Country City Hospital Hospital wards Status of the
testing at finalization of guidelines (October 2008)
Local tool preparation and/or adaptation
AFR Mali Bamako Hôpital du
Point G
Pilot testing complete in nine units including medicine, surgery, emergency, anaesthesia and intensive care, gynaecology and obstetrics
Concluded • Leaflet for hand hygiene campaign launch • WHO-recommended
formulation
• Promotional tee-shirts
AMR Costa Rica San Jose Hospital Nacional de Niños
Targeted on subset of wards, including infectious disease
Step 5 • Training film • Hand hygiene song • Posters
• WHO-recommended formulation
SEAR Bangladesh Chittagong Chittagong Medical College Hospital
Five wards representing 450 beds
Step 4 • Translation into Bengali of most WHO tools
• Simplified 2-moments observation tool including the case of 2 patients per bed • WHO- recommended
formulation
EUR Italy National network Network of 41 ICUs ICUs selected according to the following criteria: - Having a reliable
system for HCAI surveillance (HELICS protocol; surveillance system for MRSA bacteraemia) - Explicit consent to
provide requested data (results from all WHO surveys and HCAI rates) - No other major prevention project concurrently to the strategy implementation - Compliance with the
time line agreed with WHO
Concluded • Guide to Implementation summary
• Posters
• Use of the fingertip method to educate HCWs
WHO region
Country City Hospital Hospital wards Status of the
testing at finalization of guidelines (October 2008)
Local tool preparation and/or adaptation
EMR Saudi Arabia
Riyadh King Saud Medical Complex
Hospitalwide Step 5 • Campaign original logo • Posters and banners displayed
outside the hospital
• Pens, mugs, t-shirts, round big buttons with campaign logo • Screen saver
• DVD, educational brochures and pocket leaflets for HCWs, patients (adults and children) and visitors translated into 4 different languages (arabic, english, tagalog, urdu) • Demonstrations of the hand
hygiene technique
• Use of finger tip printculture to educate HCWs and patients • Drawing book for children
with cartoons related to the campaign
• WHO-recommended formulation with alternative fragrances and emollients • National hand hygiene
guidelines
• Hand hygiene guideline summary for the HCWs during pilgrimage season Saudi Arabia Riyadh King Abdulaziz Medical City
Nine pilot areas including 7 ICUs and 2 surgical wards
Concluded • Banners and posters • Brochures for HCWs • Brochures for patients • Pocket leaflets for HCWs • Badges, pens and mugs Pakistan Islamabad Pakistan
Institute of Medical Sciences (PIMS)
Medical, surgical and neonatal ICUs
Step 4 • Translation of posters into Urdu • WHO-recommended
formulation
WPR China Hong Kong SAR Four pilot hospitals: Queen Mary Hospital, Caritas Medical Centre,
Selection of tests and control wards in the four hospitals
Concluded • Giant banners for the outside wall of the hospital
• Cartoons and other posters • Q&A leaflet responding to
HCWs’ concerns about the use of alcohol-based handrubs • WHO-recommended Table I.21.5.1
Table I.21.5.2
Lessons learnt from testing in pilot sites
Country Site Lessons learnt and suggestions for improving the WHO strategy Mali Hôpital du
Point G
• Strong support from the WHO country office was critical to overall pilot success, particularly for ministerial engagement and proposed scale-up activities
• Active support from the hospital directorate was critical to the project endorsement and development • Difficulties were experienced with some questions’ comprehension and the collection of the perception
questionnaires. These should be shortened and simplified
• Procurement of some ingredients and dispensers for the WHO-recommended formulation was not possible within the country.
• Finding an effective method for the distribution of handrub pocket bottles has been a challenging issue, especially because of the risk of being taken along outside the hospital
• Successful implementation at this pilot site has been critical to demonstrate the feasibility of the WHO Multimodal Hand Hygiene Improvement Strategy in a setting with limited resources in the African region
Costa Rica Hospital Nacional de Niños
• The national pledge was a strong driver for action
• Strong support from WHO regional and country offices has been critical to overall pilot success, particularly for proposed scale-up activity
• Strong medical and nurse leadership at the facility level was also a key factor of success
• Translation and adaptation of tools and the sourcing of alcohol-based handrub were significantly more time-consuming than originally planned and resulted in delays
• Strengthening local capacity to verify quality of the WHO formulation would significantly speed up the process for regional scale-up
• Strengthening local capacity for monitoring and evaluation, particularly data analysis, would yield significant regional and country benefits
• Advocacy could be strengthened and assist in securing donor funding, particularly having a strong case for the intervention and associated advocacy materials
• There were initially numerous aesthetic concerns relating to the alcohol-based hanrubs, particularly the perception of “dead microbes” remaining on hands as a disincentive to use the handrub
• There were recycling and environmental concerns related to alcohol- based handrub dispensers. Bottle reprocessing offered a solution
Country Site Lessons learnt and suggestions for improving the WHO strategy Bangladesh Chittagong
Medical College Hospital
• The national pledge was a strong driver for action
• Strong support form WHO regional and country offices has been critical to overall pilot success, particularly in relation to proposed scale-up activity
• Facility preparation, especially installation of handwash basins, took more time than expected. Local procurement of heavy duty sanitary equipments such as lever operated pillar taps was not possible. • The close collaboration of a doctor and a nurse as project coordinators was essential to effectively
develop and maintain hand hygiene behavioural change among all HCW and patient attendants • At the facility level, commitment by the director, strong support by the head of the newly formed
infection control committee, and strong medical and nurse leadership were significant drivers for improvement
• Production of a handrub at the para-statal Essential Drug Company Ltd (EDCL) was effective and facilitates the process to add alcohol-based handrubs to the government approved essential medical and surgical requisition list, aspect which is important for budget implication of the national scale-up • The handrub quality control, performed by the EDCL, in future should be complemented through a
WHO quality control mechanism
• The Guide to Implementation was a very useful basis for all discussions between WHO headquarters and the country and facility leads
• The five-step approach was adhered to but adaptations were made based on real-life application, in particular usability was considered an area requiring improvement (need for a simpler guide) • Strengthening local capacity for monitoring and evaluation, particularly data analysis, would yield
significant regional and country benefits
• In many cases, relatives provide routine physical care to their patient and are being encouraged to use the sinks and handrubs. Need to provide patients and relatives with information on HCAI or hand hygiene.
