Megan DiGiorgioThe COVID-19 pandemic substantially impacted health care, particularly long term care facilities (LTCFs). Even before the pandemic, there was a need for increased focus on patient safety and infection prevention, as evidenced by the U.S. Government Accountability Office reporting that most nursing homes had infection control deficiencies before the COVID-19 pandemic and half had persistent problems.1

As LTCFs emerge from the acute phase of the pandemic and navigate the new normal, it is clear that substantial changes are imperative, but many LTCFs don't always know where to begin. While improving the quality of long term care will take concerted reform efforts, there are small but impactful changes that can happen now. A targeted focus on basic infection prevention, particularly hand hygiene, is an excellent place to start.

The Need to Regain Lost Ground
Hand hygiene is the most foundational practice, yet perhaps the most difficult to improve. Nevertheless, hands are the most common mode of pathogen transmission. Further, hand hygiene is an important indicator of the safety and quality of care delivered in any health care setting.2 While studies are lacking in LTCFs due to hand hygiene being less commonly measured, studies in hospitals published since the pandemic report either there were no gains despite the situation or that hand hygiene initially improved and quickly decreased back to baseline levels or below.3,4 These data suggest that for many health care facilities, including LTCFs, there's work to be done to regain lost ground.

When the New England Journal of Medicine Perspective was published in February 2022 calling for building more resilient health care systems,5 many were seeking innovative next steps. When it comes to improving hand hygiene, however, novel, innovative approaches may not be needed. LTCFs may just need to get back to the basics.

Getting Back to Basics
The World Health Organization (WHO) hand hygiene guidelines encourage a multi-modal improvement strategy.2 Chief among the strategy has been system change, or simply put, making hand hygiene possible, easy, and convenient with readily available alcohol-based hand rub (ABHR).

LTCFs have long struggled with balancing the need for creating a home-like environment and managing the risk of ingestion of ABHR among residents while implementing these important hand hygiene requirements. However, the risk of ingestion of ABHR has likely been overly inflated at the expense of patient safety as there is a lack of data reporting on such cases. Further, the Centers for Medicare & Medicaid Services (CMS) clearly support the placement of ABHR dispensers, stating, “Facilities should ensure adequate access to ABHR since a main reason for inadequate hand hygiene adherence results from poor access."6 The bottom line is that getting dispensers up on the walls is an imperative first step to getting ABHR on health care workers' (HCWs) hands.

An aspect of ABHR placement that can't be underestimated is offering a high-quality product that HCWs can have confidence in—ensuring that it is not only safe and efficacious but also maintains skin health and is aesthetically pleasing to use. Early in the pandemic, when many new manufacturers and distilleries began making ABHR for the first time, there was a lot of unpleasant ABHR in the marketplace that was runny, smelly, or sticky. (Plus, it turned out some contained dangerous impurities, inadequate levels of active ingredients, and other safety concerns that led the FDA to include more than 350 brands of hand sanitizers on their 'do-not-use' list.7) While it's unclear how much sub-par ABHR remains on the market, its impact on HCWs' overall perception of ABHR is cause for concern, and a return to products with strong research and development behind them is critical moving forward.

Setting up hand hygiene infrastructure (i.e., making hand hygiene easy and accessible) is one aspect of the bundle of interventions that is the multi-modal strategy. The abundant recommendations in the multi-modal strategy are carefully laid out for facilities looking to make changes. But, because of the complexity and opportunity in these recommendations, prioritization is critical and change takes time.

From Understanding to Behavior
For the individual HCW, the most important change they can make is performing hand hygiene before and after every resident interaction. It may seem very simple, but it's important to note that there is a difference between conceptually understanding or knowing something and following through with behavior. HCWs can know conceptually what they need to do and when they need to do it, but once inside the context of their busy and often chaotic workday, they may have difficulty following through with behaviors despite what they know.

Periodic hand hygiene education is insufficient to ensure that hand hygiene is performed at the right moment. On the other hand, proximity can have a very powerful impact on behavior in the moment. Programs designed to encourage speaking up and encouraging everyone on the front lines to provide consistent reminders for missed opportunities can help create and sustain a new set of habits and practices.8 Simple and continued reinforcement by management and peers can help hand hygiene become part of a patient safety culture.

Trying to implement all of the guidelines and recommendations for hand hygiene can seem overwhelming, and for facilities regrouping post-pandemic, it may be too much at once. A focus on making access to ABHR easy and convenient and getting HCW to use the dispensers at a minimum upon room entry and exit are two good first steps in the journey. Getting back to the basics during this transition period will strengthen the promise of a safer post-pandemic future. Admittedly, this is hard work. It will take commitment, persistence, and endurance to hold fast to a journey that will span years and not months. But this is how we change hand hygiene culture.

Megan DiGiorgio, MSN, RN, CIC, FAPIC, is a senior clinical manager at GOJO Industries—the makers of PURELL products.

1.     US Government Accountability Office. Infection Control Deficiencies were widespread and persistent in nursing homes prior to COVID-19 pandemic. Published May 20, 2020. Accessed September 1, 2022. Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic | U.S. GAO
2.     World Health Organization. WHO Guidelines for hand hygiene in health care. Geneva, Switzerland: World Health Organization; 2009.;jsessionid=3337A802E44723C3B4CDC131B90B2B9C?sequence=1
3.     Moore LD, Robbins G, Quinn J, Arbogast JW. The impact of COVID-19 pandemic on hand hygiene performance in hospitals. Am J Infect Control. 2021; 49(1):30-33.
4.     Sandbøl SG, Glassou EN, Ellermann-Eriksen S, Haagerup A. Hand hygiene compliance among health care workers before and during the COVID-19 pandemic. Am J Infect Control. 2022;50(7):719–723.
5.     Fleisher LA, Schreiber M, Cardo D, Srinivasan A. Health Care Safety during the Pandemic and Beyond - Building a System That Ensures Resilience. N Engl J Med. 2022;386(7):609-611.
6.     Centers for Medicare and Medicaid Services. Center for Clinical Standards and Quality/Quality, Safety & Oversight Group. Updates and initiatives to ensure safety and quality in nursing homes. November 22, 2019. QSO 20-03 Updates and initiatives to ensure safety and quality in nursing (
7.     U.S. Food & Drug Administration. FDA updates on hand sanitizers consumers should not use. Accessed Sept. 1, 2022.
8.     Sickbert-Bennett EE, DiBiase LM, Teal LJ, Summerlin-Long SK, Weber DJ. The holy grail of hand hygiene compliance: Just-in-time peer coaching that leads to behavior change. Infect Control Hosp Epidemiol. 2020;41(2):229-232.