The healthcare zone includes all surfaces outside of the patient zone. If the healthcare zone becomes contaminated with pathogens (i.e., MDROs), it increases the risk and opportunity for transmission (WHO, 2009a). Cross-contamination to a medical device (e.g., central line, ventilator) could lead to an HAI or death. If the five moments of hand hygiene are observed, adverse outcomes such as cross-colonization of the patient and HCW and cross-contamination of the environment are significantly reduced. To view the WHO’s 5 moments of hand hygiene poster see: https://cdn.who.int/media/docs/default-source/integrated- health-services-(ihs)/infection-prevention-and-control/your-5- moments-for-hand-hygiene-poster.pdf?sfvrsn=83e2fb0e_16 Moment one is before patient contact. This moment reduces transmission from the last surface contact made and reduces cross-colonization of the patient. This usually happens when moving from the healthcare zone to the patient zone. An example is touching the door handle and then shaking the patient’s hand. Moment two is before an aseptic task. This moment reduces transmission after hand or patient contact (to clothes or other objects) and before performing a task (e.g., opening venous access, giving an injection, wound care). Colonization from a transient pathogen carried from the last surface touched is prevented when hand hygiene is performed. If gloves are used, hand hygiene should be performed prior to donning gloves. This moment is critical to patient safety, as HCWs often touch a surface within the patient zone before touching a clean site. Chavali and colleagues (2016) found that nurses were least hand hygiene compliant with moment two (39%) compared to allied staff (89%). Similarly, another study found that moment two had Hand hygiene compliance Healthcare facilities monitor hand hygiene performance using a variety of approaches. Examples include observing “gel in, gel out” of a patient’s room, the amount of product used, and the WHO’s five moments of hand hygiene. Typically, hand hygiene audits are carried out via direct observation by unidentified observers (i.e., “secret shoppers”). Training the observers keeps the data collection consistent with some accuracy. While direct observation is the gold standard, there are limitations because it can be time consuming and is periodic monitoring (WHO, 2009a). Srigley and colleagues (2014) experienced the Hawthorne effect when the observer was visible during hand hygiene data collection, and performance improved. Musu and colleagues (2017) suggest decreasing the Hawthorne effect by increasing the observation time. By increasing the observation time, the HCWs get accustomed to seeing the observers and may perform hand hygiene as they usually would. Physicians have lower adherence to hand hygiene practices. A study evaluating physician practices in an outpatient setting found compliance to be very low (6%) (Kato et al., 2021). Higher adherence was seen among physicians specializing in endocrinology and respiratory diseases. A meta-analysis of hand hygiene compliance among physicians and nurses found that overall compliance was higher for nurses (52%) than physicians (45%) (Bredin et al., 2022). Observations were done covertly and overtly, with nurses having greater compliance with overt observations. There were no differences between the two disciplines with covert observations. Similarly, Yoo and colleagues (2019) used a covert observation method and found that nurses’ hand hygiene compliance was 60%, whereas physicians’ hand hygiene compliance was 47%. Covert observations were a better indicator of hand hygiene compliance. The WHO recommends using the five moments of hand hygiene to monitor compliance (WHO, 2009a). Numerous studies have measured these critical moments and provide a better idea of when hand hygiene is performed (Table 1). Some authors suggest that HCWs’ hand hygiene practices reflect an attitude
“problematically low” hand hygiene compliance (Diefenbacher et al., 2022). Moment three is after a body fluid exposure risk. This moment reduces the risk of colonization or infection of HCWs and reduces transmission of pathogens from a colonized site to a clean body site on the same patient (WHO, 2009a). An example is performing wound care and then performing central line care. After body fluid exposure, hand hygiene should be performed before hand-to-surface contact. Performing hand hygiene is strongly recommended after glove removal, as hands are not sufficiently protected by gloves (CDC, 2002). Chavali and colleagues (2016) found this moment to have the highest hand hygiene compliance compared to the other moments. Moment four is after patient contact. This moment reduces the contamination of HCWs’ hands from the patient’s flora and cross- contamination to the environment. This moment is when leaving the patient zone; however, HCWs usually touch several objects within the patient zone before going to the healthcare zone. This moment may be in conjunction with moment five, after contact with patient surroundings within the same patient zone. For example, hand hygiene should be performed when patient care is done, the bedside table is moved closer to the patient, and the call light is handed to the patient. Then hand hygiene should be performed again. Moment five is after contact with the patient’s surroundings. This moment reduces transmission to surfaces within the patient zone and the patient. This moment is similar to moment four, and the intent is to prevent environmental contamination. Chavali and colleagues (2016) found this moment to have the least compliance among allied staff (70%), and nurses’ compliance was lower (50%). of protecting oneself rather than protecting patients, as the “before” moments have less compliance than the “after” moments (Chavali, 2016; Musu et al., 2017). Chavali and colleagues (2016) observed HCWs (n = 38) working in an intensive care unit of a tertiary-level multispecialty hospital. The hand hygiene observations were collected over the course of 10 days. Overall compliance with the WHO’s five moments was 78%, with allied health staff compliance being higher (87%) than nurses (69%). Allied health staff had higher hand hygiene compliance than nurses for all five moments. Nurses were better at moments three and four, after body fluid exposure and after patient contact. Nurses combined moments one and two and did not perform any additional hand hygiene before an aseptic or clean procedure. Eliminating hand hygiene before an aseptic or clean procedure increases the risk of transmitting pathogens to the patients. Musu and colleagues (2017) observed physicians, nurses, and nurses’ aides in six intensive care units in six different hospitals. Keeping with the ‘five’ theme, they observed over a five-day period and observed for five hours. Their observations went beyond the five moments, they included before preparing food and medication and adherence to the recommended handwashing technique. The authors found that overall hand hygiene adherence was higher for nurses’ aides compared to nurses and physicians, and physicians had consistently lower hand hygiene compared to nurses’ aides and nurses. Moments one and five had the lowest adherence, and the after moments had higher adherence. An alarming observation was physicians’ adherence (64%) to handwashing when their hands were visibly soiled. Additional results showed that nurses’ adherence to hand hygiene prior to handling medications (30%) was significantly lower than prior to handling food (95%) (Musu et al., 2017). Nurses had higher adherence than physicians after removing gloves (71% compared to 61%); however, they exhibited similar adherence when moving from a contaminated to a clean body (58% vs. 57%). Overall handwashing technique was good, with
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