Hand Hygiene: Where Technology and Tradition Meet

Infection Control TodayInfection Control Today, March 2021 (Vol. 25 No. 2)
Volume 25
Issue 02

Hand hygiene is always important, but during this pandemic it’s crucial to preventing transmission. Now technology is making it possible for hospitals not only to monitor compliance, but also potential viral exposure.

A clinician walks out of a patient’s room. Seconds tick by. The clinician takes a bit too long to clean his hands. “Please sanitize,” a calm voice says. It’s coming from his belt, apparently.

Actually, it’s coming from the badge attached to the belt. The badge reel contains Bluetooth technology, which communicates with sensors affixed to soap and sanitizer dispensers parked in various places around the patient care area.

If hospital administrators could have 1 wish, it might be to have 100% adherence with hand hygiene protocols. So, they are doing everything they can to encourage adherence, which is particularly critical now when people (including 3142 health care workers as of January 7, 2021) are still dying of coronavirus disease 2019 (COVID-19).1

Electronic monitoring, sensors, and voice prompts aren’t new, and the technology keeps evolving. The Clean Hands–Safe Hands system allows users to customize the audio file reminder with their preferred voice and content, such as an infection preventionist (IP) or a child.

Personalized touches like that are born of experience. Hospital experts know that monitoring alone doesn’t change behavior. In fact, technology alone isn’t always the answer either. Some of the most effective systems are a hybrid of the latest technology and traditional methods such as rewards and recognition.

Computer Screensavers

Take the solutions they came up with at Sentara Healthcare, a not-for-profit integrated health care system based in Norfolk, Virginia. With 12 hospitals, 4 medical groups, and more than 30,000 employees, it’s Virginia’s largest health care system. Nearly 10 years ago, after a large group of health care professionals there did some brainstorming about best hand hygiene practices, Sentara hired QualPro, a quality control consultancy, to test and analyze 21 interventions. Eventually, Sentara decided on interventions that included computer screen savers encouraging hand hygiene and awarding Hero of the Month titles to employees with high adherence rates. Other low-tech interventions included red stop signs to remind staff to wash their hands and random quizzes.

They didn’t stop there. Sentara’s adherence rates “are generally in the 90s, but ‘secret shopper’ audits show lower adherence that varies,” says Linda Estep, manager of infection prevention and control. “This is driving the push for electronic auditing that captures all opportunities we set up, and measures adherence more widely and accurately. Our manual audits are time-consuming and may not cover all shifts consistently. Currently, we’re reviewing electronic hand hygiene monitoring to expand our ability to capture a wider picture of adherence across all shifts.”

In fact, methods such as secret shoppers have underscored the need for more advanced methods of monitoring adherence. Study findings have shown that direct observation captures only a small percentage of all events. What’s more, it can massively overstate actual adherence.

Sentara’s ongoing hand hygiene campaigns are very successful, Estep says. “We update our approach regularly and we pay careful attention to our rates, as well as what we see when rounding on patient care units.” Keeping the message fresh is important, she notes.

Sentara not only has a top-down approach led by divisional leaders, but also peer-coaching efforts that address and overcome the “authority” gradient. “Sentara has a solid, long-standing culture that infection prevention is everyone’s job,” Estep says.

That means getting everyone on board. One of Sentara’s most successful campaigns is All Hands On Deck (AHOD). AHOD is Sentara’s code word to remind staff they forgot to clean their hands when required. “It’s a fun way to deliver the reminder,” Estep remarks. Leaders also model the correct response: Thank the person for the reminder and immediately sanitize hands. “Negative responses prevent our more shy staff from stepping up to coach,” Estep says. “We’re all responsible for creating a culture that promotes coaching.”

