November 07, 2018
5 min read

Three-step hand hygiene protocol improves compliance

You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

We were unable to process your request. Please try again later. If you continue to have this issue please contact

In a clinical setting, a three-step hand hygiene protocol resulted in higher compliance with both hand hygiene technique and indications compared with the six-step method endorsed by WHO, according to study findings.

Writing in Clinical Infectious Diseases, Sarah Tschudin-Sutter, MD, MSc, a physician and researcher in the division of infectious diseases and hospital epidemiology at the University Hospital of Basel in Basel, Switzerland, and colleagues explained that hand hygiene compliance at most institutions remains “insufficient” despite multiple interventions. According to the study, health care-associated infections can be reduced by 6% with just a 10% improvement in hand hygiene compliance.

“The technique for the use of hand rub outlined in the WHO guidelines consists of six steps to ensure entire coverage of the hands,” Tschudin-Sutter and colleagues wrote. “A systematic review evaluating the evidence base for this technique for reducing the microbial load on the hands of health care workers provides evidence for its effectiveness but does not identify the most effective hand hygiene technique; furthermore, the recommended application time for hand rub has been challenged by a study demonstrating that a reduction in application time” — to just 15 seconds — “may result in improved compliance, while having a similar microbiological effect.”

Previously, Tschudin-Sutter and colleagues demonstrated the slight superiority that a three-step hand hygiene technique has over the six-step process in reducing bacterial load. However, the experimental study did not show the impact the technique may have in a clinical setting.

So they conducted a cluster-randomized trial from October 2015 to November 2015 at the University Hospital of Basel, a tertiary academic care center, randomly assigning 12 wards to either the three- or six-step technique. According to the study, the three-step process consists of covering all surfaces of the hands followed by rotational rubbing of fingertips in the palm of the alternate hand and rotational rubbing of both thumbs. Both the three- and six-step technique were performed for 30 seconds with 3 mL of hand rub, Tschudin-Sutter and colleagues explained. The primary endpoints were compliance with the assigned hand hygiene technique and a bacterial count reduction on health care workers hands.

Among 294 health care workers, Tschudin-Sutter and colleagues observed 2,923 hand hygiene indications with an overall compliance rate of 70.7% (n = 2,066). On wards assigned to the three-step technique, compliance with hand hygiene indications was 75.9% and technique compliance was 51.7%. On wards assigned to the six-step technique, hand hygiene indication compliance was 65% and compliance to technique was 12.7%, according to the study. Furthermore, when both techniques were compared, the reduction factor of bacterial counts did not differ (P = .629).

The study demonstrates noninferiority of the three-step hand hygiene technique as compared to the six-step protocol in a clinical setting. The researchers believe a simpler hand hygiene protocol could safely replace the current standard.

“We observed higher compliance with both hand hygiene technique and indications on wards assigned to a three-step as compared to the conventional six-step hand hygiene technique,” Tschudin-Sutter and colleagues wrote. “Further trials in other clinical settings are required to externally validate our findings.” – by Marley Ghizzone

Disclosures: Tschudin-Sutter reports being a member of the Astellas and MSD Advisory Boards for Clostridium difficile and reports grants from the Swiss National Science Foundation NRP72 (407240_167060), the Gottfried und Julia Bangerter-Rhyner Stiftung and the Fonds zur Förderung von Lehre und Forschung der Freiwilligen Akademischen Gesellschaft Basel, and reports grants from Jubiläumsstiftung von Swiss Life, outside the submitted work. Please see the study for all other authors’ relevant financial disclosures.