Hand-Hygiene

Compliance
Daniela Wallace

Introduction
It is estimated that 1530% of all HAIs can be prevented by avoiding crosstransmission of microorganisms on the hands of healthcare workers (Huis et. al, 2013,
pp. 520).
One in every 10-20 patients is at risk of HAIs in the U.S. (Radhakrishna et al.,
2015).

The easiest way to reduce HAIs is by maintaining hand hygiene (Al-Tawfiq, Abed,
Al-Yami, & Birrer, 2013, p. 482)
According to the Centers for Medicare & Medicaid Services (2014), UAMC scored worse
than the national average on
C. diff intestinal infections
MRSA blood stream infections
Colon surgical site infections
U. S. Department of Veterans Affairs (2015).. Retrieved from
http://www.publichealth.va.gov/ flu/materials/posters/hand-hygiene.asp.

PICOT
What is best practice to improve hand
hygiene compliance of nurses in high
acuity settings during a 12-hour shift?
P: High acuity nurses
I: Demonstrate best practice to improve hand hygiene
compliance
C: As compared to current standards

O: Improve hand hygiene compliance.

T: Over a span of a 12-hour shift

Retreived from http://www.compliancesigns.com/NHE26603.shtml

Current Practice - Local

Hand sanitizer dispensers outside of patient rooms in ICU

Hand washing posters outside of patient room doors and in the bathrooms

Screen savers on computers promoting hand hygiene

5 times to wash hands

before touching a patient

before clean/aseptic procedure

after body fluid exposure risk

after touching a patient

after touching patient surroundings

Wash hands prior to and after the use of gloves, mask, eye protection, or gown (PPE)

Hand washing with soap and water for Clostridium difficile patients and visibly soiled hands

20 seconds to wash hands

(World Health Organization, 2015)

Current Practice - State

Arizona has adapted the CDC and WHO guidelines for hand hygiene

Requiring a minimum of 20 seconds for hand washing

No artificial nails

Natural nail tips less than 1/4 long

Arizona Infection Prevention Week October 18-24 raises awareness of
the role infection prevention plays to improve patient safety and

promotes the belief that everyone plays a role in infection prevention

(World Health Organization, 2015)

Current Practice - National

CDC posters showing how you should properly wash your hands and rub your
hands

Guidelines set by WHO as well as a self-assessment framework which includes

availability of soap, sinks, water, sanitizer, and other factors.

Guidelines set by the Joint Commission on Accreditation of Healthcare

Organizations (JCAHO)

Alcohol based waterless hand sanitizer is recommended for routine hand

hygiene. However, if the hands are visibly soiled, it is necessary to wash hands
with soap and water

("Student Nurse Converse: Finally getting our hands dirty...or clean. Nursing Practicals!," 2013)

Synopsis of Current Literature

Importance of hand hygiene interventions?

Staffing, workload (Muller, Carter, Siddigui, & Larson, 2015).

When was hand hygiene usage the highest?

Main intervention topics: electronic monitoring,

visual/olfactory cues, education/feedback for
healthcare workers
Electronic monitoring:
Real time feedback using wireless technology
badges (Marra et al., 2014).
Radio Frequency Identification (RFID) and
wireless mesh networks to provide real-time
alarms for increasing hand hygiene
compliance (Radhakrishna et al., 2015).

(Cummings, Anderson, & Kaye, 2010).

(Radhakrishna et al., 2015).

