Hand washing and personal protective equipment

Hand washing in the ICU is one of those basic things which we never expect to be asked about. It falls into the spectrum of Strategies to Prevent the Transmission of Multi-resistant Organisms, and the scientific foundations of this topic are discussed elsewhere. There, the reasons for hand washing and PPE are explored in some depth. This chapter is more about the administrative and bureaucratic aspects of implementing hygiene and infection control measures. The college examiners love that stuff, as they are often directors of units for whom hand hygiene is an important part of routine quality assurance. As a junior staff specialist or post graduate fellow, the exam candidate is expected to demonstrate a keen interest in this tedious business. There are two questions about this in the papers:

Question 11 from the second paper of 2007 asked candidates "to put in place initiatives to improve hand washing in your intensive care unit". The question was passed by 65% of the candidates. The college model answer was sadly brief and likely does not represent a passing level (being guilty of general statements such as "however very poor compliance with hand washing in ICUs".) A better answer would have its foundations in the available evidence, and this is offered in the discussion section for Question 11

LITFL have an excellent resource on this. Indeed, one can add little to the college answer, except some references. The definitive guide worldwide would probably be this WHO Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy. The entire 45 page document is a thrilling read. A summary of the major recommendations in point form is offered here.

Scale of the problem

According to  Jacob et al (2016) and  Kingston et al (2016) 

  • Hand hygiene compliance research is conducted predominately in Europe and the USA
  • The ICU is a dominant location for such research (i.e. we are under closer scrutiny than other settings)
  • The prevalence of health-care-associated infections attributable to poor hand hygiene is highest in the ICU, where up to 20% of patients end up with such an infection. A recent ECDC point prevalence study (Zarb et al, 2012) revealed that at any given point 5.7% of all ICU patients (1 in 18) have such an infection. 
  • Hand washing is worst during the night shift
  • Only about 50% of hand hygiene opportunities are used by the ICU staff
  • Nurses are better at this than doctors
  • No altruism or desire to improve patient care drives hand-washing ("the major motivation for hand washing was fear of contracting disease").
  • On average, compliance with WHO hand-washing guidelines was 34.1% on meta-analysis by Kingston et al
  • From interventions, the net improvement in compliance rates seems to be around 23% (ranging from 7% to 30%).

"Moments" of hand hygiene

Question 14 from the second paper of 2023 asked about Moment 5, which is where you step away from the patient, still coated in a thick layer of multiresistant Pseudomonas  straight after handling their infected organs and tissues, and immediately wallow all over the shared areas and surfaces of your ICU, spreading the contagion to your colleagues. Some of that question asked for a definition and rationale.

A hilarious paper by Chou et al (2012, from the Bone and Joint Journal) revisits the same ground from a highly critical perspective, appearing to be making the case that handwashing is not important. 

In short, the "moments" model prompts healthcare workers to clean their hands at five distinct stages of caring for the patient.  In brief:

  • Moment 1: Before touching a patient - because this can transmit resistant organisms from some random donor surface around the hospital, eg. the last patient you saw when you did not remember Moment 5.
  • Moment 2: Before a procedure: because a clean site can be contaminated, leading to colonisation and perhaps even infection
  • Moment 3: After a procedure when you are covered with infected body fluids - it is not surprising that this moment has the best evidence to support it, getting a 1A grade of recommendation in the 2009 WEHO guidelines.
  • Moment 4: After touching a patient - mostly to prevent the colonisation of the environment with that patient's resistant flora. 
  • Moment 5: After touching the patient's surroundings - mostly because they may be a reservoir of pathogens, and one may not wish to take those pathogens for a ride around the hospital.

Strategies to improve hand hygiene

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

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

Evalation and feedback

  • 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

There is a massive amount of literature out there.

Here is a synopsis of a few papers:

According to Kaplan et al:

  • Complicance with handwashing seems to be proportional to the number of sinks per patient.Ideally, the ratio should be 1:1.

According to Dubbert et al:

  • Handwashing classes are helpful
  • Feedback to staff about observed handwashing errors (it improves compliance to 97%!)

According to Panhotra et al:

  • Education campaign must be continuous
  • Posters are helpful

According to Mayer et al:

  • A good emollient handwash is all-important

According to Naikoba and Hayward:

  • Once-off education sessions have little effect
  • Automated sinks improve the quality of handwashing
  • Continued feedback of performance seems to be the strongest strategy.

Ultimately, all authors note that the best way to improve handwashing is "regular feedback" - that is to say, somebody constantly watching everyone, and telling them off for not washing their hands.


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.

Kaplan, Lois M., and Maryanne McGuckin. "Increasing handwashing compliance with more accessible sinks." Infection Control (1986): 408-410.

WHO have this statement: A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy (2009)

Jacob, Digina Anna. "A Study On Hand Hygiene Practices Among Health Care Professionals In Critical Care Units." Global Journal For Research Analysis 5.4 (2016).

Musuuza, Jackson S., et al. "Assessment of Fidelity in Interventions to Improve Hand Hygiene of Healthcare Workers: A Systematic Review." Infection Control & Hospital Epidemiology 37.05 (2016): 567-575.

Kingston, L., N. H. O'Connell, and C. P. Dunne. "Hand hygiene-related clinical trials reported since 2010: a systematic review." Journal of Hospital Infection 92.4 (2016): 309-320.

Zarb, P., et al. "The European Centre for Disease Prevention and Control (ECDC) pilot point prevalence survey of healthcare-associated infections and antimicrobial use." Euro Surveill 17.46 (2012): 20316.

Chou, D. T. S., P. Achan, and M. Ramachandran. "The World Health Organization ‘5 moments of hand hygiene’: the scientific foundation." The Journal of Bone & Joint Surgery British Volume 94.4 (2012): 441-445.

Gupta, Stuti, et al. "Hand-hygiene compliance: The importance of WHO's “moment 1” in the prevention of healthcare-associated infections." Indian Journal of Medical Microbiology 44 (2023): 100374.

Neo, Jun Rong Jeffrey, et al. "Evidence-based practices to increase hand hygiene compliance in health care facilities: An integrated review.American Journal of Infection Control 44.6 (2016): 691-704.