American Journal of Infection Control 40 (2012) 320-3

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American Journal of Infection Control American Journal of

Infection Control

journal homepage: www.ajicjournal.org

Major article

Effectiveness of an audible reminder on hand hygiene adherence

Morkos Fakhry MBBS, PhD a, George B. Hanna PhD, FRCS a, *, Oliver Anderson BSc, MRCS a,
Alison Holmes MD, MPH, FRCP b, Dinesh Nathwani FRCS a
a
Department of Surgery and Cancer, Imperial College London, London, UK
b
Centre for Infection Prevention and Management, Imperial College London, London, UK

Key Words: Background: Multimodal interventions aim to improve health care workers’ adherence to hand hygiene
Cross-infection guidelines. Visitors are not primarily targeted, but may spread epidemic infections. Effective interven-
Prevention tions that improve the adherence of visitors to hand hygiene guidelines are needed to prevent the
Guideline
transmission of epidemic infections to or from health care environments.
Handwashing
Methods: An electronic motion sensoretriggered audible hand hygiene reminder was installed at
Health personnel
Infection control hospital ward entrances. An 8-month preinterventional and postinterventional study was carried out to
measure the adherence of hospital visitors and staff to hand hygiene guidelines.
Results: Overall hand hygiene adherence increased from 7.6% to 49.9% (P < .001). The adherence of
visitors and nonclinical staff increased immediately from 10.6% to 63.7% and from 5.3% to 34.8%,
respectively (P < .001). Adherence of doctors, nurses, and physiotherapists increased gradually from 4.5%
to 38.3%, from 5.4% to 43.4%, and from 8.7% to 49.5%, respectively (P < .001). Improved adherence was
sustained among visitors and clinical staff (P < .001), but not among nonclinical staff (P ¼ .341).
Conclusions: The electronic motion sensoretriggered audible reminder immediately and significantly
improved and sustained greater adherence of hospital visitors and clinical staff to hand hygiene
guidelines. This is an effective addition to multimodal hand hygiene interventions and may help control
epidemic infections.
Copyright Ó 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc.
Published by Elsevier Inc. All rights reserved.

Multimodal interventions aim to improve the adherence of
health care workers to hand hygiene guidelines, with the goal of
reducing health careeassociated infections. Multimodal interven-
tions include adequate provision of alcohol-based hand rub and
soap and water, training and education, evaluation and feedback of
performance, provision of workplace reminders, and a culture of
safety.1 Visitors may transmit epidemic infections and are not
primarily targeted by multimodal interventions. The present study
was initiated in response to the H1N1 influenza pandemic of 2009.
There is a need for an effective, rapidly deployable, yet inexpensive
intervention aimed at improving the adherence of visitors to hand
hygiene guidelines to prevent the transmission of epidemic infec-
tions to or from health care environments without the need for
education or training.
The World Health Organization’s (WHO) “Five Moments for
Hand Hygiene” are recommended indications for hand hygiene,
* Address correspondence to George B. Hanna, PhD, FRCS, 10th Floor QEQM
Building, St Mary’s Hospital, London W2 1NY, UK.
E-mail address: g.hanna@imperial.ac.uk (G.B. Hanna).
Conflict of interest: None to report.
which include before and after touching a patient and after
touching a patient’s surroundings.2 The hand hygiene guidelines
from the Centers for Disease Control and Prevention and the WHO
mandate that alcohol-based hand rub sanitizers be made available
at the entrance to patient rooms or other convenient locations.3,4 If
patients are not confined to single rooms, then the entrance to
patient rooms is synonymous with the entrance to the ward. This
represents the last doorway passed through before touching
a patient and the first doorway passed through after touching
a patient or a patient’s surroundings. Even though this is not
strictly one of the WHO’s five moments, 28% of hospitals in the
Republic of Ireland currently provide alcohol-based hand rub
sanitizers at the entrance to every ward.5 This convenient location
for hand hygiene is used by visitors more often than sanitizer
located at patient bedsides, and accounts for 21% of all alcohol-
based hand rub consumption in National Health Service hospital
wards.6 Local guidelines promote hand hygiene before entering or
leaving a ward.7 Alcohol-based hand rub sanitizers were provided
at the entrance to a New Zealand hospital during the H1N1 influ-
enza pandemic; the use of sanitizer rose to 18% during the
pandemic8 and dropped to 8% four months later.9

