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Measuring Healthcare Worker Hand Hygiene Activity: Current Practices and Emerging Technologies

Published online by Cambridge University Press:  02 January 2015

John M. Boyce*
Affiliation:
Yale University School of Medicine, New Haven, Connecticut
*
1450 Chapel Street, New Haven, CT 06511 (jboyce@srhs.org)

Abstract

Monitoring hand hygiene compliance and providing healthcare workers with feedback regarding their performance are considered integral parts of multidisciplinary hand hygiene improvement programs. Observational surveys conducted by trained personnel are currently considered the “gold standard” method for establishing compliance rates, but they are time-consuming and have a number of shortcomings. Monitoring hand hygiene product consumption is less time-consuming and can provide useful information regarding the frequency of hand hygiene that can be used to give caregivers feedback. Electronic counting devices placed in hand hygiene product dispensers provide detailed information about hand hygiene frequency over time, by unit and during interventions. Electronic hand hygiene monitoring systems that utilize wireless systems to monitor room entry and exit of healthcare workers and their use of hand hygiene product dispensers can provide individual and unit-based data on compliance with the most common hand hygiene indications. Some systems include badges (tags) that can provide healthcare workers with real-time reminders to clean their hands upon entering and exiting patient rooms. Preliminary studies suggest that use of electronic monitoring systems is associated with increased hand hygiene compliance rates and that such systems may be acceptable to care givers. Although there are many questions remaining about the practicality, accuracy, cost, and long-term impact of electronic monitoring systems on compliance rates, they appear to have considerable promise for improving our efforts to monitor and improve hand hygiene practices among healthcare workers.

Type
Review Articles
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2011

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References

1. Boyce, JM, Pittet, D, and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings. MMWR Morb Mortal Wkly Rep 2002;51(RR-16):145.Google Scholar
2. World Health Organization. WHO guidelines on hand hygiene in health care. Geneva: World Health Organization; 2009. http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf. Accessed August 10, 2011.Google Scholar
3. Haas, JP, Larson, EL. Measurement of compliance with hand hygiene. J Hosp Infect 2007;66:614.Google Scholar
4. Boyce, JM. Hand hygiene compliance monitoring: current perspectives from the USA. J Hosp Infect 2008;70(suppl 1):27.Google Scholar
5. Gould, DJ, Chudleigh, J, Drey, NS, Moralejo, D. Measuring hand-washing performance in health services audits and research studies. J Hosp Infect 2007;66:109115.Google Scholar
6. Gould, DJ, Drey, NS, Creedon, S. Routine hand hygiene audit by direct observation: has nemesis arrived? J Hosp Infect 2011; 77:290293.Google Scholar
7. Pittet, D, Mourouga, P, Perneger, TV, Members of the Infection Control Program. Compliance with handwashing in a teaching hospital. Ann Intern Med 1999;130:126130.Google Scholar
8. Pittet, D, Hugonnet, S, Harbarth, S, Mourouga, P, Sauvan, V, Touveneau, S. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000;356:13071312.CrossRefGoogle ScholarPubMed
9. Dedrick, RE, Sinkowitz-Cochran, RL, Cunningham, C, et al. Hand hygiene practices after brief encounters with patients: an important opportunity for prevention. Infect Control Hosp Epidemiol 2007;28:341345.Google Scholar
10. Wendt, C, Knautz, D, von Baum, H. Differences in hand hygiene behavior related to the contamination risk of healthcare activities in different groups of healthcare workers. Infect Control Hosp Epidemiol 2004;25:203206.Google Scholar
