Hand Hygiene

Professor Didier Pittet, MD, MS,

Infection Control Program
University of Geneva Hospitals, Switzerland

Lead, 1st Global Patient Safety Challenge, World Health

Organization (WHO) World Alliance for Patient Safety
 Maternal mortality rates,
First and Second Obstetric Clinics,
GENERAL HOSPITAL OF VIENNA, 1841-1850
8 10 12 14 16 18

Intervention
May 15, 1847
Maternal Mortality

First
Second
6
4
2
0

1841 1842 1843 1844 1845 1846 1847 1848 1849 1850

Semmelweis IP, 1861

Parameters associated with successful
hand hygiene promotion
Pittet, Infect Control Hosp Epidemiol 2000 / Pittet & Boyce, Lancet Infectious Diseases 2001

1. Education
2. Routine observation + feedback
3. Ingeneering control
Make HH possible / easy / convenient / ...
4. Patient education
5. Reminders in the workplace
6. Administrative sanction / rewarding
Parameters associated with successful
hand hygiene promotion
Pittet, Infect Control Hosp Epidemiol 2000 / Pittet & Boyce, Lancet Infectious Diseases 2001

7. Change in hand hygiene agent

8. Promote / facilitate HCW’s skin care
9. Obtain active participation at individual
and institutional level
10. Obtain / drive an institutional safety climate
11. Enhance individual and institutitional
self-efficacy
12. Use a multimodal strategy
 Compliance and Professional Activity
Pittet et al, Ann Intern Med 1999, 130:126

N Opportunities Compliance

Nurse (520) 1875 ( 66 %) 52 %

Student nurse (48) 131 (4.7 %) 43 %
Nurses' aide (166) 378 (13 %) 47 %
Mid-wife (14) 35 (1.3 %) 66 %
Physician (158) 281 (10 %) 30 %
Phys/Resp therapist (23) 48 (1.7 %) 28 %
Radiology Techinician (4) 12 (0.4 %) 8%
Others (58) 74 (2.7 %) 27 %
TOTAL 2,834 (100 %) 48 %
Non-Compliance with hand hygiene,
Pittet et al, Ann Intern Med 1999, 130:126
100
Compliance with hand hygiene (%) HUG 1994
opp > 10 per hour of care Time constraint is the
75 main explanatory factor
When the number of opp
> 10 per h,
50 compliance decreases on
average by 5 % ( + 2 % )
per 10 opp/h of care

25

0
0 25 50 75 100
Opportunities for hand hygiene per hour of care
Relation between opportunities for hand hygiene
for nurses and compliance across hospital wards
, %)

65
pediatrics
Compliance with hand hygiene (

On average,
55 medicine 22 opp / hour
surgery
for an ICU nurse

45 ob / gyn

ICU
35

8 12 16 20
Opportunities for hand hygiene per patient-hour of care
adapted from Pittet D et al. Annals Intern Med 1999; 130:126
Trends in prevalence of nosocomial infections
and MRSA cross-transmission, HUG 1993-1998

Pittet et al. Lancet 2000 356:1307

 Use of alcohol-based hand rub HOPIRUBR (liters)
University of Geneva Hospitals, Switzerland

Hand rub Utilisation

14 year hand rub d'HOPIRUB (litres)
promotion using the “Geneva model”
(liters)
25000

20000

15000 X 16.5

10000

5000

0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Year
Compliance 48 % 74 %
 Key parameters for success
• System change
• Education of healthcare workers
• Monitoring and feedback of
performance
• Administrative support
• Leadership and culture change
• Associated with reduction in cross-
transmission and infection rates
 Objectives of the Challenge

At the global level 1. Awareness

At the political level 2. Mobilizing nations

For health care 3. Technical

settings guidelines and tools
 Countries committed to address HAI
87% of the world population covered (10/2005 – 5/2009)
Allegranzi B & Pittet D, Lancet 2008

Current Status,
Oct 2009
Hand Hygiene National/Sub-national Campaigns (38)
(WHO Survey, April 2009)
 1. System change

Alcohol-based Access to safe,

• The 5 core
handrub at point of
care
continuous water
supply, soap and
towels

components of the +
WHO Multimodal 2. Training and Education
Hand Hygiene +
3. Observation and feedback
Improvement
Strategy +
4. Reminders in the hospital
+
5. Hospital safety climate
 Field Testing the implementation

2006 - 2008 Complementary Sites (>500)

Hand hygiene compliance improvement
100
in pilot sites
90

80
75
70 69 69
64 59
60
55 55 59
56 Baseline
50 48
45 Follow-up
40 39
35
30
24 22
20

10 8
0 0
Costa Rica Bangladesh Hong Kong Italy Mali Saudi Arabia Saudi Arabia Pakistan
SAR 1 2
 Importance attributed to the elements
of the WHO strategy to achieve
hand hygiene improvement

Not important O-----O-----O-----O-----O-----O-----O Very important

4-7 5-7 4-7 3-7
7
4-7 5-7 2-7

Median Score 4

1
n
ge
lan

rs

ate
ck
ati o
ti on

in de
h an
P

C li m
ed b
io n

c
enta

Ed u
mC

R em
d Fe
A ct

fety
pl em

te
Sys

Sa
n
on a
o Im

ent
ti

Pati
de t

erva
Gu i

Ob s
 WHO Guidelines on
Hand Hygiene in Health Care
ƒ Based on evidence and
expert consensus (>100
international experts)
ƒ Summary translated in
the UN official languages
ƒ Implementation strategy
and tool package tested in
2007-2008
ƒ Final version including
ADVANCED DRAFT FINAL VERSION
evidence update and
April 2006 May 2009 lessons learned from
testing
 “My 5 Moments for Hand Hygiene”

Sax H, Allegranzi B, Uçkay I, Larson E, Boyce J, Pittet D. J Hosp Infect 2007;67:9-21

Observation
Form
Implementation tools for
Reminders in the workplace
Are your hands clean?

