Make a revolutionary’ change in hand hygiene
No brushing, no water, no artificial nails
New hand-hygiene guidelines from the Centers for Disease Control and Prevention (CDC) in Atlanta strongly advise hospitals to use waterless, alcohol-based rubs — even for surgical scrubs. The guidelines, which are still in draft form, tout the greater antimicrobial efficacy of the rubs and their benefits in reducing skin irritation and encouraging health care workers to improve hand hygiene. (See "CDC’s draft hand-hygiene recommendations" in this issue.) They also take some bold stands: No more brushing during the pre-op surgical scrub and no artificial nails. Hand lotion, once implicated in a nosocomial outbreak, can actually help reduce infection as long as it is dispensed properly.
"We think this recommendation [for alcohol-based rubs] could potentially revolutionize the practice of infection control in health care settings, hopefully by improving adherence to hand-hygiene practices," says Michele Pearson, MD, a medical epidemiologist at CDC who worked with the hand-hygiene task force.
"It’s probably one of the most revolutionary guidelines in terms of major changes in standard care that CDC has [released]. It will be a major culture change for most hospitals," says Elaine Larson, RN, PhD, professor at the Columbia University School of Nursing in New York City, an expert on hand hygiene and a member of the task force. "If they haven’t been keeping up, they’ll be shocked at some of these recommendations. [However], they’re all data-based, evidence-based."
The guidelines were developed by a joint task force of four organizations and advisory groups: CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC), the Society for Healthcare Epidemiology of America (SHEA), the Association for Professionals in Infection Control and Epidemiology (APIC), and the Infectious Diseases Society of America (IDSA). The task force will consider comments to the draft guidelines at its February meeting.
Over the past 10 years, research gradually has changed the thinking about what works in hand hygiene. Hand washing with antimicrobial soap has been considered the preferred practice after patient contact. The existing CDC guidelines, issued in 1985, advise the use of waterless rubs when soap and water aren’t available.
But repeated hand washing with soap and water lead to cases of dermatitis among health care workers. That concern, along with other factors such as inaccessibility of sinks, led to low rates of hand washing. A review of literature found that, on average, only 40% of health care workers follow recommended hand-hygiene procedures.1
The waterless, antimicrobial agents are more convenient, less irritating, and more effective at preventing the spread of infection, notes Jane D. Siegel, MD, professor of pediatrics at South-western Medical School of the University of Texas in Dallas. "Studies have shown there’s actually better efficacy of the waterless products in removing microorganisms from the hands than soap and water. Because they contain emollients, they’re easier on the skin and they seem to be better accepted by health care workers."
Some hospitals already have switched to waterless products. But the guidelines still present a challenge to the health care community as they call for changes in long-standing practice. Cost is one barrier to acceptance of the recommendations. The alcohol-based rubs are more expensive than traditional soaps and would require the installation of convenient dispensers in patient rooms. Yet just one health care-acquired infection would cost more than a hospital’s entire annual budget for hand-hygiene products, according to the task force. "It’s been shown that preventing infection more than outweighs the cost," Siegel says.
Surgical scrubbing sheds skin, organisms
The biggest culture change urged by the hand-hygiene task force involves the surgical scrub. Rather than a prolonged scrub with soap and water, the guidelines call for using antimicrobial agents without using a brush. Scrubbing with a brush, soap, and water may seem like a meticulous way to remove bacteria. But the brush actually sheds skin, and "skin shedding is the way organisms are spread from health care worker’s hands to patients," Larson says. The brush also increases damage to the skin, which also undermines hand hygiene. "When you have skin damage, sometimes you become colonized with less desirable organisms," she says.
Meanwhile, in an article in the journal of the Association of periOperative Registered Nurses in Denver, Larson reported greater efficacy of alcohol-based products than the traditional scrub.2 One reason: Alcohol-based rubs actually may remain on the hands after gloving and continue to provide antiseptic activity, Siegel says.
Hand lotion once was considered a culprit in nosocomial outbreaks, but the task force noted that lotion can reduce irritant contact dermatitis and improve acceptance of hand-hygiene practices among health care workers. The recommendation: Hospitals should provide health care workers with lotions or creams.
The task force took a strong position on the relationship between nails and hand hygiene. Artificial nails should not be worn by anyone providing patient care, and natural nails should be less than one-quarter inch long, the guidelines state. "Once we presented our data to nursing management, they were actually quite receptive," says Siegel of her experience at Southwestern Medical Center. "They felt this was something we have to do."
Easy access to alcohol-based hand rubs can lead to better hand hygiene, the task force stated. But access isn’t the only issue. Health care workers need to be educated about the efficacy and importance of hand hygiene. Their adherence should be monitored and hospitals should provide feedback on performance, the task force said. Hospitals need to review everything from written policies to the impact of high workloads and understaffing on hand hygiene, it explained. Administrative support is critical to make hand hygiene a part of a broader "safety climate," they concluded.
As hospitals select new products to comply with the guidelines, employees should be involved in the choice, the guidelines state. Employees may prefer different products based on color, smell, feel, and other qualities. Their involvement in selection gives them a sense of "ownership" in the change, Siegel says.
Meanwhile, hospitals should monitor their experience with the new products, Larson advises. "Since these products have not been used extensively in the U.S., we need to do careful monitoring to make sure there aren’t side effects we haven’t detected," she says. However, Larson notes that major side effects haven’t occurred in Europe, where alcohol-based products have been used for years.
While the guidelines represent a substantial change in practice for many hospitals, the switch from soap and water to a waterless rub shouldn’t be too difficult for health care workers to overcome, says Siegel. "We’ve been desperately trying to get people to wash their hands for decades, and we still struggle to get the adherence," she says. "So I don’t know that people are all that bonded to washing their hands."
References
1. Boyce JM, Pittet D, the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force and the Healthcare Infection Control Practices Advisory Committee. Draft Guideline for Hand Hygiene in Health Care Settings. November 2001. Web site: www.cdc.gov/ncidod/hip/hand/handhygiene2001.pdf.
2. Larson EL, Aiello AE, Heilman JM, et al. Comparison of different regimens for surgical hand preparation. AORN J 2001; 73:412-414, 417-418.
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