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 About SAVE LIVES: Clean Your HandsSAVE LIVES: Clean Your Hands brings people together in support of hand hygiene improvement globally and to progress the goal of maintaining a global profile on hand hygiene in health care. The campaign aims to galvanise action at the point of care to demonstrate that hand hygiene is the entrance door for reducing health care-associated infection and patient safety. It also aims to demonstrate the world's commitment to this priority area of health care. WHO's role includes encouraging engagement and action to maintain this global movement. Numbers are a great awareness-raising mechanism, as demonstrated by the growing number of health-care facilities registered for SAVE LIVES: Clean Your Hands but they are not the end point. Sustaining the efforts to improve patient safety requires dedicated action and innovation both of which are now more crucial than ever. WHO have appreciated receiving communications about country and health-care facility activities. Action must continue; use the WHO tools to support your actions. BackgroundAs part of a major global effort to improve hand hygiene in health care, led by WHO to support health-care workers, the SAVE LIVES: Clean Your Hands annual global campaign was launched in 2009 and was a natural extension of the WHO First Global Patient Safety Challenge: Clean Care is Safer Care work which is now WHO IPC global unit. The central core of SAVE LIVES: Clean Your Hands is that all health-care workers should clean their hands at the right time and in the right way. WHO SAVE LIVES: Clean Your Hands annual initiative is part of a major global effort led by the World Health Organization (WHO) to support health-care workers to improve hand hygiene in health care and thus support the prevention of often life threatening HAI. SAVE LIVES: Clean Your Hands incorporates a global annual day to focus on the importance of improving hand hygiene in health care with WHO providing support for these efforts. A suite of hand hygiene improvement tools and materials have been created from a base of existing research and evidence and from rigorous testing, as well as working closely with a range of experts in the field. The tools aim to help the translation into practice of a multimodal strategy for improving and sustaining hand hygiene in health care. More background to Clean Care is Safer Care Hand Hygiene videos in The New England Journal of Medicine in YOUR language
The My 5 Moments for Hand Hygiene approach defines the key moments when health-care workers should perform hand hygiene. This evidence-based, field-tested, user-centred approach is designed to be easy to learn, logical and applicable in a wide range of settings. This approach recommends health-care workers to clean their hands
Health care associated infections are considered to be a significant health burden and safety issue throughout the world.1 Factors independently associated with such infections include age > 65 years, emergency or intensive care unit (ICU) admission, hospital stay > seven days, insertion of invasive devices, surgery, immunosuppression and impaired functional or coma status.1 In the United Kingdom and other developed countries, methicillin-resistant Staphylococcus aureus (MRSA) has become a significant health care associated and surgical site infection (SSI). A higher prevalence of MRSA infection has been reported in trauma and orthopaedic departments compared with the general hospital.2-3 The financial implications of health care associated infections are large. A study by the Department of Health demonstrated that patients with one or more such infections in trauma and orthopaedics incurred costs which were 2.6 times greater than those for uninfected patients.4-5 In an attempt to reduce the burden of health care associated infections in 2005, the World Health Organization (WHO) launched the first Global Patient Safety Challenge; Clean Care is Safer Care.6 The aim was to promote best hand hygiene practices globally, as an initial step towards achieving high standards of infection control and patient safety. Four years later, its profile was raised through the campaign entitled SAVE LIVES: Clean Your Hands.7 In 2007 Sax et al8 expanded on the ‘5 moments’ approach to hand washing.8 Many NHS trusts in England have adopted the WHO ‘5 moments of hand hygiene’ approach to hand-washing in order to reduce the risk of health care associated infections. This new model prompts health care workers to clean their hands at five distinct stages of caring for the patient (Fig. 1). The WHO claims that it is evidence-based, logical and applicable in a wide range of settings worldwide. Fig. 1 The World Health Organization ‘5 moments of hand hygiene’. In the mid-nineteenth century, initial work by Ignaz Semmelweis in Vienna demonstrated that infections were transmitted via the hands of health care workers.9 More recently, between 1960 and 2008, at least 20 hospital-based studies of the effect of hand hygiene on the risk of acquiring a health care associated infection were published.10-29 These studies suggested that improved hand hygiene practices reduced the risk of transmission of pathogenic micro-organisms and the risk of associated infection. Although the studies to date have repeatedly demonstrated a reduction in pathogen transmission and colonisation, very few have focused on the presence of infection and burden of disease.23-24,30 Furthermore, most of the available studies are semi-experimental and cannot determine a definitive relationship between hand washing and infection due to the lack of statistical significance, the