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  • 1 Deanship of Quality and Academic Accreditation, Imam Abdulrahman Bin Faisal University (Formerly University of Dammam), Kingdom of Saudi Arabia
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Background and aims

Few studies have reported the correlation between hand hygiene (HH) practices and infection rates in Saudi Arabia. This work was aimed to study the effect of a multicomponent HH intervention strategy in improving HH compliance and reducing infection rates at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia between January 2014 and December 2016.

Methods

A yearlong multicomponent HH intervention, which included various strategies recommended by the World Health Organization, was introduced. HH compliance among staff and infection rates observed in the inpatient wards were assessed and compared at pre- and post-interventional phases.

Results

There was a significant increase in mean HH compliance from 50.17% to 71.75% after the intervention (P < 0.05). Hospital-acquired infection (HAI) and catheter-associated urinary tract infection (CAUTI) rates decreased from 3.37 to 2.59 and from 3.73 to 1.75, respectively (P < 0.05). HH compliance was found to be negatively correlated with HAI (r = −0.278) and CAUTI (r = −0.523) rates.

Conclusions

Results show that multicomponent intervention is effective in improving HH compliance, and that an increase in HH compliance among hospital staff decreases infection rates. Further studies on cost-effectiveness of such a model could augment to these findings.

Abstract

Background and aims

Few studies have reported the correlation between hand hygiene (HH) practices and infection rates in Saudi Arabia. This work was aimed to study the effect of a multicomponent HH intervention strategy in improving HH compliance and reducing infection rates at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia between January 2014 and December 2016.

Methods

A yearlong multicomponent HH intervention, which included various strategies recommended by the World Health Organization, was introduced. HH compliance among staff and infection rates observed in the inpatient wards were assessed and compared at pre- and post-interventional phases.

Results

There was a significant increase in mean HH compliance from 50.17% to 71.75% after the intervention (P < 0.05). Hospital-acquired infection (HAI) and catheter-associated urinary tract infection (CAUTI) rates decreased from 3.37 to 2.59 and from 3.73 to 1.75, respectively (P < 0.05). HH compliance was found to be negatively correlated with HAI (r = −0.278) and CAUTI (r = −0.523) rates.

Conclusions

Results show that multicomponent intervention is effective in improving HH compliance, and that an increase in HH compliance among hospital staff decreases infection rates. Further studies on cost-effectiveness of such a model could augment to these findings.

Introduction

Globally, hospital-acquired infections (HAIs) pose a significant burden to healthcare workers and patients with respect to health, time, resources, and cost. The prevalence of HAIs widely varies from 5.7% to 19.1%, and the data pertaining to it are often reported unconventionally due to lack of unified strategies [1]. Although reports on the nationwide prevalence of HAIs in Saudi Arabia are not readily available, a few studies have reported the prevalence of HAIs in different provinces of the Kingdom. For example, studies conducted in Taif Hospitals reported that the infection type in 48.3% of hospitalized patients with identified infections was diagnosed to be of nosocomial origin [2, 3].

Up to 23% of healthcare-associated infections occurring in intensive care units and about 40% of infections occurring in all units of a hospital are device-associated [4]. Catheter-associated urinary tract infections (CAUTIs) are regarded as some of the most common nosocomial infections. About 2%–4% of hospitalized patients with CAUTIs are reported to have been affected with bacteremia, and their fatality rate is three times higher than that of patients with no bacteriuria [5, 6]. A recent study on the incidence of CAUTI in three Gulf Cooperation Council (GCC) countries, such as Bahrain, Oman, and Saudi Arabia, reported that the risk of urinary tract infection was 35% higher in the hospitals of these GCC nations than in those of the United States National Healthcare Safety Network [7].

Of the various causes of HAI that have been identified, unclean hands are often considered to be unrecognized sources of transmission [8, 9]. Hand hygiene (HH) and infections are inversely related. Strict adherence to HH is a vital step in preventing healthcare-related infections. Unfortunately, this basic step is often ignored by workers in healthcare settings. Various methods have been tried and tested by clinicians and researchers across regions to improve HH compliance among healthcare workers. The “Clean Care is Safer Care” initiative by the World Health Organization (WHO) is reported to have had a positive impact on HH compliance. Many studies augmenting this WHO approach with numerous multifaceted improvement techniques have been implemented. Such studies have reported remarkable decreases in the infection rates of HAI and CAUTI with even slight increases in HH compliance [10–14].

Despite there being a growing concern worldwide on the increase in HAI and CAUTI rates, very few studies on this issue have been reported from the Middle East [15]. The correlation between HH practices and infection rates has rarely explored in the Saudi Arabian context. This work was conducted with the aim of studying the effect of a multicomponent HH intervention in improving HH compliance and reducing healthcare-associated infection rates at a university hospital in Saudi Arabia.

