Hand Sanitizer Location Influences Use Among Hospital Visitors

The tendency of hospital visitors to use alcohol-based hand sanitizers (AHS) was the focus of a newly published study in the American Journal of Infection Control. The larger issue, hospital visitor hand hygiene compliance (HHC), has been identified as a critical factor in reducing new infections among others in clinical settings.^{1, 2} Despite its importance, adherence to HHC measures by hospital visitors is considered to be poor.^3,4 Furthermore, very little is known about the factors that may influence hospital visitor use of AHS; however, the results of one study suggested that the location of AHS stations in hospital entrances could influence visitor HHC.⁵

According to the lead author on the publication, Mary A. Hobbs, from the Department of Industrial Engineering at Clemson University, the objectives of the study were, "... to explore how individual characteristics (eg, age and sex), individuals entering alone or as part of a group, and the location of AHS influence the visitor’s likelihood of using AHS."

For the purposes of this observational study, Hobbs et al defined a visitor as, "... an individual who was not a hospital employee (ie, not wearing scrubs or employee badges), a patient (ie, not wearing hospital gowns or patient bracelets), or working for an outside company entering the hospital wearing clothing or uniforms or carrying objects (eg, cab drivers, food delivery, or parcel delivery)."

This study was conducted in the lobby of the main visitor entrance of a 749-bed hospital. All study data were collected by two observers over a period of three weeks. Based on the results of a study that identified 10—11:30 AM and 4–5:30 PM as the busiest times for visitors entering a hospital,⁵ all observations were conducted during these time periods on Mondays, Wednesdays, and Sundays.

The AHS dispenser units were black, mounted on a black stand, and had no associated signage. Three locations within the lobby were selected based on their proximity to the entrance, as well as their ease of accessibility. An area with no landmarks or barriers directly ahead of those entering the lobby through its double doors was selected as Location 1. Location 2 was furthest from the entranceway and centered in front of the information desk at the far end of the lobby. Location 3 was closest to the entranceway, but was surrounded by landmarks or barriers.

Each location was observed for one week. The observers recorded several visitor characteristics including their sex (female or male) and age (child, young adult, adult, or elderly), whether or not they were part of a group or alone, the size of the group if applicable, and whether they used AHS.

Of the 6,603 visitors observed during the study, the majority were male (56.5%) and middle-aged (59.3%). Wednesday was the most popular day for visits (37.4%), and morning and afternoon visits occurred with almost equal frequency (47.9% and 52.1, respectively).

In general, few visitors used AHS (3.71%). Regarding location, 7.26%, 1.46%, and 2.53% of visitors used AHS at Locations 1, 2, and 3, respectively. A logistic regression model revealed that the differences between Locations 1 and 2 and between Locations 2 and 3 were statistically significant. For example, visitors were 5.28-fold more likely to use AHS at Location 1 as compared to Location 2, and 1.77-fold more likely to use AHS at Location 3 than at Location 2. Hobbs and colleagues speculated that these differences were attributable not only the placement of the AHS stations, as Locations 1 and 3 were both closer to the entrance than Location 2, but also to the lack of obstacles or barriers near Location 1 as opposed to Location 3.

The same model detected that visitor age, day of the week, and time of day were found to have effects on AHS usage. More specifically, younger visitors, afternoon visitors, and visitors entering in groups were more likely to use AHS than other visitors.

In a summation of their findings regarding the relationship between ASH location and usage, Hobbs et al suggested, "... a potentially high return on investment for implementing these changes associated with AHS for addressing visitor HHC across the population of hospital visitors."

Collectively, the findings of this study suggest that improved rates of AHS usage are needed, and that careful consideration of the AHS dispenser location may be a critical component in ongoing efforts to improve visitor HHC.

William Perlman, PhD, CMPP is a former research scientist currently working as a medical/scientific content development specialist. He earned his BA in Psychology from Johns Hopkins University, his PhD in Neuroscience at UCLA, and completed three years of postdoctoral fellowship in the Neuropathology Section of the Clinical Brain Disorders Branch of the National Institute of Mental Health.

References

1. Hilburn J, Hammond BS, Fendler EJ, Groziak PA. Use of alcohol hand sanitizer as an infection control strategy in an acute care facility. Am J Infect Control 2003;31:109—16.
2. Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect 2009;73:305—15.
3. Willison-Parry TA, Haidar EA, Martini LG, Coates AR. Handwashing adherence by visitors is poor: is there a simple solution? Am J Infect Control 2013;41:928—9.
4. Pittz EP. Availability and use of hand hygiene products, by visitors, at the entry points of hospitals. Am J Infect Control 2009;37:E69—70.
5. Birnbach DJ, Nevo I, Barnes S, et al. Do hospital visitors wash their hands? Assessing the use of AHS in a hospital lobby. Am J Infect Control 2012;40:340—3.