Going Touchless is a High-Tech Solution to Hand Hygiene Compliance

While handwashing compliance among healthcare workers (HCWs) and allied staff remains notoriously low in numerous hospitals, perhaps it’s time to realize that their behavior as “civilians” when not on the job may have a lot to do with it. Recent surveys indicate that an alarming number of people don’t wash their hands after using a public restroom. In a recent observational study sponsored by the American Society for Microbiology (ASM) and the Soap and Detergent Association (SDA), 77 percent of men and women washed their hands in public restrooms, a 6 percent decline from a similar study conducted in 2005.1 Yet, in a separate telephone survey, 92 percent of adults said they wash their hands in public restrooms. Americans’ self-reported hygiene behavior in 2007 remains consistent with what past surveys show; among 1,001 men and women interviewed via telephone in 2007, 92 percent say they always wash their hands after using a public restroom and 86 percent say they do likewise after using the bathroom in the home. In 2005, those figures were 91 percent and 83 percent, respectively.1

A recent survey conducted as part of ASM’s Clean Hands Campaign revealed that although 95 percent of men and women claim that they wash after using a public toilet, observations made by researchers discovered that only 67 percent actually do.1 And a survey conducted by Impulse Research Corporation found that 30 percent of Americans use restrooms away from home only when absolutely necessary. The same survey discovered that among people who do use public restrooms, nearly 66 percent use a variety of maneuvers to avoid touching anything, including using their feet to flush toilets, their elbows to open doors, and paper towels to turn off faucets and open handled doors on their way out.

In a healthcare environment, contaminated environmental surfaces are often the vectors for multidrug-resistant organisms — especially those in the washroom. Kelly2 observes, “Surfaces such as toilets, sinks, faucets and flushing handles, door handles, stall doors and paper towel dispensers all can pick up bacterium from unwashed hands, passing it along to the next user ... studies have shown that even healthcare workers aren’t always able to wash their hands as often or as effectively as necessary to prevent cross-contamination. In fact, the Institute for Healthcare Improvement has indicated that compliance by healthcare workers with recommended hand-hygiene procedures has remained unacceptable, with compliance rates generally below 50 percent of hand-hygiene opportunities.”

Kelly2 continues, “Hospital staff can’t be expected to guard washrooms against those who use the toilet, neglect to wash their hands and then go on to touch other public surfaces, such as restroom door handles, before heading back to the hospital operating rooms or other patient areas. For this reason, even the most careful hand-washers are still at risk for contamination simply by touching a door handle used by someone who didn’t wash. For many hospitals, creating a touchless environment has boosted the level of staff comfort concerning the washroom, in many cases allowing them to use the facilities without touching even one surface from the time the enter the washroom to the time they exit. These include: auto-on and auto-off faucets; automatic, self-flushing toilets and urinals; auto-on and auto-off soap dispensers; automatic paper towel dispensers; and toilet seat covers activated by the touch of a button.”

“Touchless technology is a good idea, because hard surfaces are significant transfer points for bacteria and viruses,” says Charles Gerba, PhD, a microbiologist at the University of Arizona, Tucson. “Much of what people put down on a surface can be picked up by the next person who comes along, and in an age where people share more spaces and surfaces than ever before, touchless technology can help prevent cross-contamination.”

It is intuitive to think that the less a potentially contaminated surface is touched, the better, so the advent of automated sink fixtures as well as soap and towel dispensers has been heralded as an important way to reduce the opportunities for cross contamination and hand carriage of pathogenic micoorganisms. But how many clinicians consider the role that handwashing stations play in opportunities for cross-contamination?

As experts debate the role inanimate objects play in the transmission of infectious agents, few would doubt that the contamination of environmental surfaces such as handwashing sinks is a major issue. “Clearly inanimate surfaces play a role, particularly with organisms such as vancomycin-resistant Enterococcus (VRE) and Clostridium difficile,” says Columbia University’s Elaine Larson, RN, PhD, FAAN, CIC.3 “But it seems pretty clear that direct contact (i.e., person-to-person touching) remains the most important mode of cross transmission. Nevertheless, housekeeping and environmental cleaning seem to have taken too much of a back seat and we need to re-emphasize the great importance of keeping the healthcare setting (as well as the people) free of a large microbial bioload.”3

