The Five Moments assume that the decision to undertake hand hygiene is always under the direct control of healthcare workers , but they are frequently confronted with competing priorities .”
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or they don ’ t . In one hospital I visited , the infection control team admitted that they were sometimes referred to as the ‘ handwashing Nazis .’ There is an unfortunate part of the profession that still embraces this identity and so the absolutism of the Five Moments makes sense . Is it the same individual who enjoys barking at clinicians , regardless of their seniority , who we would expect to proactively work with busy healthcare workers to redesign their processes to make hand sanitization easier ?”
Instead of continuing the status quo , the researchers suggest as a solution that the guidelines for hand hygiene practice should be rewritten and audits based on newer methodologies , such as the one from the National Institute for Health and Care Excellence in the UK . As the researchers note , “ Straightforward interventions such as asking about optimal placement of alcohol handrub and positioning dispensers where workflow is high can promote uptake .” They also emphasize the importance of considering the preferences and opinions of healthcare personnel and patients .
The second inconvenient truth , and perhaps one of the most important , is that it is not always possible to implement the Five Moments for all patients all the time . As the researchers emphasize , “ Accounts of the Five Moments are frequently illustrated with a diagram depicting how pathogens can be transmitted to an acutely sick patient , but patients have widely differing needs and receive care in diverse settings , and the Five Moments do not adapt well to all the many differences between individuals and clinical settings .” They explain that many patients have a very high risk of infection yet receive much or all their care in outpatient and community settings where delineation into the patient and healthcare zones is less straightforward . They add , “ As it is not always possible to identify which patients are at high risk in a given situation , it is safer to promote hand hygiene throughout healthcare premises regardless of which groups of patients occupy them , for example by providing hand hygiene products at key locations such as ward entry points .”
As a solution , the researchers suggest implementing hand hygiene dispensers
at hospital , clinics and ward entrances and throughout wards with prompts , monitoring at all locations , engaging in publicity and using signage to convey the importance of hand hygiene in all areas of the healthcare institution . They explain , “ Notices combined with visual or audible alerts can promote uptake at entrances to hospitals , clinics and wards . Consistent use at these locations would prompt hand hygiene at least twice before health workers or visitors reach settings where care is delivered . Devices to promote and monitor uptake at these locations are commercially available .”
The third inconvenient truth according to Gould and Purssell , et al . ( 2022 ) is that the patient zone is not a fixed entity , because as patients move between clinical areas on the same ward and to non-clinical areas , they carry their microbes with them . The researchers say that seeing the patient zone as “ a single , homogenous area oversimplifies the complexity of healthcare environments .” Heavy-traffic areas of the hospital such as corridors or lobbies are likely to be more heavily contaminated than wards , the researchers say , emphasizing that “ Peripatetic health workers and others moving between wards and departments can disseminate large numbers of microorganisms picked up in general hospital locations , with shedding en route .” Several studies have documented that patients staying in rooms formerly occupied by infectious patients are at increased risk of colonization and infection although they occupy the same physical space consecutively rather than occupying the same patient zone . Additionally , the researchers astutely observe that many healthcare personnel never enter the patient zone , although they handle equipment that can function as fomites that will enter it .
As a solution , the researchers suggest several strategies , including placing hand hygiene dispensers at hospital , clinic and ward entrances with prompts , monitoring and publicity , as well as introducing a stochastic approach to hand hygiene programs and audit at agreed ‘ set points .” Additionally , they recommend refreshing hand hygiene training to reflect hand hygiene at the agreed “ set points ” as well as introducing non-touch technology ( such as automatic doors ).
As Gould and Purssell , et al . ( 2022 ) explain , “ Computer simulations demonstrate that hand contamination and transmission both have random elements . Individual hand contacts represent low risk of transmission ; it is the overall risk at system level and the cumulative frequency of hand contacts that successively increase risk . Cumulative risk could be overcome by introducing thorough antisepsis at the beginning and end of health workers ’ shifts and at predetermined intervals throughout to compensate for hand hygiene opportunities that might be overlooked or inadequately performed . We suggest that these new set points should augment the Five Moments , not replace them . With this system , hand hygiene frequency would require modification according to patient vulnerability and under particular circumstances . Visitors to healthcare facilities would need to be included in these arrangements , especially if they engage in patient care . Audits would need to be adjusted to include adherence at the new set points and to obtain data in relation to both frequency and thoroughness . All those present in the clinical environment throughout an audit period would need to be included . An agile approach adapted in response to frequent adjustments would be required and an audit tool to monitor thoroughness would need to be developed . A new hand hygiene program based on a stochastic approach could be taken as the catalyst to revitalize clinicians ’ hand hygiene . Adjustments to set points and audits to meet immediate clinical need would provide the periodic refreshers that have been identified as necessary to revitalize hand hygiene campaigns . Health workers will need education and training to promote this new approach to hand hygiene .”
Interestingly , the researchers ’ fourth inconvenient truth addresses the fact that the Five Moments overlook barriers that can reduce hand hygiene compliance . As they explain , “ The Five Moments assume that the decision to undertake hand hygiene is always under the direct control of healthcare workers , but they are frequently confronted with competing priorities . Hand hygiene can be compromised by high workload and clinical and non-clinical interruptions . When the pace of work is rapid , health workers segue between one task and the next without pause , and multitask , particularly in acute-care settings . It is not always possible to determine precisely when hand hygiene is necessary .”
While some Five Moments devotees may cry heresy , Gould and Purssell , et al . ( 2022 ) say as the fifth inconvenience truth that adherence to the Five Moments cannot prevent all risks of transmission , and this model is not a silver bullet against transmission risk .
As the researchers explain , “ Surfaces distant from patient care areas are often heavily contaminated with pathogens able to cause HAI . They can withstand desiccation , survive for long periods in the inanimate environment and frequently contaminate health workers ’ hands . If the Five Moments are applied , cross-infection should be avoidable providing hand hygiene is undertaken before the health worker enters the patient zone or initiates
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18 • www . healthcarehygienemagazine . com • may 2024