Better compliance and better tolerance in relation to a well-conducted introduction to rub-in hand disinfection

Assessment of Alcohol-Based Hand Sanitizers for Long-Term Use, Formulated with Addition of Natural Ingredients in Comparison to WHO Formulation 1

During the spread of COVID-19, many laboratories used the "Formulation 1" proposed by the World Health Organization to prepare hand sanitizers. Taking into consideration its ingredients and the prolonged use of hand sanitizers, "Formulation 1" (P1) was compared with two gel formulations (P2 and P3) prepared with the addition of natural emollients and two different viscosity enhancers to define their chemical-physical stability, biocidal efficacy, and in vivo acceptability and tolerability. P1 resulted in the most efficient biocide but was poorly tolerated by the skin and not acceptable in volunteer hedonic evaluation, especially in terms of irritation and drying effect, with an expectable reduction in the compliance. Moreover, its liquid formulation is unpractical and can cause ethanol evaporation. P2 and P3 proved to be both good products regarding pH and alcohol strength values. However, in terms of viscosity, texture, ease of use, and application, P3 seemed to be a better gel product than P2. Moreover, they were well tolerated by the skin, increasing the hydration of the stratum corneum, due to the addition of Calendula officinalis and Aloe vera. Despite a lower ethanol concentration than P1, P2 and P3 also showed a good biocide efficiency, with better results in P2. In conclusion, these gel formulations proved to be more convenient for long-term use with a good balance between efficacy, safety, and compatibility with the skin.

Comparing rubbing and scrubbing surgical hand antisepsis with propan-1-ol 60% in accordance with European regulation UNE-EN 12791:2016+A1:2018

A crossover trial was conducted to compare hand rub and hand scrub-brush methods for reducing bacterial loads when using propan-1-ol-60% according to European regulations. Both methods significantly reduced the bacterial load immediately after antisepsis, but only the hand rub method achieved significant bacterial load reduction 3 hours after the procedure.

Hand Bacterial Repopulation Dynamics Following Two Methods of Surgical Hand Preparation during Elective Orthopedic Surgeries

Context:

Antiseptic hand preparations are routine prior to surgical procedures to reduce microbial load on the operating gloved hands. Two methods of surgical hand preparations available are the antibacterial detergent hand wash and an alcohol-based hand rub.

Aim:

The aim of the study was to compare quantitatively, the efficacy of the two methods in hand bacterial reductions during elective orthopedic surgeries.

Setting and Design:

This comparative study was conducted at the orthopedic surgery department of a tertiary health facility.

Subjects and Methods:

One-hundred and sixty dominant hands of operating surgeons and nurses involved in forty elective orthopedic surgeries were studied. The subjects were randomly assigned to either the antibacterial detergent hand-washing (HW) or the alcohol-based hand-rubbing (HR) groups. Swab samples were obtained from the hands before and after hand preparations and at the end of surgeries following removal of the operating gloves. These samples were then subjected to culture. The bacterial counts on these were then obtained through an automated colony counter, and the results were expressed in logarithmic values (log₁₀).

Statistical Analysis Used:

The analysis was done using IBM SPSS software version 20. The mean results obtained were subjected to an independent t-test analysis with the statistical significance level set at P < 0.05.

Results:

Both methods of hand antisepsis showed comparable efficacies in attaining surgical hand hygiene at 1-min postapplication (P = 0.73). HR group, however, showed greater sustained effects during the period of surgeries, though not statistically significant (P = 0.18).

Conclusion:

Scrubbing using the HR method is a viable alternative to the HW method during elective orthopedic surgery.

Glycerol content within the WHO ethanol-based handrub formulation: balancing tolerability with antimicrobial efficacy

Background

The World Health Organization (WHO) ethanol-based handrub (EBHR) formulation contains 1.45% glycerol as an emollient to protect healthcare workers' (HCWs) skin against dryness and dermatitis. However, glycerol seems to negatively affect the antimicrobial efficacy of alcohols. In addition, the minimal concentration of glycerol required to protect hands remain unknown. We aim to evaluate the tolerance of HCWs to the WHO EBHR formulation using different concentrations of glycerol in a tropical climate healthcare setting.

Methods

We conducted a cluster-randomized, double-blind, crossover study among 40 HCWs from an intensive care unit of a tertiary-care hospital in Brazil, from June 1st to September 30, 2017. We tested the WHO EBHR original formulation containing 1.45% glycerol against three other concentrations (0, 0.5, and 0.75%). HCWs used one formulation at a time for seven working days during their routine practice and then had their hands evaluated by an external observer using the WHO scale for visual inspection. Participants also used a WHO self-evaluation tool to rate their own skin condition. We used a generalized estimating equations of the logit type to compare differences between the tolerability to different formulations.

Results

According to the independent observation, participants had 2.4 times (95%CI: 1.12-5.15) more chance of having a skin condition considered good when they used the 0.5% compared to the 1.45% glycerol formulation. For the self-evaluation scale, participants were likely to have a worst evaluation (OR: 0.23, 95%CI: 0.11-0.49) when they used the preparation without glycerol compared to the WHO standard formulation (1.45%), and there were no differences between the other formulations used.

Conclusion

In a tropical climate setting, the WHO-modified EBHR formulation containing 0.5% glycerol led to better ratings of skin tolerance than the original formulation, and, therefore, may offer the best balance between skin tolerance and antimicrobial efficacy.

Impact of a simulation-based training in hand hygiene with alcohol-based hand rub in emergency departments

BACKGROUND

Hand hygiene is the primary measure for reducing nosocomial infections based on 7 steps recommended by the WHO. The aim of this study was to assess the duration and the quality of hand hygiene before and after simulation-based training (SBT).

METHODS

The study took place in a University Hospital Pediatric Department among its residents and nurses. In assessment A, 10 hand-rubbing procedures per participant during a work day were scored by observers using a validated, anatomically based assessment scale. Two weeks later, all participants received a didactic course and SBT, followed 1 month later by assessment B, observation of 10 hand-rubbing procedures. Assessments were performed by 2 independent observers. Before-and-after testing was used to evaluate the demonstration of theoretical knowledge.

RESULTS

In total, 22 participants were included, for whom 438 hand hygiene procedures were assessed: 218 for assessment A and 220 for assessment B. The duration of hand rubbing increased from 31.16 seconds in assessment A to 35.75 seconds in assessment B (P=.04). In assessment A, participants averaged 6.33 steps, and in assessment B, participants averaged 6.03 steps (difference not significant). Significant improvement in scores was observed between assessments A and B, except for the dorsal side of the right hand. The wrist and interdigital areas were the least-cleaned zones. A difference between assessments A and B was observed for nail varnish (P=.003) but not for long nails or jewelry. Theoretical scores increased from 2.83 to 4.29 (scale of 0-5; P<.001).

CONCLUSION

This study revealed that an optimal number of steps were performed during hand-rubbing procedures and that SBT improved the duration and quality of hand hygiene, except for the dorsal right side. Emphasis should be placed on the specific hand areas that remained unclean after regular hand-rubbing procedures.

