The Golden Rules For Hand Hygiene Best Practices
The golden rules forhand hygiene best practicesBenedetta AllegranziInternal LeadClean Care is Safer CareWHO Patient SafetyESCMID/WHO WCC/GINERB-SIMIT WorkshopRome, 30 November-2 December 2011
The golden rules for hand hygiene bestpracticesŶ Please do it!¾because of hand transmission
Hand transmissionŶ Hands are the most common vehicleŶ Skin microbial floraŶ Resident flora long term, S epidermidis and othersŶ Transient floraShort term minutes-hrs-days-wksBacteria - S aureus (10-78%), VRE, GNB, C difficileFungi- yeastsViruses,-rotavirus, rhinovirus, HCVŶ Transmission requires 5 sequential steps
Step 1:Germs are present on patient skin andsurfaces surrounding the patientŶ Germs present on intact skinŶ Skin squames containing viablegerms are shed continuously from normalskin - immediate surroundings(bed linen, furniture, objects) becomecontaminatedŶ Pathogen and count can vary patient,microorganism and environmentalcharacteristicsPittet D et al. The Lancet Infect Dis 2006
Step 2:Patient germs contaminate HCW hands by directand indirect contactŶ Risk varies type and duration of patient care, location etcŶ Glove contamination similar to hand contaminationŶ Gloving does not fully protect hands from contaminationŶ In a general health-care facility,29% nurses carried S. aureusand 17 30% GNB on their handsŶ Hands contaminated even during³&OHDQ DFWLYLWLHV OLIWLQJ SDWLHQWV taking the patient's pulse etc),e.g. 100 1,000 CFU of Klebsiella spp.Pittet D et al. The Lancet Infect Dis 2006
Step 3:Germs survive and multiply on health-careworkers' handsŶ Germs can survive on hands for differing lengths of timeŶ The duration depends on several factors including the pathogen,humidity, skin area etcPittet D et al. The Lancet Infect Dis 2006
Length of survival of organismPathogenLength of survival of organismInfluenza virus24-48 hours on nonporous surfacesParainfluenza virus10 hours on nonporous surfaces; 6 h on clothingSARS-associated coronavirus24-72 hours on fomites and in stool samplesNoroviruses 14 days in stool samples; 12 days on carpetsHepatitis B virus7 daysClostridium difficile5 months on hospital floorsPseudomonas aeruginosa7 hours on glass slideAcinetobacter baumannii33 days on plastic laminate surfacesMRSA ZHHNV DIWHU GU\LQJ GD\V RQ SODVWLF ODPLQDWH VXUIDFHVVRE GD\V RQ FRXQWHUWRSV7
Step 4:Defective hand cleansing results in handsremaining contaminatedŶ Insufficient amount of product and/or insufficient duration ofhand hygiene action lead to poor hand decontaminationŶ Transient flora are still recovered on hands followinghandwashing with soap and water, whereas handrubbingwith an alcohol-based solution has been provensignificantly more effectivePittet D et al. The Lancet Infect Dis 2006
Step 5:Germ cross-transmission between patient A andpatient B, devices and environment via handsTransmissibility depends on type of surface, inoculum load, moisturelevel of surface, microorganism etcPittet D et al. The Lancet Infect Dis 2006
The golden rules for hand hygiene bestpracticesŶ Please do it!because of hand transmission¾ because you think you do it but you don't!¾
Hand hygiene complianceis a problem !12
Compliance with hand hygienein different health-care facilities - WorldwideAuthorYearSectorCompliance (%)Preston1981General -wide45DonowitzAverage: 38.7%1987Neonatal ICU301990ICU321990ICU81Pettinger1991Surgical ICU51Larson1992Neonatal 94Emergency Room32Pittet1999Hospital-wide48GrahamDubbertWHO Guidelines on Hand Hygiene in Health Care 2009, Chapter 16
engeria%AlComplianceHand hygiene compliance in low income countries6053503832302217600
