Revision of National Hand hygiene Guideline
Programme Manager Hand Hygine & Surgical Care WHO Ban activity 2010-2011
NATIONAL GUIDELINE ON HAND HYGIENE FOR PREVENTION OF HOSPITAL ACQUIRED INFECTION (HAI)
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INDEX LIST OF ABBREVIATIONS:
PREFACE:
PART – I 1.1 Introduction: 1.2 Background 1.3 Objective of Hand Hygiene: 1.4 Target of Hand Hygiene: 2. GENERAL INFORMATION ABOUT HOSPITAL ACQUIRED INFECTION (HAI) 2.1 Definition of HAI: 2.2 Spread of Hospital Acquired Infection: 2.3 Development of Hospital Acquired Infection 2.4 Microorganisms associated with Hospital acquired infections: 2.5 Morbidity of Patients: 2.6 Drug Resistant & its Development: 2.7 Economic Burden of HAI. 2.8 Hospital Staying: 2. 8 Successful Examples : 3. UNDERSTANDING HEALTH CARE ASSOCIATEDINFECTION & HAND HYGIENE: 3.1 Prevention of Health Care Associated Infection. 3.2 Importance of Hand Hygiene in Health Care. 3.3 Methods for practicing hand hygiene. 3.4. The most important indications on Hand Hygiene during health care delivery. 3.5. Indications for Hand washing and Hand Antisepsis. 4. HAND WASHING TECHNIQUE : 4.1 SKIN CARE: 4.2 The opportunity 4.3 The hand hygiene action 5. USE OF GLOVES : 6. OBSERVATION OF HAND HYGIENE 6.1 Instructions For Observer: (Why Observe Hand Hygiene?) 6.2 How Do You Observe Hand Hygiene? 6.3 How Do You Evaluate Hand Rub Tolerability & Acceptability Among Health-Care Workers: 7. STRATEGIC PLAN FOR IMPLEMENTATION OF GUIDELINE: 8. STRUCTURE OF NATIONAL HAI CONTROL PROGRAMME IN BAGLADESH: HAND HYGIENE PROGRAMME (HHP) BDHS STRUCTURE
9. ORGANOGRAM & TOR 9.1 National /Central level: 9.2 Divisional level: 9.3 Medical College Hospital, specialist hosp. (govt. & private) 9.4 District level : 9.5 Upazila level : 9.6 Union & Community level:
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9.7
Private clinics & hospitals
PART –II Implementation strategy 1. 2. 3. 4. 5. 6.
7. 8.
9. 10. 11. 12. 13.
OVERVIEW OF KEY ISSUES OF IMPLEMENTATION. REVIEWING THE GUIDELINE FOR IMPLEMENTATION “CLEAN CARE IS SAFER CARE”- A COUNTRY COMMITMENT GOVERNMENTAL AND INSTITUTIONAL RESPONSIBILITIES: 4.1 For Hospital Administrators: WHO Guideline list which can make a multimodal strategy. STEPWISE ACTIVITIES: 6.1 Facility Preparedness: A) Medical College Hospitals & Specialized Hospitals: B) District Hospitals: C) Upazila Health Complex: D) Union Health Center / FWC / H & FWC Community Clinic : INFECTION PREVENTION COMMITTEE 7.1 Terms of Reference of HIPAC: (TOR) INFECTION CONTROL RESPOSIBILITY: A. Role of Hospital Management: B. Role of Physicians: (Infection prevention Doctor) C. Role of nurse in-charge of the ward : ( Infection prevention Nurse) IMPLEMENTATION SUPERVISION AND MONITORING: PROMOTION DEVELOPEMENT AND PRINTING OF FESTOONS, BANNERS, POSTERS, DVD AND OTHER MATERIALS: TERM DEFINITIONS CHECKLIST
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LIST OF ABBREVIATIONS: AIDS : Acquired immunodeficiency syndrome. CDC
: Center for Disease control and Prevention.
HAV
: Hepatitis A Virus.
HBV
: Hepatitis B Virus.
FDA
: Food and Drug Administration.
HAI
: Hospital Acquired Infection.
HCAI : Health-Care Associated Infection. HICPAC
: Health-Care Infection Control Practices Advisory Committee.
ICU
: Intensive Care Unit.
MIC
: Minimal Inhibitory Concentration.
MRSA
: Methicillin-resistant Staphylococcus aureus.
NHS
: National Health Service
NICU : Neonatal Intensive Care Unit HCW : Health Care Worker OPD
: Out Patient Department
SICU : Surgical Intensive Care Unit. WHO : World Health Organization. TB
: Tuberculosis.
MOH&FW
: Ministry of Health & Family Welfare
DGHS
: Director General of Health Services
HHP
: Hand Hygiene Programme.
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PREFACE At the present day, Hospital acquired infection is a major public health problem and one of the significant causes of morbidity and mortality in Bangladesh. Hand Hygiene maintenance is one of the accepted methods in health care delivery for providing germ-free care to the patients. The first global patient safety challenge, Clean Care is Safer Care, is concerned with seeking and securing global commitment and action on the reduction of HAI through working with various stakeholder in our country. Action to address “Clean Care is Safer Care” at country level is very important to ensure individual health facility improvement. So “Clean Care is Safer Care” – by maintaining Hand Hygiene during health care delivery is a challenge for all Health Care Workers. It is concerned with seeking and securing national commitment and action on the reduction of HAI through working with WHO offices in our country level. I hope our commitment and action for ensuring “Clean Care is Safer Care” - once will be the milestone of quality health care delivery in our health care facilities. To review the previously developed National Guideline on Hand Hygiene for Prevention of Hospital Acquired Infection was an important activity of this programme. We tried our best & try to incorporate the necessary observation in this guideline during the formation of working group. It was enriched further during the group presentation. It will be very helpful for all categories of Health Care Workers both govt. and private during their day to day practice, for training, health education and as a reference.