Methods

This prospective interventional study was conducted at King Fahd Hospital of the University (affiliated to Imam Abdulrahman Bin Faisal University), Al-Khobar, Saudi Arabia, between January 2014 and December 2016. First, the HH compliance rate was assessed among the staff with direct patient access in the inpatient wards of the hospital by directly observing the number of HH opportunities and the number of positive actions taken against those who did not follow HH conventions. The observations were recorded in a discrete manner to avoid the Hawthorne/observer effect. A period of five moments, as suggested by the WHO, for a healthcare staff to practice HH while making patient contact were considered [16, 17]. Based on this recommendation, any incident that required HH was considered an opportunity, and the corresponding response to that opportunity was considered an action.

HAI and CAUTI rates in the inpatient wards were then observed. While the HAI rate was calculated per 1,000-patient days, the CAUTI rate was calculated per 1,000-catheter days. A yearlong multicomponent intervention was introduced for improving HH practices. HH compliance among hospital staff and rates of HAI and CAUTI observed in the inpatient wards were again assessed after the intervention and were compared with pre-interventional values.

The Ethical Committee of Imam Abdulrahman Bin Faisal University (formerly University of Dammam) reviewed the study procedures and gave its approval for the conduct of this research.

The author of this manuscript has certified that he comply with the principles of ethical publishing in Interventional Medicine & Applied Science: Szél Á, Merkely B, Hüttl K, Gál J, Nemes B, Komócsi A: Statement on ethical publishing and scientific authorship. IMAS 2, 101–102 (2010).

Multimodal intervention

The multicomponent intervention to improve HH compliance used in this study was carried out for a period of 12 months, and it mainly comprised WHO’s multimodal HH intervention strategy [18, 19]. The interventional steps that fall under the five-point WHO strategy [20] include the following:

  1. 1.Increasing the availability and ease of access to alcohol-based hand rub and water supply;
  2. 2.Holding educational events on HH and infection control;
  3. 3.Offering training and support with monthly evaluation and feedback analysis;
  4. 4.Presenting visual displays to promote HH practices; and
  5. 5.Ensuring a climate of institutional safety.

In addition, the following interventional steps were carried out:

  • – Holding timely meetings with the hospital management and staff to involve them in achieving effective HH practices;
  • – Assessing the infrastructural and consumable requirements at the hospital;
  • – Providing intensive education sessions on “five moments for hand hygiene” based on WHO methods;
  • – Using PowerPoint presentations, video screening, and training handouts in English and Arabic;
  • – Placing posters above washbasins in the wards and theaters;
  • – Installing screensavers on computers to display HH moments;
  • – Providing adequate personal protection equipment to healthcare workers and teaching them how to use such equipment properly;
  • – Adhering strictly to visitors’ policy and educating visitors to keep hands clean and not contact vulnerable patients.

Statistical analysis

SPSS version 20.0 was used for data analysis. A value of P ≤ 0.05 was considered statistically significant. Percentages and 95% confidence intervals (95% CIs) were used to present HH adherence, whereas frequency and 95% CI were used to present infection rates. A correlation analysis was conducted to confirm the presence of any relationship between HH compliance and nosocomial infections.

Results

There was a significant increase in mean HH compliance from 50.17% (95% CI: 44.84, 54.67) to 71.75% (95% CI: 70.59, 72.83) after the multicomponent intervention (P < 0.05) (Table I).

Table I

Hand hygiene compliance rates over years

95% confidence interval
Hand hygiene compliance ratesStatisticBiasStandard errorLowerUpper
2014N12001212
Mean50.1667−0.08042.482944.835554.6667
Standard deviation9.00337−0.482011.622345.1901211.43343
2015N12001212
Mean66.0833−0.07922.036161.583369.8333
Standard deviation7.42794−0.400761.195134.579359.17602
2016N12001212
Mean71.75000.00240.605570.583372.8333
Standard deviation2.17945−0.109720.253191.497472.50303
OverallN12001212
Mean62.6667−0.05241.507859.166765.3319
Standard deviation5.44949−0.288580.981592.968956.65778
Valid N (listwise)N12001212

HAI rates observed in the inpatient wards showed a decreasing trend from 3.37 (95% CI: 3.05, 3.69) pre-intervention to 2.59 (95% CI: 2.23, 2.90) post-intervention. Furthermore, CAUTI rates reduced from 3.73 (95% CI: 2.47, 5.04) to 1.75 (95% CI: 0.90, 2.74) (Tables II and III). The reduction in the rates of both of these nosocomial infections was statistically significant (P < 0.05).