Perceived hand hygiene complianceamong health-care workers (2137 respondents)Perceived percentage of opportunities with correct handhygiene by oneself(median and 25-75th percentile)120100%806040200Costa RicaItalyMaliPakistanKAMCKSMCPilot SiteAllegranzi B et al. ECCMID 2010
Impact on hand hygiene practices in Mali7060604850424140%333132302024 252016 17 171410422BaselineFollow-up2-y studedMDoctor0Allegranzi B et al. Infect Control Hosp Epidemiol. 2010 Feb;31:133-41
Self-reported factors for poor adherence withhand hygieneŶ Often too busy/insufficient timeŶ Hand hygiene interferes with HCW-patient relationŶ Low risk of acquiring infection from patientsŶ Lack of role model from colleagues or superiorsŶ Not thinking about it/forgetfulnessŶ Scepticism about the value of hand hygieneŶ Disagreement with the recommendationsŶ Lack of scientific information of definitive impact of improvedhand hygiene on HAIŶSkin irritation, glove useWHO Guidelines on Hand Hygiene in Health Care 2009
The golden rules for hand hygiene bestpracticesŶ Please do it!because of hand transmission¾ because you think you do it but you don't!¾ because it's your duty!¾
%DODQFLQJ ³1R %ODPH ZLWK Accountability in Patient Safety"Many health care organizations haverecognized that a uni-dimensional focus oncreating a blame-free culture carries itsRZQ VDIHW\ ULVNV« 7KHUHIRUH WKH need tocreate accountability for failure to followgold-standard practices KDV EHHQ LGHQWLILHG«Robert M. Wachter and Peter J. Pronovost. NEJM 2009
Addressing some ofWKH ³EDUULHUV Saint S et al. Jt Comm J Qual Patient Saf. 2009;35:239-46
The golden rules for hand hygiene bestpracticesŶ Please do it!because of hand transmission¾ because you think you do it but you don't!¾ because it's your duty!Ŷ Promote it through a multimodal strategy!¾
Impact of hand hygiene promotion on HAIŶ 1977- Feb 2011, 30 studies investigated the impact of handhygiene (as a single intervention) to reduce HAIŶ 27 showed that behavioural change, illustrated by improvedhand hygiene compliance, leads to the reduction of HAI,particularly BSI and SSIŶ Only 3/30 studies showed no significant impact on HAI butin 2 hand hygiene compliance did not increase significantlyŶ An increasing number of studies have investigated thecorrelation between alcohol-based handrub consumptionand HCAI rates B. Allegranzi & D. Pittet. JHI 2009;73:305-15 B. Allegranzi & D. Pittet. Hand hygiene. In: Principles and Practice of Disinfection,Preservation and Sterilization. Wiley-Blackwell B. Allegranzi & D. Pittet. Hand hygiene improvement. In: Hospital Infection Control.Decision Support in Medicine, LLC
Impact of hand hygiene (HH) promotion on MRSA ceImpact on MRSA infection2000Larson E etalMICU/NICUMultiple components intervention organizational culture changeNANo significant change in MRSA2000Pittet D et alHospital-wideAlcohol-based HR, HH observation,training, performance feedback, postersFrom 48% to66%Significant reduction annual prevalence ofHAI (42%) and MRSA cross-transmissionrates (87%).2004MacDonaldA et alHospital-wideAlcohol-based HR, HH observation,posters, performance feedback, informaldiscussionsNS increase ofHH complianceSignificant reduction in MRSA cases (from1.9% to 0.9%)2005Johnson etalHospital-wideAlcohol-based HR, HH observation,training, posters, promotional gadgetsFrom 21% to42%Significant reduction (57%) in MRSAbacteremia2008Grayson MLet al1) 6 pilot hospitals2) all publichospitals in Victoria(Australia)Alcohol-based HR introduction, HHobservation, training, posters,promotional gadgets1) From 21% to48%2) From 20% to53%Significant reduction of MRSA bacteraemiaand of clinical MRSA isolates2008Cromer ALet alHospital-wideDirect HH observation, feedbackFrom 72.5% to90.3%*Significant reduction in MRSA from 0.85 to0.52 per 1000 patient-days2009Lederer JWet alHospital-wide,seven acute