Programme Manager Hand Hygiene & Surgical Care WHO Ban 2010-2011
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PART-1 1.1 Introduction “Nosocomial infections are widespread. They are important contributors to morbidity and mortality. They will become even more important as a public health problem with increasing economic and human impact because of: Increasing numbers and crowding of people. More frequent impaired immunity (age, illness and treatments). New microorganisms. Increasing bacterial resistance to antibiotics.” (Ducel 1995) Hospital acquired infection also called Nosocomial infection occurs world wide and affect both developed and developing countries. The highest frequencies of nosocomial infection were reported from hospitals in the Eastern Mediterranean and south East Asia Regions (11.8 and 10.0% respectively) with a prevalence of 7.7 and 9.0% respectively in the European and Western Pacific Regions. Though exact data is lacking in Bangladesh but it will be near to or even more than south east Asia regions. The economic costs are considered due to prolong stay in hospital, increased use of days, the need for isolation and use of additional laboratory and diagnostic tests. Apart from economical cost functional disability, emotional stress, morbidity and mortality are also a major concern in HAI. The importance of hands in the transmission of hospital infections has been well demonstrated and can be minimized with appropriate hand hygiene. Compliance with hand washing, however, is frequently suboptimal. This is due to a variety of reasons, including lack of appropriate accessible equipment, high staff-to-patient ratios, allergies to hand washing products, insufficient knowledge of staff about risks and procedures, too long duration recommended for washing, and the time required. Hand hygiene is one of the most important procedures for preventing the transmission of hospitalacquired infections. Hand hygiene is a general term that encompasses handwashing, antiseptic hand wash, antiseptic handrub or surgical hand antisepsis. The importance of hand hygiene in preventing transmission of Hospital-acquired infections has been demonstrated in numerous studies. The challenge, however, is to improve adherence with appropriate hand hygiene on the part of health care personnel (HCP)
1.2
Background
Hospital acquired infection is now a big challenge for developing country. For centuries, hand washing with soap and water has been considered a measure of personal hygiene, but the link between hand washing and the spread of disease has only been established in the last 200 years. In the mid-1800s, studies by Ignaz Sommeliers in Vienna and Oliver Wendell Holmes in Boston established that hospital-acquired diseases, now known to be caused by infectious agents, were transmitted via the hands of HCWs. In the community, hand hygiene has been acknowledged as an important measure to prevent and control infectious diseases and can significantly reduce the burden of disease, in particular among children in developing countries. In the health-care setting, a prospective controlled trial conducted in a hospital nursery and investigations conducted during the past 40 years have confirmed the important role that contaminated hands of HCWs play in the transmission of health care-associated pathogens. Currently, hand hygiene is considered the most important measure for preventing the spread of pathogens in health-care settings. The 1980s represented a landmark in the evolution of concepts of hand hygiene in health care. The first national hand hygiene guidelines were published in the 1980s, followed by many others in more recent years. These guidelines were essentially issued in countries in the northern hemisphere, including the United States of America (USA), Canada and some European countries. Therefore, it can be seen that hand hygiene concepts have much evolved over the past two decades. In 1961, the United States public health service produced a training film that demonstrated hand washing techniques recommended for use by HCWs. At that time, it was recommended to wash
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hands with soap and water for 1 to 2 minutes before and after patient contact. Rinsing hands with an antiseptic agent was believed to be less effective than hand washing and was recommended only in emergencies or in areas where sinks were unavailable. Twenty years later, the United States national guidelines still recommended waterless antiseptic agents only in situations where sinks were not available, and hand washing with soap and water was considered the standard of care. Subsequent hand hygiene guidelines in the USA included more detailed discussion of alcohol-based hand rubs and supported their use in more clinical settings than what had previously been recommended. In 1995 and 1996, the United States Centers for Disease Control and Prevention (CDC)/ Healthcare Infection Control Practices Advisory Committee (HICPAC) recommended that either antimicrobial soap or a waterless antiseptic agent be used for cleansing hands upon leaving the rooms of the patients with multidrug-resistant pathogens such as vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA). More recently, the CDC/HICPAC guidelines issued in 2002 defined alcohol-based hand rubbing as the standard of care for hand hygiene practices in health-care settings. In central European countries, the use of alcohol-based rubs for hand hygiene has been the method of choice for many years. However, in many other countries, hand washing is still considered the standard of care and alcohol-based hand rub is reserved for particular situations only. WHO publications addressing infection control measures to reduce the spread of pathogens in health-care settings have emphasized hand hygiene as a key measure. However, the guidance referring to hand hygiene technique has so far not clearly classified hand rubbing as the gold standard when compared to hand washing with soap and water. The recommendations for the control of MRSA suggest hand rubbing as an alternative in the absence of good water supply or running water. Two recent WHO infection control guidelines provide a more detailed description of the hand rubbing technique, and suggest that hand hygiene be performed by either hand washing or hand rubbing, but without stating any advantage of one over the other. In Bangladesh no such guideline exist about hand hygiene practice. So this guideline will through a light in the prevention of HAI in Bangladesh. 1.3 1.4
Objective of Hand Hygiene: To reduce hospital acquired Infection by standard hand hygiene practice. Target of Hand Hygiene:
Implementation of hand hygiene practice in the Health Care Facility of Bangladesh to reduce hospital acquired Infection considerably.
2.
GENERAL INFORMATION ABOUT HOSPITAL ACQUIRED INFECTION (HAI)
2.1
Definition of HAI: Hospital acquired infection is defined as a localized or systemic condition 1) that results from adverse reaction to the presence of an infectious agent(s) or its toxin(s) and 2) that was not present or incubating at the time of admission to the hospital. For most bacterial hospital acquired infections, the infection usually becomes evident 48 hours (i.e., the typical incubation period) or more after admission.
2.2
Spread of Hospital Acquired Infection:
Hospital acquired infections can be caused by bacteria, viruses, fungi and parasites. However, the majority of health care-associated infections are caused by bacteria and viruses. Protozoa infections are rare. Hospital acquired infections can be caused by microorganisms already present in the patient’s skin and mucosa (endogenous) or by microorganisms transmitted from another patient or from surrounding environment(exogenous). The spread of microorganisms typically occurs by one or more of three distinct routes: ♣ Contact ♣ Airborne ♣ Droplet infection Contact spread transmission: Contact spread describes transmission that occurs when the patient makes contact with the source and it may occur through direct contact, indirect contact. Direct contact: Direct physical contact between the source and the patient, e.g. person to person contact. Indirect contact:
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Transmission of the infectious agent from the source to the patient occurs passively via intermediate object (usually inanimate), e.g. transfer of enteric organism to a susceptible host via endoscope that was previously contaminated by infected patients. In most cases, the hands of the health care workers are the source or the vehicle for transmission of microorganism from patient’s skin into mucous (such as the respiratory tract) or normally sterile body compartments (blood, CSF, pleural fluid, etc.) and from other patients or the contaminated environment. Besides, in common-vehicle transmission, a contaminated inanimate object/item, e.g. food, water or medication, act as a vector for transmission of the microbial agent to the patients. Air borne transmission: The infection usually occurs by the respiratory route, with the agent present in aerosols (infectious particles 5µm in diameter) 2.3
Development of Hospital Acquired Infection All hospitalized patients are at risk of acquiring an infection from their treatment or surgery. Some patients are at greater risk than others, especially ► ► ►
Young children The elderly and Persons with compromised immune systems.
The risk factors for hospital-acquired infections in children include parenteral nutrition (tube or intravenous feeding), the use of antibiotics for more than 10 days, use of invasive devices, poor postoperative status, and immune system dysfunction. Other risk factors that increase the opportunity for hospitalized adults and children to acquire infections are: A prolonged hospital stay Severity of underlying illness Compromised nutritional or immune status Use of indwelling catheters Failure of health care workers to wash their hands between patients or before procedures Prevalence of antibiotic-resistant bacteria from the overuse of antibiotics Any type of invasive procedure can expose a patient to the possibility of infection. Some common procedures that increase the risk of hospital-acquired infections include: Urinary bladder catheterization Respiratory procedures such as intubations or mechanical ventilation Surgery and the dressing or drainage of surgical wounds Gastric drainage tubes into the stomach through the nose or mouth Intravenous (IV) procedures for delivery of medication, transfusion, or nutrition. 2.4
Microorganisms associated with Hospital acquired infections: Many different pathogens may cause nosocomial infections. The infecting organisms vary among different patient populations, different health care settings, different facilities, and different countries. The common microorganisms areBacteria: Staphylococcus aureus
Coagulase negative staphylococcus E. coli Proteus Klebsiella
Enterobacter Clostridium Serratia marcescens Pseudomonas
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Legionella spp. Viruses: Hepatitis B Hepatitis C Respiratory syncytial virus, Rotavirus Enteovirus
Parasites and fungi: Giardia lamblia Candida albicans Aspergillus spp. Cryptococcus neoformans Cryptosporidium
2.5
Morbidity of Patients:
Hospital acquired infections occur worldwide, both in developed and developing world. They are a significant burden to patients and public health. They are major cause of increased morbidity in hospitalized patients. They may cause increased functional disability and emotional stress and may lead to conditions that may reduce quality of life. The recent Prevalence survey of Healthcare-associated infections in England 2006 shows the infections associated with increased morbidity of the patients:
Infection Type
Percentage of Hospital acquired infection
Gastrointestinal System Urinary Tract Pneumonia Surgical site Skin & soft Tissue Primary Bloodstream Lower respiratory tract(pneumonia) Eyes, ENT or mouth Bone and joint Systemic Cardiovascular system Reproductive Tract Central Nervous System
22 19.7 13.9 13.8 10.5 6.8 6.0 2.9 1.2 1.2 1.1 0.6 0.3
2.6 Drug resistance & its development: Drug resistance and its spread among bacteria is generally the result of selective antibiotic pressure. Resistant bacteria are transmitted among patients, and resistance factors are transferred between bacteria, both occurring more frequently in health care settings. The continuous use of antimicrobial agents increases selection pressure favoring the emergence, multiplication, and spread of resistant strains. The other contributory factors are☼ ☼ ☼ ☼
Inappropriate and uncontrolled use of antimicrobial agents Administration of suboptimal doses Insufficient duration of treatment Misdiagnosis leading to inappropriate choice of drug,
MRSA (methicillin – resistant Staphylococcus aureus): Some strains of methicillin resistant Staphylococcus aureus (MRSA) have a particular facility for nosocomial transmission. MRSA strains are often resistant to several antibiotics in addition to the
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penicillinase-resistant penicillins and cephalosporins and occasionally are sensitive only to vancomycin and teicoplanin. MRSA infections are► ► ► ► ► ► ►
2.7
Wound infection Lower respiratory tract infections Septicemia Infections of sites for invasive devices, Pressure sore Burns Ulcers
Economic Burden of HAI.
