Implementing the Hand Hygiene Guidelines
Q: Q. How does a facility get access to the Guide to Implementation and associated toolkit?
A: A number of the tools are accessible directly via the website. However, to gain access to all of the implementation tools and the Guide to Implementation it is currently necessary to register as a Complementary Test Site. Registration also provides access to a community platform where it is possible to contact other implementers and post questions regarding the strategy. Register at:
Q: Do the Guidelines provide incentives for Health-Care Workers to use them?
A: Focusing attention on hand hygiene has benefits in terms of elevating hand hygiene improvement to an important position within health care generally, but specifically within the field of infection control and patient safety.
Incentives for adoption or incorporation of these recommendations within existing infection control and patient safety strategies are predicated on the added-value which the whole package can bring to a health system. Since the Guideline recommendations are evidence-based and are constructed around models which have had success in terms of sustainability, the intention is that member states (and even individual facilities) will be motivated to adopt the Guideline recommendations in order to ensure long-term success in health-care worker behaviour change and hand hygiene improvements.
Added-value components designed to motivate key actors around the world to take action on HAI prevention include the toolkit for implementation, with its simple but effective resources designed to convey core messages. The Guidelines outline in detail a range of strategies for successful hand hygiene improvement, which can be tailored to resource-poor countries as well as those with resources to invest in wide-scale campaigning.
Q: Are there many other hand hygiene guidelines across the globe?
A: There are very few stand-alone, evidence-based guidelines. There is general consensus that the WHO Guidelines is the most comprehensive evidence-based document ever produced on the topic, as it incorporates the key recommendations from previously published national or international guidelines. In addition, the added-value component of the implementation strategy and toolkit makes the WHO Guidelines potentially more relevant and applicable.
Q: Why should countries use the WHO Guidelines, rather than continue to use their own?
A: Countries are advised to review their existing guidelines and where necessary to consider the use of the WHO strategies and guidelines. Where existing guidelines are in alignment with the WHO recommendations there is no need to make unnecessary changes. In many cases, however, the WHO are aware that stand-alone hand hygiene guidelines simply do not exist. The WHO Guidelines provide a blueprint for the development of robust stand-alone guidelines, which carry weight within a country or a facility.
Q: What are the other WHO plans to further help the global community to prevent and control the spread of HAI?
A: WHO’s programmes on blood safety, immunization safety, safe clinical procedures, and safe water and sanitation, are all aimed at preventing and controlling the spread of HAI. The WHO also provides detailed advice on infection prevention and control in specific fields such as SARS, or preparedness against a potential influenza pandemic.
Hand hygiene is an essential part of standard precautions, and together with droplet precautions (which essentially means wearing a mask when appropriate), is the primary action to limit cross-transmission of influenza, including influenza viruses of avian origin, which can be readily inactivated by alcohol-based hand rubs.
Hand hygiene education and promotion campaigns in the community are ongoing in certain parts of the world (some are briefly reviewed in the Guidelines document itself), and strategies for education, promotion and behaviour changes, while sharing common elements, do differ in the community compared to health-care settings. The focus of the Guidelines is on hand hygiene within health-care settings; however, it is clear that a joined-up approach will result in a better chance of success.
The Third Global Patient Safety Challenge will focus on the serious problems posed to patient safety by antimicrobial resistance and links closely with the work of the First Challenge.
Q: will this challenge end?
A: The Global Patient Safety Challenge started its life as a biennial programme of the World Alliance for Patient Safety. However, the work of the first Challenge will continue as a long-term programme, to support activity started as a result of the Challenge and ensure, for example, that the Guidelines related work and tool development does not become frozen in time. This will ensure that pilot testing and enhanced efforts at global awareness continue, maximizing the window of opportunity afforded by such a challenge.
Q: What are the resources needed for achieving hand hygiene improvement according to the WHO multimodal strategy?
A: The WHO Multimodal Strategy for Hand Hygiene Improvement is a low-cost health-care intervention. Resources required will depend on the position occupied by the country or facility on the hand hygiene improvement continuum and on the sophistication of the chosen approach. In a situation where hand hygiene improvement has never before been addressed, and based on the minimum criteria for implementation contained within the Guide to Implementation, likely costs are as follows:
- Human Resource
- A responsible person to coordinate activity. This person should have a clinical background at a senior level and this can be incorporated within an existing role incurring no up-front cost; however, a dedicated person is preferable.
