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

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American Journal of Infection Control American Journal of

Infection Control

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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
Department of Surgery and Cancer, Imperial College London, London, UK
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
transmission of epidemic infections to or from health care environments.
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 which include before and after touching a patient and after
health care workers to hand hygiene guidelines, with the goal of touching a patient’s surroundings.2 The hand hygiene guidelines
reducing health careeassociated infections. Multimodal interven- from the Centers for Disease Control and Prevention and the WHO
tions include adequate provision of alcohol-based hand rub and mandate that alcohol-based hand rub sanitizers be made available
soap and water, training and education, evaluation and feedback of at the entrance to patient rooms or other convenient locations.3,4 If
performance, provision of workplace reminders, and a culture of patients are not confined to single rooms, then the entrance to
safety.1 Visitors may transmit epidemic infections and are not patient rooms is synonymous with the entrance to the ward. This
primarily targeted by multimodal interventions. The present study represents the last doorway passed through before touching
was initiated in response to the H1N1 influenza pandemic of 2009. a patient and the first doorway passed through after touching
There is a need for an effective, rapidly deployable, yet inexpensive a patient or a patient’s surroundings. Even though this is not
intervention aimed at improving the adherence of visitors to hand strictly one of the WHO’s five moments, 28% of hospitals in the
hygiene guidelines to prevent the transmission of epidemic infec- Republic of Ireland currently provide alcohol-based hand rub
tions to or from health care environments without the need for sanitizers at the entrance to every ward.5 This convenient location
education or training. for hand hygiene is used by visitors more often than sanitizer
The World Health Organization’s (WHO) “Five Moments for located at patient bedsides, and accounts for 21% of all alcohol-
Hand Hygiene” are recommended indications for hand hygiene, 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
* Address correspondence to George B. Hanna, PhD, FRCS, 10th Floor QEQM
Building, St Mary’s Hospital, London W2 1NY, UK.
at the entrance to a New Zealand hospital during the H1N1 influ-
E-mail address: (G.B. Hanna). enza pandemic; the use of sanitizer rose to 18% during the
Conflict of interest: None to report. 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.
M. Fakhry et al. / American Journal of Infection Control 40 (2012) 320-3 321

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

Table 1

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

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
Fig 2. Effect of audible reminder on hand hygiene adherence. 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
Improved adherence was sustained among visitors and clinical staff successfully and might be suitable for this purpose.10 The efficacy of
(P < .001), but not among nonclinical staff (P ¼ .341) (Fig 2). this intervention on the transmission of pathogens has not been
tested; however, complete adherence to hand hygiene guidelines
DISCUSSION may reduce health careeassociated infections by 40%.22
We have shown that an electronic motionesensor triggered
This is the first report of the effectiveness of an electronic motion audible hand hygiene reminder can significantly improve adher-
sensoretriggered audible reminder aimed at increasing the hand ence to hand hygiene guidelines. This intervention may be most
hygiene adherence of hospital ward visitors. This interventional study suitable for helping prevent the transmission of epidemic infec-
includes data on nearly 3,000 hand hygiene opportunities at the tions to and from health care environments.
entrances to hospital wards. Before the intervention, the overall rate
of hand hygiene adherence was 7.6%. After the intervention, the Acknowledgment
overall rate of hand hygiene adherence increased by 42.3%. Although
this was a significant improvement, and more substantial than that We thank Amal Mohamed, clinical assistant at Charing Cross
from any other ward or patient room entrance hand hygiene inter- Hospital, for collecting data in the latter period of the study. We
vention reported thus far, hand hygiene was still not performed on acknowledge the support of the Centre for Patient Safety and
half of the occasions when it was indicated. Comparing the second Service Quality, which is funded by the National Institute of Health
half of the intervention phase with the preintervention phase Research, the Centre for Infection Prevention and Management,
revealed that nonclinical staff was the only group of subjects whose which is funded by the UK Clinical Research Collaboration and the
improved adherence to hand hygiene was not sustained. This group Biomedical Research Centre at Imperial College London.
was composed mainly of porters. Adherence to hand hygiene is
known to vary among professional groups.11,12 The identification of References
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