Healthcare-associated infections (HAIs) are the most commonly occurring adverse events in healthcare settings worldwide. In fact, the World Health Organization (WHO) estimates that hundreds of millions of patients acquire HAIs every year at rates of 7 percent and 10 percent in developed and developing countries, respectively.
As HAIs can lead to highly unfavorable or fatal outcomes, there is a need for caregivers to minimize their spread.
Published literature shows that frequent handwashing in hospitals is the best way of achieving this goal. But how long should a health worker wash or sanitize his or her hands to achieve optimal hand hygiene?
Latest Hand Hygiene Guidelines
There is a general consensus on the need for handwashing, when to do so and the best materials to use; however, confusion surrounds the best timing for hand hygiene. According to the latest Centers for Disease Control and Prevention guidelines, when washing with soap and water, the crucial scrubbing stage should last for at least 20 seconds—the length of the song Happy Birthday sung twice through.
The WHO recommends that visibly soiled hands should be washed with soap and water for 40 to 60 seconds. However, it does not specify how long should be dedicated to the scrubbing phase. But, with over half of its 11-step handwashing procedure taken up by this important phase, it is likely that at least half of those 40 to 60 seconds will be spent on scrubbing, corresponding with the CDC’s recommended timing.
As the friction created when lathering soap is needed to effectively clean hands with soap and water, there is less scope for reducing the time spent on this practice. However, hand hygiene using alcohol-based sanitizer relies primarily on alcohol rather than friction for microbial elimination.
This may be why the WHO’s guidelines suggest that just 20 to 30 seconds are all it takes to achieve optimal hand hygiene when using an alcohol-based formula.
Why Hand Hygiene Timing Matters
While CDC recommendations suggest that hand hygiene should be carried out at seven key moments in healthcare settings, including before and after contact with patients, research has shown that compliance with this remains low. According to the WHO, baseline rates of compliance range from 5 percent to 89 percent, representing an overall average of just 38.7 percent.
Better education on the importance of hand hygiene and more regular reminders are likely to help to improve compliance rates, but it is also important to consider the impact of the time demands of hand hygiene on compliance.
If, as suggested by the CDC, workers are expected to carry out hand hygiene before eating, before and after touching patients’ skin, before and after handling bodily fluids, after using the restroom, after glove removal and when moving from a contaminated to clean body site, it is vital to increase the ease with which this can be carried out. Minimizing time demands is an effective way of doing this along with providing prompts to ensure that workers remember to follow through.
With this in mind, it is unsurprising that attention has now turned to determining how quickly hand hygiene can be effectively carried out. A 2017 study published in the journal Infection Control and Hospital Epidemiology seems to suggest that in some circumstances, just 10 seconds may be effective.
In this study, the researchers tested the real-life effectiveness of the WHO’s hand hygiene recommendations. First, the hands of 32 healthcare personnel were contaminated with E. coli ATCC 10536. Participants were then asked to clean their hands for 10, 15, 20, 30, 45 or 60 seconds using 3ml of alcohol-based rub following the WHO’s technique. Analysis of E. coli contamination levels after cleaning showed no significant difference in hands rubbed for less than 30 seconds compared with those rubbed for 30 seconds or more.
The Future of Hand Hygiene
While premature (in light of the small study size), the findings from the aforementioned study provide much food for thought. If replicated on a larger scale, this study could set a new precedence for alcohol-based hand hygiene standards in healthcare settings. In the meantime, it seems that less is not more—at least where hand hygiene is concerned. Healthcare workers can be sure that they are achieving effective hand cleaning only if they stick to the WHO and CDC’s recommendations to scrub their hands with soap and water for at least 20 seconds and rub alcohol-based cleaner for 20 to 30 seconds.
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Lauretta Ihonor is a medical doctor and a freelance health journalist/writer. She is based in London, UK and specializes in writing about medical technology and general medicine. She has worked for CNN International, BBC and Sky News.
World Health Organization. Healthcare-Associated Infections Factsheet. Available at: https://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf. Last accessed 5th March 2019.
Centers for Disease Control and Prevention. Handwashing: Clean Hands Save Lives. Available at: https://www.cdc.gov/handwashing/when-how-handwashing.html. Last accessed 5th March 2019.
World Health Organization. WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge: Clean Care is Safer Care. Geneva, Switzerland: WHO Patient Safety; 2009. Available at: https://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf 5th March 2019.
Pires D, Soule H, Bellissimo-Rodrigues F, et al. Hand Hygiene with Alcohol-Based Hand Rub: How Long is Long Enough? Infect Control Hosp Epidemiol. 2017 May;38(5):547-552.