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Patient-centered hand hygiene: The next step in infection prevention
Timothy Landers RN, PhD
*, Said Abusalem RN, PhD
, Mary-Beth Coty RN, PhD
, James Bingham MS
College of Nursing, The Ohio State University, Columbus, OH
School of Nursing, University of Louisville, Louisville, KY
GOJO Industries, Inc, Akron, OH
Health careeassociated infection
Hand hygiene has been recognized as the most important means of preventing the transmission of
infection, and great emphasis has been placed on ways to improve hand hygiene compliance by health
care workers (HCWs). Despite increasing evidence that patients’ﬂora and the hospital environment are
the primary source of many infections, little effort has been directed toward involving patients in their
own hand hygiene. Most previous work involving patients has included patients as monitors or auditors
of hand hygiene practices by their HCWs. This article reviews the evidence on the beneﬁts of including
patients more directly in hand hygiene initiatives, and uses the framework of patient-centered safety
initiatives to provide recommendations for the timing and implementation of patient hand hygiene
protocols. It also addresses key areas for further research, practice guideline development, and impli-
cations for training of HCWs.
Copyright Ó2012 by the Association for Professionals in Infection Control and Epidemiology, Inc.
Published by Elsevier Inc. All rights reserved.
In efforts to prevent infection and improve patient safety, one
area of priority focus has been the improvement of hand hygiene
compliance health care workers (HCWs). This focus has included
signiﬁcant wide-reaching initiatives, including the World Health
Organization (WHO) 5 Moments for Hand Hygiene and the Centers
for Disease Control and Prevention (CDC) hand hygiene guide-
Continuing technological innovation has resulted in
improved monitoring options to evaluate hand hygiene activity,
and the widespread use of alcohol-based hand rubs (ABHRs) have
increased the availability and tolerability of hand hygiene products.
To date, initiatives aimed at improving hand hygiene have primarily
targeted HCW practices, without full consideration of the patient
and the patient’s caregiver network. However, emerging evidence
suggests that most infections occur as a result of bacteria present
within the patient’sownﬂora and bacteria present on surfaces
within the health care environment. Because patients and HCWs
touch surrounding items and surfaces, including patients in the
performance of hand hygiene could decrease pathogen trans-
mission and the risk of health careeassociated infections (HAIs).
In this review, we provide an overview of previous efforts to
include patients in hand hygiene activities, highlight the importance
of patient hand hygiene as a means to prevent infection, and frame
patient hand hygiene in the context of a patient-centered safety
initiative. After reviewing current approaches, we advocate for the
development and implementation of strategies to include patient
hand hygiene as part of routine care. Although the role of the patient
in hand hygiene as a means to prevent infection has been recom-
mended by others, this review suggests that patient hand hygiene
remains an underused method of preventing HAIs. Existing clinical
practice guidelines, recommendations for clinical application, and
implications for HCW training and education are identiﬁed.
For the purpose of this review, patient hand hygiene is deﬁned
as hand hygiene practices performed by the patient on his or her
own hands, including handwashing, use of ABHRs, and use of dis-
infecting wipes. In certain situations, this care may need to be
provided to patients by professional caregivers or family members.
It is well documented that the hands of HCWs are involved in the
transmission of health careeassociated pathogens. Transmission via
the hands of HCWs accounts for a high proportion of HAIs, and
improvement of hand hygiene practices has been linked to reduced
transmission of health careeassociated pathogens and reduced
Current evidence clearly indicates that increasing
hand hygiene compliance directlyresults in a reduction in HAIs, and
* Address correspondence to Timothy Landers, RN, PhD, College of Nursing, The
Ohio State University, 1585 Neil Avenue, Columbus, OH 43210-1216.
E-mail address: firstname.lastname@example.org (T. Landers).
Publication of this article was made possible by GOJO Industries, Inc.
Conﬂict of interest: T.L., M.-B.C., and S.A. received an honorarium or educational
grant from GOJO Industries for their participation in the Consortium. J.B. is an
employee of GOJO Industries.
Contents lists available at ScienceDirect
American Journal of Infection Control
journal homepage: www.ajicjournal.org
American Journal of
0196-6553/$36.00 - Copyright Ó2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
American Journal of Infection Control 40 (2012) S11-S17
both the CDC and the WHO consider hand hygiene the most impor-
tant measure for preventing HAIs and the spread of pathogens.
To date, hand hygiene guidelines and policies have focused
primarily on HCWs.
In light of strong evidence supporting the
role of HCW hands in HAI transmission, the major focus of studies
regarding the role of patients in hand hygiene has been on patients
as monitors or auditors of HCW hand hygiene. The primary goal of
including patients in hand hygiene has been to improve HCW hand
hygiene compliance, and various campaigns have been created to
involve patients as monitors of hand hygiene.
In the United States, the Joint Commission’s“Speak Up”program
urges patients to take a role in preventing health care errors by
becoming active, involved, and informed participants in the health
The Joint Commission publication “Five Things You Can
Do to Prevent Infections”instructs patients to ask HCWs to clean
their hands before any treatments and provides recommendations
on when and how patients should clean their own hands.
Internationally, various campaigns have been created to include
patients as observers of hand hygiene. In 2009, the “Save Lives:
Clean Your Hands”campaign, an extension of the 2005 “Clean Care
is Safer Care”WHO Patient Safety Challenge, was launched to
stimulate international efforts in promoting hand hygiene compli-
ance among HCWs in an endeavor to reduce HAIs.
Lives campaign, which promoted My 5 Moments for Hand Hygiene
for HCWs, also recommended that patients ask HCWs to wash their
hands in an effort to improve hand hygiene practices among
In the United Kingdom, the National Patient Safety Agency
initiated the “Cleanyourhands”campaign, aimed at best practices in
hand hygiene compliance among HCWs, with an emphasis on
performing hand hygiene “at the right time and in the right
A central message of this campaign was “It’s OK to ask,”
encouraging patients to ask HCWs whether they had performed
hand hygiene before providing patient care.
