Hand hygiene: It's ginormous

An important new paper in the American Journal of Infection Control helps to put hand hygiene compliance efforts into perspective. The authors performed the study in 12 patient rooms in an adult medical ward in a 746-bed teaching hospital. Using video surveillance, they analyzed the number of hand hygiene opportunities using the World Health Organization My 5 Moments framework. The key finding was that there are approximately 72 hand hygiene opportunities per patient-day. Nurses account for 75% of the opportunities, while physicians account for 5%. Care of patients >65 years presented more opportunities than younger patients (80/day vs. 67 for those 50-64 years vs. 64 for those under 50 years). The proportion of opportunities for each WHO Moment is shown in the figure below:
Most hospitals that measure compliance using direct observation are primarily measuring Moments 1 and 5, about 65% of the opportunities. One might argue that these are the two most important moments in terms of overall magnitude of risk, but Moment 2 is also very important from the standpoint of transmission risk per opportunity.

If we assume that 72 opportunities per patient day is roughly the average (ICUs likely more, lower acuity wards likely less), and apply that to my hospital, which had 207,000 patient days last year, I can estimate that we have about 15 million hand hygiene opportunities yearly. This does not include procedural areas or the Emergency Department. Fifteen million is a lot better than my old nebulous estimate of infinitely many. Lord Kelvin would be proud. But it also means that we are directly observing <0.5% of all the opportunities. It's daunting to think that our goal is near perfect compliance with 15 million acts of human behavior, but like any other health-related behavior, change is incremental and reaching the goal typically requires decades of work. Infection prevention is not a pursuit for the faint of heart!


  1. Excellent post Mike. 15 million. Do you have a sense of how many of these observations we need to observe to accurately measure hand hygiene? It seems like we could use simple statistical power calculations to determine how many observations we need to observe. Many companies now make automated surveillance technologies and some claim we need to measure all opportunities to be accurate.

  2. The number of opportunities and compliance varies by type of healthcare worker and hospital unit, so I suspect there would need to be a sampling strategy.

  3. Dear Mike,

    I can't agree with you more regarding the issue of hand hygiene and doctor/nurse compliance. My business partner and I came across this issue several years ago and started working on a system to improve the process. Our viewpoint is that even if we get people to wash their hands when they are supposed to, most of them don't do so correctly. Recent studies show that people scrub for about 8-10 seconds instead of the CDC recommended 20 seconds. This means that most people, even when washing their hands frequently, still leave over 50% of their hands dirty! To combat this we developed the Enforc Hygiene System. Our system requires people to maintain soap on their hands for the CDC recommended 20 seconds while at the same time educating them on the proper scrubbing technique. We believe this can have a great impact in healthcare, food-service, and education. Please visit our website and if you are willing please share our facebook page at www.facebook.com/enforchygiene

    We will be starting a crowdfunding campaign in the next 2-3 months and appreciate any help we can get spreading the word about our system and how it can help to reduce illnesses and save lives!

    Thank You


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