critical sites corresponds to either “a clean/aseptic procedure” or “a body fluid exposure procedure”, and in the case of simultaneous risk, to “a clean/aseptic and body fluid exposure procedure”.

21.4.2. The concept and its practical application

“My five moments for hand hygiene” explained

The geographical representation of the zones and the critical sites (Figure I.21.5a) is useful to introduce “My five moments for hand hygiene”. The correlation between these moments and the indications for hand hygiene according to the present guidelines is given in Table I.21.4. To further facilitate ease of recall and expand the ergonomic dimension, the five moments for hand hygiene are numbered according to the habitual care workflow (Figure I.21.5b).

Figure I.21.5a

Unified visuals for “My five moments for hand hygiene”. The patient zone is defined as the patient’s intact skin and his/her immediate surroundings colonized by the patient flora and the health-care area as containing all other (more...)

Table I.21.4

“My five moments for hand hygiene”: explanations and link to evidence-based recommendations.

Figure I.21.5b

Unified visuals for “My five moments for hand hygiene”. The patient zone, health-care area, and critical sites with inserted time-space representation of “My five moments for hand hygiene” (Figure I.21.5b). Reprinted from (more...)

Moment 1. Before touching a patient

From the two-zone concept, a major moment for hand hygiene is naturally deduced. It occurs between the last hand-to-surface contact with an object belonging to the health-care area and the first within the patient zone – best visualized by crossing the virtual line constituted by the patient zone (Figure I.21.5a). Hand hygiene at this moment will mainly prevent colonization of the patient with health care-associated microorganisms, resulting from the transfer of organisms from the environment to the patient through unclean hands, and exogenous infections in some cases. A clear example would be the temporal period between touching the door handle and shaking the patient’s hand: the door handle belongs to the health-care area outside the patient zone, and the patient’s hand belongs to the patient zone. Therefore hand hygiene must take place after touching the door handle and before shaking the patient’s hand. If any objects are touched within the patient zone after opening the door handle, hand hygiene might take place either before or after touching these objects, because the necessity for hand hygiene before touching objects within the patient zone is not supported by evidence; in this case the important point is that hand hygiene must take place before touching the patient.

Moment 2. Before a clean/aseptic procedure

Once within the patient zone, very frequently after a hand exposure to the patient’s intact skin, clothes or other objects, the HCW may engage in a clean/aseptic procedure on a critical site with infectious risk for the patient, such as opening a venous access line, giving an injection, or performing wound care. Importantly, hand hygiene required at this moment aims at preventing HCAI. In line with the predominantly endogenous origin of these infections, hand hygiene is taking place between the last exposure to a surface, even within the patient zone and immediately before access to a critical site with infectious risk for the patient or a critical site with combined infectious risk. This is important because HCWs customarily touch another surface within the patient zone before contact with a critical site with infectious risk for the patient or a critical site with combined infectious risk.

For some tasks on clean sites (lumbar puncture, surgical procedures, tracheal suctioning, etc.), the use of gloves is standard procedure. In this case, hand hygiene is required before donning gloves because gloves alone may not entirely prevent contamination (see Part I, Section 23.1).⁷³^,⁸⁸⁴

Moment 3. After body fluid exposure risk

After a care task associated with a risk to expose hands to body fluids, e.g. after accessing a critical site with body fluid exposure risk or a critical site with combined infectious risk (body fluid site), hand hygiene is required instantly and must take place before any next hand-to-surface exposure, even within the same patient zone. This hand hygiene action has a double objective. First and most importantly, it reduces the risk of colonization or infection of HCWs with infectious agents that may occur even without visible soiling. Second, it reduces the risk of a transmission of microorganisms from a “colonized” to a “clean” body site within the same patient.⁸⁸⁵ This routine moment for hand hygiene concerns all care actions associated with a risk of body fluid exposure and is not identical to the – hopefully very rare – case of accidental visible soiling calling for immediate handwashing.

Disposable gloves are meant to be used as a “second skin” to prevent exposure of hands to body fluids. However, hands are not sufficiently protected by gloves, and hand hygiene is strongly recommended after glove removal (see Part I, Section 23.1). Hence, to comply with the hand hygiene indication in Moment 3, gloves must be removed and subsequently cleansed.

Moment 4. After touching a patient

When leaving the patient zone after a care sequence, before touching an object in the area outside the patient zone and before a subsequent hand exposure to any surface in the health-care area, hand hygiene minimizes the risk of dissemination to the health-care environment, substantially reduces contamination of HCWs’ hands with the flora from patient X, and protects the HCWs themselves.

Moment 5. After touching patient surroundings

The fifth moment for hand hygiene is a variant of Moment 4: it occurs after hand exposure to any surface in the patient zone, and before a subsequent hand exposure to any surface in the health-care area, but without touching the patient. This typically extends to objects contaminated by the patient flora that are extracted from the patient zone to be decontaminated or discarded. Because hand exposure to patient objects, but without physical contact with the patients, is associated with hand contamination, hand hygiene is still required.

Coincidence of two moments for hand hygiene

Two moments for hand hygiene may sometimes fall together. Typically, this occurs when moving directly from one patient to another without touching any surface outside the corresponding patient zones. In this situation, a single hand hygiene action will cover the two moments for hand hygiene, as moments 4 and 1 coincide. Another example of such a simultaneous moment would be the direct access to a central venous line as a first hand-to-surface exposure after entering the patient zone. In this example, moments 1 and 2 coincide.

Two patients within the same patient zone

Health-care settings and situations have very different features across the world. It may happen that two or more patients are in such close contact that they occupy the same physical space and touch each other frequently. For example, this situation could be represented by a mother with her newborn child, or two patients sharing a single bed or bedding space. In these cases, the application of the patient zone and the actual compliance with the five moments is conceptually and practically difficult. Nevertheless, the two close patients may be viewed as occupying a single patient zone. Hand hygiene is certainly still required when entering or leaving the common patient zone and before and after critical sites according to their specific nature, but the indication for hand hygiene when shifting intact skin contact between the two patients is probably of little preventive value because they are likely to share the same microbial flora.

