Hand hygiene: still not sufficiently recognised in European hospitals

Didier Pittet
MD MS
Lead
WHO World Alliance for Patient Safety Global Patient Safety Challenge
Infection Control Programme
University of Geneva Hospitals
Switzerland
E: [email protected]

Julie Storr
BN
Project Manager
E: [email protected]

Benedetta Allegranzi
MD
Deputy Project Lead
E: [email protected]
WHO World
Alliance Global Patient Safety Challenge

Patient safety is a global issue that affects both developed and developing countries. It is a critical component to improving the quality of healthcare worldwide. Following a resolution of the 57th World Health Assembly in October 2004, the World Health Organization (WHO) launched the World Alliance for Patient Safety to lead the process of establishing global standards and to support national efforts in developing patient safety policies, practices and monitoring systems. A core component of the Alliance is the formulation of a global patient safety challenge to be identified for action over an initial two-year cycle. The challenge covers a significant aspect of risk to patients during healthcare delivery, relevant to every WHO Member State.

The first topic for 2005–2006 is healthcare- associated infection (HAI); it clearly presents many of the characteristics of a major patient safety problem, affecting patients and sometimes healthcare workers. Throughout the world, hundreds of millions of patients annually fall victim to HAI. This increases the length of stay in hospital, causes individual physical and emotional suffering, and sometimes results in long-term disability and death. Moreover, increased morbidity, mortality and added costs due to HAI clearly have an impact on the finances and quality performance of healthcare systems.

The global patient safety challenge “Clean care is safer care” aims to implement several actions to tackle HAI worldwide – regardless of the level of development of the healthcare system and the availability of resources. Implementation strategies include integrating multiple interventions derived from existing WHO programmes in different healthcare settings in the areas of blood, injection and clinical procedure safety, as well as water, sanitation and waste management. The promotion of hand hygiene in healthcare will be the cornerstone of this effort.

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Hand hygiene compliance and its impact on HAI
Hand hygiene is considered the most effective measure to prevent HAI. However, its importance is not sufficiently recognised by healthcare workers, and compliance with hand hygiene recommendations during daily healthcare delivery remains unacceptably low; mean baseline rates range from 5–81%, with an overall average of about 40%.(1) Among the key parameters associated with noncompliance, the leading factors are time constraint, lack of knowledge about indications for hand hygiene and the absence of role models and institutional support.(2-4) Studies in advanced healthcare systems have shown that high workload is a significant determinant of poor hand hygiene compliance and nosocomial infection risk. According to the most recent guidelines, the use of alcohol-based handrub formulations can overcome the problem of time constraint and, when available, replace handwashing in most indications as the new standard of care.(5) It can be easily used at the point of care and requires only 20 seconds. It acts immediately and is more efficient in reducing bacterial counts on hands than washing hands with soap and water.

Healthcare workers’ behavioural attitudes towards compliance with recommended practices are extremely complex and influenced by many factors.(6-8) Experts agree that a successful programme must be multidisciplinary and multifaceted to counteract reasons for poor compliance through a combination of actions aimed at promoting hand hygiene (Box 1). A number of studies have measured the impact of these interventions on HAI rates. Despite some study limitations, these reports – mostly based on multimodal strategies and including the introduction of an alcohol-based handrub – showed a clear temporal relation between improved hand hygiene practices and reduced infection rates. In particular, some demonstrated the effectiveness of hand hygiene improvement to contain outbreaks or endemic cross-transmission of multiresistant pathogens such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci and multiresistant Klebsiella spp, while others succeeded to show a hospital-wide or ward-wide reduction of most HAI rates.(5)

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New guidelines for hand hygiene in healthcare
In considering the effectiveness of hand hygiene as a preventive measure in healthcare, the first step to lay the foundation of the global patient safety challenge was preparing new evidence-based guidelines with the contribution of more than 100 experts of international renown.(5) The aim is to provide healthcare workers, administrators and health authorities with a thorough review of the available scientific information to support hand hygiene promotion. The perspective is global and targets all countries – regardless of their level of development. Within the framework of the guidelines, several innovative topics are being addressed:

• Local preparation of a low-cost handrub formulation and its availability at the point-of- care.
• Successful methods to conduct staff training and encourage behavioural change.
• The issue of glove use and reuse.
• Safe water accessibility for hand hygiene.
• Strategies for national campaigning.
• Cultural and religious aspects of hand hygiene.
• Patient involvement in hand hygiene promotion.

