Hand to hand combat

Improved formulations and monitoring improves hand-hygiene compliance

Photo courtesy Ecolab

It has been almost 200 years since discovery of the connection between handwashing and reduction of infection in the healthcare setting. Yet, most healthcare facilities still struggle to enforce hand-hygiene (HH) compliance. Fortunately, there are a variety of solutions available to help healthcare workers (HCWs) to improve.

A report recently published in the American Journal of Infection Control found that patient involvement can also help up HH-compliance rates of physicians.1

Results showed that when patients used a patient empowerment tool (PET), there were positive results: 64 percent of adult patients and 70 percent of parents of admitted children believed the PET made them feel more in control of their care; parents were nearly 20 percent more likely than adult patients to speak up if a physician did not cleanse his or her hands. HH-compliance rates increased from 48 percent, which is the normal average, to approximately 75 percent.

Breaking the cycle of skin damage

Skin damage from repeated hand cleansing is a major reason for non-compliance. Products that not only cleanse but heal encourage HH compliance while helping to break the cycle of damaged, painful skin due to constant cleansing.

Healthy skin is the first line of defense against colonization by pathogens that can be transferred from HCWs’ hands to patients. Dry, cracked hands hurt, but they also provide a multitude of tiny nooks and crannies for pathogens to hide and breed.

Greg Skorczewski, Advanced Technical Service Specialist, 3M, described contributors to damaged skin, as well as solutions. “Formulation matters,” he stated. “Damaged hands are prevalent among healthcare professionals because of frequent handwashing with harsh agents. Many HCWs report having problems with their hands, including dry, scaly, cracked skin; red, blotchy skin; or stinging. The frequency of exposure to antimicrobial agents is among the most common reasons cited for damaged skin.

“Maintaining skin-barrier function as an adjunct to antimicrobial activity is a key consideration when selecting HH products,” continued Skorczewski. “3M Avagard D and Avagard (chlorhexidine gluconate 1 percent and ethyl alcohol 61 percent, w/w) Surgical and Healthcare Personnel Hand Antiseptic with moisturizers delivers substantive emollients that have been shown in clinical studies to maintain skin integrity and enhance skin hydration.”

Avagard Surgical and Healthcare Personnel Hand Antiseptic with moisturizers, from 3M

Skorczewski noted the importance of addressing HCW likes and dislikes in hand cleansers, because if a user does not like the product they are less likely to comply. “3M Avagard D and Avagard Surgical and Healthcare Personnel Hand Antiseptic with moisturizers are formulated with a unique, patented, liquid-crystalline emulsion system. In addition, the Avagard Gel antiseptic is formulated with an aloe-based emollient. The Avagard Foam antiseptic rounds out a choice of emollients to meet user preference, which has been shown to be a significant factor in sustaining HH compliance.”

Skorczewski referred to research that evaluated the effects of those products. “All three studies assessed subjects’ hands for skin dryness, erythema, appearance, moisture content, and intactness. The unique formulation of Avagard D and Avagard Surgical and Healthcare Personnel Hand Antiseptic with moisturizers preparation was shown to be less drying and more gentle to the skin than traditional handwash agents by maintaining the integrity of the stratum corneum, which was associated with statistically significantly better skin-condition scores for appearance, intactness, moisture content, and sensation.”

Joey Suntken, Marketing Vice President-Healthcare, GOJO, agreed that formulation is critical. “Expert formulation is essential to achieving efficacy without causing severe irritation from high-frequency usage.” Suntken said that GOJO worked with a dermatitis specialist to identify the leading causes of severe skin irritation from washing, including irritating ingredients.

“We formulated the new PURELL Healthcare HEALTHY SOAP products with CLEAN RELEASE Technology to be free from harsh preservatives and gentle on skin. Using a proprietary surfactant system, this patent-pending, non-antimicrobial soap reaches into skin’s cracks and crevices, removing over 99 percent of soil and germs. It also works better than regular soap on dry and irritated skin, leaving 3.4 times fewer germs behind.”

from GOJO

Last year, GOJO also launched PURELL Healthcare Advanced Hand Sanitizer ULTRA NOURISHING Foam, which is enhanced with skin conditioners proven to improve skin condition in three days, even with frequent use. “It also kills 99.99 percent of the most common illness-causing germs in a healthcare setting, including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus,” Suntken said.