21.4.2.1. Understanding the visual message

A critical feature to facilitate the understanding and communication of “My five moments for hand hygiene” lies in its strong visual message (Figure I.21.5b). The objective is to represent the ever-changing situations of care into pictograms that could serve a wide array of purposes in health-care settings. The main visual focus depicts a single patient in the centre to represent the point of care of any type of patient. The patient zone, health-care area, critical sites and moments for hand hygiene action are arranged around and on this patient to depict the infectious risks and the corresponding moments for hand hygiene action in time and space. This visual representation is congruent with the point of care concept.

Some limitations can be envisaged in this model and are discussed elsewhere.¹

21.4.2.2. Training

There are important interpersonal differences when it comes to learning styles. Some individuals respond well to conceptual grouping and will readily understand the risk-based construct of zones and critical sites and the five moments for hand hygiene. The rationale of the current concept is a strong motivator. With these trainees, it is helpful to insist on the main reason for each of the five moments for hand hygiene. Other people respond better to circumstantial cues. For them, it is useful to list the most frequent examples occurring in their specific health-care settings. The five moments’ model also offers many possibilities for the development of training tools, including on-site accompanied learning kits, computer-assisted learning, and off-site simulators. It is of importance to understand that HCWs often execute quite sophisticated medical tasks without conscious cognitive attention. Their behaviour is triggered by multiple cues in the environment that are unconsciously processed. To build hand hygiene into their automatic behaviour for these situations, they may need training in a given environment with multiple cues for action. “My five moments for hand hygiene” would serve as solid basic building blocks for such training. It is crucial to determine the delimitation of patient zones and critical sites with local staff in their unique setting, which has the added benefit of increasing process ownership by the concerned staff.

21.4.2.3. Monitoring

Direct observation is the gold standard to monitor compliance with optimal hand hygiene practice. The five moments model can be a valuable aid to observation in several ways. Many care activities do not follow a standard operating procedure, so it is difficult to define the crucial moment for hand hygiene. The five moments’ concept lays a reference grid over these activities and minimizes the opportunities for inter- observer variation. Once HCWs are proficient in the five moments concept and its application, they are able to become observers with minimal additional effort, thus reducing training costs.¹ Furthermore, the concept solves the typical problems of clearly defining the denominator as an opportunity and the numerator as a hand hygiene action (see Part III, Section 1.2).

21.4.2.4. Reporting

Reporting results of hand hygiene observation to HCWs is an essential element of multimodal strategies to improve hand hygiene practices.⁵⁸^,⁶⁰ Based on the five moments, it is possible to report risk-specific hand hygiene performance in full agreement with training and promotional material. The impact of feedback is thus increased, as the different moments can be individually discussed and emphasized.

21.5. Lessons learnt from the testing of the WHO Hand Hygiene Improvement Strategy in pilot and complementary sites

Since 2006, the WHO Hand Hygiene Improvement Strategy (see Part I, Sections 21.1–21.4) has been tested in a number of health-care settings around the world to generate information on feasibility, validity, and reliability of the interventions, to provide local data on the resources required to carry out the recommendations, and to obtain useful information for the revision and adaptation of the proposed implementation strategies.⁶²

Before and during implementation, the Pilot Implementation Pack tools were translated into the six official languages of WHO (Arabic, Chinese, English, French, Russian, and Spanish) and also into some local languages (e.g. Armenian, Bengali, and Urdu). Eight hospitals were selected in seven countries (Table I.21.5.1) located in the six WHO regions (Africa, the Americas, South-East Asia, Europe, Eastern Mediterranean, and the Western Pacific) to participate in the pilot test phase with technical support and careful monitoring from the First Global Patient Safety Challenge team. Field testing has been made also possible through the support of the WHO Regional Patient Safety Focal Points and the WHO representatives at country level, as well as collaboration with expert technical and academic partners and professional associations. Diversity was built into the selection of pilot sites to ensure comparability of the results across the six regions, and they represented a range of facilities in developed, transitional, and developing countries.

Table I.21.5.1

Pilot sites for the testing of the WHO Guidelines on Hand Hygiene in Health Care and its strategy and tools.

All sites identified a project and deputy coordinator and formed a committee mandated to give advice and take decisions on the project plan. The instructions included in the Guide to Implementation and the steps proposed in the action plan were carefully followed in all sites, and all implementation tools were used at the suggested steps (see Part I, Sections 21.1–21.3). Therefore, hand hygiene promotion was conducted according to the WHO strategy, and baseline and follow-up evaluation included the detection of hand hygiene compliance, alcohol-based handrub consumption, perception of hand hygiene by senior managers and HCWs, HCWs’ knowledge, and structures related to hand hygiene.

At the same time, a wide range of different health-care settings worldwide also requested to use the WHO Hand Hygiene Improvement Strategy and tools. For this reason, a web-based community forum was established where any health-care facility could enrol in order to access all the tools included in the Pilot Implementation Pack and to ask questions related to implementation. In this way, any health-care facility has been able to participate in field testing as a “complementary test site” (CTS). For logistic and economic reasons, support offered by the WHO to a CTS is limited and mainly web-based. Through the web community, experiences and solutions related to the implementation have also been shared with other test sites. This has provided a discussion forum exclusively for CTSs and an opportunity for mutual support and exchange during the implementation process.

Pilot testing has been completed in most sites and results have been made available. Similarly, a process of evaluation has been undertaken in some CTSs (Section 21.5.2). Data and lessons learnt from testing have been of paramount importance to revise the content of the present Guidelines and to confirm the validity of the final recommendations. Furthermore, when appropriate, they enabled modification and improvement of the suite of implementation tools.

Sections 21.5.1 and 21.5.2 briefly summarize the experience and lessons learnt from the official pilot sites and a number of CTSs. In Section 21.5.1, the specificities of each pilot site regarding implementation and impact and sustainability at local and national/regional levels have been highlighted in brief paragraphs and the lessons are summarized in Table I.21.5.2. A detailed and exhaustive report will be published separately after a careful scrutiny of all data and information available. Specific information about critical aspects of the local production of alcohol-based handrubs is detailed in Section 12.2.