SAVE LIVES
Clean Your Hands
 SAVE LIVES: Clean YOUR Hands
5 May 2009-2020

A WHO Patient Safety Initiative 2009

Through an annual day focused on hand hygiene

improvement in health care, this initiative
promotes continual, sustainable best practice in
hand hygiene at the point of care in all health-
care settings around the world

Clean Care is Safer Care

Global Patient Safety Challenge
 N=5801
5801 hospitals
(125 countries)

~ 1.75 mio beds

~ 4.45 mio HCWs
1000
2000
3000
4000
5000
6000
7000

0
8-14 Dec 08
15-21 Dec 08
22-28 Dec 08
29 Dec - 4 Jan 09
5-11 Jan 09
12-18 Jan 09
19-25 Jan 09
26 Jan - 1 feb 09
2-8 Feb 09
9-15 Feb 09
16-22 Feb 09
23 Feb - 1 Mar 09
2-8 Mar 09
9-15 Mar 09
16-22 Mar 09
23-29 Mar 09
30 Mar - 5 April 09
6-12 April 09
13-19 April 09
20-26 April 09
27 April - 3 May 09
4-10 May 09
11-17 May 09
19-24 May 09
25-31 May 09
1-7 June 09
Registered for SL:CYH

8-14 June 09
15-21 June 09
22-28 June 09
(up to Sunday 25 October 2009)
Cummulative Number of Hospitals

29 June - 5 July 09
6-12 July 09
13-19 July 09
20-26 July 09
27 July - 2 August
3-9 August 09
10-16 August 09
17-30 August 09
31 Aug - 13 Sept
14 - 27 Sept 09
28 Sept - 11 Oct
12 - 25 Oct 09
 Hospitals Registered for Save Lives: Clean Your Hands
by WHO Region
,000

,500
2,450

,000
1,762

,500

,000

566
500 368
348 307

0
AFRO AMRO EMRO EURO SEARO WPRO
5801 hospitals registered
as of 25 October 2009

http://www.who.int/gpsc/5may
 SAVE LIVES Clean Your Hands
Web Pages

– Video message from

Sir Richard Branson
– 'Promotional DVD'

– Case studies from

health-care settings
– Country 5 may
http://www.who.int/gpsc/en/ activities
SAVE LIVES: Clean YOUR Hands
5 May 2009-2020

A WHO Patient Safety Initiative 2009

Encourage health-care facilities to show their

commitment by signing up now on:
http://www.who.int/gpsc/5may

Clean Care is Safer Care

Global Patient Safety Challenge
 From country pledge

… to patient point of care

Key steps in hand hygiene
improvement

1. System change:
alcohol handrub at the point of care
2. 5 elements multimodal promotion
3. 5 moments for hand hygiene
4. Adaptability of actions / interventions
5. Leadership commitment / Safety culture
Hand hygiene – System change
Perspectives & Research agenda
- Alcohol-based handrub
- Antimicrobial efficacy as first step for selection
- Skin tolerance and acceptability
- Associated with optimal compliance
- Formulation (rinse, gel, foam, …)
- Role of additional active agent(s)
- At the point of care / Optimal placement-ergonomy
- Associated with impact on infections/transmission
- Access – Reducing costs – Local production
- Alternatives to alcohol-based solutions ???
Hand hygiene – Education
Perspectives & Research agenda
- Educating HCWs
- 5 moments for hand hygiene
- 5 moments for hand hygiene
- 5 moments for hand hygiene
- …reinforce « before touching patient »
- Value of e-learning / Distance learning
- Accreditation of HCWs
« the driving license to patient care »
 Hand hygiene –
Perspectives & Research agenda
- Monitoring performance + Feedback
- (Homogeneous) use of available tool(s) for monitoring
- Validation of monitoring
- Continuous vs. Regular
- Mode, type and frequency of feedback
- Value of surrogate markers of performance

Monitoring performance
+ feedback
 Hand hygiene –
Perspectives & Research agenda
- Workplace reminders
- Role in promotion/sustainability
- Role of adaptation for increase / better adoption
- Role of institutional participation
- Is there a « NO LIMIT » policy to materials produced?

Reminders
 Hand hygiene – Safety culture
Perspectives & Research agenda
- Institutional (…and broader) safety culture
- Study institutional (…and broader) parameters
- Leadership commitment (parameters of)
- Role of internal / external benchmarking
- Roel of “next-door” ward, hospital, region, country…
- Role of role models
- Role of patient participation / empowerment
- Role of society
- Role of government / Min. of Health
- Study cultural influences
 Hand hygiene –
Perspectives & Research agenda
- Scaling up
- Minimal parameters at ward, department, institution
- Study key parameters for successful scale-up

- Sustainability of actions / interventions