Pilot testing in the WHO South-East Asia Region (SEAR)
Bangladesh - Chittagong Medical College Hospital
The Chittagong Medical College Hospital (CMCH), in Chittagong, is a government-run tertiary referral centre with 1010 beds serving 40 million people. Five wards were selected for pilot testing: neonatal care, surgery, orthopedics, paediatric and adult intensive care units.
Baseline conditions of the hospital were critical with 162% bed occupancy, no infection control professional, no data on healthcare-associated infection and antimicrobial resistance, and significant infrastructural deficiencies. The observation of hand hygiene was challenging because of cultural sensitivities, overcrowding and high bed occupancy (two patients per bed in some wards) which made it difficult to apply the "patient zone" concept.
The alcohol-based handrub, based on the WHO recommended formulation II was manufactured locally by the national Essential Drug Company Ltd and made available through wall dispensers and pocket bottles. Sinks (one for every 15 beds) were installed in all the pilot wards, when previously located only at nursing stations and doctors’ rooms. In order to improve inadequate water supply, two deep tube wells were dug and major water supply lines were enhanced. The hand hygiene promotion phase at CMCH was launched through a high-profile event with the attendance of the Minister of Health, the country WHO representative, senior ministerial officials, and public and private hospital representatives. Posters translated into Bengali were displayed throughout the wards next to the alcohol-based handrub dispensers, above washbasins, between each bed, and at the ward entrance. All ward-based staff received training on hand hygiene and refresher courses were offered every two weeks.
One of the main achievements of the project was the improvements to the facility infrastructure, described above. In addition, an infection control committee was established at CMCH which initiated a number of new activities, including a prevalence study on health care-associated infection. Baseline hand hygiene observations yielded controversial data and therefore cannot be reported; given the infrastructure inadequacy prior to the strategy implementation, however, hand hygiene practices were likely to be very deficient. Most importantly, at follow-up a good level of overall hand hygiene compliance was reported (65.2%). Health-care workers' knowledge about health care-associated infection and hand hygiene also showed significant improvement after training.
Key success factors
System change and the introduction of the alcohol-based handrub were critical to overcome obstacles to hand hygiene performance. The signing of the pledge to Clean Care is Safer Care by the Ministry of Health and strong support from the WHO regional and country offices were important drivers of action in this pilot site. Other success factors at the facility level include commitment by the director and significant support by the head of the newly formed infection control committee as well as medical and nurse leadership.
Continuous provision of handrub has been assured and improvement of hand hygiene compliance has been consolidated in pilot wards. A very strong climate, supportive of patient safety has been established hospital-wide and the extension of the strategy has been initiated in other areas of the hospital with training of all health-care workers. The infection control committed regularly meets every three months and has also focused on new antibiotic utilization policies, sterilization improvement and environmental cleaning. As a result of the success showed at CMCH, the Director General of Health Services is planning a national roll-out of the hand hygiene improvement strategy, including alcohol-based handrub production, and the reinforcement of a national infection control infrastructure. These goals remain a high national priority but have been slowed because of lack of funds and human resources.