Infection Control Today Exclusive: The Challenge of Health Care-Associated Infections (HAIs) and Evolving Prevention: A Focus on Hand Hygiene


Health care-associated infections (HAIs) significantly impact patient outcomes, hospital expenses, and mortality rates in the United States. Hand hygiene stands as the most effective preventive method. While manual observation often produces biased results, Electronic Hand Hygiene Monitoring Systems (EHHCM) offer evolving methods for more accurate adherence assessment.

Hand hygiene     (Adobe Stock 417724081 by Roman)

Hand hygiene

(Adobe Stock 417724081 by Roman)

Health care-associated infection (HAI) is one of the biggest public health problems that the United States is now dealing with. According to the Agency for Healthcare Research and Quality, HAIs are the most common complication of hospital care and are one of the top 10 leading causes of death in the United States.1 Patient outcomes, mortality, escalating hospital expenses, and lost revenue are all impacted by HAIs.2 There is an abundance of research on prevention methods due to the threat that HAIs pose to our public health. According to an analysis of numerous published journal articles, hand hygiene is the most effective prevention method to combat HAIs.3

Even though hand hygiene practice in health care has been around since the 1800s, it is continually developing. The first national hand hygiene guidelines were published less than 50 years ago, in the 1980s4; however, there is still room for improvement. Advancement is particularly needed in observing hand hygiene activity and using data to make more informed decisions and strategies for healthier care environments.

Direct or Manual Hand Hygiene Monitoring

Direct or manual observation is the typical technique used in hospitals and other health care facilities around the United States to assess and report hand hygiene adherence. Manual observation is when a person is assigned to a hospital unit to covertly observe the hand hygiene routines of patient care and other staff members and report what they see following a set of guidelines. Due to potential observer bias and the Hawthorne Effect (the effect that the act of being watched changes the actions of the subjects), manual adherence numbers may only be partially accurate, and many people believe that the adherence values obtained using this method are overstated. According to a World Health Organization (WHO) 2019 global study, the United States and other high-income countries often have hospital hand hygiene adherence rates of over 60%, although they rarely exceed 70%.5 Hospitals that performed higher and were deemed hand hygiene champions have the following successful strategies in place: consistent supply and proximity of soap and hand sanitizer dispensers throughout the facility; ongoing training and education; regular signage or reminders of proper hand hygiene techniques and differentiation between soap and sanitizer usage throughout the facility; prompt evaluation of employee performance; and finally, reporting to direct workers and at a systematic level including leadership feedback.5

Electronic Hand Hygiene Monitoring

The field of technology known as Electronic or Automatic Hand Hygiene Adherence Monitoring Systems (EHHCM) is new. The earliest EHHCM systems have been operating for around 20 years, yet the field continually expands and innovates. Electronic hand hygiene monitoring systems come in various forms, generally categorized into 5 types: group monitoring without reminders, group monitoring with reminders, individual monitoring without reminders, individual monitoring with reminders, and, at the most stringent level, individual monitoring with reminders and room preparation assignments.

Group Monitoring EHHCM systems are room-based and dispenser-based systems that, at the most fundamental level, tally the frequency of soap or sanitizer distribution from a dispenser. At this level, it is challenging to establish a quantifiable value for adherence. At a more advanced level, this can be combined with room-level data, such as a location-specific motion sensor, to count the number of entries and the number of soap or sanitation events to determine room adherence. Expanding one degree from the prior includes concurrent use of a reminder system that typically uses lights or noise to signal when hand hygiene is required. This can be set up based on the number of room entries or exits and the number or proximity of dispensers. Because there is no user-specific assignment, it is difficult to tell if the actions—or lack thereof—come from staff, patients, or visitors when employing group monitoring systems to assess adherence in particular hospital units.

Individual Monitoring EHHCM products have evolved from and alongside group monitoring systems. Individual monitoring takes adherence reporting to the next level by adding a wearable device by health care staff that works either in conjunction with a group monitoring system, through its form of hand hygiene performance tracking, or a mixture of both. These systems allow for a unique advancement in hand hygiene adherence reporting quality. With an individual monitoring system in place, it is possible to determine a precise level of adherence, person by person or room by room. There are also ways to track patient-area workflow to prevent further cross-contamination. Individual EHHCM systems without reminders are useful for simply tracking data, whereas systems with reminders work to aid faculty and thwart potentially harmful mistakes.

Individual Monitoring with Reminders and Room Assignments is currently the most meticulous EHHCM system type. An addition to individual EHHCM design, a room-level component allows a health care facility to designate specific rooms as soiled, contact precautions, isolation, etc, so special action needs can be performed. This allows for reminder types and durations to be customized. By having a custom room, a facility can allow for more time for personal protective equipment (PPE) to be donned or set a reminder to differentiate when physical hand washing with soap and water is needed (rather than sanitizer) to prevent specific pathogen contamination.

Recording Adherence

Whether the hand hygiene performance is recorded by direct observation or through the hand hygiene health management system (EHMS), the data is the same. The only differences are in the volume of data collected, its completeness, and the time it takes to report feedback. Room entries, exits, and in-patient area hand hygiene moments are captured. Types, times, and durations of hand hygiene activities are recorded. Any deficiencies or cross-contamination actions are also noted.

Once data is collected, it is compiled in some form, whether through manual observation with aiding computer software or applications or a system specific to each EHHCM. Once the data is aggregated, it can be used to form a comprehensive picture. For example, EHHCM data can provide hand hygiene count, adherence, and cross-contamination information at a facility, department, job category, nursing unit, room, or individual faculty member level. Depending on the level of reporting advancement, this data can also be used for staff rounding and disease-spread contact-tracing reports.

