Maximizing Healthcare Worker Hand Hygiene: A Study of the Optimal Number and Location of Alcohol Based Hand Rub Dispensers

Background: Hand hygiene (HH) prevents hospital associated infections (HAI), but HH compliance has remained unacceptably low among healthcare workers (HCW). Alcohol based hand rub (ABHR) is widely used in healthcare settings due to its increased accessibility and tolerability over traditional hand washing and has led to improved HH compliance, but the optimal number and placement of ABHR dispensers to maximize HH is not known. Moreover, in the United States, restrictive fire codes limit the amount of ABHR allowable in healthcare settings.

Objective: To determine if increasing the number of ABHR dispensers in an inpatient unit increases HCW HH and to determine the most utilized dispenser locations.  

Methods: Our 6 month study took place in a 10 bed medical inpatient unit at an academic medical center. 13 wall-mounted ABHR dispensers with internal electronic counters were installed at the beginning of the study (1 dispenser in each single room and 3 in hallway locations near high use nursing areas); these counters triggered each time ABHR was dispensed. Daily HH event counts from each dispenser were collected and monitored using statistical process control charts. Once a stable baseline was obtained dispensers were systematically added, alternating additions between the inside of rooms and the hallway until there were 51 total dispensers (3 inside each room and 21 in the hallway). During the study period infection preventionists conducted routine observations of HH compliance.

Results: Local fire codes allow a maximum of 19 wall-mounted dispensers for this unit. At baseline, with 13 dispensers, the total number of daily HH events for the unit was 299. After 10 additional hallway dispensers were added the daily HH events increased 24% to 370 (p=0.01). The addition of more hallway or room dispensers was not associated with further increases in HH events. Changes in total unit count strongly correlated with changes in total hallway usage (R=0.85, p<0.001). Room dispensers mounted immediately inside the doorway were used more than dispensers near the end of the bed which were used more than dispensers mounted by the bathroom (75% vs. 19% vs. 6%, respectively). The hallway dispensers used most were those in high traffic areas and areas of HCW congregation. Observed HH compliance was 79% prior to beginning the study and 89-100% during the study.

Conclusions: Maximum ABHR usage occurred with dispensers in each room and in the hallway outside each room. Even this number of dispensers exceeded fire code limits, which may be too restrictive to allow optimal HH compliance. Our study suggests that electronic counters may be helpful in identifying optimal dispenser locations within a unit, and that location may be more critical than absolute number of dispensers. Further study of the impact of number and location of dispensers in units with lower initial HH compliance is needed.