Evaluation of a patient education model for

increasing hand hygiene compliance in an

inpatient rehabilitation unit
Maryanne McGuckin, Dr ScED, Alexis Taylor, Veronica Martin, MSN, Lois Porten, and Richard Salcido, MD
Philadelphia, Pennsylvania

Background: Transmission of microorganisms from the hands of health care workers is the main cause of health care–acquired
infections. Recent studies on bacterial contamination of hands by medical care specialty found the highest bacterial contamination
on the hands of health care workers from rehabilitation units. The objective of this study is to determine the effect of a patient
education model on hand hygiene (HH) compliance in a rehabilitation unit.

Methods: A 6-week pre- and post-intervention study with a 3-month follow-up using a patient education model was conducted in
a 24-bed inpatient rehabilitation unit located in an acute care hospital. Thirty-five patients were enrolled in the intervention phase
of the study after agreeing to ask all health care workers who had direct contact with them, ‘‘Did you wash/sanitize your hands?’’
Compliance with the program was measured through soap/sanitizer usage per resident-day before, during, and after the
intervention.

Results: Usage increased from 5 HH per resident-day during the preintervention to 9.7 HH per resident-day during the intervention
(P\.001), 6.7 HH per resident-day postintervention (6 weeks) (P\.001), and 7.0 HH per resident-day at 3 months (P\.001).

Conclusions: Patient education increased HH compliance in an inpatient rehabilitation unit by 94% during the 6-week
intervention, 34% during the 6 week post intervention, and 40% at 3-month follow-up. This program empowers patients with
responsibility for their own care and provides ongoing HH education. (Am J Infect Control 2004;32:235-8.)

Hand hygiene (HH) compliance is one of the most
important components of an infection control pro-
gram. Lack of compliance has been documented over
the last 2 decades in several studies, all showing that
health care workers (HCWs) wash their hands less
often and for a shorter time than recommended.1-4
Several reports have been published on the role of HH
in reducing the transmission of potential pathogens on
the hands,5 with subsequent reductions in morbidity
and mortality for health care–acquired infections.6-7
From the University of Pennsylvania.
Presented at (1) Second Annual Research Day Symposium, University
of Pennsylvania, Department of Rehabilitation Medicine, January 2002;
(2) American Congress of Rehabilitation Medicine Annual Meeting,
Philadelphia, October 2002; and (3) Society for Healthcare Epidemi-
ology of American Annual Meeting, Arlington, Virginia, April 2003.
Supported in part by an unrestricted grant from Pfizer, Inc, New York,
NY.
Reprint requests: Maryanne McGuckin, Dr ScED, Department of
Rehabilitation Medicine, University of Pennsylvania, 3400 Spruce St, 5
West Gates Building, Philadelphia, PA 19104-4283.
0196-6553/$30.00
Copyright ª 2004 by The Association for Professionals in Infection
Control and Epidemiology, Inc.
doi:10.1016/j.ajic.2003.10.005
Pittet8 reported on the bacterial contamination of
hands by medical care specialty and found that the
highest bacterial counts were on the hands of HCWs in
a rehabilitation unit. Similar results were reported on
infection rates for rehabilitation units when compared
with acute care settings.9
The high contamination level of bacteria on the
hands of HCWs from rehabilitation is not surprising
given the amount of direct care contact provided to
patients. With this increase in direct patient contact,
and admission to a rehabilitation unit from both acute
and long-term care settings, there is also the potential
for transmission of multiple-resistant bacteria. This is
supported by the findings of Singh,10 in which the
highest levels of methicillin-resistant Staphylococcus
aureus were found on the pagers of physicians
involved in chronic wounds.
In 1997, McGuckin11 developed a patient education
model for increasing HH compliance and empowering
patients with responsibility for their care. The program
Partners in Your Care (University of Pennsylvania,
Philadelphia) provides the infection control practi-
tioner with a continuing means of HH education, out-
come monitoring, and compliance with HH through
soap/sanitizer use and does not require additional time,
staff, or costs compared with the potential savings of