The Johns Hopkins Hospital in Baltimore, Maryland, has also found that the personal touch helps keep an adherence program from running out of steam. The hospital doubled rates of adherence with hand hygiene protocols between 2007 and 2008, and increased adherence again by 27% between 2008 and 2009.2 How? With a hospital-wide communication and education campaign called WIPES:

  • Wash/clean hands
  • Identify and isolate early
  • Precautions use (eg, gowns, gloves, and masks)
  • Environment kept clean
  • Share the commitment, raise your hand

Hanan J. Aboumatar, MD, MPH, a family practitioner focusing on behavior change and an assistant professor at Johns Hopkins School of Medicine and Johns Hopkins Bloomberg School of Public Health, and Polly Trexler, MS, CIC, director of operations for the Department of Hospital Epidemiology and Infection Control at The Johns Hopkins Hospital, started the program “because there was a lot of work to do.” They spent about a year planning, looking at behavior, and researching how to change it. They used focus groups with hospital staff and leaders to understand the issues and which behavior models to support.

Accountability Matters

The WIPES project included the usual steps of putting up posters and hosting sessions about the importance of using sanitizers. “The program helped increase adherence significantly,” says Trexler. “Then we stalled for a while. People were lagging behind. So, about 5 years into the project we added [the component of] direct feedback. We hired someone in addition to secret shoppers to address those employees who were a little more resistant to change.”

A successful program includes accountability, she believes, referring to “a new buzzword: Just Culture.” That is, applying discipline in a fair way to be sure staff understand expectations. But it’s also important to make it possible for them to adhere easily, for example, by having dispensers everywhere. “We set expectations to clean hands on entry and exit, changing the behavior of only cleaning on entry and then thinking ‘I didn’t touch anything’ so not cleaning on exit,” Trexler says. “We did it on purpose to create habits, and to make it simple to keep the new habits.”

The accountability model also includes escalating consequences for nonadherence, beginning with a note to the employee, a note to the supervisor, then a talk with the supervisor, and up the chain of command. Nonadherence after 6 observations in the year means termination. But “we never go over 3 observations,” Trexler says.

The traditional methods—positive reinforcement, educational posters, reminders, rewards, recognition, secret shoppers—help keep the day-to-day level of adherence up, but technological innovations can make it easier for administrators to spot and calibrate for weak areas. An online reporting tool allows managers to collect data entered into a phone or iPad. “It’s real-time data that can be pulled up by hospital, service, unit, health care worker type, and timeframe,” Trexler says.

At Johns Hopkins, adherence is rewarded with the old-fashioned kind of positive reinforcement—compliments and congratulations—but also with data-based reinforcement. Taylor McIlquham, MPH, an infection control epidemiologist at The Johns Hopkins Hospital, says, “We present data to the IC [infection control] committee every month about which units are doing well, and which aren’t, and which ones have reached more than 92% adherence in the previous 3 months.” High performers are treated to individually wrapped cookies (pre–COVID-19, they had pizza parties). Leadership comes to the meeting to thank them (the personal touch again).

COVID-19 has intensified just about everything to do with infection control, including the need to find the right tools for the right situations. According to McIlquham, Johns Hopkins has spent the past 2 years looking into electronic monitoring systems, made by everyone from GE to smaller startups. Time constraints make it hard to rely on secret shoppers, she says. “We have over 50 clinical units to observe each month. Also, it can create bias [in the data] if staff begin to recognize the secret shopper.” Badges and digital monitors take out the human element, she adds. “We’re interested in technology primarily to reduce bias and understand what the numbers actually are, to be as accurate as possible. And to use data to target which interventions improve outcomes.”

It’s a big undertaking. “Even just doing studies, it’s a huge, huge infrastructure,” says McIlquham. “Think about thousands and thousands of people on our campus who would need the badges and monitoring tools. But we’ll continue exploring. We were doing short-term trials. Right before COVID-19 we were just about to do another but put it on the back burner for now.”

COVID-19 Factor

Hand hygiene is always important, but during this pandemic it’s crucial to preventing transmission. Now technology is making it possible for hospitals not only to monitor adherence, but also potential viral exposure.

SwipeSense, which initially was intended to track whether staff were washing their hands correctly, has a new application: contact tracing. Via sensors added to staff badges, managers can create a virtual “historical” map of staff whereabouts. If someone has received a COVID-19 diagnosis, administrators can better identify where the person was and who might have been in contact with them.