11. Eveillard, M, Hitoto, H, Raymond, F, et al. Measurement and interpretation of hand hygiene compliance rates: importance of monitoring entire care episodes. J Hosp Infect 2009;72: 211217.CrossRefGoogle ScholarPubMed
12. Mertz, D, Dafoe, N, Walter, SD, Brazil, K, Loeb, ME. Effect of a multifaceted intervention on adherence to hand hygiene among health-care workers: a cluster-randomized trial. Infect Control Hosp Epidemiol 2010;31:11701176.Google Scholar
13. Allegranzi, B, Sax, H, Bengaly, L, et al. Successful implementation of the World Health Organization hand hygiene improvement strategy in a referral hospital in Mali, Africa. Infect Control Hosp Epidemiol 2010;31:133141.Google Scholar
14. Marjadi, B, McLaws, ML. Hand hygiene in rural Indonesian healthcare workers: barriers beyond sinks, hand rubs and in-service training. J Hosp Infect 2010;76:256260.CrossRefGoogle ScholarPubMed
15. Nthumba, PM, Stepita-Poenaru, E, Poenaru, D, Cluster-randomized, crossover trial of the efficacy of plain soap and water versus alcohol-based rub for surgical hand preparation in a rural hospital in Kenya. Br J Surg 2010;97:16211628.CrossRefGoogle Scholar
16. Owusu-Ofori, A, Jennings, R, Burgess, J, Prasad, PA, Acheampong, F, Coffin, SE. Assessing hand hygiene resources and practices at a large African teaching hospital. Infect Control Hosp Epidemiol 2010;31:802808.Google Scholar
17. Larson, EL, Norton Hughes, CA, Pyrak, JD, Sparks, SM, Cagatay, EU, Bartkus, JM. Changes in bacterial flora associated with skin damage onhands of health care personnel. Am J Infect Control 1998;26:513521.Google Scholar
18. Gould, D, Ream, E. Assessing nurses' hand decontamination performance. Nurs Times 1993;89:4750.Google ScholarPubMed
19. Larson, E. Compliance with isolation technique. Am J Infect Control 1983;11:221225.Google Scholar
20. Zimakoff, J, Stormark, M, Larsen, SO. Use of gloves and hand-washing behaviour among health care workers in intensive care units: a multicentre investigation in four hospitals in Denmark and Norway. J Hosp Infect 1993;24:6367.Google Scholar
21. Buffet-Bataillon, S, Leray, E, Poisson, M, et al. Influence of job seniority, and hygiene education, and patient-to-nurse ratio on hand disinfection compliance. J Hosp Infect 2010;76:3235.CrossRefGoogle ScholarPubMed
22. Bischoff, WE, Reynolds, TM, Sessler, CN, et al. Handwashing compliance by health-care workers: the impact of introducing an accessible, alcohol-based hand antiseptic. Arch Intern Med 2000;160:10171021.Google Scholar
23. van de Mortel, T, Murgo, M. An examination of covert observation and solution audit as tools to measure the success of hand hygiene interventions. Am J Infect Control 2006;34:9599.Google Scholar
24. Marra, AR, Moura, DF, Paes, AT, et al. Measuring rates of hand hygiene adherence in the intensive care setting: a comparative study of direct observation, product usage, and electronic counting devices. Infect Control Hosp Epidemiol 2010;31:796801.Google Scholar
25. Bittner, MJ, Rich, EC, Turner, PD, Arnold, WH Jr. Limited impact of sustained simple feedback based on soap and paper towel consumption on the frequency of hand washing in an adult intensive care unit. Infect Control Hosp Epidemiol 2002;23: 120126.Google Scholar
26. Tibballs, J. Teaching hospital medical staff to handwash. Med J Aust 1996;164:395398.CrossRefGoogle ScholarPubMed
27. Harbarth, S, Pittet, D, Grady, L, et al. Interventional study to evaluate the impact of an alcohol-based hand gel in improving hand hygiene compliance. Pediatr Infect Dis J 2002;21:489495.CrossRefGoogle ScholarPubMed
28. Pittet, D, Simon, A, Hugonnet, S, Pessoa-Silva, CL, Suvan, V, Perneger, TV. Hand hygiene among physicians: performance, believes, and perceptions. Ann Intern Med 2004;141:18.Google Scholar
29. Maury, E, Moussa, N, Lakermi, C, Barbut, F, Offenstadt, G. Compliance of health care workers to hand hygiene: awareness of being observed is important. Intensive Care Med 2006;32: 20882089.CrossRefGoogle ScholarPubMed