Table I.21.5.2

Lessons learnt from testing in pilot sites.

21.5.1. Implementation in pilot sites

WHO African Region (AFR)
Mali - Hôpital du Point G

Hôpital du Point G, an acute-care, 456-bed university health-care facility serving the population of Bamako and its surroundings and being a referral hospital for the entire country, was selected as the pilot site representing the African region. No infection control expertise was available before the enrolment. A pharmacist underwent training in infection control and learnt how to produce the WHO formulation I at the University of Geneva Hospitals and became the project co-ordinator.

The preparation phase was very intensive, in order to set up the conditions for implementation. A committee was established to advise on action plan and take decisions; the hospital directorate showed strong leadership in the promotion and support to the project kick off. Nine units (two surgical, gynaecology and obstetrics, urology, nephrology, infectious diseases, internal medicine, and accident and emergency) representing 13 wards and 224 HCW were selected for pilot testing. The WHO strategy was faithfully implemented fulfilling all steps, starting from December 2006. The WHO-recommended formulation based on ethanol, produced locally from sugar cane and included in the hospital budget, was manufactured at the hospital pharmacy and bottled in 100 ml pocket bottles; a cleaning/recycling process was put in place. At very low cost, 3700 bottles were produced and quality control tests confirmed accordance with the optimal quality parameters in all samples (see also Part I, Section 12.2).

The baseline infrastructure survey identified severe deficiencies in hand hygiene facilities and products. Although clean water was permanently available, only a minority of patient rooms was equipped with sinks (sink:bed ratio equal to 1:22) and no soap and towel were available. This partly explains the very low overall level of hand hygiene compliance (8.0%) among 1932 observed opportunities at baseline. Compliance markedly differed among professional categories, ranging from an average of 3.2% for nursing assistants to 20.3% for doctors and an average of 4.4% for nurses. Compliance also varied among medical specialities, with the lowest level observed in intensive care (2.4%). The level of HCWs knowledge was also very low, with limited understanding of the pathogen transmission dynamics, of the concept of colonization and of the infection risk. Interestingly, according to the baseline perception surveys, the level awareness of the epidemiologic importance of HCAI and of its impact was higher among senior managers than among HCWs.

Implementation of hand hygiene promotion was launched on 2 November 2007 in an official ceremony chaired by the Minister of Health, the WHO representative in Mali and the hospital director, and involving all HCWs. During the event, chairs and HCWs were invited to sign a giant bottle of alcohol-based handrub as a symbol of their commitment, and information leaflets and T-shirts with the project logo were distributed. During the following months, visual posters featuring the WHO project, hand hygiene indications and the technique for handwashing and handrubbing were displayed in study wards. Following the launch, five three-hour education sessions using WHO materials and including feedback of baseline survey results were organised for all study ward HCWs. All participants were given a 100 ml individual pocket bottle of alcohol-based handrub and trained to use it in practice. From this time on, alcohol-based handrub has been regularly distributed by the pharmacy to the study ward head nurses upon return of the empty bottles.

Interestingly, the improvement of critical deficiencies in infrastructure for handwashing was not considered by the hospital directorate as a top priority for improving practices because of resource and cultural issues. Firstly, improving sink:bed ratio is associated with economic constraints at UHPG. Secondly, HCWs consider that sinks in patient rooms are for patient use and are therefore usually reluctant to use them. Thirdly, in patient rooms, soap bars would very likely be taken by patients and/or visitors and to install wall-mounted liquid soap dispensers would be too expensive.

At follow-up evaluation (six months after implementation kick off) hand hygiene compliance increased to 21.8% and handrubbing became the quasi-exclusive hand hygiene technique (93.3%). Improvement was observed among all professional categories and medical specialties, especially as far as indications “after body fluid exposure risk” and “after touching a patient” are concerned. Knowledge scores the following educational sessions increased significantly (p<.05) among professionals. The HCWs perception survey highlighted the importance of each component of the strategy for successful promotion.

The project was strongly supported by the hospital directorate which engaged, together with key staff members, in an in depth evaluation of the results of the pilot phase in order to enable sustainability, expansion and further improvement. Hand hygiene promotion and measurement activities have been included in the annual management plans for the entire hospital. Locally adapted posters are in preparation and innovative methods for hand hygiene promotion among most resistant professional categories and for patient involvement will be part of the forthcoming boostering phase of the campaign. The study successful results about the feasibility of the strategy implementation and practice improvement have motivated the Mali government to expand the production of the alcohol-basedhandrub and the dissemination of the strategy to the national level.

WHO Region of the Americas (AMR)/Pan American Health Organization (PAHO)
Costa Rica: Hospital Nacional de Niños (HNN)

The strategy was implemented from March 2007 to September 2008 in 12 wards (290 beds) of HNN, a paediatric hospital in San José, Costa Rica. All steps of the action plan were completed and the facility is now developing a review cycle and a five-year plan to ensure sustainability.

The alcohol-based handrub was produced according to the WHO recommendations by a private company, which accepted to donate the product and the dispensers. The validation of the local production of the WHO-recommended formulation took much longer than expected because of several initial failures at the quality control test level (see Part I, Section 12.2). An engineer reviewed the hospital plan to place the new dispensers at the point of care according to local safety criteria. The system change was critical to the improvement of hand hygiene practices, because alcohol-based handrubs were not previously widely available and, in some areas of the hospital, significant infrastructure deficiencies (sink to bed ratio <1:10) constituted an important barrier.

Observers for hand hygiene monitoring underwent two days of intensive training and were subsequently validated. An official ceremony, chaired by the minister of health, was organized to launch the hand hygiene promotion campaign (Step 3). Giant dolls in the shape of a handrub bottle were prepared and used to market the improvement for promotional purposes. HNN committed also to patient involvement and families were informed of the pilot project and encouraged to use the alcohol-based handrub when caring for their children.