SwipeSense CEO Mert Iseri is fully aware of the implications of the monitoring, but in a recent interview with CNBC insists the company is “taking steps to alleviate the ‘creep’ factor.” For example, the system doesn’t track people throughout their day. Acknowledging the potential for misuse, he said, “We have to be really thoughtful about the technology we’re building.”3

Used wisely, the technology is a benefit in fighting COVID-19 spread. At Edward-Elmhurst Health in Illinois, where more than 3000 workers agreed to wear the SwipeSense badge, the data populated a dashboard that, by the end of March 2020, could help administrators monitor exposures. In 1 case, they determined that 75 employees had been in the room of a patient who tested positive, so they tested those workers and isolated them for 72 hours. One tested positive and was further isolated, and the virus was contained.3

Hazard Appalachian Regional Healthcare (ARH) in Kentucky is also using the SwipeSense technology for contact tracing. “We are 1 of only 3 hospitals in the nation who are currently utilizing this technology for contact tracing,” James J. Hensley, MLS (ASCP), CIC, system director of infection prevention for ARH, wrote in a blog on the hospital’s website.4 In addition to contact tracing for staff, ARH attaches radio-frequency identification asset tags to mobile equipment such as ventilators. Through the SwipeSense Asset Tracking app, the hospital can virtually map and track equipment throughout the facility.

“This helps us identify equipment that may need [to be] assessed, cleaned, and even quarantined,” Hensley said. “The facility has location hubs connected all over, including in common areas, which ‘talk’ to staff badges and asset tags to log data for asset tracking and also for contact tracing.”3

Sentara’s Estep says, “The pandemic has reaffirmed our focus on correct, consistent use of [personal protective equipment] and hand hygiene to prevent exposures. We’re compliant with the Virginia Emergency Temporary Standard for the prevention of SARS-CoV-2 [severe acute respiratory syndrome coronavirus 2], which has a high focus on staff training, including correct hand hygiene technique. We created a training video, Safe at Sentara, that covers all aspects of COVID-19 prevention, and we plan for it to become an annual educational requirement.”

Sentara also continues to explore adherence-enhancing technology. “This will not only emphasize our commitment to 100% hand hygiene adherence,” Estep says, “but also our willingness to identify gaps and opportunities and commit to the technology cost of such a project. We’re also using the more stringent Leapfrog requirements to justify electronic monitoring, since receiving additional points involves a much higher volume of audits than we can achieve manually.” (The Leapfrog Group is a national watchdog organization focused on health care safety.)

The original WIPES program at Johns Hopkins increased adherence in hand hygiene to more than 80%; the enhancements have boosted it to the 90% range, and COVID-19 has made it critical. “Adherence is higher this year than ever before,” Trexler says. “People are more conscientious. We’re hoping this habit will bleed over after the pandemic.” She sees reason for optimism. “COVID-19 will have one benefit: changing behavior.”

Hospitals might get their wish for 100% adherence granted after all.

JAN DYER is a writer and editor specializing in clinical topics. She lives in Suffern, New York.


  1. Guardian. Lost on the frontline. Guardian. August 11, 2020. Accessed January 7, 2021. https://www.theguardian.com/us-news/ng-interactive/2020/aug/11/lost-on-the-frontline-covid-19-coronavirus-us-healthcare-workers-deaths-database
  2. Aboumatar H, Ristaino P, Davis RO. Infection prevention promotion program based on the PRECEDE model: improving hand hygiene behaviors among healthcare personnel. Infect Control Hosp Epidemiol. 2012;33(2):144-151. doi:10.1086/663707
  3. Farr C. Some hospitals are tracking Covid-19 by adding sensors to employees’ badges. CNBC. August 2, 2020. Accessed January 7, 2021. https://www.cnbc.com/2020/08/02/hospitals-tracking-covid-19-with-badge-sensors-swipesense-technology.html
  4. Hazard ARH uses SwipeSense technology to speed up contact tracing for COVID-19. Appalachian Regional Healthcare blog. Accessed January 7, 2021. https://www.arh.org/portfolio_page/hazard-arh-uses-swipesense-technology-to-speed-up-contact-tracing-for-covid-19/

Using Technology to Stay Safer

In 1999, Kevin Ashton, of Procter & Gamble, coined the term “Internet of Things” to describe that universe of computers communicating with each other almost independently of humans.

