A 5-year WHO-based HH initiative consisting of the 5 Components, the 5 Steps, and the HHSAF significantly increased ABHR consumption in a nonteaching secondary hospital in Japan with long-term care wards. ABHR consumption had a significant positive correlation with the HHSAF score.
Repeating a minimum 5-year cycle of the 5 Steps of the stepwise approach and applying the 5 Components is recommended in the WHO guideline. Despite the recommendation, the majority of previous studies reporting the effect of a multimodal WHO-based HH programme focused only on the 5 Components. Although several studies followed the stepwise programme [13,14] or a 5-year programme [18,19], to the best of our knowledge, there have been no previous studies reporting a 5-year programme with the 5 Steps. Additionally, our study is the first to report the 5-year change in the HHSAF score in a single facility.
The rationale for the importance of a 5-year programme is not given in the WHO guidelines. The target amount of ABHR consumption recommended in the guideline is 20 ml/PD (HHSAF: 3.3c), and in Pittet’s study published prior to the publication of the guidelines, a period of 5 years was necessary to increase ABHR consumption from 4.1 to 20.8 ml/PD [20]. Additionally, previous studies have suggested that behavioural changes are important in the improvement of HH [21-23] and that this improvement took time, sometimes years. Similar results were reported from a 6-year initiative in a tertiary teaching hospital [24] and a 4-year initiative in a long-term care facility [25]. Welsh et al. identified seven key elements of behaviour change that were characteristic of success in the challenge of reducing healthcare-associated infections: organizational learning; support, resources, and accountability; communication and collaboratives; frontline staff engagement; local, focused implementation; and feedback and reinforcement [26]. Out of these elements, we mainly focused on “frontline staff engagement” and “local, focused implementation” and took many careful steps and an appropriate amount of time needed to embed them.
Component 5, “Institutional safety climate”, is meant “to create an environment and perceptions that facilitate awareness-raising about patient safety issues while guaranteeing consideration of HH improvement as a high priority at all levels” [11], and “behavioural change” is one of its main purposes. In this component of the HHSAF, there are 2 indicators corresponding to “frontline staff engagement”; 5.4a: “A system for designation of HH champions”, and 5.4b: “A system for recognition and utilization of HH role models”.
An HH champion is “a person who is an advocate for the causes of patient safety and HH standards and takes on responsibility for publicizing a project in his/her ward and/or facility-wide”. One of our first priorities in the initiative was to allocate the ICMs as the HH champions. For this purpose, we started up new systems and planned campaigns to make opportunities for them to work as active HH champions. This took 3 years altogether to put on track. In the last 2 years, the ICMs’ activities shifted to leading “local, focused implementation” with the support of the LNs. The HH role model is “a person who serves as an example, whose behaviour is emulated by others”. From the third year of the initiative, we started the election of “HH masters” as the HH role model as one of the events in the HH campaign month. The HH masters of each local field were elected from the frontline staff members by themselves. The number of HH masters gradually increased in the last 2 years. From these experiences, we retrospectively recognized that 5 years was a reasonable length of time to change systems and empower frontline staff engagement for local focused implementation.
The WHO guideline states that Step 5 of the stepwise approach is a crucial step for developing long-term plans to ensure that improvement is sustained and progresses. Many activities corresponding to each of the five components are suggested in the GTI for this step. We noticed that each component includes items indicating the “establishment of plans for the next year”. We also considered one of the activities in Component 5 as an important factor; “setting annual goals” as in GTI, or “establishing an institutional target” as in 5.6b of the HHSAF. Therefore, we focused mainly on “planning specific activities” and “setting the annual institutional aim and target” in this step, based on the annual data reported in Step 4.
The annual institutional aim was decided from the findings by direct observations. We conducted direct observations constantly but did not apply any of these data as an outcome or a quantitative measure. The initiative was carried out with no additional staff reinforcement or high-tech recording devices, and obtrusive observations were not possible. The health care workers noticed that they were being observed after 5-10 minutes of observation, and adherence sharply rose, almost up to 100 % in some wards. This was clearly not their usual behaviour, obviously due to the Hawthorn effect; therefore, reliable quantitative data could not be obtained. However, we were able to obtain qualitative data by “examining in detail the barriers and opportunities to increase HH compliance” [27].