Design and validation of an anatomically based assessment scale for handwashing with alcohol-based hand rub

An anatomically based assessment scale of handwashing quality with alcohol-based hand rub was designed. Contents of the scale divided each hand into 40 zones. Psychometric measurements were studied in 30 participants (120 hand sides). The scale was both valid (Cronbach α: 0·83 dorsal side and 0·73 palmar side) and reproducible (linear regression R2, 0·91; intraclass correlation coefficient, 0·99).

Preoperative Hand Decontamination in Ophthalmic Surgery: A Comparison of the Removal of Bacteria from Surgeons' Hands by Routine Antimicrobial Scrub versus an Alcoholic Hand Rub

PURPOSE

The goal of this experiment was to evaluate and compare the antimicrobial efficacy of routine preoperative hand washing using commercial medicated sponge brushes versus an alcoholic hand rub, by comparing bacterial growth on ophthalmic surgeons' hands after application of each of these methods.

METHODS

Twenty ophthalmic surgeons were recruited at the Hadassah-Hebrew University Medical Center in Jerusalem, Israel. Samples were collected twice from the hands of each surgeon after hand decontamination using two different protocols during routine surgical practice. The routine preparation consisted of a 3-minute surgical scrub using commercial brush-sponges incorporating either 4% chlorhexidine gluconate (CHG) or 1% povidone-iodine (PVP-I) formulations with detergent, followed by drying the hands with a sterile towel, while the 70% ethanol solution was applied for 60-seconds and allowed to air dry. Half of the group was randomly assigned to provide samples first after the routine method and the alcoholic solution a week later, and the other half of the group was sampled in the reverse order. Viable counts of bacteria were evaluated using a modified glove juice method. Bacterial colonies were enumerated after incubation for 24 hours and expressed as colony forming units (CFU)/mL for each pair of hands.

RESULTS

Geometric mean counts were 1310 and 39 CFU/mL, in the routine and alcohol rub groups, respectively, representing a mean log₁₀ reduction in 1.53. The difference between the paired bacterial counts for the routine versus the alcohol rub was statistically significant (p < 0.0001). There was no statistically significant difference between log₁₀ reductions for CHG and PVP-I (p = 0.97).

CONCLUSIONS

This study provides evidence that an alcohol rub protocol is more effective in reducing bacterial counts on hands than routine surgical hand preparation with PVP-I and CHG in a population of practicing ophthalmic surgeons in the operative clinical setting. Thus, it provides a safe alternative as a preoperative hand disinfection method.

Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Assessment of Fidelity in Interventions to Improve Hand Hygiene of Healthcare Workers: A Systematic Review

OBJECTIVE

Compliance with hand hygiene in healthcare workers is fundamental to infection prevention yet remains a challenge to sustain. We examined fidelity reporting in interventions to improve hand hygiene compliance, and we assessed 5 measures of intervention fidelity: (1) adherence, (2) exposure or dose, (3) quality of intervention delivery, (4) participant responsiveness, and (5) program differentiation.

DESIGN

Systematic review

METHODS

A librarian performed searches of the literature in PubMed, Cumulative Index to Nursing and Allied Health (CINAHL), Cochrane Library, and Web of Science of material published prior to June 19, 2015. The review protocol was registered in PROSPERO International Prospective Register of Systematic Reviews, and assessment of study quality was conducted for each study reviewed.

RESULTS

A total of 100 studies met the inclusion criteria. Only 8 of these 100 studies reported all 5 measures of intervention fidelity. In addition, 39 of 100 (39%) failed to include at least 3 fidelity measures; 20 of 100 (20%) failed to include 4 measures; 17 of 100 (17%) failed to include 2 measures, while 16 of 100 (16%) of the studies failed to include at least 1 measure of fidelity. Participant responsiveness and adherence to the intervention were the most frequently unreported fidelity measures, while quality of the delivery was the most frequently reported measure.

CONCLUSIONS

Almost all hand hygiene intervention studies failed to report at least 1 fidelity measurement. To facilitate replication and effective implementation, reporting fidelity should be standard practice when describing results of complex behavioral interventions such as hand hygiene.

Strategies to prevent healthcare-associated infections through hand hygiene

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Multicenter Intervention Program to Increase Adherence to Hand Hygiene Recommendations and Glove Use and to Reduce the Incidence of Antimicrobial Resistance

Objective.

To determine whether a multimodal intervention could improve adherence to hand hygiene and glove use recommendations and decrease the incidence of antimicrobial resistance in different types of healthcare facilities.

Design.

Prospective, observational study performed from October 1, 1999, through December 31, 2002. We monitored adherence to hand hygiene and glove use recommendations and the incidence of antimicrobial-resistant bacteria among isolates from clinical cultures. We evaluated trends in and predictors for adherence and preferential use of alcohol-based hand rubs, using multivariable analyses.

Setting.

Three intervention hospitals (a 660-bed acute and long-term care hospital, a 120-bed community hospital, and a 600-bed public teaching hospital) and a control hospital (a 700-bed university teaching hospital).

Intervention.

At the intervention hospitals, we introduced or increased the availability of alcohol-based hand rub, initiated an interactive education program, and developed a poster campaign; at the control hospital, we only increased the availability of alcohol-based hand rub.

Results.

We observed 6,948 hand hygiene opportunities. The frequency of hand hygiene performance or glove use significantly increased during the study period at the intervention hospitals but not at the control hospital; the maximum quarterly frequency of hand hygiene performance or glove use at intervention hospitals (74%, 80%, and 77%) was higher than that at the control hospital (59%). By multivariable analysis, preferential use of alcohol-based hand rubs rather than soap and water for hand hygiene was more likely among workers at intervention hospitals compared with nonintervention hospitals (adjusted odds ratio, 4.6 [95% confidence interval, 3.3-6.4]) and more likely among physicians (adjusted odds ratio, 1.4 [95% confidence interval, 1.2-1.8]) than among nurses at intervention hospitals. A significantly reduced incidence of antimicrobial-resistant bacteria among isolates from clinical culture was found at a single intervention hospital, which had the greatest increase in the frequency of hand hygiene performance.

Conclusions.

During a 3-year period, a multimodal intervention program increased adherence to hand hygiene recommendations, especially to the use of alcohol-based hand rubs. In one hospital, a concomitant reduction was found in the incidence of antimicrobial-resistant bacteria among isolates from clinical cultures.

Alcohol-Based Handrub: Evaluation of Technique and Microbiological Efficacy with International Infection Control Professionals

Background And Objective:

The Centers for Disease Control and Prevention has published a new guideline on hand hygiene promoting the use of the alcohol-based handrub, but the technique was not addressed. The goal of this study was to evaluate the influence of technique on the efficacy of the alcohol-based handrub.

Participants:

Healthcare workers (HCWs) attending a course in hospital epidemiology.

