PRACTICE IMPROVEMENT
KEEP IT CLEAN: A VISUAL APPROACH TO
REINFORCE HAND HYGIENE COMPLIANCE IN THE
EMERGENCY DEPARTMENT
Authors: Lynn L. Wiles, PhD, MSN, RN, CEN, Chris Roberts, BSN, RN, CEN, and Kim
Schmidt, BSN, RN, Norfolk and Virginia Beach, VA
Problem: Although hand hygiene strategies significantly reduce
health care–associated infections, multiple studies have docu-
mented that hand hygiene is the most overlooked and poorly
performed infection control intervention.
Methods: Emergency nurses and technicians (n = 95) in a 41-bed
emergency department in eastern Virginia completed pretests and
posttests, an education module, and two experiential learning
activities reinforcing hand hygiene and infection control protocols.
Results: Posttest scores were significantly higher than pretest
scores (t (108) = –6.928, P = .048). Hand hygiene compliance
and hygiene (HH) is considered the most crucial H measure for
preventing the spread of infection, yet studies document that HH is the
most overlooked and poorly performed infection control intervention,1
with a
2 The reduction of HAIs is a major objective outlined in
median compliance rate of 40%. Health care–associated
infections (HAIs) claim more lives annually than do AIDS,
3 8
breast cancer, and motor vehicle crashes combined. HAIs
occur during the course of receiving treatment in health
4 5
care settings and affect 5% of all hospitalized patients or
6
1.7 million people annually, resulting in 99,000 deaths. In
Lynn L. Wiles, Member, Tidewater Chapter, is Assistant Professor, Old
Dominion University School of Nursing, Norfolk, VA, and Per-diem Staff
Nurse, Sentara Virginia Beach General Hospital, Virginia Beach, VA.
Chris Roberts, Member, Tidewater Chapter, is Nurse Manager, Sentara
Virginia Beach General Hospital, Virginia Beach, VA.
Kim Schmidt, Member, Tidewater Chapter, is Director of Emergency
Services, Sentara Virginia Beach General Hospital, Virginia Beach, VA.
This research project was supported in part by a grant from the Old
Dominion University Research Foundation, Norfolk, VA.
For correspondence, write: Lynn L. Wiles, PhD, MSN, RN, CEN, 4608
Hampton Blvd, Norfolk, VA 23529; E-mail: lwiles@odu.edu.
J Emerg Nurs ■.
0099-1767
Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
http://dx.doi.org/10.1016/j.jen.2014.11.012
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rates improved at the conclusion of the project and 3
months after the study (F (2, 15) = 9.89, P = .002).
Implications for Practice: Interfaces with staff as they
completed the interactive exercise, as well as anecdotal
notes collected during the study, identified key times when
compliance suffered and offered opportunities to further
improve hand hygiene and, ultimately, patient safety.
Keywords: Infection control; UV light technology;
Experiential learning; Hand hygiene
2008, HAIs were classified as preventable complications
that preclude hospitals from receiving reimbursement from
7
the Centers for Medicare and Medicaid Services.
The Joint Commission’s Center for Transforming Healthcare
report. This report, along with documented low national
HH compliance rates and unacceptable HAI rates, establishes
the need for ongoing staff education and compliance
monitoring. It has been suggested that “a multi-faceted
intervention, including use of feedback, education, the
introduction of alcohol-based hand wash, and visual
9
reminders” may effectively improve HH compliance. A pilot
study implemented by investigators in the University of
California, San Francisco, neurological ICU used video
surveillance monitors and tickertape feedback to improve HH.
Findings indicate that HH compliance in the rooms with the
near–real-time feedback significantly exceeded the HH
10
compliance in rooms that were not monitored.
Because almost 40% of hospital admissions stem from
the patients who make approximately 119 million annual ED
11
visits, ED staff have a unique opportunity to decrease HAI
rates by improving HH compliance. Compliance can be
improved by implementing Centers for Disease Control and
Prevention (CDC) infection control guidelines as patients
enter the health care system. The purpose of this project was
to increase staff awareness about HH guidelines and improve
HH compliance rates in the emergency department.
