Abstract:
A desirably sanitary environment such as a hospital will have hand hygiene stations dispersed in some of the patient rooms, hallways, common areas, staff bathrooms and the like. Workers entering and exiting these rooms and areas should comply with proper hand hygiene protocols as they move from contact with one patient to another. A system, method and implementation are provided for increasing the likelihood of proper hand hygiene protocols. Identifying credentials unique to each worker, sensors tracking the room entry and exit activities of each credential, electronic hand hygiene substance dispensers responsive to the credentials and a computerized network are combined to count completed hand hygiene protocol cycles to the credit of each credential for use in a compliance awards program to encourage proper hand hygiene. Each credential may include green, yellow and red LED&#39;s to alert as to “hands clean,” please sanitize” and “hands dirty” conditions.

Description:
BACKGROUND OF THE INVENTION 
   This invention relates generally to maintaining hygienic protocols in desirably sanitary environments and more particularly concerns a system, method and implementation for increasing a likelihood of practice of better hand hygiene habits by workers in a desirably sanitary environment such as in a hospital, clinic or medical or dental office or a food preparation, packaging or handling facility or the like. 
   There is an immediate need for improvement in hand hygiene practices in hospitals, clinics and medical and dental offices and food preparation, packaging and handling businesses. For example, serious nosocomial, hospital-acquired infections affect more than two million patients per year and have been estimated to cause 90,000 patient deaths per year at a cost of treatment approximating $4.5 billion per year in the United States. At the same time, hand washing compliance rates are at an unacceptable 18 to 40 percent and have been reported to be lowest in intensive care units, the highest risk areas of a hospital. Thirty-three percent of hospital acquired infections can be prevented and hand-hygiene is the single most important factor in preventing these infections. 
   Patients often carry resistant bacteria such as methicillin-resistant  S.aureus  (MRSA) or vancomycin-resistant  enterococci  (VRE) on their skin. Numerous studies show that proper hand hygiene reduces the spread of bacteria in various healthcare settings. Nurses, doctors and other healthcare workers can contaminate their hands by doing simple tasks, including taking a patient&#39;s blood pressure or pulse, assisting patients, touching a patient&#39;s gown or bed sheets or touching equipment such as bedside rails, over bed tables and IV pumps. The problem is complicated by the circumstance that the sanitary condition of the hands is essentially invisible and undetectable to patients, restaurant workers or other types of workers. 
   Frequent washing of the hands with plain soap and water or with antimicrobial soap and water has long been recommended. Under new guidelines developed by the Centers for Disease Control and Prevention (CDC) and infection-control organizations, it is now recommended that healthcare workers use an alcohol-based hand rub, whether a gel, rinse or foam, to routinely clean their hands between patient contacts. However, alcohol based rubs are recommended only if the hands are not visibly contaminated with blood or body fluids. More than 20 published studies prove that alcohol-based hand rubs are more effective than soap in reducing the number of bacteria on hands. Therefore, alcohol-based hand-rubs are preferred for routinely cleaning hands before having direct contact with patients, after having direct contact with a patient&#39;s skin, after touching equipment or furniture near the patient and after removing gloves. Moreover, several studies also show that nurses who routinely clean their hands between patients by using an alcohol-based hand rub experience the added advantage of less skin irritation and dryness than nurses who wash their hands with soap and water. This advantage is achievable because alcohol-based hand rubs contain skin conditioners or emollients that help prevent the drying effects of alcohol. 
   Despite the recommendations, there are many relatively obvious and unsophisticated factors which contribute to the prevailing pattern of poor hand washing compliance. Sinks and gel dispensers may be inconveniently located. Hands may already be irritated and dry, discouraging continued washing. Some workers are just “too busy.” Some assume or believe that the risk of spreading infection is low. And some simply forget. Some institutions do not emphasize hand hygiene as a priority. Some institutions offer hand hygiene education to their workers but neither sanction the non-compliers nor reward the compliers. In fact, scientific evidence demonstrates that education alone does not change behavioral patterns. Rather, behavioral pattern changes are promoted by operant conditioning in the form of rewards, such as green lights and redemption points, and in the form of sanctions, such as red lights and poor performance reports. 
   It is, therefore, an object of this invention to provide a system, method and implementation to promote the benefits of improved hand hygiene. Another object of this invention is to provide a system, method and implementation to increase the likelihood of practice of better hand hygiene habits by workers in a desirably sanitary environment. Still another object of this invention is to provide a system, method and implementation which make hand hygiene products more available and convenient to workers in a desirably sanitary environment. An additional object of this invention is to provide a system, method and implementation which are capable of reminding workers of the need to use the hand hygiene system. Yet another object of this invention is to provide a system, method and implementation which are capable of monitoring workers&#39; hand hygiene activities. A further object of this invention is to provide a system, method and implementation which are useful in encouraging both workers and others present in the vicinity of a desirably sanitary environment to consistently practice proper hand hygiene protocol. It is also an object of this invention to provide a system, method and implementation which are able to provide feedback useful in improving habits fostering hand hygiene. Another object of this invention is to provide a system, method and implementation which provide a basis for implementing a strategy of rewards and sanctions which will encourage the practice of better hand hygiene. 
