Clean Care is Safer Care

Pilot testing in the WHO European Region (EUR)

Italy - a network of 41 intensive care units

Flower-bed with the shape of the Clean Care is Safer Care logo at the main entrance of one of the Italian pilot hospitals.
Mario Angelini
Flower-bed with the shape of the Clean Care is Safer Care logo at the main entrance of one of the Italian pilot hospitals.

Setting

A network of 41 intensive care units (ICUs) participating in the Italian national hand hygiene campaign was invited to become the pilot site for testing the WHO Guidelines on Hand Hygiene in Health Care in EUR. Criteria for selecting the ICUs were: 1) Having a reliable system for health care-associated infection (HCAI) surveillance; 2) explicit consent to provide WHO with requested data 3) no other major prevention project concurrently to the strategy implementation; 4) compliance with the time line agreed with WHO. Implementation was coordinated by the national reference centre for HCAIs (Agenzia Sanitaria e Sociale Regionale Emilia-Romagna). Most ICUs undertook the implementation step (step 3, improvement activities) between October 2007 and January 2008.

Implementation characteristics

The entire range of tools included in the WHO Pilot Implementation Package was translated into Italian and the printed material distributed to the pilot ICUs; the WHO strategy and action plan were fully adopted in a very consistent way. In the context of the national campaign a web platform was created on the ministry of health site for tool downloading, technical questions, and interactive discussion among the sites; in addition, one national and four regional training courses for pilot coordinators and observers were organized.

Main results

Hand hygiene leaflet hung at the bedside in a pilot ICU, Italy.
Peter Santa
Hand hygiene leaflet hung at the bedside in a pilot ICU, Italy.

A significant 13% increase of overall hand hygiene compliance was detected following implementation in the ICU network. Improvement was significant in all professional categories, apart from therapists/technicians. Interestingly, compliance increase at follow-up was higher in ICUs with lower compliance at baseline. Permanent availability of alcohol-based handrubs improved from 70% to 100%. Staff knowledge about hand hygiene significantly improved; the knowledge questionnaire results identified areas that need further amelioration, e.g. the understanding of the dynamics of microrganism transmission and the role of different sources of infection. According to the perception questionnaire most respondents attributed the highest scores (6 and 7 of a 7-point Likert scale) to each component of the WHO strategy when asked about the importance of the strategy components in determining their hand hygiene performance improvement.

Key success factors

Strong support from the national coordination centre and the regional coordinators was critical to the overall success of the testing in the ICU network. The WHO brand on this initiative was a powerful factor motivating personnel to participate in it and for them to achieve the programme’s intended objectives. The multimodal approach of the WHO strategy and the step-wise implementation plan were considered as a very successful model.

Long-term sustainability

Local and national coordinators of the Italian network of ICUs testing the hand hygiene improvement strategy.
WHO
Local and national coordinators of the Italian network of ICUs testing the hand hygiene improvement strategy.

After the pilot phase the promotion of hand hygiene best practices continued in most ICUs. In many of them the WHO strategy approach became a model for integrating additional prevention measures. In many hospitals, staff working on the wards not involved in the pilot testing requested hand hygiene promotion to be extended to their settings. Two national events took place in 2008 and 2009 to discuss the results of testing in the ICU network and of the national campaign going on in parallel. Working groups and plenary discussions provided very interesting information about the implementation feasibility and invaluable suggestions for improving the WHO tools.

In the context of the ongoing national campaign, all participating hospitals were invited to undertake hand hygiene observations during the first trimester of 2010. A national event will take place on 5 May 2010 to share results and to discuss actions to strengthen the ongoing campaign. The national reference centre for HCAIs translated in Italian the WHO Hand Hygiene Moment 1 Observation Form and invited all health-care facilities to participate in the WHO Global Survey launched on and around 5 May 2010.

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