A healthcare-associated infection (HCAI) is defined as a problem that develops as a direct result of healthcare interventions, for example, medical or surgical treatment, or because of direct contact with a healthcare setting (NICE Clinical Knowledge Summaries, 2024). It is the most common adverse incident experienced by people in hospital and is something that pervades all healthcare systems regardless of the resources available. In a modelling exercise Guest et al (2020) estimated that in any given year there are approximately 834 000 HCAIs in the NHS in England with 28 500 deaths. This translates to 7.1 million occupied bed days, equivalent to 21% of the annual number of bed days across all NHS hospitals. The financial cost of HCAI is thought to exceed £2.7 billion. In addition, it is responsible for 79 700 days of absenteeism among frontline health professionals (Guest et al, 2020). The causes of HCAI are multifactorial, but many of the pathogens responsible are spread through the contaminated hands of healthcare workers (HCWs) (Loveday et al, 2014).
In their review, ‘Hand hygiene in hospitals; anatomy of a revolution’, Vermeil et al (2019) traced the historical landmarks of hand hygiene in health care, to its now preeminent position within the armoury of infection prevention and control interventions. A key milestone came in 2005 when the World Health Organization (WHO) launched the Global Patient Safety Challenge with the theme ‘Clean care is safer care’ and produced an advance draft of hand hygiene guidelines in healthcare. In 2007, WHO expanded on guidance from the US Healthcare Infection Control Practices Advisory Committee for hand hygiene before and after entering a patient's room (Armstrong-Novak et al, 2023) and introduced the concept of ‘5 Moments for Hand Hygiene’ (Table 1).
| Moment | When (according to WHO) |
|---|---|
| 1. Before touching a patient | Clean your hands before touching a patient when approaching him/her |
| 2. Before clean/aseptic procedure | Clean your hands immediately before performing a clean/aseptic procedure |
| 3. After body fluid exposure risk | Clean your hands immediately after an exposure risk to body fluids (and after glove removal) |
| 4. After touching a patient | Clean your hands after touching a patient and her/his immediate surroundings, when leaving the patient's side |
| 5. After touching patient surroundings | Clean your hands after touching any object or furniture in the patient's immediate surroundings, when leaving – even if the patient has not been touched |
Source: World Health Organization, 2009b
The 5 Moments is a time and space framework that delineates when hand hygiene should be performed (Sax et al, 2007). It has become the dominant paradigm for the organisation, practice, policy and research in relation to hand hygiene (Gould et al, 2022). This article is not intended as a criticism of the 5 Moments framework in itself – it can be an excellent resource for educators and auditors – but rather seeks to question whether the way it is implemented in many cases can have unintended consequences
Evidence base
The design and delivery of robust, ethical, high-quality studies in the field of hand hygiene is challenging. As a result, recommendations are often based on a combination of non-randomised controlled trials and expert opinion derived from systematically appraised professional, national and international guidelines (Loveday et al, 2014). What can be verified about hand-mediated cross-infection, with a high degree of confidence, is a moot point. In its seminal guidelines WHO (2009a) drew the following conclusions. Pathogens can be recovered from the normal, intact skin of patients, their mucous membranes, healthcare devices, wounds, and the inanimate environment. These pathogens can be transferred to the hands of HCWs, but the extent of this will depend on the species, the number of microorganisms on the surface and the skin moisture. Microorganisms will then survive on hands but the amount is dependent on the species and the inoculating dose. Different hand hygiene products, the volumes used, and technique employed, will result in the removal of different levels of transient flora from the hands. Cross-transmission of microbes from the hand will occur, but again is dependent on the type of organism, the source and destination of the surface, the moisture level and size of inoculums (WHO, 2009a). Although the epidemiological evidence strongly supports hand-mediated transmission as a major factor in the acquisition and spread of infection in hospital (Guest et al, 2019), the observation that many examples of suboptimum hand hygiene does not result in a greater incidence of HCAI is possibly because of the conditions stated above. In short, many examples of poor hand hygiene do not result in HCAI.
Developing this theme, it is also difficult to quantify the impact that hand hygiene has on the incidence of HCAI: does 40% compliance reduce HCAI incidence by 40%, 70% by 70% and so forth? Historically there was no set frequency for hand hygiene. Writing in 1997, the Infection Control Nurses Association (ICNA) stated that frequency should be determined by actions, those completed and those intended to be performed (ICNA, 1997). In other words, the ICNA encouraged the HCW to make their own risk assessment. But drawing on an evolving body of knowledge, the 5 Moments model was an attempt to give firmer guidance. Despite this, the architects of the model accepted that when they developed the concept, they ‘faced some fundamental difficulties which were rooted in the lack of detailed scientific evidence on hand transmission and its implication in the aetiology of specific infectious outcomes'(Sax et al, 2007). The conclusion they drew was that, if the relative risk of a specific care task is unknown, a safe system must be to treat them on an equal level. This absolutist stance adopts the ‘precautionary principle’, that if one is not sure what may happen, caution is the proper course of action.