Educational activities with feedback of data collected during the baseline period (Step 2) were organized with the participation of all HCWs from the test units. Overall, 1421 and 1640 hand hygiene opportunities were detected at baseline and followup (after 5 months of implementation), respectively. Overall compliance increased from 25.2% to 52.2%. The key success factors of implementation in this site were the high-level, medical leadership and the pragmatic, continuous action by head nurses. Strong support from the government not only facilitated the excellent pilot implementation of the WHO strategy, but also led to its national scale-up with a National Call to Action made by the minister of health to all hospitals in the country.

The Costa Rica experience has had a catalytic influence on other countries in AMR. The expertise of the pilot project team has been successfully exploited by the WHO Regional Office for the Americas (AMRO) in collaboration with PAHO, which has coordinated training initiatives involving other countries. Argentina, Brazil, Colombia, Ecuador, Peru, and Trinidad and Tobago are now preparing to adopt the WHO strategy.

WHO South-East Asia Region (SEAR)
Bangladesh, Chittagong Medical College Hospital (CMCH)

CMCH has been implementing the WHO Hand Hygiene Improvement Strategy since September 2007 in five wards (neonatal care, surgery, orthopaedics, and paediatric and adult ICUs). Given the critical conditions of the hospital (162% bed occupancy, no infection control professional, no data on HCAI and antimicrobial resistance, significant infrastructural deficiencies), there was much scepticism at the time of the pilot enrolment about the feasibility of the project and its worthiness in the presence of other major priorities. To overcome these obstacles, the hospital directorate took the decision to make a major investment in the project. From the CMCH staff, one doctor and one nurse were selected as pilot project coordinators and trained in Lahore and then in Chittagong with the support of the WHO country office. A multidisciplinary infection control committee including the departmental heads of all relevant units was established. The alcohol-based handrub, based on the WHO recommended formulation II (isopropyl alcohol) was manufactured locally by the national Essential Drug Company Ltd. A survey was undertaken to establish the best position for the alcohol-based handrub dispensers to meet the point of care concept. Sinks (1 for every 15 beds) were installed in all of the pilot wards, as only the nursing station and doctors rooms had a sink. In order to improve inadequate water supply, two deep tube wells were sunk and major water supply lines were improved.

Following a preliminary assessment, which clearly highlighted that no hand hygiene action was regularly performed by HCWs because of absence of sinks, running water and soap in the wards, outside the doctors’ rooms and the nurses’ stations, the decision was taken not to undertake baseline hand hygiene observations and to consider compliance equal to 0% at baseline. Specific challenges to the observation of compliance were the high bed occupancy (two patients per bed in some wards) and overcrowding that made it difficult to apply the patient zone concept, the complexity of the WHO method, and cultural sensitivities to be observed. However, baseline HCW perception surveys yielded some interesting findings. Bearing in mind the infrastructural deficiencies with respect to sink availability, it is significant that during the pre-pilot phase 83.5% and 44.5% of respondents, respectively, stated that their hand hygiene compliance exceeded 50% (most respondents estimated it to be between 80% and 100%) and that they had received formal training in hand hygiene. In addition, 87.8% considered that the performance of hand hygiene required a major effort, and 54.7% stated that the availability of alcohol-based handrub at the point of care would have no or little effect on the improvement of hand hygiene practices.

To launch the implementation phase, a high profile event was held at the hospital with the attendance of the WHO representative, the minister of health, senior ministerial officials, and public and private hospital representatives. Five hundred persons attended the event. In the wards, alcohol-based handrub was made available through wall dispensers and pocket bottles distributed to all HCWs. Posters translated into Bengali were displayed throughout the wards at the locations of alcohol-based handrub dispensers, above washbasins, and between each bed space, and large-size versions of the posters were positioned at the ward entrance. All ward-based staff, both doctors and nurses, were trained to follow the Guidelines with refresher courses every fortnight. Some perception difficulties emerged in the use of the WHO educational concepts and tools (see Table I.21.5.2) and a simplified “two moments” approach was adopted. Evaluation of the implementation impact with the use of the WHO surveys has been undertaken (Step 4) and data are under analysis.

The project has led to very beneficial actions beyond hand hygiene improvement both at CMCH and at national level. The CMCH infection control committee is well established and meets regularly every month – or more often if necessary – and plans to expand the WHO strategy to the entire hospital. It is in the process of developing an antibiotic utilization policy, to conduct a prevalence study, and has already pilot infection registers on wards. An audit on surgical procedures is planned to investigate the appropriateness of surgical instruments reprocessing and of surgical hand preparation.

The Joint Secretary Hospital of the Ministry of Health and Family Welfare (MOHFW) visited CMCH during implementation of the pilot and has called for a national roll-out of the pilot project without delay. The MOHFW thus expressed its strong commitment to strengthen infection control across the country, in particular by ensuring that each hospital has a functioning infection control team and propoer access to handwashing facilities by installing one washbasin per 10 beds in all hospitals. Alcohol-based handrub will be procured on a national scale and its use promoted as the gold standard for hand hygiene of non-soiled hands. The proposed timeframe is for roll-out during the financial year 2008–2009 with consolidation during 2009–2010, and a specific budget has already been allocated that includes the strengthening of human resources. The WHO country office will support the MOHFW in the adaptation and updating of guidelines and norms required for the success of the initiative.

WHO European Region (EUR)
Italy: network of 41 ICUs

In November 2006, the Italian ministry of health decided to join the “Clean Care is Safer Care” initiative by launching a national campaign organized by a national coordinating centre for HCAIs (Agenzia Sanitaria e Sociale Regionale Emilia-Romagna) and funded by the National Centre for Disease Control (Centro Nazionale per la Prevenzione e il Controllo delle Malattie, CCM).