30. Kohli, E, Ptak, J, Smith, R, et al. Variability in the Hawthorne effect with regard to hand hygiene performance in high- and low-performing inpatient care units. Infect Control Hosp Epidemiol 2009;30:222225.CrossRefGoogle ScholarPubMed
31. Eckmanns, T, Bessert, J, Behnke, M, Gastmeier, P, Ruden, H. Compliance wtih antiseptic hand rub use in intenstive care units: the Hawthorne effect. Infect Control Hosp Epidemiol 2006;27:931934.Google Scholar
32. Dhar, S, Tansek, R, Toftey, EA, et al. Observer bias in hand hygiene compliance reporting. Infect Control Hosp Epidemiol 2010;31:869870.Google Scholar
33. Rosenthal, T, Erbeznik, M, Padilla, T, Zaroda, T, Nguyen, DK, Rodriguez, M. Observation and measurement of hand hygiene and patient identification improve compliance with patient safety practices. Acad Med 2009;84:17051712.CrossRefGoogle ScholarPubMed
34. Randle, J, Arthur, A, Vaughan, N. Twenty-four-hour observational study of hospital hand hygiene compliance. I Hosp Infect 2010;76:252255.CrossRefGoogle ScholarPubMed
35. Sax, H, Allegranzi, B, Uckay, I, Larson, E, Boyce, J, Pittet, D. “My five moments for hand hygiene”: a user-centred design approach to understand, training, monitor and report hand hygiene. J Hosp Infect 2007;67:921.CrossRefGoogle ScholarPubMed
36. Sax, H, Allegranzi, B, Chraiti, M-N, et al. The World Health Organization hand hygiene conservation method. Am J Infect Control 2009;37:827834.Google Scholar
37. World Health Organization. Clean care is safer care, http://www.who.int/gpsc/5may/en/. Accessed April 17, 2011.Google Scholar
38. McAteer, J, Stone, S, Fuller, C, et al. Development of an observational measure of health-care worker hand-hygiene behaviour: the hand-hygiene observation tool (HHOT). J Hosp Infect 2008;68:222229.Google Scholar
39. Hlady, CS, Severson, MA, Segre, AM, Polgreen, PM. A mobile handheld computing application for recording hand hygiene observations. Infect Control Hosp Epidemiol 2010;31:975977.CrossRefGoogle ScholarPubMed
40. Kahlert, C, Schoebi, B, Goldinger, S, Schlegel, M. Mobile electronic monitoring, with instantaneous analysis of adherence to hand hygiene procedures in ten Swiss hospitals. Presented at the 50th Interscience Conference on Antimicrobial Agents and Chemotherapy, September 12, 2010, Boston, MA. Abstract K-513.Google Scholar
41. Bittle, MJ, LaMarche, S. Engaging the patient as a server to promote hand hygiene compliance in ambulatory care. Jt Comm J Qual Patient Saf 2009;35:519525.Google Scholar
42. McGuckin, M, Waterman, R, Porten, L, et al. Patient education model for increasing handwashing compliance. Am J Infect Control 1999;27:309314.Google Scholar
43. McGuckin, M, Waterman, R, Storr, IJ, et al. Evaluation of a patient-empowering hand hygiene programme in the UK. J Hosp Infect 2001;48:222227.Google Scholar
44. Longtin, Y, Sax, H, Leape, LL, Sheridan, SE, Donaldson, L, Pittet, D. Patient participation: current knowledge and applicability to patient safety. Mayo Clinic Proc 2010;85:5362.Google Scholar
45. Larson, E, McGinley, KJ, Grove, GL, Leyden, JJ, Talbot, GH. Physiologic, microbiologic, and seasonal effects of handwashing on the skin of health care personnel. Am J Infect Control 1986;14: 5159.Google Scholar
46. O'Boyle, CA, Henly, SJ, Larson, E. Understanding adherence to hand hygiene recommendations: the theory of planned behavior. Am J Infect Control 2001;29:352360.CrossRefGoogle ScholarPubMed
47. Larson, EL, Aiello, A, Cimiotti, JP. Assessing nurses' hand hygiene practices by direct observation or self-report. J Nurs Measur 2004;12:7789.Google Scholar
48. Moret, L, Tequi, B, Lombrail, P. Should self-assessment methods be used to measure compliance with handwashing recommendations? a study carried out in a French university hospital. Am J Infect Control 2004;32:384390.Google Scholar
49. Jenner, EA, Fletcher, BC, Watson, P, Jones, FA, Miller, L, Scott, GM. Discrepancy between self-reported and observed hand hygiene behaviour in healthcare professionals. J Hosp Infect 2006;63:418422.Google Scholar