Various studies have demonstrated infections stemming from faucet aerators,4 splash from sink drains5 and handwashing machines.6 In a paper underwritten in part by Georgia-Pacific, a team of researchers determined the organic, microbial and staphylococcal load on contact surfaces (faucet handles, soap dispensers and paper-towel dispensers) in four British hospitals that could be touched during handwashing, and to evaluate hand-mediated cross-infection.7 Manual faucet handles had a higher mean ATP level than manual soap or paper-towel dispensers, yet the latter were shown to present some presence of bacterial contamination. The study showed that contamination of hand-contact surfaces could act as a reservoir for microorganisms and could contribute to hand contamination before or after handwashing. In addition, the sink environment and its organic matter could serve as a breeding ground for potential pathogens.

A number of studies confirm that paper-towel dispensers also can be implicated in the transmission of MDROs. Researchers from the United Kingdom and the United States studied the transfer and cross-contamination potential between hands, towels, and dispenser exits if one or more is contaminated using bacteria representative of the skin’s flora.8 They write, “Hand drying is the critical last stage of the handwashing process and needs to be implemented in a way that reduces, rather than increases, the risk of cross-contamination. This requires that the drying is effective and that contamination of hands does not take place. However, concerns are now starting to be expressed about the dispensing of handwashing materials and the functionality of dispensing systems.”9-10

The three methods frequently used for hand drying are hot air dryers, cloth towels, and paper towels. Whereas paper towels are recognized as the most hygienic method of hand drying, paper towels, and dispensing mechanisms (levers and mount location) have been identified as potential sources of contamination, especially for paper towels hanging in sink splash zones, according to the researchers.11-12

The researchers used a generic wall-mounted paper-towel dispenser and a variety of different paper towels. Volunteers with either clean or contaminated hands were asked to remove, using a range of protocols, towels from dispensers which were either clean or contaminated. Previously clean surfaces were then microbiologically tested. The investigators found that recoverable bacterial transfer rates from a contaminated hand to clean dispenser exits ranged from 0.01 percent to 0.64 percent, depending on the bacteria used with an even higher transfer rate for clean towels. The reverse transfer, from contaminated exits to clean hands, was between 12.4 percent and 13.1 percent. The results indicate that zig-zag transfer of bacteria between paper-towel dispensers and hands can take place if either one is contaminated, and should be considered in the design, construction, and use of paper-towel dispensers.

The investigators write, “This study has shown that even ‘manual pull’ disposable folded towels and towel dispensers that are considered ‘hands free’ or touchless can become contaminated if the surfaces at the dispenser exit are touched. This usually occurs when the paper towel is not cleanly delivered to a user, and this varies considerably depending on the compatibility of paper towel and dispenser combination. The total number of bacteria isolated from the dispenser exits after freeing a jammed towel with a contaminated hand was relatively low but should be viewed within the context of the number of times per day this activity may need to be carried out. It is also important to note that in some cases, although the minimum infective dose can be variable, only small numbers of pathogens, especially for intestinal disease, may be required to cause illness. A number of these pathogens are known to cause outbreaks in hospitals, therefore, even the low estimates obtained in the present study still allowed for sufficient bacteria to be transferred for them to exceed the minimum infective dose for a number of human pathogens. This was particularly true of the numbers transferred from wet, contaminated hands to dry towels remaining in the dispenser. The type of contamination demonstrated in this study, coupled with the survival potential of some pathogens causing hospital acquired infections, could also assist in the spread of organisms within the hospital environment. There was an even greater transfer of both the resident and transient bacteria to the towels pulled or remaining within the dispenser. Paper towels with damp patches or spots may, in addition to being aesthetically unappealing, present an infection risk.”

The Rise of Touchless Technology

Supporters of touchless technology frequently point to a study by Larson et al.13 that compared the frequency of use of manually operated and touch-free dispensers of alcohol sanitizer installed in the emergency department and an intensive care unit of a large pediatric hospital for two, two-month periods for each type of dispenser. Counting devices installed in each dispenser and direct observations were used to determine actual frequency of and indications for hand hygiene. Larson et al. found that the touch-free dispensers were used significantly more often than were the manual dispensers. The means for the number of episodes of hand hygiene per hour were 4.42 for the touch-free dispensers and 3.33 for the manual dispensers (P = .04); the means for the number of episodes per patient per hour were 2.22 and 1.79, respectively (P = .004); and the means for the number of uses of the dispenser per day were 41.2 and 25.6, respectively (P = .02). However, the overall compliance rate was 38.4 percent (2,136 episodes of hand hygiene per 5,568 indications for hand hygiene).

