Promoting Hand Hygiene in Long-term Care Facilities (LTCF) using WHO Multimodal Strategy

Background:

The World Health Organization (WHO) has introduced guidelines and program on hand hygiene (HH) but its application is mainly limited to the acute care setting. This is the first study showing that utilization of the WHO hand hygiene guidelines is effective also in LTCF.

Objective: To examine the impact of a multimodal program developed by the WHO on HH in promoting appropriate knowledge, beliefs and compliance for HH among health care workers (HCW) in LTCF.

Methods:

A prospective interventional study was done in four phases [baseline (P-I), intervention (P-II), 1 month (P-III) and 4 months (P-IV) after intervention] from August 2007 in eight registered nursing homes with 650 HCW in Hong Kong. At P-I, P-III & P-IV, direct observation was conducted by trained nurses (interrater reliability =1.0) to measure HH compliance based on WHO methodology and questionnaire survey was done to assess HH knowledge and beliefs. Interventions followed WHO multimodal improvement strategy, and included educational talk, system change especially with alcohol-based hand rubs (AHR) provision at all point-of-care, poster-reminders, performance feedbacks and seeking formal endorsement from management that is important for developing safety culture. Focus group discussion was done at P-IV to evaluate effectiveness of interventions perceived by HCW. Generalised estimating equation (GEE) was used to analyse compliance and run multivariate analysis on factors associated with HH adherence.

Results:

A total of 8030 HH opportunities were observed at P-I, P-III and P-IV. The overall HH compliance rate increased from 45.4% at baseline to 80.0% at P-III (p<0.001) and 80.6% at P-IV (p<0.001). Compliance by handrubbing with AHR showed significant increase from 25.9% to 71.5% (P-III) and 76% (P-IV) with p<0.001. Increase in compliance was also significant (p <0.001) in different types of HCWs and for all WHO five moments. Multivariate analysis showed compliance was strongly associated with the multimodal strategy adjusted for different institutions, time periods, types of five moments and activity index (P-III: OR = 5.27, CI= 4.04-6.88; P-IV: OR = 5.81, CI= 4.43-7.62). Adherence to HH was particularly high with after touching patient (OR = 4.53; CI: 3.52-5.84) and after touching patient’s surroundings (OR = 2.25; CI: 1.32-3.82) when comparing to after touching body fluids. The program is also effective in improving HCW's knowledge on AHR (60.8% vs 84.8% at P-IV, p=0.004), promoting favourable HH belief as over 83% HCWs believed AHR could improve their own HH compliance (p=0.001) and over 86% believed AHR could promote HH (p=0.002) in their institution. Focus groups reported that HCW perceived educational talk as the most effective intervention and AHR as highly effective in HH promotion with time-saving and usage convenience.

Conclusions:

WHO multimodal HH strategy, that is successful in acute care facilities, is effective in LTC setting.