Is It Time for a Paradigm Shift in Hand Hygiene?

By Kelly M. Pyrek

One of the widely recommended, but deceptively difficult strategies for improvement and pervasive problems that seem to resist solution is hand hygiene compliance. While it plays a significant role in breaking the chain of infection, hand hygiene is a venerated strategy that can sometimes be protected from scrutiny and untouchable from the perspective of determining if certain aspects still hold up over time or still make sense for evolving real-world conditions and challenges in the healthcare environment.

Some clinical constructs have become so entrenched so as to be virtually unassailable, and a good example of this is the World Health Organization (WHO)’s Five Moments for Hand Hygiene, described by Gould and Purssell, et al. (2022) as a “time-space framework to identify points in the sequence of care when hand hygiene should occur to prevent transmission.”

As we know, the Five Moments model conceptualizes risk in relation to two virtual areas: the patient zone –  the patient and their immediate surroundings –  and the healthcare zone, which comprises everything outside the patient zone.

Sax, et al. (2007) explain that “’My five moments for hand hygiene’ bridges the gap between scientific evidence and daily health practice and provides a solid basis to understand, teach, monitor and report hand hygiene practices.”  The five moments are: Before touching a patient, before a clean/aseptic procedure, after body fluid exposure risk, after touching a patient, and after touching patient surroundings.

While it has become the most widely accepted framework since its formal launch in 2009, not everyone was on board with this paradigm. For example, Chou, et al. (2012) analyzed the scientific foundation for the five moments of hand hygiene and explores the evidence, as referenced by WHO, to support these recommendations. They said they “found no strong scientific support for this regime of hand hygiene as a means of reducing healthcare-associated infections,” and cautioned further, “Consensus-based guidelines based on weak scientific foundations should be assessed carefully to prevent shifting the clinical focus from more important issues and to direct limited resources more effectively. We recommend caution in the universal adoption of the WHO '5 moments of hand hygiene' … and emphasize the need for evidence-based principles when adopting hospital guidelines aimed at promoting excellence in clinical practice.”

In the years since, the Five Moments framework has prevailed but recently, some experts have come to question the absolute reign of this framework. As Gould and Purssell, et al. (2022) observe, “The Five Moments are the dominant paradigm used to organize practice, policy and research in relation to hand hygiene,” but they identify five “inconvenient truths” limiting the Five Moments and begging the question of whether the development of a more effective paradigm is possible.

The WHO’s Five Moments framework has been the dominant hand hygiene paradigm -- with the  Centers for Disease Control and Prevention (CDC)’s recommendations and the Compendium recommendations from the Society for Healthcare Epidemiology of America (SHEA) followed in the U.S. – but is it a blind loyalty? In healthcare, practitioners are often advised to consider the local as well as the global when identifying and implementing the best clinical strategies for improving patient outcomes, but the WHO’s paradigm seems to eclipse other approaches.

“I believe it’s due to a common logical fallacy associated with the idea that the best logic must be the most rigorous one,” says Jacob McKnight, PhD, of the Health Systems Collaborative, Nuffield Department of Clinical Medicine, Oxford, UK. “In my view, the WHO’s My Five Moments sets the bar unhelpfully high, but once it was set thus, it is very difficult to move away from it without appearing as if one is watering it down.”

McKnight, who was a co-author on the Gould and Purssell, et al. (2022) paper, continues, “I’m also interested in the mindset of those who designed the approach. You can hardly fault the research – they were very thorough in their approach, and the logic is also very sound. I also like the simplicity of the idea as it’s very easy to understand and share. It’s a tremendous training tool as you are able to show all of the ways in which infection can happen and this abstraction can be applied to a number of different practical examples. Where it falls down is in its extension from a tool of analysis and training, into a paradigm for action: it’s simply not workable in some settings at some times and the culture around handwashing is such that we can’t even talk about this without fear of reproach.”

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