The researchers concluded that while the type of dispensing system influenced hand hygiene behavior, overall compliance remained low and that in order for interventions to have a major effect on hand hygiene, multiple factors must be considered.

Larson et al write, “Although no evidence indicates that devices that must be manually pressed to dispense cleanser increase the risk of transferring microbes, healthcare staff may express concern about the safety of touching dispensers and may prefer dispensers that are more accessible and easier to use than the manual ones are.14-15 Such concerns may be a deterrent to using manual dispensers.” Larson et al. write further, “Our finding that the number of hand hygiene episodes overall was higher for the touch-free dispenser than for the manual dispenser is consistent with the hypothesis that the delivery system has an effect on behavior and that a touch-free dispenser may be preferred by healthcare professionals.”

Kampf,16 Girard,17 Bischoff18 and Pittet19 concur that hand hygiene compliance is boosted when convenient, readily accessible dispensers are installed, although Muto et al.20 found that compliance did not improve when alcohol dispensers were placed by every patient’s door in two units. While every hospital’s experience with touchless dispensers will undoubtedly be different, the hope of decreased cross-contamination and improved hand hygiene compliance is usually the biggest reason why healthcare facilities embrace this technology.

“Customers have been asking for hands-free dispenser technology for years,” says Charles Kilfoyle of STERIS Corporation. “Although we haven’t seen clinical proof it’s going to help eliminate infections, we wanted to meet our customers’ needs. They believe it will help improve compliance because the dispensers are fun to use.”

In December, STERIS will launch a wall-mounted hands-free dispenser for its Cal Stat® Plus Antiseptic Handrub, as well as an add-on piece that can easily convert existing STERIS manual dispensers into touch-free dispenders.

Kilfoyle adds, “I’ve talked to ICPs who say when they’ve installed hands-free dispensers, their compliance goes up dramatically. I say, how do you know that, and they say their consumption goes up dramatically — they are measuring how much they spend each month on hand sanitizer product. We all know that compliance is low to begin with, so if these dispensers increase usage, they are going to increase compliance.”

Larson et al.13 suggest that in monitoring hand hygiene compliance, the volume of hand hygiene products can be used as an indicator of the number of hand hygiene episodes. They write, “Two baseline parameters would be needed to develop a performance monitoring system to assess appropriate hand hygiene practice: the number of indications for hand hygiene and the number of actual occurrences of hand hygiene. The volume of product used could be determined for known values of these two parameters and could be used as a comparative value.”

Preventing Cross-Contamination

As concerns about cross-contamination increased among infection prevention professionals, industry responded, introducing touchless sink fixtures and hardware as well as soap and paper towel dispensers. In fact, an entire generation has nearly grown up around this kind of touchless environment, making it the standard for restrooms everywhere, but most notably in healthcare facilities to decrease infections.

Nichols21 observes, “One area where microorganisms can flourish is the restroom. Lavatory surfaces — such as faucets, toilet handles, sinks or dispensers for bathroom tissue, paper towels or soap — that are touched frequently may serve as reservoirs of microbial contamination. When hands come into contact with these surfaces, microbial agents can then be transferred to the nose, mouth, eyes or environmental surfaces via indirect contact transmission. Touchless dispensing solutions are one way to help reduce the spread of germs in a restroom. The electronic revolution that has taken place in the washroom in recent years has greatly enhanced restroom hygiene by eliminating the need to touch dispensers, faucets and toilet handles during use. These systems can help make the task of using as well as maintaining the restroom easier, more efficient and more cost-effective, while providing improved hygiene and sanitation features.”

Nichols21 adds, “By eliminating one potential source of germs, touchless dispensers can help reduce their spread. With these systems, restrooms visitors are not required to touch handles, levers or buttons to flush toilets, turn on water, or dispense washroom tissue and towel products. Some public restrooms continue the no-touch theme by using doorless entryways so that freshly washed hands don’t have to grab a dirty door handle on the way out of the restroom. Touchless systems can operate in different ways. Some are decidedly high-tech, with sensor-activated devices that dispense bath tissue or paper products, turn on faucets and even turn lights on and off. Touchless systems are especially crucial for hand towel dispensers, since hand towels are typically used once hands are clean, after having been washed and rinsed. The newest touchless towel dispenser are quieter and more versatile than ever — providing adjustable settings for sheet length, time delay and sensitivity.”