The institutional target amount was decided mainly based on the annual ABHR consumption that was achieved in the previous year. After the first two years, our annual ABHR consumption nearly reached 20 ml/PD, which is the target amount stated in 3.3c of HHSAF. Thus, for years 3 to 5, we focused on our ideal ABHR consumption with 100 % HH adherence, which was estimated to be approximately 50 ml/PD. Therefore, we set the target for the years 3, 4, and 5 as ½ (50 %), ⅗ (60 %), and ⅔ (66 %) our ideal amount, respectively.
We strategically evaluated the annual HHSAF score to plan specific activities for the following year. HHSAF helps to identify key issues requiring attention and the resources and tools useful for achieving them [15,16]. We referred to the “Template Action Plan” (TAP) [28] prepared for our HH level at the very beginning of the implementation of our initiative. However, once our HH initiative had started, we made our annual plans for the following year by choosing tools and activities mainly from the components that scored lowest in the HHSAF. This was effective not only because appropriate activities that were required at the moment were selected but also because it provided convincing reasons why this particular activity was chosen for the year. The frontline staff members could comprehend the meaning of each activity by explaining the details of our HHSAF score and identifying our weaknesses. We believe this empowered the local initiatives mainly led by the ICMs. Therefore, we continued to focus on improving the components with the lowest HHSAF scores for 5 consecutive years.
We found that ABHR consumption and HHSAF score were significantly positively correlated. We expected both would increase as a result of the initiative but did not expect that the 2 variables would show such a strong correlation. A prior study from Japan [29] suggested that adherence would be improved by increasing HHSAF scores. In this study, the HH adherence rate obtained by direct observation and the HHSAF scores were compared between 3 Japanese hospitals. They ranked in the same order for both measurements: hospital A was first with 38.3 % HH adherence and a score of 335 points, followed by hospital B with 30.4 % HH adherence and a score of 290 points, and hospital C was last with 26.1 % HH adherence and a score of 232.5 points. Our findings supported their results and indicated the possibility of adopting HHSAF as a process measure in a single facility. This may be useful for some other hospitals as well, especially for those with low baseline adherence and HHSAF scores, when conducting a long-term initiative. Further reports from other hospitals and multi-centred reports are needed to confirm this.
Few previous studies have reported both ABHR consumption and the HHSAF score. In a benchmarking survey from Greece, it was reported that the median ABHR consumption was 63.6 ml/PD, and the median HHSAF score was 258 points [30]. In a similar study from Italy, the average ABHR consumption was 38 ml/PD in the ICUs and 9 ml/PD in the non-ICU wards, and the mean HHSAF score was 332.22 points [31]. Our annual ABHR consumption in the final year of the study was 34.4 ml/PD, and the HHSAF score was 445 points. It may be possible to compare our results with those of the 2 previous studies; however, inter-facility comparisons may reflect the different sizes and complexity in different socioeconomic settings [15].
Our study was challenging in several aspects. Although national and subnational HH initiatives based on the WHO HH strategy have been introduced in many countries [3,5-7], such as full-scale initiatives, had not been introduced in Japan by the time of this study, and HH initiatives were left to each hospital’s own efforts. In addition, having long-term care wards with many patients on ventilators, as well as daily recreational activities, made our situation even more complex. Furthermore, similar to many other non-teaching hospitals in our country, we could not afford additional personnel for covert observations or high-tech recording devices to assess HH adherence. However, by tracking the ABHR consumption, together with the HHSAF score as a process measure, we were able to complete the 5-year, 5 Steps cycle, including the 5 Components. Our 5-year initiative resulted in an eight-fold increase in ABHR consumption, from 4.2 to 34.4 ml/PD, which is similar to the increase reported by Pittet, from 4.1 to 30.6 ml/PD, over 7 years [20].
We cannot say for certain which part of our initiative was most effective. Reviewing our present position with data on HH adherence and the HHSAF score at Step 4 gave us a bird’s eye view of what we have accomplished and what is left to be done. TAPs according to the total HHSAF score are available, but even if the total scores were the same, the priorities of the activities required to make the initiative most effective would differ between facilities. Providing essential hospital-wide systems (such as staffing, education and surveillance) and ABHR to each point of care would obviously be important for most facilities when initiating an HH programme. However, once these are adequately provided, the actual action that would be most effective at each moment should vary greatly depending on the type of the facility, the level of support from the executive members, and the level of frontline involvement. We had continuous support from the executives, so we did not need to spend much effort in this respect. On the other hand, we put effort into increasing frontline staff involvement each year, as our long-term patients had many daily contacts with staff members of many different professions. The effective measures needed to increase such awareness differ between professions and are best found by the staff members themselves. For example, the ICMs created original reminders with different messages, adapting to their everyday routine work in each local field. We observed that continuous HH improvement depended on the awareness of each member of the frontline staff; fields with active HH leaders introducing new original measures continued to improve, whereas fields with low awareness experienced difficulties.