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PRACTICE IMPROVEMENT/Wiles et al

A seminal study conducted almost a decade ago
suggested that “clean” activities such as taking vital signs,
shaking hands, or touching an area higher in organism growth
like the groin can contaminate nurses’ hands with 100 to 1000
12
colony-forming units of Klebsiella species. Similarly, one
study documented health care records as a source of bacterial
transmission; investigators found that bacteria can survive on
paper for up to 4 days and be transferred from paper to hands
13
to clean paper. Another study suggested that 63% of nurses’
uniforms were contaminated with pathogens, including
14
antibiotic-resistant microorganisms. Moreover, 92% of the
curtains in patient rooms in ICUs and medical/surgical units
were contaminated within 7 days of being washed and
harbored potential pathogens, including methicillin-resistant
Staphylococcus aureus (21%), vancomycin-resistant
enterococ-cus (42%), and other gram-negative rods, including
15
entero-coccus species or S aureus (66%). During each
patient encounter, health care workers are exposed to
organisms that can be transmitted from patient to patient or
health care worker to health care worker if proper HH
recommendations are not followed.
Traditional education and social pressures to perform
HH have not provided sustained improvements in HH
compliance. Educational interventions that provoke fear for
personal safety or disgust may be the most effective method
16
to improve HH compliance. Kolb’s experiential learning
theory served as the theoretical framework for this study
because it focuses on using concrete, skill-based learning
17
experiences to reinforce didactic content. Based on Kolb’s
tenets, the experiential learning activity was designed with the
expectation that simulation of spreading microorganisms
would allow ED staff to immediately see the spread they
caused. We believe that this approach has a more lasting
impact than didactic learning alone because this strategy
significantly improves nursing students’ understanding of and
18
compliance with HH protocols.
3.What changes in HH compliance occur as a result of
the learning activities?
This project took place in the 41-bed emergency
department of a 276-bed acute care hospital that is accredited
in trauma, stroke, and cardiac care. The hospital is located in
a resort city in the mid-Atlantic region of the United States.
All 95 ED RNs and technicians were invited to take part.
Participation was voluntary, and no demographic data were
collected. Completion of the online pretest implied consent.
Human subjects’ protection approval was obtained prior
to the project. Baseline HH knowledge was established using
a 25-question online pretest. Next, volunteers participated in
an experiential learning activity in which they applied Glo
19
Germ lotion (Glo Germ Company, Moab, UT) to their own
hands and, after it dried, performed HH as per their usual
routine. Researchers then shined an ultraviolet (UV) light on
the participants’ hands, providing a visual represen-tation of
the effectiveness of their HH and the spread of the Glo Germ
throughout the hand-washing area. As needed, researchers
reinforced the HH guidelines for staff who did not comply
with CDC recommendations. In addition, during selected
shifts, researchers placed a small amount of microsphere
20
powder (Cospheric LLC, Santa Barbara, CA) in common
locations (eg, telephone, computer mouse area, point of care
testing machines, and fax machine) throughout the emergency
department (Figure 1). After 2 to 4 hours, the ED spaces and
equipment were photographed using UV light. At the next
monthly staff meeting, staff viewed a presentation that
showed the spread of the microsphere powder throughout the
emergency department and rein-forced the need to comply
with HH guidelines. Proper

Methods

The purpose of this descriptive pretest-posttest quality

improvement project was to evaluate the impact of an
experiential hand-washing learning activity and
simulated infectious disease spread activity on ED
clinical staff’s knowledge of HH guidelines and
adherence to HH protocols in an ED work environment.
The following specific research questions were asked:
1.What is the baseline knowledge of the ED staff related
to HAIs and the CDC HH guidelines?
2.What changes in the knowledge of the ED staff FIGURE 1
related to HAIs and the CDC HH guidelines occur Ultraviolet photograph showing the spread of microsphere powder on a mouse
after the learning activities? and mouse pad.

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techniques for using alcohol-based foam/gel and HH practices
were again reviewed. Finally, participants completed the
online posttest that was identical to the pretest.
Two measures were used for this study: the pretest/
posttest knowledge assessment and the hospital’s audit tool
used to collect HH compliance data. Pretest and posttest
questions were developed from content found on the public
domain CDC Web site and the University of Miami-Jackson
Memorial Hospital Center Web site (used with permission).