50. Johnson, PDR, Martin, R, Burell, LJ, et al. Efficacy of an alcohol/ chlorhexidine hand hygiene program in a hospital with high rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection. Med J Austr 2005;183:509514.Google Scholar
51. Muller, A, Denizot, V, Mouillet, S, et al. Lack of correlation between consumption of alcohol-based solutions and adherence to guidelines for hand hygiene. J Hosp Infect 2005;59: 163164.Google Scholar
52. Boyce, JM, Ligi, C, Kohan, C, et al. Lack of association between an increased incidence of Clostridium difficile-associated disease and the increasing use of alcohol-based hand rubs. Infect Control Hosp Epidemiol 2006;27:479483.Google Scholar
53. Eckmanns, T, Schwab, F, Bessert, J, et al. Hand rub consumption and hand hygiene compliance are not indicators of pathogen transmission in intensive care units. J Hosp Infect 2006;63: 406411.Google Scholar
54. Eldridge, NE, Woods, SS, Bonello, RS, et al. Using the six sigma process to implement the Centers for Disease Control and Prevention Guideline for Hand Hygiene in 4 intensive care units. J Gen Intern Med 2006;21:S35S42.Google Scholar
55. Pessoa-Silva, CL, Dharan, S, Hugonnet, S, et al. Dynamics of bacterial hand contamination during routine neonatal care. Infect Control Hosp Epidemiol 2004;25:192197.Google Scholar
56. Harrington, G, Watson, K, Bailey, M, et al. Reduction in hospitalwide incidence of infection or colonization with methicillin-resistant Staphylococcus aureus with use of antimicrobial hand-hygiene gel and statistical process control charts. Infect Control Hosp Epidemiol 2007;28:837844.Google Scholar
57. Somner, JEA, Scott, KM, Gibb, AP. What is the optimum location of alcohol-based hand cleanser? Infect Control Hosp Epidemiol 2007;28:108109.Google Scholar
58. Stone, S, Slade, R, Fuller, C, et al. Early communication: does a national campaign to improve hand hygiene in the NHS work? initial English and Welsh experience from the NOSEC study (National Observational Study to Evaluate the Clean Your Hands Campaign). J Hosp Infect 2007;66:293296.CrossRefGoogle Scholar
59. Ebnother, C, Tanner, B, Schmid, F, et al. Impact of an infection control program on the prevalence of nosocomial infections at the tertiary care center in Switzerland. Infect Control Hosp Epidemiol 2008;29:3843.Google Scholar
60. Marra, AR, D'Arco, C, de Arruda Bravim, B, et al. Controlled trial measuring the effect of a feedback intervention on hand hygiene compliance in a step-bound unit. Infect Control Hosp Epidemiol 2008;29:730735.Google Scholar
61. Vernaz, N, Sax, H, Pittet, D, et al. Temporal effects of antibiotic use in hand rub consumption on the incidence of MRSA and Clostridium difficile . J Antimicrob Chemother 2008;62:601607.Google Scholar
62. Scheithauer, S, Faefher, H, Schwanz, T, et al. Compliance with hand hygiene nonsurgical, medical, and urologic intensive care units: direct observation versus calculate the disinfectant usage. Am J Infect Control 2009;37:835841.CrossRefGoogle Scholar
63. Thomas, BW, Berg-Copas, GM, Vasquez, DG, et al. Conspicuous versus customary location of hand hygiene agents dispensers on alcohol-based hand hygiene product usage in an intensive care unit. J Am Osteopath Assoc 2009;109:263267.Google Scholar
64. Grammatico-Guillon, L, Thiolet, J-M, Bernillon, P, et al. Relationship between the prevalence of methicillin-resistant Staphylococcus aureus infection and indicators of nosocomial infection control measures: a population-based study in French hospitals. Infect Control Hosp Epidemiol 2009;30:861869.Google Scholar
65. Kaier, K, Hagist, C, Frank, U, et al. Two time-series analyses of the impact of antibiotic consumption and alcohol-based hand disinfection on the incidences of nosocomial methicillin-resistant Staphylococcus aureus infection and Clostridium difficile infection. Infect Control Hosp Epidemiol 2009;30:346353.Google Scholar
