Hand Hygiene; Bring on the Alcohol Rubs

Hand hygiene is the single most important factor in preventing the spread of pathogens and antibiotic resistance in healthcare settings. Hand hygiene reduces the incidence of healthcare associated infections. The Centers for Disease Control and Prevention (CDC) estimate that each year 2 million patients in the United States become infected while in a hospital. About 90,000 of these patients die as a result of their infections. The number infected in outpatient healthcare facilities is not known. More widespread use of hand hygiene products that improve adherence to recommended hand hygiene practices would promote patient and practitioner safety and prevent infections.1-5

MICROBIAL FLORA ON HANDS

Hand hygiene is concerned with removal and/or destruction of microorganisms present on human skin. There are 2 types of microbial flora present—transient and resident.1-3

Transient flora (also called contaminating or noncolonizing flora) are microorganisms isolated from the skin but not shown to be consistently present in the majority of people. Although considered to be transient in nature, such microbes are of concern because they could be pathogenic and could cause infection to their hosts or could be transmitted to other people. Transient flora need to be removed by mechanical friction and soap and water or destroyed by the application of antiseptic agents.

Resident flora (also called colonizing or normal flora) are microorganisms persistently isolated from the skin of most persons. These microbes are considered permanent residents and are not readily removed by mechanical friction. Resident flora are opportunistic pathogens, causing infection when normal host defense mechanisms are impaired. Resident flora, however, can be passed from one person to another.

HAND HYGIENE AND HEALTHCARE-ASSOCIATED INFECTIONS

Outbreak investigations have indicated a relationship between infections and understaffing or overcrowding. This association was consistently linked with poor adherence to hand hygiene policies.1-10 Healthcare-associated pathogens can be recovered not only from infected or draining wounds but also from frequently colonized areas of normal, intact patient skin. Extra concern has been extended to the carriage of multiple drug-resistant bacteria on the hands of healthcare workers (HCW). Of course, such microorganisms could cause opportunistic infections among HCW.1-8,11

HCW can contaminate their hands even when performing “clean procedures” or touching intact areas of patient skin. Contacting contaminated surfaces has infected HCW. Other studies have indicated that hands and gloves can be contaminated while handling inanimate objects in treatment rooms. None of these studies determined if the HCW contamination resulted in transmission of pathogens to susceptible patients.

ADHERENCE WITH HAND HYGIENE RECOMMENDATIONS

In some observational studies conducted in hospitals, HCW washed their hands an average of 5 to 30 times a shift. Some nurses washed over a 100 times day. Washing hands more than 40 times a day would not be exceptional for some dental personnel. Frequency of handwashing can be related to a specific occupation.1-5,12-14

Duration of handwashing or hygienic handwashing episodes by HCW averaged 6.6 to 24.0 seconds in observational studies. Personnel also often failed to cover all the surfaces of their hands or fingers when handwashing. A dual shortfall was thus noted—too short a washing interval and poor coverage of areas needed to be cleaned.1-5,12-14

Other observational studies indicated that adherence by HCW to hand hygiene recommendations has been poor, ranging from 5% to 81%. The overall average of 33 studies was about 40%. Adherence rates varied greatly by occupation.1,3

HCW have reported several factors that may negatively impact their adherence to recommended practices. These included the following: handwashing agents causing irritation and dryness; sinks  inconveniently located; lack of soap and paper towels; insufficient time; understaffing or overcrowding; and patient priorities. Lack of knowledge of guidelines and protocols, forgetfulness, and disagreement with the recommendations were also self-reported factors for poor adherence to hand hygiene.1,3

