Huge increase in hand hygiene compliance to...32%!?!?

There is a lot of pressure on hospitals to improve hand hygiene compliance and it seems even more more pressure from industry to install expensive electronic hand hygiene monitoring systems. This investment might be worth it if (A) the systems accurately measure hand hygiene compliance and (B) are cost effective. One additional benefit claimed regarding these electronic hand hygiene surveillance systems (but not yet proven in the peer-reviewed literature) is that these "surveillance" systems actually improve compliance over the long haul.

Last year at IDWeek, John Boyce and colleagues presented results of a quasi-experimental study analyzed using high-quality statistical methods that showed that installation of an electronic "RTLS-based" monitoring system was associated with a 36% decline in entry compliance rate (p=0.191) and 32% decline in the exit compliance (p < 0.001). These declines in directly observed hand hygiene compliance may have been driven by the fact that the badge accuracy was only 60%. Note: it would be nice to see this study published in the peer-reviewed literature. 

Now there is new report out of the 2013 APIC conference assessing a similar system installed at the John Peter Smith Hospital in Fort Worth, Texas. The authors reported a "huge" increase in compliance from 16.5% to 31.7% over a 3-month study period. After the study period the compliance declined to 25.8%.  Some comments: (1) When your hand hygiene compliance rate is 16.5%, you could do almost anything to improve it. I would imagine having your hospital epidemiologist dress up as a clown while carrying around a bottle of hand rub would do it and doing nothing would probably do it too. That's called regression to the mean; (2) I know a 92% relative increase seems large, but when the high point is 32% compliance, I don't think headline writers and companies should get too excited and claim a "Huge increase." Humility and a call for action should probably take precedence over excitement; (3) A 19% relative decline in compliance from 31.7% to 25.8% after 3 months should give them pause, even if it's above baseline.

To sum up the current evidence, electronic hand hygiene monitoring systems may be more accurate than directly observed compliance, although the jury is still out. However, there is no evidence that these systems effectively or cost-effectively sustain hand hygiene compliance improvements. In fact, based on these two abstracts, the evidence appears just the opposite. There needs to be a lot more research and work put into these systems.

Image source: Uzbekistan Global Hand Washing Day (2012)


  1. Dear Eli,

    I can't agree with you more regarding the issue of hand hygiene and doctor/nurse compliance. My business partner and I came across this issue several years ago and started working on a system to improve the process. Our viewpoint is that even if we get people to wash their hands when they are supposed to, most of them don't do so correctly. Recent studies show that people scrub for about 8-10 seconds instead of the CDC recommended 20 seconds. This means that most people, even when washing their hands frequently, still leave over 50% of their hands dirty! To combat this we developed the Enforc Hygiene System. Our system requires people to maintain soap on their hands for the CDC recommended 20 seconds while at the same time educating them on the proper scrubbing technique. We believe this can have a great impact in healthcare, food-service, and education. Please visit our website and if you are willing please share our facebook page at

    We will be starting a crowdfunding campaign in the next 2-3 months and appreciate any help we can get spreading the word about our system and how it can help to reduce illnesses and save lives!

    Thank You


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