   SUMMARY OF THE INVENTION 
   A desirably sanitary environment may include multiple areas in which appropriate hand hygiene is to be maintained. In a hospital, for example, any number of separate patient, laboratory and treatment rooms may be located throughout an environment that is to be hygienically clean. Such an environment will likely also have a number of hand hygiene stations dispersed throughout, some in the rooms, some in hallways or common areas outside the rooms and some in separate rooms such as staff bathrooms and the like. Workers are continuously entering and exiting all of these rooms and areas and should be complying with proper hand hygiene protocols as they move from contact with one patient to another. Consequently, in accordance with the invention, a system, method and implementation are provided for increasing the likelihood of hand hygiene in a desirably sanitary environment. 
   The system includes use of credentials employing infrared, radio frequency, bar code, magnetic strip card, proximity sensor, wiegand, bar-code, induction circuit, capacitance circuit or similar technology, with or without another form of recognition such as biometric sensors, to identify each worker. In implementation, each worker who is anticipated to have access to the desirably sanitary area is provided with a credential unique to that worker. In effectuating the method, the worker wears or otherwise transports the credential, perhaps in the form of a badge, while on the job. Preferably, the credential will include video and audio indicators, such as red, yellow and green lights and a beeper. The visual and audio indicators on the credentials, in conjunction with timing circuits in the network, serve as reminders of compliance or non-compliance with predetermined hand hygiene protocols determined by the system user. 
   The system also includes sensors that detect and respond to the presence of the credentials. In implementation, the sensors are located to monitor the various access passages of the protected rooms of the desirably sanitary environment. In effectuating the method, on entry and exit of a credential to and from a protected room of the desirably sanitary environment, the detecting sensors cause a corresponding signal to be emitted to the network processor so as to enable registration of the “entry” and “exit” events. 
   The system further includes a wired or wireless network which, in implementation, is connected to electronic dispensers such as alcohol rub dispensers and soap or soap and water dispensers located at the hand hygiene stations of the desirably sanitary environment. Each dispenser has a credential detecting proximity reader. In effectuating the method, in response to a proximity reader demand, the station dispenses the correct amount of rub solution or soap and water and emits a signal to the processor so as to enable recording of the event. 
   The system network processor receives the input signals from the various sensors and dispensers and processes them so as to monitor and record compliance with the protocols established for the system and to produce reports with respect to worker compliance. For hand hygiene stations located outside of the desirably sanitary environment, an appropriate protocol would be to sequentially sanitize the hands, enter the area within a predetermined time after sanitizing, exit the area and again sanitize the hands within a predetermined time after exiting. For hand hygiene stations located inside of the desirably sanitary environment, an appropriate protocol would be to sequentially enter the area, sanitize the hands within a predetermined time after entry, again sanitize the hands and exit the area within a predetermined time after the second sanitization. Depending on the application and the associated floor plan, other protocols may be established. In implementation, the processor will be programmed to acknowledge each completion of either or both the described protocols or such other protocols as may be established. For example, the system is preferably further programmable so as to permit changes in the protocol cycle depending on local definition or new medical evidence and recommendations. In effectuating the method, upon a completion of a protocol cycle, the processor will acknowledge successful completion of the cycle by counting the completed cycle to the credit of the associated credential and/or causing activation of visual confirmation, such as the green light associated with the credential, as a notice of compliance with a selected portion of the protocol. If the processor is unable to determine compliance with protocol, for example if an improper sequence of event identifying signals is received by the processor or an inordinate time delay occurs between events, the processor may cause activation of the yellow or red light and/or the beeper on the credential to alert the worker and others in the area of the non-compliance with protocol. If the red light is activated, the worker can reset the credential to a green light condition by performing an appropriate hand-hygiene activity at any of the hand hygiene stations while the credential is detected by a sensor at that station. Preferably, if a protocol cycle is initiated but not completed, the processor will either acknowledge the failure to complete the cycle by counting the incomplete cycle as a debit with respect to the associated credential or, in the alternative, simply not permit any portion of an incomplete cycle to contribute as a credit with respect to the associated credential. 
   It is desirable, in implementing the system, that sensors be located to monitor all staff bathroom doorways and sinks as part of the network to more completely account for bathroom related hand sanitizing compliance. It is also desirable, in implementing the system, that workers receive a monthly print-out of their hand hygiene performance record as well as a cumulative statement of their monthly credits and debits, perhaps with a comparative ranking to enable them to personally evaluate their own performance in relation to the performance of a group of workers taken as a whole. As a further incentive, workers may be given the opportunity to receive more tangible benefits from good hand hygiene performance by the redemption of their accumulated credits, such as by credit toward purchases in a cafeteria, gift shop, coffee shop or from a rewards catalog. Such reward programs may be implemented on group and/or individual bases. 