HAI also has considerable ‘economic' impact on hospital services and national health care. Measurement of the cost of HAI is difficult and the financial impact varies between different healthcare systems. Nevertheless, in simple terms, HAI can have the following economic results: (1) (2)
HAI delays patient discharge, resulting in increased cost. The patient suffers additional cost due to increased absence from work and relatives suffer costs of time and travel to visit the patient.
(3)
Infections require increased treatment cost (for example, increased therapy and increased numbers of procedures, including repeat surgery.
(4)
HAI is accompanied by increasing numbers of laboratory and imaging investigations.
(5)
HAI increases infection control cost, including epidemiological investigations and medical, nursing and management time.
(6)
HAI is often the subject of litigation, the costs of which may be huge.
(7)
Increased rates of HAI associated with blocked beds and closed wards and theatres, results in increased unit cost for admissions and procedures. (8) Patient morbidity resulting from HAI will also have large community and society cost that are difficult to estimate but may have considerable impact. In England Hospital acquired infections cost over 1 billion pounds per year, kill 500 patients and consume resources of 27 four hundred beds hospitals. Another study showed that a case of HAI costs an extra 3150 pounds and consumes 14 extra bed days. 2.8
Hospital Staying:
Patients with hospital-acquired infection diagnosed in hospital remained in hospital about 2.5 xs longer than uninfected patients, an average of 11 additional days. (Plowman et al. Socio-economic burden of hospital acquired infection. London: PHLS, 1999.) 2. 9
Successful Examples : SUCCESSFUL EXAMPLES OF MULTIMODAL CAMPAIGNS TO PROMOTE HAND HYGIENE
University Hospitals of Geneva, 1994 to 1997 • Sustained improvement in compliance with hand hygiene from 48% to 66% • Significant reduction of hospital acquired infection from 16.9% to 9.9% • Costs equal to less than 1% of costs associated with hospital infections A Neonatal Intensive care Unit in China, Province of Taiwan,, 1998- 1999 • Significant improvement in compliance with hand hygiene (from 43% to 88%) • Significant reduction of hospital infection rates ( from 15.1per 1000 to 10.7 per 1000 patient days)
3. 3.1
UNDERSTANDING HEALTH CARE ASSOCIATED INFECTION & HAND HYGIENE: Prevention of Health Care Associated Infection. Several studies clearly demonstrate that the implementation of well structured infection control programs lead to a reduction of HAI and it is cost effective. The study of the efficacy of
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Nosocomial infection control conducted in about 500 hospitals in the USA in the 1980’s , was one of the first reported interventions which successfully reduced HAI rates by one third, through the introduction of effective surveillance systems and infection control programmes. Some studies demonstrated that similar results are also achievable in countries with limited resources. “Standard precautions” encompass all the basic principles of infection control that are mandatory in all health care facilities. Their application extends to every hospital patient, regardless of their diagnosis, risk factor and presumed infectious status, to reduce the risk to patient and staff of acquiring an infection. Hand hygiene is very much at the core of standard precautions and is the undisputed, single most effective infection control measure. Standard precautions essentially provide a clean environment and promote patient safety at a very basic level. “Transmission based precautions” include Airborne, Droplet and Contact precautions. In addition to these, some specific measures are very effective for the prevention of sitespecific or device related infections, in particularly UTI, Surgical site infections, and Pneumonia and Bloodstream infections. Therefore steps must be taken to develop and follow guidelines of best practices to minimize the risk of developing an infection associated with an invasive procedure or device. 3.2
Importance of Hand Hygiene in Health Care.
Hands of health-care workers are the most common vehicle for the transmission of microorganisms from one patient to another, from one body site to another within the same patient and from contaminated environment to patient. Importantly health care worker’s hands become progressively colonized with germs as well as with pathogens during patient care. In the absence of hand hygiene action, the longer the duration of care, the higher the degree of hand contamination. Health care workers are less adapted to good hand hygiene practice. Nurses and physicians usually clean their hands less than half as often as they should. In critical care situations where there are severe time constraints and the workload is higher, the hand hygiene adoption rate might be as low as 10%. In several centers, strategies to improve hand hygiene have led to substantial decrease in HAI rates, both in critical care and hospital-wide. Major interventions have targeted changes in the health care system and of health care workers behavior through the adoption of alcohol based hand rub and the implementation of educational programmes. Hand hygiene improvement combined with other infection control measures has been effective in reducing the transmission of harmful pathogens both in outbreak and endemic situations. Multimodal strategies are the most effective approach for promoting hand hygiene practices and successful examples have demonstrated their effectiveness in reducing HAI. Key elements include Staff education and motivation programmes, Adoption of alcohol- based hand rub as the gold standard, Use of performance indicators and strong commitment by all stakeholders, such as frontline staff, managers and health care leaders. 3.3
Methods for practicing hand hygiene. Hand hygiene may be practiced by rubbing hands with an alcohol-based handful or by washing with soap and water. The most effective way to ensure optimal hand hygiene is by using an alcohol-based hand rub; this has the following immediate advantages: Elimination of the majority of germs; Availability of the product closes to the point of care* (in the healthcare worker's pocket, at the patient bedside, in the room); The short time required (20 to 30 seconds); Good skin tolerability; No need for any particular infrastructure (clean water supply Network, washbasin, soap, hand towel). According to the recommendations of WHO (WHO Guidelines on Hand Hygiene in Health Care - Advanced Draft - p. 95), when an alcohol-based hand rub is available, it should be used as the first choice for hand hygiene when indicated (IB); alcohol-based hand rub should not be used after antiseptic soap for hand wash (II). To comply with routine hand hygiene recommendations, healthcare work* should ideally perform hand hygiene at the point and moment of care*. This calls for the use of an alcohol-based product. Hands need to be washed with soap and water when they are visibly dirty or contaminated by organic matter (body fluids, pertinacious material), when exposure to potential spore-forming organisms is strongly suspected or proven, or after using the lavatory (II).
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The efficacy of the alcohol-based hand rub depends on the quality of the product (conformity with European and US standards), the amount of product used, time spent rubbing and the hand surface rubbed. These parameters for efficacy also apply to hand washing with soap and water.