Image retrieved from (Centers for Disease Control and Prevention, 2011)

Visual and Olfactory Cues

Visual Cues (Nevo et al., 2010)

What was the most significant
immediate improvement in
hand hygiene compliance?
Olfactory Cues (Birnbach, King, Vlaev,
Rosen & Harvey, 2013)

Fresh scent hand sanitizer vs.

standard scentless hand
sanitizer.
Image retrieved from: (Centers for Disease Control and Prevention, 2011)

Dispenser in line of sight

Dispenser in baseline location and

enhanced with flashing lights

Images retrieved from: (Marra et al., 2014)

Warning sign on the door

Education and Feedback

Multi-disciplinary team (Al-Dorzi et al., 2014)

Education, reminders, empowerment, and contact precautions
Hand hygiene education, hand hygiene breaks, active feedback from
supervisors, and warning letters for repeat violators
Hand hygiene program in Saudi Arabia: (Al-Tawfiq, Abed, Al-Yami, & Birrer, 2013)
Educational presentations, communication campaigns, leadership
commitment, availability of hand sanitizers, on the spot observation
campaigns, and distribution of pins promoting hand hygiene
Effects on:
Healthcare-acquired MRSA
Ventilator associated infections
Central line associated bloodstream infection
Catheter-associated urinary tract infection

A Multifaceted Approach

Combination of electronic monitoring, cues, and education/feedback

Automated dispensing units
Evaluation of performance after 15 weeks of intervention
Intervention:
2 color posters on each unit
Research staff and infection control would present the poster
each month
Effect of supplemental intervention on electronic dispenser counts?
Electronic devices vs. direct human observation

(Morgan et al., 2012)

Summary of Strengths/ Limitations

of Research
Strengths:
Real time feedback showed evidence of increased hand
hygiene compliance
Electronic monitoring maintains patient privacy
Realistic interventions
Cost-effective
Applicability to various healthcare settings
The use of electronic software provides useful
information
Retrieved from:http://www.comicvine.com/forums/fan-fic8/how-to-write-troubleshooting-685961/

Summary of Strengths/Limitations
of Research- CONT
Limitations:

External factors

Influence of Hawthorne Effect

Methodology

Lack of randomization

Results obtained might not generalize to other countries

Hand hygiene compliance was only measured via the

use of hand gel

The results obtained did not have a time stamp

Retrieved
from:http://www.comicvine.com/forums/fan-fic8/how-to-write-troubleshooting-685961/

Evidence-Based of Nursing
Recommendations that Support
Best Practice

Radio Frequency Monitoring

Visual cues
Education
(Healthcare Facilities Today, 2013)

How is your hand hygiene today?

Current research shows only 50 % of ICU

nurses comply with hand hygiene.
YOU can change that statistic!

Be a Hero:
Wash your
hands!

Overall Application and Implementation

Wireless Radio Frequency

Identification (RFID) System

Installation
One tag per nurse
One pressure sensor per hand
sanitizer
One reader per patient room
Personnel
installation personnel
staff training personnel
IT training personnel

Images retrieved from (Radhakrishna, et al.,

2015)

Overall Application and

Implementation

Visual Cues

Posters on patients doors

Posters in bathrooms
Posters in medication rooms
Screen savers on unit computers

Discuss hand hygiene during morning huddle.

Hand hygiene correlation with hospital acquired infections
Hand hygiene protocols
Hand hygiene breaks

Education

(Retrieved from The University of Manchester,

2012)

Cost Analysis
Electronic Monitoring:
The cost of using Radio
Frequency identification in
promoting hand hygiene
costs slightly under $20,000
The estimate for a
20 bed ICU is $25,000.
(Fuller et al., 2014).

Retrived from: http://www.prnewswire.com/news-releases/university-of-chicago-medical-center-chooses-proventixs-ngage-quality-compliancemonitoring-system-104852314.html

Visual cues :
Free hand hygiene posters from the Centers for Disease
Control and Preventions hand hygiene guidelines. Cost of
printing: Color Printing at the Copy Technology Services at Arizona

Health Science Center (Available in Library Computer Lab 75 cents per

page) For each unit, 10 posters will cost $7.50.
Other options include printing centers at the university libraries or retail
such as Staples. (Nevo et. al, 2010)

Retrieved fromhttp://www.cdc.gov/handwashing/posters.html
Retrieved from
http://resources.ahsl.arizona.edu/services/cts/submitjob.html
Retrieved from
http://www.staples.com/sbd/content/copyandprint/posters.html.
Retrieved from library.arizona.edu/services/express-documentcenter

