hand hygiene
hand hygiene
By Robert Lee
Hand Hygiene: Have We Improved? The Post-COVID Story of Hand Hygiene and Hospital Infections
When the COVID-19 pandemic struck, hand hygiene quickly became a frontline defense— one of the simplest yet most powerful tools in our infection control arsenal. As fear spread and hospitals scrambled to protect both patients and staff, compliance with handwashing protocols soared. Alcohol-based handrubs appeared everywhere. Posters reminded us to scrub for 20 seconds. For a while, it seemed we were finally winning the decades-long battle for better hand hygiene. And in many ways, we were.
During the peak of the pandemic, studies from hospitals around the world reported dramatic improvements in hand hygiene compliance. Some facilities saw rates rise from below 50 percent to more than 80 percent, even reaching near-perfect adherence in specific units during crisis periods. In China, for instance, compliance at one major hospital jumped from around 82 percent in 2017 to nearly 90 percent by 2022— most of that increase occurring after COVID-19 began.
Similarly, U. S. hospitals recorded significant spikes in hygiene behavior, driven by real-time fear and institutional campaigns. But as the months wore on and the immediate threat of the virus receded, those gains began to taper off.
Recent studies suggest that while hand hygiene compliance is still better than pre-pandemic levels, it has declined from its COVID-era highs. For example, compliance rose to roughly 70 percent during 2020 to 2021, up from about 54 percent in earlier years, but dropped back slightly afterward. Fatigue, staffing shortages, and shifting priorities have all contributed to a modest backslide. The urgency that fueled near-perfect compliance has faded and maintaining that momentum has proven difficult.
Still, the temporary rise in hygiene standards appears to have had a meaningful impact, particularly on hospital-acquired infections( HAIs). Initially, some hospitals saw infection rates spike in early 2020, largely due to overwhelmed systems and disrupted care. But as hospitals stabilized and hand hygiene improved, infection rates began to fall again. In fact, a 2023 report found that approximately 85 percent of hospitals in the U. S. saw reductions in serious HAIs like MRSA, central line-associated bloodstream infections( CLABSI), and catheter-associated urinary tract infections( CAUTI) after the peak of the pandemic. Even infections that are notoriously difficult to control, like Clostridioides difficile, saw declines in settings where hand hygiene was emphasized. This reinforces a longstanding truth in infection control: better hand hygiene saves lives.
Yet the progress isn’ t universal. Some hospitals still struggle with inconsistent compliance, and resistant infections remain a growing concern, especially those fueled by pandemic-era antibiotic overuse. Sustaining high levels of hygiene compliance in the long term will require more than just occasional campaigns. It demands leadership, feedback systems, accountability, and continuous education.
So, have things improved? The answer is yes— with nuance. We have seen that hand hygiene can improve quickly when systems and motivation align, and we’ ve seen corresponding drops in many hospital infection rates. The challenge now is turning those emergency-era gains into lasting standards of care.
Because the real test isn’ t whether we can wash our hands well during a crisis— it’ s whether we keep doing it when the crisis ends.
Based on WHO and infection control guidelines, the following strategies are recommended:
➊ System-change implementation Ensure ABHR dispensers are strategically located, maintained, and available in portable formats
➋ Education and training reinforcement
Recurrent, role-specific training focusing on WHO’ s Five Moments, proper volume, technique, and duration( more than 30 seconds)
➌ Monitoring and feedback mechanisms Transition to electronic monitoring systems for accuracy and real-time clinician feedback Infection Control
➍ Leadership and cultural modeling Encourage senior clinicians and administrators to visibly model expected behaviors and reinforce norms.
➎ Address visitor behavior Provide ABHR at points of entry / exit, signage, and awareness messaging to improve visitor hand hygiene rates.
➏ Manage workflows and fatigue Address staffing levels, restructure shift workflows, and integrate hygiene into routine care without adding perceived burdens.
Despite early pandemic improvements, hand hygiene compliance remains fragile across healthcare settings and among visitors. Key challenges include workload strain, supply shortfalls, suboptimal techniques, weak monitoring, and declining risk perception. Regaining and sustaining compliance demands a multimodal, leadership-driven approach grounded in WHO principles: system change, training, monitoring, reminders, and culture development.
As some final thoughts, I ask the following questions:
➊ What do we lag behind the world in understanding hand hygiene compliance? The world uses the WHO 5 Moments and we are still stuck on entry / exit of a patient room.
➋ Why are we not measuring the right things when it comes to hand hygiene compliance? The world is moving toward measuring hand hygiene compliance inside the patient room and high-touch surfaces. Why are we still measuring at the door? 70 % of the opportunities are in the room.
➌ Why are we not measuring ourselves and our interventions against HAI reduction and antibiotic resistance? Why are we not tying infection rates to hand hygiene compliance rates vs. the current error base metric of room entry / exit?
Ladies and gentlemen, the knowledge, common sense, technology and data are available, and the economics are very powerful. Why are we not all over this initiative?
Robert Lee, BA, the CEO and founder of MD-Medical Data Quality & Safety Advisors, LLC, is the senior biologist and performance improvement consultant. MD-MDQSA is the home of The IPEX- The Infection Prevention Exchange, a digital collaboration between selected evidence-based solutions that use big data, technology, and AI to reduce risk of HAIs.
sept-oct 2025 • www. healthcarehygienemagazine. com •
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