The WHO “my five moments for hand hygiene” represents a standardized approach for training, implementation, monitoring and reporting of hand hygiene compliance. The five moments identified in this strategy are: Moment 1: Before patient contact; Moment 2: Before an aseptic task; Moment 3: After body fluid exposure risk; Moment 4: After patient contact and Moment 5: After contact with patient surroundings [5
]. Although optimal compliance with hand hygiene remains a cornerstone of preventing HAIs, studies in developed and developing countries continue to demonstrate sub-optimal compliance. A myriad of factors are associated with poor compliance with significant variations in monitoring and reporting according to the setting and resources available. Identification of factors and specific timings missed opportunities during patient care is critical so that these can be addressed for future compliance strategies. In contrast to previous reports from Saudi Arabia, this is the first study documenting the utilization of the WHO hand hygiene observation method in the country [8
]. With this approach, the key moments of missed opportunity during patient care our critical care units were identified as Moments 1, 2 and 5. The WHO hand hygiene observation method provides objective identification of the missed opportunities for hand hygiene which can be targeted in future educational campaigns.
To improve adherence to hand hygiene practices, several interventions such as performance feedback on hand hygiene compliance, display of hand hygiene posters and introduction of alcohol-based hand rubs have been described.[11
]. A similar multimodal approach has been incorporated in this study, and an extended follow-up of the intervention strategy was conducted [11
]. In addition, we have evaluated the long term impact of educational campaign in the implementation of this hand hygiene strategy. Similar to other studies, the findings indicate a poor baseline hand hygiene compliance with significant improvement observed in the immediate post intervention period [13
]. However, extended follow up shows that this high level of improved compliance was not sustained as shown by decline in Phases III and IV. It is however notable that at the end of the study period, overall improvement in hand hygiene compliance was observed. The observed inability to achieve sustained hand hygiene compliance suggests that changing behavior is complex. Intervention campaigns such as that carried out in this study play a role in temporary behavior modification; however, for sustained hand hygiene compliance other factors are indicated. Various researchers have applied the theory of planned behavior to investigate hand hygiene compliance [15
]. One of the important postulates of this theory is that intention to perform hand hygiene is influenced by beliefs about the expectations of others which are perceived as important [15
]. The effect of this form of social pressure in behavior modification is not uniformly reflected in our findings. As the reporting of results of hand hygiene observation to healthcare workers is an essential element of multi-modal strategies to improve hand hygiene practices, regular feedback and open discussions were carried out. However, this did not have a universal effect of improving compliance rates in all hospital units and across all categories of staff. This approach was found to be effective in the NICU and ICU where the trend of increased compliance was attributed to teamwork and having a team leader. A team approach with the guidance of a team leader has been suggested as a modality for behavior change in sustaining hand hygiene compliance [17
]. Further study to identify effective parameters and explore the role of team leaders for sustained behavior modification in our setting is being undertaken.
High levels of compliance were found among nursing staff. This is similar to other reports in the literature [19
]. However, similar to other reports physician compliance remained very low and the absence of a physician leader was identified as a barrier to improving compliance among doctors in all units. [19
]. Although institutional backing and individual education are critical for the success of the hand hygiene implementation program, our findings show that these strategies are by themselves insufficient for sustaining compliance. A recent study has shown that repeated hand hygiene campaigns over a one year period only marginally increased compliance [9
]. The involvement of physicians and nursing staff managers in hand hygiene activities, dissemination of feedback and evaluations has been suggested as critical [17
]. Indeed, the presence of team leaders contributed to increased compliance in among the nursing staff in general. However, lack of physician team leader was detrimental to compliance rates among physicians.