This 25-item survey included 22 true/false statements and 3
multiple-choice items about HH, HAI, standard precautions,
and transmission-based precautions. HH compliance data are
routinely collected by hospital staff internal and external to
the emergency department. These audits covered all shifts,
including weekdays and weekends. Auditors categorize HH
opportunities as soap and water or alcohol foam events and
document whether the correct procedure was followed.
SPSS software version 21 (IBM Corp, Armonk, NY) was
used to analyze the data. Only aggregate group comparisons
were used to indicate the organizational changes that
occurred. The number of subjects from the pretest and
posttest were described as counts and measures of central
tendency for the test items. The Assessment Score Reliability
(KR-20) was 0.63 for the pretest and 0.70 for the posttest. The
change in scores between pretest and posttest was analyzed
using an independent t test for the entire cohort. Testing for
statistical significance of HH compliance data was performed
using analysis of variance (ANOVA) comparing baseline, end
of study, and 3-month follow-up data. Ninety-five percent
confidence intervals were calculated for key parameters.
Results
Fifty-nine clinical staff members completed the pretest, and
51 completed the posttest. Staff demographics were not
collected to help maintain anonymity. Scores for the pretest
ranged from 60 to 95 with a mean of 82.6 (standard deviation
[SD] = 8). Posttest scores ranged from 80 to 100 with a mean
of 91.7 (SD = 5.5). An independent-samples t test was
conducted to evaluate the hypothesis that pretest scores would
be different than posttest scores. The test was significant, with
t (108) = –6.928 and P = .048 using Levene’s test of
inequality to compensate for unequal sample sizes. Compared
with baseline knowledge, clinical staff knowledge about
current CDC HH guidelines increased significantly after
completing the learning activities.
HH compliance rates were also compared. The mean HH
compliance rates in this emergency department were higher than
the nationwide mean at baseline (70%), the conclusion of the
study (84%), and 3 months after the study (81%). A one-
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Wiles et al/PRACTICE IMPROVEMENT
way ANOVA was conducted to evaluate the relationship
between HH compliance rates prior to the study, at the
conclusion of the study, and 3 months after the study. This
finding was significant (F (2, 15) = 9.89, P = .002). Follow-up
tests were conducted to evaluate pairwise differences among
the means. The Tukey HSD test showed a statistically
significant increase in both baseline to end of study HH
compliance rates (P = .002) and baseline and follow-up HH
compliance rates (P = .0012). The difference between the end
of study and follow-up HH compliance rates (P = .645) were
not significant, suggesting that postintervention HH compli-
ance was sustained 3 months after completion of the project.
In addition to the increase in overall HH compliance,
documented spikes in HH compliance were linked with the 2
experiential learning activities (Figure 2). The first spike
occurred as the staff participated in the Glo Germ HH activity
that included visual reinforcement of hand and sink area
contamination. The second spike, and one that produced
sustained HH compliance rates, occurred after the micro-
sphere powder photographs showing contamination through-
out the emergency department (Figures 3, 4, and 5) were
shared at the staff meetings. The increase in HH compliance
after visual reinforcement of gaps in HH practices supports
the study premise that a multifaceted intervention with visual
reminders would be more effective at producing results than
didactic education and verbal reminders alone.
Overall, HH compliance rates for this emergency
department exceeded national averages; however, better than
average HH compliance is not our goal. Providing a safe
environment and minimizing patient harm (ie, reducing HAIs)
require more than 80% compliance with CDC guidelines.
Nurses who collected HH data made anecdotal comments
identifying breaks in HH compliance. One gap repeatedly
observed was that staff did not follow HH protocols when
removing equipment (eg, IV carts or rolling laptops) or
specimens from patients’ rooms. Because alcohol foam soap
dispensers are located outside patient rooms, HH monitors
were able to track staff activities until the equipment was
returned to its proper location and to look for HH completion
at that time, as well as when the staff exited the room.
Auditors also noted that when staff used soap and water, often
the length of time they spent hand washing did not comply
with CDC recommendations, and staff were observed turning
off water with their clean hands rather than with a dry paper
towel. A final behavior observed was that nurses with fewer
than 5 years of experience were more likely than the more
experienced nurses to demonstrate correct soap and water
procedures and to verbalize the superior effectiveness of
alcohol foam over soap and water in most patient care
instances. The necessity of using soap and water for patients
with actual or suspected Clostridium difficile was
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PRACTICE IMPROVEMENT/Wiles et al
FIGURE 2
Hand hygiene (HH) compliance compared with visual reinforcement activities.
common knowledge for ED nurses but not for the ED
technicians. These identified gaps in knowledge and
practice were addressed with all staff during the debriefing
meetings when study results and photographs were shared.
