The problem with 'My Five Moments for Hand Hygiene'

‘The problem with…’ series covers controversial topics related to efforts to improve healthcare quality, including widely recommended, but deceptively difficult strategies for improvement and pervasive problems that seem to resist solution. Healthcare-associated infections (HCAIs) are the most common adverse events affecting patients.1 The pathogens responsible are often carried on health workers’ hands, and on the evidence of epidemiological and microbiological studies, in theory hand hygiene ought to break the chain of infection.2 The WHO3 promotes ‘My Five Moments for Hand Hygiene’4 as a ‘time-space’ framework to identify points in the sequence of care when hand hygiene should occur to prevent transmission. The Five Moments conceptualise risk in relation to two virtual areas: the patient zone and the healthcare zone.4 The patient zone comprises the patient and their immediate surroundings: intact skin and all inanimate surfaces in direct contact with the patient and all the surfaces handled by healthcare workers. The healthcare zone comprises everything outside the patient zone. Except for the original definition of zones provided by Sax et al ,4 no other definition of patient and healthcare zones appears to exist. The model assumes that the healthcare zone is contaminated with potentially harmful micro-organisms (ie, those able to cause exogenous infection and/or resistant to antimicrobials). The Five Moments are the dominant paradigm used to organise practice, policy and research in relation to hand hygiene. In this paper we identify five ‘inconvenient truths’ limiting the Five Moments: (1) the development of the Five Moments did not include the perspectives of stakeholders; (2) it is not always possible to implement Five Moments for all patients all the time; (3) the patient zone is not a fixed entity; (4) the Five Moments overlook barriers that reduce hand hygiene adherence; and (5) adherence to the Five Moments …