To the Editor—Hand hygiene (HH) is a fundamental practice to prevent healthcare-associated infections by interrupting a microbe’s transmission cycle, and as such, must be performed consistently and in accordance with the current evidence base. To maximize the benefits of HH monitoring programs, it is important to eliminate inconsistencies between how HH is taught and how adherence is measured. We propose an optimized set of HH recommendations that are understandable, operational, and measurable (Table 1). These are intended to improve patient safety by explicitly expecting HH prior to touching the patient environment and specifying the necessity of performing HH before and after glove use. In addition, clearly stating that HH should be performed with entering and exiting the patient’s care area, allows the moments to be aligned with existing HH auditing systems and signals healthcare worker (HCW) dedication to patient safety. The proposed times at which HH should be performed conform, with minor modifications, to those that have been set forth by the World Health Organization (WHO) Five Moments for Hand Hygiene and the Centers for Disease Control and Prevention (CDC) Healthcare Infection Control Practices Advisory Committee (HICPAC) recommendations. ^1,2 We strongly recommend closely emulating Public Health Ontario’s (PHO) Your Four Moments for HH with modifications mentioned to best address identified gaps. ³

Table 1. World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), Public Health Ontario (PHO), and Proposed Hand Hygiene Practice Recommendations

In the publication used to substantiate the adoption of the WHO Five Moments for Hand Hygiene, before patient contact is defined as “occur[ing] between the last hand-to-surface contact with an object belonging to the healthcare zone and the first within the patient zone.” The example provided is touching a door handle belonging to the healthcare zone and the patient’s hand. Notably, this guidance mentions that not only will HH at this time prevent cross colonization of the patient but “occasionally, exogenous infection” as well. ^{Reference Sax, Allegranzi, Uckay, Larson, Boyce and Pittet4} The first moment does not specifically mention the need to perform HH before touching the patient’s environment, including commonly touched surfaces by the patient, and others, such as the bedside table. If HCWs strictly adhere to the first WHO moment, or CDC HICPAC recommendations, they likely contribute to cross-contamination of the patient’s environment through contact with that environment using contaminated hands. Additionally, during patient care, HCWs may touch contaminated objects within the patient environment, followed by the patient, aiding in transmission. One study demonstrated that 33.5% of visits only included touching the environment, shedding light on the potential frequency at which environmental contamination may occur. ^{Reference Cohen, Hyman, Rosenberg and Larson5} The role the environment plays as a reservoir of organisms that can cause infection has been well documented and recognition of the environment as a contributor to multidrug-resistant organism transmission has been mounting. ^{Reference Boyce, Potter-Bynoe, Chenevert and King6,Reference Chia, Sengupta, Kukreja, Ponnampalavanar, Ng and Marimuthu7} Therefore, HH before contact with the patient environment should be incorporated into HH practice recommendations, similar to the PHO’s first recommendation, which comprises 2 different moments for HH. The authors of a recently published letter to the editor of Infection Control and Hospital Epidemiology eloquently articulate the possibility of recontamination after HH, regardless of glove use, due to touching contaminated surfaces or objects. ^{Reference Gon, Dancer, Dreibelbis, Graham and Kilpatrick8} This plausible and likely common scenario should provide further attention to the need for decreasing the environmental microbial burden by performing HH before contact with surroundings.

The CDC HICPAC recommendations explicitly mention the need to perform HH after gloves are removed, but they do not overtly state the need to perform HH before putting gloves on. Gloves are often used even when not clearly indicated, and use of gloves has been associated with lower HH compliance. ^{Reference Fuller, Savage and Besser9} HCWs are more likely to perform HH after tasks, than before, regardless if it was deemed critical or noncritical. ^{Reference Chang, Reisinger and Schweizer10} One study found that 96% of patients (n = 250) thought it important that physicians clean their hands before touching anything in the room. ^{Reference Michaelsen, Sanders, Zimmer and Bump11} Patient perception or satisfaction can be leveraged to justify the incorporation of adding “before contact with the patient environment” to hand hygiene policies. Moreover, when auditing HH compliance, many inpatient facilities do review whether or not HH was performed prior to donning gloves and additional personal protective equipment in addition to entering or exiting a patient’s room. By formalizing these instances to align with HH training programs and policies, HCWs will be more cognizant of their expectations.

This letter serves as an impetus for institutions to conduct a thorough assessment of their HH practice recommendations alongside the current evidence base. In our opinion, it is necessary to incorporate HH before touching the patient environment, before donning gloves, and after doffing gloves when providing patient care. Alignment with institutional policy, education (eg, new or annual training modules, introductory videos, health professional education), and methods for measuring compliance should also be evaluated. These recommendations have the potential to improve patient safety by preventing healthcare-associated infections. Additional benefits, such as improved patient satisfaction or perception, and alignment with existing auditing programs, may also result.