Implementation of surgical

handrub-experience from a
University Hospital in Vietnam
Tuan Huynh, MD, PhD
Dept. of Infection Control
University Medical Center – Ho Chi Minh City
Content
• Background
• Experience on how to implement new protocols (and surgical
handrub) of surgical hand hygiene in UMC hospital
• WHO multimodal strategy with appropriate modification
• Key challenges and solutions
• Summary and conclusion
Background
International guidelines (WHO, CDC, AORN…)
National guidelines (Vietnam MoH)
• All recommend and confirm that SURGICAL HAND HYGIENE is critical in
reducing the incidence of SSI
• Scrubbing or rubbing is acceptable
• Still challenging in reality
Brief introduction – UMC Surgical Dept.
• Number of surgeries: 30,662 cases/year
• Emergency: 27,464
• Program: 27,464
• Laparoscopic: 8,699
• Open: 2,196
• About 120~150 operations/day
Multimodal strategy for improving surgical hand
hygiene at UMC-HCMC

Source: WHO 2009

System change
• Hospital regulations
• Policy/procedures/instruction for hand hygiene
• Set Hand hygiene quality index
• Establish Hand hygiene “task force”
• Infrastructure: Equipments (hand wash basins vs handrub stations),
chemistries & other supplies
Regulations on surgical hand hygiene
Hospital quality index
• Surgical hand hygiene
• Minimum 99%
Surgical hand hygiene “Task force”

Mixed team including:

• Surgical dept.
• Board of Director
• Different senior surgical specialists
• Infection control
• Quality management
• Nursing dept.
Standard surgical hand wash basin

• Stainless steel
• Automatic lever/foot
pedal
• Microbial quality
control of water
• Ultrafiltration
membrane
• Cotton/disposable
paper towel
Chemicals and other supplies
Hand scrubbing
- 4% chlorhexidine antibacterial
soap solution
(sealed container, with an
automatic dosing pump or by
hand-free dosing dispenser )
- Disinfected water
- Sterile soft nail brush (or nail
pick)
- Sterile/disposable towel
Handrubing
- Ordinary soap solution
(closed containers, with automatic
dosing pump or by hand-free
dosing dispenser )
- Sterile soft nail brush (or nail
pick)
- Clean/sterilized hand towel
- Alcohol-based hand rub solution
(EN 12791/ASTM E1115) in
each operating room
ABHR “station” in each operating room
Training & Education
• Subjects
- Surgeons, Anesthesiologists, Instruments staff, staff of surgical team, student
participating in surgery
- Supervisor: IPC staff and IPC network staff
• Contents
- The importance of surgical hand hygiene
- Technical processes
- Processes of Monitoring & Feedback
• How to train?
- In the lecture hall
- On-site instruction/simulation/surveillance & coaching
Training plans
• Orientation/new staff
• Annually/everyone
Speaker is very important
• “Idol” speaker
• Senior
• Chief of dept.
 Different kinds of training activities

In lecture hall Microscope training Simulation station Off-site

activities
Staff can see microbes
visually
Posters & brochures
• Detailed brochures
adapted from WHO &
MoH
Training documents available “everywhere”

• Documents
• Pictures
• Clips

• Easily accessible
• Hospital intra
network
Evaluation & Feedback
• Surgical hand hygiene compliance rate
- direct observation
- camera observation
• Equipments and means used in surgical hand hygiene
• Amount (monthly) of soap solution and ABHR solution
• Assessing knowledge, attitude and practice of HCW about the
surgical hand hygiene
Monitoring plans
 On-site monitoring:
• Noticed to all depts.
– Time
– Place
– Who is supervisor

 Distance monitoring via camera

Different kinds of monitoring activities

Direct observation Camera observation

IPC staff monitor compliance through a desktop in office
IT is key to reduce workload
• App in Ipad
• No paper
• Data will be
entered
automatically
into a central
computer
Feedback
• Immediately
• Personally
• May use
other social
means (viber)
Next level of feedback: compliance rates
• Each dept.
• Intra network
Compliance rates per staff groups

Anesthesiologists Surgeons Instrument staff

Compliance rates per departments

OBGYN DSA SURGICA

L
Reminders at work-places
• Posters (at hand wash area, operating room area)
• Brochures
• All surgical hand hygiene documents are posted on the hospital
website (intra network)
Posters at hand wash areas
& in Operating rooms
Documents on website
• Surgical hand hygiene
handbook
• Surgical hand hygiene
clips
• Posters: 5 moments and
how-to
• Available 24/7 and easily
accessible to every health
worker
Institutional safety (hand hygiene) climate

The Director of Hospital/Leaders of Depts.

sign hand hygiene commitment
Role models/Championship of Hand
Hygiene
Challenges
• Some HCWs have not yet complied with the Surgical HH technical
procedures issued by the Hospital
• Perform a “traditional” surgical hand hygiene procedure using a brush
• Not enough time
• Missed steps required
• Shortage or not providing adequate equipment suitable for surgical hand
hygiene methods
• Scrubbing: the nail brush is not suitable (actually we don’t have a good nail pick)
• Rubbing: not fully equipped corresponding to the procedure (not very good
dispensers for normal soap solution and ABHR solution, ABHR solutions not
according to EN standards 12791 or ASTM E-1115)
Using “traditional brush technique”
Senior surgeon wants to use traditional
brush

There is a senior surgeon.

He sent many emails, saying that:
- Using brush is CORRECT
- Asking for regulations not allow to use brush
Not enough time required
Missed steps required
Not appropriate brush for nail
Some of solutions we have done
• Training, training, and training on surgical hand hygiene
• Strengthen monitoring and feedback
• Installation dedicated clocks for surgical hand hygiene: reduce the
rate of time non-compliance
• Look for and ask for investment on appropriate equipments,
supplies, standardized chemiscals
• Applying in parallel two methods of surgical hand hygiene (scrubbing
vs rubbing)
Training & re-training plans
• Approved by Director
• Having awards for individual/team
• “No blame No shame” culture
Presence required for all HCW & surgical
staff
Strengthening monitoring & feedback

Monthly list of non-

compliance and send it to
Via email (other social the Faculty/Unit's Leaders
means) to individuals Seldomly
Last level of feedback
Dedicated clocks for surgical hand hygiene

Reduce the rate of time non-compliance

2 methods in parallel

Providing:
- Antimicrobial soap
- “Normal” soap
In parallel
Instalation of ABHR automatic dispensers
Conclusion
• Scientific guidelines and legal regulation all over the world: surgical
hand hygiene is critical in prevention of SSI
• In order to implement/improve surgical hand hygiene: we must have
an appropriate strategy (WHO multimodal strategy is one of the
good one)
• Each hospital/place has its own challenges, we have to face with
and work up solution. Facing with challenges is sometime the best
start.
Contact info
Tuan Huynh, MD, MS, PhD
Dept. of Infection Control
University Medical Center – Ho Chi Minh City

Cell: +84 90 934 9918

Email: huynh.tuan@umc.edu.vn
Thank you very much
for your attention.