Table II

Healthcare-acquired infection rates over years

95% confidence interval
Hospital-acquired infection ratesStatisticBiasStandard errorLowerUpper
2014N12001212
Mean3.3700−0.00240.16743.04763.6925
Standard deviation0.59809−0.036200.105930.346130.75865
2015N12001212
Mean2.42080.00350.14982.12922.7166
Standard deviation0.52460−0.033510.097330.303420.67577
2016N12001212
Mean2.5483−.00470.17502.22922.9000
Standard deviation0.63221−0.041120.128020.311490.80114
OverallN12001212
Mean2.7797−0.00120.08902.61292.9586
Standard deviation0.31647−0.020170.046490.198460.38261
Valid N (listwise)N12001212
Table III

Catheter-associated urinary tract infection rates over years

95% confidence interval
Catheter-associated urinary tract infection ratesStatisticBiasStandard errorLowerUpper
2014N12001212
Mean3.7267−0.00150.63562.46935.0444
Standard deviation2.40777−0.128360.366231.531122.92702
2015N12001212
Mean2.2083−0.00300.81130.67563.9667
Standard deviation2.92806−0.218230.729691.222493.98839
2016N12001212
Mean1.75080.00950.46240.90212.7407
Standard deviation1.70099−0.091490.252891.140122.05290
OverallN12001212
Mean2.56190.00170.38351.79963.2944
Standard deviation1.44927−0.078750.228450.900361.78200
Valid N (listwise)N12001212

The correlation analysis showed that there is a weak-negative correlation between HH compliance and the HAI rate. However, a moderate negative correlation was found between HH compliance and CAUTI rate was negatively correlated with HAI (r = −0.278) and CAUTI rates (r = −0.523) (Table IV).

Table IV

Correlation analysis between hand hygiene and infections

CorrelationHHHAICAUTI
HHPearson correlation1−0.278−0.523
Sig. (two-tailed)0.3810.081
N121212
HAIPearson correlation−0.2781−0.143
Sig. (two-tailed)0.3810.656
N121212
CAUTIPearson correlation−0.523−0.1431
Sig. (two-tailed)0.0810.656
N121212

CAUTI: catheter-associated urinary tract infection; HAI: hospital-acquired infection; HH: hand hygiene

Discussion

This work studied the impact of a multicomponent HH intervention in reducing infection rates in a university hospital in Saudi Arabia. The results showed that the yearlong intervention improved the HH practices among the hospital staff. Furthermore, such an increase was observed to be correlated with the decrease in infection rates in the inpatient wards.

Most studies on HH within the Kingdom have focused mainly on the knowledge, attitude and behavior of hospital staff, and healthcare students toward such practices; however, only a few studies have analyzed the rate of adherence to the number of HH opportunities [21–23]. A 12-month observational study conducted in a general hospital in Makkah, Saudi Arabia, reported that the rate of compliance to HH was 50.3%, which was like the pre-interventional compliance rate (50.17% ± 9.00%) observed in this work [24]. Appropriate education and training are imperative in enhancing staff knowledge on HH [25].

Many studies across the world have highlighted the need for a multifaceted approach to improve HH practices; the types and number of approaches that are documented in the literature vary widely from hospital to hospital and country to country, mostly depending on the availability of resources, knowledge of hospital staff, as well as the cost involved in implementing each model [16]. Despite the availability of modern interventions in improving HH compliance, certain standard strategies as used in this study remain effective even in a low-resource setting. Active and passive educational programs, motivational campaigns, displays of posters, distribution of pamphlets, increased numbers of alcohol hand rub solution stations, and implementation of WHO’s five-moments scheme form important elements of the list of proven approaches [26–29]. In this study, the author has chosen these standard tactics, along with the use of accountability and performance feedback and regular audits.

Adherence to HH in this study gradually increased from 50.17% ± 9.00% in 2014 to 66.08% ± 7.43% in 2015 and 71.75% ± 2.18% in 2016, indicating the success of the multicomponent approach implemented in this study in enhancing the HH practices. A similar trend in the gradual increase of compliance (37.5%–51.7%) was reported in studies by Sastry et al. [30] after implementing an HH audit as an intervention strategy, and by Chhapola and Brar [31] after implementing an educational program (46%–69%). Some studies reported the effectiveness of multifaceted approaches on HH improvement based on the WHO strategy; one regional example on this could include a study by Mahfouz et al. [16], which reported that a multimodal program involving the WHO approach showed an increase in HH practices from 60.8% in 2011 to 86.4% in 2013 in an intensive care unit in Abha, Saudi Arabia. Al-Tawfiq et al. [32] reported that a multimodal HH program improved the adherence from 38% to 85% over a period of 5 years, which highlights the sustainable benefits of such multifaceted initiatives. However, Mazi et al. [33] documented that even though a multicomponent strategy involving WHO approach could enhance the HH compliance rate, the results were not sustainable in certain critical care areas that lacked team leaders.