Methods:

A fluorescent dye was added to a hand antiseptic, and hands were checked under ultraviolet light after antiseptic cleansing. Data regarding the numbers of predefined fluorescent areas on the skin were collected in addition to demographic data such as age, gender, job description, and job experience. Results of the visualization test were compared with the data from microbiological samples before and after the procedure by the hand plate technique.

Results:

Sixty HCWs were tested, 63% of whom had worked in infection control for more than 10 years. Sixty-six percent of all participants still had detectable bacteria after antisepsis. The mean log10 CFU reduction was 2.0 (range, 0–3.85). Twenty-five percent of all HCWs achieved less than 1.1 log10 CFU. Staphylococcus aureus was isolated from 13% (one of them being methicillin resistant) and gram-negative bacilli from 6.7%. After using the alcohol handrub, one subject still remained positive for S. aureus. Years of experience was the single most important factor predicting antimicrobial efficacy.

Conclusions:

Technique is of crucial importance in hand antisepsis. Major deficiencies were detected among even highly trained HCWs. Training should be provided before switching from handwashing to the alcohol handrub.

Systematic Review of Studies on Compliance with Hand Hygiene Guidelines in Hospital Care

Objectives.

To assess the prevalence and correlates of compliance and noncompliance with hand hygiene guidelines in hospital care.

Design.

A systematic review of studies published before January 1, 2009, on observed or self-reported compliance rates.

Methods.

Articles on empirical studies written in English and conducted on general patient populations in industrialized countries were included. The results were grouped by type of healthcare worker before and after patient contact. Correlates contributing to compliance were grouped and listed.

Results.

We included 96 empirical studies, the majority (n= 65) in intensive care units. In general, the study methods were not very robust and often ill reported. We found an overall median compliance rate of 40%. Unadjusted compliance rates were lower in intensive care units (30%–40%) than in other settings (50%–60%), lower among physicians (32%) than among nurses (48%), and before (21%) rather than after (47%) patient contact. The majority of the time, the situations that were associated with a lower compliance rate were those with a high activity level and/or those in which a physician was involved. The majority of the time, the situations that were associated with a higher compliance rate were those having to do with dirty tasks, the introduction of alcohol-based hand rub or gel, performance feedback, and accessibility of materials. A minority of studies (n= 12) have investigated the behavioral determinants of hand hygiene, of which only 7 report the use of a theoretical framework with inconclusive results.

Conclusions.

Noncompliance with hand hygiene guidelines is a universal problem, which calls for standardized measures for research and monitoring. Theoretical models from the behavioral sciences should be used internationally and should be adapted to better explain the complexities of hand hygiene.

Social Marketing Analysis of 2 Years of Hand Hygiene Promotion

Objective.

To assess published hand hygiene behavioral interventions that employed a social marketing framework and to recommend improvements to future interventions.

Methods.

We performed a systematic literature review by searching the PubMed database and the Cumulative Index to Nursing and Allied Health Literature for published articles about hand hygiene behavioral interventions in healthcare facilities, schools, and community settings. Our analysis included articles that describe multifaceted interventions and evaluated them with predefined social marketing benchmark criteria.

Results.

Of 53 interventions analyzed in this review, 16 (30.2%) employed primary formative audience research, 5 (9.4%) incorporated social or behavioral theories, 27 (50.9%) employed segmentation and targeting of the audience, 44 (83.0%) used components of the “marketing mix,” 3 (5.7%) considered the influence of competing behaviors, 7 (13.2%) cultivated relationships with the target audience, and 15 (28.3%) provided simple behavioral messages. Thirty-five (66.0%) of the interventions demonstrated a significant improvement in performance, but only 21 (39.6%) were considered to have a strong evaluative design. The median duration of the interventions was 8.0 months.

Conclusions.

From a social marketing perspective, the promotion of hand hygiene could be improved in several ways. The effectiveness of social marketing in hand hygiene promotion should be tested in future interventions.

Cohort Study of Adherence to Correct Hand Antisepsis Before and After Performance of Clinical Procedures

Objective.

To investigate the rate of adherence by hospital staff members to the correct use of alcohol-based hand rub before and after performance of clinical procedures.

Design.

A cohort study conducted during the period from 2006 through 2007 and 2 cross-sectional studies conducted in 2006 and 2007.

Setting.

Århus University Hospital, Skejby, in Århus, Denmark.

Participants.

Various hospital staff members.

Methods.

Following an ongoing campaign promoting the correct use of alcohol-based hand rub, we observed rates of adherence by hospital staff to the correct use of alcohol-based hand rub. Observations were made before and after each contact with patients or patient surroundings during 5 weekdays during the period from 2006 through 2007 in 10 different hospital units. A logistic regression model was used to estimate the rate of adherence to the correct use of alcohol-based hand rub before and after performance of a clinical procedure.

Results.

A total of 496 participants were observed during 22,906 opportunities for hand hygiene (ie, 11,177 before and 11,729 after clinical procedures) that required the use of alcohol-based hand rub. The overall rates of adherence to the correct use of alcohol-based hand rub were 62.3% (6,968 ofthe 11,177 opportunities) before performance and 68.6% (8,041 ofthe 11,729 opportunities) after performance of clinical procedures. Compared with male participants, female participants were significantly better at adhering to the correct use of alcohol-based hand rub before performance (odds ratio [OR] 1.51 [95% confidence interval {CI}, 1.09–2.10]) and after performance (OR, 1.73 [95% CI, 1.27–2.36]) of clinical procedures. In general, the rate of adherence was significantly higher after the performance of clinical procedures, compared with before (OR, 1.43 [95% CI, 1.35–1.52]). For our cohort of 214 participants who were observed during 14,319 opportunities, the rates of adherence to the correct use of alcohol-based hand rub were 63.2% (4,469 of the 7,071 opportunities) before performance and 69.3% (5,021 of the 7,248 opportunities) after performance of clinical procedures, and these rates increased significantly from 2006 to 2007, except for physicians.

Conclusion.

We found a high and increasing rate of adherence to the correct use of alcohol-based hand rub before and after performance of clinical procedures following a campaign that promoted the correct use of alcohol-based hand rub. More hospital staff performed hand hygiene with alcohol-based hand rub after performance of clinical procedures, compared with before performance. Future campaigns to improve the rate of adherence to the correct use of alcohol-based hand rub ought be aware that certain groups of hospital staff (eg, male staff members) are known to exhibit a low level of adherence to the correct use of alcohol-based hand rub.

Prospective observational study to assess hand skin condition after application of alcohol-based hand rub solutions

BACKGROUND

The use of alcohol-based hand rub solutions (ABHRSs) in health care settings has been associated with increased hand hygiene compliance and reduced rates of nosocomial infection. Deterioration in hand skin condition leads to impaired barrier function, changes in skin flora, and increased bacterial shedding. Thus, poor skin condition can increase the risk of infection. This study evaluated the hand skin condition and dermal tolerance among health care workers (HCWs) after ABHRS application.

METHODS

The study group comprised 231 HCWs (34% nurses, 22% nurse assistants, and 15% hospital cleaners). The mean participant age was 40 years. Stratum corneum hydration and superficial sebum content and surface pH of the skin were measured on the back and palm of each participant's dominant hand before and after ABHRS use. A self-assessment questionnaire was administered to collect information about the participants, their skin problems, and their perception of the ABHRS.

