Looking back to move forward: Development of automated hand hygiene solutions

A Short History of Hand Hygiene Monitoring

For centuries, handwashing with soap and water has been considered a measure of personal hygiene. In the 1980s, the first national hand hygiene guidelines were published (1). Several years later, using either antimicrobial soap or a waterless antiseptic agent upon leaving patient rooms was established as a recommendation (2).

Hospitals and other healthcare facilities developed measures to monitor hand hygiene compliance (HHC) by recognising the importance of hand hygiene levels. Manual direct observation has long been a “Gold Standard” for hand hygiene monitoring. In this process, the hospital hires an observer to monitor the healthcare workers washing their hands as needed and offer timely feedback when improvements are required.

Should we reconsider direct observation as the most effective tool? Direct observation for hand hygiene monitoring has numerous drawbacks despite its documented benefits. Direct observation takes time, and it necessitates formal training of dedicated personnel to assess hand hygiene performance and human observers paying close attention to each hand hygiene event (3). Furthermore, compliance data is determined based on a small sample of hand hygiene practices, which may not reflect actual hand hygiene performance across a healthcare facility. In addition, the data is susceptible to observer bias or the Hawthorne Effect, which occurs when providers become aware of the presence of an observer (3). One Canadian study pointed out that hospital staff performed nearly three times more hand disinfections when observed than the period with no observer present (4).

Although direct observation is still an effective, low-cost tool that can influence positive changes, other monitoring methods may give a more precise picture by gathering more data than a human observer.

How can we obtain valid hand hygiene data?


Proper hand hygiene is crucial to preventing the spread of many HAIs and avoiding unnecessary extended hospital stays. Electronic hand hygiene monitoring systems (EHHMS) measure hand hygiene levels to eliminate observer bias. Hand hygiene data is measured constantly and autonomously via the system, allowing the healthcare personnel to monitor hand hygiene compliance in real-time and provide relevant feedback.

“Several advantages of automated monitoring systems are recognized: the possibility of continuous monitoring, a lower Hawthorne effect, saving human resources and the possibility of downloading and analyzing data automatically for repeated measurement. Apart from monitoring, the implementation of these systems has also been studied as an intervention to improve hand hygiene with successful results.” – WHO, 2013

What is the future of hand hygiene monitoring?

Recently, the World Health Organization (WHO) has advocated for increased use of EHHMS in hospitals, provided that the systems incorporate the WHO Five Moments for hand hygiene indications. Moreover, the WHO sees these technologies as promising future hand hygiene compliance measurements (6).

Sani Nudge is committed to providing cutting-edge research that contributes to the adequate evaluation of the validity and advantages of EHHMS.

Read more about our key achievements and findings in the links below:


  1. Bjerke NB. The evolution: Handwashing to hand hygiene guidance. Crit Care Nurs Q. 2004;27(3):295-307. doi:10.1097/00002727-200407000-00007
  2. Garner JS. Guideline for isolation precautions in hospitals. The Hospital Infection Control Practices Advisory Committee [published correction appears in Infect Control Hosp Epidemiol 1996 Apr;17(4):214]. Infect Control Hosp Epidemiol. 1996;17(1):53-80. doi:10.1086/647190
  3. WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care. Geneva: World Health Organization; 2009.
  4. Srigley JA, Furness CD, Baker GR, Gardam M. Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study. BMJ Qual Saf. 2014;23(12):974-980. doi:10.1136/bmjqs-2014-003080
  5. WHO Systematic Literature Review of Automated/Electronic Systems for Hand Hygiene Monitoring. Geneva: World Health Organization; 2013. https://www.who.int/gpsc/5may/automated-hand-hygiene-monitoring.pdf?ua=1
  6. Allegranzi B, Kilpatrick C, Sax H, Pittet D. “My Five Moments”: understanding a user-centred approach to hand hygiene improvement within a broader implementation strategy. BMJ Quality & Safety. Published online February 7, 2022:bmjqs-2021-013680. doi:10.1136/bmjqs-2021-013680

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