Participation in the campaign was proposed to all of the 21 Italian regions and public hospitals. Overall, 190 hospitals from 16 regions joined the campaign, accounting for 315 hospital wards, mostly ICUs and surgical and medical units. The entire range of tools included in the WHO Pilot Implementation Package was translated into Italian and the printed material distributed. One national and four regional training courses for coordinators and observers were organized; the WHO strategy and action plan were entirely adopted (see Part I, Section 21).⁸⁸⁶ A web platform was created on the CCM web site for tool downloading, technical questions, and interactive discussion among the sites. One hundred sixty one hospitals reported their findings and experience to the national coordination centre and sent the databases of all surveys included in the WHO strategy. Preliminary analysis of hand hygiene observations related to 66 953 opportunities detected at baseline in 172 hospitals indicate that overall compliance was 43% and that, in 71% of hand hygiene actions, handwashing was the technique used.

Given the high level of data collection accuracy and adherence to the WHO strategy in the Italian campaign, a network of participating ICUs was selected to become the pilot site for EUR according to pre-established criteria (Table I.21.1). Forty-one ICUs from eight regions were eligible, and most of them implemented hand hygiene promotion between October 2007 and January 2008 and conducted baseline and follow-up evaluations during 3–6 months before and after the implementation. Thirty ICUs sent the complete set of baseline and follow-up data of all WHO surveys.

Observations related to 9 828 and 9 302 opportunities were carried out at baseline and follow-up, respectively, with an equal distribution of professional categories and types of indication. Overall, a significant improvement in hand hygiene compliance (from 55% to 69%) was detected following implementation of the hand hygiene strategy. Comparing baseline with followup, use of handrubs to perform hand hygiene increased from 36.9% to 60.4% of hand hygiene actions. This is reflected in the structure surveys results from 30 ICUs which indicate that permanent availability of alcohol-based handrubs improved from 70% to 100% and that pocket bottles were available to each HCW in 92% of cases at follow-up (vs 52% at baseline). Improvement was more striking among nurses and nursing students (compliance increased from 58% to 73% and from 52% to 69%, respectively); compliance increased from 48% to 59% among medical doctors and from 56% to 69% among auxiliary nurses. A comparison of the knowledge questionnaire results at baseline and follow-up (1238 vs 802 respondents, respectively) identified areas that need further improvement, e.g. the understanding of the dynamics of microrganism transmission and the role of different sources of infection. In contrast, there was an interesting, positive correlation between the increase of hand hygiene compliance before patient contact (from 49% to 65%) and before an aseptic/clean task (53% to 70%) and the improvement of knowledge at follow-up when answering questions related to these two indications.

According to the perception questionnaire (1116 vs 902 respondents at baseline and follow-up, respectively), the percentage of HCWs who underwent training on hand hygiene increased from 39.7% to 86.6%, respectively. Most respondents attributed the highest scores (6 and 7 of a 7-point Likert scale) to every component of the WHO strategy when asked about the importance of the strategy components in determining their hand hygiene performance improvement.

Working group discussions with 24 pilot ICU coordinators using the CTS evaluation interview template (see Part I, Section 21.5.2) provided very interesting information on the implementation strategy feasibility and invaluable suggestions for improvement (Table I.21.5.2). The discussion was very instructive, particularly to identify actions for securing the sustainability of the hand hygiene promotion programme. In most pilot hospitals, staff working on the wards not involved in the pilot testing requested hand hygiene promotion to be extended to their settings. The campaign is becoming hospital-wide in many institutions and additional health-care facilities have spontaneously joined the national campaign.

WHO Eastern Mediterranean Region (EMR)

For several reasons, more than one pilot site was selected in EMR. Although all sites have committed to undertake all activities included in the action plan for the implementation of the WHO Hand Hygiene Improvement Strategy, they are at different stages of implementation.

Kingdom of Saudi Arabia

Two different health-care settings agreed to participate in the pilot testing in Riyadh, Saudi Arabia. In both sites, a hand hygiene campaign was undertaken in 2005, following the ministerial pledge to the First Global Patient Safety Challenge and the launch of a national campaign. In connection with the latter, all hospitals affiliated to the Ministry of Health were provided with alcohol-based handrubs as the gold standard for hand hygiene according to the WHO strategies. Since 2007, hand hygiene promotion has been further reinforced with participation in the testing of the WHO strategy. In both cases, the hospital bore the entire cost of implementation.