HAND HYGIENE

Table 1. Definition of important hand hygiene terms*

Term Definition
Alcohol-based hand rub An alcohol-containing preparation designed for application to the hands for reducing the number of viable microorganisms on the hands; in the United States, such preparations usual- ly contain 60% to 95% ethanol or isopropanol
Antimicrobial soap Soap (eg, detergent) containing an antiseptic agent
Antiseptic agent Antimicrobial substances that are applied to the skin to reduce the number of microbial flora; examples include alcohols, chlorhexidine, chlorine, hexachlorophene, iodine, chloroxylenol (PCMX), quaternary ammonium compounds, and triclosan
Antiseptic handwash Washing hands with water and soap or other detergents containing an antiseptic agent
Antiseptic hand rub Applying an antiseptic hand-rub product to all surfaces of the hands to reduce the number of microorganisms present
Cumulative effect A progressive decrease in the number of microorganisms recovered after repeated application of a test material
Decontaminate hands To reduce bacterial counts on hands by performing
antiseptic hand rub or antiseptic handwash
Detergent Detergents (eg, surfactants) are compounds that process a cleaning action; they are composed of both hydrophilic and lipophilic parts and can be divided into 4 groups: (1) anionic, (2) cationic, (3) amphoteric, and (4) nonionic detergents, although products used for handwashing or antiseptic handwash in healthcare settings represent various types of detergents
Hand antiseptic Refers to either antiseptic handwash or antiseptic hand rub
Hand hygiene A general term that applies to handwashing, antiseptic handwash, antiseptic hand rubs, or surgical
hand antiseptic
Handwashing Washing hands with plain (eg, nonantimicrobial) soap and water
Persistent activity Prolonged or extended antimicrobial activity that prevents or inhibits the proliferation or survival of microorganisms after application of the product
Plain soap Detergents that do not contain antimicrobial agents or contain low concentrations of antimicrobial agents that are effective solely as preservatives
Substantivity An attribute of certain active ingredients that adhere to the stratum corneum (eg, remain on the skin after rinsing or drying) to provide an inhibitory effect on the growth of
bacteria remaining on the skin
Surgical hand antisepsis Antiseptic handwash or antiseptic hand rub performed pre- operatively by surgical personnel to eliminate transient and reduce resident hand flora; antiseptic detergent preparations often have persistent antimicrobial activity
Visibly soiled hands Hands showing visible dirt or visibly contaminated with proteinaceous material, blood, or other body fluids
Waterless antiseptic agent An antiseptic agent that does not require use of exogenous water; after applying the agents, the hands are rubbed together until the agent has dried
* modified from references 1 through 5  

There is substantial evidence that hand hygiene reduces the incidence of infection.1-5,12-14 HCW handwashing is a simple, elementary procedure that is essential to reduce patient nosocomial infections and HCW occupationally acquired infections. Traditionally, hand hygiene has been achieved through handwashing, which suspends microorganisms and mechanically removes them by rinsing with water or removes and kills microorganisms when one uses a soap containing an antimicrobial ingredient. A list of terms associated with hand hygiene is presented in Table 1.

Table 2. Types of hand hygiene*

(1) Routine handwashing

Purpose: To remove soil and transient microorganisms

Methods: Nonantimicrobial soap or detergent and water for 15 seconds**

Agents: Liquid soap dispensed using a hands-free device; avoid bar soaps

Inductions: When hands are visibly soiled or contaminated with pertinacious materials such as blood and other body fluids; before and after treating patient (before gloving and after gloving); when touching barehanded object known or likely to be contaminated with blood or saliva; before replacing defective gloves; and before leaving the operatory or laboratory (eg, before eating or after using the restroom)

(2) Routine hand asepsis

Purpose: To remove or destroy transient microorganisms; may also affect normal resident flora

Methods: (1) Alcohol-based hand rub: Add proper amount to dry hands and then rub hands until alcohol has evaporated (hands and forearms are dry)—use products with known persistent activity;# or (2) water and antimicrobial agent/detergent for 15 seconds**

Agents: (1) Generally, contain 60% to 95% ethanol or isopropanol or combination, emollient additive, gel medium, and antimicrobial agent such as chlorhexidine, quaternary ammonium compounds, octenidine, or triclosan. (2) Examples of active agents include alcohols, chlorhexidine, chlorine, hexachlorophene, iodine, chloroxylenol (PCMX), quaternary ammonium compounds, and triclosan

Inductions: When hands are not visibly soiled or contaminated with pertinacious materials such as blood;
routine decontamination of hands in clinical situations; before and after treating patient (before gloving and after gloving); when touching barehanded object known or likely to be contaminated with blood or saliva;
before replacing defective gloves; and before leaving the operatory or laboratory (eg, before eating or after using the restroom)

(3) Surgical hand antisepsis

Purpose: To remove or destroy transient microorganisms and reduce resident flora with a persistent
agent effect