• Comment boxes are present in hospitals and subject to regular review, demonstrating high-level commitment and a culture supportive of patient perspectives
• The “Five moments-2” concept was considered complicated, especially as far as observation is concerned
• Initial cultural sensitivities have emerged as regards observation – staff did not like being observed • Perception, knowledge, and structure questionnaires raised questions in relation to their cultural
suitability
• The training film was not used due to lack of easy access to equipment and and re-shooting the film in a Bangladesh hospital is planned to aid scale-up
• It was not possible to procure locally durable, economic and purpose-designed wall mounted handrub dispensers and procurement abroad would have delayed the project by at least 6 months. Instead liquid soap dispenser were procured
• With the installation of sinks in the wards, soap use (and with it some theft) increased. Due to a normative annual budgeting and procurement cycle of the hospital consumables, difficulties to supply increased amounts of soap to the wards were experienced
• Local production of heavy duty flip-top dispenser head or spray head for pocket-carry bottle was not possible. Instead large numbers of spare flip-top heads were procured
• Paper towels and paper towel holder were procured from local markets
• Staff feedback on the WHO formulation was positive, though an unpleasant smell after application was reported
Italy Network of ICUs
• Strong support from the national coordination centre and the regional coordinators has been critical to the overall success of the national campaign and the testing in the ICU network
• The fact that the campaign was in partnership with a WHO campaign generated a lot of stimulation and motivation to participate and achieve the intended objectives
• The strategy approach was particularly appreciated as a very suitable model for practical
implementation of recommendations. Recommendation was made to use the same model for other interventions
Table I.21.5.2
Country Site Lessons learnt and suggestions for improving the WHO strategy Saudi Arabia King Saud Medical Complex
• Strong infection control team and support from the hospital directorate were keys to the success • In general, the WHO strategy requires considerable investment, particularly in human resources. This is
not very clear in the Guide to Implementation
• WHO should offer training on using Epi Info for data entry and especially data analysis
• When the WHO formulation (liquid) was introduced, some HCWs expressed their preference for gel products
• The knowledge questionnaire is difficult to understand in many places, especially questions 23, 24, and 25 Saudi Arabia King Abdul Aziz Medical City
• Leadership is an important success factor.
• Assessing shared beliefs and values regarding the issue of patient safety is highly important in order to create a safety culture
• A patient-centred/customer-focused approach would be beneficial. • It is important to build on system thinking and not individual thinking
• More training is needed for co-ordinators on: behavioural theories; change management; and project management principles
• A post description is needed to facilitate co-ordinator selection.
• Some questions regarding the perceptions and knowledge questionnaires are redundant and others are difficult to understand and need re-wording
• A “facilitators guide” together with the PowerPoint presentation can be very helpful. The presentation should include slides that assess the feelings (emotions) of the HCWs, i.e. photos of infections, experiences of people who were infected, etc.
• The “Let us do it Together” form to assess the “how to” perform hand hygiene (psychomotor) should be added to the other WHO tools
• A standardized “sample” reporting format is needed where metrics are shown in a consistent manner • An Excel sheet could be helpful for the calculation of product consumption
• Communication is the key component of success: to provide ideas on the topic in a very helpful and informative manner (communications management plans)
• A small guide is needed on how to overcome resistance to change
• Coordinators and project facilitators should be trained on how to address HCWs’ resistance, i.e. surprise, apprehension of the unknown, scepticism, cynicism, complacency, strong resistance, etc.
Pakistan Pakistan Institute of Medical Sciences (PIMS)
• The success of this project was possible due to strong commitment of PIMS senior management. • The project is very demanding in terms of time to be dedicated to education, because of shortage of
permament members of staff and high turnover of medical and nursing students
• Language barriers exist (especially among non-medical staff), and there is a need for translation of the WHO material into the local language (currently been undertaken)
• There are difficulties to identify some tasks as “aseptic”, e.g. dental/oral care; therefore, the wording of Moment 2 is not adequate
• Availability and production of good quality 100 ml flip-top bottles to dispense alcohol-based hand rub was challenging
• Providing a dedicated room with adequate temperature control and storage facilities for the production and storage of alcohol was a difficult task
• The Guide to Implementation was complex and difficult to understand
• Delay to obtain quality control information of locally produced WHO formulation from Geneva because of restriction of sending liquid sample by postal and couriers services
• Staff were delighted at the introduction of the WHO formulation as the commercial product previously in use had a very high incidence of dermatitis
• No religious issues were raised on the use of the alcohol-based handrub product
Hong Kong SAR
Four pilot hospitals
• Barriers to implement system change: HCWs’ concerns about the use of alcohol-based handrubs (potential skin damage, fire safety, and pocket bottle contamination) and the perception that hands are clean only after handwashing.
• Difficulties to allocate time to attend the education sessions
• No hand hygiene compliance improvement was observed among doctors. The WHO strategy should include suggestions and ideas how to induce behavioural change in different professional categories Table I.21.5.2
Table I.21.2
Action plan step-by-step
Step 1: