It’ s exciting to think that one day you could have an electronic system where it could give a warning that an outbreak might start occurring. That may be science fiction, but this is something we might see at some point in our careers.”— Dr. Yves
Longtin pointed to the mixed-methods study by Kerri Thom and Heather Reisinger, interviewing 25 healthcare workers from three hospitals, where the researchers found high rates of glove misuse, low rates of hand hygiene compliance, gloves used for self-protection, skepticism that hand hygiene is required if gloves are worn, and that it is more acceptable to skip hand hygiene before gloving( wet hands, time, skin irritation). There was a gap between observed( 42 percent) and reported( 100 percent) compliance.
“ We need to perhaps rethink our guidelines, because their conclusion was, what if hand hygiene before donning non-sterile gloves isn’ t beneficial?” he noted.“ The study said that combining( requiring) hand hygiene before glove use may be ideal but it might be contributing to low compliance. It questioned whether‘ perfect is the enemy of good enough.’ Paradoxically, eliminating this step could improve both glove and hand hygiene compliance. Eliminating excess glove use would be helpful, but is skipping hand hygiene before gloving safe?”
He added,“ In that cluster randomized controlled trial at the University of Maryland by Kerri Thom in four ward types( ICUs, pediatrics, emergency departments and dialysis units), the primary outcome was adherence to expected practices on entry to contact precautions rooms. We collected a lot of baseline data on hand hygiene compliance and glove use through more than 4,000 observations. Overall hand hygiene compliance among healthcare personnel was 33 percent before gloving and a range of 33 percent to 47 percent were direct gloving without hand hygiene. And 17 percent did neither. The units were randomized and were almost exactly the same – 37 percent direct gloving, driven by the emergency department, but if you remove this unit, it ends up being 35 percent versus 37 percent. So, the primary outcome was 87 percent in the direct-gloving arm of the study, and if they did hand hygiene before gloving, they weren’ t penalized; it was 41 percent in the usual-care arm of the study, so a big increase in compliance.”
Perencevich continued,“ So, we’ ve changed the definition and we knew we were going to see this. It’ s not the most important outcome you’ re worried about, right? But are the hands contaminated? In the study, 4 percent had a pathogen on gloves upon room entry, 2 percent with usual care, and the colony counts were 16 versus 9. If you look at adult ICU and dialysis, there was basically no change, no statistical difference. But there was a 65 percent reduction in colony counts in pediatrics. In the ED, there was a 7 percent increase in colony counts, 10 times increase in detection on gloves in the ED. If we were doing an independent risk factor analysis, the major positive risk factor was that the ED physicians had better compliance, or less contamination, which makes sense – they’ re never practicing hand hygiene in the ED, they are too busy, so it is building up on their hands.” Other findings were that there were no secondary harms from the direct gloving intervention in non-contact precaution rooms. Room entry hand hygiene was 72 percent versus 66 percent, and room exit hand hygiene was 84 percent versus 85 percent.”
Perencevich concluded his talk by summarizing that“ There is poor compliance with hand hygiene before gloving, and direct gloving led to improved adherence with expected practices and did not increase colony counts, except in very low-compliance emergency departments. Direct-gloving is associated with time savings, and healthcare workers don’ t believe hand hygiene is necessary before gloving – and forcing them to do it may have no benefits, and they may be right, we should probably listen to healthcare workers.”
HAND HYGIENE Compliance monitoring
In the presentation,“ Should We Continue to Perform Compliance Monitoring by Discreet Direct Observation?” Yves Longtin, an infectious disease specialist, medical microbiologist, and a clinician-scientist researcher as well as chair of the Infection Prevention and Control Unit of the Jewish General Hospital( JGH) in Montreal, reviewed the main types of hand hygiene monitoring.
“ The IDSA / SHEA / APIC Compendium guidance is clear in its recommendations but also very vague in the sense they are saying that you have to use multiple methods to measure adherence to hand hygiene and you should concentrate on the advantages and limitations of each type of monitoring,” Longtin said.“ What they don’ t tell us is how many different methods should we select, which ones, and are there combinations that are more effective than others? Overall, there are about six main monitoring strategies for hand hygiene – there is direct overt observation where the person is aware that they’ re being monitored, and direct covert observation, where no one’ s supposed to know. You can also ask patients to observe hand hygiene of healthcare personnel. You can also use remote video observation, or automatic Wi-Fi-enabled dispensers for electronic monitoring, and you can use product-usage metrics.”
Longtin reviewed the benefits and disadvantages of each method and then referenced a number of studies, including a review by Gould, et al.( 2024) which acknowledged that manual hand-hygiene audit is time-consuming, labor-intensive and inaccurate, adding that“ Automated hand-hygiene monitoring systems( AHHMSs) offer advantages including generation of standardized data, and avoidance of the Hawthorne effect. Their review of 43 articles that met the acceptance criteria assessed the current state of the literature for AHHMSs and offered recommendations for use in real-world settings. Most of the studies examined were of small scale and short duration. The researchers found that AHHMSs-- in conjunction with additional interventions( visual or auditory cue or performance feedback)-- could increase hand hygiene compliance in the short term but their impact on infection rates was difficult to determine. In the few publications where costs and resources were considered, time devoted to improving hand hygiene compliance increased when an AHHMS was in use. Additionally, the researchers found that healthcare workers’ opinions about AHHMSs were mixed. Gould, et al.( 2024) concluded that,“ At present too little is known about the longer-term advantages of AHHMSs to recommend uptake in routine patient care. Until more longer-term accounts of implementation( over 12 months) become available, efforts should be made to improve direct observation of hand hygiene compliance to improve its accuracy and credibility.”
“ The typical study design is an uncontrolled before-and-after study, as control groups are rare in
20 • www. healthcarehygienemagazine. com • nov-dec 2025