   
     BRIEF DESCRIPTION OF THE DRAWINGS 
     Other objects and advantages of the invention will become apparent upon reading the following detailed description and upon reference to the drawings in which: 
       FIG. 1  is a sample floor plan of a desirably sanitary environment with embodiments of the worker tracking and hygienic substance dispensing systems of the hand hygiene system superimposed thereon; 
       FIG. 2  is a front view of an embodiment of a credential to be transported with the worker for interaction with the tracking and dispensing systems of  FIG. 1 ; 
       FIG. 3  is a schematic diagram of the tracking system of  FIG. 1 ; 
       FIG. 4  is a schematic diagram of the dispensing system of  FIG. 1 ; 
       FIG. 5  is a flow diagram of an embodiment of the credential-approval routine of the hand hygiene system; 
       FIG. 6  is a flow diagram of an embodiment of the credential-entry-options routine of the hand hygiene system; 
       FIG. 7  is a flow diagram of an embodiment of the credential-exit-options routine of the hand hygiene system; and 
       FIG. 8  is an embodiment of a report of hand hygiene data generated by the hand hygiene system. 
   

   While the invention will be described in connection with preferred embodiments, methods and implementations thereof, it will be understood that it is not intended to limit the invention to those embodiments, methods or implementations or to the details of the construction or arrangement of parts or steps illustrated in the accompanying drawings. 
   DETAILED DESCRIPTION 
   Turning first to  FIG. 1 , an exemplary floor plan of a desirably sanitary environment  10  is provided for the purpose of describing the invention. More particularly,  FIG. 1  illustrates a skeletal layout of at least a portion of a hospital care area. While the invention is described in relation to this illustrated environment  10 , the embodiments, methods and procedures of the invention are applicable to any environment which is targeted for improvement in hand hygiene practice. 
   The illustrated environment  10  is divided into areas including a hallway  11 , patient rooms  12 - 17  and lavatories  18  and  19 . Each of the areas  11 - 19  has doors or accesses  21 - 29 . Some of the rooms  12 - 19  have one or more sinks  32 - 39 . Assuming that a worker may come in contact with a patient in any of the patient rooms  12 - 17 , it is desirable to assure that the worker has implemented suitable hand-hygiene protocol before and after contacts with each patient with as great a degree of diligence as possible. While the protocol may differ according to the nature of the environment and even according to the special standards of a particular environment, the principles are the same. To this end, in this exemplary case, sensors  40 - 49  are located throughout the environment  10  to monitor the locations of the workers in the environment  10  on a continuous real time basis. To facilitate the practice of suitable hand hygiene activities, each of the sinks  32 - 39 , and the hallway  11  in which no sink is available, are provided with gel or soap dispensers  51 - 59 . For convenience in following the description, the associated elements of each area  11 - 19  are assigned identifying numbers with common digits. For example, a room access  22 , a sink  32 , a sensor  42  and a soap dispenser  52  are all associated with one room  12 . Similarly, another room  13  has an associated room access  23 , a sink  33 , a sensor  43  and a soap dispenser  53 . The identifying numbers of elements associated with the remaining areas and rooms are similarly coordinated for convenience of description. In areas having more than one element, the common elements are alphabetically grouped. For example, the lavatory  18  has two sinks  38 A and  38 B. The main doors  21 A and  21 B accessing the interior of the environment  10  are operable by a proximity reader  60  and power door operators  61 A and  61 B. 
   As seen in  FIG. 1 , the system tracks workers by tracking permanently issued credentials  120 A-D or temporary credentials  120 E-F which are made available to workers who do not have or have forgotten to carry their permanently issued credential and are, in real time, approved to access the desirably sanitary environment  10 . Looking at  FIG. 2 , an embodiment of a typical credential  120  is shown in greater detail. The credential  120  includes a case  121  with an infrared (IR) transmitter  122  and a transceiver  123 . The credential  120  has green, yellow and red LED&#39;s  124 ,  125  and  126 , and a beeper/speaker  127 . A clip (not shown) may be provided on the back of the case  121  to facilitate attachment of the credential  120  at a visible location on the apparel of the worker. A “zinger”  128  mounted on the bottom of the badge  120  permits retraction and extension of a cord  129  which is connected to a magnetic stripe, proximity and/or embedded chip card  131 . The card  131  may display photo identification  132  and/or printed identification  133  of the worker to whom it is assigned. Any or all of the permanent  120 A-D and temporary  120 E-F credentials shown in  FIG. 1  may have the same embodiment as the typical credential  120  illustrated in  FIG. 2 , but other embodiments of the credentials may be configured according to the needs of a particular application or environment. The credentials may, as shown, be structurally unitary or may employ structurally discrete components. For example, an IR system presently available from Versus Technology tracks workers by the use of IR badges which emit their own unique IR signal every three seconds for detection by IR sensors mounted on the ceilings of the areas selected for monitoring. BCM4317 single-chip wireless transceivers by Broadcom and associated transceiver/indicator/alert badges may be used in conjunction with the Versus Technology IR badges. Green and red LEDs on the badges can be used to indicate the state of hand-hygiene of the worker as being “hands clean” or “hands dirty,” respectively. Additional “please sanitize” visual indicators, such as yellow LEDs, may also be incorporated on each of the badges to remind the workers in the event of a failure to initiate dispensation of the hand-hygiene substance within a predetermined time after entering or exiting a monitored area. Similarly, audible alerts can be incorporated on each of the badges to provide unique sounding alarms corresponding to the red and yellow “hands dirty” and “please sanitize” visual indicators. 
