Hand hygiene: Sounds easy, but not when it comes to implementation

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Article

Reference

Hand hygiene: Sounds easy, but not when it comes to implementation

KILPATRICK, Claire, et al.

KILPATRICK, Claire, et al . Hand hygiene: Sounds easy, but not when it comes to

implementation. Journal of Infection and Public Health , 2019, vol. 12, no. 3, p. 301-303

DOI : 10.1016/j.jiph.2019.04.008 PMID : 31053515

Available at:

http://archive-ouverte.unige.ch/unige:134647

Disclaimer: layout of this document may differ from the published version.

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JournalofInfectionandPublicHealth12(2019)301–303

ContentslistsavailableatScienceDirect

Journal of Infection and Public Health

j o u r n al ho me p ag e :h t t p : / / w w w . e l s e v i e r . c o m / l oc a t e / j i p h

Hand hygiene: Sounds easy, but not when it comes to implementation

Hand hygiene is an action, and ultimately, an important behaviour for people both providing or receiving care. At ﬁrst glance, it soundseasy to implement acrossall healthcare set- tingsandsystems,irrespectiveofcultural,geographicalorresource backgrounds.However,hand hygieneis notinherent tohuman nature,andchallengestohandhygieneimplementationhavebeen recognised[1].Successreliesonamultimodalapproachtoimple- mentation across different healthcare settings, staff categories, wardtype,healthsystemsandcountries[2,3].TheannualWorld HandHygieneDayisfacilitatedbytheWorldHealthOrganization (WHO)andcommemoratedonandaroundevery5thofMaysince 2009.Eachyear,theWHOSAVELIVES:CleanYourHandscampaign hasa differentthemeaimedatengaging peopleinpatient and healthworkersafety.Itsmainobjectiveistodrivethemomen- tumaroundinfectionpreventionandcontrol(IPC)moregenerally, andinparticular,tosustainawarenessforcontinuoushandhygiene improvement.Thisyear,the5Maythemeis“Cleancareforall–it’s inyourhands”.

Timelyandappropriate handhygieneaction preventsavoid- ableharmandsaveslivesthroughreducinghealthcare-associated infections(HAI),andsavingresources[1].Thesystematicrecourse to alcohol-based handrubbing, at key moments during patient carehasproventobecriticalfor patientsafety.Facedwiththe ever-increasingburdenofantimicrobialresistance,theimpactof aseeminglysimplegestureneedstobeemphasized,considering its potential to limit the use of antibiotics by reducing cross- transmissionandlimitingtheresistancereservoir[4].Inaddition, thelinktothisyear’s5thofMaycampaigntheme,theuniversal healthcoverage(“healthforall”)agenda,providesanopportunity tofurtherdemonstratethat IPCmeasures,andhandhygiene in particular,arecornerstonetosafe,qualityhealthcaredelivery.

Considering all the recognized advantages of implementing handhygiene,anditscriticalroleinsafe,qualityhealthcaredelivery,onewouldassumethatsuchalife-savinginterventionwould be applied universally, at appropriate times [5] using therec- ommendedtechnique[6].Thisishowevernotthecase.Evenin situationswhenthemajorityoftheelementsofthemultimodal strategyforbehaviourimprovementareinplace,theomissionof asingleelementcanresultindefective,orattheleastsuboptimal, handhygieneaction[7].

TheWHOapproach

TheWHOmultimodalimprovementstrategy(MMIS)includes both individual and collective aspects of behaviourand infras- tructurechanges,and hasprovensuccessfulin a largerange of

healthcare settings [2]. It comprises ﬁve elements which both introduceandsubsequentlysupportsustainedbehaviourchange, namely;(1)systemchange,(2)trainingandeducation,(3)monitor- ingandperformancefeedback,(4)remindersintheworkerplaces, and(5)institutionalsafetyclimate/culturechange(Fig.1).

