The preparation process of the WHO Guidelines on Hand Hygiene in Health Care involved the steps that are briefly described in this section.
2.1. Preparation of the Advanced Draft
The present guidelines were developed by the “Clean Care is Safer Care” team (Patient Safety Department, Information, Evidence and Research Cluster).
A Core Group of international experts in the field of infection control, with specific expertise in hand hygiene, participated in the writing and revision of the document. The group was constituted at WHO Headquarters in Geneva in December 2004. During its first meeting, the experts discussed the approach to be emphasized in these guidelines and their content and drew up a plan for their preparation. The objectives identified were to develop a document including a comprehensive overview of essential aspects of hand hygiene in health care and evidence- and consensus-based recommendations for optimal hand hygiene practices and successful hand hygiene promotion. Users were meant to be policy-makers, managers and HCWs in different settings and geographical areas. It was decided to adopt the CDC Guideline for Hand Hygiene in Health-Care Settings issued in 2002 as a basis for the present document but to introduce many new topics. A distinctive feature of the present Guidelines is the fact that they were conceived with a global perspective; therefore, they are not targeted at only developing or developed countries, but at all countries regardless of the resources available (see also Part VI).
Various task forces were established () to examine different controversial topics in depth and reach consensus on the best approach to be included in the document for both implementation and research purposes. According to their expertise, authors were assigned various chapters, the content of which had to be based on the scientific literature and their experience. A systematic review of the literature was performed through PubMed (United States National Library of Medicine), Ovid, MEDLINE, EMBASE, and the Cochrane Library, and secondary papers were identified from reference lists and existing relevant guidelines. International and national infection control guidelines and textbooks were also consulted. Authors provided the list of keywords that they used for use in the next update of the Guidelines.
Task forces for discussion and expert consensus on critical issues related to hand hygiene in health care.
In April 2005 and March 2006, the Core Group reconvened at WHO Headquarters in Geneva for task force meetings, final revision, and consensus on the first draft. Recommendations were formulated on the basis of the evidence described in the various sections; their terminology and consistency were discussed in depth during the expert consultations. In addition to expert consensus, the criteria developed by the Healthcare Infection Control Practices Advisory Committee (HICPAC) of the United States Centers for Disease Control and Prevention (CDC), Atlanta, GA, were used to categorise the consensus recommendations in the WHO Guidelines for Hand Hygiene in Health Care (). In the case of difficulty in reaching consensus, the voting system was adopted. The final draft was submitted to a list of external and internal reviewers whose comments were considered during the March 2006 Core Group consultation. The Advanced Draft of the WHO Guidelines on Hand Hygiene in Health Care was published in April 2006.
Modified CDC/HICPAC ranking system for evidence.
2.2. Pilot testing the Advanced Draft
According to WHO recommendations for guideline preparation, a testing phase of the guidelines was undertaken. In parallel with the Advanced Draft, an implementation strategy (WHO Multimodal Hand Hygiene Improvement Strategy) was developed, together with a wide a range of tools (Pilot Implementation Pack) to help health-care settings to translate the guidelines into practice (see also Part I, Sections 21.1–4). The aims of this testing were: to provide local data on the resources required to carry out the recommendations; to generate information on feasibility, validity, reliability, and cost–effectiveness of the interventions; and to adapt and refine proposed implementation strategies. Eight pilot sites from seven countries representing the six WHO regions were selected for pilot testing and received technical and, in some cases, financial support from the First Global Patient Safety Challenge team (see also Part I, Section 21.5). Other health-care settings around the world volunteered to participate autonomously in the testing phase, and these were named “complementary test sites”. Analysis of data and evaluation of the lessons learnt from pilot and complementary sites were undertaken and are reported in Part I, Section 21.5.
2.3. Finalization of the WHO Guidelines on Hand Hygiene in Health Care
In August 2007, the expert Core Group reconvened in Geneva to start the process of guideline finalization. Authors were asked to update their text according to relevant new publications up to October 2007 and to return the work by December 2007; some authors were asked to write new chapters by the same deadline. The First Global Patient Safety Challenge team and the Guidelines’ editor contributed with the content of several chapters and took the responsibility to revise the updated and new material, to perform technical editing, and to add any further relevant reference published between October 2007 and June 2008. Six new chapters, 11 additional paragraphs, and three new appendices were added in the present final version compared with the Advanced Draft. External and internal reviewers were asked again to comment on the new parts of the guidelines.
In September 2008, the last Core Group consultation took place in Geneva. The final draft of the Guidelines was circulated ahead of the meeting, including relevant comments from the reviewers. A specific session of the meeting was dedicated to the evaluation of data and lessons learnt from the testing sites and how to integrate these aspects into the text. Final discussion took place about the content of the final version of the document with a particular focus on the recommendations and the research agenda, and reviewers’ comments and queries; approval was obtained by consensus. Following the consultation, the final amendments and insertions were made and, at the latest stage, the document was submitted to a WHO reference editor.