King Abdulaziz Medical City (KAMC), Riyadh, is a 960-bed teaching hospital delivering high-quality primary, secondary and tertiary health-care services for the Saudi Arabia National Guard. The infection control committee appointed the coordinator and his deputy and also identified infection control practitioners and infection control “champions” (focal points) to implement the activities.
The KAMC ICUs (seven units: adult, paediatric, neonatal, burn, adult and paediatric cardiovascular, and medical cardiac) and two surgical units were selected to be the pilot wards based on the acuity of care provided, the high risk of microorganism transmission, and the high number of hand hygiene opportunities. Alcohol-based handrub was already available at KAMC, but during the campaign preparation phase a new product was selected among several proposed according to WHO criteria, and the number of fixed dispensers located at the point of care was increased. The goal of the campaign was to reach at least 90% or above compliance with hand hygiene practices.
Through the use of a specific form, evaluation of the quality of the hand hygiene technique was added to the range of other WHO surveys at baseline and follow-up. Each unit had a champion in charge of carrying out the surveys, coordinating staff training on hand hygiene, and liaising with the campaign coordinator and his deputy. Champions had also to be prepared to meet specific, challenging situations in their interaction with HCWs and others, such as surprise, apprehension of the unknown, scepticism, cynicism, and strong resistance.
Feedback was given to HCWs, leaders, and key players during the launch day when the promotion campaign was inaugurated. Formal reports on local compliance data were distributed to the respective area directors. The campaign was launched on 13 April 2008 with an official ceremony by the hospital director and other high-level authorities and an advertisement on the KAMC web site. A leaflet was prepared to inform the patients and invite them to participate in the campaign by asking HCWs to perform hand hygiene. An original aspect of implementation at KAMC was the organization of mobile stands inside and around the hospital, which moved to a different location every two to three hours in order to reach all HCWs and patients. These stands, managed by the infection control practitioners, displayed WHO and non-WHO posters and documents on hand hygiene. Stand visitors could watch the WHO training film and were taught the correct technique to perform hand hygiene antisepsis. Throughout a two-month period, 23 training sessions were organized with the participation of 530 staff members from the pilot units. Several promotional tools and posters were adapted from the WHO versions or newly produced in English and Arabic (Table I.21.5.1).
Overall, 1840 and 1822 hand hygiene opportunities were detected at baseline and follow-up (after three months since implementation), respectively. Overall compliance increased from 45.1% to 59.4% with improvement greatest among nurses (43.9 vs 62.8%). Compliance rates with Moment 3 (after body fluid exposure risk) and Moment 4 (after touching a patient) were high during both observation periods (82.9% vs 85.0% and 67.7% vs 76.2%, respectively). Compliance with Moment 2 (before clean/aseptic procedure) achieved the greatest increase (45.8% vs 84%); improvement was also detected with Moment 1 (before touching a patient) (29.4% vs 58.1%, respectively) and Moment 5 (after touching patient surroundings) (13.2% vs 30.0%, respectively).
King Saud Medical Complex (KSMC), Riyadh, is a 1446-bed teaching hospital delivering primary, secondary, and tertiary care, under the government of the Saudi Arabia Ministry of Health. It consists of four hospitals: a general hospital, maternity hospital, children’s hospital, and a dental centre.
In September 2007, a hand hygiene committee was created to plan and carry out the activities related to the project. Together with four infection control professionals, three infection control nurses were identified to play the role of trainers for the education sessions and observers. Sessions “train the trainers” were organized and led by the coordinator and deputy coordinator.
The WHO strategy was implemented hospitalwide, but the observation of hand hygiene practices was carried out only in selected areas. Alcohol-based handrub dispensers were already installed in all wards and departments, but the decision was taken to introduce the WHO formulation. A local company was appointed by the ministry of health to produce different samples of alcohol-based handrub according to the WHO Guide to Local Production. Four types of solutions were produced: one corresponded to the WHO formulation 1 (based on ethanol), while the other three were the same formulation but with some modifications such as a different fragrance or emollient. All four formulations were made in the form of a solution, and all four products were quality control-tested at the University of Geneva Hospitals in Switzerland and found to be consistent with WHO requirements for the final concentrations of the ingredients. Following the reception of these results, the test of acceptability and tolerability of these products among HCWs was carried out according to the WHO method. The best tolerated and most appreciated product was selected and distributed in wall dispensers at the point of care.
Hand hygiene observations were conducted monthly and during the baseline period. KSMC overall hand hygiene compliance was 56%. Feedback of results of the surveys conducted during the baseline period, in particular hand hygiene compliance, was given to all decision-makers on 19 May 2008.
Great emphasis was placed on education at this pilot site. From September 2007 to October 2008, the members of the hand hygiene committee managed to lead 56 sessions during which 998 HCWs were trained in the concepts promoted by the First Global Patient Safety Challenge, in particular, “My five moments for hand hygiene”. In addition, a weekly training session was scheduled every Sunday and attendance was a contract requirement for new staff and for staff renewing their contracts. In 2008, 1297 HCWs participated in these sessions. Much effort was dedicated to producing a large range of new posters on hand hygiene with more visual impact and adapted to the local culture. These were distributed in large quantities across all wards.
Monthly observations during the implementation period (from May to September 2008) documented an increase of the average compliance rate to 75%, with specific departments reaching rates as high as 88.8%.

Pakistan, Institute of Medical Sciences (PIMS)

Three ICUs – medical (9 beds), surgical (14 beds), and neonatal (17 beds) – were selected for pilot testing the WHO Hand Hygiene Improvement Strategy at PIMS, a tertiary referral hospital with 1055 beds. Alcohol-based handrubs have been in use at PIMS since the emergency situation following the 2005 earthquake. In keeping with the WHO project, the WHO-recommended formulation based on isopropanol was produced at PIMS where it replaced the alcohol-based handrub previously purchased from a commercial source at a much higher price (US$ 3.00 per 500 ml vs US$ 1.85 per 500 ml).

Baseline structure evaluation pointed out no relevant deficiency related to handwashing: sink-to-patient ratio was about 1:3, and clean, running water was regularly available. In contrast, alcohol-based handrubs were available (intermittently) in only one of the three ICUs. A high level of awareness of the impact of HCAI and of the importance of hand hygiene was demonstrated by the 123 HCWs responding to the perception survey. It is widely reported that most HCWs believe that compliance in their hospital is higher than 50%. At PIMS, among 755 observed opportunities, the overall hand hygiene compliance at baseline was 34.7% with no significant differences between the major professional categories. Compliance was highest with Moment 1, before touching a patient (60.0% by nurses and 55.5% by doctors), and there was a remarkable difference in the compliance with Moment 4, after touching a patient, between nurses (48.8%) and doctors (22.9%).

On 11 August 2008, a training workshop on hand hygiene was held at PIMS to train the trainers and key individuals involved in the project, and the implementation phase was launched. All staff members of the pilot ICUs were subsequently trained and the WHO hand hygiene posters were made available in Urdu to overcome language barriers. An interesting specificity of the promotion campaign at PIMS was that training was not limited only to regular staff, but was simplified also and offered to the so-called “janitors”, illiterate support employees who are in charge of clinical and human waste disposal and the emptying of urinary bags. The adaptation of educational messages to their level of knowledge was a very challenging task.

The WHO project implementation in ICUs had an overall, positive impact at PIMS because an infection control doctor and three full-time infection control nurses were appointed, and an infection control committee was established. For the first time, proper surveillance of HCAI was also established in the Neonatal ICU using WHO tools. As a result of this project, HCAI has now become a high priority as a part of quality and patient safety agenda of the hospital. In addition, given the substantial cost savings and the potential availability of additional funds, it is planned that the production of the WHO formulation will be expanded for distribution to other wards and departments. In addition, the previous health secretary at the federal ministry of health has expressed an interest to train 100 000 health visitors throughout Pakistan and distribute alcohol-based handrub to them. It is also anticipated that by the end of the project, the WHO representative and the federal ministry of health will explore the feasibility of the production of the WHO formulation on a national scale using public/private partnership.