0196-6553/$36.00 - Copyright Ó 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
doi:10.1016/j.ajic.2011.05.023
 M. Fakhry et al. / American Journal of Infection Control 40 (2012) 320-3
Fig 1. Configuration of the audible hand hygiene reminder. The green symbols are alcohol-based hand rub dispensers.
One of the WHO’s objectives for future research is the imple-
mentation and evaluation of individual multimodal hand hygiene
intervention components.1 A study investigating improved re-
minders at individual patient room entrances found a significant in-
crease in alcohol-based hand rub use and reduced health
careeassociated infection rates, but did not establish the effect on
visitors or at hospital ward entrances.10
In this article, we report the effectiveness of an electronic
motion sensoretriggered audible hand hygiene reminder in
increasing the use of alcohol-based hand rub by visitors and health
care workers at the entrances to hospital wards.
METHODS
We conducted a preinterventional and postinterventional study
over an 8-month period in one hospital. Local infection prevention
and control guidelines already promoted the use of alcohol-based
hand rub by visitors and health care workers through the Intranet
and posters. Two clinical researchers directly observed visitors and
hospital staff entering and exiting wards via 4 separate doors to
measure their adherence to hand hygiene guidelines using alcohol-
based hand rub placed at each entrance. The researchers disguised
their observations by pretending to be waiting for the elevator
(Fig 1). Any hand hygiene attempt, regardless of technique, at the
moment of entering or exiting the ward was rated as adherence. The
designation of the subject (visitor, doctor, nurse, physiotherapist, or
nonclinical staff) was recorded. Observations were completed over
three 15-minute periods during the day. The preintervention phase
took place over 2 months from November to December 2009, and
the postintervention phase extended for 6 months from January to
June 2010. No other hand hygiene interventions were implemented
during the study period.
Implementation of the intervention involved the installation of
electronic motion sensoretriggered audible hand hygiene reminders
(Technical Initiatives UK, Essex, UK). The motion sensors and
321
speakers were located in the ceiling in the corridor outside the ward
entrances. The audible alert sounded the following message: “Please
clean your hands with hand rub dispensers when entering or exiting
any clinical ward.” Alcohol-based hand rub dispensers had already
been installed by the doors. After activation, the alert deactivated for
20 seconds. The entire system comprised 4 motion sensors and 3
speakers, cost $500, and was installed in half a day.
The resulting data were first analyzed to compare hand hygiene
adherence during the preintervention and postintervention phases.
Then the preintervention phase and the second half of the post-
intervention phase were compared to detect sustained improve-
ments in adherence. The percentage adherence values are calculated
from the numerator, consisting of the number of hand hygiene
opportunities used, and the denominator, consisting of the total
number of hand hygiene opportunities. We used Pearson’s c2 to test
binomial data (a ¼ 0.05, 2-tailed). All analyses were carried out using
SPSS version 18 (SPSS Inc, Chicago, IL).
This study was granted approval from the Imperial Healthcare
National Health Service Trust’s Audit Department.
RESULTS
A total of 2,863 hand hygiene opportunities were observed
during 54 periods over the entire 8-month study period, including
706 opportunities in the preintervention phase and 2,157 oppor-
tunities in the postintervention phase. Visitors were the most
frequently observed subject group (Table 1).
Overall, hand hygiene adherence increased from 7.6% to 49.9%
(P < .001). Adherence increased from 10.6% to 63.7% in visitors
(P < .001), from 4.5% to 38.3% in doctors (P < .001), from 5.4% to
43.4% in nurses (P < .001); from 8.7% to 49.5% in physiologists (P <
.001), and from 5.3% to 34.8% in nonclinical staff (P < .001). The
effect was immediate in visitors and nonclinical staff and gradual
in clinical staff, including doctors, nurses, and physiotherapists.
322 M. Fakhry et al. / American Journal of Infection Control 40 (2012) 320-3

