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Copyright © 2016

         Clinical intelligence for supply chain leadership


October 2011

Infection Prevention

Infection Control Update

Can changing a single word on a sign motivate doctors and nurses to wash their hands?

Campaigns about hand-washing in hospitals usually try to scare doctors and nurses about personal illness, says Adam Grant, a psychological scientist at The Wharton School, University of Pennsylvania. "Most safety messages are about personal consequences," Grant says. "They tell you to wash your hands so you don’t get sick." But his new study, published in an issue of Psychological Science, a journal of the Association for Psychological Science, finds that this is the wrong kind of warning.

Hand-washing is an eternal problem for hospitals. Healthcare professionals know it’s the best way to prevent the spread of germs and diseases. But, on average, they only wash their hands about a third to a half of the time they come into contact with patients and germs.

Grant had done research in hospitals before, on topics like getting nurses to speak up about safety and reducing burnout among doctors. But when his first daughter was born, Grant’s attention was drawn to the hospital’s signs about hand-washing.

As a psychologist, Grant knew about "the illusion of invulnerability"—that most people think they aren’t at risk of getting sick. His own research had also shown that people aren’t motivated only by avoiding dangers for themselves; they also go to work because they want to protect and promote the well-being of others. The problem was, the signs warned about personal risks. These messages should fall on deaf ears among healthcare professionals, who are frequently exposed to germs but rarely get sick. "If I don’t wash my hands, I’ll be okay. But patients are a vulnerable group," he says.

To test that, Grant and his coauthor, David Hofmann of the University of North Carolina at Chapel Hill, came up with two signs to post over dispensers for soap and hand sanitizer. One said "Hand hygiene prevents you from catching diseases." The other said "Hand hygiene prevents patients from catching diseases." They posted these signs above different dispensers in a hospital and recorded how often people washed, measuring how much soap and gel was used― and having trained observers spy on their colleagues.

The sign about patients was the winner. Healthcare professionals were much more likely to wash their hands if they were reminded that they were keeping patients safe. The patient sign increased soap and gel use by 33% per dispenser, and healthcare professionals were 10% more likely to wash their hands. The sign about personal risks did no good.



Hand Hygiene

Defeat infections with hand-to-hand combat

Compliance requires hands-on accountability

by Susan Cantrell, ELS

Sometimes things are not really as they seem, even things that we see everyday and think we know well. For example, look at the palms of your hands. They look fairly flat, smooth, and clean. Take a closer look. Look at it from the viewpoint of the tiniest of creatures, bacteria, fungi, and viruses. To them, your hand, particularly if it is rough and dry from frequent cleansing, looks like a series of hills and valleys furnished with a multitude of comfortable nooks and crannies for hiding and breeding. You probably never thought of your hand as being a tryst for bacterial love, but it is.

In an article on (
x566174664/ONeill-Are-your-hands-giving-germs-a-free-ride), O’Neill stated: "The average hand harbors more than 1,500 bacteria per square centimeter (an area smaller than a dime), ready to be transported to eyes, mouths or other objects." You might think that with such an astounding number of organisms reproducing on our hands every day that healthcare workers (HCWs) would be more alert to handwashing opportunities; yet, compliance with handwashing guidelines remains a critical problem.

Embracing personal accountability

Clearly, some thinking outside the box is warranted. An interesting study by Grant, recently published in Psychological Science (
patients-health-motivates-workers-to-wash-their-hands.html), suggested that perhaps the message of the importance of handwashing is somewhat misdirected. Posted handwashing reminders often are directed toward the caregivers’ health rather than the patients’. In this study, two signs were posted over soap and hand-sanitizer dispensers. In some places the sign read: "Hand hygiene prevents you from catching diseases." In other places, the sign said: "Hand hygiene prevents patients from catching diseases."

The appeal to altruism worked. Caregivers tended to think they would be fine without washing their hands; however, when it was pointed out that their behavior directly affected patients’ well-being, soap and gel use rose by 33% per dispenser, and healthcare professionals were 10% more likely to wash their hands. Even a 10% increase in handwashing is welcome when estimates put compliance shamefully low at 30% to 60%. Remarkably, it took only a slight shift in perspective and a simple one-word change to reap better results. Not even a penny extra was spent.

