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Hygienic hand disinfection is known to be the most important measure for preventing nosocomial infections.

Six-step hand disinfection—or three?

A simpler alternative to the well-established 6-steps of hygienic hand disinfection is now being proposed. Is this a fundemental change for hand hygiene?

Hygienic hand disinfection is known to be the most important measure for preventing nosocomial (or hospital-acquired) infections. In hospital hygiene, no other measure has such high epidemiological evidence for patient protection. Hospitals rely on alcohol-based sanitizers, which are primarily intended to kill or inactivate pathogens of the transient skin flora. This choice stems from sanitizers being more effective than soap at killing or inactivating pathogens.

However, the act of hand disinfection alone is not a magic bullet—the interaction of several parameters determines its effectiveness. To be truly hygeinic, the sanitizer needs to have the right antimicrobial spectrum for its intended use. Microorganisms are susceptible to different chemical disinfectant formulations. The sanitizer must, at the very least, be effective against bacterial pathogens and yeasts. Limited virucidal or virucidal agents, depending on the viral disease, are also commonly used in everyday medical practice.

Hand disinfection requires sufficient withdrawal volume

When it comes to hand disinfection in wards, the amount dispensed is key to achieving the desired germ-reduction. The Robert Koch Institute, for example, recommends a dosage of at least three milliliters (ml). [1] Even though this knowledge is widespread in healthcare, implementing this requirement often fails. Studies have revealed that hospital staff often withdraw less than the required volume. A paper by Prof. Scheithauer at Aachen University Hospital found an average withdrawal of 1.69 ml per hand disinfection. Only through regular hand hygiene feedback to nurses and physicians did the value rise to 2.66 ml per disinfection. [2]

Hand hygiene consumption.
Increased hand hygiene quality through feeback.

The influence of the amount of hand disinfectant on the hand is illustrated in a study by Prof. Günter Kampf. When less than 2 milliliters is taken, gaps in the application of disinfectant appear. These gaps can cover over 60 percent of the skin. These dry patches play into the hands of the pathogens, so to speak. [3]

Hand disinfectant: How to rub it in?

Once enough sanitizer has been dispensed, the alcohol-based formulation still has to make it into all areas through thorough rubbing. The basis for these steps of hygienic hand disinfection is DIN EN 1500, a European standard to that establishes hygienic handrub processes and evaluations. The model is based on a 30-second procedure and covers the palms, backs of the hands, fingertips, thumbs, nail folds and also the wrists. Both national and international institutions follow this standard, which is intended to serve as a guide for medical staff in everyday clinical practice. So far so good.

Six steps of hand disinfection
6 Steps of Hygienic Hand Disinfection

However, there are also people who are critical of this approach. These critics favor a simplified method. Among other things, they point to the low-levels of hand hygiene compliance in hospitals as a problem with the status quo. These opponents of the 6-step method claim that an easier rub-in method may lead to an increase in hand disinfections and an overall improvement in patient protection.

The 3 steps of hand disinfection

To test this hypothesis, scientists at the University Hospital Basel investigated the impact of simplifying the conventional six steps of hand hygiene to three steps in hospitals. In addition, they researched the impact of the modified technique on germ reduction. [4]

The study was conducted by a research team led by Sarah Tschudin-Sutter on twelve wards at the renowned university hospital. The new, 3 steps of hygienic hand disinfection included:

  1. spreading on the palms and backs of the hands, including the wrists
  2. rubbing the fingertips in a circular motion in the opposite hand
  3. rubbing the thumb in a circular motion in the opposite hand.

The rub-in time and the amount of disinfectant removed remained unchanged with the adapted technique (30 seconds with 3 ml of hand disinfectant).

Hand hygiene compliance improved?

To compare how the hand hygiene behavior of hospital staff changed as a result of the simplified method, four trained staff members observed what was happening on the wards. Based on the five moments of hand hygiene, the observers recorded whether disinfection also occurred at a required time.

Over two months, more than 2,900 required hand disinfections were observed in participating hospital wards, split roughly equally between the 3-step method and 6-step method.

The results showed that the simplified rub-in technique leads to significantly better hand hygiene compliance compared to the classical approach (75.9% vs. 65.0%).

Microbiological evaluation

This increase in compliance means little if the three-step method left more germs on the skin than the six-step approach. Clinically relevant pathogens such as Staphylococcus aureus were taken into account in the study and the reduction was recorded on the basis of colony-forming units. In comparing the two methods, there are no significant differences with regard to germ reduction. From a microbiological point of view, a simplification of the rub-in method is unobjectionable.

Conclusion for hospital hygiene

right hand disinfection with the ingo-man SmartNose
The ingo-man smart with integrated feedback LED.

The six steps of hygienic hand disinfection cannot be viewed as a natural law or guidance that is set in stone. A simple and easier-to-remember alternative has led to increased compliance—with no downsides.

Ultimately, it is important that all skin areas are lathered using 3 ml of disinfectant for 30 seconds. The frequently forgotten areas on the fingertips and thumbs require special attention, as the germ density is comparatively high here.

Technological innovations in the field of hand hygiene, like the ingo-man SmartNose, lead to further hand disinfection improvements, both quantitatively and qualitatively. Through feedback from a flashing green LED, the dispenser lets medical staff immediately know when enough hand disinfectant has been taken from the Euro dispenser.


[1] Kommission für Krankenhaushygiene und Infektionsprävention beim Robert Koch-Insitut “Händehygiene in Einrichtungen des Gesundheitswesens.” Bundesgesundheitsblatt-Gesundheitsforschung-Gesundheitsschutz 9 (2016): 1189.

[2] Scheithauer  S et al. Do WiFi-based hand hygiene dispenser systems increase hand hygiene Compliance? Am J Infect Control. 2018;46:1192-1194

[3] Kampf G et al. Less and less–influence of volume on hand coverage and bactericidal efficacy in hand disinfection. BMC infectious diseases. 2013;13: 472.

[4] Tschudin-Sutter, Sarah, et al. “Simplifying the World Health Organization protocol: 3 steps versus 6 steps for performance of hand hygiene in a cluster-randomized trial.” Clinical Infectious Diseases 69.4 (2019): 614-620.


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