Safety Institute initiated a national hand hygiene campaign, “Stop!
Clean Your Hands,”which speciﬁed 4 moments for HCWs to wash
their hands and addressed the patient’s role in hand hygiene.
The literature suggests that patient participation programs can
help to increase HCW hand hygiene compliance. For example, 2
studies found that when patients were encouraged to ask HCWs if
they performed hand hygiene, soap consumption increased by
reﬂecting increased hand hygiene among HCWs.
Similarly, McGuckin et al
reported a 94% increase in hand hygiene
events when patients asked whether HCWs performed hand
hygiene. Although initiatives that engage patients as monitors of
hand hygiene have yielded positive results, the long-term sustained
effect on hand hygiene compliance and impact on infection rates
A positive byproduct of these efforts has been the inclusion of
patients in health care activities and decisions related to their own
safety. Empowering patients to become partners in ensuring safe
care has been described as patient collaboration, patient involve-
ment, partnership, and patient-centered care. Studies have shown
that patients are willing to participate in hand hygiene programs,
but that their participation often depends on the type of program
and how it was developed.
For example, Longtin et al
that of 198 patients asked to participate in the promotion of HCW
hand hygiene compliance, approximately 75% did not feel
comfortable asking their nurse or physician to perform hand
hygiene. However, when HCWs invited patients to ask about HCW
hand hygiene, 83% of patients felt comfortable asking nurses and
78% felt comfortable asking physicians.
patients’apparent willingness to participate, McGuckin and
reported that only 60%-70% of patients actually ask
their HCW about performing hand hygiene.
Including patients in their care has been used as a strategy to
promote medication adherence, improve patient safety after
surgery, and foster open communication with health care
A variety of factors inﬂuence the willingness of HCWs
and patients to share responsibility for patient care (Fig 1). Factors
that inﬂuence patient participation in patient safety include
behavioral aspects, attitudes, norms, and beliefs, as well as
perception of the risk of infection
; for example, it has been sug-
gested that having an extroﬁgverted personality may increase
a patient’s willingness to participate in hand hygiene moni-
However, only 55% of highly extroverted patients in one
study reported that they would always ask their nurse about hand
Other patient factors associated with willingness to act
as monitors of HCWs hand hygiene activities are shown in Table 1.
The trend of including patients in safety initiatives is growing.
Major organizations involved in patient safety, including Health
Canada and the Joint Commission, have published brochures that
instruct patients on how to help prevent care errors through
appropriate communication and behaviors.
as active participants in their care appears to have much potential
for improving patient safety.
Patient participation in
disease-management programs has been shown to be effective for
asthma and type 2 diabetes, resulting in better disease control and
improved patient outcomes.
A review of patients’ability to
inﬂuence physician decisions found that patients who asked for
a prescription were 3 times more likely to get it than those who did
not, and patients who asked for a referral were 4 times more likely
to receive one than those who did not.
Finally, a systematic
review of patient-centered safety research by Schwappach et al
suggested that successful interventions had some common key
features: they directly engaged the patients’perspectives, used
multiple measures to promote complex behavior change, empha-
sized the patients at the center of care, and encouraged staff to
engender and maintain a trusting relationship with their patients.
Thus, patient hand hygiene can serve as an important measure to
prevent infection, and also may advance broader patient engage-
ment in safety initiatives.
Increasing patient safety through increased patient engagement
and empowerment presents a potential paradox.
Along with the
desire to improve patient outcomes, there is concern that patients
may feel an undue burden for their own safety in these campaigns,
and that such perceptions could undermine trust.
Fig 1. Conceptual model of factors inﬂuencing patient participation in preventing errors. (Reprinted with permission.
T. Landers et al. / American Journal of Infection Control 40 (2012) S11-S17S12
Despite this paradox, evidence suggests that patient participa-
tion does yield positive results, and that most patients are willing
and able to participate in their own hand hygiene. Accumulating
evidence suggests that attention to patient hand hygiene can play
a critical role in preventing the spread of infection, because patients
can be involved in the spread of pathogens through multiple routes.
Patients may be involved in the transmission of pathogens and
HAI risk in 4 signiﬁcant ways: through the transfer of pathogens
within the environment, by directly spreading pathogens to other
patients, by cross-contamination through direct contact with
HCWs, and by increasing their own risk of infection from an
endogenous source. Organisms residing on the skin can be trans-
ferred by hands to other surfaces; thus, patients’hands can transfer
pathogens to HCWs, to their surrounding environment, to other
patients, and to high-risk areas on their own bodies, such as inci-
sion sites, healing surgical wounds, access sites of invasive and
intravascular devices, and the mouth.
This underscores the
importance of patients in the carriage and transmission of organ-
isms capable of causing HAIs.
In the hospital environment, patients diagnosed with HAIs,
such as infections with Clostridium difﬁcile, vancomycin-resistant
Enterococcus (VRE), and methicillin-resistant Staphylococcus aureus
(MRSA), contaminate their surrounding environment.
particular, bacterial contamination has been detected on various
high-touch environmental surfaces, such as bed rails, bedside tables,
call buttons, toilet seats, and phones in patient rooms.
addition, asymptomatic carriers of health careeassociated patho-
gens also contribute to contamination of the hospital environment.
In the case of C difﬁcile, patients may continue to shed spores into the
environment for 5-6 weeks after symptoms have resolved and
antibiotic treatment has been stopped.
pathogens can survive on inanimate hospital surfaces for months
and can be transferred via hands to other objects.
Cleaning and disinfection regimens do not always eliminate
pathogens from surfaces.
