Diversey’s Dr. Claire Khosravi caught up with Professor Pittet ahead of the World Hand Hygiene Day celebrations on May 5th.
Professor Pittet, renowned for his work in infection control, patient safety, and hand hygiene, talked about how his interest in these topics developed and what drives his passion still today. He also discussed the role of Private Organizations for Patient Safety, a group of which Diversey is a proud member, and how this group is driving positive change.
This year's World Hand Hygiene theme focuses on Civil Society, and so he spoke of the importance of involving civil society in promoting hand hygiene. He also emphasized the responsibility of everyone working in healthcare to promote hand hygiene. He concluded with a message encouraging everyone to prioritize hand hygiene and cultivate a culture of safety in their institutions and encouraged us to celebrate World Hand Hygiene Day together and save lives by cleaning our hands. To take action together and work towards promoting hand hygiene." Read the full interview here.
Professor Pittet, you have had a brilliant career. For many years, you served as the Director of the Infection Control Programme at the University of Geneva Hospitals and Faculty of Medicine. Since the early 1990s, you have collaborated with the World Health Organization (WHO) on a variety of patient safety topics. You have been a disruptive force in infection control, patient safety, and particularly hand hygiene. What is it that initially piqued your interest in these topics, and what ignites your passion, which is still so evident today?
Thank you for that nice introduction. Actually, it was very simple. The reason we focused on hand hygiene from the very beginning of the activities of the Infection Control programme in Geneva is that, at first, we monitored infections using prevalence studies and some incidents from the ICU. However, we soon realized that these infection rates were higher than anticipated, ranging from 15 to 18%. Most of these infections were linked to cross-transmission, which often meant poor hand hygiene.
We looked at the literature and found that hand hygiene compliance was often reported to be lower than 40%, and frequently between 10 and 20%. So we asked ourselves, "Why is this?" I had training in epidemiology in the US, so the idea was born out of a strong epidemiological bias. We decided to conduct a real study on the behavior of healthcare workers to understand the risk factors for noncompliance with hand hygiene. We wanted to do a prospective monitoring study, but we needed to define when to clean your hands. We created a series of indications for when to clean, which we now call the "five moments."
However, at that time, we had more than 290 actions during patient care. We started by going onto the ward and recording these activities so we could frame them differently. We recorded what we called "opportunities for hand hygiene" in different types of patient care. Through this, we realized that compliance was even lower than we first thought. We monitored the number of opportunities per hour for patient care that any healthcare worker would have and realized that this number was very high. Soon, it was evident that the higher the number of opportunities, the lower the compliance. Today, it may seem obvious, but at that time, we needed a special program to analyze the data.
We observed healthcare workers day and night, over weekdays and weekends, in every single department of the hospital, and collected a multitude of data over three weeks. We realized that it was always true, whether you were in the ICU, pediatrics, or the psychiatric ward: the more opportunities, the less compliance. With so many opportunities, it was impossible to wash with soap and water. We timed how long it took to wash with soap and water, and it was between 1 and 1.5 minutes, sometimes even more if they had to travel to the sink. They simply had no time to do it. This is when we decided to replace soap and water hand washing with alcohol-based hand rubbing, and that was the very beginning of what became an intervention in infection control, the very beginning of the replacement of soap and water hand washing with alcohol-based hand rubbing.
Of course, you also asked about passion. The passion came from the research; it was so evident that we needed to find a solution, and we wanted to find a solution that works. This drove us to do it, and the rest is implementation.
In 2004, the WHO asked you to help in the global delivery of hand hygiene promotion and to host the first "Global Patient Safety Challenge," which rapidly became extremely powerful in mobilizing nations from all around the world. What progress have we made since then? How many countries have signed the Hand Hygiene Challenge today, and do any messages from 2004 still ring true today?
Well, in 2004, the WHO launched the patient safety movement and approached me for the first time. However, we actually started the first Global Patient Safety Challenge in 2005. At that time, healthcare-associated infections were still a taboo subject that few people spoke about. So, we embarked on a mission to get Ministries of Health from as many countries as possible to sign a pledge, recognizing that infections were a problem in hospitals in their countries. This was the primary point of the campaign. The second point was to ask them to use the tools we developed to promote hand hygiene in their countries. These tools were developed through the "Clean Care is Safer Care" campaign that the University of Geneva ran from 1994 to the beginning of 2005. We shared these tools with the WHO and worked with them to create universal tools. We worked with people from all around the world, creating a dream team of experts. The third element of the pledge was to share data on the impact of this strategy.
