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Beginning the journey of hand hygiene compliance monitoring at a 2,100-bed tertiary hospital in Vietnam

      As part of the first hospital-wide hand hygiene campaign at Hue General Hospital, Vietnam, we audited hand hygiene compliance following health care worker education and the introduction of alcohol-based handrub. Alcohol-based handrub was chosen more frequently than plain soap and water (83% and 17%, respectively; P = .0001). Hand hygiene compliance averaged 47% (1,310 actions/2,813 opportunities; 95% confidence interval: 45%-48%) with markedly different rates among departments, ranging from 5% to 69% (P = .0001).

      Key Words

      Hand hygiene compliance in health care is a new concept in Vietnam, and it has now become a national priority to improve health care workers' practices according to current recommendations. In this study, we audited hand hygiene compliance among health care workers (HCW) following an intervention including education and the introduction of alcohol-based handrub during the first hospital-wide hand hygiene campaign conducted at a 2,100-bed, tertiary hospital in Hue, Vietnam. Recourse to alcohol-based handrub was more frequent than handwashing with plain soap and water (83% and 17%, respectively; P = .0001). Hand hygiene compliance averaged 47% (1,310 actions/2,813 opportunities; 95% confidence interval [CI]: 45%-48%) with markedly different rates among departments, ranging from 5% to 69% (P = .0001).
      Hand hygiene is a simple and effective measure to reduce the spread of infection and multiresistant organisms.
      • Pittet D.
      • Allegranzi B.
      • Sax H.
      • Dharan S.
      • Pessoa-Silva C.L.
      • Donaldson L.
      • et al.
      Evidence-based model for hand transmission during patient care and the role of improved practices.
      Current evidence reports that the burden of health care-associated infection (HCAI) is much higher in resource-limited health care settings.
      • Allegranzi B.
      • Bagheri Nejad S.
      • Combescure C.
      • Graafmans W.
      • Attar H.
      • Donaldson L.
      • et al.
      Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis.
      In April 2009, Vietnam became the 118th country to pledge government support and commitment to the World Health Organization (WHO) First Global Patient Safety Challenge “Clean Care is Safer Care.”
      • Allegranzi B.
      • Storr J.
      • Dziekan G.
      • Leotsakos A.
      • Donaldson L.
      • Pittet D.
      The First Global Patient Safety Challenge “Clean Care is Safer Care”: from launch to current progress and achievements.
      This pledge represented an official acknowledgement by Vietnam of the importance of HCAI and the urgency to promote best hand hygiene practices in an effort to reduce HCAI risks countrywide. Established in 1894, Hue General Hospital has approximately 2,100 beds and is the leading tertiary referral and training hospital for the central region of Vietnam. Single beds with adequate spacing are available in the intensive care unit (ICU), but it is common practice in the general ward areas for patients to share a single bed because of the high rate of hospital admissions. It has been estimated that the total bed occupancy is unofficially 3% higher per day because of bed sharing. Family visitors are responsible for feeding the patient and providing general hygiene care and may also be found sharing the patient's bed.
      In support of the WHO “SAVE LIVES: Clean Your Hands” global annual campaign and to acknowledge the hospital's 115th anniversary celebration, the Hue Central Hospital director announced the start of a hand hygiene campaign in 2010.
      • Mathai E.
      • Allegranzi B.
      • Kilpatrick C.
      • Bagheri Nejad S.
      • Graafmans W.
      • Pittet D.
      Promoting hand hygiene in healthcare through national/subnational campaigns.

      World Health Organization. SAVE LIVES: Clean Your Hands: WHO's global annual campaign. Available from: http://www.who.int/gpsc/5may/en/index.html. Accessed January 26, 2013.

      • Kilpatrick C.
      • Pittet D.
      WHO SAVE LIVES: Clean Your Hands global annual campaign. A call for action: May 5, 2011.
      The campaign focused on hospital-wide access to alcohol-based handrub (ABHR), hand hygiene education, training of all HCW, and an inaugural audit of hospital-wide hand hygiene compliance.

      World Health Organization. Clean Care is Safer Care: tools and resources. 2009 (updated 2009). Available from: http://www.who.int/gpsc/5may/tools/en/. Accessed January 26, 2013.

      Prior to the intervention in 2010, ABHR was not provided hospital wide on a routine basis. The aim of our study was to report the compliance rate following the introduction of ABHR and HCWs' training.