presence of confounding factors, and the absence of randomisation. This has been demonstrated by the inconclusive results drawn from systematic reviews on the topic.31,32 When the Clean Care is Safer Care Challenge was launched in 2005, the WHO stated that health care associated infections were a significant burden for the patient, family and public health. This was qualified by a prevalence survey conducted under their direction in 55 hospitals in 14 countries – mostly in the developing world – which revealed that, on average, 8.7% of hospital patients acquired a health care associated infection.6 The WHO, however, realised that the true burden of these infections worldwide was not adequately understood and so in 2011, they referenced a systematic review and meta-analysis by Allegranzi et al,1 which formed the evidence base for their campaign on improving hand hygiene in order to reduce health care associated infections worldwide. This publication has some significant weaknesses, which the authors have themselves identified, such as a high proportion of low-quality studies, the use of non-standardised definitions and substandard surveillance methods. Nevertheless, in high-income countries, the prevalence of hospitalised patients who acquire at least one health care associated infection ranges from 3.5% to 12% (9% in the UK).33-34 The burden is significantly higher amongst patients in ICU where approximately 30% are affected by at least one episode of health care associated infection with much associated morbidity and mortality.35 Although the ‘5 moments’ regime promotes hand hygiene at five distinct times during health delivery (Table I), the original WHO guidelines in 200536 recommended hand washing at eight distinct points (Table II). In order to improve compliance, the WHO discarded three of their original indications for hand washing: moving from a contaminated body site to a clean site, after removing gloves and before handling medication or food. It is suggested that by adhering to the remaining five moments, microbial transmission is effectively interrupted.8 There is no scientific evidence to show that health care associated infections are reduced when adopting the selected ‘5 moments’ approach over and above the ones that were discarded.
Each of the five moments has been assigned a recommendation category based on a WHO ranking system that depends on the strength of the scientific evidence which supports that particular recommendation (Table III).36 Only one of the five is strongly supported by well-designed studies (rank 1A). The remaining four are supported by strong theoretical rationale and some experimental, clinical or epidemiological studies (rank 1B). The scientific papers referenced by the WHO for hand washing in these distinct situations are summarised below.
This guideline comprises two of the ‘5 moments’ and is supported by observational studies demonstrating that hand washing can reduce the transmission of pathogens.13,37-41 There is no strong evidence suggesting a reduction in actual pathogen transmission or acquisition of health care associated infection in a clinical setting if hand washing is performed both before and after touching a patient. The study by Hirschmann et al42 defines a complication as one of the following: local reddening, swelling, pain, purulence or fever of unknown origin. These are non-specific end points and may not represent a health care associated infection of any significance. Furthermore, no meaningful randomisation or blinding techniques were incorporated into this study. Eggimann et al43 suggest that a combination of prevention strategies can decrease the incidence of health care associated infection but do not provide any indication as to the relative reduction achieved by individual strategies. The above studies, as referenced by the WHO, do not provide strong scientific evidence to support the idea that hand hygiene prior to insertion of an invasive device reduces the incidence of infection. This is the only one of the five moments strongly supported by well-designed studies.9,43-46 Those by Ojajärvi44 and Lucet et al45 do not demonstrate reduction of health care associated infection following hand hygiene. Larson46 reviewed 423 articles, out of which only 3.3% addressed the link between hand washing and infection. Most relate to hand hygiene products, behavioural studies, methodological studies and review articles. Together with the low number of relevant studies in the review, the authors were also unable to demonstrate a specific relationship between health care associated infection and hand hygiene. These observational studies indicate that patients’ surroundings may be contaminated with pathogens and therefore could be a reservoir of infection in the hospital.47-50 The role of hand washing in the prevention of the transmission of pathogens to a patient from their immediate environment and the subsequent acquisition of a health care associated infection as a result has yet to be scientifically verified. In summary, the WHO has referenced mostly experimental and observational studies to support their guidelines. Therefore, the science used to suggest that adopting the five moments approach will lead to a reduction in health care associated infections is weak. In order to illustrate the practicalities of these guidelines, we describe a sample case of a routine post-operative review of a patient following a total hip replacement: wash hands – shake patient’s hand – adjust patient’s bed to help them sit up – wash hands – review wound – wash hands – assess sciatic nerve function – wash hands – prepare cannulation equipment – wash hands – apply