3.4. The most important indications on Hand Hygiene during health care delivery. CONSENSUS RECOMMENDATIONS: It was agreed that the CDC / HICPAC system for categorizing recommendations be adopted as follows: Category 1A. Strongly recommended for implementation and strongly supported by well designed experimental, clinical or epidemiological studies. Category 1B. Strongly recommended for implementation and strongly supported by some experimental, clinical or epidemiological studies and a strong theoretical rationale. Category 1C. Required for implementation as mandated federal and / or state regulation or standard. Category II. Suggested for implementation and supported by suggestive clinical or epidemiological studies or a theoretical rationale or a consensus by a panel of experts.
TABLE OF CORRESPONDENCE BETWEEN THE INDICATIONS AND THE WHO RECOMMENDATIONS INDICATIONS CHAPTER BEFORE PATIENT CONTACT BEFORE ASEPTIC TASK
Consensus recommendations (WHO Guidelines on Hand Hygiene in Health Care-Advanced Draft-p.95) C. a) before and having direct with patients (1B)
C. c) before handling an invasive device for patient care, regardless of whether or not gloves are used (1B). C. e) if moving from a contaminated body site to a clean body site during patient care (1B). AFTER BODY FLUID C. d) after contact with body fluids or excretions, mucous membrane, non intact skin or wound dressings. (1A) EXPOSURE RISK C. e) if moving from a contaminated body site to a clean body site during patient care (1B) C. b) after removing gloves. (1B) AFTER PATIENT C. a) before and after having direct contact with patients (1B) CONTACT C. b) after removing gloves. (1B) AFTER CONTACT WITH C. f) after contact with inanimate objects (including medical equipments) in the immediate vicinity of the patient (1B) PATIENT SURROUNDINGS C. b) after removing gloves. (1B) A. B. C.
3.5. Indications for Hand washing and Hand Antisepsis. Washing hands with soap and water when visibly dirty or contaminated with pertinacious material or visibly soiled with blood or other body fluids or if exposure to potential sporeforming organisms is strongly suspected or proven. Preferably an alcohol based hand rub is used for hand antisepsis in all other clinical situations. Perform hand hygiene
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a) b) c) d) e) f) D. E.
Before and after having direct contact with patients. After removing gloves. Before handling an invasive device for patient care, regardless of whether or not gloves are used. After contact with body fluids or excretions, mucous membranes, non intact skin or wound dressing. If contaminated body site to a clean body site during patient care. After contact with inanimate objects (including medical equipments) in the immediate vicinity of the patient. Wash hands with either plain water or antimicrobial soap and water or rub hands with an alcohol based formulation before handling medication or preparing food. When alcohol based hand rub is already used, do not use anti microbial soap concomitantly.
4.
HAND WASHING TECHNIQUE :
A. dry.
Apply a palmful of the product and cover all surfaces of the hands. Rub hands until hands are
B. When washing hands with soap and water, wet hands with water and soap the amount of product necessary to cover all surfaces. Vigorously perform hand rubbing on both hand palms and backs, interlace and interlock fingers to cover all surfaces. Rinse hands with water and dry thoroughly with a single use towel or tissue paper. Use running and clean water whenever possible. C. Make sure hands are dry. Use a method that does not recontaminate hands. Make sure towels are not used multiple times or by multiple people. Hence tissue paper is suitable. Avoid using hot water, as repeated exposure to hot water may increase the risk of dermatitis. D. Liquid, bar, leaf or powdered form of plain soap is acceptable when washing hands with a non-microbial soap and water. When bar soap is used small bar of soap in racks that facilitate drainage should be used.
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Figure 1
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Figure 2
4.1 A.
SKIN CARE: Include information regarding hand care practices designated to reduce the risk of irritant contact dermatitis and other skin damage in education programmes for HCW.
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B.
C.
Provide alternative hand hygiene products for HCWs with allergies or adverse reactions to standard products (WHO formula of hand rub) used in the health care settings. WHO formula for alcohol based hand rub is proven good skin tolerability in Pilot works of Chittagong Medical College Hospital. When needed to minimize the occurrence of irritant contact dermatitis associated with hand antisepsis or hand washing, provide HCWs with hand lotion or cream.
DI AG RAM PATIENT SURROUNDINGS AND CARE ENVIRONMENT C.d)
C.b)
after contact with body fluids or excretions, mucous membranes, non intact skin, or wound dressings (IA) if moving from a contaminated body site to a clean body site during patient care (IB) after removing gloves (IB) before and after having direct contact with patients (IB) after removing gloves (1B) after contact with inanimate objects (including medical equipment) in the immediate vicinity of (he patient (IB) after removing gloves (IB)
4.2
THE OPPORTUNITY
C.e) C.b) Ca) Cb) C.f)
The opportunity for hand hygiene is a matter for the observer. From the point of view of the observer, the opportunity exists whenever one of the indications for hand hygiene is present and observed. Each such opportunity must correspond to an action. Several indications may come together to create an opportunity. This means that there may be several simultaneous reasons for a hand hygiene action. The opportunity is an accounting unit for the action; it determines the need to perform the hand hygiene action, whether the reason (the indication that leads to the action) be single or multiple. It constitutes the denominator for measuring the rate of compliance of hand hygiene by health-care workers, 4.3
THE HAND HYGIENE ACTION
If properly carried out, the hand hygiene action implies recognition of the indications by health-care workers during their activities and within the process they organize care. The hand hygiene action is not just an additional "task" to be performed, essential one that marks the activities of health-care workers, even if there is no physical obstacle preventing the tasks from being carried out without hand hygiene. This is probably one of the difficulties in observing hand hygiene and a fact makes it easy to neglect it. To measure hand hygiene compliance, the action is compared with the opportunity. The action is considered necessary provided it corresponds to at least one indication.
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The action performed (the positive action) can be done in two ways: by the hands with an alcohol-based hand rub or by hand washing with soap and according to the body of current scientific evidence, if the action is performed there is no indication for it, it has no impact in terms of preventing microbial transmission and is not to be considered as an act of compliance. Absence of hand hygiene action also refers to the indications. Absence of action may only be considered as such when there is a need for an action. In this case absence of the hand hygiene action is considered to be non-compliance. The relationship between the activities, the indications, the opportunity for Hand Hygiene and the actions, and the calculation of compliance are illustrated below
The opportunities constitute the denominator for compliance, i.e. the positive actions observed are compared with the actual opportunities for hand hygiene. The opportunities constitute the denominator for compliance, i.e. the positive actions observed are compared with the actual opportunities for hand hygiene. The five indications are justified by the risks of germ transmission. The dynamics of activities mean that risks of microbial transmission are dissociated or associated. II When there is a risk of transmission, there is an indication for hand hygiene; when there is an indication, there is an opportunity for hand hygiene. Several indications may come together to constitute a single opportunity for hand hygiene. Each opportunity, regardless of the number of indications from which it is determined, must be associated with a hand hygiene action, whether by rubbing with an i alcohol-based hand rub or washing with soap and water. Hand hygiene compliance by health-care workers is objectively expressed by the 1 ratio between positive actions and opportunities.
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To summarize: Indications for hand hygiene are justified by the risk of transmission. All health-care workers are concerned during their various health-care activities. There is a risk of transmission because there is contact between different surfaces, particular, involving health-care workers’ hands. Health-care safety depends on the action taken in response to the indication since hand hygiene makes it possible to prevent the risk of germ transmission. 5. A. B. C. D. E.
