Are your staff washing their hands of basic practices?

Provide education, then make it easy to implement

Like most health care institutions, Sacred Heart Medical Center in Spokane, WA, has made hand hygiene the cornerstone of infection-control policy. "When we have more of a particular organism in an area than we would normally see, we re-emphasize hand-washing techniques to the staff, and the rates go down," says Kathy Caldero, RN, infection control coordinator at Sacred Heart.

"As basic as hand washing is, it plays a vital role in patient care and in controlling the spread of infections," agrees Virginia Reyes-Vargas, RN, MSN, infection control practitioner at the New Mexico VA (Veterans Affairs) Health Care System in Albuquerque. When organisms are on the hands of a health care worker, they can be introduced to a patient. Organisms that are resistant to antibiotics are the most worrisome, she says.

Evidence that hand washing is effective in the prevention of infection dates back to the mid-1800s when researchers demonstrated the link between the spread of infection and the hands of health personnel, says Susan M. Slavish, BSN, MPH, infection control coordinator at Queen’s Medical Center in Honolulu.

Formal recommendations for hand-washing practices in hospitals have been in place since 1975 when the Atlanta-based Centers for Disease Control and Prevention (CDC) first published hand-washing guidelines. The Association for Professionals in Infection Control and Epidemiology in Washington, DC, also has published guidelines, reports Slavish.

The Healthcare Infection Control Practices Advisory Committee, which is a CDC advisory committee, is in the process of publishing a "Guideline for Hand Hygiene in Healthcare Settings." "This guideline will provide all of us with the most current state of the science associated with hand washing and the use of alcohol-based hand rubs for routine hand sanitizing as well as surgical scrubs," she says.

While proper hand washing is an important element of staff and patient education to prevent the spread of infection, knowing the proper technique and doing it often are two different issues. Time frequently is a factor. In a study completed in Switzerland, researchers found more than 40 opportunities per hour for hand washing in an intensive care unit, says Caldero.

"There are a huge number of opportunities for health care providers to wash their hands. Yet if they spent an average of one minute each time, that would take 40 minutes in the course of an hour. There isn’t time to take care of the patient," she explains.

In an effort to comply with the CDC-updated hand-hygiene guidelines currently in draft form, the infection control department at Grant/Riverside Methodist Hospitals in Columbus, OH, uses four methods to increase compliance. They include education, providing facilities for staff hand washing, reminding staff about hand washing, and the use of alcohol-based hand disinfectants, says Judy Bournique, RN, MT, ASCP, infection control coordinator.

There are many opportunities to teach staff proper hand-washing techniques and remind them to be compliant, says Bournique. The best place to start is in new employee orientation. Teaching tools at Grant/Riverside Methodist include a video on infection control that was produced in-house that has information on how and when to wash hands in a health care setting.

To help emphasize the ease at which germs can spread, the group is given a ball that is passed around several times after they are told that whatever is on their hands gets transferred to whatever they touch. "Ultimately, I ask the group how many people they had contact with," she says.

A similar teaching technique is used during an infection control presentation for residents and medical students. This time, "GloGerm," a florescent compound, is smeared onto a ball before it is passed around. Then residents are asked to place their hands under a special lamp that illuminates the compound to see how much of it was transferred to their hands. "That florescent compound is supposed to show the bacteria that can be transmitted," she explains.

Following the demonstration, everyone is asked to wash their hands and then put them under the lamplight again to determine if they are washing their hands correctly. Sometimes, the florescent compound is put on a chart because residents and medical students pick up charts throughout the day.

Make it convenient

On the annual competency for infection control, staff are required to complete questions on hand washing, says Bournique. These questions often focus on when hand washing is appropriate. "Most studies show that reinforcement of hand-washing education should recur fairly frequently, which is why we include it with our annual competency," she says.

Another opportunity to provide education on hand hygiene is via staff newsletters. "We publish a quarterly newsletter and one [issue] covered hand washing. That particular issue was mailed to all the physicians," says Bournique.

Rather than devote an entire issue to hand washing, Queen’s Medical Center periodically publishes articles on hand washing in the employee newsletter, says Slavish.

This year during infection control week, staff at Grant/Riverside Methodist will set up display boards in the atrium on infection control that will include hand washing. The atrium was selected rather than the employee cafeteria because it is more public and therefore patients and their family members will see the information as well, says Bournique. (For more information on staff education, see staff teaching sheet on hand hygiene produced by The Ohio State University Medical Center in Columbus.)