Repeating the review process for 5 consecutive years may have been the most important key of our initiative. This has become a sustainable routine for us over this period of time. Although we have reached the ‘Advanced level’ and our HHSAF score has only 55 points left to improve, there are still ‘Leadership Criteria’ to be obtained, which we are working on now. We will continue repeating this 5-step cycle to sustain our improvement in HH practice.
There are several limitations of this study. First, this is a report from a single Japanese hospital, providing long-term care for many patients with heavy medical needs, with no previous effective HH campaigns or initiatives. The amount of ABHR required in our hospital may be larger than in many other hospitals that do not need to set such a high target. In addition, hospitals with higher HH adherence at baseline may not experience such an increase in ABHR consumption.
Second, we could not continuously record direct HH adherence. Some amount of ABHR may have been discarded or used incorrectly. As we did not provide incentives or punishment for the amount of ABHR consumed, we assume that there was not much advantage for each staff member to discard the substance. Although we found from our direct observations that the staff members with high ABHR consumption tended to use ABHR adequately, the possibility of discarded substance and incorrect use cannot be ruled out. In addition, the amount of ABHR that was used by patients and visitors was included in the ABHR consumption. As patient involvement in hand hygiene is recommended to improve the culture and climate of HH and to reduce hospital-acquired infections, we included patient/visitor ABHR consumption as part of the total HH improvement in our hospital.
ABHR consumption monitoring is not considered the gold standard for monitoring HH adherence. However, conducting obtrusive direct observations, the current gold standard, continuously and daily for years is difficult for most hospitals and cannot be widely recommended in terms of feasibility. On the other hand, ABHR consumption monitoring has been officially recommended in “The surveillance procedures for small and medium sized medical facilities” since 2009 in Japan. It has also been applied by the European Centre for Disease Prevention and Control [32] for standardized surveillance purposes. Currently, many reports from European countries have adopted indirect monitoring of HH activity based on ABHR consumption systems, as they are good surrogates for assessing HH adherence [10,30,31,33]. A report from Africa also corroborates the use of ABHR consumption systems [34]. So long as direct observations are also conducted for qualitative measures and no punitive approaches are taken, ABHR consumption monitoring may be reconsidered as a practical measure, especially for assessing improvement in long-term initiatives, for facilities with limited resources.
Third, the outbreaks that we experienced within this study period—a two-drug-resistant Acinetobacter baumanii outbreak in 2014 and a multiple-drug-resistant Pseudomonas aeruginosa (MDRP) outbreak in 2016—may have affected our results. Such outbreaks themselves can induce an increase in ABHR consumption, and the possibility of their influence cannot be excluded. However, the effects from these situations were expected to be temporary and limited to the ward in which the outbreak occurred. Our hospital-wide ABHR consumption continued to increase, regardless of the convergence of these outbreaks.
Fourth, the number of patient hospitalization days decreased between the preintervention period and the intervention period. This may be due to a change in the hospital policy in April 2014, which requires a referral letter from every first visit patient. It is known that poor HH adherence is associated with higher patient-to-staff ratios [35], so the decrease in the numbers of patients may have had some influence on increasing ABHR consumption per patient day. However, the 7.8 % decrease in the mean number of patients alone could not have caused the eight-fold increase in the mean annual ABHR consumption (from 2013 to 2018), although it may have provided some positive effect.
Fifth, the HHSAF includes the amount of ABHR consumption as one of its scores. The maximum score given to the ABHR consumption is 5 points, which is 1 % of the total score. HH adherence by direct observation is also included, with a maximum score of 30 points. Our score for direct HH adherence remained 20 points for the final 4 years. Altogether, our highest score for direct and indirect HH adherence was 25 points, which is 5 % of the total score. This is not a large proportion; however, it cannot be said that the HHSAF score and ABHR consumption are completely independent variables.