66. Kaier, K, Frank, U, Hagist, C, et al. The impact of antimicrobial drug consumption and alcohol-based hand rub use on the emergence and spread of extended-spectrum beta-lactamase-producing strains: a time-series analysis. J Antimicrob Che-mother 2009;63:609614.Google Scholar
67. Herud, T, Nilsin, RM, Svendheim, K, et al. Association between use of hand hygiene products and rates of health-care-associated infections in a large uiversity hospital in Norway. Am J Infect Control 2009;37:311317.CrossRefGoogle Scholar
68. Pantle, AC, Fitzpatrick, KR, McLaws, ML, et al. A statewide approach to systematizing hand hygiene behavior in hospitals: clean hands save lives. Pt 1. Med J Aust 2009;191(suppl 8): S8S12.Google Scholar
69. Ananda-Rajah, MR, McBryde, ES, Buising, KL, et al. The role of general quality improvement measures in decreasing the burden of endemic MRSA in a medical-surgical intensive care unit. Intensive Care Med 2010;36:18901898.CrossRefGoogle Scholar
70. Cheng, VCC, Tai, JWM, Chan, WM, et al. Sequential introduction of single room isolation and hand hygiene campaign in the control of Memphis one-resistant Staphylococcus aureus in intensive care unit. BMC Infect Dis 2010;10:263.CrossRefGoogle Scholar
71. Marra, AR, Reis Guastelli, L, Pereira de Araujo, CM, et al. Positive deviance: a new strategy for improving hand hygiene compliance. Infect Control Hosp Epidemiol 2010;31:1220.Google Scholar
72. Benning, A, Dixon-Woods, M, Nwulu, U, et al. Multiple complement patient safety intervention in English hospitals: controlled evaluation of second phase. BMJ 2011;342:d199.Google Scholar
73. Kacelnik, O, Forland, OJ, Iversen, B. Evaluation of the national campaign to improve hand hygiene in nursing homes in Norway. J Hosp Infect 2011;77:359360.CrossRefGoogle ScholarPubMed
74. Magiorakos, AP, Leens, E, Drouvot, V, et al. Pathways to clean hands: highlights of successful hand hygiene implementation strategies in Europe. Euro Surveill 2010;15(pii)19560.Google Scholar
75. Carlet, J, Astagneau, P, Brun-Buisson, C, et al. French national program for prevention of health-care-associated infections and antimicrobial resistance, 1992-2008: positive trends, but perseverance needed. Infect Control Hosp Epidemiol 2009;30: 737745.Google Scholar
76. Jarlier, V, Trystram, D, Brun-Buisson, C, et al. Curbing methicillin-resistant Staphylococcus aureus and 38 French hospitals through a 15-year institutional control program. Arch Intern Med 2010;170:552559.CrossRefGoogle ScholarPubMed
77. Sroka, S, Gastmeier, P, Meyer, E. Impact of alcohol hand-rub use on methicillin-resistant Staphylococcus aureus: an analysis of the literature. J Hosp Infect 2010;74:204211.CrossRefGoogle ScholarPubMed
78. McGuckin, M, Taylor, A, Martin, V, Porten, L, Salcido, R. Evaluation of a patient education model for increasing hand hygiene compliance in an inpatient rehabilitation unit. Am J Infect Control 2004;32:235238.Google Scholar
79. McGuckin, M, Waterman, R, Govednik, J. Hand hygiene compliance rates in the United States: a one-year multicenter collaboration using products/volume usage measurement and feedback. Am J Med Qual 2009;24:205213.Google Scholar
80. Larson, EL, Early, E, Cloonan, P, Sugrue, S, Parides, M. An organizational climate intervention associated with increased handwashing and decreased nosocomial infections. Behav Med 2000;26:1422.Google Scholar
81. Larson, EL, Albrecht, S, O'Keefe, M. Hand hygiene behavior in a pediatric emergency department and a pediatric intenstive care unit: comparison of 2 dispenser systems. Am J Crit Care 2005;14:304311.Google Scholar
82. Kinsella, G, Thomas, AN, Taylor, RJ. Electronic surveillance of wall-mounted soap and alcohol gel dispensers in an intensive care unit. J Hosp Infect 2007;66:3439.CrossRefGoogle Scholar
83. Boyce, JM, Cooper, T, Dolan, MJ. Evaluation of an electronic device for real-time measurement of alcohol-based hand rub use. Infect Control Hosp Epidemiol 2009;30:10901095.Google Scholar