Nichols continues, “Not all touchless systems are electronic, however. There are also mechanical no-touch towel dispensers, with no levers to pull, that provide the same hygienic benefits as sensor-activated dispensers. Users can easily reach the sheets they need, without “fishing around” inside a potentially dirty dispenser. Other non-electronic hygienic options include folded towel dispensing systems that dispense towels one at a time so users only have to touch the towels that they need.”21

Many infection prevention professionals believe that touchless technology is having an impact on the prevention of cross-contamination in the healthcare environment. “Touch-free technology is helping create a culture of healthcare workers that embrace hand hygiene,” says Beth Young, RN, BSN, CIC, an infection control consultant for GOJO Industries, with 30 years of experience in infection prevention. “As an infection control practitioner, I know and understand the importance of avoiding the possibilities of cross-contamination. For example, the simple act of turning off a water faucet can lead to hand contamination. That’s why we teach healthcare workers to use a paper towel to turn the handles.”

Young continues, “The development of touch-free dispensing technology for soap and hand sanitizer is a positive step toward reducing the possibility of hand contamination because your hands never touch the dispenser.” Young adds, “I know from personal experience that healthcare workers really like the touch-free technology. In feedback to me, they prefer touch-free dispensers because they feel this is a cleaner way to dispense soap and sanitizer.”

Choices abound in the marketplace. GOJO’s high-capacity, sanitary-sealed TFX™ Touch Free Dispensing System dispenses a variety of hand hygiene products, including Purell Instant Hand Sanitizer and Purell Instant Hand Sanitizer Foam, as well as Purell Surgical Scrub with Moisturizers and Provon Foam Handwash and Provon Medicated Foam Handwash. Clorox Commercial Solutions introduces its new Hand Sanitizer Touchless Dispenser for its premeasured dose delivery of the Clorox Hand Sanitizer, a bleach-free, 71 percent ethyl alcohol formulation. Ecolab’s Touch Free Dispenser dispenses its general-purpose soap Endure or Germa-Care cleansers, its professional Bacti-Stat handwashes, its Endure surgical scrubs, and its Endure waterless antimicrobial hand rinses.

Touchless dispensers are not limited to hand sanitizer, of course. Georgia-Pacific’s enMotion® Touchless Dispensing System offers towels automatically to users in a speedy and hygenic manner. Adjustable settings for sheet length, time delay, sensor range and dispensing mode controls usage and increases operational efficiency, while one-at-a-time towel dispensing reduces waste and lowers operating costs.

Kimberly-Clark Professional’s electronic bath tissue dispenser, the JRT Electronic Coreless, eliminates the need for users to touch the dispenser during use. The system automatically dispenses a pre-measured amount of toilet paper when users place their hands under the dispenser, thus combining the benefits of advanced touchless electronics with high-capacity coreless bathroom tissue for enhanced restroom hygiene, reduced consumption and compliance with the Federal Americans with Disabilities Act (ADA) because of the system’s one-handed dispensing.

Kimberly-Clark Professional has also introduced an electronic touchless towel system that improves upon other existing Kimberly-Clark towel dispensing systems by offering the hygienic benefits of hands-free dispensing along with the highest capacity on the market and a range of other innovative features. The system is quieter than similar electronic touchless towel systems and more user-friendly, via a smart sensor on the bottom that allows people to place their hands in a more natural position to dispense the towels. It also features adjustable settings for sheet length and time delays, so the system can be fine-tuned to meet a facility’s particular needs.