Methods: (1) Water and antimicrobial agent or detergent and scrub for 2 to 6 minutes—use agents capable of producing a persistent effect; or (2) nonantimicrobial soap or detergent and water for 15 seconds and dry hands and forearms completely, followed by alcohol-based hand rub. Rub hands until alcohol has evaporated (hands are dry)#

Agents: (1) Examples of active agents include alcohols, chlorhexidine, chlorine, hexachlorophene, iodine, chloroxylenol (PCMX), quaternary ammonium compounds, and triclosan; or (2) liquid soap dispensed using a hands-free device—avoid bar soaps, dry hands and forearms, then use products that contain 60% to 95% ethanol or isopropanol or combination, emollient additive, gel medium, and antimicrobial agent such as chlorhexidine, quaternary ammonium compounds, octenidine, or triclosan

Inductions: Prior to placement of sterile surgeons’ gloves as preparation for surgical procedures

* modified from references 1 through 5
** process involves vigorous, brief rubbing together of all lathered hands and fingers, followed by an adequate rinse; then hands should be dried thoroughly
# apply prescribed amount to palm of one hand and rub hands together covering all surfaces of hands and fingers until skin surfaces are dry

For HCW, there are 3 basic types of hand hygiene—routine handwashing, routine hand asepsis, and surgical hand asepsis. A comparison of the 3 practices is made in Table 2. Each meets a specific need and requires certain products and procedures.

The emphasis of this article is on alcohol-based hand rubs. These products are relatively new in the United States, and not all dental personnel may be conversant with their use. Only the use of these will be presented in detail. However, a comparison of handwashing and alcohol-based hand rub characteristics is offered in Table 3.

USING ALCOHOL-BASED HAND RUBS

On October 25, 2002, the CDC published its Guideline for Hand Hygiene in Health-Care Settings.1 The guideline includes references to the use of alcohol-based hand rubs (preparations containing 60% to 95% alcohol). These products have been shown to be effective and may help improve hand hygiene compliance. The CDC guideline states that alcohol-based hand rubs significantly reduce the number of microorganisms on skin, are fast acting, and cause less skin irritation.1-5,15-17

Before introducing an alcohol-based hand rub, discussion with practice personnel should be performed. Several factors that can affect the overall efficacy and acceptance of such products should be considered.15 These include the following:

•A review of current hand hygiene practices and relative levels of compliance.

•Comparison of product efficacy.

•Obtaining feedback from personnel concerning the feel, fragrance, and skin tolerance of products under consideration.  Products that are not well accepted by personnel could result in lower levels of compliance.

•Assuring training of personnel in the operation of dispenser systems, especially considering the correct system for the product recommended.

•Obtaining information from manufacturers regarding any known adverse interactions between products and skin and gloves.

Alcohol-based hand rubs will not replace the need for sinks or other hand hygiene supplies (eg, plain soap, antimicrobial soaps, and detergents and paper towels) because when hands are visibly dirty or soiled with blood or other body fluids, they must be washed with either a nonantimicrobial soap and water or an antimicrobial soap and water. Also, because personnel may experience a “buildup” of emollients on their hands after repeated use of alcohol-based products, certain manufacturers recommend washing hands with soap and water after 5 to 10 applications of a gel.1-8,15

Frequent use of alcohol-based formulations for hand hygiene can cause drying of the skin unless emollients, humectants, or other skin-conditioning agents are added to the formulations. Allergic contact dermatitis due to alcohol hand rubs is very uncommon. However, with increasing use of such products by HCW, it is likely that allergic reactions will eventually occur.1-8,15  

ROUTINE HANDWASHING OR HAND ANTISEPSIS WITH ALCOHOL-BASED HAND RUB PRODUCTS

Alcohol-based hand rubs are appropriate when hands are visibly clean. When using an alcohol-based hand rub, apply the product to the palm of one hand and rub hands together, covering all surfaces of hands and fingers until hands are dry. The ideal volume of product to apply to the hands is not known and may vary for different formulations. However, if hands feel dry after rubbing them together for 10 to 15 seconds, an insufficient volume of product likely was applied. Note that the volume needed to reduce the number of bacteria on hands varies from product to product. Follow the advice of the product’s manufacturer.1-8,15

