Healthcare worker with hand raised to obtain hand cleansing lotion from dispenser
Hand cleansing

More quick wins to consider

In this step we introduce you to another quick win which you may find useful and there are more available in “downloads”.

Introduction of alcohol based hand rub in a hospital in central India

The absence of infection control and non prevention of infection may increase antibiotic use.

Hand hygiene has been reported to be an important, cost effective method to prevent infection especially in the context of rising healthcare associated infections. The main challenge in improving hand hygiene compliance is in change behaviour.

This story from a hospital in central India describes how a dedicated team of individuals applied behaviour change models, confidence building activities and a modified WHO-ABHR formulation to improve hand hygiene acceptability and practice.

Women working on a road in India Women working on a road repairing, Umaria district, Madhya Pradesh,India. CC licence

Scenario

C R Gardi hospital is a rural, tertiary care teaching hospital with 570 beds situated in a village in Ujjain district, Madhya Pradesh in central India. As many patients come from poor socio-economic backgrounds the hospital provides services at low cost.

Hand holding antibiotics Antiobitics. Credit: Iqbal Osman CC by 2.0

The problem

Healthcare associated infections (HAI) occur globally. In low and middle income countries (LMIC) a pooled prevalence of 15.5% has been reported. HAI leads to increased mortality, morbidity, economic burden and risk of contracting antibiotic resistant bacteria. A major cause for HAIs is contamination of hands of healthcare workers and this is a problem in India. In studies the incidence based on previous reports has been between 5% and 23.7%. HAI increases the need for antibiotic use and antibiotics that may often be used for HAI are newer, reserved antibiotics such as vancomycin, carbapenems and cephalosporins. This in turn raises the risk of increased bacterial infection.

hand using sanitiser pump A lab technician putting soap on her hand Credit CDC Kimberly Smith Public Domain.

The intervention

To decrease the use of antibiotics for HAI it was important to reduce the cases of HAI. Appropriate hand hygiene practice is an important and cost effective method to prevent and reduce transmission of HAIs with evidence of a reduction in the incidence of HAIs up to 40%.

WHO has recognised alcohol based hand rub (ABHR) as a gold standard for hand hygiene for visually clean hands. LMIC settings, with high patient load, may necessitate the use of ABHR due to the ease of use and shorter time to undertake compared to conventional hand washing. In addition, issues of erratic and poor water supply in LMIC may support the use of ABHR over hand washing.

However, commercial ABHR products may be unaffordable for resource poor settings therefore, an alternative may be in-house production of the WHO recommended hand rub formulation.

Confidence building activities were conducted for health care workers for HAIs especially in high risk wards to improve compliance of ABHR. These activities included finger tip culture, visual portrayal method and handmade posters.

Data and analysis

The introduction, popularisation and compliance with this ABHR can be an important step to promote hand hygiene in settings such as this hospital in central India. However, all healthcare workers (doctors, nurses and allied staff) need to comply with hand hygiene. To facilitate the behaviour change and compliance a step-wise approach was developed for the introduction and use of ABHR by applying theories such as the Precede-Proceed, Trans Theoretical model of behaviour change, Front Line Ownership (FLO) and social marketing models. The WHO slogan “Clean hands - Save lives” was used to support the introduction of in-house prepared ABHR.

A modified WHO-ABHR formulation, the “test product” and “WHO product evaluation form” was completed by healthcare workers for acceptability. A locally developed feedback from was used to evaluate the impact.

Indian female health worker preparing vaccination Community health worker gives vaccination in Odisha State, India CC licence. Pippa Ranger, Innovation Advisor, DFID

The result

Overall 183 healthcare workers were enrolled for assessment of the ABHR. Of these 108/130 (83%) of doctors and 50/53 (94%) of nurses were satisfied with the ABHR.

The confidence building activity was conducted with 116 participants with 82% expressing their confidence in the ABHR. A complete reduction in colony forming until on incubated blood agar plates was seen for 15 (13%) of participants and significant reduction was seen for 61 (53%).

The full paper by Sharma et al outlining this project is available in “downloads” below.

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This article is from the free online course:

Antimicrobial Stewardship: Managing Antibiotic Resistance

University of Dundee