Figure 1: Manual Observation vs EHHCM Hand Hygiene Adherence

(Credit: author)

Figure 1: Manual Observation vs EHHCM Hand Hygiene Adherence

(Credit: author)

Adherence Comparison Between Electronic and Direct Monitoring

Manual or direct observation of hand hygiene adherence monitoring within a health care facility is one of the first steps in addressing our public health HAI challenge. The action is well-defined, and the reporting needs are known and established through one form or another. The biggest problem with direct observation is that it is done on just a sample of workers and events throughout the day. The Leapfrog Group sets a goal for acute care hospitals to report 200 monthly observations per unit.6 The evolution of adherence reporting uses at least one individual-level EHHCM system, which captures hand hygiene observations at a real-time pace, with many facilities exceeding that minimum requirement of 200 observations in a unit daily. When using an individual-level EHHCM system with a reminder component, an additional level of reporting is gained—the number of corrected cross-contaminated actions. With this level of reporting, users can research what accurate adherence numbers are and compare them to what manually observed adherence numbers might be.

One individual-level EHHCM company, with a reminder component and room assignment capabilities, sought to investigate this adherence comparison through a descriptive study. The company first chose a short-term acute care hospital to define an adherence comparison. Hospitals treat the largest variety of age groups, and short-term acute care hospitals make up more than half of the hospitals in the country, with the average number of beds in a short-term acute care hospital at 186.7


Using this data and factors, the EHHCM institution applied a few levels of filtering and selected a midwestern hospital that met all the following criteria: was a short-term acute care facility, had a bed count between 175 and 199 beds, had average or below average HAI counts on all 5 infection types reported by the Centers for Medicaid Services (CMS) at least 1 year before EHHCM installation, and had a Leapfrog Hand-Hygiene grade of an A and a 100 Hand Hygiene score in the 6-month report before implementation. This criterion needed to be met to compare an already successful facility in hand hygiene and control for other infection prevention factors. This research aims to compare the overall adherence reported by the EHHCM system for the first year post-implementation and the adjusted adherence with corrected cross-contamination counts from system reminders removed. To support an adherence difference, a comparison of CMS HAI counts for 4 quarters ahead of installation was juxtaposed to the first 4 quarters after to see if there was any infection reduction to support an adherence change.


The result of one year of EHHCM-collected data was over 4.1 million HHOs captured, total adherence just above 95%, and nearly 528,400 corrected cross-contamination events after a reminder sequence from the EHHCM system. By removing the corrected cross-contamination counts from the adherence calculation, the adherence value dropped approximately 13% to a low of 82%. CMS HAI data was also compared for 1-year pre- and post-EHHCM installation to support this adherence change's validity further using clinical significance. What was observed was a 41.38% overall reduction in infection acquired in the facility across the 2 years. No changes in the number of cases of Methicillin-resistant Staphylococcus aureus (MRSA) or surgical site infections were reported each year. However, there were 0 MRSA cases reported and less than 5 surgical site infections in both years. There was a 67% reduction in central line-associated bloodstream infections, a 57% depletion in catheter-associated urinary tract infections, and a 31% alleviation of Clostridioides difficile cases. It should be noted that Clostridioides difficile is an infection type where hand washing is required to kill the pathogen, and this facility had used Contact Plus room assignment sparingly in this first year.


There are 2 limitations to the data in this study. The first is that the data comes from usage one year1 post-EHHCM installation, meaning that staff may still need to be fully acquainted with the system and that continued training and situational adjustments may be needed to better fit the workflow of the specific facility. This issue could affect adherence in both directions, making numbers slightly underinflated or overinflated due to a margin of error. Secondly, because the EHHCM system has a reminder, there may be a Pavlovian response from staff members. As the staff knows a reminder is coming, and they will need to sanitize in a way to satisfy the system, this may, in turn, influence increased adherence beyond what would be done without a system in place.


Even a hospital with top-notch hand hygiene programs and average or below-average HAI counts isn't getting the most accurate data on staff adherence using only manual observation. The more precise the hand hygiene adherence data, the better leadership and staff can do to improve infection prevention and control and make their facility a safer place. Electronic hand hygiene systems of all types, but particularly at the most robust levels, help hospitals achieve the criteria they need to have in place to be considered "hand hygiene champions" and continue to allow hospitals to evolve their data and insights into the fullest picture they need to reduce the public health issue of hospital-associated infection spread across the United States.


  1. Agency for Healthcare Research and Quality. Healthcare-Associated Infections. Accessed October 31, 2023.
  2. Definitive Healthcare. Three key statistics on hospital-acquired conditions. Accessed October 31, 2023.
  3. Haque M, McKimm J, Sartelli M, Dhingra S, Labricciosa FM, et al. Strategies to Prevent Healthcare-Associated Infections: A Narrative Overview. Risk management and healthcare policy. 2020;13:1765–1780. DOI:
  4. Medline. Why is hand hygiene the first line of defense against HAIs? Accessed October 31, 2023.,recent%20years%20in%20different%20countries
  5. de Kraker ME, Tartari E, Tomczyk S, Twyman A, et al. Implementation of hand hygiene in health-care facilities: Results from the WHO hand hygiene self-assessment framework global survey 2019. The Lancet Infectious Diseases. 2022;22(6):835–844. DOI:
  6. The Leapfrog Group. Factsheet: Hand Hygiene. Accessed October 31, 2023.
  7. Definitive Healthcare. What is the average number of beds in a U.S. hospital? Accessed October 31, 2023.,130%20beds%2C%20according%20to%20HospitalView.
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