Multimodal Strategy to Improve Hand Hygiene

The World Health Organization has been doing research on ways to improve compliance with hand hygiene worldwide since 2010.

From highly industrialized nations to rural Africa, the experts at the WHO have resources, toolkits, and education for educators and influencers.

Their “calls to action” are designed for:

  • Health care workers
  • Infection control and prevention leaders
  • Health facility leaders
  • Ministries of health (especially critical in less developed nations)
  • Patient advocacy groups

The message is simple: Save Lives: Clean Your Hands

May 5

Each May 5 since 2010, the WHO has started a new campaign to emphasize a different aspect of infection prevention and related patient safety measures. This year’s emphasis is sepsis. The organization developed tools to teach health professionals how to prevent healthcare associated infection (HAI), and, once an infection occurs, preventing its progression to sepsis.¬† WHO research demonstrates a 50% reduction in HAI when workers follow the 5 Moments for Hand Hygiene

May 5 Campaigns

Each annual campaign includes free resource material, Webinars, toolkits and evidence-based recommendations for implementation.

  • 2010: 5 Moments; Hand Hygiene Moment 1
  • 2011: Track your progress, plan actions and aim for sustainability
  • 2012: Create an action plan based on your facility’s results
  • 2013: Celebrate successes and include patients
  • 2014: No action today, no cure tomorrow; using the 5 Moments to combat resistant germs
  • 2015: A year of activities to support SAVE LIVES: Clean Your Hands
  • 2016: Improving hand hygiene practice in all surgical services through the continuum of care
  • 2017: Fight antibiotic resistance: it’s in your hands
  • 2018: It’s in your hands: prevent sepsis in health care

Evidence-based recommendations

The WHO has used every opportunity from these annual campaigns to collect data and test implementation strategies in a variety of healthcare environments.  As a result, they have published their research and guidelines; all WHO publications are free to download. Their areas of focus include:

  • Hand hygiene
  • Injection safety
  • Focus on antimicrobial resistance
  • Surgical site infection
  • Core components for infection prevention and control
  • Other interventions, identified by the PROHIBIT team (Prevention of Hospital Infections by Intervention and Training, funded by the European Union)

In addition to the formal recommendations, WHO also provides downloadable posters and infographics that convey information graphically and can be posted for access by all healthcare workers.


Benefits of Beating Heart CABG After MI

Researchers from Australia have published (before print) an analysis of non-elective CABG using bypass, cardiac arrest and aortic cross clamping compared with beating-heart revascularization.

They did a retrospective review of 5851 patients who had urgent CABG within 7 days of acute MI (AMI). Only 77 patients had beating-heart surgery. Factors associated with off-pump operations were:

  • Age in the 70s
  • Peripheral vascular disease
  • Redo surgery
  • Cardiogenic shock
  • Single-vessel disease

When patients were matched for statistical analysis, there was no significant difference in 30-day mortality (p=0.85), major adverse cardiac and cerebrovascular events (death within 30 days, postop MI, postop stroke, or non-elective surgical redo) (p=0.84), or 12-year survival (p=0.89) ~64%

Beating heart patients were more likely to have fewer distal anastamoses and incomplete revascularization (some resulting stenosis).

Bottom Line

The authors note that fewer patients had off-pump surgery because the surgeons were less experienced with that technique. However, for at-risk patients, the technique is safe and effective in high-risk patients requiring CABG shortly after acute MI. Off-pump surgery is an acceptable approach in those are not good candidates for cardioplegic cardiac arrest and aorta cross-clamping, and in patients who are hemodynamically unstable.


Zhu MZL et al.: On-pump beating heart versus conventional coronary artery bypass grafting early after myocardial infarction: A propensity-score matched analysis from the anzscts database. Heart, Lung and Circulation 2018;


Evidence-Based Competency Curriculum

Nurses at the University of Alabama at Birmingham have published a detailed competency-based curriculum to assess nurse practitioner’s transition into the critical care practice role. Unfortunately, the authors note that often, there is little to no time set aside for the transition from critical care bedside nurse to advanced practitioner; this curriculum was developed to address that need.

Elements of Competence

The authors identify the 3 key elements of competence (the KSA Model)

  • Knowledge
  • Skills
  • Attitudes

Remember, competence is knowing what to do, how to do it, and performing in the environment of practice. A checklist outlining equipment set-up is only one element of competence in caring for patients requiring chest drainage, for example.

APRN Critical Care Practice

The topics included in this curriculum are:

  • Professional development
  • Scientific foundation of practice
  • Procedural skills
  • Diagnostic studies
  • Mechanical ventilation
  • Management of complex diseases
  • End-of-life care
  • Patient safety
  • Pharmacology

The nurse researchers who developed this curriculum tested it by sending it to 109 faculty  and practitioners who had graduated within the past two years within the U.S. They were asked to score the parts of the curriculum on a 1-4 Likert scale, based on relevance to practice.

What is Most Relevant?

The highest mean ratings, meaning those most relevant to APRN practice:

  • Management of complex diseases (3.92)
  • Diagnostic studies (3.89)
  • Pharmacology (3.89)

These are consistent with the Accreditation Council for Graduate Medical Education’s requirements for medical residents.

The lowest mean ratings:

  • Scientific foundation of practice (3.61)
  • Professional development (3.63)

While the focus on clinical practice without the underlying nonclinical science may be troubling, the authors believe that some of the details for these competencies were thought to be doctoral level practice, not Master’s level.

Kopf, RS, et al.: A competency-based curriculum for critical care nurse practitioners’ transition to practice. American Journal of Critical Care 2018;27(5):398-408

Time to Talk About Grief

The most recent issue of AACN Advanced Critical Care has two important articles about nurses dealing with grief. In Creating a Healthy Workplace, author Hui-wen Sato from Children’s Hospital Los Angeles makes these observations:

  • Nurses carry a unique and complicated burden of grief, trauma and moral distress
  • Critical Care is a mentally demanding, emotional place to work
  • The critical care culture values quick responses and “strong nurses,” which may make it difficult for nurses to process complicated emotions, or admit they are present
  • We need to move beyond, “Are you OK?” to “How did that patient’s care affect you?”
  • Nurses should develop support systems to recognize unresolved grief and allow ourselves to be vulnerable and talk about it.

In Ethics in Critical Care, authors Elizabeth Broden and Melissa Kurtz Uveges from Children’s Hospital in Philadelphia and the Center for Bioethics at Harvard respectively apply grief and bereavement theory to critical care nursing practice, focusing on end-of-life care.


Sato H:Building healthier workplaces by giving space for work-related grief. AACN Advanced Critical Care 2018;29(3):244-245