Pilot testing in the WHO Eastern Mediterranean Region (EMR)
Pakistan - Pakistan Institute of Medical Sciences
The Pakistan Institute of Medical Sciences (PIMS) in Islamabad is a tertiary referral hospital with 1055 beds. Three intensive care units (ICUs) – medical, surgical and neonatal – were selected for pilot testing. Awareness of hand hygiene was reasonably good before the start of the project. Alcohol-based handrub was already available due to the fact that most Pakistani earthquake victims had been admitted there and handrub for hand hygiene was used to deal with patient overflow.
The campaign was launched on 29 October 2007. Baseline evaluation revealed a sink-to-patient ratio of approximately 1:3 with clean, running water available. In contrast, alcohol-based handrubs were actually available in only one of the three ICUs (intermittently).
The WHO-recommended formulation II was produced at PIMS where it replaced the alcohol-based handrub previously purchased from a commercial source at a much higher price (US$ 3.00 per 500 ml vs US$ 1.85 per 500 ml, respectively). In August 2008, the campaign was launched with a training workshop on hand hygiene to train the trainers and key individuals involved in the project and the health-care workers in the pilot units. The WHO hand hygiene posters were made available in Urdu to overcome language barriers. An interesting specificity of the campaign at PIMS was that training was also offered to the so-called “janitors”, illiterate support employees in charge of clinical and human waste disposal, and educational material was adapted to correspond to their level of knowledge.
One of the main achievements of the project was the establishment of an infection control committee for the first time at PIMS, composed of an infection control doctor and three full-time infection control nurses. Surveillance of health care-associated infection was also established in the neonatal ICU using WHO tools. At follow-up evaluation, hand hygiene compliance had increased by 20.3% with improvement in all indications for hand hygiene. Health-care workers' knowledge about health care-associated infection and hand hygiene also showed significant improvement following training.
Key success factors
Strong commitment of the senior management to improve infection control, including hand hygiene, was critical to the success of the project at PIMS. Successful production of the alcohol-based handrub demonstrated the feasibility of local production in a resource-limited setting and in a country with strict regulations on the use of ethanol.
As a result of the hand hygiene campaign, health care-associated infection has become a high priority on the quality and patient safety agenda of PIMS. Following the conclusion of pilot testing, the campaign has been extended to all other PIMS units to ensure the sustainability of hand hygiene improvement at facility level. Alcohol-based handrubs have been available without any interruption of stock supplies and training sessions have been conducted in other hospital wards. Although education activities have been renewed both in the pilot ICUs and other units, the measurement of hand hygiene compliance and handrub consumption monitoring were not affordable after the end of pilot testing. A promising achievement of this project is that the federal ministry of health has expressed an interest to train 100 000 health visitors throughout Pakistan and distribute alcohol-based handrub. For this reason, the feasibility of the production of the WHO formulation on a national scale using a public/private partnership is being explored.