WHO Western Pacific Region (WPR)
China, Hong Kong Special Administrative Region (SAR): four pilot hospitals

The implementation of the WHO Hand Hygiene Improvement Strategy started in Hong Kong SAR in 2006, a few months after the pledge signature in October 2005. Four pilot hospitals with 20 study wards in total have progressively enrolled since April 2006. Enrolled wards were surgery, internal medicine, adult ICUs, orthopaedics, and geriatrics. Each hospital selected a coordinator and a team of infection control professionals to carry out the project. Aspects specific to the study design for Hong Kong SAR pilot hospitals included that each test ward be associated with a control ward of the same type, and the conduct of a long-term follow-up of hand hygiene compliance measurement.

During the preparation phase, much energy was devoted to setting up the local production of the WHO formulations in the perspective of ensuring cost–effectiveness and large-scale production. Production was put out to tender, and the company proposing the lowest price (including the purchase of plastic fixed dispensers and pocket bottles) was selected. The quality of the final products was ascertained at Geneva’s University Hospitals (see Part I, Section 12.2). The WHO tolerability and acceptability survey (double-blind, randomized, crossover design) was carried out, and 65% of HCWs indicated a preference for one of the two WHO alcohol-based handrub formulations in use, although some considered it to have an unpleasant odour. All 41 Hong Kong SAR public hospitals are currently purchasing the WHO formulations from the selected local company at the price of US$ 0.50 for the 100 ml bottle and US$ 1.60 for the 500 ml dispenser. Compliance at baseline (April–October 2006) was 20.7% and 22.2% in study and control wards, respectively. Such low rates are surprising in Hong Kong SAR, when considering the major achievements with hand hygiene compliance only a few years previously at the time of the severe acute respiratory syndrome (SARS) outbreak.

Implementation in the test wards of the Hong Kong SAR pilot hospitals involved original aspects of adaptation of the WHO strategy and tools. Education was carried out by presentations targeted to the different professional categories. Different scenarios simulating real care situations were presented to staff, and solutions and explanations were given. All possible efforts were made to enhance HCWs access to alcohol-based handrubs by increasing the number of dispensers at the point of care in test wards, distributing the new products in pocket bottles as well with special belts and clip holders, and making powder-free gloves available in test wards. A question and answer (Q&A) leaflet was prepared, responding to all HCWs’ concerns about the use of alcohol-based handrubs (e.g. skin damage, fire safety, bottle contamination), and topics were discussed with HCWs according to the needs. Feedback about hand hygiene performance was given to HCWs individually and immediately after observation. A competition was announced to identify the best slogan to promote “Clean Care is Safer Care” in Chinese. To boost implementation, emphasis was placed on role modelling after the first and the second follow-up periods.

Three periods of follow-up observations were carried out every 3–4 months. In the first period (October 2006–March 2007), overall compliance rates were 56.6% and 18.3% in the test and control wards, respectively. In test wards, compliance improved in all professional categories apart from doctors (15.5% compliance at baseline) who showed no improvement and a significantly lower compliance at all follow-up measurements (mean 23.4%). Between July 2007 and January 2008, the hand hygiene campaign was announced hospitalwide in all pilot hospitals, with an official launch ceremony. All the above-mentioned actions were extended to all wards and no longer limited to test wards only. After the hospitalwide roll-out, compliance rates in test wards remained 52.4%, whereas it increased to 43.8% in the control wards. On 21 January 2008, following the success of the WHO strategy implementation in the pilot hospitals, the Hospital Authority, Hong Kong SAR, launched a national campaign aiming to create an institutional safety climate and improving hand hygiene in 38 public hospitals. At that time a big banner (15 m wide and 9 m hight) was posted up outside the Hospital Authority Head Office for increasing public awareness of the importance of hand hygiene. Most of these hospitals are currently displaying a giant banner on hand hygiene at their entrance to show their participation and using the WHO Implementation Strategy, toolkit, and methodology. It is also of note that the strategy was adapted and successfully implemented in seven home-care facilities in Hong Kong SAR.

21.5.2. Lessons learnt from complementary test sites

Since the start of the testing phase of the WHO Multimodal Hand Hygiene Implementation Strategy, complementary test sites (CTS) were able to access the entire range of tools included in the Pilot Implementation Pack following registration through an interactive web platform created for this purpose. Although CTS did not receive direct monitoring by the First Global Patient Safety Challenge team, a process of evaluation has been undertaken when the implementation phase reached an advanced stage. A structured framework was developed including three levels: level I, the mapping exercise; level II, quantitative evaluation; and level III, qualitative evaluation. The mapping exercise was conducted with the use of an online form and allowed to collect general information about the healthcare settings, their progress in the implementation of the WHO Strategy and which tools had been adopted or adapted. Sites at advanced/semi-advanced stages of implementation and which had used most of the WHO tools underwent evaluation levels II and III through a semi-structured telephone interview with the coordinators. The interview included both open and ranking questions (7-point Likert scale) on different components of the WHO Strategy and the Pilot Implementation Pack. The objective was to receive feedback on the drawbacks and advantages of the implementation of the strategy, feasibility of alcohol-based handrub local production, and the validity and obstacles encountered in the use of the tools. For the purpose of quantitative evaluation, the coordinators were requested to send the available data on key indicators e.g. hand hygiene compliance, alcohol-based handrub and soap consumption, as well as the results of the knowledge/perception/structure surveys. Level II evaluation is ongoing.

A total of 114 complete responses were received for the level I survey and concerned both single sites and networks of healthcare settings. Forty-seven coordinators from the advanced and semi-advanced sites, representing 230 health-care settings from Egypt, France, Italy, Malta, Malaysia, Mongolia, Spain, and Viet Nam, participated in the level II and III evaluation.

