Question 14

The latest hand hygiene compliance for your ICU is 69% with compliance for Moment 5 (World Health Organization classification) being the lowest.
a) Define Moment 5 and explain why it is necessary. (2 marks)
b) Outline strategies to improve hand hygiene compliance of ICU staff. (8 marks)

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College Answer

Syllabus topic/section:

2.3.1 Intensive Care Administration.


Hand hygiene is internationally standardized, and part of routine standard of care.

A question on a core topic of daily relevance to intensive care practice. Generally, well answered. Many candidates answered by reproducing a generic "audit cycle" template, with limited marks able to be awarded. Answers containing information on specific strategies to improve hand hygiene compliance attracted higher marks. Candidates are reminded to read the question carefully, and answer the specific question being asked – a generic listing of the 5 moments of hand hygiene was not adequate to pass the first part of the question, rather an understanding of the rationale for moment 5 was expected.


The definition of Moment 5, as per the Australian Commission on Safety and Quality in Healthcare, is "After touching a patient's surroundings", and the plain language rationale explanation for its importance is "To protect the healthcare worker and the healthcare environment from becoming contaminated with the patient’s microorganisms." 

Moment 5: "After touching the patient's immediate surroundings": it is necessary to wash hands at this stage because the patient's immediate environment may be a reservoir of pathogens. Handwashing may interrupt the spread of resistant organisms from the donor surfaces around one patient to another patient.

Strategies to improve compliance:

  • System change
    • Regular workplace survey to assess unmet goals
    • Ensure that products for hand hygiene are available at the point of care.
    • Improve tolerability of hand hygiene products
    • Improve ward infrastructure to improve access to handwashing facilities
      • Complicance with handwashing seems to be proportional to the number of sinks per patient.Ideally, the ratio should be 1:1.
  • Training and education
    • Health-care workers should check each others' compliance
    • Regular education meetings
    • Engage external educators
    • Engage internal educations who can act as role models
    • Focus on the doctors, who are generally the worst offenders
  • Reminders in the workplace
    • Posters
    • Promotions and rewards
    • Schedule presentations
    • Frequent educational sessions
      • Handwashing classes are helpful
      • Feedback to staff about observed handwashing errors (it improves compliance to 97%!)
  • Evalation and feedback (That "generic audit cycle template" again):
    • Regular monitoring of compliance
    • System of observers with centralised reporting
    • Rewards and demerits for compliance (or its lack)
    • Audit of changes in incidence of health care associated infections
    • Establish a system for continuous recording and reporting hand hygiene product consumption


Dubbert, Patricia M., et al. "Increasing ICU staff handwashing: effects of education and group feedback." Infection Control and Hospital Epidemiology(1990): 191-193.

Panhotra, B. R., A. K. Saxena, and Al-Ghamdi AM Al-Arabi. "The effect of a continuous educational program on handwashing compliance among healthcare workers in an intensive care unit." British Journal of Infection Control 5.3 (2004): 15-18.

Mayer, Joni A., et al. "Increasing handwashing in an intensive care unit."Infection Control (1986): 259-262.

Naikoba, Sarah, and Andrew Hayward. "The effectiveness of interventions aimed at increasing handwashing in healthcare workers-a systematic review." Journal of Hospital Infection 47.3 (2001): 173-180.