System change needs toenable IPC practices and therefore shouldincludeaspectstoimproveinfrastructure,equipment,sup- pliesandadditionalresources,intherightplacesandtherighttimes [5].Systemchangemustbeachievedinorderforallactorstoview handhygieneas“easy”todointheirroutinehealthcarepractices.

Systemchangemeansthatalcohol-basedhandrubmustbeavail- ableatthepointofpatientcare,i.e.withinanarm’sreachforthe healthworker.

Trainingand education aimsto improvehealth care worker knowledge[7].Theseactionsplayakeyrole inincreasinghand hygiene compliance. Atthe facility level, team and taskbased strategies shouldbe regular, participatory and include bedside andsimulationtrainingtoensurethathandhygieneimprovement affectstherisksofHAIandantimicrobialresistance.

Monitoringand performance feedbackassesses the problem athand,drives appropriatechangeand canensuredocumenta- tion of practiceimprovement totrack progress over time. This hasbeen demonstrated through many aspects of IPC, and was recentlyoutlinedatthegloballevel throughthepublicationon twosurveyswherehealthcarefacilitiescompletedtheWHOhand hygiene self-assessment framework [8]. It has been acknowl- edgedthatpositive feedbackcanbeanincentiveforhealthcare workers, as evaluating theperformance of IPC programmes in a non-punitive way supports theright institutional culture for improvement.

Reminders in the workplace and communications aim to promote the WHO 5 Moments for Hand Hygiene and desired healthcareworkerbehavior[5].Itisimportanttonotethatallele- mentsofthepromotionstrategyareimportant,andthatworkplace reminderswillnotworkiftheotherelementsofthestrategyare notinplace.

Achievinganinstitutionalsafetyclimate,andapositivesafety culturechangewithinhealthcarefacilitiesmeansthattheorganiza- tionmustvaluetheinterventionandneedstofocusoninvolvement of senior managers, champions or role models. This last point is oftenthemostchallenging, but essentialtoallowfor lasting behaviourchange.Itisoftendependentondeeplocalunderstand- ingofhowtoinﬂuencehealthcareworkerbehaviour.Healthcare facilitiesthatdemonstrateleadershipqualities,andenhancethe safetyculturemustalsoincludepatientinvolvementandempow- erment[9].

https://doi.org/10.1016/j.jiph.2019.04.008

1876-0341/©2019TheAuthors.PublishedbyElsevierLimitedonbehalfofKingSaudBinAbdulazizUniversityforHealthSciences.Thisisanopenaccessarticleunderthe CCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

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302 Handhygiene:Soundseasy,butnotwhenitcomestoimplementation/JournalofInfectionandPublicHealth12(2019)301–303

Fig.1. WHOmultimodalimprovementstrategy.

Essentially,inordertoaffectbehaviouritisnotenoughtomake ataskeasier;thetaskmustbecomeasnaturalaspossiblewithin healthcarepracticesandultimatelymustbeadoptedasanormby allinvolved.

Afocusonaffectingbehaviour

Modificationofhabits,inparticularinthefieldofhealthcare,is attheheartofarelativelynewdisciplineinmedicine:thescience ofimplementation.Implementationsciencecanbedefinedas“the scientificstudyofmethodstopromotethesystematicuptakeof researchfindingsandotherevidence-basedpracticesintoroutine practice,and,hence,toimprovethequalityandeffectivenessof healthservicesandcare”[10].Studiesconductedinthisfield,show theadvantagesofusingpsychologicalbasisinimplementationpro- grammesthataimtointroducenewbehaviour[11].

AccordingtoWHO,itisimportanttoconsiderthepsychologi- calandbehaviouralaspectsinordertofacilitatealastingchange [1].Therearemultiplelevelstobeconsidered:individual,inter- individualorcollective.It explainswhyprogrammesthattarget onlythe individuallevel, with onlyinformation or training for example,giveonlymoderateresults.