   Looking at  FIG. 3 , the worker tracking system  70  associated with the environment  10  of  FIG. 1  includes the credentials  120  and sensors  40 - 49  above discussed. In addition, the system  70  includes collectors  71 - 73 , a concentrator  74 , a processor  75  and a transmitter  76  which receive and process data so as to continuously monitor the real-time location of each worker transporting a credential  120 . Each collector  71 - 73  can receive credential data signals from as many as 24 associated IR sensors  40 - 49  and assemble them into network ready packets. The collectors  71 - 73  relay them to a concentrator  74  which serves as the interface between the collectors  71 - 73  and the network processor  75 . A transmitter  76  communicates with the transceivers  123  of the credentials  120  under the control of the processor  75  to activate the green, yellow and red LED&#39;s  124 ,  125  and  126  and the beeper/speaker  127  on the appropriate credential  120  in accordance with the protocol established by the processor  75 . 
   Turning now to  FIG. 4 , the hand-hygiene station substance dispensing system  50  may include any one or more of various types of soap, soap and water or alcohol based gel, rinse or foam dispensers, such as Sloan Optima Electronic Soap Dispensers or Savona Auto Electronic Dispensers or the like. Each dispenser  51   d - 59   d  has an associated proximity reader  51   p - 59   p  which detects the workers&#39; unique credentials. For example, card readers such as HID Proximity Readers or Magtek 21080203 Card Readers or other devices may be used. Each dispenser  51   d - 59   d  is connected via a controller  62  to the network processor  75 . Each proximity reader  51   p - 59   p  is also connected to the network processor  75 . Detection of a credential  120  by a proximity reader  51   p - 59   p  signals the processor  75  to activate the controller  62  to cause its associated dispenser  51   d - 59   d  to release a predetermined quantity of soap, soap and water, gel, foam or rinse and to send a signal indicative of completion of such release to the network processor  75 . The network processor  75  then records the event and causes a wireless signal to be emitted by the transmitter  76  to the transceiver  123  of the corresponding credential  120  to energize its green “hands clean” LED  124 . 
   The network processor  75  is preferably programmed to accept some protocol cycles of hand-hygiene behavior and to reject all others. If an acceptable protocol cycle of hand-hygiene is completed, the processor  75  will cause the event to be recorded as a positive cycle for the worker. If an acceptable protocol cycle of hand-hygiene is required but not completed within a predetermined time period, the processor  75  will cause the failure to be recorded as a negative event for the worker. As above noted, the protocols may vary from application to application. In  FIGS. 5 ,  6  and  7 , the operation of the improved hand hygiene system is illustrated in relation to preferred embodiments of the environment access, patient room entry and patient room exit procedures  200 ,  250  and  280 , respectively, carried out by the network processor  75  and associated programming for a typical protocol. 
   Looking at  FIG. 5 , the environment access procedures  200  are based on the protocols pursuant to which a worker will be entitled to gain access to the desirably sanitary environment  10 . The environment access procedure  200  may apply to one or more of three possible options or scenarios. If a worker has no active credential  120  in possession at the time access to the environment  10  is desired, in the first scenario  201 , a temporary credential  120 F will be available within the confines of the environment  10  and in the second scenario  221 , a temporary credential  120 E will be available outside of the environment  10 . In the third scenario  231 , the worker will have an assigned active credential  120  in possession at the time access is desired. 
   It is presumed that, in an application in which one or both of the first and second scenarios  201  and  221  may occur, the access doors  21 A and  21 B to the environment  10  will be monitored so as to enable verification of the identity of the worker prior to entry. It is also presumed that some means of communication exists between the point of entry to the environment  10  and the location at which security personnel monitoring access to the environment  10  are present. Such communication should include means for the worker to signal a desire to gain access and for the security personnel to either activate an accessible temporary credential or release a temporary credential which has already been activated and/or to operate the entry doors  21 A and  21 B. It is preferred that the communication means be in communication with the network processor  75  so as to notify the system of a request for a temporary credential. It is also preferred that the communication means be in communication with the network processor  75  so as to notify the system of the approval by the security personnel of the request. It is further preferred that the communication means, in executing the release or activation of the temporary card, also be in communication with the network processor  75  to confirm that a temporary credential has been activated or released. 