The presence of soil combined with
the need for proper surface coverage and adequate disinfectant
contact time makes proper disinfection a challenge in health care
settings. Although existing policies may contain appropriate
recommendations, actual disinfection practices may be inconsis-
tent within an institution. Consequently, pathogens shed into the
environment might persist despite disinfection and/or cleaning
regimens. As a result, a patient is at greater risk of acquiring an
antibiotic-resistant organism when admitted to a room previously
occupied by a patient infected with such a pathogen.
presence of pathogens in the patient environment make the
patients’hands an important vehicle for transmission of organisms
to HCWs, other susceptible patients, environmental surfaces, or
even their own wounds or invasive devices.
Patients not only contaminate their environment with the
organisms that they may be carrying, they also can acquire path-
ogens from the environment and through contact with HCWs. It is
widely believed that many patients who acquire an HAI become
infected with strains originating from their own skin and ﬂora.
Antibiotic-resistant organisms such as VRE, MRSA, Acineto-
bacter spp, C difﬁcile, and Pseudomonas aeruginosa can be detected
on the skin in such areas as the groin, arms, abdomen, chest,
Organisms residing on the skin can be readily
transferred by the hands to other surfaces,
the importance of patients in the carriage and transmission of
health careeassociated pathogens. There is also strong evidence
that patients may play a more important role than HCWs in path-
ogen transmission to other patients. For example, patient-indexed
cases of norovirus were associated with signiﬁcantly more cases
compared with staff-indexed cases (39.5 cases/patient-indexed vs
24.3 cases/staff-indexed), and exposure to an infected patient was
associated with a markedly increased risk of developing norovirus
infection compared with exposure to an infected staff member
(odds ratio, 4.8).
Thus, patients can play a key role in transmitting
pathogens to other patients.
Even though a complete picture of the role of patients’hands in
the transmission of HAIs has not yet emerged, the literature strongly
reinforces the need for patient hand hygiene programs. This appears
to be true for patients with known HAIs as well as those otherwise
assumed to be uninfected; for example, in one study, fecal coliform
colonization was detected in 20.4% of patients in a general medical
ward and 35.8% of patients in a spinal ward.
are more likely to have antibiotic-resistant organismsas part of their
normal ﬂora compared with outpatients.
One study reported that
after 7 days in a hospital, 62% of all patients were positive for en-
terococcal hand contamination, compared with 10.7% of nonhospi-
Similarly, Istenes et al
found that 39% of patients
had at least one hospital-associated pathogen on their hands within
48 hours of admission. Althoughwhether these patients’hands were
contaminated on admission was unknown, this study supports
patient hands as an important source of contamination. Taken
together, these studies suggest that the entire patient population
should be included in hand hygiene. Patient hand hygiene may
prove to be a critical aspect in HAI prevention, given the role of
infected and even uninfected patients in transmitting pathogens to
Factors associated with patient willingness to participate in prompting HCWs to perform hand hygiene
Factors that may inﬂuence a patient’s willingness to participate in hand hygiene monitoring
Extroverted personality Longtin et al
; Duncanson and Pearson
Internal control belief (that he or she can control HCWs’hand hygiene behavior) Davis et al
Age Duncanson and Pearson
Awareness of severity of HAIs Longtin et al
; Davis et al
Invitation from HCW to ask about hand hygiene Longtin et al
Religious beliefs Longtin et al
Provision of alcohol-based hand sanitizer to patient Pittet et al
Factors that may limit a patient’s willingness to participate in hand hygiene monitoring
Assumption that HCWs had already cleaned their hands Pittet et al
Older age Duncanson and Pearson
Feeling uncomfortable asking about hand hygiene Longtin et al
Trust that HCW would perform hand hygiene Pittet et al
Role of HCW (physician vs nurse) McGuckin et al
Factors not shown to be related to willingness to participate
Previous hospitalizations, infection, or isolation Duncanson and Pearson
T. Landers et al. / American Journal of Infection Control 40 (2012) S11-S17 S13
the environment, to HCWs and to other patients, and through
infections originating from their own ﬂora.
Regarding the reported discomfort many patients experience
monitoring HCW hand hygiene, initiatives that focus on patient
hand hygiene may help them overcome this discomfort and allow
them to more fully engage as active participants in other aspects of
their care as well in HAI reduction. Literature focusing on the
engagement of patients in their own hand hygiene is sparse,
however. As early as 1983, Lawrence
speculated on the impor-
tance of patient hand hygiene, and in 1995, Burnett et al
gested that patient hand hygiene could play an important role in
infection control. Yet, only 10 years later, a literature review by
Banﬁeld and Kerr
reported a dearth of studies focusing on patient
hand hygiene and urged an increased focus on this topic.
This call to action has remained largely unaddressed, however.
Few studies have examined the possible impact of patient hand
hygiene practices on the reduction of HAIs, although the existing
reports are compelling.
In one notable study, Gagne et al
uated a comprehensive approach that included greeting patients
and visitors at the door, explaining the importance of hand hygiene,
and instruction on the proper use of ABHRs. The program was well
received by patients and families, with “virtually all”participating,
and produced a 51% reduction in the total number of MRSA infec-
tions and a 71% decrease in overall mortality from MRSA over
a 1-year period. Interestingly, implementing the patient-centered
hand hygiene program was also associated with an w30% increase
in HCWs’compliance. Grabsch et al
also indicate that patient hand
hygiene could play a signiﬁcant role in reducing VRE contamination,
and in another study, supervised use of ABHR every 4 hours by
psychiatric patients was associated with a decrease in the number of
unit-based respiratory outbreaks from 4 per year to 1 per year and
a decrease in cases of respiratory illness from 60 to 6.
There are few published descriptive studies on patients perfor-
mance of hand hygiene. One observational study conducted during
peak visiting hours in 27 wards in 9 hospitals reported that out of
290 total observed uses of soap or alcohol-based hand rub, not one
of them was by a patient.
To address the need for patient hand hygiene, Ward
a range of strategies to better promote patient hand hygiene.
Although some studies have suggested that patients’poor hand
hygiene can be attributed to lack of knowledge, perceived impor-
tance (as demonstrated by HCWs), impeded movement, and
physical impairments, the fundamental question may be whether
or not patients are encouraged to clean their hands at all.
