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Hand Washing: Six Steps Are Better Than Three

By Alexandra Wilson Pecci  
   April 26, 2016

A World Health Organization-endorsed six-step hand hygiene technique using alcohol-based hand sanitizer gel is more effective at removing bacteria than a three-step technique that the CDC recommends, research shows.

One of the most critical things healthcare workers can do to prevent the spread of infection also seems to be one of the simplest: Handwashing.

"Hand hygiene is the most important intervention we can all do to prevent disease and infection," Jacqui Reilly, PhD, professor of infection prevention and control at Glasgow Caledonian University in Scotland, said via email.

But two recent studies show that hand hygiene is not as simple as it appears to be.

Reilly was lead author of one of those studies, which showed that a World Health Organization-endorsed six-step hand hygiene technique using alcohol-based hand sanitizer gel is more effective at removing bacteria than a less complex, three-step technique that the CDC suggests.

"Our study examined the difference between three-step and six-step hand hygiene techniques in healthcare specifically," Reilly said. "The study found that the six-step [method] significantly reduced the microbial load of bacteria on healthcare workers hands significantly better than the three-step technique."

She added that, "The average ratio of the bacterial level after the six-step process compared to before the six-step is 0.33, which could colloquially be explained as the six-step [technique] washes away 67% of the bacterial load on average within a person. The median ratio of the bacterial level after three-step compared to before the three-step is 0.65, which could colloquially be explained as the 3-step washes away 35% of the bacterial load on average within a person."

But another study shows that debating the merits of a three-step or six-step technique may be moot if medical staff don't wash their hands at all.

That study, published in the American Journal of Infection Control, found that staff at outpatient care facilities failed to wash their hands 37% of the time.

Only following guidelines "two-thirds of the time is not really going to prevent infection effectively," says lead author Deborah Thompson, MD, MSPH, Medical Director of Patient Safety for Presbyterian Healthcare Services and former Medical Epidemiologist for the New Mexico Department of Health.

In that study, medical students discreetly observed staff at 15 geographically dispersed outpatient facilities. Of the 330 hand hygiene observations, 33.9% used alcohol-based hand rub, 29.1% used soap and water, and 37% did nothing.

Both Thompson and Reilly say that more needs to be done to improve hand hygiene practices.

"Investing in improvement activities and using multimodal campaigns within healthcare prevents unnecessary infections and saves lives and healthcare resources," Reilly says. She points to "WHO-recommend multi-modal campaigns" that focus "primarily on improving hand hygiene compliance by healthcare workers who work with patients" and directs people to WHO's guidance on the matter.

But Thompson says that getting healthcare workers to wash their hands has a lot to do with comfort and discomfort.

Being comfortable and accustomed to their environments means that they sometimes overlook hand hygiene.

"Because we live in those environments all day long, and we don't get sick ourselves, there's a little bit of a disconnect and not a conscious one," she says.

On the other hand, discomfort with holding others accountable for hand hygiene can sometimes be a barrier to speaking up when co-workers don't wash hands.

She says healthcare leaders need to need to create an environment and culture where staff members have the "psychological safety" to say someone, "Hey I noticed you didn't wash your hands."

Alexandra Wilson Pecci is an editor for HealthLeaders.


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