   In the first scenario with “no active credential in possession”  201  and with a temporary credential  120 F available inside the confines of the environment  10 , the worker will use the communication system with the security personnel to request access to the temporary inside credential  120 F. Preferably, this request will automatically signal to the system “request for access to temporary inside credential”  202 . The system will then inquire as to whether “access approved”  203  by the security personnel. If the answer to the inquiry “access approved”  203  is “NO”  204 , the system will return to the status “no active credential in possession”  201  until another “request access”  202  is made. If the reply to the inquiry “access approved”  203  is “YES”  205 , the system will proceed to inquire as to whether the “access door opened”  206 . The answer to the inquiry “access door opened”  206  can be determined, for example, by electronically monitoring the status of the power door operators  61 A and  61 B or the doors  21 A and  21 B. If the answer to the inquiry “access door opened”  206  is “NO”  207 , the system will return to the status “no active credential in possession”  201 . If the reply to the inquiry “access door open”  206  is “YES”  208 , the system will inquire as to whether “entry detected”  209 . If the reply to the inquiry “entry detected”  209  is “NO”  210 , the system will return to the status “no active credential in possession”  201 . If the reply to the inquiry “entry detected”  209  is “YES”  211 , the system will next inquire as to whether “access door closed”  212 . If the reply to the inquiry “access door closed”  212  is “NO”  213 , the system will preferably cause an indication of this condition to be communicated to the security personnel. If the reply to the inquiry “access door closed”  212  is “YES”  214 , the system will next inquire as to whether “temporary credential timely acquired”  215 . If the reply to the inquiry “temporary credential timely acquired”  215  is “NO”  216 , the system will preferably advise security personnel of this condition. If the reply to the inquiry “temporary credential timely acquired”  215  is “YES”  217 , the system will proceed to the status “in hall with credential”  248  indicative of the presence of a worker in the environment  10  with an active credential  120  and the yellow LED  125  will be activated  249  to the “please sanitize” status. 
   In the second scenario with “no active credential or possession”  221  and with a temporary credential  120 E available outside of the environment  10 , the operation of the communication system to request access from the security personnel will automatically signal to the system a “request temporary outside credential”  222 . The system will then inquire as to whether “request approved”  223 . If the answer to this inquiry is “NO”  224 , the system will return to the status “no active credential in possession”  221  and wait for such a request. If the reply to the inquiry “request approved”  223  is “YES”  225 , the security personnel will then activate or release the temporary credential  120 E and the action taken by the security personnel will preferably automatically cause a signal to the system of the status “temporary credential activated or released”  226 . Once the temporary credential  120 E is activated and/or released to the possession of the worker, the procedure of the second scenario  221  will continue as in the third scenario  231  hereinafter described. 
   In the third scenario with an “active credential in possession outside”  231 , the worker outside of the environment  10  may have either an active credential  120 A which was issued to them or a temporary credential  120 E acquired outside of the environment  10  pursuant to the second scenario  221 . In either event, the system constantly inquires as to whether “proximity detected”  232  for any credential. If the answer to the inquiry “proximity detected”  232  is “NO”  233 , the system returns to the status “no active credential in possession”  231 . If the answer to the inquiry “proximity detected”  232  is “YES”  234 , the system will next inquire as to whether the “access door opened”  235 . If the answer to the inquiry “access door opened”  235  is “NO”  236 , the system will preferably notify the security personnel of this status. If the answer to the inquiry “access door opened”  235  is “YES”  237 , the system will inquire as to whether “entry detected”  238 . If the reply to the inquiry “entry detected”  238  is “NO”  239 , the system will preferably cause the access door to close and notify the security personnel of this status. If the reply to the inquiry “entry detected”  238  is “YES”  240 , the system will inquire as to whether the “access door timely closed”  241 . If the answer to the inquiry “access door timely closed”  241  is “NO”  242 , the system will preferably cause the door to close and notify security personnel. If the reply to the inquiry “access door timely closed”  241  is “YES”  243 , the system proceeds to the status “in hall with credential”  248  and the yellow LED  125  will be activated  240  to the “please sanitize” status. 
   Turning to  FIG. 6 , the end result of each of the environment access procedures  200  for any of the scenarios  201 ,  221 , or  231  is to achieve the status “in hall with credential”  248  indicative of the presence of a worker in the environment  10  with an active credential  120 . When the status “in hall with credential”  248  is achieved, the system will activate the yellow LED  125  on the credential  120  so that the worker and those in contact with the worker will know that the worker is present in the environment  10  and has not yet properly completed a hand-hygiene protocol. 
   The system now monitors the worker&#39;s activities in accordance with the protocols determined by the user for that particular application. In  FIG. 6 , one embodiment of the protocol for “patient room entry”  250  is illustrated. Once the worker is in the environment  10  and the yellow LED  125  is activated  249  to the “please sanitize” status, the system continually inquires as to whether an event “dispense outside”  251  has occurred. Such an event is signaled when an outside dispenser detects the proximity of a credential  120 . In this regard, looking at  FIGS. 1 and 4 , rooms  12 - 17  are rooms in which a worker may come in contact with a patient. Soap dispensers  52 - 57  are located in these rooms, respectively. All other dispensers, including the gel dispensers  51 A,  51 B and  51 C in the hall  11  and the soap dispensers  58 A,  58 B,  59 A and  59 B in the lavatories  18  and  19  are outside dispensers. 
