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Infection prevention and control

Since antiquity, health care-associated infection has been areality and a source of suffering for countless millions ofpatients and their families worldwide, but patient safety hasonly really become a major topic over the past 1015 years.Despite a body of constantly expanding research, many questionsstill remain. For example, the reasons for the uneven geographicdistribution of infection rates are not fully understood, notably thestriking differences in the epidemiology of nosocomial infectionsand multiresistant bacteria between the United States and Europe.Disparities may be explained by several determinants: : surveillance methods, including diagnostic practices and

laboratory recognition; : infection control practices; : antibiotic prescribing practices; : population characteristics and patient case-mix; : cultural factors (e.g., human behaviour); : factors related to the health care systems and available

resources; : political commitment.

Clearly, the effects exerted at the macrolevel by the health caresystem and the political environment contribute substantially to theobserved differences in infection rates, but these should serve alsoas an additional incentive to drive forward innovation and creativethinking for new preventive strategies.

Current conceptual thinking on patient safety places the primeresponsibility for adverse events on defects in system design,organization and operation, rather than on individual providers orindividual products. Most adverse events, such as health care-associated infection, are not the result of negligence or lack oftraining, but rather occur because of latent causes within systems.Safety is a fundamental principle of patient care and a criticalcomponent of quality management. Infection control is the

DIDIER PITTET DIRECTOR, INFECTION CONTROL PROGRAMME AND WHO COLLABORATING CENTRE ON PATIENT SAFETY, UNIVERSITY OFGENEVA HOSPITALS AND FACULTY OF MEDICINE, SWITZERLAND AND LEAD ADVISOR, FIRST GLOBAL PATIENT SAFETYCHALLENGE, WHO PATIENT SAFETY AND QUALITY IMPROVEMENT UNIT, SERVICE DELIVERY AND SAFETY DEPARTMENT,WORLD HEALTH ORGANIZATION, GENEVA, SWITZERLAND

Provoking Eureka moments foreffective infection control strategies

entrance door to patient safety and innovative strategies need tobe developed. However, most great ideas are not the result of aflash of inspiration they are rather the result of hard efforts, teamwork and conflict. Eureka moments do not happen overnight.

The Geneva hand hygiene model: A breakthrough innovationIn the mid-1990s, initial observation studies in Geneva showed alow compliance with basic hand hygiene practices and a lack ofawareness by health care workers that the main cause of cross-transmission of microorganisms is by hands (1). Time constraintwas identified as the major determinant for poor compliance (2).The challenge was to facilitate hand hygiene for staff and to find aninnovative way to do so. We tried to think out of the box and to seeif perhaps there were sources of inspiration outside the infectioncontrol field. This led us to investigate concepts from the socialsciences to help understand the main determinants driving healthcare worker behaviour and that led to the creation of a multimodalstrategy. My own Eureka moment was when I realized that thekey component was obviously the introduction of alcohol-basedhand rub at the point of patient care to replace handwashing at thesink (system change), thus bypassing the time constraintimposed by handwashing (3).

Driving commitment to fight health care-associated infectionThe first multimodal intervention ran from 1995 to 1998 at theUniversity of Geneva Hospitals with a spectacular decrease of 50%in hospital-associated infections and almost 80% in methicillin-resistant Staphylococcus aureus transmission in parallel with asustained improvement in compliance with hand hygiene. Themethodology and results were published in the Lancet in 2000 witha tremendous impact and the strategy soon became known in thescientific literature as The Geneva hand hygiene model (3).Furthermore, the strategy proved to be largely cost-effective when

ABSTRACT: Safety is now a fundamental principle of patient care and a critical component of quality management. Healthcare-associated infection prevention strategies need to be constantly revisited and updated to be effective. The Genevahand hygiene model is a typical example of a breakthrough innovatory campaign that caught fire and went viralworldwide, thanks to its adoption by the World Health Organization (WHO) as the First Global Patient Safety Challenge.The campaign remains an inspiration for further innovation. To encourage new and disruptive technologies with thepotential to improve patient safety through the successful implementation of the WHO multimodal strategy, the Universityof Geneva Hospitals/WHO Collaborating Centre on Patient Safety, together with the Aesculap Academy, have created aseries of Hand Hygiene Excellence Awards and Hand Hygiene Innovation Awards worldwide.

