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Clin Infect Dis. 2018 Nov 3. doi: 10.1093/cid/ciy948. [Epub ahead of print]

Simplifying the WHO protocol: Three steps versus six steps for performance of hand hygiene - a cluster-randomized trial.

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Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland.
Department of Internal Medicine, University Hospital Basel, Basel Switzerland.
Division of Clinical Microbiology, University Hospital Basel, Basel, Switzerland.



In an experimental setting, a simplified 3-step hand hygiene technique for applying alcohol-based hand rub was non-inferior in terms of reduction of bacterial counts as compared to the conventional WHO-6-step technique. We therefore compared compliance and microbiological efficacy between both hand hygiene techniques in routine clinical practice.


We performed a cluster-randomized trial from 10/2015-11/2015 at the University Hospital Basel, Switzerland - a tertiary academic care center (ISRCTN45923734). Twelve wards were randomly assigned to either the 3-step technique or the conventional 6-step technique for use of hand rub. The primary endpoints were compliance with the assigned technique and reduction of bacterial counts on hands of healthcare workers.


Overall, 2923 hand hygiene indications were observed and compliance was 70.7% (2066/2923). Compliance with technique and indications was 51.7% (595/1151) and 75.9% (1151/1516) on wards assigned to the 3-step technique, as compared to 12.7% (116/915) and 65.0% (915/1407) on wards assigned to the 6-step technique (p<0.001). The reduction factor (RF) of bacterial colony counts did not differ between both techniques (median RF 0.97 log10 CFU, IQR 0.39-1.59 for the 3-step technique vs. median RF 1.04 log10 CFU, IQR 0.49-1.52 for the 6-step technique, p=0.629).


The simpler hand hygiene technique consisting of three steps resulted in higher compliance with both hand hygiene indications and technique as compared to the six steps in a clinical setting. As the results of the microbiological analyses exclude inferiority, the conventional six steps could be safely replaced by a simpler hand hygiene technique.


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