It’s an assumption some managers hear year after year: Practice and training are all it takes to ensure employees meet hand-hygiene standards.

But when they perform competency tests at skilled nursing facilities, a drop of UV-sensitive dye reveals an awkward truth. Many employees asked to wash with hand sanitizer are shocked at what they find when they place their hands under a black light.

“They go to use it, and they see they missed the tips of two fingers or a crevice,” says Betsy Staar, product manager for Medline’s Sterillium hand care line. “They say, ‘Wow. I really need to do a better job.’ ”

Proper hand-washing remains the frontline defense against infections in healthcare settings, according to the Centers for Disease Control and Prevention. New employees get the drill when hired, and almost all facilities provide annual training on how and when to wash with soap and water or alcohol-based sanitizers.

But the CDC says industry-wide compliance with these policies lags below 50%, a scary thought given that the spread of infectious agents risks patient and employee health, as well as facilities’ bottom lines.

Staar says many viruses have an extended shelf life. A few examples: norovirus, 7 days; MRSA, 7 months; E. coli, 16 months. 

C. diff alone is responsible for 263,000 nursing home infections annually, with $2.2 billion in excess healthcare and sanitation costs, according to a study cited by the Association for Professional in Infection Control and Epidemiology.

The Centers for Medicare & Medicaid Services continues to penalize facilities whose patients contract certain healthcare-associated infections, and hospitals aim to release their patients to long-term care facilities that have a low number of infections.

“Hand hygiene is not a ‘good-to-do’ thing anymore,” says Vicki Allen, MSN, RN, an infection prevention manager for CaroMont Health, which is based in Gastonia, NC. “It is an expectation to protect patient health and save the facilities money.”

In long-term care settings, employees report three major reasons for skipping mandated hand washes: lack of time, limited access and unhappiness with cleansers. Pam Wagner, RN, a clinical application specialist for GOJO, says it’s critical that administrators emphasize the importance of basic hand hygiene given that up to 15% of long-term care residents will acquire some type of infection annually.

“When I explain the guidelines, people say, ‘We’ve been taught to do that our whole lives, since we could stand up,’ ” Wagner says. “But that doesn’t mean it’s happening.”

Time investment

Compliance is time-consuming, with nurses in one study pausing to wash hands an average of 13 to 30 times a day. The length of these hygiene breaks depends largely on the products being used.

Between walking to a sink and washing, 10 nurses in the Emerging Infectious Diseases study spent 16 hours of their shared shift on hand hygiene. But if those same nurses obtained an alcohol-based product from a bedside dispenser, they would need just four hours per shift, researchers said.

A similar study estimates nurses spend 56 minutes washing with soap and water per eight-hour shift, compared to 18 minutes with alcohol-based products.

Staar says she’s often heard the “too busy” excuse. Medline’s Sterillium liquid requires a 2 mL pump for a 99.999% kill rate, while the same line’s gel product needs just a 1.2 mL dollop, company reps say. Similarly, GOJO’s Purell far exceeded the FDA standard with just 1.1 mL.

Other products require 3 mL to distribute enough alcohol to kill germs. But less product means less drying time, and may lead to higher compliance. Wagner says healthcare employees tell GOJO reps they want a product that absorbs in six to 10 seconds.

“The question is, how low can we go?” she says.

It’s also critical to remember that protocol requires a soap-and-water wash in certain situations, including when hands are visibly soiled. SCA professionals say a “gel in, gel out” mentality disregards the benefits of a proper wash, in which a towel physically removes particles from hands.

Julie Nitchie, RN and medical supply product manager for Briggs Healthcare, says individually wrapped wipes offer the convenience of portability and the friction of a towel. Briggs’ DisCide Ultra wipes have a formulation that kills 99.999% of germs, including MRSA, VRE, staph and others, she says. It takes less than a minute to apply and dry.

Access and acceptability

Although F-Tag 441 calls for hand sanitation after all direct resident care, many facilities still have dispensers only in common areas.

Wagner says that’s partly due to efforts to create homelike rooms, but it then requires busy employees to interrupt workflow to follow hygiene rules. Striking a balance between aesthetics and infection control is challenging.

Touch-free soap and paper towel dispensers can  eliminate extra touches. Wall-mounted units, tubs of wipes and carry-on gels worn on an employee’s lanyard all can deliver germ-fighting power.

If a facility opts for portable products, it’s important that they don’t travel between patients, wings or floors, says Jessica Lan, skin care product manager for SCA North America’s personal care line.

No matter where the product is placed, it needs to be something staff members are willing to use. Chemist Ron Barnhart has spent more than 20 years in the industry and says choosing a product for price alone could be a mistake.