Improvement in HH compliance had been reported to indirectly minimize nosocomial infections, thereby ensuring patient safety. In this study, the rates of HAI decreased from 3.37 ± 0.60 to 2.55 ± 0.63 after the multicomponent intervention. A similar decrease in HAI rate was reported by a Taiwanese study wherein the implementation of the WHO multimodal strategy resulted in the reduction of HAI rates from 3.7 to 3.1 [34]. The results of a three-year study with step-by-step interventions showed significant hospital-wide improvement in HH compliance and infection control (4.8–3.3) [35].

The rates of CAUTI in this study showed a gradual decline from 3.73 ± 2.41 in 2014 to 2.21 ± 2.93 in 2015 and 1.75 ± 1.70 in 2016. HH practices form a vital strategy in preventing CAUTI rates [11]. An Egyptian study investigated the use of a combined interventional strategy with HH as a key component, and the results showed that the pre-interventional rate of 90.12 reduced to 65.69 after the intervention [36]. In another study, a multimodal supervision program, involving HH as one of the interventions, resulted in 47.1% reduction of CAUTI incidence [37]. Al-Tawfiq et al. [32] observed that there was a reduction of CAUTI rates from 7.08 to 3.5 after HH intervention in a community hospital in the Eastern Province of Saudi Arabia.

A landmark study published in 1988 reviewed the literature data available over more than 100 years and studied the casual link between handwashing and infection control [38]. There were strong evidences available on the correlation between the improvement in HH practices and reduction in HAI rates. The results obtained in this study add more value to the existing literature, especially with respect to the Saudi context. HH compliance was found to be negatively correlated with HAI and CAUTI rates, and the relationship observed between HH compliance and HAI rate was weak-negative, whereas between HH compliance and CAUTI rate was moderate-negative.

Limitations

Although the results of this study add value to the available literature on the link between HH practices and infection control, the study has certain inherent limitations. First, the infection rates of methicillin-resistant Staphylococcus aureus (MRSA) were not assessed before, during, or after the mentioned interventions. MRSA infection is a critical setback for a hospitalized patient, as it involves multiple factors, including HH. Further studies may focus on analyzing this infection. Second, unlike other studies from Saudi Arabia that have focused on the knowledge and attitude of hospital staffs and students, this study did not assess the individual adherence rates among different stakeholders. Further studies can also assess diurnal variation in compliance rate and suggest methods to prevent such variation.

Conclusion

Multicomponent intervention is effective in improving HH compliance and reducing nosocomial infection rates. The results suggest that active educational intervention with timed evaluation of practices help reduce infection rates significantly. Although many novel methods are being introduced in enhancing HH compliance among healthcare staff, improvement strategies as suggested by WHO seem to be simple and practically easy to implement. Further studies on cost-effectiveness of such a model could augment the evidence obtained in this study.

Author’s contribution

AAK collected the data, designed and conducted the study and its analysis, wrote, and revised the manuscript.

Conflict of interest

The author declares no conflict of interest.

References

  • 1.

    Yallew WW , Kumie A , Yehuala FM : Point prevalence of hospital-acquired infections in two teaching hospitals of Amhara region in Ethiopia. Drug Healthc Patient Saf 8, 7176 (2016)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2.

    Abdel-Fattah MM : Surveillance of nosocomial infections at a Saudi Arabian military hospital for a one-year period. Ger Med Sci 3, Doc06 (2005)

    • Search Google Scholar
    • Export Citation
  • 3.

    Sabra SM , Abdel-Fattah MM : Epidemiological and microbiological profile of nosocomial infection in Taif Hospitals, KSA (2010–2011). World J Med Sci 7, 0109 (2012)

    • Search Google Scholar
    • Export Citation
  • 4.

    Gaid E , Assiri A , McNabb SJN , Banjar W (2016): Device-associated nosocomial infection in General Hospitals, Kingdom of Saudi Arabia, 2013–2016. Poster available at http://kingabdullahfellowship.com/wp-content/uploads/Eiman-Poster-Final-4-27-16.pdf. Accessed on Apr 20, 2017.

    • Export Citation
  • 5.

    Kazi MM , Harshe A , Sale H , Mane D , Yande M , Chabukswar S : Catheter associated urinary tract infections (CAUTI) and antibiotic sensitivity pattern from confirmed cases of CAUTI in a tertiary care hospital: A prospective study. Clin Microbiol 4, 193 (2015)

    • Search Google Scholar
    • Export Citation
  • 6.

