We agree with Dr. McGuckin that noncompliance with hand hygiene in hospitals is nothing new. The proposal to turn the patient into an enforcer of hand hygiene is provocative, but hardly the only possibility. Our study suggests several reasons why this approach may have limited effectiveness in reducing cross-contamination. First, patient enforcement cannot be implemented in intensive care units, which care for patients who generally have impaired consciousness and communication ability, and where compliance was lowest among all hospital wards. Second, handwashing is required in many situations other than before patient contact (1); the latter indication represented only 14% of all opportunities to wash hands recorded in our study. Third, compliance was worst among physicians, who may be the most difficult for a patient to interrupt and ask to go wash their hands (at least in European countries, where the physician still carries an aura of prestige and professional authority). Furthermore, bacterial hand contamination of hospital staff is a dynamic process that results from multiple factors (2); patient enforcement should be repeated several times during the same sequence of care to prevent cross-transmission.

Our study did suggest a possible "solution" to the problem: literally, use of an antiseptic solution instead of soap-and-water handwashing. We observed that the intensity of care was correlated with noncompliance, and simple computations suggested that soap-and-water handwashing of sufficient duration is too time-consuming to be feasible (3). If this was true, reminders by patients would increase frustration (on both sides) more than they would increase compliance. Our approach has been to implement a hospital-wide campaign that promotes the use of an alcohol-based hand disinfection solution, packaged in individual pocket bottles, at the bedside. The results of this intervention are being analyzed, and preliminary data are encouraging (4).

The issue is not which measure—patient enforcement or bedside hand disinfection—is better. All imaginative proposals to resolve the problem of poor hand hygiene practices are welcome and deserve empirical testing.