WHO 5 Moments of Hand Hygiene

Hand hygiene at the right moments is the single most consequential infection prevention behaviour in healthcare. The WHO 5 Moments framework defines when hand hygiene must occur. It’s the UK standard, adopted by NHS England, NICE and the NMC.

The five moments

Moment 1: Before touching a patient

Before any contact with the patient or their immediate environment (the bed area, the table next to them, anything within their personal space).

Examples: before taking a pulse, before helping with personal care, before assisting with mobility.

Why: prevents transferring organisms from the environment to the patient.

Moment 2: Before a clean or aseptic procedure

Immediately before any procedure that breaches a clean barrier: IV cannulation, catheterisation, wound care, medication administration, mucous membrane contact.

Why: prevents introducing organisms during the procedure.

Moment 3: After body fluid exposure risk

Immediately after any task that involves body fluid risk, even if gloves were worn. Includes after removing gloves.

Examples: after personal care, after handling specimens, after wound dressing, after IV procedures, after suctioning.

Why: prevents the registrant from carrying organisms onward to other patients or the environment.

This is the most commonly missed of the five moments. Easy to skip when busy.

Moment 4: After touching a patient

After contact with the patient, even when no body fluid was involved.

Examples: after taking a pulse, after helping with mobility, after a routine examination.

Why: prevents carrying the patient’s organisms onward.

Moment 5: After touching patient surroundings

After contact with the patient’s immediate environment, even without touching the patient directly.

Examples: after adjusting bedding, after handling the bed table, after replacing a glass of water.

Why: the patient’s surroundings carry their organisms.

This is the second most commonly missed of the five moments.

The technique

Alcohol-based hand rub (most common application):

1. Apply enough product to cover both hands.
2. Rub palm to palm.
3. Right palm over back of left hand, fingers interlaced; then reverse.
4. Palm to palm, fingers interlaced.
5. Backs of fingers to opposing palms with fingers interlocked.
6. Rotational rubbing of left thumb in right palm; then reverse.
7. Rotational rubbing, backwards and forwards, with clasped fingers of right hand in palm of left; then reverse.

Total time: 20-30 seconds. Continue until dry.

Soap and water (visibly soiled hands, after C. difficile or norovirus contact):

Same 6-step technique applied to wet, soapy hands, for at least 20 seconds, then rinse and dry thoroughly.

When to use which

Alcohol gel:

• Routine hand hygiene between most moments.
• Hands not visibly soiled.
• C. difficile not suspected.
• Norovirus outbreak not in effect.

Soap and water:

• Visibly soiled hands.
• After contact with C. difficile (alcohol gel ineffective against spores).
• After contact with norovirus (alcohol gel less effective).
• After visiting the toilet.
• Before eating.

Most trusts have wall-mounted alcohol gel and dedicated handwashing sinks. The choice between them is a clinical decision per situation.

Why hand hygiene matters

The evidence base is unusually strong:

• Hand hygiene compliance correlates directly with healthcare-associated infection rates.
• 10 percentage point improvements in compliance produce measurable reductions in HAI.
• Hand hygiene is consistently identified as the highest-impact, lowest-cost IPC intervention.

NICE NG139 and NHS England’s IPC framework both place hand hygiene at the centre of the strategy.

Common compliance gaps

Audit data across the NHS shows consistent patterns:

• Moments 1, 2 and 4 are commonly done. Most staff complete hand hygiene before touching a patient and before procedures.

• Moment 3 is often missed. After body fluid risk, especially when gloves were worn, hand hygiene gets skipped because the gloves felt like adequate protection.

• Moment 5 is often missed. After touching only the patient’s environment without touching the patient, the cognitive trigger is weaker.

The pattern means most missed hand hygiene happens at the end of patient contact rather than the beginning. The fix is making the post-contact moments equally automatic.

Glove use

Gloves are an addition to hand hygiene, not a replacement. The standard sequence:

1. Hand hygiene.
2. Don gloves.
3. Carry out the procedure.
4. Remove gloves.
5. Hand hygiene again.

Gloves can harbour organisms on the outside; they can also tear or fail. Hand hygiene before and after maintains the barrier.

Hand hygiene in the OSCE

OSCE examiners watch every hand hygiene opportunity. Missing one or two moments in a station typically loses marks. Missing several can fail the station regardless of clinical technique.

Be visible about hand hygiene. Apply gel where there’s a wall dispenser. Verbalise the moment if it helps you remember (“I’ll perform hand hygiene before I touch the patient”).

The next chapter covers PPE selection, the IPC equipment that pairs with hand hygiene.