Clean care for all—it’s in your hands: The May 5, 2019, World Health Organization’s “SAVE LIVES: Clean Your Hands” campaign

Alexandra Peters MA1, Tcheun Borzykowski MS1, Ermira Tartari MS1, Claire Kilpatrick MSc2, Safiah Hwai Chuen Mai PhD2, Benedetta Allegranzi MD2 and Didier Pittet MD, MS, CBE1 1Infection Control Program and WHO Collaborating Center on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland and 2Infection Prevention and Control Global Unit, Department of Service Delivery and Safety, World Health Organization, Geneva, Switzerland

Quality healthcare should be available to everyone. The World Health Organization's (WHO's) concept of universal health coverage (UHC) 1 embodies the urgent need for access to healthcare for all people around the world. In addition to access, the concept of UHC incorporates the critical element of the necessary quality of delivered healthcare services. Infection prevention and control (IPC), with hand hygiene as the most effective measure, is a practical and evidence-based approach with a demonstrable impact on quality of care and patient safety across all levels of the health system.
Each year, the WHO "SAVE LIVES: Clean Your Hands" campaign aims to bring people together in support of hand hygiene improvement globally on or around May 5 th . 2 This year's theme for global annual hand hygiene day reflects a strong focus on providing clean care, equally protecting all patients and healthcare workers from infection and antimicrobial resistance transmission, across all countries, including in low-resource settings.
The WHO urges ministries of health, healthcare facility leaders, IPC leaders, healthcare workers, and patient advocacy groups to contribute to effective IPC action including hand hygiene as a cornerstone of quality in healthcare ( Table 1). The WHO invites all healthcare facilities to join the 2019 WHO Global Survey on IPC and Hand Hygiene using 2 validated assessment tools: one for evaluating the core components of IPC program and the other for a deep dive into hand hygiene activities (https://www.who.int/ infection-prevention/campaigns/ipc-global-survey-2019/en/).
On a facility level, the use of these tools gives institutions a clear understanding of the strengths and weaknesses of their IPC and hand hygiene program and recommends concrete actions to address existing gaps. These tools allow institutions to improve their IPC practices and policies in concrete and measurable ways, at their own speed and in their own context. The surveys are anonymous, and global results will be made available using only aggregated data. Thus, facilities and ministries of health can commit fully to working on improving IPC and patient safety without fear of scrutiny or possible negative repercussions.  Globally, this survey will allow the WHO to provide a situational analysis of progress of current IPC and hand hygiene activities around the world and inform future efforts and resource use for IPC capacity building and improvement. Global surveys using the hand hygiene self-assessment framework were also conducted in 2011 and 2015, [3][4][5] making this year's survey even more crucial for tracking the implementation of hand hygiene and IPC on a global scale (Fig. 1).
Each improvement in IPC contributes toward quality UHC. "Clean care for all-it's in your hands!" To the Editor-We read "Implementation Strategies to Reduce Surgical Site Infections: A Systematic Review" 1 by Ariyo et al with great interest. Identifying ways to improve implementation and uptake of infection prevention interventions is critical as the field moves toward translating and implementing evidence-based findings into day-to-day clinical practice.

Real-world challenges in infection prevention: Differential implementation between stable and unstable patients may influence clinical effectiveness of interventions
A key finding of the systematic review by Ariyo et al was that few high-quality trials have examined different implementation strategies in infection prevention. Adding to the limitations of the current literature identified in the outstanding review, some of our recent work across multiple procedural and surgical specialties highlights the challenges in bringing infection prevention practices to the bedside and operating room. In particular, we found that implementation of prevention practices is unevenly applied across the spectrum of care. This variation in effective implementation may lead to significant bias and confounding that impacts the apparent benefits of different infection prevention interventions.
A consistent finding across multiple specialties and clinical care areas has been that more stable patients receive more systematic, protocolized care. Processes of care are standardized and systematically applied to the stable, elective patient population. However, that is not true for more urgent or emergent cases, which tend to be identified for surgical procedures in inpatient settings. This inherently sicker and higher-risk population may be less predictable and more difficult to track and control, with environmental barriers to implementation that do not exist for the outpatient population.
We have identified these findings across different types of invasive procedures and using different methodologies. For example, during qualitative interviews with frontline electrophysiologists, we learned that,