235
236 Vol. 32 No. 4
preventing health care–acquired infections. Therefore,
the objective of this study was to determine HH baseline
data in a rehabilitation unit and to evaluate the effect of
Partners in Your Care on HH compliance in this setting.
METHODS
Setting
A 24-bed inpatient rehabilitation unit located in an
acute care university hospital in Pennsylvania.
Study design
A prospective 6-week pre- and post-intervention
study with a 3-month follow-up.
Intervention
Partners in Your Care, a patient, family, and HCW
education program for increasing and monitoring HH.
Components of the Partners in Your Care
program
After review and expedited approval by the Insti-
tutional Review Board, 5 steps were followed in im-
plementing the program:
1. Patients were visited by a premedical undergrad-
uate student within 24 hours of admission to
discuss the importance of HH by staff in
preventing health care–associated infections.
2. Patients received an education brochure describ-
ing the who, why, how, when, and where of HH.
Brochures were pilot-tested for clarity of pre-
sentation and content among a random popula-
tion of nonhospitalized persons.
3. Patients were asked to become Partners in Your
Care by asking all HCWs who had direct contact
with them, ‘‘Did you wash/sanitize your hands?’’
4. Patients were shown a 7-minute video during
breakfast (in the common dining area) on the
importance of HH and the procedures most likely
to cause transmission of bacteria in the rehabil-
itation setting.
5. As a reminder to ask or for patients who said
they might be too shy to ask, patients were given
a prompting visual aid (fuzzy weeble) that had
a 4-inch banner printed with ‘‘Did You Wash
Your Hands?’’ to stick on their hospital gowns
and a mug that said, ‘‘Did You Wash/Sanitize Your
Hands?’’ At the time of discharge, all enrolled
patients were asked to complete a patient
satisfaction form designed for Partners in Your
Care to determine the patient’s compliance.
The following questions were asked:
1. Did you read the brochure?
2. Did you realize people get infections in the
hospital?
McGuckin et al
3.Did you know the importance of handwashing?
4.Did you ask a health care worker?
5.Did you ask a nurse?
6.Did you ask a doctor?
7.Did you ask a technician?
8.Did you ask a physical therapist/occupational
therapist?
9. Were you comfortable asking health care work-
ers?
10. What was the HCW’s response?
Health care worker
The nurse manager of the unit was asked to be
a member of our research team. She identified a clinical
nurse specialist to be our liaison with the staff. The
nursing staff was informed of the program after
baseline data were collected by the clinical nurse
specialist. Similarly, the chairman of the department
was informed of the program, and it was presented to
the physicians by the principal investigator at a faculty
meeting. All HCWs on the unit were given a flyer with
their paycheck 1 week before the intervention. This
flyer presented the program and asked them to become
partners with their patients.
Family
Because patients were educated about the program
at the end of their daily rehabilitation schedule, which
was usually during visiting hours, family members
were included in the presentation of the program to the
patient and were encouraged to ask as well if their
relative was unable to ask HCWs.
Data collection/analysis
Soap/sanitizer usage per resident-day was moni-
tored preintervention, intervention, and at 3 months
for calculation of HH per resident-day. The preinter-
vention (baseline) phase was 6 weeks, as were the
intervention and the postintervention phases. These
periods were continuous. After postintervention, there
was a 6-week period of no intervention or monitoring,
followed by a 6-week period in which patients were
given a brochure on admission to the unit but no direct
education about the program other than to have the
nurse tell them to read the brochure and to be a partner
with them. During these 6 weeks, which ended at 3
months post initial intervention, we monitored soap/
sanitizer usage and residents. Soap/sanitizer usage per
resident-day was calculated by multiplying the number
of packets of soap/sanitizer used in a dispenser by the
number of milliliters in a packet, and this was divided
by the number of resident-days. The number of
handwashings/hand sanitizing per resident-day was
calculated by dividing soap/sanitizer usage per resi-
dent-day by 1.7 mL for each HH encounter.
 McGuckin et al
Patient compliance to the program was determined
by completion of a patient satisfaction form at dis-
charge. A Poisson distribution model was used to test
significance of the intervention. The number of soap/
sanitizer packets used during the course of the study
