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Tracking the healthcare-associated burden and hand hygiene: progress

Sepideh Bagheri Nejad MD
Benedetta Allegranzi MD
Didier Pittet MD
Global Patient Safety Challenge,
Clean Care is Safer Care WHO Patient Safety,
WHO Headquarters, Geneva, Switzerland
Infection Control Programme and World Health Organization Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
Six years have passed since the launch of the World Health Organization (WHO) First Global Patient Safety Challenge Clean Care is Safer Care (CCiSC), which is aimed at tackling health care-associated infection (HAI).(1,2) The main objectives of CCiSC are awareness-raising of this worldwide patient safety issue, catalysing political and stakeholders’ commitment to reduce HAI, developing technical guidance and recommendations, and supporting related actions in WHO Member States. Through CCiSC, WHO is promoting best practices in hand hygiene and has played a major role in ensuring that HAI is recognised and addressed as an endemic burden around the world. 
Thirty-one European countries have pledged so far to address the issue within their health systems. Many have translated their commitment into practice by developing or enhancing national/sub-national campaigns to promote hand hygiene among healthcare workers. In addition, several key stakeholders have joined the programme in Europe, especially national and international infection control and hygiene societies and associations. In particular, a collaboration has been developed with the European Centre for Disease Prevention and Control (ECDC) and the European Centre for Clinical Microbiology and Infectious Diseases (ESCMID) to help achieve synergy at country level and disseminate widely WHO material and strategies. We offer here a European perspective with a special focus on the HAI burden worldwide and the main CCiSC achievements. 
Extent of the global HAI burden 
HAI is the most frequent adverse event in health care,(3) but estimating its true global burden is hampered by the difficulty in gathering reliable data. Although national surveillance systems for HAI exist in several high-income countries, this is not the case in most, especially in low- and middle-income nations. This is most probably due to the fact that surveillance is demanding and resource-expensive. In addition, the diagnosis of HAI is complex and relies on multiple criteria and not just a single laboratory test. In Europe, ECDC reported that 13/28 (46.4%) European high-income countries had national surveillance systems in place in 2008 to monitor either intensive care unit (ICU)-acquired infections, surgical site infections (SSI), or both, and were regularly reporting to the Hospitals in Europe Link for Infection Control through Surveillance (HELICS) network.(4) ECDC has recently invited all Member States to participate in a European survey on HAI prevalence by 2012 (…); 10 countries have already subscribed in 2011. 
Understanding and assessing the global burden of HAI has been one of the key areas of work within the CCiSC programme. Systematic reviews of the literature have been conducted to identify published studies from both developed and developing countries to highlight the magnitude of the HAI problem. The results were recently published in the scientific literature and as a WHO report.(5,6)
According to these reviews, 131 national or multicentre studies on HAI burden conducted in 23 high-income countries were published between 1995 and 2010. Based on available data, cumulative HAI prevalence was 8% (95% CI 7.3%-8.9%) in Europe and ranged from 3.6% to 19% in high- and low/middle-income countries, respectively.(6) ECDC reported that approximately 4,131,000 patients are affected by about 4,544,100 episodes of HAI every year in Europe, with a mean HAI prevalence of 7.1%.(7) Urinary tract infection was found to be the most frequent type of infection hospital-wide (27%), followed by lower respiratory tract infection (24%), SSI (17%), and bloodstream infection (10.5%).(7) 
The HAI burden is much more severe in high-risk populations, such as patients admitted to ICUs, burn and transplant patients, and neonates. According to a European multicentre study, the proportion of infected patients in the ICU can be as high as 51%; most of these are health care-associated.(8) According to a literature review conducted by CCiSC, HAI prevalence in high-risk populations ranged between 7.9% and 88.9% in European countries. 