    Stamm WE : Catheter-associated urinary tract infections: Epidemiology, pathogenesis, and prevention. Am J Med 91, S65S71 (1991)

  • 7.

    Al Nasser W , El-Saed A , Al-Jardani A , Althaqafi A , Alansari H , Alsalman J , Maskari ZA , El Gammal A , Al-Abri SS , Balkhy HH : Rates of catheter-associated urinary tract infection in tertiary care hospitals in 3 Arabian Gulf countries: A 6-year surveillance study. Am J Infect Control 44, 15891594 (2016)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8.

    Khan HA , Ahmad A , Mehboob R : Nosocomial infections and their control strategies. Asian Pac J Trop Biomed 5, 509514 (2015)

  • 9.

    Ayliffe G , Fraise A , Geddes A , Mitchell K (2000): Control of Hospital Infection: A Practical Handbook. Hodder Arnold Publication, London

    • Search Google Scholar
    • Export Citation
  • 10.

    Mathur P : Hand hygiene: Back to the basics of infection control. Indian J Med Res 134, 611620 (2011)

  • 11.

    Chenoweth C , Saint S : Preventing catheter-associated urinary tract infections in the intensive care unit. Crit Care Clin 29, 1932 (2013)

  • 12.

    Pfäfflin F , Tufa TB , Getachew M , Nigussie T , Schönfeld A , Häussinger D , Feldt T , Schmidt N : Implementation of the WHO multimodal hand hygiene improvement strategy in a university hospital in Central Ethiopia. Antimicrob Resist Infect Control 6, 3 (2017)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13.

    Farhoudi F , Dashti AS , Davani MH , Ghalebi N , Sajadi G , Taghizadeh R : Impact of WHO hand hygiene improvement program implementation: A quasi-experimental trial. Biomed Res Int 2016, 7026169 (2016)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14.

    Mestre G , Berbel C , Tortajada P , Alarcia M , Coca R , Gallemi G , Garcia I , Fernández MM , Aguilar MC , Martínez JA , Rodríguez-Baño J : “The 3/3 strategy”: A successful multifaceted hospital wide hand hygiene intervention based on WHO and continuous quality improvement methodology. PLoS One 7, e47200 (2012)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15.

    Iyer AP , Baghallab I , Albaik M , Kumosani T : Nosocomial infections in Saudi Arabia caused by methicillin resistance Staphylococcus aureus (MRSA). Clin Microbial 3, 146 (2014)

    • Search Google Scholar
    • Export Citation
  • 16.

    Mahfouz AA , Al-Zaydani IA , Abdelaziz AO , El-Gamal MN , Assiri AM : Changes in hand hygiene compliance after a multimodal intervention among health-care workers from intensive care units in Southwestern Saudi Arabia. J Epidemiol Glob Health 4, 315321 (2014)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17.

    Al-Azraqi T : Hand hygiene among doctors and nurses in a tertiary-care hospital in Abha, KSA. J Bahrain Med Soc 19, 5355 (2007)

  • 18.

    World Health Organization (2009): Hand Hygiene Technical Reference Manual. Geneva, Switzerland. Available at http://www.who.int/gpsc/5may/tools/evaluation_feedback/en/index.html. Accessed on Apr 20, 2017

    • Search Google Scholar
    • Export Citation
  • 19.

    Sax H , Allegranzi B , Chraïti MN , Boyce J , Larson E , Pittet D : The World Health Organization hand hygiene observation method. Am J Infect Control 37, 827834 (2009)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 20.

    World Health Organization (2009): WHO Guidelines on Hand Hygiene in Health Care. Geneva, Switzerland. Available at http://apps.who.int/iris/bitstream/10665/44102/1/9789241597906_eng.pdf. Accessed on Apr 20, 2017

    • Search Google Scholar
    • Export Citation
  • 21.

    Hamadah R , Kharraz R , Alshanqity A , AlFawaz D , Eshaq AM , Abu-Zaid A : Hand hygiene: Knowledge and attitudes of fourth-year clerkship medical students at Alfaisal University, College of Medicine, Riyadh, Saudi Arabia. Cureus 7, e310 (2015)

    • Search Google Scholar
    • Export Citation
  • 22.

    Al Kadi A , Salati SA : Hand hygiene practices among medical students. Interdiscip Perspect Infect Dis 2012, 679129 (2012)

  • 23.

    Alamer N , Zabeeri N , Aburuz M , Qarneh H : Physicians knowledge about hand hygiene at King Fahad Hospital of University, Dammam, KSA. Int J Med Sci Pub Health 4, 12421246 (2015)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 24.

    Bukhari SZ , Hussain WM , Banjar A , Almaimani WH , Karima TM , Fatani MI : Hand hygiene compliance rate among healthcare professionals. Saudi Med J 32, 515519 (2011)

    • Search Google Scholar
    • Export Citation
  • 25.

