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A large-scale assessment of hand hygiene quality and the effectiveness of the “WHO 6-steps”

László Szilágyi12, Tamás Haidegger13*, Ákos Lehotsky1, Melinda Nagy1, Erik-Artur Csonka2, Xiuying Sun4, Kooi Li Ooi4 and Dale Fisher56

Author Affiliations

1 Department of Control Engineering and Information Technology (BME-IIT), Budapest University of Technology and Economics, Magyar tudósok krt. 2, Budapest H-1117, Hungary

2 Faculty of Technical and Human Sciences, Sapientia University, Tîrgu Mureş, Romania

3 Austrian Center for Medical Innovation and Technology (ACMIT), Wiener Neustadt,Austria

4 Department of Nursing, National University Health System (NUHS), Singapore, Singapore

5 Division of Infectious Diseases, University Medicine Cluster,National University Hospital, Singapore, Singapore

6 Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore

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BMC Infectious Diseases 2013, 13:249  doi:10.1186/1471-2334-13-249

Published: 30 May 2013



Hand hygiene compliance is generally assessed by observation of adherence to the “WHO five moments” using numbers of opportunities as the denominator. The quality of the activity is usually not monitored since there is no established methodology for the routine assessment of hand hygiene technique. The aim of this study was to objectively assess hand rub coverage of staff using a novel imaging technology and to look for patterns and trends in missed areas after the use of WHO’s 6 Step technique.


A hand hygiene education and assessment program targeted 5200 clinical staff over 7 days at the National University Hospital, Singapore. Participants in small groups were guided by professional trainers through 5 educational stations, which included technique-training and UV light assessment supported by digital photography of hands. Objective criteria for satisfactory hand hygiene quality were defined a priori. The database of images created during the assessment program was analyzed subsequently. Patterns of poor hand hygiene quality were identified and linked to staff demographic.


Despite the assessment taking place immediately after the training, only 72% of staff achieved satisfactory coverage. Failure to adequately clean the dorsal and palmar aspects of the hand occurred in 24% and 18% of the instances, respectively. Fingertips were missed by 3.5% of subjects. The analysis based on 4642 records showed that nurses performed best (77% pass), and women performed better than men (75% vs. 62%, p<0.001). Further risk indicators have been identified regarding age and occupation.


Ongoing education and training has a vital role in improving hand hygiene compliance and technique of clinical staff. Identification of typical sites of failure can help to develop improved training.