In the debriefing meetings, staff stated that the most
effective components of this intervention were the visual
ones. The HH activity where individuals viewed their hands
after performing soap and water HH showed staff where
potential bacteria lingered—especially in rings, around
fingernails, and on their wrists. Several staff had Glo Germ
spread to their faces from touching their skin or from water
splashes while washing. When visualizing the sink area using
the UV light, staff noted that the soap dispensers and
FIGURE 3
Ultraviolet photograph showing the spread of microsphere powder to an ED i-
stat machine.
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sink handles were covered with Glo Germ and that there was
residual splash on the side and back walls and, on one
occasion, on the top of an empty pizza box 2 feet away on the
same counter. Likewise, the photographs showing the
biosphere spread that occurred during the study made staff
feel “filthy,” “gross,” “disgusted,” and “contaminated.” Some
staff members got up during the presentation to wash their
hands. These comments and actions reinforce the premise that
educational interventions that provoke fear for personal safety
or disgust may be the most effective method to improve HH
16
compliance and support Kolb’s experi-ential learning theory
that visual reminders that show the
FIGURE 4
Ultraviolet photograph showing the spread of microsphere powder to an ED keyboard.
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FIGURE 5
Ultraviolet photograph showing the spread of microsphere powder to a ED
computer mouse.
impact of HH noncompliance on personal health and
safety are very effective educational tools.
Limitations of this study included the use of a
convenience sample, and thus caution should be used
relative to generalizing study results to the larger nursing
and ED technician population. Although pretests and
posttests were anonymous, some staff may have chosen
not to participate in the study based on the belief that they
could be identified. An unequal number of staff completed
the pretest and posttest, and researchers cannot verify that
the same staff completed both assessments. Finally,
because the sample was limited to clinical staff, findings
cannot be generalized to other providers.
Implications for Practice
This project reveals several opportunities to improve HH
compliance. Decreased compliance rates were observed when
staff entered and exited the rooms while transporting equipment.
Specimen bags have been placed on the IV cart, which permits
staff to place specimens in bags prior to leaving the bedside. This
approach frees staffs’ hands to perform HH when exiting patients’
rooms. The Cal Stat Plus alcohol-based gel dispensers (Steris
Corp, Mentor, OH) cannot be placed on the rolling laptops
because of life safety standards set forth by the Det Norske
Veritas (DNV) accrediting body but will be added to all rolling
carts (eg, IV, gynecologic, central line, and suture) to facilitate
HH. Additional dispensers have been placed throughout the
emergency department for the
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Wiles et al/PRACTICE IMPROVEMENT
convenience of staff in the high noncompliance areas
revealed during this study.
Additionally, based on the identified ease with which
organisms can spread, other options are being explored. For
example, the emergency department has purchased 3
washable keyboards that can be submerged or wiped with
Virex wipes(Virex MSDS, Sturtevant, Wisconsin). Keyboard
covers have been placed on all nonwashable keyboards and
will be used until these keyboards can be replaced. Staff are
encouraged to wipe down the keyboards, as well as phones
and other pieces of equipment, at each shift change.
All new clinical staff will participate in the Glo Germ
HH experience and complete HH computer-based training
module available on the hospital Web site. Continued visual
reinforcement with Glo Germ and the microsphere powder
will be used as needed by analyzing HH data routinely
collected by the Quality Improvement Committee.
Conclusion
HH compliance has a direct impact on patient safety and
thus, in combination with infection control practices, is a
focus of The Joint Commission’s Center for Transforming
Healthcare report. The increase in HH compliance after
this project supports use of multifaceted interventions to
produce increased HH compliance rates. As the portal for
nearly 40% of admitted patients, the emergency depart-
ment and ED staff have a key role in implementing
effective HH practices when patients enter health care
systems. Providing education, identifying gaps in practice,
and brainstorming solutions to address department-specific
challenges are key strategies for improving HH
compliance in a fast-paced environment.
Acknowledgments
We thank Dr Mona Wicks for her guidance and review
of the manuscript and Dr Miyong Kim for her statistical
analysis assistance.
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