Prompted by anecdotal reports of patients not being regularly
offered hand wipes intended for patient use at a hospital on the Isle
of Wight, Whiller and Cooper
conducted a small study to identify
whether patients were offered hand-cleansing resources after
using the commode. They found that only 50% of patients were
always offered hand hygiene resources after using the commode,
and 31% of patients were never offered them. After the introduction
of staff reminders and readily accessible resources, all patients
reported having resources offered to themat least some of the time,
and the percentage of patients who were always offered hand
hygiene resources rose from 50% to 85%.
The perception of support and/or importance of patient hand
hygiene also may play a role in promoting patient hand hygiene
behavior. In one study, 64% of nurses reported offering hand
hygiene to patients, but only 15% of patients recalled being offered
the opportunity for hand hygiene.
Although few formal programs exsist, both patients and HCWs
seem to recognize the importance of hand hygiene. Burnett et al
solicited nurses’and patients’perceptions about hand hygiene
and whether nurses encouraged and offered assistance with hand
hygiene to patients. They found that although nurses and patients
alike (100% and 95%, respectively) believed that handwashing is
important in preventing infection, hand hygiene assistance was
offered only once by a nurse in 75 patient hand hygiene opportu-
Burnett et al
followed that study with an effort
to correlate self-reported attitudes with behavior in support of
patient hand hygiene, and found that despite nurses’acknowledg-
ment of the importance of patient hand hygiene as an important
component in controlling and preventing HAIs, patients were not
consistently provided with assistance in performing their own hand
Patient performance of hand hygiene has been reported as an
example of patient involvement in the care process by many
authors and organizations, including the WHO Alliance for Patient
Safety, the Joint Commission, and the CDC. These organizations
have provided limited guidelines for patients’involvement in
patient safety and hand hygiene-related practices.
hand hygiene is to become a clinical reality and have an impact on
patient safety and the reduction of HAIs, clear guidelines and
a range of support must be established to promote patient hand
IMPLICATIONS FOR PRACTICE
In the health care setting, current best practices to promote
hand hygiene behavior include the use of multimodal strategies. As
with HCWs, successful patient hand hygiene programs will likely
require a multimodal approach that emphasizes important
features, including the formulation, design, and availability of hand
hygiene resources; timing and technique for hand hygiene
behavior; education and training of patients and caregivers;
monitoring adherence and providing feedback and reminders; and
creating a culture of hand hygiene and patient safety among
patients, HCWs, and senior hospital personnel
(Table 2). For
a review of the components of a multimodal strategy,see the article
by Pincock et al.
in this supplement.
Implementing an effective patient hand hygiene programsrelies
on the development of a multimodal set of best practice recom-
mendations speciﬁc to the role of patients in infection prevention,
and the needs and challenges of patients in the health care envi-
ronment. In particular, further work is needed on speciﬁc compo-
nents of a multimodal patient hand hygiene strategy, including
timing and technique for patient hand hygiene; product, design,
and placement considerations; best patient education and training
strategies; and HCW education and training needs for the imple-
mentation of a multimodal strategy.
Timing and technique for patient hand hygiene
Best practice recommendations are needed for the speciﬁc
indications for patient hand hygiene and steps in hand hygiene.
Although guidelines have addressed the timing and techniques of
hand hygiene in HCWs, there are fewrecommendations for both the
frequency and methods techniques applicable to patient hand
hygiene. Future work should use available resources to develop
speciﬁc recommendations for the timing of patient hand hygiene,
including preferred techniques and products, as well as methods for
of delivering both patient and HCW education and training. Patient
hand hygiene should be implementedin health professional training
programs and included in local facility policies and procedures.
For HCWs, recommended indications for hand hygiene have been
developed for speciﬁc time points or “moments”during patient care.
The WHO’s 5 Moments forHand Hygiene include (1) before touching
a patient, (2) before an invasive or aseptic procedure, (3) after
contact with body ﬂuids or excretions, (4) after touching the patient,
and (5) after touching the surrounding environment.
T. Landers et al. / American Journal of Infection Control 40 (2012) S11-S17S14
The most appropriate hand-hygiene opportunities should be
identiﬁed for patients, which may be signiﬁcantly different than
than those recommended for HCWs. For example, it will be
important to identify routine patient activities, such as eating or
bathroom activities, during which hand hygiene should be per-
formed. Table 3 presents a proposed list of moments for patient
hand hygiene based on the timing of exposure to pathogens.
Product design and placement considerations for patient
Better understanding of patient behavior, with speciﬁc attention
to the moments for patient hand hygiene, is needed to identify the
speciﬁc design attributes of patient-focused hand hygiene prod-
ucts. Preferred hand hygiene products and optimal product place-
ment require further exploration. Currently, most commercially
available hand hygiene products have been developed speciﬁcally
for use by HCWs and reﬂect the frequency with which hand
hygiene is performed. Therefore, the formulations of these products
are recommended in routine HCW hand hygiene. For patients,
speciﬁc formulations (eg, efﬁcacy, skin performance), formats (ie,
handwash, leave-on, rinse, foam, gel, wipe), and dispensing
systems need to be created and evaluated with the patient specif-
ically in mind.
Because of patients’susceptibility to infection and
likely fewer opportunities for hand hygiene, clinically effective
formulations for patients may differ from those for use by HCWs. In
addition, because many patients face unique environmental
obstacles in addition to physical challenges, more research is
needed on speciﬁc product delivery characteristics, including
usability, placement, and durability. With this information, hand
hygiene manufacturers can then create clinicallyeffective solutions
that will be accepted and used by patients.