RESULTS

The study group was 83% females. Skin hydration at the 2 assessment sites was markedly increased after ABHRS use (P < .0001). The mean pH value did not change significantly on the back of the hand, but did change significantly on the palm (P = .012). The superficial sebum content decreased significantly on the palm (P < .0001), but not on the back of the hand. HCWs reported excellent or good skin tolerance of ABHRS in 73% of cases.

CONCLUSION

ABHRSs are well tolerated and do not dry the skin. pH and superficial sebum values decreased slightly, but these decreases did not affect skin barrier function. Values remained within the physiological range.

Effectiveness of a hand hygiene promotion strategy using alcohol-based handrub in 6 intensive care units in Colombia

BACKGROUND

Hand hygiene is an effective strategy for the prevention of health care-associated infection (HAI). We investigated the effect of a hand hygiene promotion strategy introducing alcohol-based handrub (AHBR) on the incidence of HAI in a university hospital in Colombia.

METHODS

A Prospective cohort study was performed in 6 intensive care units from January 2001 to December 2005. HAI were identified using standard US Centers for Disease Control and Prevention definitions. Alcohol-based handrub dispensers were installed between February and June 2002.

RESULTS

Total ABHR consumption was 5,794 L (mean, 28.9 L per 1,000 patient-days) and significantly increased over time (+9.2% per year; P < .001). Of 14,516 patients cumulating 166,498 patient-days, 2,398 (16.5%) acquired a total of 3,490 HAI episodes (20.9 per 1,000 patient-days). Incidence densities for central line-associated bloodstream infection (CLABSI), ventilator-associated pneumonia, and urinary tract infections were 7.7, 10.6, and 3.6 episodes per 1,000 device-days, respectively. A significant decrease was observed for CLABSI (-12.7% per year; P < .001) with low nurse-to-patient ratio independently associated with infection (odds ratio, 1.11; 95% confidence interval: 1.07-1.16; P < .001).

CONCLUSION

Improved hand hygiene measured by increased ABHR consumption resulted in CLABSI reduction. Low nurse-to-patient ratio is independently associated with HAI in an upper-middle income country.

[Risk factors for dryness or irritation of staff hands in nine healthcare institutions]

OBJECTIVE

We performed a prospective multicenter study to assess dryness and irritation of hands of staff in care facilities, and to show that disinfection with alcohol-based hand rub is better tolerated than classic hand washing with mild soap.

METHOD

Dryness and irritation were self-evaluated by volunteers and hetero-evaluated by a team of investigators. The study took into account most of the individual and environmental risk factors of dryness and irritation (season, age, gender, use of protective agent, constitutional, personal and external factors, institution, function, number of consecutive working days).

RESULTS

The results from the 1932 assessments collected showed that traditional hand washing was a risk factor for dryness or irritation, while alcohol-based hand rubs caused no skin deterioration and had a protective effect even when used intensively.

COMMENT

These results should help to fight non-adherence to the use of alcohol-based hand rubs.

Epidemiology and susceptibilities of methicillin-resistant Staphylococcus aureus in Northeastern Ohio

A retrospective survey was performed on all staphylococcal infections diagnosed by the Ashtabula County Medical Center (Ashtabula, OH) during 2006 and 2007. Of the 1,612 Staphylococcus aureus isolates evaluated for their antibiotic resistances, 947 were methicillin-resistant S aureus (MRSA). In 2007, MRSA infections reached 589 cases per 100,000 inhabitants, a 77% increase compared with 2006. The increase in MRSA infections was noticeable among youth (6-25 years old), middle-aged people (45-50 years old), and elderly people (86-90 years old). MRSA infections increased among inpatients by 58%, among outpatients by 43%, and among nursing home residents by 183%. More than 66% of MRSA infections were found among healthy people in the community with no apparent risk factors. More than 88.7% of the infections belong to only 9 profiles of antibiotic resistance indiscriminately distributed among inpatients, outpatients, and nursing home residents. This report sheds further light on the rapid spread of MRSA across Northeastern Ohio, stressing the need for better education in preventive measures and infection control at the level of community and health care settings.

Engaging the nursing workforce: an evidence-based tool kit

Hand hygiene is critical to the safety of patients in hospitals today.

OBJECTIVE

Engaging staff, physicians, patients, and visitors in hand hygiene is important to create a safe environment. The author discusses the development and implementation of an evidence-based practice guideline for improving hand hygiene and application of that guideline in an academic medical center setting.

METHOD

Establishment of a multidisciplinary team committed to improving organizational performance, development of a practice guideline, organizational assessment, and the implementation of a multimodal intervention plan are all keys to success.

CONCLUSION

Organizational culture can be changed utilizing an evidence-based, organization-specific approach to hand hygiene.

[Impact of an educational intervention for promoting handwashing and the rational use of gloves in a hospital]

OBJECTIVE

To estimate the impact of educational intervention on hand washing and gloves use.

MATERIAL AND METHODS

The educational intervention consisted of a one-hour weekly workshop aimed at doctors and nurses, with a previous questionnaire on hand-washing, a presentation talk on three key points (hand washing, use of gloves, alcohol-based solutions). Adherence to hand washing and use of gloves was re-evaluated 6-9 months after the intervention.

RESULTS

We conducted 34 workshops for 296 health care workers, 239 (80.4%) women and 57 (19.6%) men, with an average age of 40.1 years (range, 18-62 years). Most were nurses (41.2%), nursing assistants (37.8%) and physicians (8.2%). Compliance to hand washing ranged between 29% and 87%. The gloves were used in maneuvers not indicated (19% before giving meals and a 27.7% when performing an ECG). Compliance with hand washing 6-9 months after the workshop improved significantly (p < 0.05) in three of the 5 items. The use of gloves was not significantly different. The intensity of the intervention was inversely related to the incidence of nosocomial infections (RR for every 100 workers intervened in the previous month = 0.89; 95% CI, 0.789-1.003; p = 0.057).

CONCLUSIONS

The training workshops had a positive impact on hand washing compliance, but there was no significant change in the use of gloves. The introduction of education has an inverse relationship to the incidence of nosocomial infections.

Nurses' perceptions of the benefits and adverse effects of hand disinfection: alcohol-based hand rubs vs. hygienic handwashing: a multicentre questionnaire study with additional patch testing by the German Contact Dermatitis Research Group

BACKGROUND

Nurses have a high risk of developing hand eczema due to hand disinfection procedures.

OBJECTIVES

To investigate the perception of nurses regarding the adverse effects of hand washing (HW) and alcoholic disinfection (ADI), and to obtain data on the prevalence of hand dermatitis and sensitization to alcohols and alcohol-based hand rubs (ABHRs).

METHODS

A self-administered questionnaire survey, carried out as a pilot study (PS), followed by a modified multicentre study (MC) in five hospitals. Patch tests to ethanol (80%), 1-propanol (60%), 2-propanol (70%) and ABHRs were performed in a subsample.