carefacilitiesEducation, HH observation andperformance feedback, posters, memosand poster-board communications, visitoreducation, internal marketing campaignFrom 49% to98% withsustained rates 90%Significant reduction of MRSA rates from0.52 episodes per 1000 pt-days to 0.24 per1000 pt-days2009McLaws etalHospital-wide in 208public hospitals(statewide)Alcohol-based HR introduction, HHobservation, training, performancefeedback, postersFrom 47% to61%Significant reduction of 6% of overall MRSAinfections/10,000 patient-days. 16%reductions in MRSA infection in non-sterilesites in ICU and 25% in sterile sites in nonICU wards2010Cheng VCCet alAdult ICUAlcohol-based HR introduction, briefingand discussion sessions, posters, HHobservationFrom 29% to64%Significant reduction of incidence density ofICU onset bacteraemic and non bacteraemicMRSA infection
Implementation strategy and toolkit for theWHO Guidelines on Hand Hygiene in HealthCareKnowledge & evidenceAction
What is the WHO Multimodal Hand HygieneImprovement Strategy?Based on theevidence andrecommendationsfrom the WHOGuidelines on HandHygiene in HealthCare (2009),made up of5 corecomponents, toimprove handhygiene in healthcare settingsONE System changeAlcohol-based handrubs at point of careand access to safe continuous water supply, soap and towelsTWO Training and educationProviding regular training to all health-care workersTHREE Evaluation and feedbackMonitoring hand hygiene practices, infrastructure, perceptions, &knowledge, while providing results feedback to health-care workersFOUR Reminders in the workplacePrompting and reminding health-care workersFIVE Institutional safety climateIndividual active participation, institutional support, patient participation
Guide to Implementation & tools to translate*XLGHOLQHV LQWR SUDFWLFH« Available at http://www.who.int/gpsc/5may/tools/en/index.html
Implementation tools:For System changeŶ Ward Infrastructure SurveyŶ Alcohol-based Handrub Planning and Costing ToolSystem change:1 Production:Ŷ Guide to dat ensuring that the necessary equipmentand/ Handrubfacilities Consumptionfor hand hygieneŶ SoapSurveyare in place.Alcohol-basedhandrubsat pointof careŶ Protocolfor Evaluationof Tolerabilityand Acceptabilityof Alcohol-basedHandrubin Use or Plannedbeandaccess to safecontinuouswatertosupply,Introduced: Method 1soap and towelsŶ Protocol for Evaluation and Comparison of Tolerabilityand Acceptability of Different Alcohol-based Handrubs:Method 2
Examples of hand hygiene productseasily accessible at the point-of-care
Implementation tools forTraining / EducationŶ Slides for the Hand Hygiene Co-ordinatorŶ Slides for Education Sessions for Trainers, Observers andHealth-CareWorkers2Ŷ Hand Hygiene Training FilmsTrainingandeducationŶ Slides Accompanying the Training FilmsŶ Hand Hygiene Technical Reference ManualŶ Frequently AskedQuestionsProvidingregular trainingŶ Key ScientifictoPublicationsall health-care workersŶ Hand Hygiene Why, How and When BrochureŶ Glove Use Information LeafletŶ Sustaining Improvement Additional Activities forConsideration by Health-Care Facilities
The importance of education within handhygiene promotion strategies (1975- June 2008)Ŷ Staff education represents one of the cornerstones forimprovement of hand hygiene practicesŶ 21/39 identified risk factors for poor hand hygiene orperceived obstacles could be addressed through bettereducationŶ 29/51 major studies to assess the effect of hand hygienepromotion included an education componentŶ Education was a core component of hand hygienepromotion in 17/18 national/sub-national campaigns in 2007Ŷ However, educational programmes alone are inadequatefor long-lasting improvement and they must be sustained(continuous training)WHO Guidelines on Hand Hygiene in Health Care 2009