    Basurrah MM , Madani TA : Handwashing and gloving practice among health care workers in medical and surgical wards in a tertiary care centre in Riyadh, Saudi Arabia. Scand J Infect Dis 38, 620624 (2006)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26.

    Cheng VC , Tai JW , Ho SK , Chan JF , Hung KN , Ho PL , Yuen KY : Introduction of an electronic monitoring system for monitoring compliance with Moments 1 and 4 of the WHO “My 5 Moments for Hand Hygiene” methodology. BMC Infect Dis 11, 151 (2011)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 27.

    Doron SI , Kifuji K , Hynes BT , Dunlop D , Lemon T , Hansjosten K , Cheung T , Curley B , Snydman DR , Fairchild DG : A multifaceted approach to education, observation, and feedback in a successful hand hygiene campaign. Jt Comm J Qual Patient Saf 37, 310 (2011)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 28.

    Monistrol O , Calbo E , Riera M , Nicolás C , Font R , Freixas N , Garau J : Impact of a hand hygiene educational programme on hospital-acquired infections in medical wards. Clin Microbiol Infect 18, 12121218 (2012)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 29.

    Wu KS , Chen YS , Lin HS , Hsieh EL , Chen JK , Tsai HC , Chen YH , Lin CY , Hung CT , Sy CL , Tseng YT , Lee SS : A nationwide covert observation study using a novel method for hand hygiene compliance in health care. Am J Infect Control 45, 240244 (2017)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 30.

    Sastry AS , Deepashree R , Bhat P : Impact of a hand hygiene audit on hand hygiene compliance in a tertiary care public sector teaching hospital in South India. Am J Infect Control 45, 498501 (2017)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 31.

    Chhapola V , Brar R : Impact of an educational intervention on hand hygiene compliance and infection rate in a developing country neonatal intensive care unit. Int J Nurs Pract 21, 486492 (2015)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 32.

    Al-Tawfiq JA , Abed MS , Al-Yami N , Birrer RB : Promoting and sustaining a hospital-wide, multifaceted hand hygiene program resulted in significant reduction in health care-associated infections. Am J Infect Control 41, 482486 (2013)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 33.

    Mazi W , Senok AC , Al-Kahldy S , Abdullah D : Implementation of the World Health Organization hand hygiene improvement strategy in critical care units. Antimicrob Resist Infect Control 2, 15 (2013)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 34.

    Chen JK , Wu KS , Lee SS , Lin HS , Tsai HC , Li CH , Chao HL , Chou HC , Chen YJ , Huang YH , Ke CM , Sy CL , Tseng YT , Chen YS : Impact of implementation of the World Health Organization multimodal hand hygiene improvement strategy in a teaching hospital in Taiwan. Am J Infect Control 44, 222227 (2016)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 35.

    Kirkland KB , Homa KA , Lasky RA , Ptak JA , Taylor EA , Splaine ME : Impact of a hospital-wide hand hygiene initiative on healthcare-associated infections: Results of an interrupted time series. BMJ Qual Saf 21, 10191026 (2012)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 36.

    Amine AE , Helal MO , Bakr WM : Evaluation of an intervention program to prevent hospital-acquired catheter-associated urinary tract infections in an ICU in a rural Egypt hospital. GMS Hyg Infect Control 9, Doc15 (2014)

    • Search Google Scholar
    • Export Citation
  • 37.

    Jaggi N , Sissodia P : Multimodal supervision programme to reduce catheter associated urinary tract infections and its analysis to enable focus on labour and cost effective infection control measures in a tertiary care hospital in India. J Clin Diagn Res 6, 13721376 (2012)

    • Search Google Scholar
    • Export Citation
  • 38.

    Larson E : A causal link between handwashing and risk of infection? Examination of the evidence. Infect Control Hosp Epidemiol 9, 2836 (1988)

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  • 1.

    Yallew WW , Kumie A , Yehuala FM : Point prevalence of hospital-acquired infections in two teaching hospitals of Amhara region in Ethiopia. Drug Healthc Patient Saf 8, 7176 (2016)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2.

    Abdel-Fattah MM : Surveillance of nosocomial infections at a Saudi Arabian military hospital for a one-year period. Ger Med Sci 3, Doc06 (2005)

    • Search Google Scholar
    • Export Citation
  • 3.

    Sabra SM , Abdel-Fattah MM : Epidemiological and microbiological profile of nosocomial infection in Taif Hospitals, KSA (2010–2011). World J Med Sci 7, 0109 (2012)

    • Search Google Scholar
    • Export Citation
  • 4.