RESULTS

The majority (PS 60.1%; MC 69.5%) of nurses considered ADI to be more damaging than HW. Mostly, ADI and HW were suspected to have irritant effects (ADI 79.2%/52.1%; HW 65.5%/36.2%) compared with an allergenic potential (ADI 10.4%/5.8%; HW 7.8%/3.9%). The prevalence of hand dermatitis in the MC was 13.4% by self-diagnosis and 22.4% by symptom-based questions. In 50 tested individuals no sensitization and only two irritant reactions to alcohols and three single-positive reactions to ABHRs were observed, none of the latter related to alcohols.

CONCLUSIONS

Although ADI is known to cause less skin irritation than HW, nurses perceive ADI as more damaging, resulting in: (i) a low compliance with ADI and (ii) a higher prevalence of hand dermatitis because the more deleterious HW is preferred. This may result in an increase in occupational disease and nosocomial infections. Educational programmes should promote ADI as a procedure with good efficiency and skin tolerability to reduce the prevalence of hand eczema in nurses and to enhance compliance with hand hygiene standards.

Field test comparison of two dermal tolerance assessment methods of hand hygiene products

This study aimed to compare the sensitivity and workload requirement of two dermal tolerance assessment methods of hand hygiene products, in order to select a suitable pilot testing method for field tests. An observer-rating method and a self-assessment method were compared in 12 voluntary hospital departments (autumn/winter of 2005-2006). Three test-periods of three weeks were separated by two-week intervals during which the routine products were reintroduced. The observer rating method scored dryness and irritation on four-point scales. In the self-assessment method, the user rated appearance, intactness, moisture content, and sensation on a visual analogue scale which was converted into a 10-point numerical scale. Eleven products (soaps) were tested (223/250 complete reports for observer rating, 131/251 for self-assessment). Two products were significantly less well tolerated than the routine product according to the observers, four products according to the self-assessments. There was no significant difference between the two methods when products were classified according to tolerance (Fisher's test: P=0.491). For the symptom common to both assessment methods (dryness), there is a good correlation between the two methods (Spearman's Rho: P=0.032). The workload was higher for observer rating method (288 h of observer time plus 122 h of prevention team and pharmacist time compared with 15 h of prevention team and pharmacist time for self-assessment). In conclusion, the self-assessment method was considered more suitable for pilot testing, although further time should be allocated for educational measures as the return rate of complete self-assessment forms was poor.

Evaluation of hand hygiene adherence in a tertiary hospital

BACKGROUND

Although hand hygiene is the most important measure in the prevention of nosocomial infection, adherence to recommendations among health care workers (HCW) is low. Evaluation of compliance with hand hygiene was carried out in a Spanish teaching hospital.

METHODS

In 2005, adherence to hand hygiene was evaluated hospital wide through direct observation, collecting data on hand hygiene carried out whenever indicated (opportunity for hand hygiene). Compliance was defined as handwashing/disinfection in an opportunity for hand hygiene according to hospital protocols. The results were analyzed using mixed effects models, with the HCW observed as the random effect.

RESULTS

A total of 1254 opportunities for hand hygiene were observed in 247 HCWs. Mean compliance was 20%. Although few differences were observed among types of HCW, compliance varied according to hospital area (69% in the intensive care unit [ICU]) and timing with respect to patient contact (compliance after contact was twice that before contact). Multivariate analyses revealed a protective odds ratio (OR) for nonadherence in ICUs (OR, 0.04; 95% confidence interval (95% CI): 0.01-0.10) and after patient contact (OR, 0.25; 95% CI: 0.17-0.38).

CONCLUSION

Low adherence observed suggests that new interventions should focus in modification of HCWs' habits and attitudes, working at several levels: individual and institutional.

Double-blind, randomized, crossover trial of 3 hand rub formulations: fast-track evaluation of tolerability and acceptability

OBJECTIVE

To compare healthcare workers' skin tolerance for and acceptance of 3 alcohol-based hand rub formulations.

DESIGN

Double-blind, randomized, crossover clinical trial.

SETTING

Intensive care unit in a university hospital.

PARTICIPANTS

Thirty-eight healthcare workers (HCWs).

INTERVENTION

A total of 3 alcohol-based hand rub formulations (hereafter, formulations A, B, and C) were used in random order for 3-5 consecutive working days during regular nursing shifts. Formulations A and B contained the same emollient, and formulations B and C contained the same alcohol at the same concentration. Use of each test formulation was separated by a "washout" period of at least 2 days. A visual assessment of skin integrity by a blinded observer using a standard 6-item scale was conducted before and after the use of each formulation. Univariate and multivariate analyses were used for the assessment of risk factors for skin alteration, and product acceptability was assessed by use of a customized questionnaire after the use of each formulation.

RESULTS

Thirty-eight HCWs used each of 3 formulations for a median of 3 days (range, 3-5 days). The mean amount of product used daily (+/-SD) was 54.9+/-23.5 mL (median, 50.9 mL). Both subjective and objective evaluation of skin conditions after use showed lower HCW tolerance for product C. Male sex (odds ratio [OR], 3.17 [95% confidence interval {CI}, 1.1-8.8]), fair or very fair skin (OR, 3.01 [95% CI, 1.1-7.9]), skin alteration before hand rub use (OR, 3.73 [95% CI, 1.7-8.1]), and use of formulation C (OR, 8.79 [95% CI, 2.7-28.4]) were independently associated with skin alteration.

CONCLUSIONS

This protocol permits a fast-track comparison of HCWs' skin tolerance for different alcohol-based hand rub formulations that are used in healthcare settings. The emollient in formulation C may account for its inferior performance.

Clinical effectiveness of alcohol-based products in increasing hand hygiene compliance and reducing infection rates: a systematic review

Reducing the incidence of healthcare-associated infection represents a major challenge. This systematic review of the evidence base considers the clinical effectiveness of incorporating an alcohol-based hand hygiene product into procedures aimed at improving compliance with hand hygiene guidelines, and thereby reducing the incidence of healthcare-associated infections. Multi-component interventions that included alcohol-based products were as effective as those that did not, both in achieving sustained hand hygiene compliance and in reducing infection rates. However, a number of difficulties were encountered in assessing hand hygiene studies: the problem of attributing efficacy to an alcohol-based product when used in a multi-component intervention; the variability inherent in the design of such studies; and how to use data from uncontrolled, unblinded studies in the assessment.

Grado de cumplimiento y determinantes de las recomendaciones sobre la higiene de manos

INTRODUCTION

A basic indicator for assessing a program aimed at improving hand hygiene (HH) is the degree of compliance with the recommendations established for this purpose. The aim of this study is to investigate this indicator and related determinant factors in a general hospital.

METHODS

We performed 166 observation periods of one hour's duration, distributed over three work shifts and covering all the hospitalization units; 3957 HH opportunities were recorded. Variables associated with the observation period, the professionals involved and the medical activity taking place were also recorded. The Chi-square test, and calculation of the raw OR and the adjusted OR with a logistic regression model were used to study associations between the variables studied and failure to perform HH.