tourniquet to patient – wash hands – insert cannula – wash hands. This single encounter has necessitated seven hand washes that, when extrapolated, would amount to one hundred and fifty during the course of a morning ward round. Although some authors suggest that adequate hand hygiene requires three to 30 applications of hand-rub per hour during patient care51 there is no evidence to suggest that these numbers reduce the risk of health care associated infection. There is also real concern with regards to skin irritation, dryness and damage with excessive use of hand hygiene products. Contact dermatitis is very common among health care workers, with a prevalence of 25% to 55%, and up to 85% in those with a history of skin problems.52 Frequent hand washing can lead to progressive depletion of surface lipids thereby exposing deeper layers of the skin to the washing solutions.53 Skin damage can change the skin flora, resulting in more frequent colonisation by staphylococci and Gram-negative bacilli.54,55 An attempt has been made to reduce the adverse effects of repeated hand washing with the provision of emollients and less irritant products such as alcohol-based hand rub containing humectants (hygroscopic emollients). Nevertheless, the question of the efficacy of repeated hand washing in line with the ‘5 moments’ approach for the reduction of health care associated infections remains unanswered. The factors affecting health care associated infections in developing countries cannot be compared directly with those in developed countries. The conditions in any given country vary with respect to hygiene and sanitation, availability of equipment, infrastructure, and population variance in the level of nutrition and disease. High quality research is needed to show that health care associated infections in the United Kingdom are a direct result of health care workers not washing their hands over and above the accepted social standards of hand hygiene. More studies need to be undertaken in order to understand when hand washing should be performed to prevent health care associated infections. It is clear that vulnerable patients such as those in intensive care units and those requiring invasive procedures are at a much higher risk of acquiring such an infection. Resources should also be directed towards the improvement of other important infection control measures. The intense focus on hand hygiene guidelines and the re-packaged WHO guidelines must not divert us from all the many aspects of infection control. Cleanliness of wards and the quality of hospital cleaning services may have deteriorated,56 basic nursing care has been gradually passed on to less experienced members of the care team,57 higher patient-to-nurse ratios on the wards have at times resulted in sub-optimal patient care,58 bed and side-room shortages have led to inappropriate mixing of infected, non-infected and vulnerable patients59 and frequent transfers of patients from one unit to another in order to meet government-dictated treatment time targets, which have become more frequent in the United Kingdom,60-62 can contribute to increasing environmental contamination. Prevention therefore requires a multimodal approach and co-operation between all hospital staff including management, physicians and surgeons, nursing staff, house-keeping and other affiliated services. Infection control bodies, such as the Healthcare Infection Control Practices Advisory Committee and the Hand Hygiene Task Force, consider hand hygiene to be the most important measure for the prevention of health care associated infection and the spread of antimicrobial resistant pathogens.63 Considering the paucity of high-quality evidence, hand hygiene should be promoted as one of many important measures in preventing health care associated infections. While it cannot be denied that hand hygiene has a role to play in the fight against infection, there needs to be a more accurate and balanced approach to all strategies employed to reduce infection. The WHO intended the ‘5 moments’ approach to meet many objectives, including improving compliance, training, and the reporting of performance. However, the scientific basis for this approach is weak. Clinical and fiscal focus may therefore have shifted away from more important issues. While level 1 evidence may never exist for certain valid practices, it is crucial that NHS trusts carefully assess the value of adopting consensus-based guidelines based on weak scientific foundations to ensure that the safety of patients and health care workers is not compromised. In the age of evidence-based practice, the adoption of such guidelines may create a feeling of distrust towards policymakers. Rather absurdly, the creators of the ‘5 moments’ approach state that in order to achieve standardisation they feel it is best not to educate health care workers to recognise the risks of the transmission of pathogens autonomously and to wash their hands whenever they consider it appropriate, but instead suggest that they exclusively follow the ‘5 moments’ approach.8 We feel that this cannot be the best way to promote patient safety amongst health care workers who build their daily practice on the principles of evidence-based medicine. References
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Supplementary material. Four tables detailing the findings of the studies cited by the World Health Organization in support of each of the ‘5 moments of hand hygiene’ are available with the electronic version of this article on our website www.jbjs.boneandjoint.org.uk |
When was 5 moments of hand hygiene introduced
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