Research for infection protection

WHO Moments model for outpatient medicine

In 2005, WHO launched its “Clean Care is Safer Care” campaign to improve the compliance with hand hygiene protocols and thus prevent nosocomial infection. The “Moments model”, which was developed for inpatient care in hospitals, defines 5 indications that require hand disinfection. These correspond to clearly defined situations, in which pathogens may be transmitted and thus endanger the health of patients and staff. In outpatient medicine as well, pathogens and nosocomial or healthcare-associated infections are a relevant threat. To promote hand hygiene compliance also in this field, together with WHO, the German “Aktion Saubere Hände” (Clean Hands Campaign) adapted the “5 Moments for Hand Hygiene” model for outpatient care.

Hand hygiene in outpatient medicine

A nosocomial infection may worsen the condition of a patient, delay the healing process or even trigger life-threatening septicaemia and pneumonia. The staff’s compliance with hand hygiene protocols has a direct impact on the patient’s safety: the higher the compliance, the more effectively the spread of pathogens is prevented.

Similar to hospitals, nosocomial infection is a common complication in outpatient care. However, a scientific study from Spain shows: around 80 % of these complications are preventable (1).

One possible cause of nosocomial infection is the insufficient compliance among healthcare workers: studies, for example, attest paediatricians, dermatologists and nephrologists a compliance of below 50 % (2-4). The consequence: staphylococci were found on the hands of around 85 % of the physicians – 9 % were even colonised with MRSA (2, 3). Also the hands of nurses and medical assistants can be potentially dangerous: in a dialysis unit, researchers detected RNA of hepatitis C viruses (HCV) on the hands of around every fourth employee responsible for HCV-positive patients (5). Another study revealed that patients colonised with VRE contaminate almost every second dialysis stretcher and thus the direct patient surroundings with VRE (6). In case of lacking compliance among healthcare workers, dangerous pathogens may thus be transmitted to other patients.

What is a moment for hand hygiene?

A moment for hand hygiene is a situation that requires a hand disinfection. It is the moment when there is a risk of a transmission of pathogens. Hand disinfection can prevent such a transmission efficiently.

Moments for hand hygiene in outpatient, non-invasive areas

In outpatient medicine, the direct patient surroundings can normally not be defined. Hence, employees need to disinfect their hands in accordance with the following four indications:

  1. BEFORE touching a patient
  2. BEFORE aseptic procedures (e.g. injections, punctures, dressing changes, etc.)
  3. AFTER body fluid exposure risk (e.g. with blood, vomit, secretion from a wound, nasal secretion, saliva, etc.)
  4. AFTER touching a patient

What is a patient contact?

A patient contact is a medical or caregiving interaction, in which the skin is touched directly and intensively and the patient’s privacy is not preserved. Examples are palpation or auscultation.

Indications in outpatient, invasive areas

Dialysis, endoscopic or radiological examinations are invasive methods that are carried out in outpatient medicine. For these, the patient is treated in a defined location and with materials exclusively assigned to her/him. In these situations, it is possible to delimit the patient surroundings. Here, healthcare workers additionally need to observe the fifth indication:

5.AFTER touching surfaces in the immediate patient surroundings

The direct patient surroundings include the examination couch, the patient bed (e.g. for dialysis), personal items of the patient, endoscopes, side tables to deposit materials, and all materials and devices used to treat the patient.

Hand Hygiene in Outpatient and Home-based Care and Long-term Care Facilities. A Guide to the Application of the WHO Multimodal Hand Hygiene Improvement Strategy and the “My Five Moments for Hand Hygiene” Approach, 2012, World Health Organisation

Terminologie und Konzept der "5 Indikationen zur Händedesinfektion“, 2016, „Aktion Saubere Hände“

(1) Aranaz-Andres JM et al. A study of the prevalence of adverse events in primary healthcare in Spain. European Journal of Public Health, 2011 [E-pub November 29, 2011] doi:10.1093/eurpub/ckr168
(2) Cohen HA et al. Handwashing patterns in two dermatology clinics. Dermatology, 2002, 205: 358-361.
(3) Cohen HA et al. Handwashing patterns in primary pediatric community clinics. Infection, 1998, 26:45-47.
(4) Arenas MD et al. A multicentric survey of the practice of hand hygiene in haemodialysis units: factors affecting compliance. Nephrology, Dialysis, Transplantation, 2005,20:1164-1171.
(5) Alfurayh O et al. Hand contamination with hepatitis C virus in staff looking after hepatitis C-positive hemodialysis patients. American Journal of Nephrology, 2000, 20: 103-106.
(6) Grabsch EA et al. Risk of environmental and healthcare worker contamination with vancomycin-resistant enterococci during outpatient procedures and hemodialysis. Infection Control and Hospital Epidemiology, 2006, 27: 287-293.