Hand Washing: Six Steps Are Better Than Three

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."

Leaders can do this by talking about hand hygiene practices during staff meetings and conversations, asking people to be partners in improving those practices, and agreeing to use "whatever language feels safe" to remind each other of hand hygiene. The recipient of such a reminder should agree to "take a breath and say thank you" when someone points out that they didn't wash their hands. It's shifting from being punitive and accusatory to being helpful and friendly.

"We need to actually actively invite that conversation." Thompson says. "It just takes one person starting to open that conversation."

How to Wash Hands

Jacqui Reilly told HealthLeaders via email about the two different hand-hygiene techniques that her team studied:

"The WHO HH [hand hygiene] technique has been promoted in healthcare and used across many countries for many years," she says. "The steps are [using sanitizer gel]:"

1. Rub palms together.
2. Rub each palm front to back over the back of the other hand, interlacing fingers.
3. Twist palms with fingers interlaced, and rub between fingers.
4. Interlock your fingers, (thumbs should be on opposite sides), and twist again, this time, backs of fingers against palms.
5. Clasp your left thumb in your right hand and move thumb in circular motion — then switch thumbs.
6. Press your right fingers together and rub them in a circular motion on your left palm, then switch.

"The uptake of this six-step technique, or any other hand hygiene technique, is not measured at the international level, although many countries do measure hand hygiene compliance in healthcare settings," she says. "Some countries, such as the USA, have promoted a simpler process historically which in essence is covering all of your hands, the three steps are:"

1. Apply the sanitizer to one palm.
2. Rub both palms together.
3. Rub product over your hands until dry Our study provides the first evidence in a trial in healthcare settings that the 6 step technique is superior to the 3 step technique in reducing the microbial load on the hands.