In 2015, in an interview with Smithsonian Magazine, he said, “In the 20th century, computers were brains without senses—they only knew what we told them. That was a huge limitation: There is many billion times more information in the world than people could possibly type in through a keyboard or scan with a barcode. In the 21st century, because of the Internet of Things, computers can sense things for themselves.”1

Consequently, we now have GPS; smart phones, TVs, and refrigerators; and devices that know when we’re home and when we aren’t.

We also have systems that can tell when health care personnel are washing their hands and when they aren’t—and reminds them when they don’t. The data those systems provide also help hospital managers understand transmission risk. In this coronavirus disease 2019 (COVID-19) pandemic, knowing where hotspots might be lurking is critical.

Here’s a brief look at some of the technological tools available:

  • Clean Hands–Safe Hands (CHSH) technology helps hospitals identify the most efficient path to improving hand hygiene. Its patented process, which includes gamification, “nurtures a culture of proactive HAI [health care–associated infection] prevention.” According to CHSH, hospitals that have used its technology and followed its process for at least 6 months have seen a decrease in HAIs of between 45% and 81%.
  • AUVS’ KR615 UV-C Germicidal Enclosure has been named a “Best Infection Prevention Product” by Newsweek, in association with the Leapfrog Group. Its 55-second disinfection “UV Box,” used throughout more than 700 hospitals and hospital groups, provides up to 99.999% disinfection. According to AUVS, the surface disinfection technology in its products is similar to the technology used in the air systems at the US Pentagon to protect against bioterrorism.
  • BioVigil, with a configurable dashboard, provides on-demand intelligence and actionable insights about adherence and clinical workflows. The insights are color coded and available in easy-to-read graphs, making it simple to track adherence history. The company says study results have found its use reduces HAIs and staff absenteeism due to illness.
  • The DebMed Electronic Hand Hygiene Adherence System is, according to the company, the only research-based, badge-free system that tracks adherence based on the World Health Organization’s 5 Moments, the Canadian 4 Moments, and the Centers for Disease Control and Prevention’s (CDC) hand hygiene standards. The system can capture 100% of hand hygiene events and opportunities, beyond just room entry and exit. Having an accurate number of hand hygiene opportunities and comparing them to 100% of all hand hygiene events collected, the system provides true adherence rates, providing actionable feedback for the group “without singling out individuals.”
  • SwipeSense is a cloud-based sensor network that runs multiple applications simultaneously and monitors core metrics in one place. It does this “without the burden of logging in to multiple systems,” and with “little involvement from IT teams,” the company says. The system is compatible with existing or new wall dispensers. At-a-glance insights include time series comparisons, day vs night shifts, and soap vs sanitizer use. According to the company, because SwipeSense relies on proven behavior change methodologies rather than short-term gimmicks such as alerts or reminders, it leads to hospital-wide adoption.
  • The Vitalacy SmartBand was recently recognized in Newsweek’s Best in HealthCare 2020 as one of the best monitoring products for infection prevention. The band measures proximity to other SmartBands in the office. If they’re “too close for too long,” the users are notified by Vitalacy that they may have been exposed. The product does not track user location and keeps all user data anonymous from other team members and their employer. The company says the band is also the only adherence-monitoring wearable that records and improves hand wash duration.


  1. Gabbai A. Kevin Ashton describes “the Internet of Things.” Smithsonian Magazine. January 2015. Accessed January 7, 2021. https://www.smithsonianmag.com/innovation/kevin-ashton-describes-the-internet-of-things-180953749/

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