Multimodal strategy for hand hygiene in field hospitals of COVID-19

doi:10.1590/0034-7167-2020-0487

Brasil

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REFLECTION • Rev. Bras. Enferm. 73 (suppl 2) • 2020 • https://doi.org/10.1590/0034-7167-2020-0487 linkcopy

Multimodal strategy for hand hygiene in field hospitals of COVID-19

Estrategia multimodal para higiene de las manos en hospitales de campaña para COVID-19

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ABSTRACT

Objective: Reflect and propose adaptations to the Multimodal Hand Hygiene Strategy for field hospitals, in the context of the COVID-19 pandemic.

Method: Reflective study, carried out in April 2020, based on the recommendations of the World Health Organization and the guide for the implementation of the five components of the Multimodal Strategy: system change related to infrastructure; training/education; evaluation and feedback; reminders in the workplace; and institutional security climate.

Results: The Multimodal Strategy, proposed for hospitals in general, can be adapted for field hospitals in order to reduce the transmission of the SARS-CoV-2 virus. Investments to adapt the infrastructure and education of workers require foresight and speed and are of special relevance to promote hand hygiene in this care context.

Final considerations: Adjusting the Multimodal Strategy, especially for the reduced time in the execution of each component, is necessary for field hospitals with a view to preventing COVID-19.

Descriptors: Hospitals; SARS Virus; Delivery of Health Care; Hand Hygiene; Patient Safety

Component: "System Change" (Infrastructure)

DESCRIPTION
It aims to ensure the necessary infrastructure to allow professionals to carry out the practice of HH. This component is originally composed of Unit Preparation and Initial Diagnosis.
EXPECTED TIME
Considering the pandemic situation, this component must occur in parallel with the implantation of the field hospital or, at most, in the first fortnight of operation. In the face of the pandemic, the exclusive preparation is considered to be operational, due to the time limitation prior to the installation of the hospital and through the progressive composition of the team.
KEY ACTIONS FOR HH AND PATIENT SAFETY
• List a key leadership team (nurses and/or doctors) to implement the strategy, including a coordinator and their alternate⁽²⁾. The patient safety team is composed of the leadership and professionals, being responsible for prevention and infection control actions⁽⁷⁾. In a pandemic situation, the leadership needs to use management tools to involve the team in the immediate response to the continuous demands within the provisional structure, as well as, to indicate observers who will act as auditors of adhesion and adequacy of the HH practice.
• Make supplies available, such as drinking water, liquid soap, paper towels and alcoholic solution, at the service/assistance point, in circulation corridors, at entrances and other environments, in sufficient quantity⁽²^,⁸⁾. The availability of alcoholic solution close to the point of assistance provides opportunities for its use, before and after touching the patient or the care environment, reducing the risk of carrying the virus.
• Consider pocket flasks containing alcoholic preparations for health and support professionals⁽²⁾, a fundamental strategy in preventing virus transmission.
• Install washbasins with sufficient size and depth for washing hands and forearms, observing the sink/patient's bed ratio of at, least 1:10⁽²⁾. If there are no other possibilities, portable washbasins can be used in field hospitals, as long as strict water supply and sewage processes are established⁽¹⁰⁾. This recommendation is fundamental, considering structures adapted for health care.

Component: "Training/Education"
DESCRIPTION Vital component that integrates strongly with the other components and induces behavioral and cultural changes through adequate theoretical and practical training⁽²^-³⁾. EXPECTED TIME This component must be conducted previously at the start of activities at the field hospital, as well as in parallel, during activities, considering the high transmissibility of SARS-CoV-2. Educational activities should occur continuously whenever new professionals are hired or, also, if there is low effectiveness of previous educational interventions, measured by audits or evidenced by horizontal virus transmission indicators between patients and workers, who are part of another item of the multimodal structure, which for now will not be discussed in this study. KEY ACTIONS FOR HH AND PATIENT SAFETY • Establish requirements for basic education for trainers, observers and health professionals. For example, workers' lack of knowledge about policies, standards, protocols, standard operating procedures directed to HH⁽²⁾, especially those related to COVID-19, should be a topic for educational activities. Still, these educational actions must take place, in particular, on the occasion of the emergency hiring of health professionals to work in field hospitals, in view of the possible inexperience condition of the new professionals. • Train/qualify the assistance and support team about HH through the adoption of a solid permanent education program⁽²^-³^,⁸⁾. If it is not possible to maintain a continuing education program, to meet the emergency demands of the pandemic, at least basic training on the importance of HH must be carried out to ensure patient safety⁽²⁾, using, for example, reminders in the workplace, which will be further discussed in the next component, to highlight the importance of HH. • Among the educational tools, training with the use of active strategies and online platform stands out. It is worth mentioning that knowledge about the transmission of the virus may still be incipient for certain categories of workers, requiring special attention. Optionally list applications and/or distance courses that address HH in the context of health⁽³⁾ and the pandemic of COVID-19, as educational strategies. Attention should be given to workers who do not have or do not master technological resources, and other tools should be considered, such as conversation circles and the use of audiovisual resources⁽²⁾.
Component: "Reminder in the workplace"
DESCRIPTION Use of fundamental instruments to alert and remind health and support professionals, patients, family members about the importance of HH and the appropriate indications and techniques for this practice⁽²^-³⁾. EXPECTED TIME This component should be applied concurrently to educational activities, and continuously during the operation of the hospital. KEY ACTIONS FOR HM AND PATIENT SAFETY • Distribute visual alerts such as posters, plaques and posters at the entrance of temporary structures and in strategic locations, with information on the correct technique⁽²^-⁴⁾, and the importance of hands in transmitting the virus to the person and for environmental dissemination. • Highlight the effectiveness of alcoholic solutions against the virus, its spread and survival in the environment, and the relevance of cleaning and disinfecting surfaces. • Provide alert slogans adhered to the dispensers of alcoholic preparations for hands and devices⁽³⁾, with emphasis on their effectiveness against the virus. • Distribute motivational phrases, in the corridors and computer screens, that encourage workers to join HH and understand their fundamental role in controlling the spread of the virus in the context of the pandemic.

Component: "Evaluation and feedback"

DESCRIPTION
Essential component to identify areas that deserve great efforts and to subsidize the updating of the action plan and increment of actions⁽²^-³⁾, with a view to reducing the cross-transmission of the virus. When considering the speed of information and guidelines related to the pandemic, evaluation and feedback are fundamental points for continuous adjustments.
EXPECTED TIME
Considering the pandemic, and the need for updates, this component should be operational within the first month of operation, weekly or fortnightly, according to the context.
KEY ACTIONS FOR HM AND PATIENT SAFETY
• Investigating workers' confidence in the effectiveness of HH and alcohol gel against the virus is a fundamental strategy.
• Perform an audit during the practices of dressing and de-dressing that are part of the daily care of patients with COVID-19, which is essential for detecting errors with risk of self-contamination, as well as for the correct HH in the initial and final stages direct care.
• Encourage team suggestions to improve this process; and developing new strategies.
• Establish and compare the results of care related to the practice of HH, such as cases of horizontal transmission in the following areas: patient-worker, worker-worker, patient-companion and worker-companion. Provide feedback to workers, individually or collectively⁽⁴⁾.
• Evaluate and monitor infectious adverse events, especially the occurrence of cases and outbreaks of COVID-19⁽⁷⁾ among health professionals and in-hospital transmission to patients.

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