That was the beginning, and to answer your question, the first message we gave at the beginning is still very relevant today. We must ensure that healthcare-associated infections are known and recognized. In some countries around the world, those infections are still taboo, and people still don't like to speak about them, which means hiding the problem. The second message is that we need to use the tools that have been developed, which is increasingly relevant today. We have to make sure people understand the tools, use them, and adapt them to the resources and language of the country to obtain a change in behavior. Finally, the third element of the pledge is still highly relevant. We need to share data between regions, hospitals, and nations within the framework of science.
The strategy to promote hand hygiene is not only to ensure alcohol-based hand rub is available at the point of care but is a multimodal strategy based on five elements. We must ensure that the product is effective and tolerable on the hands, that it is available everywhere and that the dispensers are working. Next, we must educate with the five moments, how to hand rub, and a promotional strategy and campaign to enable people to endorse and embark on the strategy. We developed instruments to monitor the practices of healthcare workers and provide feedback on hand hygiene compliance. We ensured that hospitals received feedback regularly so that we could monitor progress at the facility or country level. To promote hand hygiene, we developed posters and gadgets to provoke change, and we asked for cultural change. Cultural change is so important, and hand hygiene must become part of the safety culture in every single institution and be promoted by the entire institution. This is more important than ever, especially after going through periods of COVID, which highlighted the importance of hand hygiene in the community and in healthcare settings.
Today, when you walk into healthcare facilities around the world, you can expect to see alcohol-based hand rubs, but this was not always the case. You provoked major system change as part of the multimodal strategy that replaced soap and water hand washing with the use of alcohol-based hand rubbing. Do you feel proud when you see these rubs? What led you to understand what the future of hand hygiene in healthcare needed to be, and what do you see as the future of hand hygiene in healthcare today?
I think it's clear that some people have definitely called it a revolution in healthcare. We brought about major system change to our institution, then to the other institutions that came to learn from us, and finally to the world through the WHO campaign and the vast number of activities that we ran globally. It has been a revolution, and that revolution is here to last.
It's very clear, but everything that we do should reinforce that revolution. Teaching is so important, but always teaching the same way, and using the same tools is a little boring, right? So it's better to develop new tools that will help people evoke a major change. Speaking about promotion, education, and using new ways of teaching people is always very exciting because we not only need to teach today, but we also need to teach sustainably. We need to have a sustained impact all over the world.
This is one of the major challenges: finding the best way to mobilize people. Some people ask, "Would you sanction people who don't comply very well with hand hygiene?" It has been used, but it's not very useful, and in the long term, it's a losing partner to go for sanctions. For the long term, choosing education and creating an appetite for people to learn is best, and so you will see that there will be the development of a series of games and the development of strategies using a 3D approach. There is electronic monitoring that could provide feedback.
I mean, none of those techniques are perfect yet, but the addition of those techniques is a multimodal way to teach the multimodal strategy. Within each of the elements of the multimodal strategy, you can imagine different tools to help support and sustain the strategy. So in the long term, I hope that new generations of nurses and doctors have integrated into their behavior the necessity to apply hand hygiene at the right time using the correct technique, and this will not only be due to the classical education that we use but also by the attractive and varying tools that are proposed today.
Among those tools, some are well-validated, and others are still pioneering tools. When we started to research hand hygiene, there were a few papers published every year. Today, we are talking about hundreds of papers published every month, and that's a different story. So it means that people are interested academically. They are interested in implementation science, they are interested in new tools, and they are interested in working together to improve compliance. Those, to me, are the constant behavioral changes that we should target, and those will be the most important in our field.
Another organization you helped form is Private Organizations for Patient Safety (POPS). Diversey has been a proud member of POPS since its formation. Why do you think POPS is important, and how have organizations like Diversey impacted positive change through the platform?
The POPS movement has been of utmost importance. I created this movement within the WHO framework, which was not an easy feat as we were bringing together private companies that are usually competitors. However, we managed to bring together a group of companies to work collaboratively towards improving how we promote hand hygiene.
These companies have different capabilities, with some producing only dispensers while others produce alcohol-based hand rubs. Nonetheless, we had some companies with excellent products, which made working together advantageous. Some companies were better at education, while others excelled at research, so having all these companies at the table was crucial. We have been running the POPS effort for many years, and it is exceptional because when discussing the value of a new product or alcohol-based hand rub, some companies have researched protecting hands, while others have focused on producing a product that covers all bacteria and viruses. This collaboration means that the field of research, development, and innovation in hygiene is vast.
A few years ago, I edited the first textbook on hand hygiene with some colleagues, which had around 500 pages and an attached research agenda. This research agenda is still one of the most advanced ever produced in the field of hand hygiene and has been used for the current WHO movement, where experts from around the world are revisiting the research agenda for hand hygiene. This work has been conducted in parallel and in collaboration with academic physicians, epidemiologists, and private companies interested in hand hygiene.
