WHO hand hygiene framework easy to implement

More than 90% of responding facilities reported that the Hand Hygiene Self-Assessment Framework, which is a component of WHO’s focus on hand washing in health care facilities, was easy to implement, according to findings presented at the 50th Interscience Conference on Antimicrobial Agents and Chemotherapy.

The findings were presented by Andrew Stewardson, MD, of the WHO Collaborating Center on Patient Safety at the University of Geneva Hospital. The framework is designed to analyze structures, resources, promotion and hand hygiene practices in health care facilities.

“We wanted to help health care facilities to develop an action plan for strengthening hand hygiene,” Stewardson said. “The program was developed by an internal group before undergoing review by expert advisors and pilot testing for usability.”

There are five components of the framework that are based on WHO multimodal hand hygiene improvement strategies:

• System change;
• Staff education;
• Evaluation and feedback;
• Reminders in the workplace and institutional safety climate.

Based on international guidelines, available evidence and expert consensus, 27 indicators reflecting the key elements of each component were evaluated. These indicators were tallied and a 500-point score system was created.

“Each component was attributed a 100-point score that was further weighted by perceived relative importance,” Stewardson said. “The rationale behind the scoring system took into account fidelity to the underlying model, evidence-based programs where possible and expert opinion, among other factors.”

The framework was sent to several health care facilities in 19 countries for pilot testing — 26 facilities from all six WHO regions responded. Facilities were asked to self-assess a score and complete a survey that involved 12 questions with a five-point Likert scale and three open-ended questions, the last of which was open for general comments.

“Overall, we got a lot of positive feedback,” Stewardson said. “As for concerns, some respondents said that some things needed editing for clarity or additional definitions, and others suggested adding answer categories for some indicators or more questions.”

Facilities were assigned to one of four levels of hand hygiene promotion and compliance based on total score: the inadequate range was 0 to 125; basic was 126 to 250; intermediate was 251 to 375; and advanced was 376 to 500.

The trial also included a leadership component, the aim of which was to identify hand hygiene reference centers.

The range of scores among responding facilities was 35 to 480 (mean, 262). An hour or less was required to complete the framework at 10 of the 26 sites, and 21 sites completed the framework in less than 2 hours.

Twenty-three facilities agreed or strongly agreed that the framework was “easy to use,” and 24 facilities agreed or strongly agreed that the framework was “useful for establishing facility status with regard to [hand hygiene] promotion,” according to Stewardson. He noted that feedback from the open-ended section of the questionnaire was used to refine the program.

“The Hand Hygiene Self-Assessment Framework is easily usable with limited time investment,” Stewardson concluded. “It also allowed useful benchmarking by a variety of hand hygiene promotion programs.”

It has been accepted among infection control specialists that improvement in appropriate hand hygiene compliance is the least expensive and most effective means of reducing health care-associated infections. Studies from past decades demonstrated poor compliance. In the US and globally, there are ongoing campaigns to improve the rate of appropriate hygiene before and after patient contact. The self-assessment framework referred to in this story is available at the WHO website (www.who.int/gpsc/country_work/hhsa_framework.pdf). For those interested in the validity of data on hand hygiene compliance, I recommend the recent study by Dhar et al. Infect Control Hosp Epidemiol. 2010;31:869-870). They show that the reported rate of hand hygiene compliance is higher when the hand hygiene monitor is part of the unit compared with when the monitor is an independent non-unit-based individual.

– Robert Baltimore, MD

Yale University School of Medicine

Yale-New Haven Children’s Hospital, New Haven, CT

For more information:

• Stewardson A. K-507. Presented at: 50th Interscience Conference on Antimicrobial Agents and Chemotherapy; Sept. 12-15, 2010; Boston.