Monitor hand hygiene to reach 90% compliance

Other approach still needed to reduce infections

As concern grows over antibiotic-resistant organisms, health care workers never have been under greater scrutiny for their compliance with hand hygiene.

It is not an infectious disease cure-all. In fact, one recent study failed to show a decrease in infection rates with a rise in hand hygiene,1 but programs that use periodic monitoring and feedback to attain very high rates of compliance — 80% or higher — are reporting that hand hygiene can have a significant impact on the spread of hospital-based infections.

"I think it's extremely important, perhaps the most important thing we do in infection control," says Don Goldmann, MD, senior vice president of the Institute for Healthcare Improvement (IHI) in Cambridge and professor of pediatrics at Harvard Medical School.

Surveyors from The Joint Commission and the Accreditation Association of Ambulatory Health Care (AAAHC) observe compliance with hand hygiene during surveys.

Hand hygiene has long been a goal of IHI, which provides a free toolkit for monitoring compliance. The alcohol-based gels have enabled hospitals to reach high levels of compliance that were not possible with the abrasive and more time-consuming soap-and-water method.

3 Key Hand Hygiene Procedures

But managers must do more than just install gel dispensers. They must create a hand hygiene program that includes monitoring and feedback and maintains dispensers that are conveniently located and frequently refilled, Goldmann says. "You can't expect [hand hygiene compliance] to happen automatically if you don't put the systems in place to support it," he says.

Last year, when administrators at Massachusetts General Hospital in Boston were preparing to issue bonuses to employees, they decided to take an opportunity to emphasize the importance of hand hygiene. Half of the bonus was dependent on the hospital reaching its goal of 90% compliance with hand hygiene before and after patient contact. Even the administrators would not receive the bonus if the staff failed at that mission.

It took a few months, but the hospital met its goal, and employees received their bonuses. Meanwhile, they understood that administrators considered hand hygiene to be an important component of quality patient care, says David Hooper, MD, chief of the infection control unit at Mass General. "It also set up the concept that we're all in this together," he says.

This was not a one-time campaign. The hospital has used other incentives, as well, such a pizza parties for units that achieved high rates of compliance, and it provides continual education and accountability for hand hygiene.

The infection control department devotes 1½ FTE employees to coordinate the hand hygiene program, including monitoring through observations. They conduct about 2,000 observations per quarter, rotating on different floors at different times of day. Units receive feedback quarterly.

About eight years ago, the hospital had hand hygiene compliance rates of about 40%, which was similar to the national average. But a persistent focus on the issue not only raised the compliance, but created a sustainable program, says Hooper. "It's difficult to change behavior immediately, but over several years, our hand hygiene rates have gone up steadily and consistently and stayed up," he says. "Our rates of hospital-acquired cases of MRSA [methicillin-resistant staphylococcus aureus] have gone down 2.9-fold in a steady downward trend. Before that, we were seeing a pretty steady upward trend."

Hand hygiene isn't the only component of the infection control effort. The hospital also has stepped up its cleaning of patient rooms, he says. "It's really back to basics, [like] your mother told you. Wash your hands and clean your room," he says. "The concepts are very simple and, if done well, they can be very effective."

Improving hand hygiene will not necessarily bring immediate results related to hospital-acquired infections. But alcohol-based gels are readily accepted by health care workers and can become a part of the health care routine. Those were conclusions of a study at the University of Nebraska in Omaha compared two intensive care units — one that used alcohol-based gel and one without. With the gel, compliance with hand hygiene doubled from 35% to 70%. After a year, the gel was removed from one ICU and introduced into the other. The hand hygiene compliance dropped in the first ICU. The study was conducted from 2001 to 2003, when alcohol-based gels became widely available and the Centers for Disease Control and Prevention recommended their use.

"They responded by falling back to the baseline hand hygiene rate," says lead author Mark Rupp, MD, professor of infectious disease and director of the Department of Healthcare Epidemiology at the University of Nebraska Medical Center. "They sort of objected with their hands by dropping their hand hygiene compliance [when gels were removed]."

Health care workers using the hand gel had less microbial carriage on their hands. However, longer nails and wearing rings were associated with more microbes, Rupp says. "We found when the nails got anything longer than 2 mm, we saw increased carriage of microbes," he says. "If you hold your hand palm toward your face and you can see any nail above your fingers, they're probably too long.

Rupp and his colleagues were disappointed that they didn't find a reduction in hospital-acquired infections such as MRSA or Clostridium difficile. The infection rates were low before the study began, which would make it more difficult to detect differences, he says.

There are other possible reasons that the study didn't find that gels had an impact on infection rates, Rupp says. "The compliance was 70%; it wasn't 90% or 100%," he says. "There may be a threshold you have to cross over for hand hygiene to have a demonstrable effect, and we didn't cross that threshold."

Yet Rupp says there's still an important lesson: Managers must use a multipronged effort to reduce infections. "We may have to combine hand hygiene with other infection control practices in order to have an effect," he says.

Meanwhile, the medical center is developing an ongoing monitoring program for hand hygiene compliance. Employees on each ward are trained to conduct hand hygiene observations and record the information in a web-based data entry system. Data on compliance are available in monthly reports. "By having these observers and rapid feedback to the wards, we've been able to increase hand hygiene compliance up to the 80% to 90% range," Rupp says.


  1. Rupp ME, Fitzgerald T, Puumala S, et al. Prospective, controlled, crossover trial of alcohol-based hand gel in critical care units. Infect Control Hosp Epidemiol 2008; 29:8-15.