Impact on practice
Caution in the face of uncertainty is understandable, but the metaphorical ‘elephant in the room’ – the obvious but unaddressed issue – is the impact this unconditional approach has on policy and practice. Whether or not the authors of the model expected a literal approach to their ‘5 Moments’, this is often what a risk-averse healthcare provider has assumed. In their daily work HCWs have continuous contact with patients, surfaces, devices, medical documents, and waste. With reference to the 5 Moments this results in many daily opportunities for the hands to become colonised with potential pathogens. Taking a literal approach, Stahmeyer et al (2017) estimated that the 5 Moments would generate in the region of 218 hand hygiene opportunities per patient day in an internal medicine ICU and 271 in a surgical ICU. Full compliance would require 58.2 and 69.8 minutes respectively. Making a similar argument, Chou et al (2012) described a sample case of a routine postoperative review of a patient following a total hip replacement:
‘Wash hands - Shake patient's hand – adjust patient's bed to help them sit up – wash hands - Review wound – wash hands - Assess sciatic nerve function – wash hands - Prepare cannulation equipment – wash hands - Apply tourniquet to patient – wash hands - Insert cannula – wash hands.’
The single encounter necessitated seven hand hygiene opportunities and Chou et al concluded that if extrapolated to the whole ward round would amount to 150 episodes. Interestingly, in their original article, Sax et al (2007) did recognise that a literal interpretation of the 5 Moments could translate to one hand rub application up to every 2 minutes during intensive care activities, but rather than seeing this as a problem it did not receive further examination.
A contrary position to the stance taken by the 5 Moments model is that hand hygiene opportunities should be tiered, from the ‘essential’ to ‘ideal. In their study Chang et al (2022) reported an inverse relationship between hand hygiene compliance and workload. That is, as workload increases, HCWs begin to ration care and make choices about which opportunities to take. It has also been reported that, as the need for hand hygiene spirals, these encounters become increasingly brief, less invasive and more social in nature (Dedrick et al, 2007). Encounters that, according to the WHO model outlined earlier, generally carry less risk of transmission. In other fields of research scholars have used mathematical models as a tool for predicting infection control transmission and risk reduction. Although these articles offered convincing evidence that improved hand hygiene practices lead to a reduction in HCAI (WHO, 2014), there is some suggestion that hand hygiene may suffer from the law of diminishing returns. A study by Hornbeck et al (2011) concluded that at extreme low extremes of compliance (20%) there are clear benefits to increasing hand-hygiene compliance to 40%. However, if rates are at 80% increasing them to 90% seems to be a less effective intervention. The work is in its infancy and can be difficult to interpret but the overall question of what meets a satisfactory level of performance is equivocal.
There is the additional problem of contact dermatitis associated with excessive use of hand-hygiene products. It is estimated that each year 1000 HCWs develop work-related contact dermatitis. This is nearly seven times higher than the average for all professions (Royal College of Nursing (RCN), 2022). In an RCN survey, 46% of respondents rated the condition of the skin on their hands as either ‘poor’ or ‘very poor’ and 93% had experienced at least one skin symptom in the last 12 months (RCN, 2022). In a timeframe that chimes with the adoption of the 5 Moments, Stocks et al (2015) found that HCWs were 4.5 times as likely to suffer from irritant contact dermatitis in 2012 as in 1996. Although attempts have made to mitigate this with the provision of emollients and less irritant products such as alcohol-based hand rub these will not ameliorate the extraordinary requirements for hand hygiene in contemporary policies. Perhaps a key consideration here is: if the HCW is making choices about how to ration hand hygiene opportunities in the face of extreme expectations, are they making wise choices about which hand hygiene opportunities to commit to?
Audit
If the 5 Moments framework has become the dominant paradigm for the organisation, practice, policy, and research in relation to hand hygiene, it is important to reflect on how organisations have incorporated it into their policies. The code of practice on the prevention and control of infections, under the Health Act 2008, outlines a plethora of IPC activities, including hand hygiene, that should be monitored and subject to a rolling programme of audit (Department of Health and Social Care, 2022). Typically, NHS organisations embed the 5 Moments into their policy documents as the intervals when HCWs must decontaminate their hands. Then there is audit compliance. Invariably this audit data is captured through direct observation, considered the ‘gold standard’, as it is the only method that allows the hand-hygiene event to be evaluated in the context of patient care and provides an opportunity for correction and improving practice (Purssell et al, 2020). Nonetheless there are many epidemiologic pitfalls in relation to the direct observation of hand hygiene, including statistically underpowered samples, selection bias, measurement bias and the Hawthorne effect, which posits there is an increase in productivity in response to scrutiny (Jeanes et al, 2019).
To illustrate some of these problems, McLaws and Kwok (2018) compared audit results documented through direct observation with those captured by automated surveillance. They found that direct human rates for a medical ward were inflated by 64 percentage points, 3.1 times higher than automated surveillance rates, taking one-quarter direct human-recorded compliance as 95% whereas automated surveillance at the same point recorded 29%. Despite evidence to the contrary, clinicians remained fixed in their belief that the compliance rates were an accurate reflection of their compliance. McLaws and Kwok put much of the discrepancy down to methodological biases and the pervasive impact of the Hawthorne effect. However, there may be another explanation.
