Coming Clean

MDNG Hospital MedicineDecember 2010
Volume 4
Issue 6

From basic education to innovative tracking technologies, hospitals are vowing to clean up their act when it comes to hand hygiene.

By Kate Huvane Gamble

It’s an issue that has baffled experts for years. The solution to one of the most serious problems in the hospital setting, a place where scientific advances and sophisticated technology guide decision-making, involves a task so simple that preschoolers can do it. And yet, hand hygiene compliance eludes the medical community.

“It’s stunning that we haven’t made progress with this,” said Werner Bischoff, MD, MS, PhD, assistant professor of internal medicine, Wake Forest University Health Sciences, Winston-Salem, NC. “Patients come to the hospital to get better, not sicker.”

According to the CDC, nearly 2 million patients in North America contract an infection in a hospital every year, and of those, about 100,000 die as a result of the infection. These cases can lead to lawsuits that not only hurt a hospital’s reputation, but also its bottom line. In a 2009 report, the CDC stated that hospital-acquired infections cost the US health system as much as $35.7 to $45 billion per year (

And although there are multiple culprits behind these costs, the one that seems to frustrate health care providers most—probably due to the preventability factor—is hand washing. The CDC and Joint Commission estimate that the compliance rate nationwide is around 40%, a number that is simply staggering.

“It’s hard to understand why people who chose to go into health care and have the ability to understand micro-organisms and multi-drug resistance, and have seen hospital-acquired infections—why they still can’t just get hand hygiene into their daily routine,” says Jason Adelman, MD, MS, patient safety officer, Montefiore Medical Center, Bronx, NY. Hand hygiene, he believes, is “incredibly important, and for multiple reasons.” Most fundamentally, the intent is to protect patients from multi-drug-resistant organisms that are difficult to treat but can easily be transmitted from one patient to another in the hospital setting. “There’s a simple defense against it, which is proper hand hygiene,” he says.

However, it’s not that organizations haven’t tried to solve the problem; numerous hospitals have implemented interventions that have yielded positive results. The problem, according to Bischoff, has been a lack of sustainability with hand hygiene solutions. Once a project loses steam, success rates tend to plummet, he notes.

That was precisely the idea behind an initiative launched by the Joint Commission Center for Transforming Healthcare in 2008 in which eight participating hospitals piloted systematic process improvement tools designed to identify why processes were failing, and create solutions that were targeted to the most critical contributing factors (

Wake Forest: The power of data

Wake Forest University Baptist Medical Center was one of the eight organizations chosen, and according to Bischoff, the focus right from the start was to get an accurate read on how well clinicians and other staff were complying with hand hygiene protocols. Obtaining surveillance data, however, proved to be no easy task for the project’s leaders. The first method they tried was a “secret shopper” model in which undercover individuals were asked to document hand hygiene compliance.

The problem with this is that clinicians catch on quickly when someone they don’t recognize is watching them and taking notes, especially in a setting like the intensive care unit (ICU), he says. And “when people notice that they’re being observed, it changes their behavior,” and consequently, it becomes difficult to obtain a reliable assessment.

To that end, Wake Forest recently began piloting a real-time location system (RTLS) that utilizes monitoring technology to track hand hygiene compliance. As part of the trial, employees in the test units wear badges with embedded electronic chips that track their utilization of hand hygiene stations, and the stations contain corresponding chips that track whether soap or alcohol hand rub dispensers are being used, according to a statement ( by Donny C. Lambeth, president of North Carolina Baptist Hospital, which is part of Wake Forest University Baptist Medical Center.

With this technology, says Bischoff, the organization can obtain solid data on how well physicians and nurses are complying, while gaining insights into what can improve adherence. Being able to provide feedback to personnel is critical, he adds. “Studies have shown that if you ask people if they’ve washed their hands, pretty much everyone will say yes. And I believe that they think they are doing this. But the data that we’ve collected so far does not reflect that, unfortunately.”

Individual accountability, he says, is one of the most powerful tools that organizations can utilize, and should not be overlooked. “If you can go to an individual and show them the data, that is a big step in changing behaviors,” he says, noting that while it might be less time-intensive to appeal to the staff as a whole to improve compliance, it isn’t as effective as approaching staffers one at a time—with data.

“It’s a tricky subject,” he says, adding that although project leaders might be met with resistance—and will likely hear several excuses—from physicians and nurses, it’s important to push on. “With electronic tools, you can use data to show people what is happening, and I think that’s very important.”

Since Wake Forest first started assessing compliance and taking steps like determining better locations for hand hygiene stations, medications, supplies, and materials for disposal, and moving barcode medication scanners from shared carts to the bedside, Wake Forest has realized—and been able to sustain—significant improvements. According to Robert Sherertz, MD, professor of medicine and associate hospital epidemiologist at Wake Forest University School of Medicine, the baseline rate of hand hygiene compliance increased from 49% to 80% in the ICU since the start of the pilot, and rose from about 45% to 79% on the surgical floor.

