New hand hygiene era begins with alcohol rubs

Poor compliance leads to new emphasis

Facing a miserable history of hand-washing compliance in an era of patient safety, infection control experts are dropping the traditional soap and sink approach to open a new age of alcohol-based, waterless hand rubs. In guidelines nearing finalization as this issue went to press, the Centers for Disease Control and Prevention (CDC) officially will recommend the use of waterless alcohol products for most patient care encounters unless hands are visibly soiled.

"The major goals of the new hand hygiene guideline that will be coming out soon is to make hand hygiene fast, easy, and effective," explained John Boyce, MD, hospital epidemiologist at the Miriam Hospital in Providence, RI, and a consultant in the development of the guidelines. "In doing so, we believe that we can reduce transmission of pathogens in health care facilities," he said at the recent Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) in San Diego.

Developed by the CDC Healthcare Infection Control Practices Advisory Committee (HICPAC), the recommendations are slated for publication in an upcoming issue of the CDC’s Morbidity and Mortality Weekly Report. The CDC is expected to develop some educational materials to assist infection control professionals in converting the masses to the new approach, which has been used in European hospitals for some time.

"It’s a concern because it is very hard to change people’s ingrained beliefs and behaviors," added Elaine Larson, RN, PhD, HICPAC member and a professor of pharmaceutical and therapeutic research at Columbia University School of Nursing in New York City. "It’s going to be a huge educational burden on infection control." Larson recently moderated a hand-washing research session at ICAAC, where emerging data suggested the alcohol-based rubs may be both efficacious and well-accepted by workers. Among the studies presented was the use of a motion-detector voice-prompt device that reminds offenders to wash their hands.

An indefensible situation

Infection control professionals have been trying to improve hand-washing compliance through recommendations and strategies for decades. All to little avail. "We haven’t made any progress on improving compliance in the last 20 years; the average compliance is about 40%," Boyce told ICAAC attendees. "You know what? With all the resistant organisms that we have around today and the emphasis on patient safety, I don’t think that we can defend these kind of compliance rates any longer."

The problem, unfortunately, is multifactorial, said Boyce, a consultant to HICPAC in developing the guidelines. He cited such contributing variables as intensity of care, work loads, irritant contact dermatitis associated with frequent hand washing, inaccessible sinks, and lack of institutional commitment. "We have really no positive rewards for people who do a good job with hand washing or any effective sanctions for those people who don’t," he said. "And we haven’t done a very good job of educating our colleagues about the fact the patient’s normal intact skin is often colonized with potential pathogens."

Given this litany of woes with traditional soap and sinks, it is little wonder that waterless alcohol-based rubs have emerged as a new alternative. The results of more than 20 published studies show the solutions effectively decontaminate hands in a matter of seconds, Boyce said. "So if we use alcohol, we’re not losing anything in terms of efficacy," he said. Studies also have shown that rubs that contain emollients cause less skin irritation and dryness than washing hands with soap and water.

"Hand-washing compliance among health care workers has remained unacceptably low for decades, and it’s about time that we did something about this," Boyce said. "We need to take into account the fact that these alcohol-based hand rubs can be made more accessible. They can be placed all over the ward. They don’t require a sink. For that reason, they are faster. They actually cause less skin irritation and dryness, and they are actually more effective than washing with soap and water. And finally, there’s at least some evidence now that promoting their use can lead to improved hand hygiene compliance."

Traditional wash still has role

A traditional hand wash will remain the recommendation if blood, body fluids, or other obvious soilage contaminates a worker’s hands, he said. "We [also] recommend that you wash your hands with either a nonantimicrobial soap or an antimicrobial soap before eating and after using a rest room," Boyce said. "Now, if your hands are not visibly soiled, which is actually, I think, most of the time, then using an alcohol-based hand rub routinely before and after patient contact is recommended." The new guidelines will urge hospitals to spend the money to provide health care workers with hand lotions and creams that minimize irritant contact dermatitis, he added.

"The guideline also recommends that institutions make hand hygiene an institutional priority," Boyce said. "Now, this sounds kind of like mom and apple pie, but I can tell you that if your hospital or other health care institution doesn’t get behind you, doesn’t make resources available, and isn’t visibly in support of your program, then you’re going to have a hard time."

The new guidelines also will call for monitoring hand hygiene compliance and providing health care workers written information about their performance. "We need to feed back the information," he said. "We should consider educating patients and their family members about the importance of hand hygiene and [telling them] that it’s actually OK for them to remind their caregivers to decontaminate their hands."