USE OF GLOVES : The use of gloves does not replace the need for hand cleansing by either hand rubbing or hand washing. Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes or non intact skin will occur. Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient. When wearing gloves, change or remove gloves during patient care if moving from a contaminated body site to a clean body site within the same patient. Change or remove gloves after touching a contaminated site and before touching a clean site or the environment. Avoid reuse of gloves. If gloves are reused, implement an adequate reprocessing method to ensure glove integrity and microbiological decontamination.
Directly it does not interfere with the hand hygiene but using glove may cause the user to avoid hand wash / hand rub mistakenly, assuming his /her hands are free from contaminants. It is, however, a wrong action.
6.
OBSERVATION OF HAND HYGIENE:
6.1
INSTRUCTIONS FOR OBSERVER: (Why observe hand hygiene?)
The purpose of observing hand hygiene is firstly to determine the degree of compliance by health-care workers with hand hygiene practices, as well as to assess quality in the performance of procedures and of the facilities. Depending on the level of compliance of health-care workers and the setting together with facility priorities, measures to promote and improve hand hygiene practices are developed. An observation after a period of intervention makes it possible not only to evaluate compliance with hand hygiene but also to measure the impact achieved by the intervention. In addition, observation is a means of drawing the attention of HCWs to the importance of the act, by merely watching and showing an interest in hand hygiene, an immediate promotional effect is achieved. During observation session, the observer does not give any instructions to the HCWs or
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take no initiative for correction of procedure. The observers’ role is only to see the actions and note it down in observation form. 6.2
HOW DO YOU OBSERVE HAND HYGIENE? Direct observation of health care workers during their daily work routine is the most accurate way to study hand hygiene practices. It provides an opportunity to identify the behaviour of health professionals and to evaluate lessons learned as well as the weaknesses that remain. The results of observations help to determine the most appropriate interventions for hand hygiene promotion, education and training. Observer’s Role: The primary role of the observer is to observe practices and together data on appropriate hand hygiene. To do these, observers must familiarize themselves with the various activities of hand hygiene such as to use the tools available i.e. five indications concept etc.The result of the observations are used solely to promote, educate and train health –care workers and as a part of the “ Clean Care is Safer Care” Global Patient Safety Challenge. The observers’ will help the person and administrative staff to rectify, to promote, to teach and to provide feedback for better action and implementation. Why observe hand hygiene? The purpose of observing hand hygiene is to determine the degree of compliance by HCW with hand hygiene practice and to assess quality in the performance of procedures and of the facilities. Observation is a means of drawing the attention of HCWs to the importance of the act of hand hygiene and thus results in immediate promotional effect through watching and showing interest by the observer. Observation Session: The duration of Observation session in a precise location (Ward) from beginning to end is approx. 20 minutes. These sessions are conducted in health care settings during care delivery by HCWs. CALCULATION OF COMPLIANCE: Compliance with hand hygiene is the ratio of the number of actions to the number of opportunities as expressed by the formula: Compliance (%) =
Hand Hygiene Actions Opportunities
X 100
On the observation form, the indications observed are “classified” as opportunities for hand hygiene (the denominator) against which the actual hand hygiene action is set (the action serving as the numerator). These two variables allow compliance to be calculated. 6.3 HOW DO YOU EVALUATE HAND RUB TOLERABILITY & ACCEPTABILITY AMONG HEALTH-CARE WORKERS: According to the recommendations of WHO, one of the factors that improves acceptance of hand hygiene products is the possibility for users to be associated with their choice. Together with proven efficacy as an antiseptic, skin tolerability is one of the main criteria for product selection. A product that is pleasant to use with no harmful effect to the hands is a major asset in promoting the practice of hand hygiene. There are two methods of evaluating hand rub tolerability and acceptability. The simplest method is to ascertain tolerability and acceptability of product that is in use or which is planned to be introduced. This is the most basic way to introduce hand hygiene using an alcohol-based hand rub. A slightly different and more complex method allows to compare tolerability and acceptability of different alcohol-based hand rub. The questionnaire study is necessary for this purpose. WHO formula of alcohol based hand rub is used in 5 pilot wards of Chittagong Medical College Hospital for about one year by more than 300 health care workers. There is no untoward effect found in the users hands and acceptability of the product is proven to be good. 7.
STRATEGIC PLAN FOR IMPLEMENTATION OF GUIDELINE: 1. Guideline should be adopted and practice in health facilities all over the country. 2. Workshop to be done for dissemination of this guideline. 3. 4.
Training of the doctors, nurses & auxiliary staffs should be done. Learners module to be developed for training.
20
5. 6.
8.
BCC materials to be developed for mass people. Video presentation on hand hygiene procedure to be developed.
STRUCTURE OF NATIONAL HAI CONTROL PROGRAM IN BAGLADESH: In overcoming this situation infection prevention strategy may be the basic. Hand hygiene
practice is to be taken as the first approach to infection prevention in all points of health care service. To achieve the millennium goal of health for all the endeavor is to be taken nation wide and that needs an organized program-outline which will have a structured organogram,
policy guide line
and implementation strategy .
STRUCTURE HAND HYGIENE PRACTICE PROGRAM (HHP)
BDHS
FORMATION
LEVEL
N
MOHFW------ SECRETARY
A T I
DGHS------
O
DIRECTOR CDC (PROJECT /LINE DIRECTOR)
N A
DD CDC (PM-HHP)
L
DPM-HHP (DIST. HOSP & BELOW) ----- DPM (MEDICAL COLLEGE HOSP
DIVISIONAL DIRECTOR DEPUTY DIRECTOR ASSTT. DIR NURSING DIV.HEALTH ED.OFFICER SR.ASSTT.CHIEF MIS SUPER / CIVIL SURGEON RESIDENT M.O, SR. EMO CONSLT. UR/GYN/MED /PEAD NURSING SUPER HEALTH EDUCATOR
DIRECTOR,MCHs (GOVT. & PRIVATE ) HEAD DEPT. SUR/GYN/MED/PAED/MICROBIO DEPUTY DIRECTOR ASSTT. DIRECTOR, WHO PERSONNEL NUR.SUPER
PRIVATE CLINICS & HOSPITALS DIRECTOR / MD / SUPER / MANAGER HHEAD OF NURSINGB STAFFS MEDICAL TECHNOLOGISTS
HEALTH & F P OFFICER RESIDENT M,O CONSLT SUR/GYN/MED/PAED NURSING SUPERVISOR M.O D C /MO MCH MEDICAL ASSTT. MEDICAL OFFICER MEDICAL ASSTT/ SACMO FWV
21
D I V I S I o N D I S T R I C T U P A Z I L A U N I O N C O M M U N I
HEALTH ASSTT FAMILY WELFARE ASSTT.
FOCAL POINTS OF / H HP
MOHFW
L--1
DGHS L--2
DIR.CDC PM
DPM
DPM
L--3 DIVISIONAL DIRECTOR
SUPER / & CIVIL SURGEONs
DIRECTOR MED.COLLEGE HOSPITALS
DIRECTOR SPECIALISED HOSPITALS
HEADs OF PRIVATE HOSP
Directors / SUPERs
& CLINICS
Private Medical College. Hosptal
Dist. Hos
L-4
.
. H & FP.O
L--5 UZHCs USCs H&FWCs CCs
STRUCTURAL DIAGRAM ---HHP
9.
ORGANOGRAM & TOR
9.1
NATIONAL /CENTRAL LEVEL : •
This will be an advisory body & approval authority and steer the program centrally with total control over the program.
•
A National policy guide line will be developed and approved for HHP implementation, Give approval of training manuals designed earlier.
22
•
Give sanction of the estimated budget for the program..
•
Issue directives to procure logistics .
•
Monitor, evaluate and analyze the program performance.
•
Review the program plan.
Accountability : To the MOH&FW.
9.2
DIVISIONAL LEVEL :
1.