Anotherproblemhighlightedbystudiesfocusingonthepsy- chologicalaspectofhandhygieneisthattheactionisnotatotally newbehaviourforthecaregivers.Indeed,thefoundationsofthis behaviouralreadyappearedduringchildhoodandareassociated withaconceptofself-protectionagainstwhatisseenas“dirty”

[1,12].Therefore,withouta focusedhealth careimplementation programme,acaregiverwillcleantheirhandsonlyiftheycon- siderthattheirgestureperformedortheareatheyhavetouched isunclean.Often,simpledailygestures,suchascheckingthepulse

ofapatientorﬁxingthepatient’sbedsheets,willnotbeconsid- eredasdirty,and,thus,wouldnotinducehandhygienebehaviour (Moment1ofthe5MomentsforHandHygiene).Considerationof

“whatisclean”and“whatisnotclean”dependsonmultiplecom- ponentssuchasculture,education,habitsandlifeevents,withall ofthisbeingdifferentforeachperson.

Conclusion

Handhygieneisabeneﬁcialpracticeatmultiplelevels.Improve- mentcanbeachievedbyapplyingamultimodalbehaviourchange improvementstrategy.Thisyear’sWHOhandhygieneannualday focuses onquality health carefor all. It is a strongand timely reminder of the need toconstantly take stepsto improve and thisneedsmultifacetedaction.Handhygieneactionsandchang- ingbehavioursarenoteasy,butveryworthyofattentionwhen consideringthelivesthatcanbesavedandimproved.

Funding

Nofundingsources.

Competinginterests Nonedeclared.

Ethicalapproval Notrequired.

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Handhygiene:Soundseasy,butnotwhenitcomestoimplementation/JournalofInfectionandPublicHealth12(2019)301–303 303 Acknowledgements

This work is supported by the World Health Organization (WHO),Geneva,Switzerland,andtheInfectionControlProgramme andWHOCollaboratingCentreonPatientSafety(SPCI/WCC),Uni- versity of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland;handhygieneresearchactivitiesattheSPCI/WCCare alsosupportedbytheSwissNationalScienceFoundation(grantno.

32003B163262).

DidierPittetworkswithWHOinthecontextoftheWHOini- tiative‘PrivateOrganizationsforPatientSafety–HandHygiene’.

TheaimofthisWHOinitiativeistoharnessindustrystrengthsto alignandimproveimplementationofWHOrecommendationsfor handhygieneinhealthcareindifferentpartsoftheworld,including inleastdevelopedcountries.Inthisinstance,companies/industry withafocusonhandhygieneandinfectioncontrolrelatedadvance- menthavethespeciﬁcaimofimprovingaccesstoaffordablehand hygieneproductsaswellasthrougheducationandresearch.

Theauthorsaloneareresponsiblefortheviewsexpressedinthis articleandtheydonotnecessarilyrepresenttheviews,decisions orpoliciesoftheinstitutionswithwhichtheyareafﬁliated.WHO takesnoresponsibilityfortheinformationprovidedortheviews expressedinthispaper.

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ClaireKilpatrick InfectionControlProgrammeandWHO CollaboratingCentreonPatientSafety,Universityof GenevaHospitalsandFacultyofMedicine,Geneva, Switzerland LoïcBourqui UniversityofGenevaFacultyofMedicine,Geneva, Switzerland AlexandraPeters ChloéGuitart InfectionControlProgrammeandWHO CollaboratingCentreonPatientSafety,Universityof GenevaHospitalsandFacultyofMedicine,Geneva, Switzerland BenedettaAllegranzi InfectionPreventionandControlGlobalUnit, DepartmentofServiceDeliveryandSafety,World HealthOrganization,Geneva,Switzerland DidierPittet^∗ InfectionControlProgrammeandWHO CollaboratingCentreonPatientSafety,Universityof GenevaHospitalsandFacultyofMedicine,Geneva, Switzerland

∗Correspondingauthorat:InfectionControl ProgrammeandWHOCollaboratingCentreon PatientSafety,UniversityofGenevaHospitalsand FacultyofMedicine,4RueGabrielle-Perret-Gentil, 1211Geneva14,Switzerland.

E-mailaddress:Didier.pittet@hcuge.ch(D.Pittet)