Montefiore’s mission: Education

At Montefiore Medical Center, the university hospital for the Albert Einstein College of Medicine, the key to improving hand hygiene compliance has been education.

According to Adelman, patient safety education—which begins at orientation and continues through annual reviews for each staff member—is delivered through several methods, including e-learning modules. However, it seemed that education wasn’t enough; an assessment by leadership found hand hygiene compliance in need of significant improvement.

So after Montefiore was chosen as one of 19 hospitals to participate in the Center for Transforming Healthcare’s hand hygiene program, the organization began to employ “just-in-time” coaches to pinpoint where the problems were. As opposed to “secret shoppers,” whose primary function is to anonymously identify which staffers didn’t wash their hands for the purpose of data collection, just-in-time coaches were instructed to approach those who didn’t comply and ask them why they weren’t able to wash their hands, according to Adelman.

“We found that with just-in-time coaches, we were able to learn a lot more about the barriers that existed,” he says. In fact, the input that was obtained resulted in a few changes, including the following:

  • Adding alcohol dispensers on the outside of each room and in between patient beds
  • Developing of a protocol for mobile carts in which hands are washed before and after contact with patients
  • Educating dietary aids on hand hygiene protocols during delivery and pick up of food trays
  • Adding signs near gel dispensers with sayings like “Clean hands here”

“Some of the lessons we learned were very basic but important,” he notes. For example, putting alcohol dispensers in locations where dietary aids and nurses can easily access them and providing focused education helped to improve compliance. Another example is the “wash in, wash out” concept; whereas before, personnel were taught to wash their hands before any patient contact, Montefiore’s policy now requires all staff to wash hands before and entering a patient area. If there are two patient beds in a room, staffers must lather up when crossing the threshold from bed to bed (dispensers have been placed between beds to facilitate this).

More subtle reminders are also utilized, such as screensavers and signs reminding all care providers to wash their hands. In addition, project leaders share case examples of patients who acquired infections during the hospital stay that severely complicated their conditions. “We try to use those examples to get the point across, but education is only the beginning,” says Adelman. “We have to use data collection monitoring and constant reminders and re-education.”

Three months after starting the pilot, the hand hygiene compliance rate ballooned to 85% and continues to improve; the goal now, he says, is to sustain that level of success. “We saw a drastic difference on the pilot unit. Now we’re taking those lessons learned to the rest of the organization.”

Looking ahead

The hardest part of having a good hand hygiene program is collecting the compliance data, according to Adelman. “It’s just a daunting task,” he says, adding that utilizing secret shoppers can be “very manpower-intensive.”

As an alternative, a number of electronic systems are being introduced to assist with monitoring—from technologies that measure and monitor the amount of alcohol solution used on different units, to portable alcohol dispensers that can be affixed to a physician’s belt.

And then, there are the more sophisticated tracking technologies that are used at some hospitals to keep tabs on IV pumps, wheelchairs, and other pieces of equipment. The same technology is being used to detect whether staffers have washed their hands or used the alcohol dispenser, and if they’ve been in contact with a patient.

“I think that over the next 100 years, hand hygiene will largely be solved by one of these systems,” says Adelman. “It might not be the next 10 years, but it’s going to happen. We’re going to be able to get very good data on hand hygiene compliance.”

SIDEBAROne Step Further

A number of technologies focusing on improving infection control in the health care setting have started to emerge; among the most compelling are the following:

  • The Amelior 360° Hand Hygiene solution uses RTLS technology and disinfectant dispenser attachments to continuously monitor staff members’ compliance with defined hygiene and infection protocols (
  • Alberto Segre, PhD, and colleagues at the University of Iowa have developed iScrub (, an application for the iPhone and iPod touch that allows clinicians to monitor hand hygiene compliance without using clipboards and transcription (
  • GE Healthcare recently launched a pilot of a Smart Patient Room at Bassett Medical Center in Cooperstown, NY, in which cameras and sensors in patient rooms will track hand washing, the frequency with which caregivers check on patients, adherence with clinical best practices, and any signs of unusual activity that could put a patient at unnecessary risk (

SIDEBARWhat’s the Problem?

As part of its Hand Hygiene project, the Joint Commission Center for Transforming Healthcare compiled a list of the top causes for failure to clean hands:

  • Ineffective placement of dispensers or sinks
  • Hand hygiene compliance data are not collected or reported accurately or frequently
  • Lack of accountability and just-in-time coaching
  • Safety culture does not stress hand hygiene at all levels
  • Ineffective or insufficient education
  • Hands full
  • Wearing gloves interferes with process
  • Perception that hand hygiene is not needed if wearing gloves
  • Health care workers forget
  • Distractions

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