Patient education and training to support patient hand hygiene
Further study is needed to determine the best methods of
patient education to promote hand hygiene. The same research
used to design HCW education and training programs is needed for
patients to create solutions that will improve patient awareness,
understanding, usage, and compliance. Currently, the Joint
Commission requires hospitals to provide patients with informa-
tion on hand hygiene to patients, which will provide a foundation
The Joint Commission’s SpeakUp program includes
educational material on measures that patients can take to reduce
infections, including handwashing and use of ABHRs.
evaluation of these tools and initiatives may provide a basis on
which to develop and expand a robust program for educating
patients on patient hand hygiene practices.
HCW education and training to support patient hand hygiene
Efforts to increase awareness of patient hand hygiene among
clinicians and health care profession students should be promoted.
When evaluating the potential role of HCWs in this equation, an
important resource must include the various curricula used to
train HCWs. Speciﬁcally, the assessment of curricula used to train
health care professionals who have signiﬁcant hands-on care
responsibilities, such as physicians, nurses, physical therapists, and
Moments for patient hand hygiene
1. After using the toilet, bedpan, or commode
2. When returning to room after test or procedure
3. Before eating, drinking, taking medicine, or putting anything in your mouth
4. When visibly dirty
5. Before touching any breaks in the skin (eg, wounds, dressing, tubes)
or any care procedures (eg, dialysis, IV drug administration, injections)
6. Before dialysis, contact with IV lines or other tubes
7. After coughing, sneezing, or touching nose or mouth
8. Before interacting with visitors and after they leave
9. When there is concern about whether hands are clean
Key considerations for future work to promote patient hand hygiene
Content area Rationale Speciﬁc steps
Timing and technique
Validate and promote when patients should
perform hand hygiene.
The most critical moments for hand hygiene may
differ between patients and HCWs.
Research, validate, fortify, and promote the
framework identiﬁed here.
Encourage product providers to research, develop,
and trial various options for a patient hand hygiene
Product, design, and placement
Determine some of the key challenges, barriers, and
needs speciﬁc to the patient.
Evaluate appropriate patient product formula-
tion(s) and delivery vehicles.
Pain, mobility, and conﬁnement contribute to
a patient’s ability to participate in hand hygiene.
The formulations most applicable for patient use may
vary from formulations appropriate for HCWs.
Likewise, format (eg, rinse, gel, foam, wipe) should
be considered with the patient speciﬁcally in mind.
Identify existing barriers to patient hand hygiene.
Encourage product manufacturers to research,
develop, and trial various options for a patient hand
Patient education and training
Provide educational tools for patients and visitors.
Improving patient hand hygiene requires that
patients and HCWs understand the why, how, and
when of patient hand hygiene.
Leverage existing tools on patient hand hygiene
from such resources as the Joint Commission’s
SpeakUp program, as well as product providers.
HCW education and training
Provide education and training to HCWs on the
rationale and technique of patient hand hygiene.
Emphasize the role of HCWs in supporting patient
Assess and develop opportunities within HCW
curricular agendas to introduce and fortify a focus
on the patient hand hygiene agenda.
Identify opportunities to coordinate efforts to
promote the need for and methods of patient hand
hygiene to participants in the health care
settingdHCWs, patients, families, and visitors
It is not enough to provide the appropriate tools and
educate patients and HCWs about patient hand
hygiene. The practice also must be actively
promoted from various angles and to the full range
of health care setting participants to become part of
the culture, practice, and behavior of health care,
and to contribute to the reduction of HAIs.
Apply some of the lessons learned from multimodal
strategies intended to change hang hygiene
behavior of HCWs. Use posters, displays, reminders,
and other components to promote patient hand
hygiene across health care settings.
T. Landers et al. / American Journal of Infection Control 40 (2012) S11-S17 S15
respiratory therapists. Although each of these disciplines is unique,
with distinct curricular elements, evaluation of the individual
curricular elements of each discipline is an important consider-
ation. Based on our review of foundational literature as well as
textbooks applied to curriculum supporting front-line roles within
health care, a focus on patient hand hygiene appears to be lacking.
Coverage of an approach that teaches patients when and how to
perform hand hygiene is universally absent from the curricula.
Although some hand hygiene product manufacturers have devel-
oped tools that can be adapted to teach patients about hand
hygiene, speciﬁc patient-centered tools have not been integrated
into the education of health care professionals.
There are additionalconsiderations involved in engagingpatients
in their own hand hygiene. Technique, education and promotion,
and potential barriers may be unique to each patient’s condition. An
understanding of the barriers, timing, and other considerations for
patient hand hygiene provides an important foundation for the
ability to educate about and promote the practice. The adoption of
patient hand hygiene as the next important infection prevention
measure will require the inclusion of curricular elements that
support the goal of improved patient hand hygiene. By applying
some of the lessons learned from guidelines associated with the
WHO’s 5 Moments, as well as work derived from other guidelines
established for HCWs and families with regard to hand hygiene
practices, we can establish a potential framework for the compo-
nents of a HCW training curriculum that best recognizes and
supports the importance of patient hand hygiene. This work must
then be fortiﬁed with an understanding of the barriers, timing,
formal training in indications and techniques, and other consider-
ations speciﬁc to the patient, as well as the principles of patient-
centered care as the rationale for patient hand hygiene.
With the patient at the center of this approach, efforts should
focus on educational in-services that are patient-centered and
promote hand hygiene practices even among the most critically ill
patients. Education and training of both patients and HCWs in
patient hand hygiene will provide an important foundation for
teaching about and promoting the practice.
Importance of a multimodal strategy
A single intervention is not sufﬁcient to sustain changes in hand
hygiene behavior in either patients or HCWs. Accordingly, beyond
product design and accessibility considerations, patient and HCW
education must be augmented by a range of other supports, such as
feedback and visual and verbal reminders (eg, posters, brochures,
feedback) that are relevant to and easily understood by patients
and their families to support and sustain behavior change. These
multiple aspects must be identiﬁed and adapted to each individual
patient’s role in his or her personal hand hygiene (Table 3).
Broad support for the creation of a culture of patient-centered
care can promote a shift toward a paradigm of hand hygiene that
accepts the importance of the patient’s role and places the patient
at the center of the patient safety movement.