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assessed after eight years, with cost savings reaching US$ 24million per year in the early phase (4). In 2002, the United Kingdomconverted to The Geneva model and built up the nationalCleanYourHands campaign, which proved to be both successfuland cost-effective. Today, for US$ 1 invested, the return oninvestment is at least US$ 20.

In 2004, I was approached by the World Health Organization todisseminate and export our multimodal strategy worldwide underthe banner of the WHO First Global Patient Safety Challenge

Clean Care is Safer Care (5). The mandate was to galvaniseglobal commitment among nations and policy-makers to tacklehealth care-associated infection, which had been identified as asignificant area of risk for patients in all 194 Member States, withhand hygiene as the cornerstone of the Challenge. In 2009, WHOadded a Save Lives: Clean Your Hands initiative that attracted theadhesion of more than 17,000 health care facilities worldwide as ofMay 2014. Among the flagships of the implementation strategy, thetwo most popular cues for action are the posters promoting Whento handrub as described in My five moments for hand hygiene(6, 7) and now translated in more than 100 languages throughoutthe world and How to handrub, now featured in more than 100hand hygiene dance videos from all continents (see videos (8,9))(Figures 1 and 2).

Promoting a climate to inspire inovation and improveinfection control To encourage new and disruptive technologies with the potential toimprove patient safety through the successful implementation ofthe WHO multimodal strategy, the University of Geneva Hospitalsand the WHO Collaborating Centre on Patient Safety, inconjunction with the Aesculap Academy, have created a series ofHand Hygiene Excellence Awards and Hand Hygiene InnovationAwards worldwide: in the Asia-Pacific region since 2010, inEurope since 2012, and in Latin America in 2014. These Awardsare conceived as a platform to identify, recognize, honour andcelebrate those hospitals and health care worker groups who havecontributed to improving patient safety through their excellence,enthusiasm and innovatory methods. A unique process has beendeveloped for the Awards. First, the hospitals use the WHO-developed Hand Hygiene Self-Assessment Framework(http://www.who.int/gpsc/5may/hhsa_framework/en/), a systematic,validated tool to obtain a situation analysis of hand hygienepromotion and practices within an individual health care facility (10,11, 12). Based on their score and other criteria, selected hospitalsare visited by two members of the international panel of leadinginfection control experts. Finalists then undergo a half-day visit ofexperts for further evaluation of their programmes against setcriteria for creativity, innovation and local/regional leadership. Alarge number of tools, based on evidence and the results ofimplementation worldwide (13, 14) are available for health caresettings to improve their scores towards achieving excellence inpatient safety. Award winners in the respective regions are listed inTable 1.

Another innovation has been the designation of Global HandHygiene Expert Centres by the WHO Collaborating Centre onPatient Safety in recognition of outstanding efforts to promote handhygiene excellence. In 2011, the Singapore General Hospital(Singapore), Queen Mary Hospital (Hong Kong, S.A.R), and theAustin Health Hospital (Australia) received this nomination for theAsia Pacific region. In June 2013, The Charit University Hospital(Berlin, Germany) received the award for the Europe region.Experts from these centres visit hospitals in their regions to allocateexcellence awards and suggest further improvements.

Mobilizing patients and raising public awarenessAmong the next challenges to improve patient safety areconsidering patients as partners and raising public awareness ofthe critical importance of optimizing both institutional systems and

Figure 1: My 5 moments for hand hygiene

Region Year Health care institution Asia Pacific 2010 Artemis Health Institute Haryana / India

Monash Medical Centre Clayton (VIC) / Australia

2011 Dr Sardjito General Hospital Yogyakarta / Indonesia

National Taiwan University Hospital Taipei City / Taiwan, R.O.C. 2012 Bethesda Hospital Claremont (W.A.) / Australia

West China Hospital of Sichuan University Sichuan / R.O.C.