Bottom up consolidation & upward propagation of Budget estimation Logistics and other requirements Organizing training / Orientations. Liaison with CMMU/PWD for facility preparedness. Reporting, Record keeping, Supervision & Monitoring
2. 3. 4.
Accountability : To the Central Body 9.3 MEDICAL COLLEGE HOSPITAL, SPECIALIST HOSP. (GOVT. & PRIVATE)
1. 2. 3. 4. 5. 6.
Assess training needs & Logistic requirement Organize orientation / training Prepare facility for implementation. Procurement of logistics Implementation , Supervision , monitoring & evaluation. Reporting , Record keeping & Feed back
Accountability : To the Central Body 9.4 DISTRICT LEVEL : 1. 2. 3. 4. 5. 6. 7.
Listing up of Health facilities. Assess training needs & Logistic requirement Organize orientation / training Prepare health care facilities for implementation. Procurement of logistics Implementation, Supervision, monitoring & evaluation. Reporting , Record keeping & Feed back
Accountability : To Central Body & Division 9.5 1. 2. 3. 4. 5.
UPAZILA LEVEL : Organize orientation / training Prepare health care facilities for implementation. Procurement of logistics Implementation , Supervision , monitoring & evaluation. Reporting , Record keeping &Feed back
Accountability : To District body 9.6 UNION & COMMUNITY LEVEL: 1. 2.
Implementation, Feed back
Accountability : To Upazila body
9.7 PRIVATE CLINICS & HOSPITALS Same as medical college hospital, specialized hosp. (govt. & private )
23
Accountability : To the Central Body ( specialized hosp & private medical college hosp) To the Divisional level (Private hosp. &Clinics)
PART –II Implementation strategy
1.
OVERVIEW OF KEY ISSUES OF IMPLEMENTATION.
New guideline
Adopted by Infection Control Committee Education Programme By infection control team
24
Change in patient-care Practices
FIG.-1. Implementation of New Guidelines The usual implementation process is depicted in the Fig. 1. After the guideline is finalized, the infection control team will usually adopt a two pronged implementation process. One of these prongs consists of submitting the guideline to infection control committee for approval, and circulating it down to the chain of command with instructions for implementation. The other prong would be the education programme conducted by infection control team and given directly to front line staff.
2. REVIEWING THE GUIDELINE FOR IMPLEMENTATION The infection control guideline generally consists of a list of recommendations on appropriate patient-care practices. In the education programme, instead of covering all the Recommendations in a similar fashion for all categories of HCWs, a better strategy is to focus on patient-care practices that require alterations, particularly those that would meet resistance from HCWs.
NEW GUIDELINE
Non-established Practices
Established Practices
Implementation methods
Announcement and Communications
Easy Implementation Difficult Implementation - no resources
Usual education programme e.g. lectures & posters.
Difficult Implementation - Self resistance
Provide resources 25
Fig. 2 - Scheme for the effective education and implementation of a new guideline. The strategy in this guide to implementation has been designed to be used by any health-care facility, irrespective of its level of resources. To get the most out of this guide it should be followed in the order in which it is presented. It is a step-by-step manual to inform users about which actions are required, when and by whom. The approach focuses on improving hand hygiene compliance by staff who works with patient. The goal is to reduce both the spread of infection and multi-resistant germs as well as the numbers of patients requiring a preventable HAI. As well as trying to improve hand hygiene practices, the challenge is promoting clean care practices in relation to • • • •
Blood safety Injection and immunization safety Surgical clinical procedures Water, sanitation and waste management safety
The simple actions contained in these strategies have proven to be very effective in reducing the burden of HAI. The above challenge brings to-gather under the umbrella of “CLEAN CARE IS SAFER CARE”
3. “Clean Care is Safer Care”- A Country Commitment. The ministry of Health and Family Welfare of the Govt. of the People’s Republic of Bangladesh signed an agreement with WHO for implementing the Pilot activities on WHO Guidelines on Hand Hygiene in Bangladesh in the year 2005-2006. Hence Pilot activities are started in Chittagong Medical College Hospital in 5 wards. The pilot activities motivate the HCWs and create awareness on “Clean care is safer care” which creates a tremendous impact on overall patient care in Health care facilities.
The first global patient safety challenge, Clean Care is Safer Care, is concerned with seeking and securing global commitment and action on the reduction of HAI through working with Ministries of health and WHO offices at Ministerial country level."Pledge" Action tocommitting address Cleanto tackle HAI Care is Safer Care at country level is one of the key ways to ensure individual health facility improvement. It is listed as one of the nine recommendations of the WHO Guidelines on Hand Hygiene in Health Care. Establishing the country baseline in relation to “Clean Care is Safer Care” will Action enhance a country’s ability to ensure that clean, safe care is an integral part of existing national strategies for infection control and / or patient safety. 4. GOVERNMENTAL AND INSTITUTIONAL RESPONSIBILITIES: 1. For National Governments: ( May be divided in to two Rolecampaigns of MOHFW & ☻ areas,) National DGHS, Statement should be more specific ☻ Implementation/adaptation of WHO • Make improved hand hygiene adherence a national priority and consider provision strategies of a funded, coordinated and implemented programme for improvement. ☻ Sharing of data/information • Support strengthening of infection control capacities within health care settings.
☻
26
.....…etc
•
Promote hand hygiene at the community level to strengthen both self protection and the protection of others.
2. For Hospital Administrators: • • • • • • • • •
5.
Provide HCWs with access to a safe, continuous water supply at all outlets and access to the necessary facilities to perform hand washing. Provide HCWs with a readily accessible Hand rub ( soap, liquid soap, chlorohexidine, alchohol based etc) at the point of patient care. Make improved hand hygiene adherence an institutional priority and provide appropriate leadership, administrative support and financial resources. ( By formation of Infection Prevention Advisory Committee at institutional level) Assign health-care professionals with dedicated time and training for institutional infection control activities, including the implementation of a hand hygiene promotional programme. Implement a multidisciplinary, multifaceted and multimodal programme designed to improve adherence of HCWs to recommended hand hygiene practice. With regard to hand hygiene, ensure that the water supply is physically separated from drainage and sewerage within the health care setting and provide routinesystem monitoring and management. Formation of ICC , and appoint a person as an infection control officer Introduce Multiple Awareness programme & motivation activities for infection control Ensure adequate supply of timely & need based logistics .
WHO GUIDELINE LIST WHICH CAN MAKE A MULTIMODAL STRATEGY.
The WHO Guidelines list a number of components which make up a multimodal strategy. While it is possible to attempt all the components recommended within the guidelines. Five key components will be focused on and all sites will implement these as a minimum. These are listed below 1. System Change: ● Point of care’ Alcohol-based Handrubs. ● Access to safe, continuous water supply, soap and Tissue paper. 2. Training / Education. 3. Observation and Feedback. 4. Remainder in work place. 5. Institutional safety climate ● Active participation of institutional and individual level ● Individual / institutional self efficacy.
