Are we over-complicating effective hand hygiene technique?

The WHO method for hand hygiene is very well embedded as the ‘gold standard’ for hand hygiene technique. But is it feasible to perform every time in the busy clinical environment? A new study in Clinical Infectious Diseases seems to suggest that a shorter, simpler hand hygiene method be just as effective and more feasible in the real world.

The WHO method for hand hygiene has six steps, is very thorough, and sure makes a good dance…

But if you’ve ever spent any time on a ward, the WHO hand hygiene method is nowhere in sight (ok, it’s not quite that bad, but you take the point – the reality is that healthcare workers create their own truncated hand hygiene method). This group of researchers in Switzerland and Austria have previously published a simpler three-step hand hygiene method for applying alcohol gel, which was shown to be as effective as the six-step method in terms of bacterial reduction in an experimental setting (Figure 1). So enter this study – a clever randomised trial evaluating the performance of the three-step method in a clinical setting.

Figure 1: WHO six-step hand hygiene method vs. the proposed three-step method

12 wards were randomised to the six-step or three-step method for two months. Observation of almost 3k hand hygiene observations found that compliance with both technique and indication was significantly higher on the wards using the three-step method (Figure 2). Healthcare workers in participating wards were approached randomly to have their hands sampled before and after hand hygiene. There was no significant difference in the reduction factor of bacterial contamination on staff hands comparing wards using the six-step with the three-step method.

Figure 2: Compliance with hand hygiene technique and indication on wards using the six- or three-step hand hygiene method

Perhaps the most striking finding of this study is that the 12% compliance with technique using the six-step method can be improved to a more satisfactory (although far-from-perfect) 51%, seemingly without reducing the efficacy of the process. So, it may be time for us to step down from a six-step to a three-step method for hand hygiene!

2 thoughts on “Are we over-complicating effective hand hygiene technique?

  1. In the US, there is a struggle between what CDC (and others) recommend and what OSHA requires via the Bloodborne Pathogens Standard (29 CFR 1910.1030).

    1910.1030(d)(2)(v): Employers shall ensure that employees wash their hands immediately or as soon as feasible after removal of gloves or other personal protective equipment.
    1910.1030(d)(2)(vi): Employers shall ensure that employees wash hands and any other skin with soap and water.. as soon as feasible following contact of such body areas with blood or other potentially infectious materials.

    Also important to remember that TIMING of donning and doffing gloves can matter even more than how many steps are involved with hand gel. Are our prematurely gloved hands transmitting pathogens from surface to patient to self? Are our post-maturely non-doffed gloved hands causing harm to ourselves (our colleagues and our families) as providers?

    We can see from decades of our EPINet data in the US (occupational exposure incident surveillance) that even when there is a recordable blood/body fluid exposure incident (mucus membrane and/or non-intact skin) that only 28.1% (2017) of the time are health workers actually wearing any gloves at all. (this by the way is down notably from previous years:

    The discussion about “hand hygiene” has to be about more than how many steps it takes to use a hand gel. It has to be comprehensive… when and where to use soap and running water (as required by OSHA) and when and how to don and doff gloves. We must not forget that hand hygiene (the crappy gel only kind) is but one step in the process and that hand hygiene includes the use of PPE (gloves) that are in place to protect provider from patient, as well as patient from provider (and surfaces).

    We have to do better – global public health is depending on it.


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