    Gaid E , Assiri A , McNabb SJN , Banjar W (2016): Device-associated nosocomial infection in General Hospitals, Kingdom of Saudi Arabia, 2013–2016. Poster available at http://kingabdullahfellowship.com/wp-content/uploads/Eiman-Poster-Final-4-27-16.pdf. Accessed on Apr 20, 2017.

    • Export Citation
  • 5.

    Kazi MM , Harshe A , Sale H , Mane D , Yande M , Chabukswar S : Catheter associated urinary tract infections (CAUTI) and antibiotic sensitivity pattern from confirmed cases of CAUTI in a tertiary care hospital: A prospective study. Clin Microbiol 4, 193 (2015)

    • Search Google Scholar
    • Export Citation
  • 6.

    Stamm WE : Catheter-associated urinary tract infections: Epidemiology, pathogenesis, and prevention. Am J Med 91, S65S71 (1991)

  • 7.

    Al Nasser W , El-Saed A , Al-Jardani A , Althaqafi A , Alansari H , Alsalman J , Maskari ZA , El Gammal A , Al-Abri SS , Balkhy HH : Rates of catheter-associated urinary tract infection in tertiary care hospitals in 3 Arabian Gulf countries: A 6-year surveillance study. Am J Infect Control 44, 15891594 (2016)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8.

    Khan HA , Ahmad A , Mehboob R : Nosocomial infections and their control strategies. Asian Pac J Trop Biomed 5, 509514 (2015)

  • 9.

    Ayliffe G , Fraise A , Geddes A , Mitchell K (2000): Control of Hospital Infection: A Practical Handbook. Hodder Arnold Publication, London

    • Search Google Scholar
    • Export Citation
  • 10.

    Mathur P : Hand hygiene: Back to the basics of infection control. Indian J Med Res 134, 611620 (2011)

  • 11.

    Chenoweth C , Saint S : Preventing catheter-associated urinary tract infections in the intensive care unit. Crit Care Clin 29, 1932 (2013)

  • 12.

    Pfäfflin F , Tufa TB , Getachew M , Nigussie T , Schönfeld A , Häussinger D , Feldt T , Schmidt N : Implementation of the WHO multimodal hand hygiene improvement strategy in a university hospital in Central Ethiopia. Antimicrob Resist Infect Control 6, 3 (2017)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13.

    Farhoudi F , Dashti AS , Davani MH , Ghalebi N , Sajadi G , Taghizadeh R : Impact of WHO hand hygiene improvement program implementation: A quasi-experimental trial. Biomed Res Int 2016, 7026169 (2016)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14.

    Mestre G , Berbel C , Tortajada P , Alarcia M , Coca R , Gallemi G , Garcia I , Fernández MM , Aguilar MC , Martínez JA , Rodríguez-Baño J : “The 3/3 strategy”: A successful multifaceted hospital wide hand hygiene intervention based on WHO and continuous quality improvement methodology. PLoS One 7, e47200 (2012)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15.

    Iyer AP , Baghallab I , Albaik M , Kumosani T : Nosocomial infections in Saudi Arabia caused by methicillin resistance Staphylococcus aureus (MRSA). Clin Microbial 3, 146 (2014)

    • Search Google Scholar
    • Export Citation
  • 16.

    Mahfouz AA , Al-Zaydani IA , Abdelaziz AO , El-Gamal MN , Assiri AM : Changes in hand hygiene compliance after a multimodal intervention among health-care workers from intensive care units in Southwestern Saudi Arabia. J Epidemiol Glob Health 4, 315321 (2014)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17.

    Al-Azraqi T : Hand hygiene among doctors and nurses in a tertiary-care hospital in Abha, KSA. J Bahrain Med Soc 19, 5355 (2007)

  • 18.

    World Health Organization (2009): Hand Hygiene Technical Reference Manual. Geneva, Switzerland. Available at http://www.who.int/gpsc/5may/tools/evaluation_feedback/en/index.html. Accessed on Apr 20, 2017

    • Search Google Scholar
    • Export Citation
  • 19.

    Sax H , Allegranzi B , Chraïti MN , Boyce J , Larson E , Pittet D : The World Health Organization hand hygiene observation method. Am J Infect Control 37, 827834 (2009)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 20.

    World Health Organization (2009): WHO Guidelines on Hand Hygiene in Health Care. Geneva, Switzerland. Available at http://apps.who.int/iris/bitstream/10665/44102/1/9789241597906_eng.pdf. Accessed on Apr 20, 2017

    • Search Google Scholar
    • Export Citation
  • 21.

