An illustration showing the 5 moments of hand hygiene.

The last and least practiced moment of hand hygiene

The World Health Organization’s (WHO) Five Moments of Hand Hygiene was created to help healthcare workers protect themselves and patients and to decrease the number of healthcare acquired infections (HAIs). Some of these moments would be obvious even to people outside the profession and have a higher compliance rater, like Moment 3, when staff have come into contact with bodily fluids. Of all the moments, the fifth and final moment can prove to be especially vexing for infection control practitioners who are trying to increase hand hygiene compliance.

The fifth moment of hand hygiene comes after touching patient surroundings. Studies have found it to be the moment with the lowest level of compliance by a long shot.

A chart of the five moments of hand hygiene. 1) Before touching a patient 2) before clean/aseptic procedure 3) after body fluid exposure risk 4) after touching patient 5) after touching patient surroundings

Recently, Dr. Jon Otter, an epidemiologist focused on Infection Prevention and Control at the Imperial College Healthcare NHS Trust in London, gave a talk about the “thorny” 5th moment of hand hygiene, highlighting both its importance and its frequent neglect.

During the pandemic, we have made great strides in understanding how COVID-19 spreads. From the early days of watching videos on how to disinfect your groceries[1] to our current understanding of COVID-19 as primarily airborne virus, many people have learned about the different ways infections can spread. While the novel Coronavirus can stay alive on surfaces much longer than influenza can, it is worth understanding the potential lengths that some infectious organisms can survive on surfaces. This is a staggering four years in the case of Enterococcus spp.

Good and consistent cleaning of surfaces in hospitals is an essential deterrent for these types of transmissions, as is practicing hand hygiene after touching those surfaces. “We have mountains of evidence,” Dr. Otter points out, “that environmental surface contamination plays a pivotal role in the transmission of many pathogens that cause can cause HCAI most of the time.”[2]

Dr. Otter references a study that found that touching the surfaces close to a patient could lead to acquiring C. Difficile spores as easily as touching the patient themselves. These researchers found, specifically that “contact with commonly touched environmental surfaces (ie, bed rail, bedside table, telephone, call button) as after contact with commonly examined skin sites (ie, chest, abdomen, arm, hand).”[3]

A “both and” solution

The solution cannot be solved solely by either hand hygiene behaviour or environmental cleaning. While each those practices can individually reduce HAIs, the reduction in infection when both are practiced is dramatic. The rate of C. difficile infections drops from nearly 8 per 10000 patient days to almost 1 per 10000:

As with all things hand hygiene, a multi-modal approach nets the greatest results. Improving hand hygiene compliance, especially with the moment of hand hygiene with the lowest levels of compliance, requires excellent hand hygiene infrastructure, consistent monitoring, and consistent education and feedback.

“If we don’t focus our attention on all moments for hand hygiene,” Dr. Otter concludes, “we won’t be as effective as we could be in preventing cross-transmission.” [4]

[1] This infamous video summed up a lot of our early confusion.

[2] Otter, Jon. “The ‘Thorny 5th Moment for Hand Hygiene’: Hands and Surfaces Collide.” Reflections on Infection Prevention and Control, 23 Nov. 2021, Accessed 25 Jan. 2022.

[3] Guerrero DM, Nerandzic MM, Jury LA, Jinno S, Chang S, Donskey CJ. Acquisition of spores on gloved hands after contact with the skin of patients with Clostridium difficile infection and with environmental surfaces in their rooms. Am J Infect Control. 2012 Aug;40(6):556-8. doi: 10.1016/j.ajic.2011.08.002. Epub 2011 Oct 7. PMID: 21982209.

[4] Otter, Jon. “The ‘Thorny 5th Moment for Hand Hygiene’:

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