Clean Care is Safer Care: a worldwide priority
Authors: Didier Pittet, Liam Donaldson
Journal: The Lancet (2005)

At any time, more than 1·4 million people worldwide are afflicted by infections acquired in hospitals.1Tikhomirov E WHO Programme for the control of hospital infections.Chemiotherapia. 1987; 3: 148-151Google Scholar Between 5% and 10% of patients admitted to modern hospitals in developed countries acquire one or more infections; 15–40% of those admitted to critical care are affected.2Vincent JL Nosocomial infections in adult intensive-care units.Lancet. 2003; 361: 2068-2077Summary Full Text Full Text PDF PubMed Scopus (499) Google Scholar The risk is two to 20 times higher in developing than in developed countries. The burden of disease outside hospital is practically unknown, owing to the absence of surveillance. Importantly, no health-care setting, no hospital, no country in the world can claim to have solved the problem. On Oct 13, 2005, the WHO World Alliance for Patient Safety3WHOWorld alliance for patient safety.http://www.who.int/patientsafety/worldalliance/en/Google Scholar, 4Donaldson LJ When will health care pass the orange-wire test?.Lancet. 2004; 364: 1567-1568Summary Full Text Full Text PDF PubMed Scopus (31) Google Scholar launches the first biennial Global Patient Safety Challenge, "Clean Care is Safer Care", which targets infection associated with health care and will cover 2005–06.5WHOGlobal patient safety challenge of the world alliance for patient safety.http://www.who.int/patientsafety/challenge/en/Google Scholar But why has this area been targeted, when so many other diseases are vying for investment-priority status and public attention? In the USA, one in 136 patients becomes severely ill as a result of acquiring an infection in hospital.6Starfield B Is US health really the best in the world?.JAMA. 2000; 284: 483-485Crossref PubMed Scopus (409) Google Scholar This rate is equivalent to 2 million cases, leading to additional cost estimates of US$4·5–5·7 billion and about 80 000 deaths a year. In England, health-care-associated infections are estimated to cost £1 billion and directly cause more than 5000 deaths annually.7National Audit OfficeImproving patient care by reducing the risk of hospital-acquired infection: a progress report. Stationery Office, London2004Google Scholar In Mexico, the estimate is 450 000 infections, causing 35 deaths per 100 000 inhabitants each year.8Ponce-de-León RS Rangel-Frausto S Infection control in developing countries.in: Bennett JV Brachman PS Hospital infections. 4th edn. Lippincott-Raven, Philadelphia1998: 291-296Google Scholar In developing countries, more than half of all infants in neonatal units acquire a health-care-associated infection, with a fatality rate of 4–56%.9Zaidi AK Huskins WC Thaver D Bhutta ZA Abbas Z Goldmann DA Hospital-acquired neonatal infections in developing countries.Lancet. 2005; 365: 1175-1188Summary Full Text Full Text PDF PubMed Scopus (534) Google Scholar In turn, while caring for the sick, health-care workers are also exposed to risks, including tuberculosis, hepatitis, and HIV. During the pandemic of severe acute respiratory syndrome, the proportion of infected health-care workers ranged from about 20% to 60% of cases worldwide with differences between hospitals; the better the education in infection control, the lower the risk.10McDonald LC Simor AE Su IJ et al.SARS in healthcare facilities, Toronto and Taiwan.Emerg Infect Dis. 2004; 10: 777-781Crossref PubMed Scopus (135) Google Scholar, 11Seto WH Tsang D Yung RW et al.Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS).Lancet. 2003; 361: 1519-1520Summary Full Text Full Text PDF PubMed Scopus (715) Google Scholar Health-care-associated infection shows many of the characteristics of a major problem for patients' safety. It affects hundreds of millions of people worldwide, complicates the delivery of patients' care, contributes to patients' deaths and disability, promotes resistance to antibiotics, and generates additional expenditure to that already incurred by the patient's underlying disease. Infection has several causes related to the systems and the processes of care provision, economic constraints on systems and countries, and human behaviour. Prevention strategies reduce infection in both developed and developing countries; most are simple and not resource-demanding.12Pittet D Clean hands reduce the burden of disease.Lancet. 2005; 366: 185-187Summary Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 13Pittet D Hugonnet S Harbarth S et al.Effectiveness of a hospital-wide programme to improve compliance with hand hygiene.Lancet. 2000; 356: 1307-1312Summary Full Text Full Text PDF PubMed Scopus (1923) Google Scholar, 14Pittet D Sax H Hugonnet S Harbarth S Cost implications of successful hand hygiene promotion.Infect Control Hosp Epidemiol. 2004; 25: 264-266Crossref PubMed Scopus (110) Google Scholar Several health-care settings have succeeded in reducing the risk to patients, but others have not. Thus, gaps in patients' safety arise because existing tools and interventions are not being implemented widely. Importantly, this gap exists not only between countries, but also within the same country; where some hospitals succeed, others cannot, or even do not, try. The Global Patient Safety Challenge embraces well-established WHO strategies already addressing risks for infection in areas such as blood, injection, and immunisation, safety of clinical procedures, safe water, basic sanitation, and waste management. These actions have a direct bearing on health-care-associated infection and patients' safety and are combined with efforts to implement new WHO guidelines on hand hygiene in health care in response to the message "Clean Care is Safer Care".5WHOGlobal patient safety challenge of the world alliance for patient safety.http://www.who.int/patientsafety/challenge/en/Google Scholar The challenges are enormous, but so are the rewards: preventing illness, saving lives, improving patients' safety, and providing an overall better quality of care for millions of patients and families. Implementation of the challenge in countries comprises three major strategies: campaigning to build global awareness of the importance of health-care-associated infection and to help catalyse leadership, commitment, and action; country pledges to ensure political commitment and leadership at the highest level; and testing implementation strategies worldwide (panel).PanelCountry-level activities to achieve Global Patient