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

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

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

About the SCIMAGO INSTITUTIONS RANKINGS

RESUMEN

Objetivo:

Reflejar y proponer adaptaciones en la Estrategia Multimodal de higienización de manos para hospitales de campaña, para la COVID-19.

Método:

Estudio reflexivo, realizado en abril de 2020 basado en las recomendaciones de la Organización Mundial de la Salud y guía para implementación de los cinco componentes de la Estrategia Multimodal: cambio del sistema relacionado a la infraestructura; formación/educación; evaluación y retroalimentación; notas en el trabajo; y clima de seguridad institucional.

Resultados:

La Estrategia Multimodal, propuesta para hospitales en general, podría adaptarse a hospitales de campaña objetivando reducir la transmisión del virus SARS-CoV-2. Inversiones para adecuar la infraestructura y educación de trabajadores exigen previsión y celeridad y son de especial relevancia para promover la higienización de manos en contexto asistencial.

Consideraciones finales:

Ajustar la Estrategia Multimodal, en especial para el tiempo reducido en la ejecución de cada componente, es necesario para hospitales de campaña con objetivo de prevención de COVID-19.

Descriptores:
Hospitales; Virus del SARS; Asistencia a la Salud; Higiene de las Manos; Seguridad del Paciente

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⁽²2 World Health Organization (WHO). A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy [Internet]. Geneva: WHO; 2009 [cited 2020 Apr 29]. Available from: https://apps.who.int/iris/bitstream/handle/10665/70030/WHO_IER_PSP_2009.02_eng.pdf
https://apps.who.int/iris/bitstream/hand... ⁾. The patient safety team is composed of the leadership and professionals, being responsible for prevention and infection control actions⁽⁷7 Agência Nacional de Vigilância Sanitária (BR) . Nota técnica nº 08/2020. Orientações gerais para implantação das práticas de segurança do paciente em hospitais de campanha e nas demais estruturas provisórias para atendimento aos pacientes durante a pandemia de COVID-19 [Internet]. 2020 [cited 2020 Jun 6]. Available from: http://portal.anvisa.gov.br/documents/33852/271858/Nota+t%C3%A9cnica+n+08-2020+GVIMS-GGTES-Anvisa-+Hospitais+de+Campanha/b3b1ee50-c92f-490e-a200-f89194ef5947
http://portal.anvisa.gov.br/documents/33... ⁾. 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⁽²2 World Health Organization (WHO). A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy [Internet]. Geneva: WHO; 2009 [cited 2020 Apr 29]. Available from: https://apps.who.int/iris/bitstream/handle/10665/70030/WHO_IER_PSP_2009.02_eng.pdf
https://apps.who.int/iris/bitstream/hand... ^,⁸8 Agência Nacional de Vigilância Sanitária (BR). Nota técnica nº 69/2020. Dispõe sobre as orientações gerais sobre Hospital de Campanha durante a pandemia internacional ocasionada pelo coronavírus SARS-CoV-2 [Internet]. 2020 [cited 2020 Apr 26]. Available from: http://portal.anvisa.gov.br/documents/219201/4340788/NT+GGTES.pdf/b29aca21-15b1-4c51-91dd-dc12870c4e44
http://portal.anvisa.gov.br/documents/21... ⁾. 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⁽²2 World Health Organization (WHO). A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy [Internet]. Geneva: WHO; 2009 [cited 2020 Apr 29]. Available from: https://apps.who.int/iris/bitstream/handle/10665/70030/WHO_IER_PSP_2009.02_eng.pdf
https://apps.who.int/iris/bitstream/hand... ⁾, 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⁽²2 World Health Organization (WHO). A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy [Internet]. Geneva: WHO; 2009 [cited 2020 Apr 29]. Available from: https://apps.who.int/iris/bitstream/handle/10665/70030/WHO_IER_PSP_2009.02_eng.pdf