European estimates indicate that HAIs cause 16 million extra-days of hospital stay, 37,000 attributable deaths annually, and contribute to an additional 110,000 deaths.(7) Furthermore, in a recent study performed in four European countries, the additional length of stay per catheter-related-bloodstream infection episode varied between 4 and 14 days. Additional associated costs per episode ranged from €4200 to €13,030, representing annual costs to healthcare systems of between €53.9 million in the United Kingdom and €130 million in France.(9)
Promoting hand hygiene improvement as a solution
Most HAIs are preventable, in particular by interrupting transmission through optimal hand hygiene practices.(10) Hand hygiene is a simple and effective solution to reduce both the spread of multiresistant germs and to protect patients from HAI.(11) The development of the WHO Guidelines on Hand Hygiene in Health Care was a cornerstone among the achievements of CCiSC. These guidelines were aimed at providing a global perspective on several key aspects of hand hygiene and were accompanied by a multimodal implementation strategy and tools shown to lead to improvement of practices in a wide range of healthcare facilities around the world. To promote adoption of the guideline recommendations by countries, CCiSC invited Member States to sign a formal statement pledging their support to take action to reduce HAI through hand hygiene improvement. As a tangible result of this commitment, 15 of the 31 signatory European countries are currently running a national hand hygiene campaign and utilizing coordinated strategies to promote hand hygiene based on the CCiSC approach (Figure 1).
SAVE LIVES: Clean Your Hands – a global annual campaign
In 2009, CCiSC launched the global annual campaign SAVE LIVES: Clean Your Hands (SLCYH) to help maintain the profile worldwide and translate the guidelines into action at the point of care. Since then, there is an annual call to action and commitment on hand hygiene improvement from front-line professionals in hospitals and other healthcare facilities worldwide. Each year features a different theme and facilities are encouraged to celebrate on or around 5 May with special events. As of  5 February 2012, 14,858 health care facilities have signed up in support of SLCYH and participated in activities proposed on or  around 5 May each year. Among these, 5069 are located in European countries. 
In the run-up to 5 May 2010, all healthcare facilities registered for SLCYH were invited to participate in a global survey by observing compliance with the Moment 1 indication for hand hygiene, i.e., “before touching a patient”. A modified observation form based on the WHO method and an online data collection system were available to participants. More than 300 facilities from 47 countries submitted data and over 76,000 opportunities were included in the analysis. Overall global compliance with Moment 1 was 51% and 64% in Europe.(12)
Assessing and sustaining action on hand hygiene improvement is critical. For 5 May 2011, WHO called for the use of a new tool, the Hand Hygiene Self-Assessment Framework (HHSAF).(13) HHSAF is a structured and validated tool to perform a situational analysis of hand hygiene resources, including promotion and practices at the facility level, and to identify gaps requiring improvement. More importantly, repeated use of the tool allows to document progress over time to ensure sustainability and continued improvement. To understand where registered facilities stand on hand hygiene around the world, WHO conducted an online Global Survey based on HHSAF use. The tool has been downloaded more than 60,000 times since 2010. The call for 5 May 2012 will be to develop an Action Plan to drive forward progress related to the indicators measured through the tool, based on an interpretation of the HHSAF results. ( 
Hand Hygiene Excellence Awards
Recognising and rewarding sites where major improvements in hand hygiene have been achieved through innovative approaches is a way to highlight progress and facilitate healthy competition. The WHO Collaborating Centre on Patient Safety at the University of Geneva Hospitals and Faculty of Medicine (HUG), in conjunction with the Asia Pacific Society of Infection Control, have launched an excellence award to recognise and honour hospitals and healthcare workers in the Asia–Pacific region who have successfully adopted and implemented the WHO multimodal hand hygiene improvement strategy. Creativity and innovation is at the heart of the award, and taking a leadership role to support other institutions in their implementation is of utmost importance in the selection of the winners. HHSAF use is an integral part of the process and applicants should be able to report on their level of progress. Every two years, two winners will be announced in two categories: Excellence in hand hygiene and Best innovation in hand hygiene. Steps to establish this initiative in Europe are underway and will be launched in 2012.  
Over the last five years, the WHO approach to hand hygiene improvement has reached many healthcare settings worldwide and is currently considered as the gold standard. More and more hand hygiene indicators are being recommended and measured at the national level and promotional activities have been embedded in national priorities to ensure effective action and sustainability. Hand hygiene can also represent an entrance door for tackling broader patient safety issues. More comprehensive approaches, including quality improvement, error reporting and learning mechanisms, visible commitment by decision-makers, and increased individual accountability among healthcare workers can strengthen health systems and ultimately lead to safer care. In Europe, many countries have taken this approach and given priority to hand hygiene in healthcare. At this stage, a more solid coordination and harmony of these efforts would be beneficial. WHO CCiSC commits to facilitate the strengthening of existent networks among hand hygiene campaigns in Europe and to motivate countries to report their performance information. Monitoring and sharing will certainly stimulate race for excellence and help long-term sustainability of hand hygiene efforts.
WHO takes no responsibility for the information provided or the views expressed in this report. 
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