      Methods

      During April 2010, mandatory hand hygiene training was held for all 2,250 hospital staff. A total of 1,500 nurses, 450 physicians, and 300 ancillary staff (administrators, cleaners and technicians) was trained by infection control staff using the WHO tools.

      World Health Organization. Clean Care is Safer Care: tools and resources. 2009 (updated 2009). Available from: http://www.who.int/gpsc/5may/tools/en/. Accessed January 26, 2013.

      • Sax H.
      • Allegranzi B.
      • Chraiti M.N.
      • Boyce J.
      • Larson E.
      • Pittet D.
      The World Health Organization hand hygiene observation method.
      • Sax H.
      • Allegranzi B.
      • Uckay I.
      • Larson E.
      • Boyce J.
      • Pittet D.
      “My five moments for hand hygiene”: a user-centred design approach to understand, train, monitor, and report hand hygiene.
      All staff participated in pre- and post-training tests to assess their knowledge level, including questions on the “My five moments for hand hygiene” concept and correct hand hygiene techniques. These included locally adapted video tools and the WHO hand hygiene tool kit translated into Vietnamese.

      World Health Organization. Clean Care is Safer Care: tools and resources. 2009 (updated 2009). Available from: http://www.who.int/gpsc/5may/tools/en/. Accessed January 26, 2013.

      • Sax H.
      • Allegranzi B.
      • Chraiti M.N.
      • Boyce J.
      • Larson E.
      • Pittet D.
      The World Health Organization hand hygiene observation method.
      • Sax H.
      • Allegranzi B.
      • Uckay I.
      • Larson E.
      • Boyce J.
      • Pittet D.
      “My five moments for hand hygiene”: a user-centred design approach to understand, train, monitor, and report hand hygiene.
      Separate sessions involving theoretical and practical components were held for each HCW category from 2 p.m. to 4:30 p.m. during weekdays. Nurse managers from 22 selected departments were specifically trained to conduct training sessions for any HCW who did not attend their allocated sessions during April.
      Thirty HCWs were chosen to be trained as auditors. Training of auditors was divided into 4 sessions: 2 sessions were conducted for physicians and 2 for nursing staff. Each session was conducted during 1 afternoon and included lectures and practical classes to learn the method of auditing hand hygiene.

      World Health Organization. Clean Care is Safer Care: tools and resources. 2009 (updated 2009). Available from: http://www.who.int/gpsc/5may/tools/en/. Accessed January 26, 2013.

      • Sax H.
      • Allegranzi B.
      • Chraiti M.N.
      • Boyce J.
      • Larson E.
      • Pittet D.
      The World Health Organization hand hygiene observation method.
      • Sax H.
      • Allegranzi B.
      • Uckay I.
      • Larson E.
      • Boyce J.
      • Pittet D.
      “My five moments for hand hygiene”: a user-centred design approach to understand, train, monitor, and report hand hygiene.
      Auditors were trained using a video and the WHO hand hygiene audit tool to document observations and compliance translated into Vietnamese; no other modifications were made to the WHO approach to auditing. Trainee auditors completed the audit form while observing all 5 indications for hand hygiene shown on the video and marked the audit form according to the answer sheets. Trainees were required to achieve 100% to be considered as certified auditors. If the trainees were unable to achieve 100%, the video was viewed a second time, and the trainees were retested. This cycle was repeated until 100% was achieved.
      After successful completion of hand hygiene auditor training, auditors conducted one, 30-minute observation of HCW hand hygiene compliance during 1 morning shift in 22 departments in May and October 2010. Auditors were placed strategically on the ward so they could overtly observe HCW patient contact. Compliance was documented using a Vietnamese translated version of the WHO hand hygiene audit tool. Results were submitted to the infection control department for review and analysis. During the survey, observers could not easily identify the patient zone according to the WHO guideline

      World Health Organization. Clean Care is Safer Care: tools and resources. 2009 (updated 2009). Available from: http://www.who.int/gpsc/5may/tools/en/. Accessed January 26, 2013.