https://apps.who.int/iris/bitstream/hand... ⁾. 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⁽¹⁰10 Secretaria da Saúde do Estado do Paraná. Nota orientativa nº 24/2020. Orientações para adequação da estrutura física em caráter temporário, na assistência de pacientes suspeitos ou confirmados para covid-19, em decorrência da emergência em saúde pública [Internet]. 2020 [cited 2020 Apr 30]. Available from: http://www.saude.pr.gov.br/arquivos/File/NO_24_ORIENTACOES_PARA_ADEQUACAO.pdf
http://www.saude.pr.gov.br/arquivos/File... ⁾. 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⁽²2 World Health Organization (WHO). A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy [Internet]. Geneva: WHO; 2009 [cited 2020 Apr 29]. Available from: https://apps.who.int/iris/bitstream/handle/10665/70030/WHO_IER_PSP_2009.02_eng.pdf https://apps.who.int/iris/bitstream/hand... ^-³3 Organização Mundial de Saúde. Higiene das Mãos na Assistência à Saúde Extra-hospitalar e Domiciliar e nas Instituições de Longa Permanência [Internet]. Brasília: Organização Pan-Americana da Saúde/ Agência Nacional de Vigilância Sanitária, 2014 [cited 2020 Jun 6]. Available from: https://edisciplinas.usp.br/pluginfile.php/361263/mod_resource/content/1/Manual_Higiene_Saude.pdf https://edisciplinas.usp.br/pluginfile.p... ⁾. 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⁽²2 World Health Organization (WHO). A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy [Internet]. Geneva: WHO; 2009 [cited 2020 Apr 29]. Available from: https://apps.who.int/iris/bitstream/handle/10665/70030/WHO_IER_PSP_2009.02_eng.pdf https://apps.who.int/iris/bitstream/hand... ⁾, 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⁽²2 World Health Organization (WHO). A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy [Internet]. Geneva: WHO; 2009 [cited 2020 Apr 29]. Available from: https://apps.who.int/iris/bitstream/handle/10665/70030/WHO_IER_PSP_2009.02_eng.pdf https://apps.who.int/iris/bitstream/hand... ^-³3 Organização Mundial de Saúde. Higiene das Mãos na Assistência à Saúde Extra-hospitalar e Domiciliar e nas Instituições de Longa Permanência [Internet]. Brasília: Organização Pan-Americana da Saúde/ Agência Nacional de Vigilância Sanitária, 2014 [cited 2020 Jun 6]. Available from: https://edisciplinas.usp.br/pluginfile.php/361263/mod_resource/content/1/Manual_Higiene_Saude.pdf https://edisciplinas.usp.br/pluginfile.p... ^,⁸8 Agência Nacional de Vigilância Sanitária (BR). Nota técnica nº 69/2020. Dispõe sobre as orientações gerais sobre Hospital de Campanha durante a pandemia internacional ocasionada pelo coronavírus SARS-CoV-2 [Internet]. 2020 [cited 2020 Apr 26]. Available from: http://portal.anvisa.gov.br/documents/219201/4340788/NT+GGTES.pdf/b29aca21-15b1-4c51-91dd-dc12870c4e44 http://portal.anvisa.gov.br/documents/21... ⁾. 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⁽²2 World Health Organization (WHO). A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy [Internet]. Geneva: WHO; 2009 [cited 2020 Apr 29]. Available from: https://apps.who.int/iris/bitstream/handle/10665/70030/WHO_IER_PSP_2009.02_eng.pdf https://apps.who.int/iris/bitstream/hand... ⁾, 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⁽³3 Organização Mundial de Saúde. Higiene das Mãos na Assistência à Saúde Extra-hospitalar e Domiciliar e nas Instituições de Longa Permanência [Internet]. Brasília: Organização Pan-Americana da Saúde/ Agência Nacional de Vigilância Sanitária, 2014 [cited 2020 Jun 6]. Available from: https://edisciplinas.usp.br/pluginfile.php/361263/mod_resource/content/1/Manual_Higiene_Saude.pdf https://edisciplinas.usp.br/pluginfile.p... ⁾ 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⁽²2 World Health Organization (WHO). A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy [Internet]. Geneva: WHO; 2009 [cited 2020 Apr 29]. Available from: https://apps.who.int/iris/bitstream/handle/10665/70030/WHO_IER_PSP_2009.02_eng.pdf https://apps.who.int/iris/bitstream/hand... ⁾.
