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hospital spotlight
singapore general hospital
The World Health Organization (WHO) Multimodal Hand Hygiene Improvement Strategy comprising a Guide to Implementation and a range of tools constructed to facilitate implementation of each component was used in a 1600-bedded acute tertiary care general hospital in Singapore. The objective is to change healthcare workers’ behavior and improve hand hygiene compliance. During the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003, a high compliance of close to 90% in healthcare workers to hand hygiene was achieved. However, this was primarily driven by fear for transmission of pathogens to self. Following the closure of the SARS outbreak globally, we noted that the hand hygiene compliance decreased to that of the baseline before the SARS outbreak i.e. the high hand hygiene compliance was not sustainable.
The hand hygiene program was revised in early 2007 following Singapore’s signing of the pledge to the WHO “Clean Care is Safer Care” program. The multi-prong approach used includes:
1. System change:
a. Alcohol based hand rub was promoted for routine use of hand hygiene instead of the previous 4% chlorhexidine hand wash. During SARS, alcohol hand rub bottles were installed at the foot of every patient bed and all lift lobbies in an attempt to enable easy access by healthcare workers to hand hygiene products. From 2007, more alcohol hand rub bottles were installed along ward corridors and near food establishments in the hospital ground.
b. Following the review of the WHO Hand Hygiene Manual (Advanced Draft 2006), the Infection Control Committee approved the use of at least either ethanol 80% or isopropyl alcohol 75% in the procurement of hand hygiene alcohol hand products. This implies the use of a higher content of alcohol than before. From July 2009, 4% chlorhexidine hand wash agent bottles were removed from the clinical areas except for the Operating Theatres, Endoscopy Unit and Treatment rooms. This was done to reduce the incidence of dryness or skin irritation resulting from concomitant use of both alcohol and chlorhexidine. 1 Hand moisturizer was provided freely for healthcare workers’ use. They are encouraged to use it as often as possible to protect their hands.
The hand hygiene program was revised in early 2007 following Singapore’s signing of the pledge to the WHO “Clean Care is Safer Care” program. The multi-prong approach used includes:
1. System change:
a. Alcohol based hand rub was promoted for routine use of hand hygiene instead of the previous 4% chlorhexidine hand wash. During SARS, alcohol hand rub bottles were installed at the foot of every patient bed and all lift lobbies in an attempt to enable easy access by healthcare workers to hand hygiene products. From 2007, more alcohol hand rub bottles were installed along ward corridors and near food establishments in the hospital ground.
b. Following the review of the WHO Hand Hygiene Manual (Advanced Draft 2006), the Infection Control Committee approved the use of at least either ethanol 80% or isopropyl alcohol 75% in the procurement of hand hygiene alcohol hand products. This implies the use of a higher content of alcohol than before. From July 2009, 4% chlorhexidine hand wash agent bottles were removed from the clinical areas except for the Operating Theatres, Endoscopy Unit and Treatment rooms. This was done to reduce the incidence of dryness or skin irritation resulting from concomitant use of both alcohol and chlorhexidine. 1 Hand moisturizer was provided freely for healthcare workers’ use. They are encouraged to use it as often as possible to protect their hands.
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2. Training & education:
a. WHO training DVDs were used to illustrate clinical scenarios of hand hygiene opportunities to all healthcare workers. Although these were in French, they provided clear teaching on the 5 moments to the staffs. b. Creative educational tools were also used to teach healthcare attendants and junior nurses. Teddy bears dusted with Glo-germ were used as patient models in teaching healthcare workers the importance of hand hygiene as well as the WHO 5 moments. c. PowerPoint slides with detailed explanation of the 5 moments were created for doctors, nurses and allied health. These were uploaded on the hospital intranet for easy access by the staffs. 3. Evaluation and feedback: Feedback surveys are conducted annually amongst staffs to gather feedback and comments on products used or issues faced during practice. The last survey done in November 2010 confirmed that the use of posters have helped to remind staffs and public on the messages of hand hygiene. 4. Reminders in the workplace: More than 150 posters were designed from March 2007 for display at elevators and walkways. Giant posters on hand hygiene messaging (spanning nine floors) were designed to convey the hospital’s commitment to the public. Shuttle buses, floor surfaces and lift doors are used to display reminders to both staffs and public . |
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5. Institutional safety climate: Leadership’s support and commitment was clearly visible at events and meetings. The Chief Executive Officer (CEO) led the hospitals staffs in November 2009 in a pledge of commitment to the Hand Hygiene Program.
Hand hygiene compliance rate improved from 20% (in January 2007) to 61% (2010). Improvement was also seen annually in the compliance to each of the 5 moments as well as in all staff categories. Although hand hygiene compliance was lowest in the doctors’ category, it is encouraging to note that improvement was also seen year to year in this job category. The hand hygiene program was an integral part also of an ongoing MRSA reduction program in the hospital, which includes the implementation of the MRSA bundle. |
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The “MRSA bundle” includes five components of care. This bundle was first introduced by the Institute of Healthcare Improvement (IHI) in 2006 in their “Protecting 5 Million Lives from Harm” campaign. It comprised the following elements:
1. Hand Hygiene
2. Decontamination of the environment/equipment
3. Active surveillance cultures
4. Contact precautions for infected and colonized patients
5. Device bundles (CLABSI, CAUTI, and VAT bundles)
1. Hand Hygiene
2. Decontamination of the environment/equipment
3. Active surveillance cultures
4. Contact precautions for infected and colonized patients
5. Device bundles (CLABSI, CAUTI, and VAT bundles)
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Most of the elements were routine practices in the hospital except for active surveillance cultures, which were implemented hospital-wide for high risk patient groups from 2008. Healthcare-associated MRSA infections were noted to reduce from 0.6 (2007) to 0.3 (2010) per 1000 patient-days. Leadership’s support of the program evidenced through visible leadership presence, messaging and release of resources is the key factor in helping to make the program a true success. The hospital was recognized as a Global Hand Hygiene Expert Centre in January 2011. The use of the WHO multi-prong interventions is successful in improving hand hygiene compliance with concomitant reduction in healthcare associated infections.
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