period was an example of ‘‘count data,’’ and the
number of resident-days was taken into account by
adding an offset to the model. Modeling the log of
the number of soap/sanitizer packets meant that the
relative, rather than absolute, change in soap/sanitizer
usage was estimated. The Poisson distribution was an
appropriate modeling technique for analyzing these
data.12
RESULTS
During the intervention phase of the study, 48
patients were admitted to the unit. Four were excluded
because of being unresponsive; 39 were educated
about the program, with 35 (89%) agreeing to be in the
study (2 refused to be enrolled in the education, and 2
were transferred). The mean age of the population was
61.5 years, with a range of 46 to 77 years; 40% were
female and 60% male. Patient diagnosis included
stroke, deconditioning secondary to medical complex-
ity such as acute respiratory disease syndrome, multi-
ple comorbidities such as craniotomy with stroke,
functional loss secondary to metastic cancer, and cran-
iotomy.
HH per resident-day increased from 5 HH per
resident-day during the preintervention to 9.7 HH per
resident-day during the intervention (P\.001), 6.7 HH
per resident-day postintervention (6 weeks) (P\.001),
and 7.0 HH per resident-day at 3 months (P\.001)
(Fig 1). Nineteen (54%) of the enrolled patients were
able to complete the discharge survey: 95% of the
patients surveyed said they asked the nurse, 40%
physician, 80% technician, and 80% physical thera-
pist/occupational therapist (Table 1); 75% of patients
were comfortable asking, and 60% of HCWs washed/
sanitized their hands when asked by the patient.
DISCUSSION
Although infection control programs have improved
the quality of care for patients, we have not been
successful in making HCWs aware of their individual
responsibility regarding HH compliance. Partners in
Your Care provides a continuous means for HH
education by having the patient become the interven-
tion for behavioral change.
It also empowers patients with responsibility for
their care, which is one of the important aspects of
rehabilitation medicine. Our results for HH compliance
rates in a rehabilitation unit, following Partners in Your
Care, were similar to those found in acute care
settings.11,13 Of interest is the sustained compliance
June 2004 237
Fig 1. Hand hygiene per resident-day for each
study phase. Overall increase in hand hygiene for all
phases = 56% (P\.001).
Table 1. Patient compliance to Partners in Your Care
Discharge survey (N = 19)
d Read brochure 18
d Did you realize people get infections in the hospital? 16
d Did you know the importance of handwashing? 15
d Asked health care worker 15
d Asked nurse 14
d Asked doctor 6
d Asked technician 12
d Asked physical therapist/occupational therapist 12
d Asked occupational therapist 6
d Comfortable asking 11
d HCWs washed/sanitized after being asked 10
after the intervention. Specifically, after the initial
intervention, compliance rates decreased but were still
34% higher than preintervention. Also of interest is our
finding that after a 6-week period of no intervention
and then the convening of only 1 component of the
programs (distribution of the educational brochure on
admission), the HH compliance rate at 3 months was
still 40% higher than baseline. This finding supports
our previous results from acute care, in which the
observation by the HCW of materials (brochure) in the
patient’s room describing the importance of HH pro-
vided enough motivation to practice HH protocols.13
Although 60% of patients said they were comfortable
asking the HCW, ‘‘Did you wash your hands?,’’ patients
asked physicians 40% of the time versus 95% for
nurses.
The limitations of the study include a small sample
size, 5 nonoperating sinks, and early discharge of 11
patients, thereby limiting information on patient
compliance to the program. However, our findings of
an overall increase in HH of 56% for the 3 phases of
this study is within the 35% to 60% range documented
238 Vol. 32 No. 4
in more than 40 other test sites.14 In December 2002,
the New Hand Hygiene Guideline in Health-Care
Settings15 was released promoting the use of alcohol-
based handrubs with the hope of increasing compli-
ance. However, we must not be fooled into thinking this
alone will increase compliance and decrease infection
rates. We must continue to educate HCWs and, more
important, involve patients in HH education programs
such as Partners in Your Care.
The authors wish to thank Richard Zorowitz, MD, Medical Director of the
Rehabilitation Unit, and the staff for their support of this study. Also thanks to Ms.
Arlene Shubin for assisting in the preparation of the manuscript.
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