Expert Explains Why the US is Falling Behind in Hand Hygiene

“Clean Hands Save Lives.” It’s a simple phrase and a scientific fact that has shaped the life and mission of leading hand hygiene expert, Professor Didier Pittet, MD, MS, CBE. Professor Pittet has been the world’s leading voice on the importance of hand hygiene and for good reason. Studies have shown that proper hand hygiene is the single most important, simplest, and least expensive means of reducing the prevalence of hospital-acquired infections and the spread of antimicrobial resistance.[1]

“It’s very clear and positive to see progress around the world. In 2010, I partnered with the World Health Organization (WHO) to create a hand hygiene self-assessment framework which allows hospitals to monitor and report on themselves. The framework is based on the WHO multimodal approach to promote hand hygiene and as a result of this tool, we have seen great progress worldwide,” explains Professor Pittet, Director of the Infection Control Programme at University of Geneva Hospitals and WHO Collaborating Centre on Patient Safety.

However, according to the WHO’s 2011 Hand Hygiene Self-Assessment Framework Global Survey Summary Report, one country that has fallen behind in hand hygiene and hospital-acquired infections is the United States. According to the study which surveyed 2,119 healthcare settings from 69 countries, on their institutional culture of hand hygiene and compliance, the United States ranked behind developing countries in Africa.

“Of the 129 US hospitals that participated, compliance levels barely reached 60% which showed that they did not do what they could to promote hand hygiene. Since the initial survey, I have visited many hospitals in the United States and hand hygiene compliance is inadequate which is certainly one among the reasons why infection rates are uncontrolled. There is still a lot of work to be done,” explains Professor Pittet.

And based on the number of hospital-acquired infections in the US, which is the most frequent result of unsafe patient care worldwide, it’s the patients who are suffering as a result of this lapse. According to the CDC, hospital-acquired infections affect 5 to 10% of hospitalized patients in the US each year. That results in approximately 1.7 million HAIs in US hospitals each year. And some HAIs are linked to increased chances of dying in the hospital. For example, patients hospitalized for MRSA have longer hospital stays and are more likely to die than patients who do not have MRSA.[2] Several studies have demonstrated that hand hygiene performed at the appropriate time and using the best technique virtually eradicates the spread of MRSA which almost invariably occurs through the hands of Health Care Practitioners.[3]

Professor Pittet believes it is a question of culture.

“Doctors understand the problem but hospitals in the United States must implement a culture of safety and take action. Right now some of the hospitals are gaming the system and as a result, they don’t know the truth about their own hospital. None of the US hospitals meet the criteria for a hand hygiene excellence center,” explains Professor Pittet.

He continues, “I think some institutions are falsely reassuring themselves. The may only be measuring hand hygiene when staff enters and exits a room but what happens in the room is also critical. You must watch when nurse and doctors touch patients.”

To illustrate, Professor Pittet points to MRSA. MRSA, or Methicillin-resistant Staphylococcus aureus (MRSA), is an infection caused by a type of staph bacteria that’s become resistant to many of the antibiotics used to treat ordinary staph infections. (Reference Mayo Clinic). Despite the CDC reporting progress in reducing MRSA infection rates,[4] recent investigative reports in the media have brought into question the rate of MRSA infections and the adequacy of the United States’ tracking system. Reuters reported that MRSA superbug much more common in the U.S. than UK[5], while a study published last year reported that they could not find definitive evidence that the incidence of MRSA infections in U.S. community or facilities is decreasing significantly. The study went on to say that by the end of 2015 there had been little change in the average facility Standardized Infection Ratio (0.988), compared to a 2010–2011 baseline and is significantly increased compared to the previous year.[6]

While there has been little change in the MRSA rate in the US, Pittet points to an enhanced hand hygiene program he introduced in the University of Geneva Hospitals, Switzerland which reduced the spread of MRSA by 80%. A combination of visual reminders, increasing access to alcohol-based hand rubs (ABHR), hand hygiene performance monitoring and feedback to hospital staff and senior management support resulted in an increase of hand hygiene compliance from 48% in 1994 to 66% in 1997. During the same period, incidence of MRSA bacteremia and MRSA clinical cultures decreased from 0.74 to 0.24 episodes per 10,000 patient-days (p < 0.001) and 2.16 to 0.93 episodes per 10000 patient-days (P < 0.001), respectively. Investigators also observed a significant year-on-year reduction in MRSA acquisition (p = 0.021). [7] “Today, MRSA is not a problem anymore in Geneva; it is totally controlled.”

“The risk is totally different in the United States because the risk is not controlled,” explain Pittet.

The elements of Pittet’s enhanced hand hygiene formed the basis for the WHO’s Multimodal Hand Hygiene Improvement Strategy which consists of five key components that need to be integrated together for successful implementation, including:

  1. System Change – Is there an alcohol based hand rub available at every point of patient care; access to a safe, continuous water supply, soap and towels;
  2. Education and Training – Does staff recognize the right moment for hand hygiene? And do they understand how and when?
  3. Monitoring of Performance – Are regular ward-based audits conducted to assess the availability of hand rubs, soap, and compliance?
  4. Reminders In the Workplace – This can be in the form of gadgets, such as buttons, posters in the workplace which remind staff and the public.
  5. Institutional Safety Culture – This means that the entire institution is behind the action.

Pittet believes that with “enhanced” hand hygiene, all hospitals can see a dramatic reduction in hospital-acquired infections.

“Our annual campaigns have mobilized millions of people each year, including hospitals in the United States but we need more hospitals to take action year-round,” said Professor Pittet.

For more information on the WHO’s program, visit and to learn more about the Patient Safety Movement Foundation’s recommendations on hand hygiene, which include recommendations from the University of Geneva Hospitals, visit


[1]  Mathur, P. (2011). Hand hygiene: Back to the basics of infection control. The Indian Journal of Medical Research134(5), 611–620.

[2] Agency for Healthcare Research and Quality (AHRQ). (2011). Healthcare-Associated Infections. Retrieved from

[3] Mathur, P. (2011). Hand hygiene: Back to the basics of infection control. The Indian Journal of Medical Research134(5), 611–620.