He believes that lack of ready availability of HH products is another reason for noncompliance, noting, “GOJO is helping to overcome this challenge with breakthrough dispenser technology. PURELL ES8 dispensers feature at-a-glance refill design, allowing a healthcare facility’s staff to easily monitor when a refill needs to be replaced. Each new refill comes with its own energy source: a coin cell battery integrated into the refill. When the empty refill is replaced, you get fresh product and fresh energy in one step, and a 68 percent reduction in battery waste, compared to leading touch-free systems on the market. This means soap and sanitizer dispensers are always ready and functioning. All PURELL ES8 dispensers can be integrated with optional GOJO SMARTLINK plug-in modules to track HH compliance, receive alerts when dispensers need service, or add other upgrades as technology evolves.”

Donna Santoro, Vice President and General Manger, Vi-Jon Inc., talked about the advantages of their product’s formulation. “Germ-X Moisturizing Hand Sanitizer Lotion is formulated to soften and condition skin, while eliminating 99.99 percent of germs in as little as 15 seconds. Its alcohol-free blend of moisturizers, vitamins, and skin conditioners leaves hands feeling soft and smooth over a full shift, all while eliminating harmful bacteria.” Santoro added that Germ-X Moisturizing Hand Sanitizer Lotion is compatible with chlorhexidine gluconate as well as latex, nitrile, and vinyl medical gloves, “making it a perfect fit for infection-control programs where repeated hand cleansing is required.”

Germ-X Moisturizing Hand Sanitizer Lotion

Kathleen Burzycki, Senior Marketing Manager, Healthcare, Ecolab, also talked about how their products address the importance of formulation in maintaining healthy skin. “Ecolab keeps hand health top-of-mind when we are formulating our products. We have a sanitizer that actually improves hand health after 14 days, soaps with emollients to help nourish skin during the wash, and lotion and cream to help moisturize the skin when needed.”

Elyptol is a hand antiseptic with a formula that deviates a bit from others. Sue Barnes, RN, CIC, FAPIC, Independent Infection Prevention Consultant, described how Elyptol is different from other alcoholic hand sanitizers. “The active ingredient, eucalyptol, is an essential oil that is added to the Elyptol formula, harnessing nature’s strengths to create a sanitizer that moisturizes and cleanses the skin without any toxic ingredients. The unique formula also helps minimize the likelihood of allergic reactions and contact dermatitis. Additionally, the therapeutic aromatherapy property of Elyptol encourages frequent use, which facilitates compliance with the WHO 5 Moments of HH protocol.2

“Essential oils, such as eucalyptol, provide a number of therapeutic properties including skin healing, aromatherapy, antibacterial properties against pathogens, anti-inflammatory and antioxidant properties, and anti-anxiety benefit,” added Barnes. “Scent, in particular, has been shown in various settings to enhance HH compliance. In a study by Birnbach et al, fresh scent was a variable introduced to enhance HH compliance among novice healthcare providers. Of 165 participants, 51 percent in the fresh-scent group demonstrated a higher rate of HH compliance. The author concluded that HH behavior may be influenced by cues in the environment such as scent.3

Elyptol Antimicrobial Hand Gel

Noting that the effect of this innovative hand sanitizer has not yet been scientifically tested, Barnes noted, “However, Elyptol, won a New Hope NEXTY award at Natural Products Expo in September 2016. These Awards are globally recognized as the best in class in the Natural Products sector, given to products that display the utmost in innovation, integrity, and inspiration, delivering more healthful, trusted, and sustainable products to consumers. Elyptol also won the ECRM Finalist Retail award and the International Design Award.”

Compliance improves with electronic monitoring

New Scientist recently reported on a pilot study4 performed by the Swiss Federal Institute of Technology in Lausanne that takes compliance monitoring to another level, stating, “Using a combination of depth cameras and computer-vision algorithms, a research team has tracked people around two hospital wards and automatically identified when they used gel dispensers. The trial was so successful that the group is now going to fully kit out three hospitals for a whole year, to see if it puts a dent in the stubborn acquired infections statistics.”

They collected images of unidentifiable individuals from cameras installed overlooking corridors, patient rooms, and alcohol-based gel dispensers, among other places. Only 30 of 170 people correctly used the gel dispensers placed outside patient rooms. Healthcare staff trained to monitor HH behavior as people moved from one spot to another across different cameras achieved an accuracy of 75 percent in telling whether people had used the dispensers. While secret shoppers are only capable of identifying whether dispensers are used correctly, cameras can provide a continuous view of everyone moving in and out of different locations 24 hours each day.

Also, there are effective electronic monitoring options available and excellent advice to consider.