Photo courtesy Kimberly-Clark

Poster used by Memorial
Healthcare System 

The connection between healthcare-acquired infections (HAIs) and handwashing is clear, but too much cannot be said about it. Wava Truscott, director, medical sciences and clinical education, Kimberly-Clark Health Care, Roswell, GA, emphasized the role of education in hand-hygiene compliance. "It is critical that infection control policies for hand hygiene are monitored for compliance regularly, as studies continue to demonstrate a reduction in patient infection rates when hand-hygiene protocols are correctly followed. A comprehensive education program is also an important element of any hand-hygiene policy. Hospital administrators should provide their staff with annual training courses to ensure that they are being kept apprised with the most current trends and best practices. As part of the education program, new staff should be required to take part in hand-hygiene–protocol training immediately following their hiring."

"Kimberly-Clark Health Care offers a program entitled ‘Getting Your Hands Around Hand Hygiene’, through the Kimberly-Clark Health Care Knowledge Network," continued Truscott. "The purpose of this educational program is to describe the role hands play in the transmission of microorganisms, to identify appropriate indications and techniques for hand hygiene, and to discuss hand-hygiene adherence rates as well as strategies to increase compliance with recommended hand-hygiene practices in healthcare facilities. Several additional courses address surface contamination and touch transfer, and means of pathogen transmission also emphasizes the critical importance of hand hygiene in breaking the chain of transmission. Kimberly-Clark Health Care’s patient and professional pamphlets and posters on hand hygiene can be found at"

Linda Homan, RN, CIC, clinical and professional services, Ecolab Healthcare, St. Paul, MN, reiterated: "Hand hygiene has long been recognized as one of the best ways to prevent the spread of HAIs. Ecolab’s products and service teams, combined with the Proventix monitoring system, address a number of barriers to improving hand-hygiene compliance by providing products that are effective, but gentle to the skin, monitoring that does not interfere or add to an HCW’s daily routine, and reporting data at the individual, department, and facility level."

Sprixx Dispenser with
Personal Hand-Hygiene Meter

Effective yet gentle products are an important component of a hand-hygiene campaign, but clearly monitoring is also an essential component. Rodney Ogrin, DDS, president and CEO, Sprixx Hand Hygiene Products, Santa Barbara, CA, commented: "Monitoring, measurement of progress, psychologically accelerates hand-hygiene–opportunity awareness, increasing personal responsibility."

Embracing that sense of personal responsibility is vital. Grant’s study demonstrated that caregivers are influenced by the reminder that their actions affect others. Grant asked: "What if your mother was the next patient you saw? The punch line here is that it’s not all about me. To motivate people to engage in safety behaviors, we should highlight the consequences for others―not only themselves."

Compliance monitoring a priority

There are so many reasons why compliance is low. We’ve heard them all: frequent cleansing is hard on the skin, there’s not enough time, supplies and facilities are inconveniently located, the product’s scent is unpleasant, and so on. Industry has been very accommodating in developing products that kill germs but don’t ravage skin. Many hand-hygiene product suppliers are going a step farther than hand-care products and are developing systems for measuring compliance to handwashing guidelines. What is needed is a cultural change. Results of compliance monitoring can reveal where to begin the change.

Ecolab’s Proventix nGage system

Homan talked about Ecolab’s approach to hand washing and compliance: "Hand-hygiene compliance is tricky, but the right combination of products, dispensers, education, training, and measurement can drive improvement. Ecolab offers the ‘High Five Hand Hygiene Program,’ which includes a full line of hand-hygiene products and dispensing options, training and support, and automated hand-hygiene compliance monitoring and reporting."

"Working with Proventix Systems, we are able to offer customers an accurate and integrated hand-hygiene compliance-monitoring program that provides clinicians with immediate feedback at the bedside as well as detailed, real-time reports to support training and awareness programs, target interventions, and improve hand-hygiene compliance. Using innovative radio frequency identification (RFID) technology in conjunction with existing healthcare identification badges, the Proventix nGage system monitors 100% of hand-hygiene events and encourages hand-hygiene compliance without workflow disruption. The Proventix nGage system fully integrates with Ecolab’s existing line of hand-hygiene products and dispensers."

Elena Fraser, director of marketing, HyGreen, Gainesville, FL, described their compliance system: "HyGreen is designed to remind HCWs to wash their hands. After washing, HCWs place their hands under the HyGreen handwash sensor that sends a wireless ‘all clean’ message to a badge worn by the HCW. A wireless monitor above the patient bed searches for the message. If it’s absent, the badge vibrates, to remind the HCW to wash before patient contact. All interactions are recorded in a database, providing an objective means of assessment of hand hygiene by infection control."


