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CE Article: Talking trash may help improve hand hygiene*

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After reading this article, you will be able to:
  • Identify two types of infection control (IC) data collection
  • Compare the advantages and disadvantages of the various types of IC data collection methods
  • Construct an IC plan incorporating appropriate methods of IC
  • Identify the benefits of hand hygiene compliance at your facility

If you want to know how well your staff members are complying with hand hygiene recommendations, you might want to check the trash.

Following the lead of other organizations, including the University of Pennsylvania, the Washington State Hospital Association (WSHA) has seen a 35% improvement in hand hygiene compliance by asking its member hospitals to track hand sanitizer and soap use by counting discarded bottles, says Carol Wagner, RN, MBA, vice president of patient safety for the Seattle-based association. For more information on hand washing with soap and water, click here.

The program began in 2005 when the association went looking for an evidence-based hand hygiene program and found it in the "Safe Table," a WSHA-sponsored forum where representatives from hospitals of all sizes gather to share best practices.

The bottle drive idea came out of those discussions. The program, voluntary for members and once driven by hospital infection control practitioners (ICP), now includes physician office representatives.

The program is appealing for many reasons, says Wagner. "One advantage to this program is that it's the only 24-hour-a-day, seven-day-a-week measurement," she explains. The program also allows for consistency among hospitals, something that is difficult to achieve through direct observation of hand hygiene compliance alone. And it gives the association a mechanism to report numbers back to the participating hospitals, providing data about the hospital as a whole and offering compliance figures for individual units.

Additionally, participating hospitals generally undertake bottle tracking in conjunction with other hand hygiene efforts, such as direct observation, education, and training.

How it works

To participate in the program, a hospital must count the amount of soap and hand sanitizers it uses at the facility. Then it must measure the number of discarded bottles against the patient census to give an accurate picture of use.

Facilities must track all bottles, from soap housed in wall dispensers to the small bottles of hand sanitizer carried by nurses in their pockets, Wagner says. "It is challenging sometimes to get some of the bottles," she adds.

The counting process is so challenging that at least one Washington hospital has opted out of the program, deciding instead to perform only direct observation of hand hygiene compliance--at least for the time being.

Sarah Smith, an ICP at Evergreen Healthcare in Kirkland, WA, says that although many organizations have had great results with the hospital association program, her facility experienced a lot of problems getting nurses to collect empty containers.

The facility had set up bins in utility rooms to collect discarded bottles and would count them each week. "We thought this wouldn't be hard at all," she says.

But they kept seeing bottles discarded in the trash rather than in the bins, and the numbers that were coming back didn't seem to match up with what observations were telling them.

Rather than wrangle with the process, the facility decided to rely exclusively on hand hygiene observation--a tactic many of the hospital association participants use in addition to the bottle counts.

Smith says the hospital may revisit the program once it has tweaked some of its systems to make it easier to do the counts accurately.

Tracking may require an innovative approach

Other hospitals have found ways to get past the counting challenge. Hospitals perform the counts differently, says Wagner. Some use housekeeping staff members to keep track of hand hygiene product usage. At other facilities, it's the ICP that tracks bottles.

The University of Washington Medical Center (UWMC) in Seattle has taken a different approach. Instead of counting bottles on the way out, it tracks the ones coming in by monitoring purchasing.

"Hand hygiene is considered to be the most important IC measure," says Estella Whimbey, MD, associate professor of medicine at the University of Washington School of Medicine, associate medical director at UWMC, medical director of healthcare epidemiology at UWMC/Seattle Cancer Care Alliance, and medical director of the Employee Health Center at UWMC. "The question always comes up, 'How can you prove that you're actually being compliant with the recommendations as issued by the CDC or WHO?' " she says. For a hand hygiene guideline fact sheet from the CDC, click here.

Whimbley's facility's answer has been to use a combination of methods.

"We began counting bottles back in 2001, even before the hospital association embarked on its initiative," she says. For most of that time, the facility has tracked purchases, but it did switch to counting empty bottles for a little more than a year, she says.

The facility switched back to the purchase method because counting the empty bottles was labor-intensive. "We didn't really gain any additional information," she adds.

However, tracking the purchases can be a difficult measure as well because hospitals don't buy a daily supply; they buy for the month or several months at a time, says Whimbey. It's also difficult to pinpoint where problems exist. For example, is a particular staff member not in compliance, or several staff members?

But tracking bottles used does allow the facility to get a rough idea of where it stands as far as hand hygiene compliance. Similar to other facilities participating in the initiative, the hospital uses direct observation to hone its numbers.

"Direct observation is the gold standard," says Whimbey, but that method also has its limitations, including the following:

  • It's labor- and resource-intensive
  • It's usually done only during certain hours and on certain units
  • People often modify their behavior when they know they are being observed

"I think the most important thing is to get out there and be on the wards. Talk to people, educate and train them. Observe them and make corrections by coaching and giving them feedback on what is appropriate and how to do it," says Whimbey.

Reinforce with education

Another critical component of any hand hygiene program is education. Ongoing education is key to a successful program, says Whimbey. For some additional materials that will help promote hand hygiene in your facility, click here.

Regardless of how facilities have chosen to adapt the hospital association initiative, the effort has had much success in raising awareness about hand hygiene among healthcare workers and the public, says Wagner. "The ICPs in the state have been so dedicated to this issue," she says. The education that has been provided through the initiative has made strides to improve care for patients.

"What affects hand hygiene compliance is intensive education and training and building a culture of safety for the patients. Everyone must buy into wanting to give the patients the safest possible care in the hospital," says Whimbey.

Source: Briefings on Infection Control, March 2008, HCPro, Inc.


  1. "Washing Hands with Soap and Water." Minnesota Department of Public Health. Available at
  2. "Hand Hygiene Guidelines Fact Sheet." Centers for Disease Control and Prevention. Available at
  3. "Materials to Promote Hand Hygiene in Your Healthcare Facility." Centers for Disease Control and Prevention. Available at

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