Throughout the world, surveillance and prevention of healthcare-associated infections (HCAIs) have become a greater priority for institutions committed to making healthcare safer. These infections have been associated with prolonged hospital stays, long-term disability, increased resistance of microorganisms to antimicrobials, massive financial burdens, high costs for patients and their families, and excess deaths. One prominent reason for the spread of HCAIs has been poor hand hygiene. In an effort to address this issue, the World Health Organization (WHO) issued guidelines on hand hygiene in healthcare in May 2009. Available at, the guidelines offer a thorough review of evidence as well as specific recommendations to improve hand hygiene practices and reduce transmission of pathogenic microorganisms to patients and healthcare workers (HCWs).

“The new WHO guidelines are an extension to recommendations issued by the CDC in 2002,” explains Maryanne McGuckin, ScEd, MT, who was on the task force that created both the WHO and CDC guidelines. “They provide an extensive literature review and inform clinicians on strategies for improvement that have tested successfully.” The WHO guidelines are designed to be used in any setting in which healthcare is delivered. Individual adaptation of the recommendations is encouraged, based on local regulations, settings, needs, and resources.

Assessing Practices & Adherence

According to the WHO guidelines, understanding hand hygiene practices among HCWs is essential to planning interventions. Adherence by HCWs to recommended procedures has been reported with significant variation, reaching unacceptably poor levels in some cases. Risk factors for poor adherence to hand hygiene recommendations have been well-documented, and there appears to be an inverse relationship between intensity of patient care and adherence to hand hygiene. Perceived barriers to hand hygiene adherence recommendations include skin irritation caused by hand hygiene agents, inaccessible hand hygiene supplies, interference with HCW-patient relationships, and the perception that patient needs take priority over hand hygiene. Wearing of gloves, forgetfulness, lack of knowledge of guidelines, insufficient time for hand hygiene, and high workload and understaffing are other perceived barriers. Furthermore, some HCWs have reported believing that they washed their hands when necessary even when observations indicated that they did not.

Enacting Real Change

The WHO guidelines provide many important recommendations, spanning the domains of indications for hand hygiene; hand hygiene technique; surgical hand preparation; selection and handling of hand hygiene agents; skin care; use of gloves; and other aspects of hand hygiene. Dr. McGuckin says that most HCWs are aware of practices that correlate with good hand hygiene, but she notes that—despite this fact—rates of adherence are still low. “The key for clinicians is to understand that good hand hygiene practices are encouraged at each and every patient encounter. Clinicians must understand when and how to use specific techniques. To enact real change, multimodal approaches and complete collaboration among all constituents are imperative. Guidelines must be disseminated, multidisciplinary efforts aimed at improving hand hygiene must be fostered, and explicit administrative support must be gained and maintained.”

The guidelines outline several strategies to implement improvement efforts for hand hygiene. “Some strategies include posting hand hygiene policies near the point of care, conducting education and training programs regularly, and ensuring that facilities are equipped properly to encourage good hand hygiene,” says Dr. McGuckin. “A helpful example is the ‘My 5 Moments for Hand Hygiene’ tool, which serves as a reminder for clinicians on when to practice hand hygiene [Figure 1]. This tool and others outlined in the WHO guidelines should be disseminated throughout healthcare settings.”

Empowering Patients & HCWs

There has been increasing interest in establishing interventions to promote hand hygiene, including (but not limited to) HCW education, performance feedback, reminders, use of automated sinks, and the introduction of alcohol-based handrubs. Dr. McGuckin says that education of HCWs and patients alike is one of the cornerstones of improvement in hand hygiene practices (Figure 2). “It’s especially critical that patients be empowered to ask their HCWs questions about hand hygiene. Likewise, providers need to be proactive and inform patients that they’re practicing good hand hygiene to protect them. Fostering and encouraging this communication is critical, and the issue must be brought to the forefront.”

Sustaining Efforts

Regular hand hygiene monitoring and feedback on adherence by HCWs are imperative to sustaining hand hygiene improvements. “The ultimate goal is to lower the rate of HCAIs,” says Dr. McGuckin. “To do that, the impact of hand hygiene interventions and promotion programs for HCWs must be measured. The clinical focus should be on specific factors that influence behavior. Strategies should be multifaceted and multimodal, and include consistent education and senior executive support.”


World Health Organization. WHO Guidelines on Hand Hygiene in Health Care, 2009. Available at: Accessed October 22, 2009.

McGuckin Methods International, Inc. Available at: Accessed October 28, 2009.

Boyce JM. Hand hygiene compliance monitoring: current perspectives from the USA. J Hosp Infect. 2008;70(Suppl 1):2-7.

Pittet D, Allegranzi B, Boyce J; World Health Organization World Alliance for Patient Safety First Global Patient Safety Challenge Core Group of Experts. The World Health Organization Guidelines on Hand Hygiene in Health Care and their consensus recommendations. Infect Control Hosp Epidemiol. 2009;30:611-622.

Sax H, Allegranzi B, Uçkay 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.