“Performance and acceptance drive compliance with hand-hygiene policies,” says Barnhart, who formulates hand care products for Spartan Chemical. 

Wagner says hand sanitizers made for the healthcare industry have come so far in the last few years that they are easier on the skin than traditional hand washing. But, she adds, it may take some encouragement to get staff to let go of their old assumptions.

“Many people still believe that alcohol is harsher on your skin. However, soap tends to be more drying,” Wagner explains. “Alcohol may sting if you have a small cut, but the way it’s made today, (sanitizer) has emollients and skin conditioners.”

In tests by BODE Chemie, Medline’s Sterillium products increased  skin hydration by 14% with repeated use over two weeks, the researchers found.

Staff also may have to accept that the best hygiene practices cramp personal style. Allen says jewelry can trap bacteria, while Nitchie points to studies showing artificial nails carry high levels of staph and pseudomonas.

“It’s just a breeding ground,” she says, noting some facilities have adopted nail-length limits.

Like hand in . . .

As with hand washing, administrators need to hammer home expectations regarding outcomes and reduce costs related to glove use, Lan says.

“Facilities are using gloves, but (employees) are not always changing them often enough,” she says. “Staff sometimes grab several pair, carry them around all day and pull them out of their pockets when they need them.”

Allen says gloves are standard when there’s any kind of insertion, including procedures on central line or foley catheter patients. Typically, they already are at increased risk of infection due to advanced age or a weak immune system.

Several supply companies say long-term care managers are ordering more gloves, with the number of situations in which they’re required having increased significantly over the last 15 years. In some cases, they have become an unsanctioned alternative to hand washing. But, Nitchie says, gloves provide “a false sense of security.”

Gloves are truly effective for infection control only if the person wearing them washes before and after each patient contact. And Staar says double gloving and then ripping the top pair off and heading directly for another patient is never acceptable. 

Even if self-reports indicate employees are using hygiene products and gloves properly, administrators shouldn’t rest easy. One of Allen’s facilities had a 100% compliance rate more than three years ago. Recognizing that it couldn’t be valid, the team implemented new reporting standards and saw its numbers drop to about 50%. They’ve rebounded to 89%, and CaroMont again has switched staff education methods to keep the pressure on.

Building-wide poster campaigns, hand-washing contests and even technology may be part of the solution. Though Briggs doesn’t sell it, Nitchie says a new product uses a chip in a badge to record every wash or gel application. Administrators can track data and identify trouble spots.

Catching an employee dirty-handed doesn’t have to be a “gotcha” moment. Wagner and Nitchie say most employees get into the industry to help. They want to protect their patients.

“It starts with the CEO … all the way to laundry services,” Allen notes. 

Hand-Hygiene Resources

Infection control experts suggest supplementing new-hire training with quarterly updates and strong messages. Product supply companies offer training and assessment tools, but free resources are also available. Consider these options:

APIC’s Infection Prevention and You Web site is designed for patients, families and healthcare professionals. The campaign includes a downloadable infographic poster with tips on how consumers can play an active role in infection prevention. Visit and click on the link for “healthcare settings.”

The Infection Preventionist’s Guide to Long-Term Care is an in-depth reference with a comprehensive approach to developing a facility-based infection prevention program, including practical tips and clinical advice. Cost: $169 for APIC members; $225 non-members. Available at

Centers for Disease Control hand-hygiene resources can be found in an online hub ( There are options for online training courses and promotional materials, including posters, podcasts, self-assessment tools and slideshows intended for healthcare workers.

Medline University’s hand-hygiene courses include titles such as “Hand Hygiene Improvement Strategies (for Administrators),” “Hand Hygiene for CNAs” and “How Effective Are Your Hand Sanitizing Techniques: New Discoveries and Considerations.” Participants who complete a course and an accompanying test (for free) can earn one CE credit through Medline University. For a full list of titles and related materials, visit and search “hand hygiene.”  

TENA Solutions from SCA provides clinical-based benchmarking, helping facilities identify gaps or deficiencies, establish new performance goals and operational integrity, and provide hands-on training to help staff create and implement new processes. Goal-setting and tracking can ensure that supplies (including gloves) are ordered in the right amounts and sizes and are used correctly.

A Glo-Germ Handwashing Kit (or similar products) can provide a much-needed visual for employees who insist they’re hand-washing experts. Tiny plastic particles in the gel glow when exposed to ultraviolet light. Participants apply Glo-Germ to hands, and, after normal washing, they spot remaining “germs” with a UV flashlight (Briggs, $73.95).