"The BIOVIGIL Hand Hygiene System is comprised of three interactive products: the BIOVIGIL Badge, Room Sensor, and Base Station," said Todd P. Smith, chief marketing officer, BIOVIGIL, Ann Arbor, MI. "The BIOVIGIL Room Sensor is a small unit that mounts atop thresholds in healthcare facilities. Using infrared and radio technology, the room sensor detects whenever an HCW, wearing our unobtrusive badge, enters or exits a patient’s room. The BIOVIGIL Badge flashes a red light and emits a tone, reminding the worker to sanitize his or her hands. After the worker has sanitized, he or she cups his or her hands over the badge. The badge detects proper sanitization, which is the presence of alcohol, and a green light illuminates, signaling that the worker is in the clear. The compliance data is stored within the badge and is downloaded to the BIOVIGIL Base Station throughout the day. Finally, the base station automatically connects with the badges to offload compliance data and push updates and other instructions to the badge. A facility can monitor all hand sanitization activity and compliance at any time during the day."

Sprixx Hand Hygiene Products addresses the complaint that lack of time and disruption of routine prevent adhering to handwashing guidelines. Using Outcome Driven Innovation and Sigma Six methodologies, Sprixx reduces the number of steps in a process, which can help to decrease the rate of error. Their product is worn on the person. You can’t get more convenient than that.

"Time, accessibility, and hand-skin irritation are the main culprits for noncompliance," Ogrin said. "Busy procedural areas, such as ICUs, are reported to have an average of 22 hand-hygiene opportunities per hour. Point-of-care dispensing does not interrupt workflow." He added: "A personal hand-hygiene meter housed in a body-attached, single-hand–operated alcohol-gel dispenser counts daily hand-hygiene events for average hourly hand-hygiene–event reporting." The personal dispensers have a meter with a built-in LCD screen that tracks how many times they have been used throughout a shift. The personal meter helps HCWs to be more aware of their compliance as compared to their peers.

Observation versus technology

       HyGreen Bed Monitor







   HyGreen Badge

A nurse using the HyGreen system.

Traditionally, observation has been used to monitor compliance with handwashing guidelines. Technology is taking over that domain, and with good reason. Observation has pitfalls to which technology is not subject. Healthcare Purchasing News asked a few vendors to compare their systems to observation. Ogrin, Sprixx, juxtaposed technology to observation as "objective versus subjective, overt versus covert," with the added benefit of "reduced personnel costs."

Fraser, HyGreen, also believes that, "Observation is a highly subjective activity. A recent Japanese study showed that observers reported a 77% hand-hygiene rate, but the actual rate was only 22.5%. This was found by watching the same rooms at the same time period with video equipment."1

"HyGreen monitors every hand-hygiene opportunity 24/7. The great thing about our system is that it not only monitors hand hygiene it also reminds. We all know that HCWs are extremely busy people who want to do the best for their patients. On those occasions when they forget to wash, HyGreen is there to remind them."

"The Proventix system is based on RFID technology that allows comprehensive, automated, objective monitoring of hand-hygiene opportunities and events 24/7," said Homan, Ecolab. "The system measures tens of thousands of hand-hygiene events in a single month, dramatically increasing the accuracy and scope of observation and allowing a full understanding of true compliance rates. An active two-way communication screen provides immediate, consistent feedback to users and positively reinforces every instance of hand-hygiene compliance at the point of care, which is key to sustaining high levels of compliance without having an impact on HCW efficiency."

"Truthfully, there is no comparison between the BIOVIGIL system and observation," said Smith. "Observation does not produce consistently accurate results. It is subject to human error, and results can be subjective in nature. Beyond that, it is costly, time consuming, and labor intensive. There is a need for a solution that can capture compliance accurately, provide feedback, and record data for use by supervisors and administrators."

"Our system is nearly infallible when it comes to monitoring and tracking hand-hygiene activity. Aside from the technology itself, BIOVIGIL’s mission is to change healthcare institutions’ culture of hand-hygiene compliance, which is a lofty goal, to be sure, but one that this system is sure to engender. With proper product training, marketing materials on-site, and a general awareness of what our products provide, patients, staff, and medical personnel working within a hospital, nursing home, or rehabilitation center will feel confident and empowered about reducing the risks of HAIs."