The Challenges of Going Touchless

There are some challenges associated with both touchless and manual dispensers, including ensuring that dispensers are functioning, full, and well maintained.10 The CDC’s hand hygiene guideline cautions, “Dispensers may discourage use by healthcare workers when they become blocked or partially blocked and do not deliver the product when accessed by personnel, and do not deliver the product appropriately onto the hands. In one hospital where a viscous alcohol-based hand rinse was available, only 65 percent of functioning dispensers delivered product onto the caregivers’ hands with one press of the dispenser lever, and 9 percent of dispensers were totally occluded. In addition, the volume delivered was often suboptimal, and the product was sometimes squirted onto the wall instead of the caregiver’s hand.”22

“STERIS didn’t jump on the touchless bandwagon immediately because we wanted to make sure the product was going to work,” Kilfoyle says. “We looked at the technology and weren’t comfortable until about two years ago that it was at the point where it won’t fail. Facilities need a product that is robust with a long battery life, as well as a dispenser that is fun, distinctive, and something people want to use.”

The cost of the dispenser, as well as the need for battery replacement, could be an issue at some facilities. Larson et al.13 note, “Although the cost of touch-free dispensers may be comparable to that of other dispensers, the touch-free devices require batteries for operation. Although the battery life is purported to be two years and a warning light on the dispenser makes it possible for housekeepers to readily detect the need for refill or battery change, the additional cost for battery operation may be a consideration in some settings. Further, we found that the hands-free dispensers were more complicated than the traditional manual units, and additional training of housekeeping staff in appropriate use and maintenance of the touch-free dispensers was needed.”

Touchless and automated technology is being scrutinized by the product evaluation and selection committees to which an increasing number of ICPs are being appointed. Kilfoyle offers a few pointers: “We recognize that users consider the dispenser and its technology to be the most important item in the decision of selecting a hand hygiene product. Yes, you need a reliable dispenser, but ultimately, what you are putting on your hands must be efficacious — actually killing the organisms — and it must be a product people like to use. If it breaks down your skin you’re going to stop using it.”

Kilfoyle cautions, “You shouldn’t just get a hands-free dispenser for the sake of getting a hands-free dispenser. You should ensure the product in the dispenser is something that will meet CDC guidelines and your expectations. Don’t just buy technology for technology’s sake; make sure the product meets your needs.”

When comparing similar dispensers, Kilfoyle says there are several criteria ICPs should look for. “Because you must encourage compliance, you should look for a dispenser that will react appropriately and dispense the product efficiently. Ask yourself, is the dispensing action smooth? Is the product dispensed nicely without stringing, or does it come out in a big glob? Is it misfiring or taking too long to dispense? Any of those experiences, although subtle, may discourage use.”

Automated Handwashing Systems

The CDC has weighed in on automated handwashing systems: “Although technologically advanced automated handwashing devices and monitoring systems have been developed recently, only a minimal number of studies have been published that demonstrate that use of such devices results in enduring improvements in hand-hygiene adherence among HCWs. Further evaluation of automated handwashing facilities and monitoring systems is warranted.”22

Some believe automated systems can increase hand hygiene compliance because they make a tedious chore quicker and more fun, as well as thorough and more uniform than a manual “splash-and-dash” approach commonly used by harried HCWs. Resurgent Health and Medical’s Radius Automated Handwashing and Monitoring System is a fully automated, touchless system available in healthcare for mechanical handwashing, rinsing and sanitizing. It performs a 10-second cycle using a chlorhexidine gluconate-based sanitizing solution, delivered by high-pressure water jets that perform a consistent wash-and-sanitize cycle every time the machine is used.

“We’re committed to helping achieve ‘zero tolerance’ in the prevention of healthcare-acquired infections,” says Jim Glenn, CEO of Resurgent Health and Medical. “Our new Radius system brings to healthcare a proven technology that has enabled other critical industries to achieve near-perfect elimination of infectious workplace pathogens. Furthermore, the Radius system introduces a total prevention approach by automating measurement and documentation of handwashing compliance.”

The Role and Efficacy of Electronic Alerts and Prompts

Sometimes, an audible reminder serves as a friendly little push that most HCWs need to remind them to practice good hand hygiene. Amron Corporation’s Hand Hygiene Prompts (HHP) is a computer-based device that collects data from sensors which report room exit and entry, toilet use and hand hygiene compliance. From these data, HHP determines if a HCW should wash their hands, and plays a pre-recorded voice message over a loudspeaker to “Please wash your hands” if they do not. According to Amron’s Stephen Lane, PhD, the system is non-intrusive, as users are not identified by badges or tags; it is non-threatening, because users are not penalized for not washing; it is non-coercive, because the device reminds, not commands; and it is neither stigmatizing nor invasive, as users are not identified as having dirty hands, and no cameras or microphones invade their privacy. Amron’s work in handwashing behavior modification through verbal messages has been funded by the National Institutes of Health for a number of years, and successful clinical trials at Johns Hopkins University Hospital and Biloxi Specialty Hospital point to increased hand-hygiene compliance and decreased infections.