Table 1
Results

Before-and-after Adaptation

Hand hygiene Hand hygiene

Number of Number of Hand hygiene Hand hygiene P value, adherence adherence, P value before
opportunities opportunities adherence adherence before first 3 months of second 3 months and after second
Subject before after before, % after, % and after intervention, % of intervention, % 3 months
Doctor 111 393 4.5 38.3 <.001 37.3 45.5 <.001
Nurse 56 381 5.4 43.4 <.001 45.2 34.5 <.001
Physiologist 69 384 8.7 49.5 <.001 49.2 50.9 <.001
Nonclinical staff 188 585 5.3 34.8 <.001 36.9 9.7 .341
Visitor 282 1,120 10.6 63.7 <.001 64.9 52.5 <.001
Overall 706 2,157 7.6 49.9 <.001 51.0 42.1 <.001

room by 8.2%, from 19.1% to 27.3%.10 In another study, placement of

Fig 2. Effect of audible reminder on hand hygiene adherence.
Improved adherence was sustained among visitors and clinical staff
(P < .001), but not among nonclinical staff (P ¼ .341) (Fig 2).
DISCUSSION
This is the first report of the effectiveness of an electronic motion
sensoretriggered audible reminder aimed at increasing the hand
hygiene adherence of hospital ward visitors. This interventional study
includes data on nearly 3,000 hand hygiene opportunities at the
entrances to hospital wards. Before the intervention, the overall rate
of hand hygiene adherence was 7.6%. After the intervention, the
overall rate of hand hygiene adherence increased by 42.3%. Although
this was a significant improvement, and more substantial than that
from any other ward or patient room entrance hand hygiene inter-
vention reported thus far, hand hygiene was still not performed on
half of the occasions when it was indicated. Comparing the second
half of the intervention phase with the preintervention phase
revealed that nonclinical staff was the only group of subjects whose
improved adherence to hand hygiene was not sustained. This group
was composed mainly of porters. Adherence to hand hygiene is
known to vary among professional groups.11,12 The identification of
a motivated champion and an engaged leader has been shown to
correlate with the success of hand hygiene interventions.13 The
feeling of being observed, the belief of being a role model, a positive
attitude toward hand hygiene, and a low workload are associated
with adherence to hand hygiene guidelines.14 These factors may need
to be addressed to promote sustained benefits of this intervention in
nonclinical staff.
Our results compare favorably with those for other hand
hygiene interventions reported previously. In one study, an elec-
tronically activated audible hand hygiene reminder improved
adherence to hand hygiene guidelines after leaving the patient’s
a conspicuous red sign at a surgical ward entrance increased hand
hygiene from 24% to 62%, an improvement of 38%.15 Comprehensive
multimodal interventions have reported improvements in hand
hygiene adherence of 18%-74.9%, along with significant reductions
in the rates of health careeassociated infections.16-20
The WHO recommends reminders including posters, leaflets, and
screensavers as part of a multimodal hand hygiene intervention.21
The present study has evaluated a novel reminder. The electronic
motion sensoretriggered audible hand hygiene reminder does not
require education or training and is rapidly deployable, inexpensive,
and immediately effective.
The WHO’s five moments2 are hand hygiene guidelines for the
bedside, which are important for preventing the transmission of
health careeassociated infection by health care workers. This inter-
vention was not tested at the bedside, and thus its effectiveness in
improving adherence to the WHO’s five moments is unknown. An
audible reminder may not be appropriate inside a ward; however,
a motion sensoretriggered visual message has been implemented
successfully and might be suitable for this purpose.10 The efficacy of
this intervention on the transmission of pathogens has not been
tested; however, complete adherence to hand hygiene guidelines
may reduce health careeassociated infections by 40%.22
We have shown that an electronic motionesensor triggered
audible hand hygiene reminder can significantly improve adher-
ence to hand hygiene guidelines. This intervention may be most
suitable for helping prevent the transmission of epidemic infec-
tions to and from health care environments.
Acknowledgment
We thank Amal Mohamed, clinical assistant at Charing Cross
Hospital, for collecting data in the latter period of the study. We
acknowledge the support of the Centre for Patient Safety and
Service Quality, which is funded by the National Institute of Health
Research, the Centre for Infection Prevention and Management,
which is funded by the UK Clinical Research Collaboration and the
Biomedical Research Centre at Imperial College London.
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