has 20 years of experience in infection prevention and health care quality. She is the director of infection prevention for Mercy, a multistate health care system, including more than 40 acute care, managed, and specialty hospitals.


Kathleen McMullen, MPH, FAPIC, CIC 

Proper hand hygiene significantly impacts health care–acquired infections (HAIs), and monitoring completion is essential to improving performance.

Some hospitals invest in electronic monitoring systems (EMSs) to alleviate concerns about traditional in-person observation methods.

 Recognizing the importance of hand hygiene and accurate data to demonstrate actual performance with efforts around quality improvement, Mercy health care system leadership implemented Clean Hands Safe Hands LLC (an EMS headquartered in Atlanta, Georgia) in 2019. The EMS was implemented house-wide in 12 acute care hospitals (> 4000 licensed beds in 26 units), including Missouri, Oklahoma, and Arkansas facilities between 2020 and 2021.

Sensor on the Side of Alcohol Foam Dispenser Communicates With Magnet Inside the Dispenser

The EMS uses a personalized badging system to identify hand hygiene adherence down to the individual health care provider (HCP) level.

 Each HCP is issued a badge holder/reel with Bluetooth technology to communicate with sensors placed in the alcohol foam and soap dispensers (

). Additional sensors (motion sensors) are placed at the door of all patient care rooms. The EMS correlates a room entry/exit with an HCP badge and interaction with a hand hygiene dispenser (sanitizer or soap) immediately before or after the entry/exit. An audible alert sounds as a reminder if a hand hygiene event is not detected within a defined time. Cloud-based technology gathers all data points, with almost real-time results available through the EMS computer program platform.

There are 2 critical areas where the EMS offered benefits to Mercy: data availability and process improvement. There was a dramatic increase in the overall number of hand hygiene observations completed, allowing observation at all times of the day or night and removing the biases of the in-person observation process. The computer system associated with the EMS was crucial in transitioning those data into useful information. Real-time feedback and adherence trending was available to unit leaders and coworkers by logging into the system. Still, there were also automated emails of results sent to many HCPs, and the data helped fuel healthy competition between individual HCPs or patient care units/departments. Information was available in general adherence reports, as well as advanced graphics that could identify HCPs or certain rooms with higher and lower performance (

Examples of Advanced Reporting Functionality by the EMS* 

(Bubble Plots that Signal HCP* by Number of Observations and Performance; Blueprints Signal Rooms by Number of Opportunities and Performance)

*EMS is emergency medical services, and HCP is health care personnel.

One key to improving hand hygiene was the audible alert when a hand hygiene event was not captured, which served as a reminder to the HCP and offered the unexpected benefit of improving the impression of patients about commitment to safety. Upon hearing the reminder, if staff cleaned their hands, they were given credit for proper hand hygiene by the EMS. Based on the results, the increased conversations around hand hygiene from bedside staff to senior leadership further drove process improvement. Workflow optimization and reduction of unnecessary steps necessitating additional hand hygiene were realized. Overall, continual process improvement activities resulted in a 26% increase in hand hygiene performance, from 50% at baseline to 76%, in 1.5 years. Current hand hygiene performance is averaging 84% across the health system.

There were some limitations to using an EMS, and some of them were unexpected. The primary drawback was a higher-than-expected amount of daily work for infection preventionists and other staff charged with maintenance, which is well described elsewhere.

 Continued education was needed to explain how the system worked, which the EMS personnel assisted with via training and resources. HCPs were required to wear a badge to be monitored, and some individuals avoided the system by not wearing their assigned badge. Breakage of the badges, sensors, or sanitizer dispensers was common.

The design of this EMS resulted in inherent “noise” in the system or some incorrect estimation of adherence, which led to initial mistrust of the system. The motion sensors were better at detecting entry/exit of 1 HCP but not as good at detecting groups and busy units, areas with sliding doors and curtains, and small patient rooms. Because of this, workarounds were created to appease the system, including hand hygiene dispenses where the product was not used on the hands. HCPs who strive for perfection are not able to attain that. Overall, there were challenges to belief in results and the ability of the EMS to impact hand hygiene performance, some of which were rectified over time.

Despite some disadvantages, Mercy found value in the EMS, most prominently the organizational efforts to implement and improve performance. Implementing a system was key to understanding that the results from the manual observation process were flawed. The large quantity of data allowed attention to be brought to procedures followed by entire departments that required consultation from infection preventionists to ensure patient safety was maintained.

1. Naikoba S, Hayward A. The effectiveness of interventions aimed at increasing handwashing in healthcare workers – a systematic review. 

 2001;47(3):173-180. doi:10.1053/jhin.2000.0882

2. Pittet D, Sax H, Hugonnet S, Harbarth S. Cost implications of successful hand hygiene promotion. 

3. Huis A, Schoonhoven L, Grol R, Donders R, Hulscher M, van Achterberg T. Impact of a team and leaders-directed strategy to improve nurses’ adherence to hand hygiene guidelines: a cluster randomised trial. 

 2013;50(4):464-474. doi:10.1016/j.ijnurstu.2012.08.004

4. Carboneau C, Benge E, Jaco MT, Robinson M. A lean Six Sigma team increases hand hygiene compliance and reduces hospital-acquired MRSA infections by 51%. 

. 2010;32(4):61-70. doi:10.1111/j.1945-1474.2009.00074.x

5. Gould D, Lindström H, Purssell E, Wigglesworth N. Electronic hand hygiene monitoring: accuracy, impact on the Hawthorne effect and efficiency. 

.2020;21(4):136-143. doi:10.1177/1757177420907999

6. Limper HM, Slawsky L, Garcia-Houchins S, Mehta S, Hershow RC, Landon E. Assessment of an aggregate-level hand hygiene monitoring technology for measuring hand hygiene performance among healthcare personnel. 

. 2017;38(3):348-352. doi:10.1017/ice.2016.298

7. Using data to improve hospital efficiency and safety. Clean Hands Safe Hands LLC. March 13, 2020. Accessed October 6, 2022. 

https://cleanhands-safehands.com/using-data-to-improve-hospital-efficiency-and-safety/

8. McMullen K, Diesel G, Gibbs E, et al. Implementation of an electronic hand hygiene monitoring system: learnings on how to maximize the investment. 

. 2022;S0196-6553(22)00879-3. doi:10.1016/j.ajic.2022.12.008

Articles

Hand hygiene requirements for inpatient health care are numerous and varied. An electronic system to help monitor adherence with some indications benefits the hospital, although it may also introduce some drawbacks.

Kathleen McMullen, MPH, FAPIC, CIC

Articles

The Advantages and Disadvantages of Using a Hand Hygiene Monitoring System