"Put simply, nothing can get 99.9% accuracy like BIOVIGIL can. A solution to the spread of HAIs cannot tolerate false positives and guesswork."

Success stories

Who doesn’t like to hear a success story, particularly when the reward is lives of patients? Success stories demonstrate that a cultural change is possible, providing hope and encouragement that others can make such strides in their own facilities.

Fraser recounted a study at Miami Children’s Hospital. "The results of a study2 presented by Miami Children’s Hospital (MCH) at the annual Society for Healthcare Epidemiology of America conference showed a 94% hand-hygiene compliance rate and a significant drop in HAIs, with the only change in practice being the use of the HyGreen Hand Hygiene Reminder System. MCH reported that, during the study period of September 3, 2010, to March 29, 2011, infections were reduced by 89%. The importance of this study is significant, as no other hand-hygiene system has been able to correlate use of their product with a reduction in HAIs."

The Proventix system achieved significant change for a facility in Alabama. Homan, Ecolab, explained: "Princeton Baptist Medical Center of Birmingham observed a marked increase in hand-hygiene compliance and a 22% reduction in infection markers over a 7-month period on a unit where the Proventix system was installed.3 The reductions resulted in a decrease of 159 patient-days and reduced net losses by over $133,000.3

Ogrin relayed Sprixx’s experience in an academic medical center: "Dartmouth Hitchcock Medical Center, Lebanon, NH, increased anesthesia-provider hand-hygiene compliance 27-fold compared to baseline rates. Use of Sprixx personal dispensers was associated with a reduction of contamination in the anesthesia work area and peripheral intravenous tubing, reducing postoperative infections dramatically: 3.8% in the Sprixx group versus 17.2% in the control group. Device use by 7.4 providers was required to prevent 1 infection. In the ICU nursing staff, physicians and respiratory therapists, in a year-long study, reduced ventilator-associated pneumonia by 61% and catheter-related bloodstream infection by 50%."

BIOVIGIL’s effectiveness was tested in a 35-bed, inpatient, orthopedics ward at Virginia Commonwealth University Medical Center, Richmond, VA. "In the first study phase," explained Smith, "1,646 hand-hygiene opportunities for all HCWs were observed, using direct observation and no BIOVIGIL Badge, with an overall compliance of 66%.4 In the second phase, 6,831 electronic observations were made, this time using the BIOVIGIL Badge. Overall compliance was 93%.4 Segmented regression analysis revealed that, immediately following the intervention, hand-hygiene compliance increased by 23%. In phase 2, individual compliance ranged from 72% to 100%, with a median compliance of 92%, and a mean compliance of 91%. Nearly half (47%) of the nurses had compliance rates of 95%. Compliance on room entry was 90% and on room exit, 94%. Twelve felt that the alcohol-sensor badge improved their compliance; one felt it had no effect; and one felt that it did not improve compliance. Ten respondents felt that all HCWs should wear the badge."

Jump on the bandwagon

This is one bandwagon it’s time to jump on. If your facility hasn’t yet tested a hand-hygiene compliance system, start checking out the available products. Lives—not to mention CMS reimbursement—may depend on it.  


1. Kunishima H, Tokuda K, Meguro M, Kobayashi T, Chiba J, Aoyagi T, et al. Assessment of hand hygiene adherence using a web camera. Presentation at the International Conference on Prevention & Infection Control (ICPIC). BMC Proceedings 2011:5(supplement 6):P104doi:10.1186/1753-6561-5-S6-P104.

2. Granado-Villar D, Simmonds B. Utility of an electronic monitoring and reminder system for enhancing hand hygiene practices in a pediatric oncology unit. Presented at the Annual Scientific Meeting of the Society for Healthcare Epidemiology of America; April 2011; Dallas, TX.

3. Yarbrough R, Davenport P, Dietz G, Brazzell B, Tucker B. Efficacy of an electronic hand hygiene surveillance and feedback monitoring device against healthcare associated infections. Presented at the Annual Association of Professionals in Infection Control and Epidemiology Educational Conference and International Meeting; June 2011; Baltimore, MD.

4. Edmond MB, Goodell A, Zuelzer W, Sanogo K, Elam K, Bearman G. Successful use of alcohol sensor technology to monitor and report hand hygiene compliance. J Hosp Infect 2010;76:364-365.