Reflecting on the role of audit in infection prevention and control, Wilson (2018) opined that it can all too easily become a routine monitoring tool that is not explicitly linked to driving practice improvement. Indeed, the success of an audit is often shaped by its context and the way it is implemented. As far back as 2008 the Department of Health instructed trusts to move towards an uncompromising vision of a healthcare system without infection. It emphasised that trusts should take a zero-tolerance stance towards non-compliance with key policies or procedures and proposed that the consequences of poor performance should be underpinned with effective HR systems (Department of Health, 2008). Indeed, according to Brewster et al (2016) the NHS has been shaped by extensive policy-driven performance management, comprising setting and measuring standards, coupled with the introduction of incentives and sanctions. In keeping with this, a literal approach to the 5 Moments provides a context and framework to monitor hand-hygiene behaviour.
Given this context, it is perhaps unsurprising that a risk-averse healthcare provider would adopt a literal approach to the 5 Moments and place the full force of its policy document behind it. This results in a policy document that typically uses a language that could be described as authoritative and unyielding (Cole, 2015). Expanding on this point, trusts, through their policies, will often set levels of compliance that can be anywhere between 90% and 100% (Bradley et al, 2017) and unveil consequences if these targets are not met. Subsequently, compliance levels reported by NHS organisations, and placed on the websites for the public to see, bear little resemblance to those in academic studies. A cursory internet search of 5 NHS trusts' annual reports revealed reported levels of compliance as 91%, 95%, 96%, 97%, 99%. Given a recent review of the literature concluded that mean compliance levels in independent studies was 41% (Clancy et al, 2021) the previous iterations as a meaningful representation of actual practice begin to enter the realm of fantasy.
In addressing the question of why trusts report unlikely levels of compliance there could be several explanations. Direct observation as a methodology to record hand-hygiene behaviour is a complex endeavour that has many epidemiologic pitfalls (Bredin et al, 2022). If this is the case in independent research studies, with trained observers given dedicated time, these difficulties will manifest in NHS trust audits where samples are extremely small, and the data is often collected by a time-poor, untrained HCW, with an allegiance with the clinical area. There is also a sense that the high levels of reporting are a consequence of an insincere audit that sets an unrealistic target and provides little investment in time, training, and personnel to collect authentic data (Mahida, 2016). Similarly, if underperformance is reported, the upshot is that reputations are damaged, performance is scrutinised and possible penalties result.
Discussion
The purpose of this article was to take a critical eye to the WHO 5 Moments of hand hygiene framework: to consider some of its strengths, but also, because of the way it has been accepted in many NHS trusts, whether it has had unwanted consequences. The 5 Moments was a historic landmark in HCAI hand hygiene. It built on a body of knowledge that elucidated the risks associated with hand-mediated cross-infection and provided a framework to provide education and audit of practice. For all these reasons it quite naturally takes a prominent position in any organisation's hand-hygiene policy.
However, the thrust of this article is that 5 Moments should actually be seen as an aspiration, an idealised view of practice. If an organisation intends to move beyond this, to a more literal interpretation and expectation of practice, with the full force of policy behind it, it needs to acknowledge some salient truths. Suboptimum compliance with hand-hygiene policies is an enduring problem and is associated with a range of situational factors such as a lack of equipment, understaffing, overcrowding, high demand for the behaviour and sore hands and social cognitive determinants such as motivation, knowledge, perceived benefits, risk perception and social pressure (WHO, 2009a). If an organisation intends to audit the 5 Moments to evaluate practice it must be prepared to hear bad news. Authentic data collection will undoubtedly demonstrate a level of compliance that at first sight may be unpalatable for commissioners of services, healthcare managers and patients alike. However, an organisation that fosters a ‘just culture’ (van Baarle et al, 2022) would make the distinction between an intentional rule violation and an enforced violation arising because the standard is a theoretical construct and does not have practical utility. A ‘just culture’ embodies fair decision making based on openness, transparency and learning from events rather than assigning blame (Murray et al, 2023).
The current approach to hand hygiene audit, underpinned by the 5 Moments, is what Muller and Detsky (2010) would call an ‘indicator-based approach’ to practice improvement; something based on rules and mandates, the goal being not necessarily to enhance the quality of hand hygiene but to protect the organisation from external scrutiny. Producing inauthentic data of 100% compliance is not good for patients as it provides no critical lens to scrutinise the effectiveness and make changes to a hand-hygiene programme. A better approach would be to capture compliance as it is and make incremental improvements.
Conclusion
The 5 Moments is a historic landmark in our understanding of how hands become contaminated with potential pathogens during the delivery of patient care. However, because it is a concept that adopts the precautionary principle a literal interpretation results in an extraordinary number of hand-hygiene opportunities and full compliance becomes implausible. Nevertheless, audit of hand-hygiene behaviour using the 5 Moments as a framework has become common throughout the NHS; because of the context in which the data is collected and reported it produces spurious results that have more to do with protecting oneself from external scrutiny than enhancing practice and reducing HCAI. Provider organisations need to reflect on how to get best use from the 5 Moments both as an educational tool and a means to understanding the true nature of compliance.