Suggested methods to achieve educationgoals (WHO Guide to Implementation)Ŷ Regular presentations, including induction of newstaffŶ e-learning/self-learning modulesŶ PostersŶ Focus groupsŶ Reflective discussionŶ Videos/practical demonstrationsŶ Feedback from assessmentŶ Buddy systems
Implementation tools forEvaluation and feedbackŶ Hand Hygiene Technical Reference ManualŶ Observation Form and Compliance Calculation3FormEvaluation and feedbackhygienepractices, infrastructure,Ŷ MonitoringPerceptionhandSurveyfor Health-CareWorkersperceptions & knowledgeŶ Perception Survey for Senior ManagersProviding results feedback to health-care workersŶ Hand Hygiene Knowledge Questionnaire forHealth-Care Workers
Implementation tools forReminders in the workplaceŶ Your 5 Moments for Hand Hygiene PosterŶ How to Handrub Poster4Ŷ How to Handwash PosterReminders in the workplaceŶ HandHygiene:and HowLeaflet workersPromptingandWhenremindinghealth-careŶ SAVE LIVES: Clean Your Hands Screensaver
Adoption and adaptation of Clean Care is Safer Care eniaCosta iaBelgiumHong KongWHO-OMSPortugalEngland & udi ArabiaSingaporeMali
Implementation tools forInstitutional safety climateŶ Template Letter to Advocate Hand Hygiene toManagersŶ TemplateInstitutionalLetter to CommunicateHand Hygienesafetyclimate5Initiativesto ManagersIndividualactive participation,institutionalsupport,Ŷ Guidance on EngagingPatientsand PatientpatientOrganizations inHandparticipationHygiene InitiativesŶ Sustaining Improvement Additional Activities forConsideration by Health-Care FacilitiesŶ SAVE LIVES: Clean Your Hands PromotionalDVD
Commitment of ministerial and hospital authorities (Mali)
Sustaining Improvement AdditionalActivities for Consideration by Health-CareFacilitiesŶ E-learning toolsŶ Symposia, lectures, debatesŶ 3UHVHQWDWLRQ SXEOLFDWLRQ RI \RXU IDFLOLW\¶V GDWD RQ documented improvements in HCAIŶ Discussion papers on hand hygieneŶ Patient involvement and empowermentŶ Sharing experience: internal/externalŶ Personal accountability for health-care workersŶ Rewards for compliance
Patient involvement and empowerment
The golden rules for hand hygiene bestpracticesŶ Please do it!because of hand transmission¾ because you think you do it but you don't!¾ because it's your duty!Ŷ Promote it through a multimodal strategy!Ŷ Do it at the right time!¾
7KH ³0\ 0RPHQWV IRU DQG \JLHQH approachProposes a unified vision: for trainers, observersand health-care workers to facilitate education to minimize interindividual variation to increase adherenceSax H et al. Journal Hospital Infection 2007
The patient zoneand the contacts occurring within it2315H Sax, University Hospitals, Geneva 202006
The geographical conceptualizationof the transmission riskHEALTH-CARE AREAPATIENT ZONECritical site withinfectious riskfor the patientCritical sitewith body fluidexposure risk
Patient zone and health-care areaŶ Focusing on a single patient, the health-care setting isdivided into two virtual geographical areas, the patientzone and the health-care area.Ŷ Patient zone: it includes the patient and some surfacesand items that are temporarily and exclusively dedicatedto him or her such as all inanimate surfaces that aretouched by or in direct physical contact with the patient(e.g. bed rails, bedside table, bed linen, chairs, infusiontubing, monitors, knobs and buttons, and other medicalequipment).
Health-care areaŶ Health-care area: it contains all surfaces in the healthcare setting outside the patient zone of patient X. Itincludes: other patients and their patient zones and thewider health-care facility environment. The health-carearea is characterized by the presence of various andnumerous microbial species, including multi-resistantgerms.
