Three-step hand hygiene protocol improves compliance

What is important to say is that the technique is called the “three-step technique.” But in fact, it is not a three-step technique; it is a technique where the three most important steps for hand cleansing of the six steps that are described in the WHO strategy are used. The WHO method had been described to cover all surfaces of the hands, and it is sometimes a little bit difficult for people to keep in mind the complete sequence of the technique so the idea of [Tschudin-Sutter and colleagues] was to simply propose to insist on the three most important steps of the WHO six step-technique, and not worry too much about the others. But still, coverage of all surfaces of the hands was requested, which means that this is, in fact, the equivalent objective of the six-step technique, with further insistence on three of the steps; i.e. the most important. In particular, one of the steps calls for the rubbing of fingertips, and it probably is the most efficient at reducing bacteria on hands. Thus, the results are not surprising.

When you speak about compliance with when to clean your hands, it is very important. If compliance is 20%, this means that if you must visit five patients, you would clean your hands for only one patient. This is not good at all. In this study, what is called compliance is the compliance with the sequence of the technique that was proposed to study participants. Of course, if I ask you to retain in your mind six names of six cities or three names of three cities, it would be easier for you to recall three names of three cities than six names of six cities in the right order. It is an analogy to explain that it is not very surprising to observe a better respect of three steps, than of six, within a sequence of events. What is very interesting is to imagine that if we could demonstrate in the future that doing the six-step technique in any order — which is what we have proposed for a long time — or if you do a three-step technique that insists on the most important steps, that could be simpler for health care workers. The fact that it is simpler would eventually create more compliance with when to clean hands, but this has not been proven yet.

This paper does not change our practices. We are currently performing a meta-analysis of all the papers in which the technique has been studied to see what is the state of the technique. We proposed the six-step technique in 2009, and now we are in 2018. It was based on the testing of the alcohol-based hand rubs in the laboratory and we will follow the literature and the evidence in order to know if this is still accurate. Of course, this paper is important and will be included in the systematic approach that is conducted by WHO, and the revision, if any, will be proposed for the next World Hand Hygiene Day that is organized by WHO, which is on May 5 of every year. So, on May 5, 2019, if the technique based on the evidence needs to be revisited, we will propose a revision. That is the process at WHO. We review all the state-of-the-art literature, we summarize it, we call groups of experts, they listen to the summary and decide if the technique needs to be adapted or not.

There are other aspects of the hand hygiene technique that are extremely important. For example, the volume of alcohol that is used is 3 mL, which is a large volume of alcohol-based hand rub, for a relatively long duration, i.e. 30 seconds. Currently, there is evidence that you can probably do it in a shorter time (15 to 20 seconds), but again this is another discussion. Shortening the duration and ensuring a volume adapted to the hand size are probably the most important factors to ensure optimal antimicrobial efficacy.

What is good is that in 2009, when we published the WHO guidelines, we proposed a research agenda and this study is part of that. This is really good and helps to promote useful clinical research, and the authors should be congratulated.