Cho Ray Hospital Ho Chi Minh City / Viet Nam

Hong Kong Baptist Hospital Kowloon / Hong Kong, S.A.R

Europe 2013 Mater Private Hospital Dublin / Republic of Ireland

Spitalul Sf. Constantin Brasov / Romania

Latin/Central America 2014 86 applications have been received

The Award will be presented in August 2014

Table 1: Hand hygiene excellence award winners

www.handhygieneexcellenceaward.com

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Infection prevention and control

health care staff behaviour. The odyssey of hand hygienepromotion has been recently addressed in a book for the lay publicauthored by the French writer Thierry Crouzet and published on 5May 2014 WHO World Hand Hygiene Day in six languages (15).The foreword of the book is co-authored by Dr Margaret Chan,WHO Director-General, and Sir Liam Donaldson, WHO PatientSafety Envoy. The book reveals also a new path open to humansociety, from a predatory economy system to an economy ofpeace.

ConclusionStrong advocacy and leadership with an inherent innovatorycapacity are required to maintain patient safety high on the politicalagenda, particularly in resource-poor countries where there aremany competing priorities. The challenge is to develop strategiesand campaigns with a potential for adaptability to diverse culturesand varying resources. o

Professor Didier Pittet is the Director of the Infection ControlProgramme and WHO Collaborating Centre on Patient Safety atthe University of Geneva Hospitals and Faculty of Medicine,Switzerland. He is also the lead adviser of the WHO GlobalPatient Safety Challenge Clean Care is Safer Care, currentlyactive in 171 of the 194 WHO Member States. In 2007, he wasawarded an honorary CBE by HM Queen Elizabeth II for servicesto the prevention of health care-associated infections in theUnited Kingdom.

References

1. Pittet D, Dharan S, Touveneau S, Sauvan V, Perneger TV. 1999. Bacterial contamination ofthe hand of hospital staff during routine patient care. Archives of Internal Medicine 159:821-826.

2. Pittet D, Mourouga P, Perneger TV, and the Members of the Infection Control Program.1999. Compliance with handwashing in a teaching hospital. Annals of Internal Medicine130: 126-130.

3. Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, Perneger TV. 2000.Effectiveness of a hospital-wide programme to improve compliance with hand hygiene.Lancet 356: 1307-1312.

4. Pittet D, Sax H, Hugonnet S, Harbarth S. 2004. Cost implications of successful handhygiene promotion. Infection Control & Hospital Epidemiology 25: 264-266.

5. Pittet D, Donaldson L. 2005. Clean Care is Safer Care: a worldwide priority. Lancet366:1246-1247.

6. Pittet D, Allegranzi B, Sax H, Dharan S, Pessoa-Silva CL, Donaldson L, Boyce JM. 2006.Evidence-based model for hand transmission during patient care and the role of improvedpractices. Lancet Infectious Diseases 6: 641-652.

7. Sax H, Allegranzi B, Uckay I, Larson E, Boyce J, Pittet D. 2007. My five moments for handhygiene: a user-centred design approach to understand, train, monitor and report handhygiene. Journal of Hospital Infection 67: 9-21.

8. World Health Organization/University of Geneva Hospitals. V1- Hand hygiene dance.http://tinyurl.com/HandHygieneDanceWHOGeneva

9. University of Geneva Hospitals. V2- Hand hygiene: from rubbing to dancing.http://tinyurl.com/HandHygieneRubToDance

10. World Health Organization. Hand hygiene self-assessment framework. 2010. Available at:http://www.who.int/gpsc/country_work/hhsa_framework_October_2010.pdf. AccessedDecember 12, 2013.

11. Stewardson AJ, Allegranzi B, Perneger TV, Attar H, Pittet D. 2013. Testing the WHO handhygiene self-assessment framework for usability and reliability. Journal of Hospital Infection83: 30-35.

12. Allegranzi B, Conway L, Larson E, Pittet D. 2014. Status of the implementation of theWorld Health Organization multimodal hand hygiene strategy in United States of Americahealthcare facilities. American Journal of Infection Control 42: 224-230.

13. World Health Organization. WHO guidelines on hand hygiene in healthcare. 2009. Availableat: http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf. Accessed May 22,2014.

14. World Health Organization. Guide to implementation: a guide to the implementation of theWHO multimodal hand hygiene improvement strategy. 2009. Available at:http://www.who.int/gpsc/5may/Guide_to_Implementation.pdf. Accessed May 22, 2014.

15. Crouzet T. Clean Hands Save Lives, Editions lAge dHomme, 2014 (T. Clegg & T. Crouzet),ISBN 978-2-8251-4432-9. Available in 6 languages also from http://blog.tcrouzet.com/le-geste-qui-sauve/downloads/

Figure 2: How to handrub

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