    Hamadah R , Kharraz R , Alshanqity A , AlFawaz D , Eshaq AM , Abu-Zaid A : Hand hygiene: Knowledge and attitudes of fourth-year clerkship medical students at Alfaisal University, College of Medicine, Riyadh, Saudi Arabia. Cureus 7, e310 (2015)

    • Search Google Scholar
    • Export Citation
  • 22.

    Al Kadi A , Salati SA : Hand hygiene practices among medical students. Interdiscip Perspect Infect Dis 2012, 679129 (2012)

  • 23.

    Alamer N , Zabeeri N , Aburuz M , Qarneh H : Physicians knowledge about hand hygiene at King Fahad Hospital of University, Dammam, KSA. Int J Med Sci Pub Health 4, 12421246 (2015)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 24.

    Bukhari SZ , Hussain WM , Banjar A , Almaimani WH , Karima TM , Fatani MI : Hand hygiene compliance rate among healthcare professionals. Saudi Med J 32, 515519 (2011)

    • Search Google Scholar
    • Export Citation
  • 25.

    Basurrah MM , Madani TA : Handwashing and gloving practice among health care workers in medical and surgical wards in a tertiary care centre in Riyadh, Saudi Arabia. Scand J Infect Dis 38, 620624 (2006)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26.

    Cheng VC , Tai JW , Ho SK , Chan JF , Hung KN , Ho PL , Yuen KY : Introduction of an electronic monitoring system for monitoring compliance with Moments 1 and 4 of the WHO “My 5 Moments for Hand Hygiene” methodology. BMC Infect Dis 11, 151 (2011)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 27.

    Doron SI , Kifuji K , Hynes BT , Dunlop D , Lemon T , Hansjosten K , Cheung T , Curley B , Snydman DR , Fairchild DG : A multifaceted approach to education, observation, and feedback in a successful hand hygiene campaign. Jt Comm J Qual Patient Saf 37, 310 (2011)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 28.

    Monistrol O , Calbo E , Riera M , Nicolás C , Font R , Freixas N , Garau J : Impact of a hand hygiene educational programme on hospital-acquired infections in medical wards. Clin Microbiol Infect 18, 12121218 (2012)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 29.

    Wu KS , Chen YS , Lin HS , Hsieh EL , Chen JK , Tsai HC , Chen YH , Lin CY , Hung CT , Sy CL , Tseng YT , Lee SS : A nationwide covert observation study using a novel method for hand hygiene compliance in health care. Am J Infect Control 45, 240244 (2017)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 30.

    Sastry AS , Deepashree R , Bhat P : Impact of a hand hygiene audit on hand hygiene compliance in a tertiary care public sector teaching hospital in South India. Am J Infect Control 45, 498501 (2017)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 31.

    Chhapola V , Brar R : Impact of an educational intervention on hand hygiene compliance and infection rate in a developing country neonatal intensive care unit. Int J Nurs Pract 21, 486492 (2015)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 32.

    Al-Tawfiq JA , Abed MS , Al-Yami N , Birrer RB : Promoting and sustaining a hospital-wide, multifaceted hand hygiene program resulted in significant reduction in health care-associated infections. Am J Infect Control 41, 482486 (2013)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 33.

    Mazi W , Senok AC , Al-Kahldy S , Abdullah D : Implementation of the World Health Organization hand hygiene improvement strategy in critical care units. Antimicrob Resist Infect Control 2, 15 (2013)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 34.

    Chen JK , Wu KS , Lee SS , Lin HS , Tsai HC , Li CH , Chao HL , Chou HC , Chen YJ , Huang YH , Ke CM , Sy CL , Tseng YT , Chen YS : Impact of implementation of the World Health Organization multimodal hand hygiene improvement strategy in a teaching hospital in Taiwan. Am J Infect Control 44, 222227 (2016)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 35.

    Kirkland KB , Homa KA , Lasky RA , Ptak JA , Taylor EA , Splaine ME : Impact of a hospital-wide hand hygiene initiative on healthcare-associated infections: Results of an interrupted time series. BMJ Qual Saf 21, 10191026 (2012)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 36.

    Amine AE , Helal MO , Bakr WM : Evaluation of an intervention program to prevent hospital-acquired catheter-associated urinary tract infections in an ICU in a rural Egypt hospital. GMS Hyg Infect Control 9, Doc15 (2014)

    • Search Google Scholar
    • Export Citation
  • 37.

    Jaggi N , Sissodia P : Multimodal supervision programme to reduce catheter associated urinary tract infections and its analysis to enable focus on labour and cost effective infection control measures in a tertiary care hospital in India. J Clin Diagn Res 6, 13721376 (2012)

    • Search Google Scholar
    • Export Citation
  • 38.

    Larson E : A causal link between handwashing and risk of infection? Examination of the evidence. Infect Control Hosp Epidemiol 9, 2836 (1988)