Beyond entry and exit: Hand hygiene at the bedside

Published:December 21, 2018DOI:


      • Opportunities for hand hygiene are frequent at the bedside.
      • Compliance with WHO 5 moments of hand hygiene in ICUs was poor, 35%.
      • Few healthcare workers recall the WHO 5 moments.


      We aimed to assess compliance, knowledge, and attitudes regarding the World Health Organization (WHO) 5 moments for hand hygiene (HH).


      We assessed HH compliance from July-August 2016, using a modified WHO HH observation form. A 26-question survey was used to assess health care personnel (HCP) knowledge, opinions, and barriers to HH. A subgroup of HCPs participated in a 2-round focused survey to assign priority to the moments.


      Three hundred two HH opportunities were observed in 104 unique HCP-patient interactions. HH was performed at 106 (35%) opportunities, 37% (25 of 68) before touching a patient, 9% (6 of 70) before aseptic procedures, 5% (1 of 22) after body fluid exposure or risk, 63% (55 of 88) after touching a patient, and 35% (19 of 54) after touching patient surroundings. Two hundred eighteen HCPs completed the survey; 63 (29%) were familiar with the WHO 5 moments but only 13 (21%) were able to recall all 5 moments. In the focused surveys, 46% (6 of 13) ranked “before aseptic procedure” as the most important HH moment, and 86% (11 of 13) identified “after touching patient surroundings” as the least important.


      We found frequent opportunities for HH with infrequent compliance. Lack of recognition of opportunities at the bedside and frequent glove use may contribute to lower compliance.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Infection Control
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Sax H
        • Allegranzi B
        • Uckay I
        • Larson E
        • Boyce J
        • Pittet D
        ‘My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene.
        J Hosp Infect. 2007; 67: 9-21
        • Strich JR
        • Palmore TN
        Preventing transmission of multidrug-resistant pathogens in the intensive care unit.
        Infect Dis Clin North Am. 2017; 31: 535-550
        • Laskar AM
        • R D
        • Bhat P
        • Pottakkat B
        • Narayan S
        • Sastry AS
        • et al.
        A multimodal intervention to improve hand hygiene compliance in a tertiary care center.
        Am J Infect Control. 2018; 46: 775-780
      1. Siegel JD, Rhinehart E, Jackson M, Chiarello L. Healthcare Infection Control Practices Advisory Committee. 2007 Guidelines for isolation precautions: preventing transmission of infectious agents in healthcare settings. Am J Infect Control 2007;35:S65-164.

      2. World Health Organization. Tools for evaluation and feedback. Available from: Accessed June 20, 2016.

        • Cusini A
        • Nydegger D
        • Kaspar T
        • Schweiger A
        • Kuhn R
        • Marschall J
        Improved hand hygiene compliance after eliminating mandatory glove use from contact precautions—is less more?.
        Am J Infect Control. 2015; 43: 922-927
        • Chang NC
        • Reisinger HS
        • Jesson AR
        • Schweizer ML
        • Morgan DJ
        • Forrest GN
        • et al.
        Feasibility of monitoring compliance to the my 5 moments and entry/exit hand hygiene methods in US hospitals.
        Am J Infect Control. 2016; 44: 938-940
        • Fuller C
        • Savage J
        • Besser S
        • Hayward A
        • Cookson B
        • Cooper B
        • et al.
        “The dirty hand in the latex glove”: a study of hand hygiene compliance when gloves are worn.
        Infect Control Hosp Epidemiol. 2011; 32: 1194-1199
        • Sunkesula VC
        • Meranda D
        • Kundrapu S
        • Zabarsky TF
        • McKee M
        • Macinga DR
        • et al.
        Comparison of hand hygiene monitoring using the 5 moments for hand hygiene method versus a wash in-wash out method.
        Am J Infect Control. 2015; 43: 16-19
        • Haac B
        • Rock C
        • Harris AD
        • Pineles L
        • Stein D
        • Scalea T
        • et al.
        Hand hygiene compliance in the setting of trauma resuscitation.
        Injury. 2017; 48: 165-170
        • Qasmi SA
        • Mahmood Shah SM
        • Wakil HY
        • Pirzada S
        Guiding hand hygiene interventions among future healthcare workers: implications of knowledge, attitudes, and social influences.
        Am J Infect Control. 2018; 46: 1026-1031
        • Pittet D
        Compliance with hand disinfection and its impact on hospital-acquired infections.
        J Hosp Infect. 2001; 48: 40-46
        • McArdle FI
        • Lee RJ
        • Gibb AP
        • Walsh TS
        How much time is needed for hand hygiene in intensive care? A prospective trained observer study of rates of contact between healthcare workers and intensive care patients.
        J Hosp Infect. 2006; 62: 304-310
        • Morgan DJ
        • Pineles L
        • Shardell M
        • Graham MM
        • Mohammadi S
        • Forrest GN
        • et al.
        The effect of contact precautions on healthcare worker activity in acute care hospitals.
        Infect Control Hosp Epidemiol. 2013; 34: 69-73
        • Harris AD
        • Pineles L
        • Belton B
        • Johnson JK
        • Shardell M
        • Loeb M
        • et al.
        Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU: a randomized trial.
        JAMA. 2013; 310: 1571-1580
        • Joint Commission
        Measuring hand hygiene adherence: overcoming the challenges.
        Joint Commission, Oakbrook Terrace, IL2009