In addition to education, it is important to make hand washing convenient to ensure that it gets done. At Northwestern Memorial Hospital in Chicago, there is a foot-operated sink in each patient room to eliminate touching handles after hand washing, says Trish Bednarz, BSN, RN, infection control coordinator. The sinks turn on automatically for 15 seconds, the amount of time that should be allocated to hand washing.

Convenience was one reason the new alcohol-based hand disinfectant was introduced at the New Mexico VA Health Care System. The disinfectant is located in the hallways and in patient rooms. "The philosophy of our epidemiologist is to make hand washing as easy and available as possible so staff really don’t have a reason not to perform hand hygiene either conventionally or with the alcohol-based disinfectant," says Reyes-Vargas.

Signs can prompt hand washing as well. Laminated signs that resemble stop signs are located near sinks in patient rooms at Grant/ Riverside Methodist Hospitals. They read: "Stop. Wash your hands," and are printed in English and Spanish. They act as a reminder for staff, patients, and visitors, says Bournique.

On the bone-marrow transplant units at City of Hope National Medical Center in Duarte, CA, a surgical mask frequently is hung over the patient’s door so those entering the room will take extra infection control precautions, says Daryl Allen, RN, ICP, infection control practitioner at the medical center. "It triggers hand washing as well," she says.

Once staff have been educated, hand washing has been made convenient, and reminders have been set in place, it is time to evaluate the effectiveness of the teaching. The coordinator of licensure and accreditation performs hand-washing audits to measure compliance with required hand washing at Northwestern Memorial Hospital.

The hand-washing audits are done by observation with the person in charge of accreditation, or the charge nurse on a specific unit, walking around and observing practice. They note the title of the health care worker, length of wash, product used, and when the hand washing is completed. Whether staff see patients without washing their hands or if they touch equipment without hand washing, also is noted, says Bednarz.

A member of the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations’ mock inspection team at Grant/ Riverside Methodist Hospitals adopts a unit and visits it on a regular basis, looking for compliance with the Joint Commission standards. "One of the items we ask these inspectors to look for is personnel hand-washing compliance," says Bournique. They observe a couple of staff members washing their hands to determine if they are washing them correctly and at the right time.

During a Joint Commission survey at the New Mexico VA Health Care System in July, hand washing seemed to be something that was evaluated by observation, says Reyes-Vargas. The health care system did prepare a binder addressing all standards for infection control that included hand-hygiene policy.

The policy is that staff wash their hands any time they have contact with a patient and gloves are provided. Staff are encouraged to wear gloves with every patient encounter and wash their hands whether they were wearing gloves or not.

"Gloves sometimes have microscopic tears in them," explains Reyes-Vargas. In addition to washing hands before and after patient care, employees are required to wash before eating and after going to the restroom or toileting a patient. Although alcohol-based hand disinfectant can be used, if hands are soiled, they need to use soap and water, says Reyes-Vargas.

Generally, health care workers have poor hand-washing compliance, in spite of the fact that it is a simple procedure, takes only a short time, and can protect both the patient and the health care worker from exposure to potentially harmful organisms, says Slavish. "It is time that we get back to basics and do what we were taught as children and in our health care educational programs — wash your hands,’" she says.


For more information about educating staff on hand washing for better infection control, contact:

  • Daryl Allen, RN, ICP, Infection Control Practitioner, City of Hope National Medical Center, 1500 E. Duarte Rd., Duarte, CA 91010-0269. Telephone: (626) 359-8111, ext. 62115. E-mail:
  • Trish Bednarz, BSN, RN, Northwestern Memorial Hospital, 251 E. Huron, Chicago, IL 60611-2908. E-mail:
  • Judy Bournique, RN, MT, ASCP, Infection Control Coordinator, Grant/Riverside Methodist Hospital, Attn. Infection Control Department, 3535 Olentangy River Road, Columbus, OH 43214. Telephone: (614) 566-5793. E-mail:
  • Kathy Caldero, RN, Infection Control Coordinator, Sacred Heart Medical Center, W. 101 Eighth Ave., Spokane, WA 99220-4045. E-mail:
  • Virginia Reyes-Vargas, RN, MSN, Infection Control Practitioner, New Mexico VA Health Care System, 1501 San Pedro Drive S.E., Albuquerque, NM 87108. Telephone: (505) 265-1711, ext. 4945. E-mail: Antonia.
  • Susan M. Slavish, BSN, MPH, Infection Control Coordinator, Queen’s Medical Center, 1301 Punchbowl St., Honolulu, HI 96813. Telephone: (808) 547-4706. E-mail: