My topic: Infection Control, My PICO(T) question: Does education on hand hygiene among healthcare workers increase the performance of hand hygiene in healthcare workers and reduce surgical site infections in postoperative surgical patients?

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Major Article
The impact of COVID-19 pandemic on hand hygiene performance
in hospitals
Lori D. Moore MPH, BS, RN a,
*, Greg Robbins BA b
, Jeff Quinn PhD c
, James W. Arbogast PhD d
a Clinical Educator, Healthcare, GOJO Industries, Akron, OH
b GOJO Industries, Akron, OH
c GOJO Industries, Akron, OH
d Hygiene Sciences & Public Health Advancements Vice President, GOJO Industries, Akron, OH
Background: Achieving high levels of hand hygiene compliance of health care personnel has been an ongoing
challenge. The objective of this study was to examine the impact of the COVID-19 pandemic on hand hygiene
performance (HHP) rates in acute care hospitals.
Methods: HHP rates were estimated using an automated hand hygiene monitoring system installed in 74
adult inpatient units in 7 hospitals and 10 pediatric inpatient units in 2 children’s hospitals. A segmented
regression model was used to estimate the trajectory of HHP rates in the 10 weeks leading up to a COVID19-related milestone event (eg, school closures) and for 10 weeks after.
Results: Three effects emerged, all of which were significant at P < .01. Average HHP rates increased from 46%
to 56% in the months preceding pandemic-related school closures. This was followed by a 6% upward shift at
the time school closures occurred. HHP rates remained over 60% for 4 weeks before declining to 54% at the
end of the study period.
Conclusions: Data from an automated hand hygiene monitoring system indicated that HHP shifted in multiple directions during the early stages of the pandemic. We discuss possible reasons why HHP first increased
as the pandemic began and then decreased as it progressed.
© 2020 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All
rights reserved.
Key Words:
Hand hygiene
Hand hygiene compliance
Hand hygiene monitoring
Electronic compliance monitoring
Automated hand hygiene monitoring
Hand hygiene is considered an important measure to prevent the
transmission of pathogens in health care facilities,1 and it is proven
that improving hand hygiene compliance significantly reduces health
care-acquired infections.2-4 Accordingly, hand hygiene has been recommended as an important strategy to help prevent the spread of
COVID-19 in hospitals.5
Monitoring hand hygiene compliance is considered a critical
aspect of an effective hand hygiene program.1,6 Data obtained can be
used to provide health care workers with feedback, to identify areas
within the hospital with poor hand hygiene compliance, and to evaluate the impact of targeted interventions.7 Gathering infection prevention data in the current environment may be challenging for most
health care facilities with resources being diverted to COVID-19 outbreak management. Process measures such as the direct observation
of hand hygiene compliance may also be compromised.8 Hospitals
with automated hand hygiene monitoring systems have an advantage during this pandemic with the ability to quickly gather robust
hand hygiene data with minimal investment of personnel time.
Effects of this pandemic in the United States are unprecedented with declarations of states of emergency, school closures,
postponement of elective surgeries and procedures, visitor
restrictions, restaurant closings, and stay-at-home quarantine
orders. School closures have attracted much attention, and it has
been estimated that those working in health care settings are
among those with the highest childcare obligations in the United
States with 28.5% of the health care workforce needing to provide
care for children aged 3-12 years.9
Little is known about the effects of national public health quarantine practices on hand hygiene compliance in hospitals. A literature
search did not reveal any studies reporting on hand hygiene compliance of health care workers in hospitals during the first pandemic of
the 21st century (influenza A/H1N1) or the current COVID-19 pandemic. A recent study of 2 pediatric hospital units during this pandemic did find that 100% hand hygiene compliance is achievable
(n = 72 health care workers),10 an encouraging finding.
* Address correspondence to Lori D. Moore, MPH, BS, RN, Healthcare, GOJO Industries, One GOJO Plaza, Suite 500, Akron, OH 44311
E-mail address: (L.D. Moore).
Funding: This study was internally funded by GOJO Industries.
Conflicts of interest: L.D.M., G.R., J.Q. and J.W.A. are employees of GOJO Industries.
0196-6553/© 2020 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
American Journal of Infection Control 49 (2021) 30−33
Contents lists available at ScienceDirect
American Journal of Infection Control
journal homepage:
The purpose of this study was to examine hand hygiene performance of health care workers in hospitals during a pandemic. To
determine if this pandemic would lead to changes in hand hygiene
behaviors, we needed to pick a point in time that might have been
related to behavioral changes. For this analysis, we chose school closures because they occurred during the same week for all hospitals in
the study.
Data analyzed in this study were captured from January 5 to May
23, 2020, utilizing data from the PURELL SMARTLINK Activity Monitoring System installed in 9 US hospitals. Elements of this system,
including the validation process, have previously been described.11,12
Outpatient units, including 2 emergency departments, were excluded
from the study. Final analysis included data from 74 adult inpatient
units in 7 hospitals (2 Academic, 4 Federal Veterans Administration,
and 1 Community) and 10 pediatric inpatient units in 2 children’s
hospitals (Academic); see data by hospital in Figure 1. Alcohol-based
hand rub and soap dispensers recorded each actuation as a hand
hygiene event. Activity monitors placed near each patient room doorway detected each entry into and exit from the room as a hand
hygiene opportunity. Data captured by dispensers and activity monitors were sent to a secure cloud-based server that stored the information at the device level. Unit level hand hygiene performance rates (a
proxy or estimate of compliance) were calculated by dividing events
by opportunities.
Statistical analyses were conducted to determine whether hand
hygiene performance differed before and after the time schools were
closed due to the pandemic. First, we computed mean values of
opportunities, dispense events, and performance rates for the periods
before and after school closures and used t tests to determine
whether these values differed significantly. In addition, we performed a segmented regression analysis13 to examine changes in
hand hygiene performance rates longitudinally, week by week. This
approach allowed us to test for significant increasing or decreasing
trends in hand hygiene performance in the weeks prior to the school
closures, at the time the school closures occurred, and in the weeks
following the school closures. For each of these 3 periods, we report
the rate of change in hand hygiene performance rate (ie, the slope of
the regression line for each segment, represented by ß) and an
estimate of the variability of the data around the slope (standard
error, SE), which are used to calculate the t statistic (t = ß/SE) used to
test for statistical significance.
Data from the 9 hospitals were aggregated, resulting in a dataset
containing 18,457,669 dispense events and 35,362,136 hand hygiene
opportunities. We computed weekly mean values for both dispense
events and hand hygiene opportunities. Analyses compared data
from the 10 weeks before the time of the school closures (the week
beginning January 5 through the week beginning March 8) with the
10-week period after school closures (the week beginning March 15
through the week beginning May 17). The week of March 15 is when
schools closed in the states where the 9 hospitals are located. Events,
opportunities, and average performance rates by week for all 9 hospitals combined are shown in Table 1.
The 2 time periods we examined (before school closures and after
school closures) did show significant differences. The weekly mean
number of hand hygiene opportunities decreased dramatically from
2,153,702 (standard deviation [SD] = 45,407) prior to the school closures to 1,382,512 (SD = 107,999) after the school closures, t
(12.09) = 20.82, P < .001. Weekly dispense events also decreased
from 1,044,060 (SD = 42,102) prior to the school closures to 801,707
(SD = 79,922) after the school closures, t(13.64) = 8.48, P < .001.
Although both opportunities and dispenses decreased, hand hygiene
performance rates increased from 48.52% (SD = 0.03) before the
school closures to 58.05% (SD = 0.04) after the school closures, t
(15.83) = 5.92, P < .001. Mean weekly opportunities, events, and
performance rates before and after school closures for all 9 hospitals
combined are shown in Table 2.
The pre- and post- t test analyses clearly demonstrated a difference in hand hygiene behavior before versus after the time when
school closures occurred. In addition, our rich data set enabled us to
dig deeper and better understand how and when hand hygiene
behavior changed over time. Specifically, we were able to examine
when the changes began and how long they lasted (whether
improvements in hand hygiene performance were fleeting or sustained). We used segmented regression analysis to track the trajectory of weekly performance rates over time providing an important
complement to the pre- and post- t test analyses. Segmented
Fig 1. Weekly opportunities (black bars), events (gray bars), and average performance rates (solid lines), for each hospital (2020).
L.D. Moore et al. / American Journal of Infection Control 49 (2021) 30−33 31
regression has been recommended as a powerful tool to measure
change in an outcome before and after an event of interest.14-16
Our regression model analyzed 3 segments of our longitudinal
data set. First, we tested for changes in performance rates within the
pre-test section of the data (the 10 weeks before the week when
school closures occurred). As can be seen in Figure 2, this first segment of the model was characterized by a statistically significant
increasing slope, ß = 0.008, SE = 0.002, t = 3.85, P < .01. Performance
rates were fairly consistent from week 1 to week 8 and then began to
increase in weeks 9 and 10. This shows that performance rates were
beginning to increase before the event of interest (school closures).
The second segment of the model shows a significant upward shift
in the level of performance rates between our pre- and post-test data,
ß = 0.13, SE = 0.02, t = 8.18, P < .001. This is depicted in Figure 2 as the
large spike in performance rates that occurred between week 10 and
week 11 (the week of school closures).
Finally, the third segment in the model, which tested for changes
in performance rates within the post-test section of the data (Fig 2,
weeks 11-20), showed a significant decrease in performance rates
over time, ß = 0.02, SE = 0.003, t = 7.33, P < .001. Performance rates
remained higher than 60% during the first 4 weeks of the post-school
closure period before declining significantly. By week 20, performance rates were still higher than the rates during weeks 1-8 of the
study but were lower than the peak performance rate which occurred
2 weeks after the week of school closures.
To our knowledge, examination of hand hygiene performance in
hospitals during a pandemic utilizing an automated hand hygiene
monitoring system has not been previously reported. In this study,
over 35 million hand hygiene opportunities were captured over the
20-week period. Hand hygiene performance rates seen in weeks 1-8
represent typical performance in 2020. Performance reached higher
than typical levels during the initial period of pandemic-related hospital and public health prevention measures (including school closures), however, began to decline. Even during pandemic conditions,
it appears to be difficult to sustain improvements in hand hygiene
A significant increase in hand hygiene performance was associated with the timing of school closures for all 9 hospitals (the
week of March 15). Possible factors for the spike in performance
include: 1) increased emphasis on the importance of hand
hygiene, 2) significant decrease in opportunities (workload) making higher performance more achievable, 3) decrease in the room
entries and exits from visitors and patients (non-health care
workers), and 4) heightened perception of risk to health care
workers themselves and their families. Perception of risk is of
particular interest. COVID-19 has received significant media
attention which can amplify perceptions of personal risk.17 Health
care workers may have improved their hand hygiene behaviors,
in part, to protect themselves and their family members. Previous
studies have reported self-protection as a major driver of hand
hygiene among health care workers.18-22
The finding of decreased hand hygiene opportunities (patient
room entries and exits) was not unexpected. It is likely due to visitor
restrictions and decreased patient census (eg, a result of postponement of elective surgeries and procedures). Additionally, bundling of
nursing activities to decrease unnecessary patient room entries and
exits and conservation of hand hygiene products and personal protective equipment may also have played a role.
Several hypotheses are possible for the most recent decrease in
performance rates (weeks 14-20 as compared to weeks 11-13). Possible contributing factors include increase in workload as opportunities
for hand hygiene increased,23 concerns over limited supplies of hand
hygiene products,20,24 use of gloves in lieu of hand hygiene,24,25 and
less frequent direct observation/reminders8 from nurse managers
and infection prevention leaders due to competing pandemic-related
Further study can include analysis of data over an extended
period of time to determine if increased hand hygiene will become
the new normal or resemble a campaign that drives an increase but
is not sustained due to lack of a multimodal, long-term program.6
Comparison of hand hygiene performance rates between hospitals
with comparison of the various unit types and COVID-patient census
may also provide insight into the impact of this pandemic on hand
hygiene in hospitals. Consideration can also be given to examining
Table 1
Summary of events, opportunities, and average performance rates by week, all 9 hospitals combined (2020)
Week Events Opportunities Performance rate
Jan 5 1,017,778 2,218,295 45.88%
Jan 12 1,011,360 2,177,610 46.44%
Jan 19 1,007,001 2,140,575 47.04%
Jan 26 1,036,834 2,182,270 47.51%
Feb 2 1,049,858 2,194,350 47.84%
Feb 9 1,032,560 2,149,565 48.04%
Feb 16 1,024,031 2,121,889 48.26%
Feb 23 1,031,279 2,157,718 47.79%
Mar 1 1,083,439 2,140,848 50.61%
Mar 8 1,146,462 2,053,898 55.82%
Mar 15 1,015,528 1,633,575 62.17%
Mar 22 835,286 1,306,496 63.93%
Mar 29 804,211 1,257,569 63.95%
Apr 5 784,709 1,301,234 60.30%
Apr 12 758,830 1,316,023 57.66%
Apr 19 772,837 1,375,098 56.20%
Apr 26 761,382 1,425,334 53.42%
May 3 740,776 1,350,726 54.84%
May 10 755,317 1,396,337 54.09%
May 17 788,191 1,462,726 53.89%
Total 18,457,669 35,362,136
Shaded area denotes the weeks after school closures.
Table 2
Mean weekly opportunities, events, and performance rates before and after school closures, all 9 hospitals combined
Before school closures After school closures P value
Opportunities 2,153,702 1,382,512 <.001
Events 1,044,060 801,707 <.001
Performance rates 48.52% 58.05% <.001
School closures occurred the week of March 15, 2020.
Fig 2. Segmented regression analysis of performance rates over time, all 9 hospitals
Shaded area denotes the weeks after school closures.
32 L.D. Moore et al. / American Journal of Infection Control 49 (2021) 30−33
the impact of visitor restrictions and reintroduction of visitors on
opportunities and performance rates by hospital.
We are currently in uncharted territory with much to be learned.
Hand hygiene is a key factor in reducing germs that can potentially
cause disease. Monitoring hand hygiene performance with direct
observation may continue to present challenges for many hospitals
throughout this pandemic. As we move forward, hospitals may benefit from implementing technology to gather hand hygiene data and
evaluate behaviors.
Thank you to the Hospitals for being early adopters of automated
hand hygiene monitoring in an effort to improve hand hygiene and
for paving the way for other hospitals. Thank you to Megan DiGiorgio,
Pamela T. Wagner, Tracy Clark, Maria Thompson for providing clinical
support and editorial input.
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