Critical Features of the multimodal Strategy to be Implemented
6. STEPWISE ACTIVITIES: 1. Facility Preparedness: A.
Medical College Hospitals & Specialized Hospitals: • Formation of Infection Prevention Advisory Committee with TOR. • Develop of SOP and performing TOT • Training / Education of the HCWs. • Designating the Infection Prevention Doctor / Nurse in each ward. • Designating one key personal to look after the projected works. 27
•
Local facility situation analysis.( Safe continuous water supply, need assessment and others) • Installation of Wash basin & Tissue paper Hanger at the point of care. (One sink for to every ten beds) • Setting of wall mounted dispenser & Posters at the point of care. Supply of plastic pocket bottle for handrub . ( soap, liquid soap, chlorohexidine, alchohol based etc) at the point of patient care. Supply of Handrub , Tissue paper & Soap. • Supply of Covered waste bin • Monthly monitoring meeting in the wards for sharing experience and identify problems. • Supervision and monitoring of hand hygiene activities by HIPAC. • Scope of research work on point prevalence, cost of treatment, Hospital staying. • Preparing an antibiotic policy for the institution. • Installation of Automated hand dryer
B. District Hospitals: • Formation of Infection Prevention Advisory Committee with TOR. Develop of SOP and performing TOT • Designating one key personal to look after the projected works. (RMO / Senior consultant) • Training / Education of the HCWs. • Designating the Infection Prevention Doctor / Nurse in each ward. • Local Facility situation analysis. ( Safe continuous water supply, need assessment and others) • Installation of washbasin and Tissue paper Hanger at the point of care. ( One sink for every ten beds) • Setting of Wall mounted Dispenser and Posters at the point of care. o Supply of Pocket Plastic Bottle for Hand rubs( soap, liquid soap, chlorohexidine, alchohol based etc) at the point of patient care. • Supply of Hand rubs & Tissue Paper • Supply of covered waste bin. • Monthly monitoring meeting in the wards for sharing experience and identify problems. • Supervision and monitoring of Hand Hygiene Activities by HIPAC. C. Upazila Health Complex: • Formation of Infection Prevention Committee with TOR. • Performing the TOT training. • Designating one key personal to look after the projected works (RMO / Consultant) . • Designating Infection Prevention Nurse with TOR. • Training / Education the HCWs. • Local Facility situation analysis (Safe continuous water supply, need assessment and others. • Installation of washbasin and tissue paper hanger at the point of care. (One sink for every ten beds) • Setting of wall mounted dispensers and Posters at the point of care. 28
• Supply of Hand rub & tissue paper • Supply of covered plastic Dustbin. • Supervision and monitoring of hand hygiene activities by HIPAC. D. Union Health Center / FWC / H & FWC Community Clinic : • Supply of Hand rub, Tissue paper and Soap from UHC. • Supply of covered waste bin • Supervision and monitoring by UHC- HIPAC.
INFECTION PREVENTION COMMITTEE
7.
An Infection Prevention Advisory Committee provides a forum for multidisciplinary input and cooperation and information sharing. This committee should include wide representation from relevant programmes. The members of the committee are • Management Personnel. • Physicians • Surgeons • Microbiologist • Matron / Nursing super • Other Health care workers • Medical technology • Central supply • Maintenance • Housekeeping • Training services The committee must have a reporting relationship directly to either administration or the medical staff to promote programme visibility and effectiveness. In an emergency (such as an outbreak) this committee must be able to meet promptly. Terms of Reference of HIPAC: (TOR) •
•
To review and approve a yearly programme of activity for surveillance and prevention. To review epidemiological surveillance data and identify area of intervention. To assess and promote improved practice at all levels of the facility. To ensure appropriate staff training in infection control and safety. To review risks associated with new technologies, and monitor infectious risks of new devices and products prior to their approval for use. To review and provide into investigations of epidemics. To communicate and cooperate with other committees of the Hospital with common interests such as Pharmacy and Therapeutics or Antimicrobial Use Committee, Biosafety or Health and Safety Committees and Blood Transfusion Committee ( where applicable). If the committee do not exist in the institution, the works are to be distributed to other personnel for proper functioning. To ensure need based timely selection, procurement & supply chain of logistics
8.
INFECTION CONTROL RESPOSIBILITY:
• • • • • •
1. Role of Hospital Management: 29
The hospital management must provide leadership by supporting the hospital infection control programme. They are responsible for •
Establishing a multidisciplinary Infection Control Committee &ensure regular monitoring & supervision • Identifying appropriate resources for a programme to monitor infections and apply the most appropriate methods for preventing infection. • Ensuring education and training of all staffs through support of programmes on the prevention of infection , disinfection and sterilization techniques. • Delegating technical aspects of hospital hygiene to appropriate staff. Such as -Nursing -Housekeeping -Maintenance -Clinical Microbiological laboratory. • Periodical reviewing the status of nosocomial infections and effectiveness of Interventions to contain them. • Reviewing, approving and implementing policies approved by the infection control committee. • Ensuring the infection control team has authority to facilitate appropriate programme function. • Participating in outbreak function. • Ensure record keeping & reporting to competent authority B. Role of Physicians: (Infection prevention Doctor) 1. By providing direct patient care using practices which minimize infection. 2. By following appropriate practice of hygiene ( hand washing, handrubing and isolation) 3. Active role playing in the infection control committee. 4. Complying the practices approved by the infection control committee. 5. Advising patients, visitors and staffs on techniques to prevent the transmission of infection. 6. Identifying nosocomial infections. 7. Investigation of type of infection and infecting organisms. 8. Surveillance of hospital infection
D. Role of nurse in-charge of the ward : ( Infection prevention Nurse) 1. Maintaining hygiene, consistent with hospital policies and good nursing practice on the ward. 2. Monitoring aseptic techniques including hand washing, hand rubbing and isolation. 3. Reporting promptly to the attending physician any evidence of infection in patients under the nurse’s care. 4. Limiting patient exposure to infection from visitors, hospital staffs, other patients or equipments used for diagnosis or treatment. 5. Maintaining a safe and adequate supply of ward equipment, drugs and patient care supplies. 6. Participating in training of personals. 7. Advising patients, visitors and staffs on techniques to prevent the transmission of infection. 30
Ref. Prevention of hospital acquired infections, A practical guide, 2nd edition, WHO / CDS/ CSR/ EPH/ 2002.12.
9.
IMPLEMENTATION: Multimodal Component
Minimum Criteria for implementation
1A. System change : ● Point of care hand rubs
● Bottles of hand rub ( soap, liquid soap, chlorhexidine, alcho based etc) positioned at the point of care in each ward, or given to staff
1B. System change : ● Access to safe, continuous water supply, soap and tissue
● One sink to every ten beds ● Soap and tissue paper available at every sink • Automated hand dryer • Waste bin
2.
Training and Education
● All staff involved in the testing receive training as per SOP ● A Programme for update training over the short, medium and long term is established
3.
Observation and feedback
● Two periods of observation monitoring are to be carried out. a At the beginning b. After one month in local level, 3 month in regional level six months in national level
4. Reminders in the workplace
● “How to” and “5 Moments” posters are displayed in all wards (e.g. patients rooms, staff areas, out-patient / ambulatory departments.)
5.
● The chief executive, Chief medical officer / Medical superintendent and chief nurse all make a visible commitment to support hand hygiene improvement ( e.g. announcements and / or formal letters to staff)
10.
Institutional safety climate
SUPERVISION AND MONITORING:
Supervision and monitoring of Hand Hygiene practices is an activity of crucial importance to baseline compliance by HCWs to evaluate the impact of promotion, interventions and to provide feedback to HCWs. Monitoring can also be helpful in investigating infection outbreaks. In assessing the potential role of hand hygiene practices, and also in determining the extent to which infection can be decreased depending on the different rates of compliance. Compliance with hand hygiene can be evaluated directly and indirectly. Direct methods include observation, patient assessment or self-report. Indirect methods include monitoring consumption of products such as soap or hand rub. Direct methods are necessary to determine precisely hand hygiene compliance rates. A direct method, according to definitions for hand hygiene indications, consists of a count of the number of hand hygiene episodes performed by HCWs divided by the number of hand hygiene opportunities. Performance feedback on hand hygiene behavior is critical to improve compliance with hand hygiene among HCWs. 11.
