3 Barriers and Solutions to Intraoperative Hand Hygiene

Publish Date: July 24, 2019

Hand hygiene is far more complex in intraoperative care than in many other nursing settings where “foam in/foam out” will get the job done.

That’s why evidence-based hand hygiene practices in the OR need to be well established, communicated, reinforced and convenient, stresses Laila Bailey, DNP, RN, CNS, CNOR, ACNS, OR service leader for urology and pediatrics at Inova Fairfax Hospital in Fairfax, Va.

When Bailey went back for her DNP in 2016, her team asked her to take a closer look at hand hygiene in intraoperative care.

She found there wasn’t a good transition between hand hygiene for bedside nursing and what was required for safe hand hygiene practices in the OR. So, she developed a unique intraoperative hand hygiene protocol with ideas from her practice colleagues on the frontline and several key evidence-based resources, including the World Health Organization’s My Five Moments for Hand Hygiene and AORN’s Guideline for Hand Hygiene.

Tackling the Barriers to Intraop Hand Hygiene Success

“Nurses want to do what’s best for our patients, especially as it relates to reducing the risk of infection transmission,” Bailey acknowledges, “but there are far more requirements for hand hygiene in the OR and we need education and processes that make the right thing to do the easiest thing to do.”

To achieve hand hygiene success in the OR, Bailey suggests tackling these key barriers and applying three solutions:

Barrier 1: Realizing the OR is NOT a sterile environment

Perioperative nurses may not be thinking about the multiple areas for contamination in the OR, including the patient as well as a computer keyboard or bovie plug that has not been cleaned between cases and can harbor pathogens.

Solution: Place hand hygiene products close by

In most care settings hand hygiene products are placed near a door for practicing hand hygiene as you move in and out of a room, but this simply won’t work in the OR setting where multiple hand hygiene moments are required in the room, Bailey explains. She says placing hand hygiene products throughout key areas within the OR, such as next to the RN circulator’s desk or next to machinery for easy access helps nurses and other members of the surgical team to easily practice hand hygiene at multiple moments through caring for a patient during a surgical procedure.

Barrier 2: Understanding when to practice hand hygiene in the OR

In the OR, Bailey says we think about hand hygiene after touching a patient when there is obvious contamination, but we are less likely to think about residual contamination from patients and providers on OR surfaces and devices.

Solution: Promote the five moments of hand hygiene

Educate nurses to practice hand hygiene at these five key moments throughout intraoperative care, she advises:

  1. Before touching the patient
  2. Before a procedure
  3. After body fluid exposure
  4. After touching the patient
  5. After touching the environment

Barrier 3: Not consistently complying with hand hygiene protocol in the OR

There is inconsistency as a perioperative community in thinking about how we define hand hygiene practices, auditing and compliance, Bailey acknowledges. “Too often auditing focuses more on the foam in/foam out approach and misses the five moments.”

Solution: Audit what you teach

She believes nurses need to be set up for success with hand hygiene by not only providing the education and hand hygiene resources at multiple points within the OR, but also building auditing tools tailored to the five hand hygiene moments in the OR.

“When nurses self-report we think we are doing hand hygiene correctly during intraoperative care, but when comparing nurse perception to recommended practice and observation of their hand hygiene practices, there is a disconnect,” Bailey says. “It’s important to build supportive mechanisms in setting up hand hygiene practices in the OR that accommodate a complex set of behaviors and actions to ensure every moment required for hand hygiene is being addressed.”


Additional Resources

Review the WHO’s My Five Moments for Hand Hygiene guidance.


Free Resources for Members

Guideline Essentials:

Get quick step-by-step instructions, ready-to-use and customizable templates, key takeaways, and more for the Guideline on Hand Hygiene.


Guideline Implementation: Hand Hygiene (1.1 CHs)

Clean Hands Count! Hand Hygiene Guideline Update (1.0 CHs)

AORN Journal CNE Articles

Guideline Implementation: Hand Hygiene (1.1 CHs)

Clinical Issues- April 2017 (1.1 CHs)

Hand Hygiene Clinical FAQs