Pilot testing in the WHO Eastern Mediterranean Region (EMR)
Saudi Arabia - King Abdulaziz Medical City
King Abdulaziz Medical City (KAMC) in Riyadh is a 960-bed teaching hospital delivering high-quality primary, secondary and tertiary health-care services to the Saudi Arabia National Guard. Seven intensive care units (adult, paediatric, neonatal, burn, adult and paediatric cardiovascular, and medical cardiac) and two surgical units were selected as the pilot test wards.
A strong infection control unit was established at KAMC before the pilot test phase. Alcohol-based handrub was already available hospital-wide, but during the campaign preparation phase a new product was selected among several proposed according to WHO 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.
The campaign was launched on 13 April 2008 with an official ceremony chaired by the hospital director and other high-level authorities and advertised on the KAMC web site. Patient participation was a strong component of hand hygiene promotion and an information leaflet invited patients to participate in the campaign by asking health-care workers to perform hand hygiene. A novel aspect of implementation was the presence of stands displaying WHO and non-WHO posters and documents on hand hygiene that moved to a different location every two to three hours in order to reach all health-care workers and patients. Several promotional tools and posters were adapted from the WHO versions or newly produced in English and Arabic. A tool to assess the “how to” perform hand hygiene was developed.
A significant increase (19%) of overall compliance was achieved at follow-up (three months after implementation) with improvement in all pilot wards. A 21% compliance increase was achieved among nurses, whereas only slight improvement was observed among doctors. Knowledge about hand hygiene did not significantly improve.
Key success factors
The hand hygiene campaign was embedded within a strong institutional safety culture and driven by a consolidated infection control team. Very powerful support by the directorate was a key factor to build up the campaign on a solid basis and guarantee its sustainability. A patient-centered approach and a smart communication plan also contributed to the success.
Success factors, but also the acknowledgement of some gaps in improvement (e.g. among doctors), strongly motivated the infection control team, the directorate, and other staff involved in hand hygiene promotion to strengthen the campaign and extend it hospital-wide after the pilot phase. This new phase focused on promotion at ward level and involvement of individual health-care workers. One “champion” committed to hand hygiene promotion was selected in each ward and trained to become a role player and deliver on-site education. Champions were also asked to intervene specifically in situations of scepticism, strong resistance, or apprehension among health-care workers.
Monthly hand hygiene compliance monitoring was conducted in 2009 with feedback to all levels of staff by regular reports and the availability of compliance results by ward/department on the hospital intranet. A poster competition with the creative input of all wards was launched on 5 May 2009. Videos with staff and patient involvement were locally produced in some wards. Notably, an interesting adaptation of the "My five moments for hand hygiene" concept was implemented in the sterilization unit. This very energetic strategy led to the enthusiastic participation of health-care workers, overcoming of some barriers, and continuous improvement of practices, even in previously resistant professional categories such as doctors. In 2009, the average hand hygiene compliance reached levels very close to the goal of 90% hospital-wide and in most clinical areas. In 2010, KAMC was awarded the first SHEA-APIC Partnership in Prevention Award for its exceptional performance and achievements in the field of infection control, including hand hygiene promotion.