HAIs occur in 1.7 million hospitalized US patients every year,
causing approximately 100,000 deaths and costing $6.7 billion
Yet the focus on hand hygiene as the single most
effective means of preventing the spread of infection has primarily
targeted HCWs. As a result, patients have been relegated to roles
that simply support and encourage hand hygiene practices of
others, rather than being engaged as active participants. The
evidence presented in this review indicates that this is a signiﬁcant
oversight, but which provides an opportunity for growth.
Twelve years after the launch of the patient safety movement,
reports from many health care agencies indicated continued
challenges in patient safety.
An approach promoting a culture
of safety and HAI reduction involves everyone, top to bottom,
in the process. By necessity, this must include the patient. If
“patient-centered care”truly has the patient as the central focus,
and patient safety is our top priority, then hand hygiene practices
must include patients and their caregiver networks in the process.
Patient hand hygiene represents the next big step in infection
prevention and in the evolving ﬁeld of patient-centered care. This
review suggests that including patients in hand hygiene practices
has the potential to provide patients with the knowledge and skill
to be true partners in their care. Fully addressing the risk associated
with HAIs requires the appropriate education, products, tech-
niques, practices, and promotional tools to directly engage our
patients to fully participate in maintaining safety and reducing HAIs
through their own hand hygiene.
We wish to acknowledge the assistance of Ebie Hoist, Strategic
Gear, in the preparation of this article and to Ruth Carrico, RN, PhD,
who provided scientiﬁc and technical assistance and served as
a scientiﬁc advisor to the development of this article.
1. Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings:
recommendations of the Healthcare Infection Control Practices Advisory
Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect
Control Hosp Epidemiol 2002;23(12 Suppl):S3-40.
2. Pittet D, Allegranzi B, Boyce J. The World Health Organization guidelines on
hand hygiene in health care and their consensus recommendations. Infect
Control Hosp Epidemiol 2009;30:611-22.
3. Doebbeling BN, Stanley GL, Sheetz CT, Pfaller MA, Houston AK, Annis L, et al.
Comparative efﬁcacy of alternative hand-washing agents in reducing nosoco-
mial infections in intensive care units. N Engl J Med 1992;327:88-93.
4. Maki DG. The use of antiseptics for handwashing by medical personnel.
J Chemother 1989;1(Suppl 1):3-11.
5. Massanari RM, Hierholzer WJ. A crossover comparison of antiseptic soaps on
nosocomial infection rates in intensive care units. Am J Infect Control 1984;12:
6. Mortimer EA Jr, Lipsitz PJ, Wolinsky E, Gonzaga AJ, Rammelkamp CH Jr.
Transmission of staphylococci between newborns: importance of the hands to
personnel. Am J Dis Child 1962;104:289-95.
7. Webster J, Faoagali JL, Cartwright D. Elimination of methicillin-resistant
Staphylococcus aureus from a neonatal intensive care unit after hand washing
with triclosan. J Paediatr Child Health 1994;30:59-64.
8. Zafar AB, Butler RC, Reese DJ, Gaydos LA, Mennonna PA. Use of 0.3% triclosan
(Bacti-Stat) to eradicate an outbreak of methicillin-resistant Staphylococcus
aureus in a neonatal nursery. Am J Infect Control 1995;23:200-8.
9. The Joint Commission. Speakup: ﬁve things you can do to prevent infection. 2009.
Available from: http://www.jointcommission.org/Speak_Up_Five_Things_You_
Can_Do_To_Prevent_Infection_Poster/. Accessed December 6, 2011.
10. Pittet D, Allegranzi B, Storr J, Donaldson L. “Clean Care is Safer Care”: the global
patient safety challenge, 2005-2006. Int J Infect Dis 2006;10:419-24.
11. Storr JA, Engineer C, Allan V. Save Lives: Clean Your Hands: a WHO patient
safety initiative for 2009. World Hosp Health Serv 2009;45:23-5.
12. National Patient Safety Agency. Cleanyourhands campaign. Available from:
http://www.npsa.nhs.uk/cleanyourhands/. Accessed January 15, 2012.
13. Pittet D, Panesar SS, Wilson K, Longtin Y, Morris T, Allan V, et al. Involving the
patient to ask about hospital hand hygiene: a National Patient Safety Agency
feasibility study. J Hosp Infect 2011;77:299-303.
14. Canada Patient SafetyInstitute. Canada’s hand hygiene challenge.Available from:
http://www.handhyg iene.ca/English/Page s/default.aspx. Accessed January 18,
15. McGuckin M, Waterman R, Porten L, Bello S, Caruso M, Juzaitis B, et al. Patient
education model for increasing handwashing compliance. Am J Infect Control
16. McGuckin M, Waterman R, Storr IJ, Bowler IC, Ashby M, Topley K, et al. Eval-
uation of a patient-empowering hand hygiene programme in the UK. J Hosp
17. McGuckin M, Taylor A, Martin V, Porten L, Salcido R. Evaluation of a patient
education model for increasing hand hygiene compliance in an inpatient
rehabilitation unit. Am J Infect Control 2004;32:235-8.
T. Landers et al. / American Journal of Infection Control 40 (2012) S11-S17S16
18. McGuckin M, Waterman R, Shubin A. Consumer attitudes about health care-
acquired infections and hand hygiene. Am J Med Qual 2006;21:342-6.
19. McGuckin M, Storr J, Longtin Y, Allegranzi B, Pittet D. Patient empowerment
and multimodal hand hygiene promotion: a win-win strategy. Am J Med Qual
20. Entwistle VA. Differing perspectives on patient involvement in patient safety.
Qual Saf Health Care 2007;16:82-3.
21. Longtin Y, Sax H, Allegranzi B, Hugonnet S, Pittet D. Patients’beliefs and
perceptions of their participation to increase healthcare worker compliance
with hand hygiene. Infect Control Hosp Epidemiol 2009;30:830-9.
