Pilot testing in the WHO African Region (AFR)
Mali - Hôpital du Point G
The Hôpital du Point G in Bamako is an acute-care, 518-bed university hospital serving the population of Bamako and the surrounding area (approximately 2 million inhabitants) and a referral hospital for the entire country. Nine units (two surgical, gynaecology and obstetrics, urology, nephrology, infectious diseases, internal medicine, and accident and emergency) representing 13 wards and 224 health-care workers were selected for pilot testing. No infection control expertise was available. A hospital pharmacist, previously trained in infection control and the local production of the WHO handrub formulation I at the University of Geneva Hospitals, was appointed as project coordinator.
From December 2006 to June 2008, the WHO multimodal hand hygiene improvement strategy was progressively put in place in the pilot units using the five recommended implementation steps. The baseline evaluation identified severe deficiencies in hand hygiene facilities and products. Although clean water was permanently available, only a few patient rooms were equipped with sinks (sink-to-bed ratio, 1:22) and no soap and towels were available. The WHO-recommended formulation based on ethanol was manufactured at the hospital pharmacy at a cost of US$ 2.97 per litre and distributed to staff in 100 ml pocket bottles. Regular quality control tests confirmed that all samples met the optimal quality parameters.
An official launch of the hand hygiene campaign took place on 2 November 2007 with a ceremony chaired by the Minister of Health, the WHO representative in Mali, and the hospital director, with the participation of all health-care workers. During the event, chairs and health-care workers were invited to sign a giant bottle of alcohol-based handrub as a symbol of their commitment, and information leaflets and T-shirts with the project logo were distributed. During the following months, education sessions were organized for all health-care workers in the pilot units and the alcohol-based handrub distributed. Visual posters featuring the WHO project, hand hygiene indications and the technique for handwashing and handrubbing were displayed.
The local production of alcohol-based handrub proved to be technically feasible and affordable. Handrubbing became the quasi-exclusive hand hygiene technique (93.3%). At follow-up evaluation, hand hygiene compliance increased by 13.9%. Improvement was observed among all professional categories and across all medical specialties. Health-care workers' knowledge about health care-associated infection and hand hygiene improved across all four main professional categories.
Key success factors
System change was crucial to enable health-care workers to perform hand hygiene and thus to allow significant improvement in practices. Strong support from the WHO country office and the hospital directorate was critical to project endorsement, development, and success. Successful implementation at this pilot site demonstrated the feasibility of the WHO multimodal hand hygiene improvement strategy in a setting with limited resources in the African region.
Following the test phase, a sustainability plan was developed and the costs of alcohol-based handrub are now incorporated into the hospital’s regular budget. The campaign continues in the pilot units and an extension hospital-wide is planned, but not yet implemented. Actual availability and investment of human resources and commitment by the directorate are essential factors for the implementation extension.
Hand hygiene observations, including research on the impact of glove use on compliance, are currently ongoing and new education sessions for all health-care workers will be undertaken in the upcoming months. The production and distribution of the alcohol-based handrub continues – except for a one-month interruption due to an ethanol shortage at national level. Monthly consumption of alcohol-based handrub is being continuously monitored and has shown constant levels of usage. A survey on skin tolerability and acceptance of the product among health-care workers yielded very positive results with only 1.7% of users who were not satisfied.
Of note, the successful results obtained in the pilot test phase have motivated the Mali government to prepare a national plan for infection control in collaboration with WHO. According to this plan, approved by the Ministerial Cabinet on 11 March 2010, the WHO hand hygiene improvement strategy will be gradually implemented in 11 reference hospitals and then nationwide. The production of alcohol-based handrub will be initially guaranteed by the Point G and G. Touré hospitals and then taken up from a national company.