SURGICAL HAND ANTISEPSIS WITH ALCOHOL-BASED HAND RUB PRODUCTS

When using an alcohol-based surgical hand rub product with persistent activity, also follow the manufacturer’s instructions. Before applying the alcohol solution, wash hands and forearms with a nonantimicrobial soap and water and dry hands and forearms completely. Apply the alcohol-based product as recommended and allow hands and forearms to dry thoroughly before donning sterile gloves.1-8,15

ALCOHOL-BASED HAND RUBS AND FIRE SAFETY

The use of alcohol-based hand rubs has been common in Europe for more than 30 years. The effectiveness of the hand rubs is well documented. The CDC recently advocated the use of alcohol hand rubs to increase hand hygiene practices by healthcare workers. However, many facilities have had difficulty implementing the recommendations due to fire safety concerns.18-20

The type and concentration of alcohol present greatly affects the effectiveness of a given product. Two of the most common formulations in the United States contain 60% or greater percentages of ethyl alcohol or isopropyl alcohol. Alcohol is a flammable liquid. Local building and fire codes regulate the storage and use of flammable liquids. The presence of alcohol-based hand rubs may pose a fire hazard in healthcare facilities.

Obviously, all healthcare facilities, including dental practices, should make every effort to prevent fires. To enable healthcare facilities to address better the need to reduce infections of patients and practitioners while still being properly attentive to fire safety concerns, the American Hospital Association and the CDC recently convened a stakeholders meeting to review  scientific evidence that supports the use of alcohol rubs and applicable fire regulations.20

Table 3. Comparison of handwashing and antiseptic hand rubs*
 
Handwashing
 

Positives

• Effective antimicrobial activity when antiseptic handwashes are used

• Minimally affected by the presence of organic materials

• Commonly used technique

• Allergies to antimicrobial agents are uncommon

• Nonallergic skin irritations can be prevented or treated through the routine use of hand lotions

Negatives

• Frequent handwashing can lead to adverse skin reactions (eg, irritation, drying, and chapping)

• Compliance is notoriously low

• Allergies can occur to select ingredients such as fragrances or preservatives

• Process more protracted than that of antiseptic hand rubs

 
Antiseptic Hand Rubs
 

Positives

• Provides superior antiseptic action on visibly clean hands

• Faster hand asepsis than traditional handwashing

• Use results in lower incidence of skin irritation and dryness when products contain emollients

• Greater accessibility because sinks are not required

• Allergic reactions to product components are rare

• If widely available, leads to greater hand hygiene compliance

• Does not promote antimicrobial resistance

Negatives

• Should not be used when hands are visibly dirty or contaminated, especially with protein-rich materials,
such as blood

• Flammable, could pose a fire hazard

• Hands should initially be dry

• Amount used is very important

* modified from references 1 through 5

The benefits of alcohol hand rubs are many (see Table 3). Improved hand hygiene has been associated with reduced healthcare-associated infection rates. The position of alcohol rubs is now firmly established in the United States. One study indicated a dramatic increase in use when the dispensers were placed in hallways outside of patient rooms, rather than being inside.18-19 A survey of 840 healthcare facilities reported that 95% of them used alcohol-based hand rubs. The responding facilities indicated a cumulative 1,430 years of product use. No fires attributable to or involving a product dispenser were reported by the facilities. However, over 11% stated they had been told by fire marshals to remove dispensers from hallways. Such incidence of reports varied geographically, with 5 states being most involved. Also, there were concerns regarding the amounts of alcohol- based hand rubs stored in a single room or floor and within the entire facility. In the end, the debate was not whether hand rubs should be used but rather how they can be used safely.20

In the United States,  there is no single fire code. National, state, and even local authorities each have independent jurisdiction. It is the responsibility of each facility to determine the types and nature of the fire code applicable in its location. However, several general recommendations can be offered21:

•Users should rub their hands until the alcohol has evaporated (hands are dry) and avoid any open flames during use.

•Alcohol-based hand rubs should be stored away from high temperatures or flames.

•Dispensers should not be installed over electrical receptacles or near potential sources of ignition.

•All storage of replacement products, independent of amount, should be in cabinets approved for flammable materials and that meet local fire codes as to amount allowed.