The promotion, teaching, and development of products and materials are synergistic, and the most important part is the synergy, working together to promote good hand hygiene. Also, no single company is present all over the world, so it's crucial to cover the globe since private companies carry the products, education, and movement at the bedside. For those companies interested in the POPS network, we organize train-the-trainer programs. When a company is interested in our team going to a particular country, we bring the best infection control practitioners, education, and promotion strategy to promote hygiene. We do this together and correctly.
One company may want to do this in France, another in Germany, a third in Australia, a fourth in Thailand, and a fifth in Brazil. This type of action can be conducted with the support of teachers worldwide and in the context of the POPS effort and support for hand hygiene promotion. We also developed the Hand Hygiene Excellence Award with one company and recognize hospitals worldwide that promote hand hygiene best. These hospitals attract others in the country and the region to improve, making it a great example of how to spread the campaign using the right tools, format, and education worldwide. This kind of collaboration is only possible with close participation between my team and the companies.
Every year, you dedicate yourself to promoting hand hygiene, specifically with the May 5th campaign. In recent years, the campaign has featured different themes. Can you explain this year's theme and why the campaign is so important?
This year is a little bit different because the idea was to mobilize civil society. It's a good time to involve civil society, in addition to people working in healthcare, infection control, and prevention, because we are almost out of the COVID period and need to mobilize society around the importance of hygiene right now.
The goal is to get civil society invested in the promotion of the campaign. We hope that one day patients, families, visitors to hospitals and healthcare facilities, and anyone in a place where care is provided will be convinced to clean their hands and engage in this hand hygiene promotion. If it becomes evident that hand hygiene is essential, even for those in the community, it is clear that it will change the mindset of healthcare workers, families of patients, and patients themselves.
What would you like to say to anyone working in a healthcare facility today who may be reading this interview?
I hope everyone understands and is convinced that everyone is important. For me, this is key. There is no greater responsibility in a healthcare setting than hand hygiene, and everybody is responsible for it, from the CEO of the hospital to the staff. The CEO needs to be clear in their mind that hand hygiene compliance is as high as possible for any situation during healthcare. We need the Chief Medical Officer and the Chief Nursing Officer to be convinced and dedicate time to allow people to receive good education in hand hygiene.
We need to ensure that a good system is in place for monitoring and feedback, and that a culture of safety is installed in the institution. As healthcare workers, we need to understand that even if we don't see the patient get infected because the patient is not in our service after that, cleaning our hands on a systematic basis means we will be one of the tens of millions of people participating in reducing infections resulting from cross-transmission, reducing multi-resistance resulting from cross-transmission, and resulting in all sorts of bad things that may happen from infections. The burden of disease from infections, including mortality, could be significantly reduced by this campaign, which is probably saving between 5 and 8 million lives every year globally, in hospitals and we are only speaking about deaths here, not about the burden of disease that a lack of compliance with hand hygiene could result in.
Once the campaign is perfectly understood outside of hospitals, the impact will be even greater. So, I would say that everyone is important, even if, as a CEO in a hospital, you don't have to clean your hands frequently because you don't take care of patients, when you go to the ward, remind the healthcare workers and thank them for keeping their hands clean at the appropriate time.
This year, we are discussing the role of civil society. When civil society endorses the importance of hand hygiene all over the world, it will have a significant impact on our daily lives and on the lives of our patients and their families. It's a good time to involve civil society, in addition to people working in healthcare, infection control, and prevention, because we are almost out of the COVID period and need to mobilize society around the importance of hygiene right now. The goal is to get civil society invested in the promotion of the campaign. We hope that one day patients, families, visitors to hospitals and healthcare facilities, and anyone in a place where care is provided will be convinced to clean their hands and engage in this hand hygiene promotion. If it becomes evident that hand hygiene is essential, even for those in the community, it is clear that it will change the mindset of healthcare workers, families of patients, and patients themselves.
Thank you very much, Professor Pittier. On behalf of Diversey, I really appreciate your time for this great interview as part of the World Hand Hygiene Day celebrations.
"It's my pleasure. Let's celebrate World Hand Hygiene Day together and save lives by cleaning our hands. Let's take action together and work towards promoting hand hygiene."
You too can get involved with this years campaign! Download the selfie board, put your name on it, and either print it or use your iPad to display it and take a selfie and post it on the social media platform of your choice with the hashtags #HandHygiene #CleanYourHands #InfectionPrevention + mention @WHO to appear on the WHO photo wall. Don't forget to mention @Diversey too so we can see your great photos.