21.5.2.1. Comments on the WHO Multimodal Hand Hygiene Improvement Strategy and the Guide to Implementation

General comments by most coordinators on the WHO Multimodal Hand Hygiene Improvement Strategy indicate that it is comprehensive and detailed, and its action plan very helpful to guide practically the local implementation. For these reasons, it was considered to be a successful model suitable to be used also for other infection control interventions. However, there is a strong need for a summarized/simplified version. Some coordinators raised concerns about the complexity of the strategy and the Pilot Implementation Pack, especially in contexts with limited human resources, while others requested more details on implementation in poorly-resourced countries. As the main focus of the strategy is on hospitals, adaptation to other types of health-care settings was strongly suggested. The overall median score attributed to the usefulness of the Guide to Implementation to help understand the rationale behind the strategy, the step-wise approach to implementation, the objectives and application of the tools was 6 (range 4–7). The section on sustainability was considered worthy of expansion with more detail by some individuals.

Some examples of the local adaptation of the strategy are the local production of posters, brochures, training films, badges and gadgets, organization of focus groups on glove use, use of the fingerprint method for educational purposes, and the involvement of patients and visitors in hand hygiene promotion.

21.5.2.2. Comments on specific elements of the WHO Strategy

System change. System change was considered a very important component of the WHO Strategy (median score 7, range 4–7). As far as handwashing was concerned, in some cases where major infrastructure deficiencies were present (e.g. lack of sinks and paper towels), these could not be completely overcome, mainly due to lack of resources.

Forty-six CTS adopted locally-produced WHO-recommended handrub formulations produced either at the hospital pharmacy or in a centralized facility. In the sites where handrub was already in use, the system was strengthened through the increase in the number of dispensers and the use of different types of dispensers.

Reported long-term obstacles to system change included staff subconsciously resistant to using handrub (mainly for self-protection reasons), leakage problem with liquid solutions, rumours about handrubs causing skin cancer, and allergic reactions.

Education. This component was considered of major importance for the success of the campaign and the WHO tools were widely used with the addition of local data in most cases. HCWs who had previously received less education expressed the most interest. In many cases, traditional educational sessions with slide-shows were used, but other methods such as interactive sessions and practical sessions on hand hygiene technique were also adopted. The “My five moments for hand hygiene” concept was perceived as the key winning message of the Strategy and the visual impact of the educational tools and the training film were highly appreciated.

Major obstacles were the limited time availability of HCWs beyond the work shifts and the reluctance of doctors to attend training sessions.

The median score attributed to the importance of education was 7 (range 5–7). Scores given to the usefulness of the different WHO educational tools were as follows: training film, 7 (range 5–7); slide presentation, 6 (range 5–7); hand hygiene brochure, 7 (range 5–7); pocket leaflet, 7 (range 5–7); and the 9 recommendations leaflet, 7 (range 5–7).

Observation and feedback. All sites adopted the WHO observation method and found it relatively easy to apply due to the precise instructions included in the Manual for Observers. The median score attributed to both the importance of observation and feedback and the usefulness of the Manual for Observers was 7 (ranges 4–7 and 1–7, respectively). Observers were mainly infection control nurses. Nevertheless, difficulties were experienced for their validation and the time availability for this task, particularly when limited manpower was available. Feedback was noted as being very important to raise awareness and to acknowledge the results achieved. The method used most frequently was a slide presentation during educational sessions; in some cases, immediate compliance feedback and a written report were given to staff and the hospital directorate. In some facilities, the reaction of HCWs to reported low rates of compliance was not positive; in others, when data were disseminated to other units, they generated much interest to take part in the implementation.

The other WHO tools for evaluation (structure, perception and knowledge surveys) were used in some sites. Although their usefulness to gather a more comprehensive understanding of hand hygiene practices was acknowledged, it was also pointed out that it was too time-consuming to perform the surveys, some questionnaires are too long, and some questions are difficult to understand. In some sites, a combined knowledge/perception questionnaire was developed locally.

Reminders in the workplace. WHO posters were used in all sites and adapted locally in some cases. They were also useful for patients and visitors and led to spontaneous patient participation. Perishability was one concern and, in some sites, posters were plasticized to overcome this problem. The median score attributed to the importance of reminders was 6 (range 3–7;) median scores attributed to the WHO posters were as follows: “5 Moments”, 7 (range 6–7); “How to Handrub”, 6 (range 5–7); and “How to Handwash”, 6 (range 5–7).

Patient safety climate. Some coordinators pointed out that the implementation of the hand hygiene campaign acted as a trigger to introduce other patient safety topics. Support from top managers and the directorate varied from strong practical support to more moral and verbal support among the different sites. No active patient participation was reported. The median score attributed to the importance of the promotion of a safety culture was 6 (range 2–7); scores attributed to the usefulness of the tools to secure managerial support were: information sheets, 5 (range 3–7); advocacy sheet, 4 (range 2–6); and senior managers’ letter template, 5 (range 2–7).

Table I.21.2Action plan step-by-step

Step 1: Facility Preparedness	Step 2: Baseline Evaluation	Step 3: Implementation	Step 4: Follow-up Evaluation	Step 5: Developing Ongoing Action Plan and Review Cycle
Activities	Activities	Activities	Activities	Activities
Identify coordinator	Baseline Assessments: undertake	Launch the strategy	Follow-up assessments: undertake	Study all results carefully
Identify key individuals/groups	Senior managers perception survey	Feedback baseline data	Health-care worker knowledge survey	Feedback of follow-up data
Undertake Facility Situation Analysis	Health-care worker perception survey	Distribute posters	Senior executive managers perception survey	Develop a five year action plan
Complete alcohol-based handrub production, planning and costing tool	Ward structure survey	Distribute alcohol-based handrub	Health-care workers perception and campaign evaluation survey	Consider scale-up of the strategy
Train observers/trainers	Local production or market procurement of handrubs	Distribute other WHO materials from the Pilot Implementation Pack	Facility Situation Analysis
Procure raw materials for alcohol-based handrub (if necessary)	Data entry and analysis	Educate facility staff	Data entry and analysis
Collect data on cost-benefit	Hand hygiene observations	Undertake practical training of facility staff	Hand hygiene observations
Evaluate computer equipment	Health-care worker knowledge survey	Undertake handrub tolerance tests	Monthly monitoring of use of products
Undertake training on data entry and analysis	Monitor use of soap and alcohol	Complete monthly monitoring of usage of products

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