RESULTS

The overall frequency of HH activity was 30%, ranging from 8.9% to 60.5% depending on the professional tasks involved. The most important independent risk factors for failure to perform HH were the following: no availability of alcohol in a pocket size bottle (OR: 2.3 [1.7-3.3]); medical activities carried out in the surgical unit (OR: 2.6 [2.0-3.3]); activities taking place before entering into contact with patients (OR: 3.2 [2.4-4.2]); and use of gloves during the activity (OR: 2.2 [1.6-3.2]).

CONCLUSION

The frequency of HH is low, but there are several potentially modifiable factors involved, which could improve with interventions. One example might be better education of hospital personnel on the importance of HH.

Skin reactions related to hand hygiene and selection of hand hygiene products

BACKGROUND

In October 2004, The World Health Organization (WHO) launched the World Alliance for Patient Safety. Within the alliance, the first priority of the Global Patient Safety Challenge is to reduce health care-associated infection. A key action within the challenge is to promote hand hygiene in health care globally as well as at the country level through the campaign "Clean Care is Safer Care." As a result, the WHO is developing Guidelines on Hand Hygiene in Health Care, designed to be applicable throughout the world.

METHODS

This paper summarizes one component of the global WHO guidelines related to the impact of hand hygiene on the skin of health care personnel, including a discussion of types of skin reactions associated with hand hygiene, methods to reduce adverse reactions, and factors to consider when selecting hand hygiene products.

RESULTS

Health care professionals have a higher prevalence of skin irritation than seen in the general population because of the necessity for frequent hand hygiene during patient care.

CONCLUSION

Ways to minimize adverse effects of hand hygiene include selecting less irritating products, using skin moisturizers, and modifying certain hand hygiene practices such as unnecessary washing. Institutions need to consider several factors when selecting hand hygiene products: dermal tolerance and aesthetic preferences of users as well as practical considerations such as convenience, storage, and costs.

Social marketing: a behavior change technology for infection control

Changing health care worker behaviors is a core function of infection control programs. The social change technologies of education and institutional policy are limited in their capacity to achieve desired behaviors on a sustained basis because they do not address the importance of opportunity and ability in practice enhancement. Social marketing addresses the health care worker's lack of opportunity and ability by offering a bundle of benefits at low cost with high accessibility and by doing this better than the behavioral status quo. This article introduces some social marketing concepts and explicates them in the context of hand hygiene promotion.

Tolerance and acceptability of 14 surgical and hygienic alcohol-based hand rubs

Tests were performed under working practice conditions to measure the tolerance and acceptability of commercially available hand rubs with proven efficacy. The products were compared with those in current use at the Hospices Civils de Lyon for surgical hand disinfection (Sterillium) and hygienic hand disinfection (Purell) to obtain information for public sector purchases. The 12 test products were Alcogel H, Assanis Pro, Clinogel, Dermalcool, Manugel Plus, Manugel Plus NPC, Manurub Liquid, Manurub Gel, Purell 85, Spitacid, Spitagel and Sterillium Gel. They were tested from mid-November to mid-April over four periods of three weeks, separated by two-week intervals during which the customary product was re-introduced. Participation of hospital wards and theatres was voluntary. Skin dryness and irritation were scored before and after each test period. Acceptability and ease of use were assessed by means of a questionnaire. Among the eight surgical hand rubs, only Manurub Liquid, Manurub Gel and Manugel Plus NPC did not cause significantly more dryness and irritation than Sterillium. For the 10 hygienic hand rubs, differences were noted depending upon the test period. Overall, Assanis Pro, Clinogel, Purell 85 and Sterillium Gel did not cause significantly more dryness and irritation than Purell. However, over the (colder) first three test periods, Assanis Pro and Sterillium Gel caused more irritation and Purell 85 caused more dryness than Purell. Responses to the questionnaires on acceptability indicated that users preferred their customary hand rubs (Sterillium and Purell). As these field tests involving many participants did not identify any superior products, previous purchase orders were renewed.

Emollients in a propanol-based hand rub can significantly decrease irritant contact dermatitis

The objective of this study is to determine the effect of emollients in a propanol-based hand rub on skin dryness and erythema. In this prospective, randomized, controlled, double-blind trial, 35 subjects participated; of them approximately half were atopic (modified Erlanger atopy score > or =8). 2 propanol-based formulations were tested in a repeated open application test, 1 contained a mixture of emollients (0.81%, w/w). 2 aliquots of 0.7 ml of each formulation were applied twice per day over 2 weeks to the cubital fossa of each subject after random assignment of the preparations. Treatment areas were assessed before each application and 3 days postfinal application by visual inspection for erythema and dryness according to a standard scale. The sum score over all assessment time-points served as primary parameter. The mean sum score for erythema and dryness was significantly lower for the hand rub with emollients (0.8 +/- 2.4) in comparison with that for the hand rub without emollients (1.5 +/- 3.5; P = 0.022; Wilcoxon signed rank test). A comparison of the atopic and non-atopic subjects revealed no significant difference for any of the products (P > 0.05; Mann-Whitney U-test). It is concluded that the addition of emollients to a propanol-based hand rub can significantly decrease irritant contact dermatitis under frequent-use conditions.

Multicentre study on hand hygiene facilities and practice in the Mediterranean area: results from the NosoMed Network

Hand hygiene literature is scarce in the southern Mediterranean area. In order to establish a baseline position, a study was performed in four Mediterranean countries. Seventy-seven hospital wards in 22 hospitals were enrolled and information on hand hygiene practice and facilities were collected. The overall compliance rate was very low (27.6%), and was significantly higher where the perceived risk was considered to be high. Intensive care units showed the highest level of compliance. Analysis by country indicated higher compliance in Egypt (52.8%) and Tunisia (32.3%) compared with Algeria (18.6%) and Morocco (16.9%). Facilities for hand hygiene, particularly consumables, were shown to be deficient. Multi-approach programmes combining the production of official local recommendations, education and regular evaluation of hand hygiene practice are much needed to improve the present situation.

Hand Hygiene Behavior in a Pediatric Emergency Department and a Pediatric Intensive Care Unit: Comparison of Use of 2 Dispenser Systems

• Background Adherence to hand hygiene standards is poor. Approaches and systems to improve hand hygiene practices warrant testing.

• Objective To compare the frequency of use of manually operated and touch-free dispensers of sanitizer for hand hygiene.

• Methods Manual and touch-free dispensers of alcohol sanitizer were placed in the emergency department and an intensive care unit of a large pediatric hospital for two 2-month periods for each type of dispenser. Counting devices installed in each dispenser and direct observations were used to determine actual frequency of and indications for hand hygiene.

