Pilot testing in the WHO Region of the Americas (AMR)/
Pan American Health Organization (PAHO)
Costa Rica - Hospital Nacional de Niños (HNN)
Hospital Nacional de Niños (HNN), is a referral paediatric hospital in San José where the WHO Multimodal Hand Hygiene Improvement Strategy was tested in 12 pilot wards (290 beds).
The alcohol-based handrub was produced according to the WHO recommendations by a private company, which accepted to donate the product and the dispensers. Despite initial failures at the quality control test, the local production of the WHO-recommended formulation was successfully implemented. An engineer reviewed the hospital plan to place the new dispensers at the point of care according to local safety criteria. An official ceremony, chaired by the Minister of Health, was organized to launch the hand hygiene promotion campaign at HNN. Giant dolls in the shape of a handrub bottle were prepared and used to market the improvement for promotional purposes. HNN committed also to patient involvement and families were informed of the pilot project and encouraged to use the alcohol-based handrub when caring for their children.
One of the main achievements of the project was the improvement to the facility infrastructure, described above. At follow-up, overall hand hygiene compliance increased very significantly by 28%. Improvement was observed in all professional categories and in all hand hygiene indications apart from "after body fluid exposure risk" for which compliance was already high at baseline.
Key success factors
The key success factors of implementation in this site were the high-level medical leadership and the pragmatic, continuous action by head nurses. Strong support from the government not only facilitated the excellent pilot implementation of the WHO strategy, but also led to its national scale-up. The system change was also critical to the improvement of hand hygiene practices, because alcohol-based handrubs were not previously widely available and, in some areas of the hospital, significant infrastructure deficiencies (sink to bed ratio <1:10) constituted an important barrier.
After the testing phase the campaign was extended hospital-wide and has continued with the essential elements described above. A poster competition with the creative input of all wards was launched in 2009. Hand hygiene compliance is being monitored quarterly and the results are reported to the ward staff. Continuous improvement of practices has been observed, especially in paediatric surgery and intensive care units but less prominently in regular paediatric units. Alcohol-based handrub consumption in 2009 was twice that in 2008. The very encouraging results of testing at HNN motivated the Ministry of Health to make a National Call to Action to all hospitals in the country for the implementation of the WHO strategy. The Costa Rica experience has also had a catalytic influence on other countries in AMR. The expertise of the pilot project team at HNN has been successfully exploited by the WHO Regional Office for the Americas (AMRO) in collaboration with PAHO. Several training initiatives involving many other countries in the Americas and the Caribbean currently adopting the WHO strategy were organized in the Region.