The Handwashingforlife Institute’s mission is to advance the science of HH and solve common HH challenges around the world. Jim Mann, Executive Director, Handwashingforlife Institute, connected the dots between accuracy in monitoring and changing HCW behavior. “Electronically assisted HH monitoring converts random handwashing into a controllable and verifiable process. Application of this technology makes it possible to motivate behavior change from the c-suite to bedside care. The meeting of agreed standards drives a report shared first with the worker and on up through the hierarchy, including risk management. Data then drives the professionalization process and assures a patient-first culture. Data defends the patient from the budget-first decision-maker. Handwashing performance becomes a career-critical measurement for all caregivers and a key indicator of supervisor leadership.”

Mann offered advice on three key features to look for in HH monitoring systems, explaining also why accuracy of reporting is important when persuading budget keepers of the necessity of electronic monitoring systems. “There is an array of handwash monitoring technologies to choose from when matching up specific goals with the most appropriate system. The WHO Five Moments provides an outline. All measure two of the five, the ‘rub-in’ and ‘rub-out.’ The best systems are those that go beyond ‘in-out’ compliance, providing reminder cues that can be visual, audio, or a gentle vibration of the identification badge.

“A second valuable feature is the ability to capture and report hand washes within the patient room. This gives credit to the caregiver and motivates consistent compliance. In one system, the technology can differentiate a soap-and-water handwash from one with alcohol hand sanitizer. If the wrong one is used in a room where a patient has Clostridium difficile, the caregiver is reminded.”

Thirdly, noted Mann, “Hand-hygiene compliance systems are major money savers when considering the cost of a single healthcare-acquired infection (HAI) but may be considered unnecessary by the budget-first breed. Their satisfaction of the status quo often stems from their infection-prevention department reporting 90 percent compliance to JCAHO rather than the reality, which could serve as a baseline for continuous improvement, the true Joint Commission standard.

“Electronically assisted observations are the new gold standard for compliance because they can be objectively verified. These systems expose the fiction perpetuated by observation-only operations.”

Ron Chappuis, Vice President of Marketing, DebMed, part of SC Johnson Professional, commented on what HCWs are up against regarding accurate HH measurement. “Most hospitals use direct-observation methods, capturing only a small percentage of HH events and usually only during room entry and exit. Studies have shown around half of HH opportunities occur at the point of patient care. It is thought that opportunities in the patient room, such as before aseptic tasks or after fluid exposure, may have potentially even greater contamination risk than room entry and exit. To date, infection preventionists and unit teams haven’t found a good way to evaluate performance in these situations.”

DebMed GMS dashboard with actionable results

Explaining how their system takes HH monitoring to the next level, Chappuis explained that DebMed Electronic Hand Hygiene Compliance System is a badge-free system that captures 100 percent of HH events, providing accurate compliance scores based on the WHO 5 Moments and Centers for Disease Control and Prevention guidance. “The way the system works is simple,” said Chappuis. “All dispensers, any brand, are monitored to record all HH events. The data is transmitted wirelessly, every day, to an offsite server, without using Wi-Fi or the hospital’s information technology infrastructure. The number of events is compared to the number of opportunities, based on the level of care, to report HH compliance rate.”

An easy-to-read dashboard report, available online or by email, provides data that tracks progress, offering a basis for performance improvement. “Reports are available for each unit, for any period of time desired, and always include the baseline starting point to show the improvement trends,” said Chappuis. “The dashboard also compares performance among units, allowing teams to benchmark against the rest of the facility. Room reports provide soap versus sanitizer use, which is useful for tracking compliance with C. diff protocols.”

Some users might appreciate the anonymity of the DebMed Monitoring System. It doesn’t use badges reporting on individual staff members; rather, it reports performance by the unit. “It’s been clearly shown that a blame-free environment and collaboration are essential features of a successful safety culture,” observed Chappuis.

“Recently, a peer-reviewed study5 demonstrated that use of the DebMed Monitoring System yielded a significant correlation between unit-specific improvements in compliance and reduction in MRSA infection rates. Greenville (South Carolina) Memorial Hospital, a 746-bed teaching hospital, achieved a 25.5 percent increase in HH compliance and a 42 percent reduction in hospital-onset MRSA infections during the 33-month study period. The study estimated $434,000 in hospital cost savings.”

Brent D. Nibarger, Chief Client Officer, BIOVIGIL, explained that their system utilizes active reminders, tones and vibrations, and a visual illuminated hand symbol to alert users and patients if HH is needed or has been performed. “These two features dramatically modify caregiver behavior and accountability to protocols. Biovigil clients report sustained compliance and 30 percent to 83 percent reduction in overall infection rates. The system also automates all data collection and reporting activities across dozens of metrics.

