Global implementation of WHO's multimodal strategy for improvement of hand hygiene: a quasi-experimental study Benedetta Allegranzi, MD, Angèle Gayet-Ageron,

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Global implementation of WHO's multimodal strategy for improvement of hand hygiene: a quasi-experimental study Benedetta Allegranzi, MD, Angèle Gayet-Ageron, MD, Nizam Damani, MD, Loséni Bengaly, PhD, Prof Mary-Louise McLaws, PhD, Maria-Luisa Moro, MD, Ziad Memish, MD, Orlando Urroz, MD, Prof Hervé Richet, MD, Julie Storr, MBA, Liam Donaldson, MD, Prof Didier Pittet, MD The Lancet Infectious Diseases Volume 13, Issue 10, Pages 843-851 (October 2013) DOI: 10.1016/S1473-3099(13)70163-4 Copyright © 2013 World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved. Terms and Conditions

Figure 1 Overall hand-hygiene compliance in pilot sites worldwide before and after implementation of WHO's improvement strategy by category of health professional (A) and hand-hygiene indication (B) Error bars show 95% CIs around the mean compliance. Observation periods before and after implementation lasted 3–4 months each. Moment 1 was before patient contact, 2 was before an aseptic task, 3 was after risk of exposure to body fluid, 4 was after patient contact, and 5 was after contact with patient surroundings. MD=medical doctor. NS=nursing student. MS=medical student. The Lancet Infectious Diseases 2013 13, 843-851DOI: (10.1016/S1473-3099(13)70163-4) Copyright © 2013 World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved. Terms and Conditions

Figure 2 System change after implementation of WHO's hand-hygiene strategy For each site, left bars show the proportion of health-care workers undertaking the hand-hygiene technique before strategy implementation, and right bars show the proportion after implementation. System change signifies access by health-care workers to alcohol-based hand rub at the point of patient care to enable their recourse to hand rubbing as the preferred method for hand hygiene. p<0·0001 for all sites, except Saudi Arabia KSMC (p=0·44). KAMC=King Abulaziz Medical City. KSMC=King Saud Medical Complex. The Lancet Infectious Diseases 2013 13, 843-851DOI: (10.1016/S1473-3099(13)70163-4) Copyright © 2013 World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved. Terms and Conditions

Figure 3 Knowledge of hand hygiene before and after training sessions Data before and after training sessions were available for only a subgroup (26 [43%] of 41) intensive-care units in Italy. KAMC=King Abulaziz Medical City. KSMC=King Saud Medical Complex. The Lancet Infectious Diseases 2013 13, 843-851DOI: (10.1016/S1473-3099(13)70163-4) Copyright © 2013 World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved. Terms and Conditions