• Results The touch-free dispensers were used significantly more often than were the manual dispensers. The means for the number of episodes of hand hygiene per hour were 4.42 for the touch-free dispensers and 3.33 for the manual dispensers (P = .04); the means for the number of episodes per patient per hour were 2.22 and 1.79, respectively (P = .004); and the means for the number of uses of the dispenser per day were 41.2 and 25.6, respectively (P = .02). However, the overall compliance rate was 38.4% (2136 episodes of hand hygiene per 5568 indications for hand hygiene).

• Conclusions The type of dispensing system influenced hand hygiene behavior. Nevertheless, overall hand hygiene compliance remained low. In order for interventions to have a major effect on hand hygiene, multiple factors must be considered.

An alcohol hand rub containing a synergistic combination of an emollient and preservatives: prolonged activity against transient pathogens

A new alcohol-based hand antiseptic (Octoxy hand rub) containing a synergistic combination of an emollient (Octoxyglycerine) and preservatives was developed and evaluated for immediate and prolonged activity against transient bacteria. The in vitro and in vivo antimicrobial efficacy was compared with other alcohol hand rubs containing preservative/antimicrobial (Prevacare and Avagard). In vitro evaluation was carried out using a tube-dilution method and a pig-skin model. Rapid and prolonged efficacy in vivo was evaluated against Staphylococcus epidermidis on the hands of volunteers. Octoxy hand rub was 100% effective in rapidly killing pathogens including methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus faecium in vitro. In volunteers, all three hand rubs gave a significant reduction in microbial count within 15s. Octoxy hand rub showed significantly higher efficacy against S. aureus and Escherichia coli than Avagard and Prevacare 15 min after application to the pig-skin model, and against S. epidermidis in both the pig-skin model and in volunteers. Use of Octoxy hand rub with broad-spectrum immediate and prolonged antimicrobial activity may be a very effective way of improving hand hygiene without exposing the hands to higher concentrations of antimicrobials.

Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs

The etiology of nosocomial infections, the frequency of contaminated hands with the different nosocomial pathogens, and the role of health care workers' hands during outbreaks suggest that a hand hygiene preparation should at least have activity against bacteria, yeasts, and coated viruses. The importance of efficacy in choosing the right hand hygiene product is reflected in the new Centers for Disease Control and Prevention guideline on hand hygiene (J. M. Boyce and D. Pittet, Morb. Mortal. Wkly. Rep. 51:1-45, 2002). The best antimicrobial efficacy can be achieved with ethanol (60 to 85%), isopropanol (60 to 80%), and n-propanol (60 to 80%). The activity is broad and immediate. Ethanol at high concentrations (e.g., 95%) is the most effective treatment against naked viruses, whereas n-propanol seems to be more effective against the resident bacterial flora. The combination of alcohols may have a synergistic effect. The antimicrobial efficacy of chlorhexidine (2 to 4%) and triclosan (1 to 2%) is both lower and slower. Additionally, both agents have a risk of bacterial resistance, which is higher for chlorhexidine than triclosan. Their activity is often supported by the mechanical removal of pathogens during hand washing. Taking the antimicrobial efficacy and the mechanical removal together, they are still less effective than the alcohols. Plain soap and water has the lowest efficacy of all. In the new Centers for Disease Control and Prevention guideline, promotion of alcohol-based hand rubs containing various emollients instead of irritating soaps and detergents is one strategy to reduce skin damage, dryness, and irritation. Irritant contact dermatitis is highest with preparations containing 4% chlorhexidine gluconate, less frequent with nonantimicrobial soaps and preparations containing lower concentrations of chlorhexidine gluconate, and lowest with well-formulated alcohol-based hand rubs containing emollients and other skin conditioners. Too few published data from comparative trials are available to reliably rank triclosan. Personnel should be reminded that it is neither necessary nor recommended to routinely wash hands after each application of an alcohol-based hand rub. Long-lasting improvement of compliance with hand hygiene protocols can be successful if an effective and accessible alcohol-based hand rub with a proven dermal tolerance and an excellent user acceptability is supplied, accompanied by education of health care workers and promotion of the use of the product.

The six golden rules to improve compliance in hand hygiene

Improvement of compliance in hand hygiene is probably the most effective step in reducing the incidence of nosocomial infections (NI). But improvement of compliance is known to be complex. Six possibilities for improving compliance are available although some of them may be difficult to carry out. Rule 1: Select an alcohol-based hand rub which has a good skin tolerance and is acceptable to health care workers to use. This has been shown to improve compliance. Rule 2: The hand rub shall be easily available. Wall dispensers near the patient and pocket bottles may well help. Other possibilities should be assessed locally. Rule 3: Implement teaching and promotion of hand hygiene, which has been shown to be very effective. This is may be the most effective tool but will cost time and money. If money is a problem, rule 4 may be the solution. Rule 4: Create a hospital budget which covers all costs involved with preventable nosocomial infection. Combine it with the budget for hand hygiene products. Even a small number of prevented NI largely outweighs the cost of effective hand hygiene products. Rule 5: Get senior staff to set a good example in order to motivate junior staff, because negligence in hand hygiene appears to correlate with the number of professional years. Rule 6: Have the patient-staff ratio well balanced. It has been shown that staff shortage decreases hand hygiene compliance. Other factors may be important as well, but implementation of these 6 golden rules could be an effective step into the right direction.

Comparative in vitro and in vivo study of nine alcohol-based handrubs

BACKGROUND

Hygienic hand disinfection using alcohol-based handrubs (AHRs) is an alternative method to conventional handwashing in hospital wards. Because a documented choice of such products would consider data from in-care evaluation, we designed a comparative study of 9 AHRs both in vitro and in vivo in actual care conditions.

METHODS

The bactericidal activity of AHRs was first measured in vitro against 4 hospital strains exhibiting multiple antibiotic resistance: Acinetobacter baumannii, Staphylococcus aureus, Pseudomonas aeruginosa, and Enterobacter aerogenes. In a second time, AHRs were tested in an intensive care unit for antibacterial activity against the cutaneous flora of personnel hands and for acceptance by the care personnel.

RESULTS

The 9 AHRs could be classified in 3 groups on the basis of their in vitro activity: products of the first group showed a bactericidal activity higher than 4 log(10) against the 4 strains. Only 1 of these products presented simultaneously an effective antibacterial activity against the cutaneous flora of care personnel hands and a good acceptance by the care personnel.

CONCLUSION

The in vitro study allowed the differentiation of the AHRs tested on the basis of bactericidal activity, but evaluation in an in-care situation allowed further discrimination through both antibacterial activity and acceptance. Thus, the combination of in vitro and in vivo evaluations should provide helpful arguments in the choice of AHRs.

A systematic review on the effectiveness of alcohol-based solutions for hand hygiene

The use of alcohol has been proposed as an option for hand hygiene. A systematic review was conducted to evaluate the clinical evidence supporting the use of alcohol-based solutions in hospitals as an option for hand hygiene. Studies published between January 1992 and April 2002 in English and Thai, related to the effectiveness of alcohol-based solutions, were reviewed. The databases searched included Medline, DARE, CINAHL and Dissertation Abstracts International. All studies were assessed as having adequate methodological quality. Results of this systematic review supported that alcohol-based hand rubbing removes microorganisms effectively, requires less time and irritates hands less often than does handwashing with soap or other antiseptic agents and water. Furthermore, the availability of bedside alcohol-based solutions increases compliance with hand hygiene among health care workers.