OPTIMAL HAND HYGIENE SHOULD BE PERFORMEDAT THEPOINT-OF-CARE
Point-of-careŶ Point-of-care place where three elements occurtogether: the patient, the health-care worker, and care ortreatment involving patient contact (within patient zone)Perform hand hygiene at recommended moments exactlywhere care delivery takes placeŶ A hand hygiene product (e.g. alcohol-based handrub)must be easily accessible and as close as possible (e.g.ZLWKLQ DUP¶V UHDFK WR SRLQW RI FDUH 3RLQW-of-care productsshould be accessible without leaving patient zoneThis enables HCW to easily fulfil the 5 indications(moments) for hand hygiene
WHO recommendations areconcentrated on 5 moments (indications)The 5 MomentsConsensus recommendationsWHO Guidelines on Hand Hygiene in Health Care 20091. Before touchinga patientD.a) before and after touching the patient (IB)2. Before clean /asepticprocedureD.b) before handling an invasive device for patient care, regardless of whetheror not gloves are used (IB)D.d) if moving from a contaminated body site to another body site during careof the same patient (IB)3. After body fluidexposure riskD.c) after contact with body fluids or excretions, mucous membrane, non-intact skinor wound dressing (IA)D.d) if moving from a contaminated body site to another body site during careof the same patient (IB)D.f) after removing sterile (II) or non-sterile gloves (IB)4. After touchinga patientD.a) before and after touching the patient (IB)D.f) after removing sterile (II) or non-sterile gloves (IB)5. After touchingpatientsurroundingsD.e) after contact with inanimate surfaces and objects (including medical equipment)in the immediate vicinity of the patient (IB)D.f) after removing sterile gloves (II) or non-sterile gloves (IB)Table of correspondence between the indications and the WHO recommendations
My 5 Moments for Hand HygieneImmediately beforeaccessing a critical site:KHQ OHDYLQJ WKH SDWLHQW¶V VLGH after touching a patient andBeforetouchingaftera touching any objectWhen leavinghis/herimmediate surroundingspatientRU IXUQLWXUH LQ WKH SDWLHQW¶V LPPHGLDWH Toprotect yourselfandhavingthe touchedsurroundings,withoutToprotect the patienthealth-careenvironment fromthe patient!againstharmful germsharmful germs!carriedon yourhandsTo protectyourselfand the health-careenvironment against germ spreadTo protect the patient againstharmful germs, including theSDWLHQW¶V RZQ HQWHULQJ bodyAshis/hersoon asa task involvingexposure risk to body fluidshas ended (and after gloveremoval)To protect yourself and thehealth-care environment fromharmful germs
The 5 Moments apply to any setting where health careinvolving direct contact with patients takes place
Practically speaking: Rethinking hand hygiene improvementprograms in health care settingsA procedure-focusedapproach and theimportance ofunderstanding handhygiene within theworkflowSon et al.Am J Infect Control 2011;39:716-24
The golden rules for hand hygiene bestpracticesŶ Please do it!because of hand transmission¾ because you think you do it but you don't!¾ because it's your duty!Ŷ Promote it through a multimodal strategy!Ŷ Do it at the right time!Ŷ Do it with the right technique!¾
Application time of hand hygiene andreduction of bacterial contaminationBacterial contamination (mean log 10 reduction)0Handrubbing is: more effective faster better toleratedHandwashingHandrubbing1234560 15sec 30sec1 min2 min3 min4 minPittet and Boyce. Lancet Infectious Diseases 2001
How to handrubTo effectively reduce thegrowth of germs on hands,handrubbing must beperformed by following all ofthe illustrated steps.This takes only 20 30seconds!
How to handwashTo effectively reduce thegrowth of germs on hands,handwashingmust last 40 60 secsand should be performed byfollowing all of the illustratedsteps.
The golden rules for hand hygiene bestpracticesŶ Please do it!because of hand transmission¾ because you think you do it but you don't!¾ because it's your duty!Ŷ Promote it through a multimodal strategy!Ŷ Do it at the right time!Ŷ Do it with the right technique!Ŷ Use gloves appropriately!¾
Hand hygiene and glove useGLOVES PLUSHAND HYGIENE CLEAN HANDSGLOVES WITHOUTHAND HYGIENE GERMTRANSMISSION
Future Microbiology 2011; 6(8), 835-837
Key points onhand hygiene and glove use (1)Ŷ Indications for glove usedo not modify anyindication for handhygieneŶ Glove use does notreplace any handhygiene action
Key points onhand hygiene and glove use (2)When indications for gloves use and hand hygiene applyconcomitantlyŶ 7KH %HIRUH ,QGLFDWLRQV - hand hygiene shouldimmediately precede glove donning122
Key points onhand hygiene and glove use (3)When indications for gloves use and hand hygiene applyconcomitantlyŶ The "After" Indications - hand hygiene should immediatelyfollow glove removal12
Key points onhand hygiene and glove use (4)When an indication for hand hygiene applies while glovesare on, then gloves must be removed to perform handhygiene as required, and changed if needed.