“Hand sanitizer use or hand washing with soap and water takes place at different times, in different ways, at different locations, and for different reasons,” said Nibarger. “The BIOVIGIL system captures, reminds, and differentiates between all the various WHO 5 Moment events and behaviors. The BIOVIGIL system also automatically reminds a user if certain protocols are not followed; for example, failure to wash hands with soap and water, versus use of sanitizer, will trigger a user alert upon exiting from a C. diff room.”

Nibarger told Healthcare Purchasing News that a data survey performed on more than 60 million collected HH events from clients across the U.S. supports achieved and sustained a 97 percent HH compliance level on a 24/7/365 basis.

The experience of the Cleveland (Ohio) Clinic parallels this claim. An efficacy study6 was recently published using BIOVIGIL system for 12 weeks in an organ-transplant unit. A second eight-week study was performed in a cardiothoracic surgery ICU. The BIOVIGIL system collected 267,566 total HH events. Data showed a sustained 98 percent and 97 percent HH compliance level, respectively.

The BIOVIGIL system

White Plains (New York) Hospital enjoyed a similar experience.7 BIOVIGIL was used in an eight-bed ICU and 25-bed step-down ICU for 11 months. “The system collected 632,404 HH events, as compared to 480 manual observations,” said Nibarger. A compliance goal of 95 percent was sustained and exceeded. “They also observed an 83 percent reduction in multidrug-resistant organisms, central-line associated bloodstream infection, and catheter-associated urinary tract infection rates; however, a study period of longer duration is necessary to achieve statistical significance. Results are expected in the fourth quarter of 2017.”

Ecolab has another product that can help facilities step up compliance.” Burzycki said, “We monitor in the patient zone, promoting safe interactions when a HCW both approaches and leaves the patient. These zones can be used anywhere from a private or semi-private room to the post-anesthetic care unit, neonatal intensive care unit, or emergency department.

“We also have Immediate Action Monitoring, so that HCWs can identify when they are compliant or noncompliant, simply by looking at lights on their badges or listening for an audio cue,” explained Burzycki. “Additionally, we provide robust reporting that will help to identify trends and change behavior. Having individual compliance data, such as when opportunities are being missed, can help to identify issues in workflow. Knowing department compliance can help to motivate groups to better themselves and not let their peers down. All of this is part of the Ecolab Hand Hygiene Program, where we are able to have an impact on outcomes by providing the products specifically formulated for the healthcare environment, robust information, service provided onsite by our 100-plus healthcare specialists in the field, and training, whether that be signage around dispensers or in-services.”

Ecolab Hand Hygiene Compliance system

Burzycki said they are already seeing results with their program. “Compliance averages above 85 percent. The entire attitude around HH changes. Having a non-intrusive system that lets HCWs know when they are and are not being compliant, and also lets patients and others know that information, changes the way that it is viewed. Burzycki added, “Having products focused on the healthcare environment ensures that when compliance does increase, hands will still stay healthy.”


1. Lastinger A, Gomez K, Manegold E, et al. Use of patient empowerment tool for hand hygiene. Am J Infect Control. 2017;45(8):824-829. http://www.ajicjournal.org/article/S0196-6553(17)30131-1/fulltext

2. Barnes S. The state of the state of hand hygiene 2017: do we need a bundle? Infection Control Today. April 2017. Last accessed September 3, 2017.

3. Birnbach DJKing D, Vlaev I, et al. Impact of environmental olfactory cues on hand hygiene behaviour in a simulated hospital environment: a randomized study. J Hosp Infect. 2013 Sep;85(1):79-81.

4. Revell T. Smart cameras spot when hospital staff don’t wash their hands: the handwash might be there, but not everyone uses it. New Scientist. 14 August 2017. https://www.newscientist.com/article/2143786-smart-cameras-spot-when-hospital-staff-dont-wash-their-hands/. Last accessed September 3, 2017.

5. Kelly JW, Blackhurst D, McAtee W, et al. Electronic hand hygiene monitoring as a tool for reducing health care-associated methicillin-resistant Staphylococcus aureus infection. Am J Infect Control. 2016 Aug 1;44(8):956-957.

6. Michael H, Einloth C, Fatica C, et al. Durable improvement in hand hygiene compliance following implementation of an automated observation system with visual feedback. Am J Infect Control. 2017 Mar 1;45(3):311-313.


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