22. Duncan C. An exploratory study of patient’s feelings about asking healthcare
professionals to wash their hands. J Ren Care 2007;33:30-4.
23. Lent V, Eckstein EC, Cameron AS, Budavich R, Eckstein BC, Donskey CJ. Evalu-
ation of patient participation in a patient empowerment initiative to improve
hand hygiene practices in a Veterans Affairs medical center. Am J Infect Control
24. Longtin Y, Sax H, Leape LL, Sheridan SE, Donaldson L, Pittet D. Patient partic-
ipation: current knowledge and applicability to patient safety. Mayo Clin Proc
25. Schwappach DL. Engaging patients as vigilant partners in safety: a systematic
review. Med Care Res Rev 2010;67:119-48.
26. Duncanson V, Pearson LS. A study of the factors affecting the likelihood of
patients participating in a campaign to improve staff hand hygiene. Br J Infect
27. Leape LL. Errors in medicine. Clin Chim Acta 2009;404:2-5.
28. Canadian Patient Safety Institute. Patient and family hand hygiene guide. 2012.
%20Families/Patient%20Family%20Guide.pdf. Accessed January 18, 2012.
29. HealthCanada. It’s yourhealth: the beneﬁtsof hand washing.2010. Available from:
Accessed January 18, 2012.
30. Davis RE, Jacklin R, Sevdalis N, Vincent CA. Patient involvement in patient
safety: what factors inﬂuence patient participation and engagement? Health
31. Davis RE, Koutantji M, Vincent CA. How willing are patients to question
healthcare staff on issues related to the quality and safety of their healthcare?
An exploratory study. Qual Saf Health Care 2008;17:90-6.
32. Lyons M. Should patients have a role in patient safety? A safety engineering
view. Qual Saf Health Care 2007;16:140-2.
33. Hayden MK, Blom DW, Lyle EA, Moore CG, Weinstein RA. Risk of hand or glove
contamination after contact with patients colonized with vancomycin-
resistant enterococcus or the colonized patients’environment. Infect Control
Hosp Epidemiol 2008;29:149-54.
34. Stiefel U, Cadnum JL, Eckstein BC, Guerrero DM, Tima MA, Donskey CJ.
Contamination of hands with methicillin-resistant Staphylococcus aureus after
contact with environmental surfaces and after contact with the skin of colo-
nized patients. Infect Control Hosp Epidemiol 2011;32:185-7.
35. Jury LA, Guerrero DM, Burant CJ, Cadnum JL, Donskey CJ. Effectiveness of routine
patient bathing to decrease the burden of spores on the skin of patients with
Clostridium difﬁcile infection. Infect Control Hosp Epidemiol 2011;32:181-4.
36. Sethi AK, Al-Nassir WN, Nerandzic MM, Bobulsky GS, Donskey CJ. Persistence
of skin contamination and environmental shedding of Clostridium difﬁcile
during and after treatment of C difﬁcile infection. Infect Control Hosp Epidemiol
37. Kim KH, Fekety R, Batts DH, Brown D, Cudmore M, Silva J Jr, et al. Isolation of
Clostridium difﬁcile from the environment and contacts of patients with
antibiotic-associated colitis. J Infect Dis 1981;143:42-50.
38. Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on
inanimate surfaces? A systematic review. BMC Infect Dis 2006;6:130.
39. McFarland LV, Stamm WE. Review of Clostridium difﬁcileeassociated diseases.
Am J Infect Control 1986;14:99-109.
40. Mulligan ME, George WL, Rolfe RD, Finegold SM. Epidemiological aspects of
Clostridium difﬁcileeinduced diarrhea and colitis. Am J Clin Nutr 1980;33(11
41. Wagenvoort JH, Penders RJ. Long-term in-vitro survival of an epidemic MRSA
phage group III-29 strain. J Hosp Infect 1997;35:322-5.
42. Wagenvoort JH, Sluijsmans W, Penders RJ. Better environmental survival of
outbreak vs sporadic MRSA isolates. J Hosp Infect 2000;45:231-4.
43. Byers KE, Durbin LJ, Simonton BM, Anglim AM, Adal KA, Farr BM. Disinfection
of hospital rooms contaminated with vancomycin-resistant Enterococcus fae-
cium. Infect Control Hosp Epidemiol 1998;19:261-4.
44. Corbella X, Pujol M, Argerich MJ, Ayats J, Sendra M, Pena C, et al. Environmental
sampling of Acinetobacter baumannii: moistened swabs versus moistened
sterile gauze pads. Infect Control Hosp Epidemiol 1999;20:458-60.
45. Eckstein BC, Adams DA, Eckstein EC, Rao A, Sethi AK, Yadavalli GK, et al.
Reduction of Clostridium difﬁcile and vancomycin-resistant Enterococcus
contamination of environmental surfaces after an intervention to improve
cleaning methods. BMC Infect Dis 2007;7:61.
46. French GL, Otter JA, Shannon KP, Adams NM, Watling D, Parks MJ. Tackling
contamination of the hospital environment by methicillin-resistant Staphylo-
coccus aureus (MRSA): a comparison between conventional terminal cleaning
and hydrogen peroxide vapour decontamination. J Hosp Infect 2004;57:31-7.
47. Jeanes A, Rao G, Osman M, Merrick P. Eradication of persistent environmental
MRSA. J Hosp Infect 2005;61:85-6.
48. Kaatz GW, Gitlin SD, Schaberg DR, Wilson KH, Kauffman CA, Seo SM, et al.
Acquisition of Clostridium difﬁcile from the hospital environment. Am J Epi-
49. Wu HM, Fornek M, Schwab KJ, Chapin AR, Gibson K, Schwab E, et al.
A norovirus outbreak at a long-term-care facility: the role of environmental
surface contamination. Infect Control Hosp Epidemiol 2005;26:802-10.