   If any proximity reader  51   p - 59   p  of an outside dispenser  51 A-C,  58 A-B or  59 A-B detects the proximity of the credential  120 , the reply to the inquiry “dispense outside”  251  is “YES”  252  and the system will automatically cause the associated dispenser to dispense its hand hygiene substance and “record outside dispense D O ”  253 . The green LED”  124  is activated  254  to the “hands clean” status. The effectiveness of the system assumes that a worker who has presented a credential to a proximity reader  51   p - 59   p  as illustrated in  FIG. 4  will receive and use the hand hygiene substance dispensed by the same dispenser  51 - 59 . After dispensing substance outside, the system inquires as to whether there has been “timely entry”  255  into a patient&#39;s room. The duration of the specified time will be established by the system user in accordance with the user&#39;s protocol needs. If the worker has not entered a patient&#39;s room within the specified time, the reply to the inquiry “entry timely”  255  will be “NO”  256 , in which case the system will return to the status “in hall with credential”  248 . The yellow LED  125  is activated  249  to the “please sanitize” status. However, if the response to the inquiry “entry timely”  255  is “YES”  257 , the system will “record timely entry E T ”  258  and the green LED  124  is activated  259  to the “hands clean” status. The system will then proceed to the status “in room-clean hands”  279 . 
   If none of the outside dispensers  51 A-C,  58 A-B or  59 A-B detects the proximity of a credential  120 , the response to the inquiry “dispense outside”  251  is “NO”  261  and the system continuously waits to detect a “room entry”  262 . If no active credential  120  is detected to have made a “room entry”  262 , the answer to the inquiry “room entry”  262  is “NO”  263  and the system returns to the status “in hall with credential”  248  with the yellow LED  125  activated  249  to the “please sanitize” status. If an active credential  120  enters into any patient room  12 - 17 , the answer to the inquiry “room entry”  262  is “YES”  264  and the system will “record entry E”  265 . In this event, the system will next inquire as to whether the appropriate inside dispenser, that is the dispenser in the entered room, has “dispensed inside timely”  266  which occurs if the proximity reader  51   p - 59   p  at the dispenser  51   d - 59   d  detects the timely proximity of the credential  120 . If the response to the inquiry “dispensed timely inside”  266  is “NO”  267 , the system will preferably “record failure”  268  and the red LED  126  will be activated  269  to the “hands dirty” status. Preferably, simultaneously, the beeper  127  will be activated to provide an audible indication of the “hands dirty” status. In this status, any event in which the credential  120  associated with the “hands dirty” status triggers the in room dispenser to “dispense inside”  270 , the green LED  124  will be activated  271  to the “hands clean” status and, if applicable, the beeper  127  deactivated. Again, the time within which the inside dispenser must detect the proximity of the credential  120  will be established by the user of the system in accordance with its particular protocol needs. If the response to the inquiry “dispensed inside timely”  266  is “YES”  272 , then the system will “record timely inside dispense D TI ”  273 . The green LED  124  is activated  274  to indicate the “hands clean” status and, if applicable, the beeper  127  is deactivated. The system now proceeds to the status “in room-clean hands”  279 . 
   Upon completion of the “patient room entry”  250  procedure, a worker will have completed the first half of an acceptable hand hygiene protocol either by a demand on outside proximity reader  51   p ,  58   p  or  59   p  for an “outside dispensing D O ” of substance followed by a “timely entry E T ” into a patient&#39;s room  12 - 17  or by an “entry E” into a patient&#39;s room  12 - 17  followed by a demand on an inside proximity reader  52   p - 57   p  for a “timely inside dispensing D TI ” of hand hygiene substance. 
   The “patient room exit procedures”  280  constituting the second half of an acceptable hand hygiene protocol are illustrated in  FIG. 7 . Once the worker has achieved the status “in room-clean hands”  279 , the green LED  124  on the credential  120  has been activated to evidence compliance with the first half of the protocol. The presence of the worker in the patient&#39;s room means that there has possibly been contact with the patient. The system, therefore, will continuously inquire as to whether another demand has been made for a sanitizing substance before the worker leaves the patient&#39;s room. It is assumed that such a demand will result in substance being dispensed to the worker making the demand. 
   If the response to the inquiry “dispensed inside”  281  is “NO”  282  and the system detects “room exited”  283 , the system will “record exit X”  284  and the yellow LED  125  is activated  285  to the “please sanitize” status. The system will then inquire as to whether a demand is made for a “timely outside dispensing”  286  of sanitizing substance, which is assumed if a proximity reader  51   p ,  58   p  or  59   p  of an outside dispenser  51   d ,  58   d  or  59   d  timely detects the proximity of a credential  120 . The permissible time delay between “room exited”  283  and “timely outside dispensing”  286  is established by the user in accordance with the user&#39;s particular protocol needs. If the response to the inquiry “timely outside dispensing”  286  is “NO”  287 , the red LED  126  will be activated  288  to evidence the “hands dirty” status and, if desired, the beeper  127  will also be activated to give audio alert to the status. In this status, the worker can make a demand for substance to be “dispensed outside”  289  to cause the green LED  124  to be activated to the “clean hands” status. If the answer to the inquiry “timely outside dispensing”  286  is “YES”  291 , the system will record “timely outside dispensing D TO ”  292  and the green LED”  124  will be activated  293  as visual indication of a “hands clean” status. The completion of the room exited X and timely outside dispensing D TO  protocol after completion of either of the acceptable room entry protocols discussed above results in a credit to the credential  120 . The green LED  124  will indicate the “hands clean” status for a predetermined time period and then will return the worker to the status “in hall with credential”  248  of  FIG. 6  with the yellow LED  125  indicating the “please sanitize” status. 