Safety Challenge, "Clean Care is Safer Care"A Challenge at country level is to: •catalyse and sustain strong and visible leadership and stewardship by government, health authorities, and professionals, and minimise complacency•promote hand hygiene along new guidelines, blood-safety strategies, injection-safety programmes, safety of clinical procedures, and efforts that ensure access to safe water and sanitation in health care•assist countries to identify and reduce national barriers to implementing these strategies and programmes•invest in development of monitoring tools and support establishment of independent systems to track progress and effect•help develop or strengthen mechanisms within countries to ensure availability of goods and commodities relating to cleaner and safer care, and access to them•identify elements of success and lessons learned from district test implementation, and disseminate them widely•work through partnerships with civil society and patient groups to maximise impact of effortsB The pledgeThe pledge is a clear statement by the minister of health of a country interested in addressing health-care-associated infection. This Statement will urge health organisations to: •acknowledge the importance of health-care-associated infection•share with WHO World Alliance for Patient Safety available information on this problem, including surveillance data if appropriate•consider the adoption of WHO strategies and guidelines to tackle health-care-associated infection•develop campaigns at national or subnational levels for improving hand hygiene among health-care providersC Pilot testingWHO is supporting pilot testing of preventive actions in several districts in developed, transitional, and developing countries to measure processes, structures, and outcomes before and after implementation, help monitor progress and assess acceptability, feasibility and impact of the integrated package of actions A Challenge at country level is to: •catalyse and sustain strong and visible leadership and stewardship by government, health authorities, and professionals, and minimise complacency•promote hand hygiene along new guidelines, blood-safety strategies, injection-safety programmes, safety of clinical procedures, and efforts that ensure access to safe water and sanitation in health care•assist countries to identify and reduce national barriers to implementing these strategies and programmes•invest in development of monitoring tools and support establishment of independent systems to track progress and effect•help develop or strengthen mechanisms within countries to ensure availability of goods and commodities relating to cleaner and safer care, and access to them•identify elements of success and lessons learned from district test implementation, and disseminate them widely•work through partnerships with civil society and patient groups to maximise impact of efforts B The pledge The pledge is a clear statement by the minister of health of a country interested in addressing health-care-associated infection. This Statement will urge health organisations to: •acknowledge the importance of health-care-associated infection•share with WHO World Alliance for Patient Safety available information on this problem, including surveillance data if appropriate•consider the adoption of WHO strategies and guidelines to tackle health-care-associated infection•develop campaigns at national or subnational levels for improving hand hygiene among health-care providers C Pilot testing WHO is supporting pilot testing of preventive actions in several districts in developed, transitional, and developing countries to measure processes, structures, and outcomes before and after implementation, help monitor progress and assess acceptability, feasibility and impact of the integrated package of actions To reduce infection associated with health care, multifaceted interventions are needed. To this end, "Clean Care is Safer Care" links to other action areas of the World Alliance to ensure that this problem forms an important part of the global agenda for patients' safety.3WHOWorld alliance for patient safety.http://www.who.int/patientsafety/worldalliance/en/Google Scholar It links in particular to "Patients for Patient Safety", thus offering opportunities for the greater involvement of patients and their families in reducing the risk of infection. Health-care-associated infections are unintended, undesirable, and intolerable. Many are preventable. Methods for change and improvement are available and it is now time for action. Success relies not only on system changes and improvement in economic constraints, but even more on human and organisational change; both developed and developing countries provide models to be followed to improve patients' safety. This is a unique chance to learn by sharing successes and failures. Adopting the philosophy behind the challenge "Clean Care is Safer Care" is not an option, but a duty to patients, families, and health-care workers. This challenge touches many aspects of health care at differing strata and requires commitment at all levels in the patient safety chain. One of the many lessons of the great cathedral builders of former times was that cathedral building requires the sharing of strength, the contribution of not just artisans and experts, but of everyone in the community. Great cathedrals were built on the foundations of earlier efforts. This is also a lesson to be learned by each partner in the health-care arena if we are to bring substantial improvement. We declare that we have no conflict of interest. We thank the group of international experts and WHO members who worked on the development of the Global Patient Safety Challenge, in particular for their participation in the two international WHO Consultations, review of the available scientific evidence, writing of the WHO draft Guidelines on Hand Hygiene in Health Care, and fostering discussion among authors and members of the different Task Forces and working groups. The complete list of participants in the development of the Guidelines documents is available at http://www.who.int/patientsafety/events/05/27_AprilParticipantList.pdf (accessed Sept 19, 2005). We also thank the Patient Safety team and other WHO staff from all the departments involved at Headquarters and in the Regional Offices for their work. DP also thanks the members of the Infection Control Programme at the University of Geneva Hospitals, and Rosemary Sudan for providing editorial assistance and outstanding support.