Implementing the global patient safety challenge
Pilot testing in selected healthcare districts worldwide is currently being conducted to monitor and evaluate the implementation strategy proposed by the new guidelines. This phase aims to collect local data on the resources needed to carry out the recommendations and to generate information on the feasibility, validity, reliability and cost-effectiveness of the proposed interventions. Tools have been prepared to help put into practice the guidelines’ content and recommendations, facilitate their adaptation to local conditions and provide solutions to obstacles to improvement. These include monitoring hand hygiene practices, structure and knowledge, local production of WHO alcohol-based formulations and strategies to promote hand hygiene and train staff.

The final outcome of this process will be validating the “toolkit” on a large scale, and revising and finalising the guidelines based on lessons learned in the field. Implementation of the global patient safety challenge at the local facility level also includes actions related to other fields fundamental to HAI prevention such as blood, injection, clinical procedure and water and environment safety.

Awareness-raising and country commitment
At international and national levels, the global patient safety challenge achievement is fostered by actions to raise global awareness and inspire commitment from individual countries. The first action includes key stakeholder involvement, a dedicated page on the WHO website to post documents, advertise events and initiatives, place news alerts and offer a forum for questions and answers. It also includes creating a database of international contacts to establish networking collaboration. Commitment from countries implies strong leadership and commitment from governments to increase resources, strengthen infrastructure processes and systems, and sustain partnerships with key players to implement simple measures to prevent HAI.

Conclusions
As a priority patient safety issue, the problem of HAI needs to be addressed by a strong and effective preventive strategy. No hospital or healthcare facility around the world, no matter its level of sophistication, can claim to have solved it. In a global perspective, it will be a question of different approaches for different settings. In developed countries, the challenge for hospitals could be finding innovative strategies for reinforcing previous campaigns or introducing new, sophisticated solutions. In a resource-poor facility in a developing country, a particular effort should be made to convey the message in the simplest way and to seek low-cost, practical solutions. Hand hygiene is a very effective measure that needs to be applied worldwide alongside minimum requirements for infection control in any healthcare setting. Its promotion on a large scale according to local needs and strategies perfectly meets the slogan of the first global patient safety challenge: “Clean care is safer care.” The challenge is enormous – but the rewards are too.

References

1. Pittet D, Boyce JM. Hand hygiene and patient care:pursuing the Semmelweis legacy. Lancet Infect Dis 2001;1:9-20.
2. Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital. Infection Control Program. Ann Intern Med 1999;130:126-30.
3. Pittet D, Simon A, Hugonnet S, et al. Hand hygiene among physicians:performance, beliefs, and perceptions. Ann Intern Med 2004;141:1-8.
4. Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000;356:1307-12.
5. World Health Organization. WHO guidelines for hand hygiene in health care (advanced draft). Available  from:http://www.who.int/ patientsafety/information_centre/Last_April_versionHH_Guidelines%5b3%5d.pdf; accessed 19 July 2006.
6. Naikoba S, Hayward A. The effectiveness of interventions aimed at increasing handwashing in healthcare workers – a systematic review. J Hosp Infect 2001;47:173-80.
7. Pittet D. Improving compliance with hand hygiene in hospitals. Inf Control Hosp Epidemiol 2000;21:381 -6.
8. Pittet D. Improving adherence to hand hygiene practice: a multidisciplinary approach. Emerg Infect Dis 2001;7:234-40.