50. Huang SS, Datta R, Platt R. Risk of acquiring antibiotic-resistant bacteria from
prior room occupants. Arch Intern Med 2006;166:1945-51.
51. Nseir S, Blazejewski C, Lubret R, Wallet F, Courcol R, Durocher A. Risk of
acquiring multidrug-resistant gram-negative bacilli from prior room occupants
in the intensive care unit. Clin Microbiol Infect 2011;17:1201-8.
52. Shaughnessy MK, Micielli RL, DePestel DD, Arndt J, Strachan CL, Welch KB, et al.
Evaluation of hospital room assignment and acquisition of Clostridium difﬁcile
infection. Infect Control Hosp Epidemiol 2011;32:201-6.
53. Lemmen SW, Hafner H, Zolldann D, Stanzel S, Lutticken R. Distribution of
multi-resistant gram-negative versus gram-positive bacteria in the hospital
inanimate environment. J Hosp Infect 2004;56:191-7.
54. Cheng VC, Wu AK, Cheung CH, Lau SK, Woo PC, Chan KH, et al. Outbreak of
human metapneumovirus infection in psychiatric inpatients: implications for
directly observed use of alcohol hand rub in prevention of nosocomial
outbreaks. J Hosp Infect 2007;67:336-43.
55. Sanderson PJ, Weissler S. Recovery of coliforms from the hands of nurses and
patients: activities leading to contamination. J Hosp Infect 1992;21:85-93.
56. Larson EL, Cronquist AB, Whittier S, Lai L, Lyle CT, Della LP. Differences in skin
ﬂora between inpatients and chronically ill outpatients. Heart Lung 2000;29:
57. Banﬁeld KR, Kerr KG, Jones KA, Snelling AM. Hand hygiene and health caree
associated infections. Lancet Infect Dis 2007;7:304 [letter].
58. Istenes NA, Hazelett S, Bingham JE, Kirk J, Abell G, Fleming E. Hand hygiene in
healthcare: the role of the patient. Am J Infect Control 2011;39:E182 [abstract].
59. Lawrence M. Patient hand hygiene: a clinical inquiry. Nurs Times 1983;
60. Burnett E, Lee K, Kydd P. Hand hygiene: What about our patients? Br J Infect
61. Banﬁeld KR, Kerr KG. Could hospital patients’hands constitute a missing link?
J Hosp Infect 2005;61:183-8.
62. Ward D. Improving patient hand hygiene. Nurs Stand 2003;17:39-42.
63. Gagne D, Bedard G, Maziade PJ. Systematic patient hand disinfection: impact
on meticillin-resistant Staphylococcus aureus infection rates in a community
hospital. J Hosp Infect 2010;75:269-72.
64. Grabsch EA, Burrell LJ, Padiglione A, O’Keefe JM, Ballard S, Grayson ML. Risk of
environmental and healthcare worker contamination with vancomycin-
resistant enterococci during outpatient procedures and hemodialysis. Infect
Control Hosp Epidemiol 2006;27:287-93.
65. Savage J, Fuller C, Besser S, Stone S. Use of alcohol hand rub (AHR) at ward
entrances and use of soap and AHR by patients and visitors: a study in 27
wards in 9 acute NHS trusts. J Infect Prev 2011;12:54-8.
66. Sierla M, Tamminen P. Patient hand hygiene in the hemodialysis environment
[thesis]. Helsinki [Finland]: Helsinki Polytechnic; 2007.
67. Whiller J, Cooper T. Clean hands: how to encourage good hygiene by patients.
Nurs Times 2000;96:38.
68. Burnett E. Perceptions, attitudes, and behavior towards patient hand hygiene.
Am J Infect Control 2009;37:638-42.
69. Pittet D, Allegranzi B, Storr J, Bagheri NS, Dziekan G, Leotsakos A, et al. Infection
control as a major World Health Organization priority for developing countries.
J Hosp Infect 2008;68:285-92.
70. Pincock T, Bernstein P, Wartham S, Holst E. Bundling hand hygiene interven-
tions and measurement to decrease health care-associated infections. Am J
Infect Control 2012;40:S18-27.
71. Tanner J, Mistry N. Hand hygiene: product preference and compliance. Nurs
72. Klevens RM, Edwards JR, Richards CL Jr, Horan TC, Gaynes RP, Pollock DA, et al.
Estimating health careeassociated infections and deaths in US hospitals, 2002.
Public Health Rep 2007;122:160-6.
73. Scott RD. The direct medical costs of healthcare-associated infections in US
hospitals and the beneﬁt of prevention. Atlanta [GA]: Division of Healthcare Quality
Promotion National Center for Pr eparedness, Detection, and Control of Infectious
Diseases, Centers for Disease Control and Prevention; 2009. Available from: http://
www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf. Accessed January 18, 2012.
74. Agency for Healthcare Research and Quality. 2007 National Healthcare Dispar-
ities Report.AHRQ Report 08-0040. Rockville [MD]:US Department of Health and
Human Services, Agency for Healthcare Research and Quality; 2008.
75. Agency for Healthcare Research and Quality. 2010 National Healtcare Dispar-
ities Report. AHRQ Report 11-0005. Rockville [MD]: US Department of Health
and Human Services, Agency for Healthcare Research and Quality; 2011.
76. Cunningham TR, Geller ES. Organizational behavior management in health care:
applications for large-scale improvements in patient safety. In: Henriksen K,
Battles JB, Keyes MA, Grady ML, editors. Advances in Patient Safety: New Direc-
tions and Alternative Approaches (Vol 2: Culture and Redesign). Rockville [MD]:
Agency for Healthcare Research and Quality (US); 2008. p. 1-7. Available from:
11.pdf. Accessed December 6, 2011.
77. Davis RE, Sevdalis N, Vincent CA. Patient involvement in patient safety: how
willing are patients to participate? BMJ Qual Saf 2011;20:108-14.
T. Landers et al. / American Journal of Infection Control 40 (2012) S11-S17 S17