      because most patients on general wards shared a bed with more than 1 other patient. Bed sharing could include also the patients' family/visitors, who traditionally assist with 24-hour basic hygiene care and meals. For this reason, the observers collected data only for 2 moments of the “My five moments for hand hygiene” approach,
      • Sax H.
      • Allegranzi B.
      • Uckay I.
      • Larson E.
      • Boyce J.
      • Pittet D.
      “My five moments for hand hygiene”: a user-centred design approach to understand, train, monitor, and report hand hygiene.
      ie, moment 1: before patient contact, and moment 4: after patient contact. Hand hygiene actions and opportunities for both these 2 moments were aggregated; the rate of compliance was calculated as aggregated actions for moments 1 and 4 divided by aggregated moments 1 and 4 total opportunities. The rationale for aggregation of moments 1 and 4 was to simplify the first data collation and reporting. Only HCWs involved in direct patient care (physicians, nursing staff, nursing assistants, allied health, and medical and nursing students) were audited. In addition to hand hygiene auditing, a poster competition was held to promote hand hygiene, and awards were given to the 10 best entries. The importance of hand hygiene was also discussed routinely during weekly nurse manager meetings.
      Between 2006 and 2008, ABHR availability was discretional and unreliable. However, in May 2009, ABHR was systematically provided at the entry and exit points to patient rooms, on the clinical trolley in general ward areas, ear/nose/throat and infectious diseases' wards, and at every bedside in the ICU and pediatric ward.
      • Pittet D.
      • Hugonnet S.
      • Harbarth S.
      • Mourouga P.
      • Sauvan V.
      • Touveneau S.
      • et al.
      Effectiveness of a hospital-wide programme to improve compliance with hand hygiene.
      A commercial ABHR (Microshield; Johnson & Johnson Medical, Sydney, Australia) was provided with locally produced WHO formulations used to increase access and availability of ABHR when required. The volume of ABHR used in the institution was retrieved from the pharmacy department.

      Results

      A total of 2,813 hand hygiene opportunities was documented during the audit conducted in 22 clinical departments. Hospital-wide hand hygiene compliance averaged 47% (1,310 actions/2,813 opportunities; 95% CI: 45-48). Most hand hygiene opportunities were contributed by nursing staff (54%; 1,525/2,813), followed by other staff (administrators, cleaners, and technicians) (41%; 1,156/2,813) and physicians (5%; 132/2,813) (P = .0001).
      Nursing staff were 1.5 times more likely (relative risk, 1.5; 95% CI: 1.6%-1.8%; P < .0001) to clean their hands than any other HCW category. Average compliance of nursing staff was 57% (875/1,525; 95% CI: 55%-60%); physician compliance, 34% (45/132; 95% CI: 26%-43%); and other staff, 34% (390/1,156; 95% CI: 31%-36%). Overall hand hygiene compliance differed significantly among hospital departments (P = .0001). The ICU average rate was 69% (95% CI: 64%-73%); aggregated ear/nose/throat and infectious diseases' departments averaged 64% (95% CI: 57%-71%); pediatrics, 64% (95% CI: 57%-71%); medical, 53% (95% CI: 46%-60%); surgery, 42% (95% CI: 44%-40%); and obstetrics, 42% (95% CI: 56%-29%).
      Average annual ABHR consumption for 2006 to 2007 was 53,000 L and 72,000 L in 2008. By the end of 2009, consumption had increased by an additional 22% to 93,000 L and had doubled to 186,000 L by the end of 2010. During 2010 audits, ABHR was used more often (83%; 1,092 hand rubbing/1,310 hand hygiene actions) than handwashing with plain soap and water (17%; 218 hand rubbing/1,310 hand hygiene actions; P = .0001).

      Discussion

      Our inaugural audit of HCW compliance identified that HCWs adopted ABHR for 83% of hand hygiene actions, therefore suggesting that they had acquired a good level of understanding of optimal practices during training.
      • Pittet D.
      • Allegranzi B.
      • Sax H.
      • Dharan S.
      • Pessoa-Silva C.L.
      • Donaldson L.
      • et al.
      Evidence-based model for hand transmission during patient care and the role of improved practices.
      • Allegranzi B.
      • Storr J.
      • Dziekan G.
      • Leotsakos A.
      • Donaldson L.
      • Pittet D.
      The First Global Patient Safety Challenge “Clean Care is Safer Care”: from launch to current progress and achievements.
      Hand hygiene is not yet practiced widely in the community, and it is not surprising that the rates are so low within some departments. The choice of ABHR has helped HCWs to overcome the lack of access to clean continuous running water, which is a common resource problem in all levels of health care facilities across Vietnam. HCWs can be denied access to basins for hand hygiene because of poor maintenance, including difficult physical access to sinks compounded by overcrowded wards. In addition, visitors and relatives frequently use sinks for food preparation and bathing patients, thus further restricting access by HCWs.
      Nursing staff compliance rates are somewhat similar to those reported in higher resourced settings during the early stages of adapting to expectations of improved hand hygiene practice.

