Clean Care is Safer Care

Case study

Hospital Pablo Tobón Uribe in Medellin, Colombia

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Submitted by:

Andrea Restrepo and Monica Valderrama
Hospital Pablo Tobón Uribe
Medellin, Colombia

What type of health-care facility or organization are you?

The Hospital Pablo Tobón Uribe, located in Medellin, Colombia (South America) is a tertiary care teaching hospital with 371 beds, of which 60 are intensive care unit beds. We admit highly complex patients such as neonates, those with liver, renal and bone marrow transplantations, and oncological, cardiac and neurosurgical diseases. The mean hospital stay is 9.6 days.

What was the situation at your facility with respect to hand hygiene and HAI before you initiated the hand hygiene initiatives?

The Clean Care is Safer Care Strategy in Colombia was originally endorsed by the Ministry of Health. In Bogotá (the capital) we heard about the project and we also had the opportunity to hear about the Costa Rican experience and decided to implement the strategy with the support of the hospital administration. We started to work on this project in November 2008. We have been using alcohol-based hand rub (ABHR) in the Hospital since 2002 and have been measuring healthcare-associated infection (HAI) rates since 2004. Before starting the hand hygiene project we did not have a well-established hand hygiene program. HAI rates during 2008, 2009, 2010 and 2011 were: 4.96, 6.21, 6.73 and 6.07 per 1000 patient days, respectively.

What were the goals of your initiative?

Our goals were to increase hand hygiene compliance up to 90%, to increase ABHR use and to reduce healthcare-associated infections. In order to develop the project, we followed the WHO Guidelines and its five recommended steps. Each year we select specific hospital wards to implement the strategy, as follows:

  • In 2009: two intensive care units, two intermediate care units and the isolation unit for patients colonized or infected with multiresistant microorganisms;
  • In 2010: two paediatric wards and interventional radiology;
  • In 2011: emergency room

We plan to cover all hospital wards in a 5 year period.

What actions have you planned or already put in place to improve hand hygiene at your facility?

We have been conducting several activities, as follows:

  • Implementation of the Clean Care is Safer Care Strategy. We used almost all the tools proposed by the WHO, including the observation form to measure compliance according to “My 5 moments for hand hygiene”.
  • Training of healthcare workers (HCW) during the induction course as well as an e-learning course;
  • In order to stimulate HCW, we did a contest to reward good hand hygiene practices;
  • Installation of alcohol dispenser at the point of care, all over the hospital.
  • Each year a supervision round is done to guarantee that all hand hygiene products and posters are in good condition.
  • Since 2009 we have been celebrating the 5 May with educational and playful activities.
  • Including patients and caregivers in the program,
  • We train HCW to perform the correct hand hygiene technique with a fluorescent concentrate (Visirub) that makes evident hand zones were the handrub was not rubbed.
  • Installation of automatic sinks and disposable towels in nursing stations and at the entrance of each ward.

Did you encounter any particular problems while planning and implementing your strategy?

The biggest barrier to increase compliance is the lack of awareness in HCW about the importance of hand hygiene. They don't recognize their hands as a risk factor for the transmission of germs to the patients and they underestimate the power of hand hygiene to prevent infections.
We also have problems with HCW attendance to the training sessions, especially doctors.
Other barrier has been to convince the engineering department that the dispensers have to be placed at the point of care, even though is not very fashion.
Solutions: To make HCW aware of the importance of hand hygiene we have done hand cultures before and after handrubbing with ABHR, and have shown them the relation between increasing compliance and decreasing infection rates. We are also taking advantage of the international accreditation process because the fifth safety goal emphasizes the importance of developing a hand hygiene program and the increase in compliance.

What were the outcomes of your initiatives?

We measure three outcomes: compliance with hand hygiene, ABHR use and infections rates. Compliance was high since the beginning in wards where contact precautions were permanent because at that time we were dealing with a carbapenem resistant K. pneumoniae outbreak. We also noted that compliance increases during the contest. The table shows compliance (%) in wards where the strategy was implemented.

Besides these observations, each year we make unnoticed observations. In 2010 and 2011 this compliance was 57 and 66% respectively.

What were your key learning points?

  • It is essential to involve hospital heads and administrators and make visible to them the high cost of an infection compared to the cost of a hand hygiene program.
  • Train ward chiefs as observers to emphasize the importance of hand hygiene. Leaders must set a good example.
  • Hand hygiene products must be of good quality, well tolerated and visible.
  • Patients, families and all hospital staff must be involved.
  • Powder-free gloves are important to facilitate hand rubbing.
  • Persistence, creativity, good sense of humour and a committed team are very important.

What are your future directions?

  • To cover all hospital services in a five year period.
  • To celebrate 5May 2012, making emphasis on the barriers for not doing appropriate hand hygiene.
  • Publish our experience in a national journal.
  • Reach the goal of 90% compliance.

Additional comments

We dream of hand hygiene and other basic infection prevention principles been included in medical curricula.