84. Boyce, JM, Cooper, T, Arbogast, JW, et al. Use of electronic devices to detect changes in hand hygiene frequency during their early H1N1 influenza outbreak and during the trial of a new alcohol hand sanitizer formulation. Fifth Decennial: In-ternational Conference on Healthcare-Associated Infections, March 2010, Atlanta, GA. Abstract 270.Google Scholar
85. Chan, BP, Homa, KA, King, GG, et al. Maximizing health-care worker hand hygiene: a study of the optimal number and location of alcohol-based hand rub dispensers. Fifth Decennial: International Conference on Healthcare-Associated Infections, March 2010, Atlanta, GA. Abstract 737.Google Scholar
86. Steed, C, Kelly, JW, Blackhurst, D, et al. Hospital hand hygiene opportunities: where and when (HOW2)? the HOW2 bench-mark study. Am J Infect Control 2011;39:1926.Google Scholar
87. Swoboda, SM, Earsing, K, Strauss, K, Lane, S, Lipsett, PA. Electronic monitoring and voice prompts improve hand hygiene and decrease nosocomial infections in an intermediate care unit. Crit Care Med 2004;32:358363.Google Scholar
88. Venkatesh, AK, Lankford, MG, Rooney, DM, et al. Use of electronic alerts to enhance hand hygiene compliance and decrease transmission of vancomycin-resistant Enterococcus in a human ecology unit. Am J Infect Control 2008;36:199205.Google Scholar
89. Sahud, AG, Bhanot, N, Radhakrishnan, A, et al. An electronic hand hygiene surveillance device: a pilot study exploring surrogate markers for hand hygiene compliance. Infect Control Hosp Epidemiol 2010;31:634639.Google Scholar
90. Polgreen, PM, Hlady, CS, Severson, MA, et al. Method for automated monitoring of hand hygiene adherence with our radiofrequency identification. Infect Control Hosp Epidemiol 2010; 31:12941297.Google Scholar
91. Edmond, MB, Goodell, A, Zuelzer, W, et al. Successful use of alcohol sensor technology to monitor and report and hygiene compliance. J Hosp Infect 2010;76:364365.Google Scholar
92. Granado-Villar, D, Simmonds, B. Utility of an electronic monitoring and reminder system for enhancing hand hygiene practices in a pediatric oncology unit. Presented at the 21st Scientific Meeting of the Society for Healthcare Epidemiology of America, April 2, 2011, Dallas, TX. Abstract 63.Google Scholar
93. Cheng, VCC, Tai, JWM, Ho, Sky, et al. Introduction of an electronic monitoring system for monitoring compliance with Moments 1 and 4 of the WHO “My 5 Moments for Hand Hygiene” methodology. BMC Infect Dis 2011; 11:151.CrossRefGoogle ScholarPubMed
94. Levchenko, Al, Boscart, VM, Fernie, GR. The feasibility of an automated monitoring system to improve nurses' hand hygiene. Int J Med Inform 2011;80:596603, doi.org/10.1016/j.ijmedinf.2011.04.002.Google Scholar
95. Stewardson, A, Sax, H, Longet-Di Pietro, S, Pittet, D. Impact of observation and analysis methodology when reporting hand hygiene data. J Hosp Infect 2011;77:358359.CrossRefGoogle ScholarPubMed
96. Davis, CR. Infection-free surgery: how to improve hand-hygiene compliance and eradicate methicillin-resistant Staphylococcus aureus from surgical wards. Ann R Coll Surg Engl 2010;92:316319.Google Scholar
97. Armellino, D, Farber, B, Hussain, E, et al. The effect of real-time remote video monitoring with feedback on health-care worker hand hygiene in critical care. 49th Interscience Conference on Antimicrobial Agents and Chemotherapy, September 13, 2009, San Francisco, CA. Abstract K-518.Google Scholar
98. Farber, B, Armellino, D, Schilling, M, et al. Hand hygiene and remote video auditing: the halo effect. 50th Interscience Conference on Antimicrobial Agents and Chemotherapy, September 12, 2010, Boston, MA. Abstract K-511.Google Scholar
99. Boscart, VM, Levchenko, Al, Fernie, GR, et al. Defining the configuration of a hand hygiene market system. Am J Infect Control 2010;38:518522.CrossRefGoogle Scholar
100. Boscart, VM, McGilton, KS, Levchenko, A, et al. Acceptability of a wearable hand hygiene device with monitoring capabilities. J Hosp Infect 2008;70:216222.Google Scholar