      World Health Organization. Clean Care is Safer Care: tools and resources. 2009 (updated 2009). Available from: http://www.who.int/gpsc/5may/tools/en/. Accessed January 26, 2013.

      • Sax H.
      • Allegranzi B.
      • Chraiti M.N.
      • Boyce J.
      • Larson E.
      • Pittet D.
      The World Health Organization hand hygiene observation method.
      Physician compliance was poor as is universally reported, irrespective of resource level.

      World Health Organization. Clean Care is Safer Care: tools and resources. 2009 (updated 2009). Available from: http://www.who.int/gpsc/5may/tools/en/. Accessed January 26, 2013.

      • Sax H.
      • Allegranzi B.
      • Chraiti M.N.
      • Boyce J.
      • Larson E.
      • Pittet D.
      The World Health Organization hand hygiene observation method.
      To improve hand hygiene compliance, it is recommended to use multimodal approaches through a combination of education, workplace reminders, and continuous performance feedback.

      World Health Organization. Clean Care is Safer Care: tools and resources. 2009 (updated 2009). Available from: http://www.who.int/gpsc/5may/tools/en/. Accessed January 26, 2013.

      • Pittet D.
      • Hugonnet S.
      • Harbarth S.
      • Mourouga P.
      • Sauvan V.
      • Touveneau S.
      • et al.
      Effectiveness of a hospital-wide programme to improve compliance with hand hygiene.
      • Erasmus V.
      • Daha T.J.
      • Brug H.
      • Richardus J.H.
      • Behrendt M.D.
      • Vos M.C.
      • et al.
      Systematic review of studies on compliance with hand hygiene guidelines in hospital care.
      • Naikoba S.
      • Hayward A.
      The effectiveness of interventions aimed at increasing handwashing in healthcare workers: a systematic review.

      Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee. Society for Healthcare Epidemiology of America. Association for Professionals in Infection Control. Infectious Diseases Society of America. Hand Hygiene Task Force. Infect Control Hosp Epidemiol 2002;23(12 Suppl):S3-40.

      We opted to engage the head of the clinical department and the nurse manager as responsible for reaching hospital targets and providing ongoing monthly feedback to help achieve this goal. However, we acknowledge that improvement may take much longer in Vietnam because HCWs may be translating community hand hygiene practice, which is uncommon, into the health care setting.
      • McLaws M.L.
      • Maharlouie N.
      • Yousefi F.
      • Askarian M.
      Predicting hand hygiene among Iranian healthcare workers using the theory of planned behavior.
      A driver of social norms where hand hygiene in the health care setting is perceived as normative behavior would be helped by conducting simultaneous hand hygiene promotion campaigns in the community and health care settings. This would require a long-term commitment for change. As patient visitors and family assume a key role in assisting with the activities of daily living, it will be essential to train and educate them to understand the role of good hand hygiene to prevent infection. The varying levels of literacy and different language dialects, further complicated by short inpatient stays, are major challenges and make sustained training programs difficult to implement.
      Finally, our experience confirms that system change through ABHR access, the main factor for successful hand hygiene promotion in health care facilities, and that the implementation of the WHO multimodal hand hygiene strategy is feasible in low-middle resource countries. Because the hospital produces the WHO ABHR formulation and the national infection control guidelines now require the provision of ABHR on all wards, it is unlikely that financial constraints would result in a return to poor availability. However, we have yet to demonstrate sustained behavior and system change.

      Acknowledgment

      The authors thank the staff of Hue General Hospital, Vietnam, for their contribution to improving the hospital infection prevention and control program.

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        Evidence-based model for hand transmission during patient care and the role of improved practices.
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        Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis.
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        Promoting hand hygiene in healthcare through national/subnational campaigns.
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        • Allegranzi B.
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        • Pittet D.
        The World Health Organization hand hygiene observation method.
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        Systematic review of studies on compliance with hand hygiene guidelines in hospital care.
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        The effectiveness of interventions aimed at increasing handwashing in healthcare workers: a systematic review.
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        • Maharlouie N.
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        Predicting hand hygiene among Iranian healthcare workers using the theory of planned behavior.
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