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Bradley Leading Yale Group Working with WHO and Chinese Government to Assess Hand and Dental Hygiene Practices in Study of Infection Control in Chinese Hospitals

Hand and dental hygiene are critical components of hospital infection control, and therefore of patient safety. The 2003 SARS outbreak highlighted the importance of infection control practices in China and brought infection control to the forefront of international attention. As a result, the World Health Organization (WHO) has joined with the Ministry of Health in China (the Ministry of Health), the Society of Infection Control Management, and hospitals from the People's Liberation Army system to conduct a new baseline survey initiative in infection control. The team includes a group of Yale researchers and Chinese national experts in infection control. The study is part of the Ministry of Health's long-term effort to further advance infection control "best practices" in Chinese hospitals.

The leader of the Yale group, Elizabeth Bradley, Ph.D., Associate Professor of Public Health and Director of the Health Management Program (HMP), notes that use of best practices in hand hygiene is a challenge throughout the world, including in the U.S., and that the work in China emphasizes a quality improvement approach focused on creating systems that promote better hand and dental hygiene practices in hospitals. That means, Bradley explains, looking at the knowledge and practice of all persons involved, from central Ministry of Health officials and hospital administrators to clinicians, as well as examining a variety of other factors, including selected aspects of the regulatory structure by which hospitals are governed, current hand and dental hygiene standards, the features of hospital organizational culture, and the financial, material, and human resources available to hospitals. "We have to be clear that problems in infection control practices, like medical errors, are a property of the system, not a property of individual practitioners. The goal is to develop systems that support individuals to do the right thing in daily practice - always a challenge when resources are scarce," says Bradley.

The Yale group recently participated in a five-day workshop in Beijing with the WHO, the Ministry of Health, the People's Liberation Army, and infection control directors from several hospitals in China. The team discussed and agreed on a common approach to gathering baseline data on infection control practices in China, and discussed the importance of hospital management and policy in supporting improved practices. "Of course, it is always easier to talk about improvement plans than to implement them," says Bradley, "but there is tremendous expertise in China in infection control, as well as eagerness to elevate practices in the hospital setting. These are key ingredients to success, so we are optimistic that the work will have impact."

Also at the workshop, infection control expert and member of the Yale group, Louise-Marie Dembry, M.D., who is an Associate Professor of Medicine and Epidemiology and Director of Hospital Epidemiology/Quality Improvement Support Services at Yale-New Haven Hospital (YNHH) captivated the Chinese officials' attention by describing hand hygiene improvement efforts in the U.S., with focus on YNHH's experience. "It's real world," says Dembry, "and there are no easy solutions; we all struggle, and the critical piece is having commitment to do a better job-- that commitment has to come from the top." Officials in attendance discussed the challenges they face in improving hand hygiene practice. A challenge cited by nearly all, Dembry says, was inadequate resources.

The team's role in the baseline study of current hand and dental hygiene practices being conducted by the Society of Infection Control Management, the Ministry of Health and the People's Liberation Army has multiple components. All of the hospitals involved are urban hospitals diverse in size and in the socioeconomic status of their clientele. A survey is being sent to randomly selected hospitals to collect data about current hand and dental hygiene practices and the resources devoted to the issue. Observers from the team will conduct on-site visits at approximately 12 hospitals in Shanghai, Beijing and Guangzhou in order to observe actual hand hygiene practices, such as what materials are used to disinfect hands, when hand hygiene occurs, and the amount of time spent on hand disinfection.

In addition, members of the team will interview key hospital personnel, such as directors of infection control and hospital administrators, to elicit what they view as key challenges and effective strategies in the effort to improve hand hygiene practice. "Many efforts have already been made, and there have been important successes in China. Our goal is to describe those, understand the effective approaches, and hopefully support their replication elsewhere in China," says Bradley. Hong Wang, M.D., Ph.D., Assistant Professor of Public Health, Yuan Fu, an M.P.H. candidate in HMP and an experienced dental hygienist, and Beth Higa, also an MPH candidate in HMP and experienced hospital consultant, are currently working in China and New Haven on the project.

Another focus of the team is a detailed comparison of the existing official policies and guidelines for hand and dental hygiene in China and in the U.S. (where such guidelines come from the Centers for Disease Control and Prevention), in order to identify meaningful differences between the policies and guidelines and, where relevant, suggest further options for infection control guidelines in China.

Examination of Chinese infection control guidelines for hand and dental hygiene requires looking not only at the standards imposed by the guidelines themselves--such as whether they require the use of antimicrobial soap and what means of hand-drying are prescribed-- but also at the means of disseminating and enforcing them. Bradley notes that China's current approach to accreditation for healthcare facilities and sometimes fragmented health regulatory system for infection control may leave room for further development. Thus, Bradley says, strengthening the regulatory apparatus may provide new opportunities for widespread improvement in hand hygiene practice.

Ultimately, the group will use its work to prepare a development plan for joint-review by WHO and the Ministry of Health. The plan can provide Chinese hospitals attempting to improve their infection control procedures and to implement best practices in hand and dental hygiene with new views of the way forward in disease control. The report will recommend areas in which infection control guidelines might be enhanced, and will also, based on field experience, make recommendations for management, surveillance, and reward strategies in hospitals. In this way, the Yale group hopes to support China's effort to further improve hand and dental hygiene practices in hospital clinical settings. The team will present its findings regarding the current status of hand and dental hygiene practice and present its development plan at a workshop to be held in China in late 2004 or early 2005.

Bradley stresses that while opportunities for improvement exist, many positive changes to Chinese infection control procedures have already been made in the wake of SARS. Among other things, hospital infection control directors with whom the team spoke indicated that they have allocated more resources to hand and dental hygiene and have conducted more staff in-services to train healthcare workers.

- Story by Christy Gordon, based on interviews with Elizabeth Bradley, Ph.D., on June 14, 2004, and Louise-Marie Dembry, M.D., on June 29, 2004.