Education :
The total cost of educating a healthcare
worker for performing hand hygiene is
minimal. How you implement the
program with reminders is up to how
creative your team is!
Examples such as:
Computer screens that remind
healthcare workers to wash their
hands.
Charge nurse reminds nurses to
wash hands during morning meeting.
Reminders between nurses.
(Al-Tawfiq et al., 2013)

Retrieved from http://psqh.com/hand-hygiene-measurement-and-education

Risk vs Benefit
Risks
Risk for hospital
Cost high in initial investment
However, the costs associated with
hospital infections will be decreased
Overall there will not be increased
cost for the hospital for long term
use of EBP
Risk for patient
no risk for patient if hand hygiene
compliance increases

Photo retrieved from: (Risk free icon, 2015)

Benefits

Lower incidence of infections

Hospital-acquired infections cause more than 98,000 deaths annually in the
United States
15-30% of HAIs could be prevented by avoiding the transmissions of
microorganisms on the hands of healthcare workers
According to the Centers for Disease Control and Prevention (CDC) one in every
1020 patients in hospitals in the United States are subjected to HAIs
By reducing HAIs with hand hygiene there would be a less incidences of deaths
due to HAIs and overall better patient outcomes
Save money from a decrease in nosocomial infections
Hand hygiene noncompliance related to annual MRSA infection related costs a
200 bed hospital $1,779,283 annually
A 1.0% increase in hand hygiene compliance results in annual savings of
$39,650 in a 200-bed hospital

(Huis et al., 2013) (Radhakrishna et al., 2015) (Al-Tawfiq et al., 2013)

Benefits of Radio Monitoring instead of Direct

Observation

Supervisors dont have to be in a

judgement role of the staff
Allows privacy of patients without
supervisors entering rooms to ensure hand
hygiene
Direct observations may also results in
distrust among staff members
Human observers have a limited ability in
the number of workers they can observe at
one time
(Morgan et al., 2014)

Photo retrieved from: (Leishman, 2015)

Evaluation
Overall Outcome:
Increase hand hygiene by 20 % in the first six months after
implementation.
Increase hand hygiene to 80 % by end of the first year after
implementing the protocol.
Educational Outcome:
Assessment of an education on hand hygiene will be
performed monthly and annually by nursing supervisors.

Evaluation
Visual Cues Outcomes:
Signs will be placed on patient doors, in staff bathrooms,
on all computers, and at any work stations within one
week of initiating the hand hygiene protocol.
Monitoring Outcomes:
All nurses will be equipped with hand hygiene monitors
and will be instructed on the use of them within one
month of initiating the hand hygiene protocol.

Summary
The Facts:
Hand hygiene compliance by nurses in the Intensive
care units can be as low as 40 % (Huis et. al, 2013)
15 to 30 % of hospital acquired infections can be
prevented by proper hand hygiene (Radhakrishna et al., 2015)
Poor hand hygiene costs the hospital money and can
possibly cost the patients their health and time

Summary
The Solution:

The research found shows that introducing a

multi-faceted approach to improving hand
hygiene through visual cues, education, and
wireless RFID monitoring can raise hand
hygiene compliance to, or above 80%.

Retrieved from: http://correctionalnurse.net/handhygiene-challenges-for-correctional-nurses/

Who wants to save money?

Who wants to improve patient outcomes?

Who wants to take C-Diff home with them?

In Conclusion
If poor hand hygiene can cause such negative
consequences such as higher infection rates and
costs, why would we not want to implement a
simple evidenced based cost effective way to save
money and patients?

Questions?

