WHO Guidelines on Hand Hygiene in Health Care - Safe Care ...

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE
<strong>WHO</strong> Eastern Mediterranean Region (EMR)
For several reasons, more than one pilot site was selected
in EMR. Although all sites have committed to undertake all
activities included in the action plan for the implementation of
the <strong>WHO</strong> Hand Hygiene Improvement Strategy, they are at
different stages of implementation.
Kingdom of Saudi Arabia
Two different health-care settings agreed to participate in
the pilot testing in Riyadh, Saudi Arabia. In both sites, a hand
hygiene campaign was undertaken in 2005, following the
ministerial pledge to the First Global Patient Safety Challenge
and the launch of a national campaign. In connection with
the latter, all hospitals affiliated to the Ministry of Health were
provided with alcohol-based handrubs as the gold standard
for hand hygiene according to the <strong>WHO</strong> strategies. Since
2007, hand hygiene promotion has been further reinforced with
participation in the testing of the <strong>WHO</strong> strategy. In both cases,
the hospital bore the entire cost of implementation.
• King Abdulaziz Medical City (KAMC), Riyadh, is a
960-bed teaching hospital delivering high-quality primary,
secondary and tertiary health-care services for the Saudi
Arabia National Guard. The infection control committee
appointed the coordinator and his deputy and also
identified infection control practitioners and infection control
“champions” (focal points) to implement the activities.
The KAMC ICUs (seven units: adult, paediatric, neonatal,
burn, adult and paediatric cardiovascular, and medical
cardiac) and two surgical units were selected to be the pilot
wards based on the acuity of care provided, the high risk of
microorganism transmission, and the high number of hand
hygiene opportunities. Alcohol-based handrub was already
available at KAMC, but during the campaign preparation
phase a new product was selected among several
proposed according to <strong>WHO</strong> criteria, and the number of
fixed dispensers located at the point of care was increased.
The goal of the campaign was to reach at least 90% or
above compliance with hand hygiene practices.
Through the use of a specific form, evaluation of the quality
of the hand hygiene technique was added to the range of
other <strong>WHO</strong> surveys at baseline and follow-up. Each unit
had a champion in charge of carrying out the surveys,
coordinating staff training on hand hygiene, and liaising with
the campaign coordinator and his deputy. Champions had
also to be prepared to meet specific, challenging situations
in their interaction with HCWs and others, such as surprise,
apprehension of the unknown, scepticism, cynicism, and
strong resistance.
Feedback was given to HCWs, leaders, and key players
during the launch day when the promotion campaign was
inaugurated. Formal reports on local compliance data were
distributed to the respective area directors. The campaign
was launched on 13 April 2008 with an official ceremony
by the hospital director and other high-level authorities
and an advertisement on the KAMC web site. A leaflet
was prepared to inform the patients and invite them to
participate in the campaign by asking HCWs to perform
hand hygiene. An original aspect of implementation at
KAMC was the organization of mobile stands inside and
around the hospital, which moved to a different location
every two to three hours in order to reach all HCWs and
patients. These stands, managed by the infection control
practitioners, displayed <strong>WHO</strong> and non-<strong>WHO</strong> posters and
documents on hand hygiene. Stand visitors could watch the
<strong>WHO</strong> training film and were taught the correct technique
to perform hand hygiene antisepsis. Throughout a twomonth
period, 23 training sessions were organized with
the participation of 530 staff members from the pilot units.
Several promotional tools and posters were adapted from
the <strong>WHO</strong> versions or newly produced in English and Arabic
(Table I.21.5.1).
Overall, 1840 and 1822 hand hygiene opportunities were
detected at baseline and follow-up (after three months
since implementation), respectively. Overall compliance
increased from 45.1% to 59.4% with improvement
greatest among nurses (43.9 vs 62.8%). Compliance
rates with Moment 3 (after body fluid exposure risk) and
Moment 4 (after touching a patient) were high during both
observation periods (82.9% vs 85.0% and 67.7% vs 76.2%,
respectively). Compliance with Moment 2 (before clean/
aseptic procedure) achieved the greatest increase (45.8%
vs 84%); improvement was also detected with Moment 1
(before touching a patient) (29.4% vs 58.1%, respectively)
and Moment 5 (after touching patient surroundings) (13.2%
vs 30.0%, respectively).
• King Saud Medical Complex (KSMC), Riyadh, is a
1446-bed teaching hospital delivering primary, secondary,
and tertiary care, under the government of the Saudi Arabia
Ministry of Health. It consists of four hospitals: a general
hospital, maternity hospital, children’s hospital, and a dental
centre.
In September 2007, a hand hygiene committee was
created to plan and carry out the activities related to the
project. Together with four infection control professionals,
three infection control nurses were identified to play the
role of trainers for the education sessions and observers.
Sessions “train the trainers” were organized and led by the
coordinator and deputy coordinator.
The <strong>WHO</strong> strategy was implemented hospitalwide, but
the observation of hand hygiene practices was carried out
only in selected areas. Alcohol-based handrub dispensers
were already installed in all wards and departments, but
the decision was taken to introduce the <strong>WHO</strong> formulation.
A local company was appointed by the ministry of health
to produce different samples of alcohol-based handrub
according to the <strong>WHO</strong> Guide to Local Production. Four
types of solutions were produced: one corresponded
to the <strong>WHO</strong> formulation 1 (based on ethanol), while the
other three were the same formulation but with some
modifications such as a different fragrance or emollient.
All four formulations were made in the form of a solution,
and all four products were quality control-tested at the
University of Geneva Hospitals in Switzerland and found
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