Dermal absorption of isopropyl alcohol from a commercial hand rub: implications for its use in hand decontamination

Isopropyl alcohol-containing hand rubs are widely used in healthcare for hand decontamination. Ten healthy adult volunteers applied a commercially available isopropyl alcohol-containing hand rub to their hands every 10 min over a 4 h period. Blood isopropyl alcohol levels were measured at the beginning and end of the study. At the end of the study, measurable blood isopropyl alcohol levels (range 0.5-1.8 mg/l) were recorded in nine subjects. We confirmed that isopropyl alcohol could be absorbed through the intact skin of adult humans. The social and medical implications are discussed.

Effectiveness of Alcohol-based solutions for Hand Hygiene: A Systematic Review

: Hand hygiene is an important measure in reducing the transmission of nosocomial infections in hospitals, but adherence is poor among health care workers (HCWs).More rapid and effective hand disinfection procedures have been proposed, such as rubbing with alcohol.Hand rubbing with alcohol-based products is commonly used in some countries instead of handwashing. This review evaluates the scientific and clinical evidence on the use of alcohol-based hand rubs in health care settings as a new option for hand hygiene.

OBJECTIVES

To conduct a systematic review to determine the best available evidence related to effectiveness of alcohol-based solutions for hand hygiene. The specific review questions addressed were: the effectiveness in reducing microorganisms, compliance with hand hygiene, and the incidence of skin problems. Application time (consumption) addressed efficiency.

CRITERIA FOR CONSIDERING STUDIES IN THIS REVIEW

This review considered all studies that included alcohol-based solutions that related to the objectives of the review. Outcomes included measures for the reduction of organisms, compliance with hand hygiene, the types of skin problems, and application time. The review primarily considered any intra-individual trials (IITs), randomised controlled trials (RCTs) and controlled clinical trials (CCTs) relating to the effectiveness of alcohol-based solutions but also included quasi-experimental designs.

SEARCH STRATEGY FOR IDENTIFICATION OF STUDIES

The search sought to find published and unpublished studies. The databases searched included: Medline, CINAHL, ProQuest and Dissertation Abstracts International. Studies were additionally identified from reference lists of all studies retrieved.

ASSESSMENT AND DATA EXTRACTION

All studies were checked for methodological quality by two reviewers and data were extracted using a tool.

DATA ANALYSIS

The study results were pooled in statistical meta-analysis using Review Manager software and summarized in narrative form where statistical pooling was not appropriate or possible.

RESULTS

This systematic review included thirty seven studies that supports the use of alcohol-based solutions for routine hand hygiene and surgical hand scrub. Alcohol-based hand rub removes microorganisms from hands of personnel more effectively, requires less time, and irritates hands less often than traditional handwashing with nonmedicated soap or other antiseptic agents and water. The combination of 61% ethanol and 1% chlorhexidine gluconate (CHG) is even more effective in producing residual antibacterial properties on the skin. Furthermore, the availability of bedside alcohol-based solutions increased compliance with hand hygiene among HCWs.

CONCLUSION

Rubbing hands with alcohol-based agents has been proved to be effective in the reduction of microorganisms from hands. Alcohols are effective for preoperative cleaning of the hands of surgical personnel. Addition of CHG to alcohol-based solution can produce residual antibacterial properties on the skin. The use of alcohol-based solutions containing emollients causes less skin irritation and dryness and requires less time than washing hands with soap or other disinfectants. The promotion of bedside, alcohol-based hand rubs contributes to the increase in compliance with hand hygiene by HCWs.

State-of-the-art hand hygiene in community medicine

Hand hygiene becomes more important in community medicine not only since antibiotic resistant bacteria such as MRSA spread within the community. Hands may be colonized with transient microorganism in up to 75%. Among those transient pathogens S. aureus, C. difficile or the hepatitis C virus may be found. During patient care the number of microorganisms on the hands steadily increases. In addition hands may be contaminated with different kinds of germs even if only "clean" activities are carried out. Gloves may be worn but do not provide complete protection from contamination due to leaks. Therefore hands should always be treated after gloves are taken off. State-of-the-art treatment of hands is the hygienic hand disinfection with alcohol-based hand rubs. They are more effective, quicker to carry out, better tolerated by the skin, with a positive effect on compliance, and cost effective in comparison to antiseptic soaps based on chlorhexidine or triclosan and in comparison to normal non-medicated soaps. Healthy skin easily tolerates alcohol-based products from the beginning on. Only health care workers with an underlying irritative contact dermatitis which is often caused by bar or liquid antiseptic soaps may have difficulties to use alcohol-based products initially. In such a case treatment of the underlying skin condition is the way to go and not staying with a preparation which has caused the dermatitis. All this knowledge is now reflected in current guidelines on hand hygiene. Beside liquids alcohol-based gels can be used if they have an antimicrobial activity equal to alcohol-based liquid preparations. Hand hygiene remains the single most important tool to avoid cross transmission of microorganisms between patients. This state-of-the-art hand hygiene should also be emphasized more in community medicine. This review may help to go the first step into this direction.

Interventional study to evaluate the impact of an alcohol-based hand gel in improving hand hygiene compliance

OBJECTIVE

To evaluate the effects of the introduction of an alcohol-based hand gel and multifaceted quality improvement (QI) interventions on hand hygiene (HH) compliance.

DESIGN

Interventional, randomized cohort study with four study phases (baseline; limited intervention in two units; full intervention in three units; washout phase), performed in three intensive care units at a pediatric referral hospital.

METHODS

During 724 thirty-minute daytime monitoring sessions, a nonidentified observer witnessed 12,216 opportunities for HH and recorded compliance.

INTERVENTIONS

Introduction of an alcohol-based hand gel; multifaceted QI interventions (educational program, opinion leaders, performance feedback).

RESULTS

Baseline compliance decreased after the first 2 weeks of observation from 42.5% to 28.2% (presumably because of waning of a Hawthorne effect), further decreased to 23.3% in the limited intervention phase and increased to 35.1% after the introduction of a hand gel with QI support in all three units (P < 0.001). The rise in compliance persisted in the last phase (compliance, 37.2%); however, a gradual decline was observed during the final weeks. Except for the limited intervention phase, compliance achieved through standard handwashing and glove use remained stable around 20 and 10%, respectively, whereas compliance achieved through gel use increased to 8% (P < 0.001). After adjusting for confounding, implementation of the hand gel with QI support remained significantly associated with compliance (odds ratio, 1.6; 95% confidence interval, 1.4 to 1.8). In a final survey completed by 62 staff members, satisfaction with the hand gel was modest (45%).

CONCLUSIONS

We noted a statistically significant, modest improvement in compliance after introduction of an alcohol-based hand gel with multifaceted QI support. When appropriately implemented, alcohol-based HH may be effective in improving compliance.