Clean Care is Safer Care

My Five Moments for Hand Hygiene

Q: How does the Five Moments concept relate to the indications for hand hygiene, contained within the WHO Guidelines on Hand Hygiene in Health?

A: The “Five Indications/Five Moments” concept incorporates all of the WHO recommendations for hand hygiene. The decision to address hand hygiene by focusing on five moments only is intended to make it easier to understand when there is a risk of pathogen transmission via the hands, to memorize them, and to assimilate them into the dynamics of health-care activities. It is intended to reduce the number of times when hand hygiene occurs to the minimum for maximum safety.

Q: What, in summary, is the underlying theory of My Five Moments for Hand Hygiene?

A: Indications for hand hygiene depend on health-care workers’ movements between geographical areas (the care environment and the patient surroundings often referred to as the "patient zone" and the "health-care zone") and on the tasks they perform in these areas. Health-care activity is made up of a succession of tasks during which health-care workers’ hands touch different types of surfaces (patient, object, body fluid, etc.). Depending on the order in which these contacts occur, pathogen transmission from one surface to another must be interrupted, as each contact is a potential source of contamination. It is during the interval between two contacts that the moments (indication or indications) for hand hygiene occur.

The “before” indications are present when there is a risk of microbial transmission to the patient; the actions that correspond to these indications protect the patient.

The “after” indications are present when there is a risk of microbial transmission to the health-care worker and/or to the health-care environment (and to any other person present); the actions that correspond to these indications protect health-care workers and the health-care environment and ultimately other patients..

The right action at the right moment will contribute significantly to the maintenance of clean and safe care in the context of pathogens transmitted by hands.

Q: What is the difference between ‘an indication’, ‘an opportunity’ and ‘a moment’ for hand hygiene?

A: THE INDICATION is the reason why hand hygiene is necessary at any given moment. It is related to the risk of pathogen transmission from one surface to another. There is an indication for hand hygiene whenever there is a risk of a health-care worker’s hands transmitting pathogens during health-care delivery. The risk of transmission may arise as a result of the risk of transmission from the health-care environment to the patient; from one body site to another in the same patient; or from the patient and the patient surroundings to the health-care worker and to the health-care environment (which includes everyone present in that setting).

Indications relate to reference points in time i.e. “before” or “after” the contact. The indications “before” and “after” do not necessarily correspond to the beginning and end of a care sequence or activity. They occur during movements between geographical areas, during transitions between tasks near patients, between patients, or some distance from them.

Five indications have been adopted and these constitute the fundamental temporal reference points for health-care workers: “Before patient contact”, “Before aseptic task”, “After body fluid exposure risk”, “After patient contact“ and “After contact with patient surroundings”. These five indications designate the moments when hand hygiene is required, in order to effectively interrupt pathogen transmission during care.

In summary, the five moments for hand hygiene are the five "indications" for hand hygiene in health care.

THE OPPORTUNITY for hand hygiene is important when observing compliance. From the point of view of the observer, the opportunity exists whenever one of the moments for hand hygiene is present and observed. At a simple level, each opportunity must be followed by an action (i.e. hand hygiene).

Several moments may come together to create a single opportunity. What this means is that there may be several simultaneous reasons for a hand hygiene action. Health-care safety depends on the action taken in response to the moments for hand hygiene, since hand hygiene makes it possible to prevent the risk of pathogen transmission.

Clear examples of moments (indications) and opportunities are given in the manual for observers, available by enrolling as a complementary test site:

Q: Why do the Five Moments not include hand hygiene before touching furniture in the patient’s immediate vicinity?

A: The Five Moments have been prioritized on the basis of the risk of pathogen transmission. There is not an indication to perform hand hygiene before touching the patient’s environment (bed frame, bedside table, patient table). The most important reason why is the fact that any object or surface in the patient's immediate surroundings is part of the "patient zone" and is considered to be contaminated by the patient's pathogens.

The first moment on approaching a patient is "Moment 1" - Before Patient Contact - clearly indicating that on entering the patient zone (crossing the theoretical dotted line which separates the patient environment from the health-care environment), the indication is immediately before touching the patient. If the bedside table is touched, hand hygiene does not need to occur before this action. Hand hygiene should occur either when entering the patient zone and before touching the table and then touching the patient, or after touching the bedside table and immediately before touching the patient. In both cases the indication is Before Patient Contact (moment 1).

Therefore when observing hand hygiene always remember each of the 5 moments and ask the question "is what I am observing an indication for hand hygiene according to the Five Moments?” If "no", then there is no need for hand hygiene. There is no indication "Before Patient Environment"; so it is not necessary to clean hands before touching the patient’s environment. If you clean your hands while entering the patient zone, you may touch the environment and then touch the patient because hands will be contaminated only with that individual patient’s pathogens.

In the event that the health-care worker touches the patient’s environment only and not the patient, hand hygiene must be performed on leaving the patient zone according to the moment "after contact with patient environment".

There may be some clinical settings where local adaptation of this particular aspect of Five Moments is necessary and we welcome feedback with regard to this.

Q: Why does “Before Aseptic Task” include many tasks which are not usually associated with the term "aseptic" e.g. oral care?

A: As part of the simplification process and to move away from fragmented and lengthy lists of indications, a decision was made to use this term, in this context, to embrace tasks and procedures which involve contact with the patient's mucous membranes and non-intact skin, or with an invasive medical device. So, within the Five Moments, "Before Aseptic Task" refers to accepted “aseptic” procedures (e.g. catheter insertion) but also any contact/procedure involving contact with mucous membranes/broken skin that constitute a risk of pathogen inoculation. The term ‘aseptic’ is used in this way in the interests of simplicity, and it is not intended to confuse the standard definitions of what constitutes asepsis.

Q: Can the Five Moments be adapted or altered?

A: If a hospital/country/professional association intends to adapt or modify the Five Moments concept, for example, to add or remove one of the moments, WHO might be interested in supporting well designed research strategies, and would consider working with the investigators to develop this. However, the potential unique selling point and added value that the Five Moments concept offers, rests with the premise that it is an evidence-based, universally relevant concept. WHO would be concerned about changes that do not take heed of underlying evidence and thereby dilute the potential power of the Five Moments, and undermine its role as a powerful campaigning tool.

Q: How do we apply the Five Moments concept in situations where there is multiple bed-occupancy?

A: Unfortunate circumstance can occur where more than one patient is sharing a patient environment/patient zone: either the same bed or the space under or around the bed. The resulting shared environment becomes a place where transmission of microbes may occur irrespective of hand hygiene. In these circumstances, the patients are likely to become colonized by the same microbes, irrespective of the frequency of hand hygiene.

In these situations, conceptually there is one set of shared microbes within the patient environment. Is hand hygiene compliance important in these situations? The answer is a resounding "yes". The emphasis, however, shifts to moments 2 and 3 for each individual patient, since compliance here is critical. Compliance with moments 1, 4 and 5, before entering and after leaving the patient/patients’ surroundings still apply. When entering the "two-patient environment", compliance with moment 1 applies. In a similar way, after contact with either or both the patients, or leaving their environment, provides an indication for hand hygiene. However, logic dictates that when undertaking tasks within the patient environment, the indications “before” and “after” patient contact, when moving from one patient to the other (in the same bed), are meaningless. This is similar to the situation encountered when caring for a mother and baby.

Q: How do you apply the Five Moments in situations where bed spacing is sub-optimal?

A: The principles should still be applied, each bed having its own 'zone' around it, within which the Five Moments apply.