- Start-up costs
- Alcohol-based handrub
- Point-of-care handrub varies in cost and availability.
- If commercial product is available, the cheapest product, which complies with international standards, should be sourced. The product should be well tolerated and accepted by staff. It may be worthwhile to assess whether the product can be sourced at a discount price.
- If there is no commercial product available, consider local production using the WHO Formulation. Costs for local production vary greatly as they are influenced by the local costs of raw materials and the quantities produced, as the following examples demonstrate:
- South East Asia: USD 4.945 to manufacture 1 litre
- Western Pacific: USD 5 per litre
- United Kingdom: USD 20
- The toolkit contains a tool to assist in estimating required quantities and likely costs
- Sink to bed ratio: facilities should aim for one sink to every 10 beds.
- Soap and fresh towels at each sink
- Training and education
- Training is a key component of the strategy. Costs associated with training include capacity to deliver training and geographical area to deliver training.
- Observation and feedback
- Two periods of observational monitoring are required (baseline and follow-up) and depending on the extent of the implementation, at least one person must be available to undertake the observations. Observers require a minimum of 2-hours training in observation techniques.
- Reminders in the workplace (posters)
- As a minimum, the "How To" (technique) posters and the "Five Moments" (when to) posters should be displayed in all clinical areas. Costs associated with translation, adaptation, and printing need to be factored in.
- Recurrent costs
- The main on-going costs relate to human resource (i.e. a person who has responsibility, not necessarily full-time) for coordinating activity over at least a 5-year period.
- Alcohol-based handrub usage is likely to increase and will form the main ongoing cost.
- Training: refresher training is required on an annual basis.
- Reminders: posters should change and evolve and ideally fit with the local culture and context. The WHO designed posters are useful at start-up, but consideration should be given to local development, using local artists/designers and marketers if available, and reflect local context. Some facilities have used local artists or volunteers with expertise in this area, at no cost and with excellent results.
Q: Can commercial companies reproduce or reprint WHO Hand Hygiene materials to use and distribute to support training and educational activities?
A: Commercial companies are not permitted to use the WHO logo. Reprinting of materials for commercial purposes is not permitted. However, any company may quote WHO in its materials, as long as the company does not imply that WHO endorses the company or its products. The World Alliance for Patient Safety recognizes the important role that the commercial sector plays in providing the products for safe clinical treatment and care. For this reason, we will be working during 2008 and beyond to explore best methods of working in partnership with colleagues in commercially relevant sectors.
Q: Can health care facilities use the WHO logo and images associated with the Challenge on locally adapted tools or guidelines?
A: Requests for permission to reproduce or translate WHO publications or illustrations within publications or training materials – whether for sale or for noncommercial use or distribution – should be addressed to WHO Press, at WHO 20 Avenue Appia, CH-1211 Geneva 27, Switzerland, fax: +41 22 791 4806; e-mail: permissions@who.int.
Any use of images should display the source and WHO copyright. Translations require a translation license signed by the WHO Director General's Office.
Q: Is it possible to prioritize the Guideline recommendations to help facilitate a country to embark on this approach?
A: The multimodal nature of the recommendations makes their prioritization difficult. Also, the overall success may depend upon several elements working simultaneously and synergistically (the sum being greater than the contributory parts). Therefore, for the best chance of success it is recommended to implement the multimodal strategy.
Q: Can the WHO Hand Hygiene Guidelines and implementation strategies be used in health-care settings other than hospitals (ambulatory care, long-term care facilities)?
While the primary focus of the Guidelines is on hospitals, the Guidelines can be applied in any setting where health care is delivered. The WHO is currently providing technical support for the testing of the strategies of the Guidelines in a wide range of health-care settings.
Q: Can the Hand Hygiene Guidelines be used outside of health care?
A: The evidence on which the Guidelines are based comes mostly from health-care settings. However, many of their recommendations are relevant to non-healthcare settings, especially with regards to behaviour change requiring a multimodal strategy.
Q: Should targets be set for hand hygiene compliance? If so, what level of increase would be good?
Any such targets should first be realistic and attainable, in view of the long-term efforts required to bring about improvements in hand hygiene behaviour. Aiming for complete compliance in the short-term would obviously be difficult to achieve in facilities where the initial compliance rate may be less than 40%.
What should be aimed for is the establishment of a baseline, and a steady, sustainable, month-by-month, year-on-year improvement.