References
Al-Dorzi, H. M., Matroud, A., Al Attas, K. A., Azzam, A. I., Musned, A., Naidu, B., Arabi, Y. M.
(2014). A multifaceted approach to improve hand hygiene practices in the adult intensive care
unit of a tertiary-care center. Journal of Infection and Public Health, 7(4), 360-364.
doi:10.1016/j.jiph.2014.02.003

Alsubaie, S., Maither, A., Alalmaei, W., Al-Shammari, A. D., Tashkandi, M., Somily, A. M., Alaska, A., & BinSaeed, A. A.
(2013). Determinants of hand hygiene noncompliance in intensive care units. American Journal of Infection Control.
41(2), 131-135.
Al-Tawfiq, J. A., Abed, M. S., Al-Yami, N., & Birrer, R. B. (2013). Promoting and sustaining a hospital-wide,
multifaceted hand hygiene program resulted in significant reduction in health care-associated infections. American
Journal of Infection Control. 41(6), 482-486.
Birnbach, D. J., King, D., Vlaev, I., Rosen, L. F., & Harvey, P. D. (2013). Impact of environmental olfactory cues on
hand hygiene behavior in a simulated hospital environment. The Journal of Hospital Infection. 85(1), 79-81.
Centers for Disease Control and Prevention. (2015e, July 22). Posters. Retrieved from
http://www.cdc.gov/handwashing/posters.html
Comic Vine. (2015). Retrieved October 28, 2015, from http://www.comicvine.com/forums/fan-fic-8/how-to-writetroubleshooting-685961/
Copy Technology Services (2015). CTS. Retrieved from
http://resources.ahsl.arizona.edu/services/cts/submitjob.html
Cummings, K. L., Anderson, D. J., & Kaye, K. S. (2010). Hand hygiene noncompliance and the cost of hospitalacquired methicillin-resistant Staphylococcus aureus infection. Infection Control and Hospital Epidemiology. 31(4),
357.

References, cont.

Express Document Center (2015). Retrieved from library.arizona.edu/services/express-document-center

Fuller, C., Besser, S., Savage, J., McAteer, J., Stone, S., & Michie, S. (2014). Application of a theoretical
framework for behavior change to hospital workers real-time explanations for noncompliance with hand
hygiene guidelines. American Journal of Infection Control. 42(2), 106-110.
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from http://www.machester.ac.uk/discover/news/article/?id=8881
Hand Hygiene Challenges for Correctional Nurses. (2015). Retrieved from Correctional Nurse:
http://correctionalnurse.net/hand-hygiene-challenges-for-correctional-nurses
Healthcare Facilities Today. (2013). Kimberly-Clark offers hand hygiene education program. Retrieved
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Rodriques, R. D., Prado, M., Victor Eda, S., Bogossian, H., Monte, J. C., Dose Santos, O. F., Oyama, C.
K., & Edmond, M. B. (2014). The use of real-time feedback via wireless technology to improve hand
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Morgan, D. J., Pineles, L., Shardell, M., Young, A., Elllington, K., Jernigan, J. A., Day, H. R., Thom, K. A.,
Harris, A. D., & Perencevich, E. N. (2012). Automated hand hygiene count devices may better measure
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References cont.

Muller, M. P., Carter, E., Siddigui, N., & Larson, E. (2015). Hand hygiene compliance
in an emergency department: The effect of crowding. Academic Emergency
Medicine. 22(10), 1218-1221.
Nevo, I., Fitzpatrick, M., Thomas, R., Gluck, P. A., Lenchus, J. D., Arheart, K. L., &
Birnbach, D. J. (2010). The efficacy of visual cues
to improve hand hygiene
compliance. Journal of the Society for Simulation in Healthcare. 5(6), 325-331.
Radhakrishna, K., Waghmare, A., Ekstrand, M., Raj, T., Selvam, S., Sreerama, S.
M., & Sampath, S. (2015). Real-time feedback for improving compliance to hand
sanitization among healthcare workers in an open layout ICU using radiofrequency
identification. Journal of Medical Systems. 39(68), 1-8. Retrieved from
http://link.springer.com/article/10.1007%2Fs10916-015-0251-1
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Staples. (2014). Retrieved from
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