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Unit-Specific Rates of Hand Hygiene Opportunities in an Acute-Care Hospital

  • Angela Han (a1) (a2), Laurie J. Conway (a3), Christine Moore (a2), Liz McCreight (a2), Kelsey Ragan (a2), Jannice So (a2), Emily Borgundvaag (a2), Mike Larocque (a2), Brenda L. Coleman (a4) (a5), Allison McGeer (a2) (a4) and the MSH Infection Control and Hand Hygiene Observer Teams...



To explore the frequency of hand hygiene opportunities (HHOs) in multiple units of an acute-care hospital.


Prospective observational study.


The adult intensive care unit (ICU), medical and surgical step-down units, medical and surgical units, and the postpartum mother–baby unit (MBU) of an academic acute-care hospital during May–August 2013, May–July 2014, and June–August 2015.


Healthcare workers (HCWs).


HHOs were recorded using direct observation in 1-hour intervals following Public Health Ontario guidelines. The frequency and distribution of HHOs per patient hour were determined for each unit according to time of day, indication, and profession.


In total, 3,422 HHOs were identified during 586 hours of observation. The mean numbers of HHOs per patient hour in the ICU were similar to those in the medical and surgical step-down units during the day and night, which were higher than the rates observed in medical and surgical units and the MBU. The rate of HHOs during the night significantly decreased compared with day (P<.0001). HHOs before an aseptic procedure comprised 13% of HHOs in the ICU compared with 4%–9% in other units. Nurses contributed >92% of HHOs on medical and surgical units, compared to 67% of HHOs on the MBU.


Assessment of hand hygiene compliance using product utilization data requires knowledge of the appropriate opportunities for hand hygiene. We have provided a detailed characterization of these estimates across a wide range of inpatient settings as well as an examination of temporal variations in HHOs.

Infect Control Hosp Epidemiol 2017;38:411–416


Corresponding author

Address correspondence to Laurie J. Conway, RN, PhD, CIC, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 130–155 College Street, Toronto, ON M5T 1P8, Canada (


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1. Boyce, JM, Pittet, D. Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR 2002;51(RR-16):145; quiz CE41-454.
2. Erasmus, V, Daha, TJ, Brug, H, et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol 2010;31:283294.
3. Mahida, N. Hand hygiene compliance: are we kidding ourselves? J Hosp Infect 2016;92:307308.
4. Brouqui, P, Aladro, AS. Alcohol hand rub consumption objectives in European hospitals need to be revisited. Clin Microbiol Infect 2016;22:577.
5. Boyce, JM. Measuring healthcare worker hand hygiene activity: current practices and emerging technologies. Infect Control Hosp Epidemiol 2011;32:10161028.
6. WHO guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care. World Health Organization website. Published 2009. Accessed February 29, 2016.
7. Haas, JP, Larson, EL. Measurement of compliance with hand hygiene. J Hosp Infect 2007;66:614.
8. Eckmanns, T, Bessert, J, Behnke, M, Gastmeier, P, Ruden, H. Compliance with antiseptic hand rub use in intensive care units: the Hawthorne effect. Infect Control Hosp Epidemiol 2006;27:931934.
9. Srigley, JA, Furness, C, Baker, GR, Gardam, M. Quantification of the hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study. BMJ Qual Safety 2014;23:974980.
10. Hagel, S, Reischke, J, Kesselmeier, M, et al. Quantifying the Hawthorne effect in hand hygiene compliance through comparing direct observation with automated hand hygiene monitoring. Infect Control Hosp Epidemiol 2015;36:957962.
11. Azim, S, Juergens, C, Hines, J, McLaws, ML. Introducing automated hand hygiene surveillance to an Australian hospital: mirroring the HOW2 benchmark study. Am J Infect Control 2016;44:772776.
12. Goodliffe, L, Ragan, K, Larocque, M, et al. Rate of healthcare worker-patient interaction and hand hygiene opportunities in an acute care setting. Infect Control Hosp Epidemiol 2014;35:225230.
13. Steed, C, Kelly, JW, Blackhurst, D, et al. Hospital hand hygiene opportunities: where and when (HOW2)? The HOW2 Benchmark Study. Am J Infect Control 2011;39:1926.
14. Larson, EL, Albrecht, S, O’Keefe, M. Hand hygiene behavior in a pediatric emergency department and a pediatric intensive care unit: comparison of use of 2 dispenser systems. Am J Crit Care 2005;14:304312.
15. Scheithauer, S, Haefner, H, Schwanz, T, et al. Compliance with hand hygiene on surgical, medical, and neurologic intensive care units: direct observation versus calculated disinfectant usage. Am J Infect Control 2009;37:835841.
16. Scheithauer, S, Oude-Aost, J, Heimann, K, et al. Hand hygiene in pediatric and neonatal intensive care unit patients: daily opportunities and indication- and profession-specific analyses of compliance. Am J Infect Control 2011;39:732737.
17. Best practices for hand hygiene in all health care settings, 4th ed. Public Health Ontario website. Published 2010. Accessed April 22, 2016.
18. Just clean your hands: education, training and tools for hospitals. Public Health Ontario website. Published 2016. Accessed April 22, 2016.
19. Alper, PM, Allison, , Blackhurst, D, Boeker, S, Moore, C. Four moments for hand hygiene vs 5—what’s the actual difference? Poster presented at the 2015 IPAC Canada National Conference; June 15, 2015, Victoria, BC.
20. Diller, T, Kelly, JW, Blackhurst, D, Steed, C, Boeker, S, McElveen, DC. Estimation of hand hygiene opportunities on an adult medical ward using 24-hour camera surveillance: validation of the HOW2 benchmark study. Am J Infect Control 2014;42:602607.
21. Eliassen, KM, Hopstock, LA. Sleep promotion in the intensive care unit—a survey of nurses’ interventions. Intensive Crit Care Nurs 2011;27:138142.
22. Radtke, K, Obermann, K, Teymer, L. Nursing knowledge of physiological and psychological outcomes related to patient sleep deprivation in the acute care setting. Med Surg Nurs 2014;23:178184.
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