Safe and soap-free: CDC endorses alcohol rubs
Hand hygiene rises with water-free products
Stop trying to get health care workers to wash their hands.
If they rub their hands with an alcohol-based gel, they can save time, avoid skin irritation, and reduce hospital-acquired infections, advises the Centers for Disease Control and Prevention (CDC).
Washing with soap and water still is the only way to remove debris, including blood and body fluids. But a fundamental change in the way hospitals handle hand hygiene will save lives, says CDC director Julie L. Gerberding, MD, MPH, as the agency released the new hand-hygiene guidelines at the annual meeting of the Infectious Diseases Society of America in Chicago.1
"We’ll end up with more people doing the right things to clean their hands more of the time — and, ultimately, a better impact for patient safety," she says.
The problem of hospital-acquired infections has gained widespread attention beyond medical circles. It was the focus of a series in the Chicago Tribune last summer, which reported that more than 100,000 people die each year of hospital-acquired infections. The newspaper used various data sources to estimate the total number of infection-related deaths and arrived at a number that is higher than CDC estimates.
By making it easier for health care workers to practice good hand hygiene, compliance will go up and infections will go down, Gerberding and task force members say.
"There are [more than] 30 studies that have been done in about the last 20 years that show that health care workers have just not been able to wash their hands as often as recommended. So this is very well-documented, and it’s not a new problem," says John Boyce, MD, lead author of the guidelines and chair of the Hand Hygiene Task Force. Boyce is chief of the division of infectious diseases at the Hospital of Saint Raphael in New Haven, CT.
In fact, the guidelines cite studies that show, on average, that health care workers comply with proper hand hygiene only about 40% of the time.
Hospitals using alcohol-based rubs that employees can carry in small bottles report dramatic improvement in hand hygiene. "The convenience and the ease with which one can perform hand hygiene is so much [better] than waiting in line at the sink and then having to do something with the towel afterward," says William Shaffner, MD, chairman of the department of preventive medicine at Vanderbilt University Medical Center in Nashville, TN.
The new hand-hygiene guidelines seek to spark a fundamental change in the way health care workers clean their hands. They state that:
- Alcohol-based hand rubs can be used in place of soap and water for surgical scrubs.
- Alcohol-based hand rubs should be used for routine decontamination before, during and after patient care.
- Antimicrobial wipes aren’t as effective as alcohol-based hand rubs or hand washing with antimicrobial soap in reducing bacterial counts.
- Washing with soap and water, either antimicrobial or nonantimicrobial, is necessary to remove visible soil such as dirt, blood, or body fluids.
- Alcohol-based products aren’t effective against the spores of Bacillus anthracis, so if exposure is suspected, health care workers should use soap and water.
- Hand hygiene should be practiced in conjunction with glove use — before and after donning gloves.
- Health care workers who have direct contact with high-risk patients, such as in the operating room or intensive care unit, should not wear artificial nails or nail extenders.
While it will take education to shift the practices of health care workers, they will quickly discover the advantages, predicts Elaine L. Larson, RN, PhD, a professor at the Columbia University School of Nursing in New York City and a hand-hygiene expert. Until recently, hand hygiene was time-consuming and difficult. Total compliance with proper hand washing in an intensive care unit would take 16 hours per nursing shift, compared with just three hours using a bedside-based alcohol-based rub, Larson says, citing a study from the Netherlands and Switzerland.2 Such frequent hand washing also would be damaging to the hands, she notes.
"There’s a huge benefit to the new guidelines recommending alcohol-based hand products in terms of the ability to actually have the time to do what the guidelines suggest," she says.
At Vanderbilt, Shaffner says he quickly expanded the new hand-hygiene products from the intensive care unit to the entire institution because of the positive response. "These are acceptable, and our health care workers were indeed involved in choosing the specific products," he says. "There is no doubt that compliance has increased."
Hand-hygiene experts expect health care workers to embrace the new products. After all, alcohol-based hand rubs that contain emollients may be less irritating than soap products, the guidelines state.
But there are differences in the products. They come in the form of gels, foams, or rinses. Health care workers should be involved in the selection of the product, Gerberding advises.
In fact, the hospital may purchase more than one product to allow a choice. If the products are drying, the hospital also may choose to provide a lotion.
"There are big differences in how they smell, how they feel, user-friendliness of the various preparations, and so it has to be a process that engages the work force in the selection and the choice of the specific materials that work for them," she says.
Meanwhile, the CDC has developed a variety of staff education materials to promote hand hygiene, including buttons and posters that say, "Clean hands save lives." The CDC also is developing other educational materials.
Monitoring compliance with hand hygiene is an essential part of the program, the guidelines state. Gathering performance indicators can help hospitals determine the effectiveness of the program and motivate workers.
"However, making an alcohol-based hand rub available to personnel without providing ongoing educational and motivational activities may not result in long-lasting improvement in hand-hygiene practices," the task force stated in the guidelines.
(To see the hand-hygiene guidelines and related materials, go to: www.cdc.gov/handhygiene.)
References
1. Guideline for hand hygiene in health care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/ APIC/IDSA Hand Hygiene Task Force. MMWR 2002; 51(RR16):1-44.
2. Voss A, Widmer AF. No time for handwashing? Handwashing versus alcoholic rub: Can we afford 100% compliance? Infect Control Hosp Epidemiol 1997; 18:205-208.
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