•Containers placed in hallways should not exceed a maximum capacity of 1.2 liters, while single containers inside a room should have a maximum capacity of 2.0 liters of alcohol-based hand-rub solutions in gel/liquid form.

•Such products should not be placed in egress corridors (exit corridors or areas open to exit corridors). Dispensers should ideally project no more than 3.5 to 4.5 inches (depending on applicable code) into a “secondary” corridor.18-21

HAND HYGIENE AND GLOVES

The use of gloves does not eliminate the need for hand hygiene. Likewise, the use of hand hygiene does not eliminate the need for gloves. Gloves reduce hand contamination by 70% to 80%, prevent cross-contamination, and protect patients and HCW from infection. Thus, wearing gloves reduces the risk for HCW acquiring infection from patients, prevents flora from being transmitted from HCW to patients, and reduces contamination of the hands of HCW by flora that can be transmitted from one patient to another.

However, microorganisms grow faster on gloved hands than ungloved ones if hand hygiene does not involve agents that have substantivity. Few HCW wear gloves for longer periods during workday or change gloves with greater frequency than do dental workers.

Hand hygiene of some type (antimicrobial soap or detergent or alcohol-based hand rub) should be used before and after each patient, just as gloves should be changed before and after each patient. The same gloves should not be used for the care of more than one patient. Hands are washable and reusable; gloves should neither be washed nor reused.1-8

Hand lotions should be used at the end of the workday to prevent skin dryness associated with glove use and handwashing. Assure the compatibility of the lotion with antiseptic hand hygiene products and glove integrity. Lotions containing petroleum and other oil emollients may have adverse effects on certain types of gloves.


References

1. Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee, HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. 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. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2002;51(RR-16):1-45, quiz CE 1-4.

2. Larson EL. APIC guideline for hand washing and hand antisepsis in health care settings. Am J Infect Control. 1995;23:251-269.

3. Centers for Disease Control and Prevention. Hand hygiene in healthcare settings – core and supplemental slides. Available at: http://www.cdc.gov/handhygiene/materials.htm. Accessed November 2003.

4. Organization for Safety & Asepsis Procedures. Hand hygiene, new CDC guidelines expand option to healthcare facilities. Infection Control In Practice. 2003;2(1):1-8. 

5. Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee, HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Am J Infect Control. 2002;30:S1-S46.

6. Steere AC, Mallison GF. Handwashing practices for the prevention of nosocomial infections. Ann Intern Med. 1975;83:683-690.

7. Sanderson PJ, Weissler S. Recovery of coliforms from the hands of nurses and patients: activities leading to contamination. J Hosp Infect. 1992;21:85-93.

8. Larson EL, Cronquist AB, Whittier S, et al. Differences in skin flora between inpatients and chronically ill outpatients. Heart Lung. 2000;29:298-305.

9. Fridkin SK, Pear SM, Williamson TH, et al. The role of understaffing in central venous catheter-associated bloodstream infections. Infect Control Hosp Epidemiol. 1996;17:150-158.

10. Harbarth S, Sudre P, Dharan S, et al. Outbreak of Enterobacter cloacae related to understaffing, overcrowding, and poor hygiene practices. Infect Control Hosp Epidemiol. 1999;20:598-603.

11. Vicca AF. Nursing staff workload as a determinant of methicillin-resistant Staphylococcus aureus spread in an adult intensive therapy unit. J Hosp Infect. 1999;43:109-113.

12. Larson E, Killien M. Factors influencing handwashing behavior of patient care personnel. Am J Infect Control. 1982;10:93-99.

13. Larson EL, Hughes CA, Pyrek JD, et al. Changes in bacterial flora associated with skin damage on hands of health care personnel. Am J Infect Control. 1998;26:513-521.

14. Taylor LJ. An evaluation of handwashing techniques: 1. Nurs Times. 1978;74:54-55.

15. USAF Dental Investigation Service. Alcohol-based hand rubs. Available at:http://www.brooks.af.mil/dis/HOT/alcoholhandwash.htm. Accessed November 2003.

16. Girou E, Loyeau S, Legrand P, et al. Efficacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial. BMJ. 2002;325:362.

17. Girard R, Aho LS, Goetz ML, et al; Members of the working gro



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