   If the response to the inquiry “dispensed inside”  281  is “YES”  295 , the system will “record inside dispensing D I ”  296 . The system will then inquire as to whether the worker has “timely exited”  297  the room. The duration of time between “dispensed inside”  295  and “timely exited”  297  is also determined by the user in accordance with the user&#39;s hand hygiene protocol needs. If the answer to the inquiry “timely exited”  297  is “NO”  298 , the system will “record failure”  299  and the red LED  126  is activated  301  to evidence the “hands dirty” status. If applicable, the beeper”  127  will also be activated to provide audio alert of the “hands dirty” status. If the answer to the inquiry “timely exited”  297  is “YES”  302 , the system will “record timely exit X T ”  303  and the green LED  124  is activated  304  to evidence the “hands clean” status. The completion of the dispensed inside D I  and timely exited X T  protocol after completion of either of the acceptable room entry protocols results in a credit to the credential  120 . The green LED  124  will indicate the “hands clean” status for a predetermined time period and then will return the worker to the status “in hall with credential”  248  of  FIG. 6  with the yellow LED  125  indicating the “please sanitize” status. 
   Thus, with respect to a single credential  120 , when any of the four possible correct protocols occurs, a credit will be applied to the account of that credential  120 . To summarize, the four acceptable protocols are:
 
D O +E T +X+D TO ;
 
D O +E T +D I +X T ;
 
E+D TI +X+D TO ; and
 
E+D TI +D I +X T .
 
   Returning to  FIG. 1 , the operation of the system in monitoring a worker, encouraging compliance with protocol and recording data useful in analyzing worker reports can be understood. If, for example, a worker does not have their personal credential  120  in their possession and desires access to the environment  10  to interact with a patient in the room  15  at the far left end of the hallway  11 , the worker would go to the location outside the entry doors  21 A and  21 B where temporary credentials such as the credential  120 E are available. At that location, using the available means of communication with security personnel, the worker would request issuance of the temporary card  120 E. That request is preferably automatically entered into the system. The security personnel would confirm that the worker was approved by the system user for access to the environment  10  and, if so, use the communication system either to activate the credential  120 E for the worker or, if the credential  120 E was already activated, to release the activated credential  120 E to the worker. Preferably, upon the taking by the worker of the activated or released credential  120 E, the communication system would automatically enter confirmation into the system of the activation or release of the temporary credential  120 E. Such confirmation would enable the system to determine the frequency of such requests as well as positive responses to such requests. Once the temporary credential  120 E has been activated or released, the temporary credential  120 E can be handled in one of two ways depending on the preference of the system user. If the user&#39;s goal is to encourage the use of permanent credentials  120 , the system can be configured so that the temporary credential  120 E will be monitored by the system to encourage compliance with hand hygiene protocol but will not be credited to the worker&#39;s credits for compliance. If, however, the user&#39;s goal was strictly to encourage hand hygiene protocol compliance, the use of the temporary credential  120 E could be credited to the worker until the credential  120 E is returned to its source. 
   Assuming a system in which credit is to be given, the system will operate in the same fashion for a temporary card  120 E as it would for a permanent card  120 A used to gain admittance through the doors  21 A and  21 B to the environment  10 . The worker would present the active card  120  to the proximity reader  60  and the access doors  21 A and  21 B would open. The sensor  40  outside of the doors  21 A and  21 B would monitor the presence of the worker outside of the doors and, upon the worker&#39;s entry into the hallway  11 , monitoring of the worker&#39;s presence would transfer to the first sensor  41 A in the hallway  11 . When the first sensor  41 A detects the worker&#39;s presence, the access doors  21 A and  21 B would close. The closing should occur within a short period of time after the opening to assure that only the approved worker in possession of the credential  120  has entered the hallway  11 . If the access door has not closed within a short enough time interval after entry of the worker, security personnel should be alerted as to the delay. If the initial sensor  41 A has detected entry and the doors  21 A and  21 B have timely closed, the system will preferably record that the credential  120  is now in the environment  10  and activate the yellow LED  125  on the credential to indicate that, at this point, the worker is in a “please sanitize” status. As the worker moves down the hallway  11 , the monitoring task will switch from the initial sensor  41 A to the intermediate sensor  41 B in the middle of the hallway  11 . As the worker continues down the hallway  11 , the monitoring responsibility will eventually transfer from the intermediate sensor  41 B to the end of hall sensor  41 C. During this time the yellow LED  125  continues to indicate the “please sanitize” status. When the worker enters the patient room  15  through entry  25 , monitoring responsibility transfers to the in-room sensor  45 . The detection of the entry into the room  15  by the sensor  45  causes the system to record the entry E as a protocol event. Since no sanitizing activity has previously been attributed to this credential, the detection of the room entry will activate a system timer to assure that a sanitizing event occurs in the room quickly enough that there is little likelihood that the worker can come in contact with the patient prior to the sanitizing action. If the proximity reader of the in-room soap dispenser  55  does not detect the proximity of the credential  120  within the specified time, the red LED  126  on the credential  120  will be activated to indicate the “hands dirty” status. Preferably, the audio or beeper  127  of the credential  120  will also be activated, so that both visual and audio alarms as to the “dirty hands” condition is given. On the other hand, if the proximity of the credential  120  is timely detected by the dispenser  55 , then the timely dispensing of the substance by the inside dispenser D TI  will be assumed and recorded by the system as a protocol event. The green LED  124  will be activated and the beeper  127  deactivated so as to indicate the “hands clean” status for the credential  120 . 