Recent studies indicate that electronic devices can play an important role in hand hygiene compliance. Venkatesh et al.23 conducted a prospective, interventional study to evaluate the use of an electronic device to measure and impact hand hygiene practices and control transmission of VRE in a 30-bed academic medical center hematology unit. The researchers identified 8,235 measurable hand hygiene opportunities during the study, with compliance improvement from 36.3 percent at baseline to 70.1 percent during the second phase of the study. The use of audible alerts improved hand hygiene compliance for both the day shift and the night shift, as well as across rooms with higher HCW traffic and lower HCW traffic.

Swoboda et al.24 attempted to determine through a three-phase study whether electronic monitoring of hand hygiene and voice prompts could improve hand hygiene and decrease infection rates in a 14-bed, university hospital-based surgical intermediate care unit. Phase I was electronic monitoring and direct observation; phase II was electronic monitoring and computerized voice prompts for failure to perform hand hygiene on room exit; and phase III was electronic monitoring only. All patient rooms, utility room and staff lavatory were monitored electronically. Participants included all healthcare personnel including physicians, nurses, nursing support personnel, ancillary staff, all visitors and family members, and any other personnel interacting with patients on the unit. All patients with an intermediate care unit length of stay greater than 48 hours were followed for hospital-acquired infections (HAIs). Electronic monitoring was conducted during all phases, with computerized voice prompts during phase II only. The researchers evaluated a total of 283,488 electronically monitored entries into a patient room with 251,526 exits for 420 days (10,080 hours and 3,549 patient days). Compared with phase I, hand hygiene compliance in patient rooms improved 37 percent during phase II and 41 percent in phase III. When adjusting for patient admissions during each phase, point estimates of HAIs decreased by 22 percent during phase II and 48 percent during phase III; when adjusting for patient days, the number of infections decreased by 10 percent during phase II and 40 percent during phase III. Although the overall rate of HAIs significantly decreased when combining phases II and III, the association between HAIs and individual phase was not significant. The researchers concluded that electronic monitoring provided effective ongoing feedback about hand hygiene compliance.

Swoboda et al.25 also hypothesized that both patient isolation and electronic hand hygiene prompts incrementally improve hand hygiene of HCWs compared with non-isolation rooms. They conducted a prospective, 14.5-month, three-phase electronic surveillance study of hand hygiene behavior on an intermediate care unit with nine patient rooms (three isolation rooms and six non-isolation rooms); phase I was electronic observation, phase II was electronic observation with automated voice messages urging hand hygiene, and phase III was electronic observation. Electronic sensors monitored room entries and exits and use of all sinks and all soap dispensers. Phase I (1,616 patient-days) HCWs were 49 percent more likely to wash their hands in isolation rooms versus non-isolation rooms; phase II (1,390 patient-days) and phase III (543 patient-days) healthcare workers were 59 percent more likely to wash their hands in isolation versus non-isolation rooms, P = .001. The researchers concluded that HCWs improve hand hygiene when constrained by isolation rooms, that electronic voice prompts further improve hand hygiene behavior, and that both physical and auditory reminders improve hand hygiene. 

References

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19. Pittet D, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, Perneger TV. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med. 2004;141:1-8.

20. Muto CA, Sistrom MG, Farr BM. Hand hygiene rates unaffected by installation of dispensers of a rapidly acting hand antiseptic. Am J Infect Control. 2000;28:273–276.

21. Nichols SK. Touchless Technology Helps Facilitate Infection Prevention Best Practices. Infection Control Today.

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23. Venkatesh AK, Lankford MG, Rooney DM, Blachford T, Watts CM, Noskin GA. Use of electronic alerts to enhance hand hygiene compliance and decrease transmission of vancomycin-resistant Enterococcus in a hematology unit. Am J Infect Control. 2008 Apr;36(3):199-205.

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25. Swoboda SM, Earsing K, Strauss K, Lane S, Lipsett PA. Isolation status and voice prompts improve hand hygiene. Am J Infect Control. 2007 Sep;35(7):470-6.

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