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⁽²2 World Health Organization (WHO). A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy [Internet]. Geneva: WHO; 2009 [cited 2020 Apr 29]. Available from: https://apps.who.int/iris/bitstream/handle/10665/70030/WHO_IER_PSP_2009.02_eng.pdf https://apps.who.int/iris/bitstream/hand... ^-³3 Organização Mundial de Saúde. Higiene das Mãos na Assistência à Saúde Extra-hospitalar e Domiciliar e nas Instituições de Longa Permanência [Internet]. Brasília: Organização Pan-Americana da Saúde/ Agência Nacional de Vigilância Sanitária, 2014 [cited 2020 Jun 6]. Available from: https://edisciplinas.usp.br/pluginfile.php/361263/mod_resource/content/1/Manual_Higiene_Saude.pdf https://edisciplinas.usp.br/pluginfile.p... ⁾. 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⁽²2 World Health Organization (WHO). A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy [Internet]. Geneva: WHO; 2009 [cited 2020 Apr 29]. Available from: https://apps.who.int/iris/bitstream/handle/10665/70030/WHO_IER_PSP_2009.02_eng.pdf https://apps.who.int/iris/bitstream/hand... 3 Organização Mundial de Saúde. Higiene das Mãos na Assistência à Saúde Extra-hospitalar e Domiciliar e nas Instituições de Longa Permanência [Internet]. Brasília: Organização Pan-Americana da Saúde/ Agência Nacional de Vigilância Sanitária, 2014 [cited 2020 Jun 6]. Available from: https://edisciplinas.usp.br/pluginfile.php/361263/mod_resource/content/1/Manual_Higiene_Saude.pdf https://edisciplinas.usp.br/pluginfile.p... ^-⁴4 Valim MD, Rocha ILS, Souza TPM, Cruz YA, Bezerra TB, Baggio E, et al. Efficacy of the multimodal strategy for Hand Hygiene compliance: an integrative review. Rev Bras Enferm. 2019; 72(2):552-65. doi: 10.1590/0034-7167-2018-0584 https://doi.org/10.1590/0034-7167-2018-0... ⁾, 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⁽³3 Organização Mundial de Saúde. Higiene das Mãos na Assistência à Saúde Extra-hospitalar e Domiciliar e nas Instituições de Longa Permanência [Internet]. Brasília: Organização Pan-Americana da Saúde/ Agência Nacional de Vigilância Sanitária, 2014 [cited 2020 Jun 6]. Available from: https://edisciplinas.usp.br/pluginfile.php/361263/mod_resource/content/1/Manual_Higiene_Saude.pdf https://edisciplinas.usp.br/pluginfile.p... ⁾, 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⁽²2 World Health Organization (WHO). A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy [Internet]. Geneva: WHO; 2009 [cited 2020 Apr 29]. Available from: https://apps.who.int/iris/bitstream/handle/10665/70030/WHO_IER_PSP_2009.02_eng.pdf
https://apps.who.int/iris/bitstream/hand... ^-³3 Organização Mundial de Saúde. Higiene das Mãos na Assistência à Saúde Extra-hospitalar e Domiciliar e nas Instituições de Longa Permanência [Internet]. Brasília: Organização Pan-Americana da Saúde/ Agência Nacional de Vigilância Sanitária, 2014 [cited 2020 Jun 6]. Available from: https://edisciplinas.usp.br/pluginfile.php/361263/mod_resource/content/1/Manual_Higiene_Saude.pdf
https://edisciplinas.usp.br/pluginfile.p... ⁾, 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⁽⁴4 Valim MD, Rocha ILS, Souza TPM, Cruz YA, Bezerra TB, Baggio E, et al. Efficacy of the multimodal strategy for Hand Hygiene compliance: an integrative review. Rev Bras Enferm. 2019; 72(2):552-65. doi: 10.1590/0034-7167-2018-0584
https://doi.org/10.1590/0034-7167-2018-0... ⁾.
• Evaluate and monitor infectious adverse events, especially the occurrence of cases and outbreaks of COVID-19⁽⁷7 Agência Nacional de Vigilância Sanitária (BR) . Nota técnica nº 08/2020. Orientações gerais para implantação das práticas de segurança do paciente em hospitais de campanha e nas demais estruturas provisórias para atendimento aos pacientes durante a pandemia de COVID-19 [Internet]. 2020 [cited 2020 Jun 6]. Available from: http://portal.anvisa.gov.br/documents/33852/271858/Nota+t%C3%A9cnica+n+08-2020+GVIMS-GGTES-Anvisa-+Hospitais+de+Campanha/b3b1ee50-c92f-490e-a200-f89194ef5947
http://portal.anvisa.gov.br/documents/33... ⁾ among health professionals and in-hospital transmission to patients.

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[1] Corresponding author: Josemar Batista. E-mail: josemar.batista@hotmail.com