   If, on the other hand, the worker used one of the outside dispensers  51 A,  51 B or  51 C in the hallway  11  or one of the outside dispensers  58 A,  58 B,  59 A or  59 B in a lavatory  18  or  19 , then the detection by the outside dispenser of the proximity of the credential  120  would cause the system to assume the dispensing of substance for use by the worker and to record an outside dispensing D O  as a protocol event. Such a dispensing would also result in the activation of the green LED  124  so as to indicate the “hands clean” status. To assure that the hands do not become contaminated after the sanitizing event, the worker must enter the patient&#39;s room  15  in timely fashion thereafter. If the room sensor  45  does not detect an entry within the specified time, then the system reverts to the in-hall status, records the failure and activates the yellow LED  125  to advise of the “please sanitize” status. However, if the sensor  45  in the room  15  detects the entry of the credential  120  within the time specified, the timely entry E T  is recorded as a protocol event. 
   Consequently, whether the worker entered the patient&#39;s room E and timely executed a sanitizing event in the room D TI  or performed a sanitizing event out of the room D O  and then timely entered the room E T , half of a satisfactory protocol cycle would have been recorded and the green LED  124  will indicate the “hands clean” status. If these events were not timely completed and the worker was in the patient&#39;s room  15 , then the red LED  126  and beeper  127  would notify of the “dirty hands” status. 
   When the worker finishes the tasks to be performed in the patient&#39;s room  15 , the worker&#39;s hands are likely contaminated as a result of contact in the room  15 . If, before exiting the room  15  the worker uses the dispenser  55 , then the system will record the inside dispensing D I  as a protocol event. If the worker exits the room  15  in timely fashion after the sanitizing event, the system will also record the timely exit X T  as a protocol event. If the worker does not exit the room  15  in time, the red LED  126  will be activated and the beeper  127  will sound to indicate the “hands dirty” status. If the worker exits the room  15  before sanitizing the system will record the exit X as a protocol event. If the worker timely sanitizes after exiting the room  15 , the system will record the timely outside dispensing D TO  as a protocol event. If the worker does not timely sanitize after exiting, then the red LED  126  will be activated and the beeper  127  will sound to indicate the “hands dirty” status. Preferably, the red LED  126  is always on when half a protocol is started and is not properly completed, the yellow LED  125  is always on when the worker is in the hall for a predetermined time period without sanitizing as a reminder to sanitize before or immediately after exiting a patient&#39;s room and the green LED  124  is always on when half a protocol is properly completed. 
   Turning to  FIG. 8 , each worker will preferably receive a monthly report or printout  320  of the positive and negative events recorded by the processor  75  for all workers performing within the system. As shown, the report  320  will indicate the month reported  321 , the total number of patient room entries  322 , the total number of completed hand hygiene protocol cycles  323  and the overall percentage of hand hygiene compliances  324 . The report  320  may also anonymously rank the individual workers according to their respective percentage of the total of positive events for the reported month  321 . As shown, each worker&#39;s unique credential  120  can be associated with a worker number  325  known only to that worker and the worker&#39;s supervisory personnel. Each worker&#39;s patient room entries  326 , completed protocol cycles  327  and percentage of completed cycles  328  can be shown for personnel comparison of that worker&#39;s individual hand hygiene performance in relation to the performance of the group. Workers, or groups of workers, can be rewarded by use of suitable event redemption programs as may be deemed appropriate by the system manager. Overall rates of hand-hygiene compliance and rates of various nosocomial infections can be tracked, tallied and recorded to evaluate the success of the system. 
   Many additional features can be incorporated into or variations made in the system. For some users or in specific situations there may be a preference between use of soap or gel. For example, where  C. difficile  infections are a concern, use of soap and water is preferred to use of a gel. The system can be programmed to prohibit the proximity readers associated with gel dispensers from detecting the credentials  120  so as to force use of the soap dispenser to complete part of a protocol. Protocol sequences and time delays can be varied. An inside dispensing before exiting a patient&#39;s room may be counted as an outside dispensing before entering another patient&#39;s room if timely performed. 
   Thus, it is apparent that there has been provided, in accordance with the invention, a system, method and implementation for increasing the likelihood of hand hygiene in a desirably sanitary environment that fully satisfies the objects, aims and advantages set forth above. While the invention has been described in conjunction with specific embodiments, methods and implementations thereof, it is evident that many alternatives, modifications and variations will be apparent to those skilled in the art and in light of the foregoing description. Accordingly, it is intended to embrace all such alternatives, modifications and variations as fall within the spirit of the appended claims.