title: Simplifying the WHO 'how to hand rub' technique: three steps are as effective as six-results from an experimental randomized crossover trial.
abstract: OBJECTIVE
  The World Health Organization (WHO) issued guidelines on hand hygiene recommending a six-step 'how to hand rub' technique for applying alcohol-based hand rub. However, adherence to all six steps is poor. We assessed a simplified three-step technique and compared it to the conventional WHO six-step technique in terms of bacterial count reduction on healthcare workers' hands.
  
  
  METHODS
  Thirty-two participants were randomly assigned to clean their hands following the six-step 'how to hand rub' technique (WHO reference group) or a simplified three-step technique (intervention group). Assignments were reversed after 1 day. The degree of bacterial killing was assessed following the European norm for testing hand hygiene products. Hands were contaminated with Escherichia coli, and the mean logarithmic reduction in bacterial counts was compared between both techniques.
  
  
  RESULTS
  Bacterial density before hand hygiene performance did not differ between the WHO reference group (median 6.37 log10CFU, interquartile range (IQR) 6.19-6.54) and the intervention group (median 6.34 log10CFU, IQR 6.17-6.60, p 0.513). After hand hygiene, the logarithmic reduction factor was higher in the intervention group (median 4.45, IQR 4.04-5.15) compared to the WHO reference group (median 3.91, IQR 3.69-4.62, p 0.021).
  
  
  CONCLUSIONS
  The WHO six-step 'how to hand rub' technique can be simplified to a 3-step procedure based on the reduction of bacterial counts on healthcare workers' hands achieved under experimental conditions. The proposed technique is easier to perform and could improve adherence to the execution of hand hygiene action.
authors.affiliation: Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland. Electronic address: sarah.tschudin@usb.ch.
authors.forename: S
authors.initials: S
authors.lastname: Tschudin-Sutter
authors.affiliation: Department of Clinical Microbiology, Institute of Hygiene and Medical Microbiology, Medical University Vienna, Vienna, Austria.
authors.forename: M L
authors.initials: ML
authors.lastname: Rotter
authors.affiliation: Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland.
authors.forename: R
authors.initials: R
authors.lastname: Frei
authors.affiliation: Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland.
authors.forename: D
authors.initials: D
authors.lastname: Nogarth
authors.affiliation: Department of Dermatology, University Hospital Basel, Basel, Switzerland.
authors.forename: P
authors.initials: P
authors.lastname: Häusermann
authors.affiliation: Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland.
authors.forename: A
authors.initials: A
authors.lastname: Stranden
authors.affiliation: Infection Control Program and World Health Organization Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland.
authors.forename: D
authors.initials: D
authors.lastname: Pittet
authors.affiliation: Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland.
authors.forename: A F
authors.initials: AF
authors.lastname: Widmer
mesh_terms: D000328:Adult; D058491:Bacterial Load; D018592:Cross-Over Studies; D004926:Escherichia coli / Q000302:isolation & purification*; D005260:Female; D006225:Hand / Q000382:microbiology*; D006235:Hand Disinfection / Q000379:methods*; D006282:Health Personnel; D006801:Humans; D008297:Male; D011897:Random Allocation; D055815:Young Adult
keywords: Bacterial counts; Hand hygiene; Reduction factor; Technique; Three steps