PROMOTION DEVELOPEMENT AND PRINTING OF FESTOONS, BANNERS, POSTERS, DVD AND OTHER MATERIALS: A. Develop a “Logo” in our country concept on Hand Hygiene. B. Poster on 5 moments of Hand Hygiene. 31
C. Poster on How Hand Wash is performed. D. Poster on How Hand Rub is performed with Hand Rub. E.A DVD on the activities of Hand Hygiene in Health Care Settings. F. Banner & Festoons on Hand Hygiene Activities. G. BCC materials for Media Communication for mass people. 12.
TERM DEFINITIONS
Hand Hygiene is a general term referring to any action of hand cleansing, which includes:
Antiseptic hand washing: Washing hands with water and soap or other detergents containing an antiseptic agent. Antiseptic hand rubbing (or hand rubbing): Applying an antiseptic hand rub to reduce or inhibit the growth of microorganisms without the need for an exogenous source of water and requiring no rinsing or drying with towels or other devices.
Hand antisepsis/decontamination/degerming: Reducing or inhibiting the growth of microorganisms by the application of an antiseptic hand rub or by performing an antiseptic hand wash. Hand care : Actions to reduce the risk of skin irritation. Handwashing : Washing hands with plain or antimicrobial soap and water. Hand cleansing: Action of performing hand hygiene for the purpose of physically or mechanically removing dirt, organic material or microorganisms. Hand disinfection is extensively used as a term in some parts of the world and can refer to antiseptic hand wash, antiseptic hand rubbing, hand antisepsis/decontamination of hand washing with an antimicrobial soap and water, hygienic hand antisepsis, or hygienic hand rub. Disinfection generally refers to inanimate surfaces, but hands disinfection is frequently used in the same sense as hand antisepsis in the literature but not in these Guidelines. Hygienic hand antisepsis : Treatment of hands with either an antiseptic hand rub or antiseptic hand wash to reduce the transient microbial flora without necessarily affecting the resident skin flora. Hygienic hand rub : Treatment of hands with an antiseptic hand rub to reduce the transient flora without necessarily affecting the resident skin flora. These preparations are broad spectrum and fastacting, and persistent activity is not necessary. Hygienic hand wash: Treatment of hands with an antiseptic hand wash to reduce the transient flora without necessarily affecting the resident skin flora. It is broad spectrum, but is usually less efficacious and acts more slowly than the hygienic hand rub. Surgical hand antisepsis/surgical hand preparation : Antiseptic handwash or antiseptic hand rub performed pre-operatively by the surgical team to eliminate transient and reduce resident skin flora. Such antiseptics often have persistent antimicrobial activity. Surgical handscrub/presurgical scrub refer to surgical hand 32
preparation with antimicrobial soap and water. Surgical hand rub refers to surgical hand preparation with a waterless, alcohol-based hand rub. In a resource poor country like Bangladesh hand hygiene practices can play a important role in prevention of HAI
Health Care Worker: All health professionals who are in direct and indirect contact with patients and their environment (e.g. via equipment or product) during their respective activities. Professional categories: 1. Nurse / Midwife 2. Auxiliary 3. Medical Doctor 4. Other Health-care worker ( Therapist, Technician, Others------) Health Care Activities and Hand Hygiene: Health-care activity may be described as a succession of tasks during which Healthcare workers hands touch different types of surfaces (patient, object, body fluid etc.). Depending on the order in which these contacts occur, germ transmission from one surface to another has to be interrupted as each contact is a potential source of contamination for healthcare workers hands. It is during this interval – between two contacts- that the indication or indications for hand hygiene are found. The Indication: The indication is the reason why hand hygiene is necessary at a given moment. It is justified by a risk of germ transmission from one surface to another. It is formulated in terms of a temporal reference point “Before” or “After” the contact. The indications “before’ and “after” do not necessarily correspond to the beginning and completion of a care sequence or activity. They occur during movements between geographical areas, during transitions between tasks near patients, between patients or some distance from them. The Opportunity: The opportunity for hand hygiene is a matter for the observer. From the point of view of the observer, the opportunity exists whenever one of the indications for hand hygiene is present and observed. Each such opportunity must correspond to an action. Several indications may come together to create an opportunity. This means that there may be several simultaneous reasons for a hand hygiene action. The opportunity is an accounting unit for the action. The Hand Hygiene Action: If properly carried out, the hand hygiene action implies recognition of the indications by health-care workers during their activities and within the process they organize care. The hand hygiene is not just an additional “Task” to be performed, but an essential one that marks the activities of health-care workers, even if there is no physical obstacle preventing the tasks from being carried out without hand hygiene. Point of Care: Refers to the place where three elements occur together, the patient, the health-care worker and care or treatment involving patient contact. The concept refers to a hand hygiene product (e. g Alcohol based hand rub) which is easily accessible to staff e. g. within arm’s reach ( as resource permit) to where patient contact is taking place. Care Environment: All those elements which make up the care environment (objects, medical equipments and people present in a hospital, clinic or ambulatory settings). Patient Surroundings: 33
A space restricted to the care environment temporarily dedicated to a patient and including equipments ( various medical devices) , furniture ( bed, chair, bedside table etc.) and personal belongings ( clothes, books etc.) handled by the patient and health-care worker when caring for the patient. Contact: When parts of two bodies touch each other. Patient Contact: ( between health-care worker and the patient ) Refers to the health-care workers hands that touch the patient’s skin and clothes. Contact with Patient Surroundings: Refers to the health-care worker’s hands touching inert objects and surface in the patient surroundings. Aseptic Task: Performed by a health-care worker means a task that touches ( whether directly or not) a mucous, damaged skin, an invasive medical device ( catheter, probe) or health-care equipments. Body Fluids: Blood and any other substance secreted by the body (mucous, saliva, sperm, tears, wax, milk etc.) excreted ( urine, stools, vomit), ex- and trans-sudation ( pleural fluid, CSF, ascitic fluid etc. with the exception of sweat) Risk of Exposure to a Body Fluid: Refers to a risk that includes potential and actual exposure to a body fluid. Alcohol-based (Hand) Rub: An alcohol – containing preparation ( liquid, gas or foam) designed for application to the hands to reduce the growth of micro-organisms. Plain Soap: Detergents that do not contain antimicrobial agents, or that contain very low concentration of antimicrobial agents effective solely as preservatives.
13. CHECKLIST STRUCTURE Hand rub at bedside / point of care - percentage of beds served by Handrub - Should a benchmark is proposed? Hand rub dispensers working Sink adequately placed with adequate water supply - Percentage of beds served by sinks - Percentage of beds served by sinks adequately equipped ( paper towel, soap) - Should a benchmark is proposed? Automatic sink & Automated hand dryer Taps / faucets not manipulated by hands Soap available Availability of paper towels Availability of gloves at point of care Availability of skin care product Adequate storage of products
34
Yes
No
Remarks
Adequate provision of hand hygiene products Written hand hygiene guidelines or recommendations available Available waste bin PROCESS Promotion of institutional climate ( Posters, awards) Extensive and complete education programme Feedback performance to staff Number of adequate manpower No overcrowding ( visitors) Active participation at individual and institutional level Senior management support Institutional / corporate commitment to the use of hand rub and monitoring of the use Regular monitoring meeting Record keeping & reporting OUTCOME Monitor adherence of hand hygiene Monitor adherence at time of outbreak Monitor appropriate use of gloves Monitor regular presence of hand hygiene products in the unit Monitor the amount of hand rub used Count used paper hand towels Reduction in infection rates Reduction in cross-infection rates Reduction in antimicrobial resistance spread Cost implication of hand hygiene promotion
35