The golden rules for hand hygiene bestpracticesŶ Please do it!because of hand transmission¾ because you think you do it but you don't!¾ because it's your duty!Ŷ Promote it through a multimodal strategy!Ŷ Do it at the right time!Ŷ Do it with the right technique!Ŷ Use gloves appropriately!Ŷ Monitor and feedback!¾
Hand hygiene monitoringŶ Monitoring hand hygiene complianceŶ Direct observation (gold standard)Ŷ Self reportingŶ Indirect measurement through product usage manual or automated
Significant reduction of Methicillin-resistant S.aureus burden in 38 French hospitals (1993-2007)ATB consumptreduction Following the launch of the ABHRcampaign the consumption of ABHRincreased regularly from 2000 to 2007(2 to 21 L per 1000 HD) In acute care hospitals, MRSA ratedecrease was sharper after the launchof the ABHR campaign (-2% vs -4.7%per year)Jarlier V et al. Arch Intern Med. 2010;170:552-559
Increased use of ABHR and successfuleradication of MRSA from a NICUABHR at the bed-side educationThe intervention in this study was ABHR location at the bed-side (previouslyavailable in the room corners) and education, but isolation and even cohortingimpossible because of nurse shortage.Sakamoto et al. Am J Infect Control 2010
60Decrease in MRSA BSI and procurement of ABHRs in148 acute NHS Trusts (July 2004-December 2007)monthAlcohol Hand RubCombinedLiquid -fold increase incombined use to 60 mlsper pt-dayAnalysis shows highlysignificant associationbetween each ml of AHRused and 1% drop fall inMRSA BSIStone S et al. ECCMID 2009 (abstract O140)
Courtesy of Dr John Boyce
Compliance with hand hygieneCOMPLIANCEperformedhand hygiene actions (x uired hand hygiene actions(opportunities)
Observation FormŶ Detailed instructions areavailable on the back ofthe form, to be consultedduring observationSax H, et al.Am J Infect Control. 2009;37:827-34.
King Abdulaziz Medical City, Saudi Arabia Hand hygiene compliance 09-May09-Jul09-Sep09-Dec10-Feb5945403020100Overall complianceCourtesy: Dr Ziad Memish/Dr H Balkhy
Grayson L et al. Med J Austr; 195; 5 Dec 2011
Hand Hygiene Self-Assessment FrameworkAims of the Framework1. Provide systematic situation analysis of hand hygienestructures, resources, promotion and practices within ahealth-care facility2. Facilitate development of an action plan forVWUHQJWKHQLQJ WKH IDFLOLW\¶V KDQG K\JLHQH LPSURYHPHQW programme3. Document progress over time through the repeated use
http://www.who.int/gpsc/5may/en/
WHO Hand Hygiene Self-AssessmentFramework Global SurveyUse the WHO Framework to identify your facility'sprogress in hand hygieneANDSubmit your results online to WHOto help obtain a global picture of hand hygieneprogress and identify areas for improvement!To participate in the global survey go tohttp://www.who.int/gpsc/5may/hhsaf submissions/en/index.htmlor send an email to WHOframework.survey@who.int
The golden rules for hand hygiene bestpracticesŶ Please do it!¾ because of hand transmission¾ because you think you do it but you don't!¾ because it's your duty!Ŷ Promote it through a multimodal strategy!Ŷ Do it at the right time!Ŷ Do it with the right technique!Ŷ Use gloves appropriately!Ŷ Monitor and feedback!Ŷ Don't think that you're done!
Sustaining hand hygiene promotion
:H KDYH D YHU\ ORQJ ZD\ WR JR \HW«EXW WKH GHPDQG is high and our commitment and motivation too!
Thank youWHO Clean Care is Safer CareFind all information at www.who.int/gpsc/5maySend enquiries to savelives@who.int
Hand transmission vHands are the most common vehicle vSkin microbial flora vResident flora long term, S epidermidis and others vTransient flora Short term minutes-hrs-day
May 02, 2018 · D. Program Evaluation ͟The organization has provided a description of the framework for how each program will be evaluated. The framework should include all the elements below: ͟The evaluation methods are cost-effective for the organization ͟Quantitative and qualitative data is being collected (at Basics tier, data collection must have begun)
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