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Reducing Hospital-Acquired Infections:A Systematic Evaluation of Two Successful Hand Hygiene Programs

Anthony Valdez 

Humboldt Center for Evolutionary Anthropology, Department of Anthropology, Humboldt State University, Arcata, California, 95521

IntroductionNosocomial or hospital-acquired infections (HAI’s), remain a major cause of morbidity and mortality in healthcare settings. One of the major ways to reduce the number of HAI’s is the implementation of successful hand hygiene (HH) programs (Pittet, 2000). Numerous studies have documented the importance of HH in health-care settings, yet HH compliance among health-care workers (HCW’s) is extremely low (Pittet, 2000). Here, I evaluated HH programs from two countries and identified factors contributing to their success. Based on the data, it is clear that a major factor in developing successful hand hygiene compliance programs is the development of a multimodal, multidisciplinary strategy that is adopted by local, state and federal levels as suggested by The World Health Organization guidelines on hand hygiene.

Implications Successful hand hygiene programs followed the World Health Organization Guidelines on hand hygiene in healthcare settings. The guidelines provide HCWs with a thorough review of evidence on HH in healthcare and specific recommendations to improve practices. The WHO guidelines are unique in that they provide global perspectives in implementation, they bridge the gap between developing and developed countries, and provide innovated insight on religious and cultural aspects. Educational and motivational programs for healthcare workers were also factors for successful hand hygiene programs, including factors that influence behavior. It is important to note that educational programs are not enough for lasting improvement and other behavioral influences should be included. Education is important and critical for success and represents one of the cornerstones for improvement of hand hygiene (www.who.int). Political commitment is essential to achieve improvement in infection control, 38 countries have national or subnational campaigns, excluding the United States (Figure 1). It is important for national governments to make improving HH adherence a national priority and consider a funded, coordinated implementation program while strengthening the infection control capacities within healthcare settings. Furthermore, national governments should encourage healthcare settings to use hand hygiene as a quality indicator in patient safety (www.who.int). The United States needs to get on board with its own hand hygiene initiative to increase compliance, to lower HAI prevalence and costs, and to save lives.AcknowledgmentsI would like to thank the Department of Anthropology, the College of Arts, Humanities, and Social Sciences, the Office of Research and Supporting Programs, and May Patiño for help with this research.

ReferencesAllegranzi, Benedetta, Hugo Sax, Loséni Bengaly, Hervé Richet, Daouda K Minta, Marie-Noelle Chraiti, Fatoumata Maiga Sokona, Angèle Gayet-Ageron, Pascal Bonnabry, and Didier Pittet.(2010). "Successful Implementation of the World Health Organization Hand Hygiene Improvement Strategy in a Referral Hospital in Mali, Africa." Infection Control and Hospital Epidemiology : The Official Journal of the Society of Hospital Epidemiologists of America , 31.2. 133-141. Grayson, M Lindsay, Philip L Russo, Marilyn Cruickshank, Jacqui L Bear, Christine A Gee, Clifford F Hughes, Paul D R Johnson, Rebecca McCann, Alison J McMillan, Brett G Mitchell, Christine E Selvey, Robin E Smith, and Irene Wilkinson. (2011). "Outcomes from the First 2 Years of the Australian National Hand Hygiene Initiative." The Medical Journal of Australia, 195.10. 615-619.Pittet, Didier. Improving Hand Hygiene Worldwide. [Webinar]. Retrieved from http://http://www.who.int/gpsc/5may/news/webinars/pittet_ppt_20100505_en.pdf.Pittet, Didier. (2000). “Improving compliance with hand hygiene in hospitals”. Infection Control and Hospital Epidemiology, 21(6), 381-386. Sax, H, B Allegranzi, I Uçkay, E Larson, J Boyce, and D Pittet. ( 2007). "'My Five Moments for Hand Hygiene': A User-centred Design Approach to Understand, Train, Monitor and Report Hand Hygiene." The Journal of Hospital Infection, 67.1. 9-21.

The World Health Organization (WHO) Guidelines on Hand Hygiene

WHO Multimodal 5 step Hand Hygiene Strategy:

One System ChangeAlcohol-based handrubs at point of care and access

to safe continuous water supply, soap and towels.

Two Training and education Providing regular training to all Health-care workers.

Three Evaluation and feedbackMonitoring hand hygiene practices, infrastructure,

perceptions, and knowledge, while providing results feedback to health-care workers.

Four Reminders in the workplacePrompting and reminding health-care workers.

Five Institutional safety climateIndividual active participation, institutional support,

patient participation.

Hand Hygiene in Mali, Africa Full implementation of the WHO strategy at University Hospital, Bamako, Mali Local production of pocket bottles of the WHO hand rubbing formulation. Increased ministerial engagement on national scale. Implementation of the WHO’s Multimodal 5 step HH Key educational messages was based on the WHO’s “My five moments for hand hygiene.” Participants attend an education session including training films. Results: Increase of HH compliance and drop in HAI prevalence.

The World Health Organization: “My five moments for hand

hygiene”

Hand hygiene is a core element of patient safety. Its promotion represents a challenge that requires a multimodal strategy using clear and simple conceptual framework.

The development of “My five moments for hand hygiene” involved a user-centered approach incorporating strategies of human factors and cognitive behavior (Sax et al, 2007). It describes fundamental reference points for HCWs in a time-space framework and designates moments when hand hygiene is necessary (Sax et al, 2007).

“My five moments for hand hygiene” bridges the gap between scientific evidence and daily health practice (Sax et al, 2007).

Australian National Hand Hygiene Initiative Based on WHO’s “My five moments for Hand Hygiene” A cultural change program that established a multi-site model which involved the employment of both central and state-based HH educators (Grayson et al, 2011). This approach allowed both the central development of important culture change, education, and data recording materials. National Program with Government funding Executive Leadership and Jurisdictional Support (Grayson et al, 2011). Conducted up to 200 training workshops in all Australian states and territories. Established a network of ‘gold standard’ auditors who helped train other HCWs. Results: Increase of HH compliance and drop in HAI prevalence.

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World Health Organization, figure 1

This graph illustrates an increase in educational engagement through the National Hygiene Initiative.

Knowledge of hand hygiene before and after the WHO’s ‘My five moments for hand hygiene’ in Mali, Africa.