Handy Solutions for Fast-Paced Hygiene

Handy Solutions for Fast-Paced Hygiene

By Jennifer Schraag

The helping hands of your staff could be potential deadly weapons. today’s surgicenter takes a look at fast, convenient, efficacious products to increase hand-hygiene compliance in today’s fast-paced healthcare facilities.

Adherence to good hand-hygiene practices in the healthcare setting has been an ongoing challenge for decades. The possibility of transmission of nosocomial infection is of course at the forefront of this never-ending push for clean hands. Regulatory and healthcare agencies are realizing the challenges of time constraints presented to healthcare workers and are working feverishly to make each shift easier.

Recent steps taken to enhance easy access and improve compliance for efficient hand hygiene in healthcare settings includes the recent approval by the Centers for Medicare and Medicaid Services (CMS) for placement of alcohol-based hand sanitizer dispensers in healthcare corridors. Other governmental proactive steps include the Centers for Disease Control (CDC) guideline, “Hand Hygiene in Healthcare Settings,” released in 2002, and the World Health Organization (WHO) is working feverishly this year to complete its global guideline “WHO Guidelines on Hand Hygiene in Healthcare.”

The push is there, but are healthcare workers (HCWs) listening? Recent statistics show hand-hygiene compliance rests at an average 40 percent and 90,000 patient deaths occur annually due to nosocomial infections, much of which is sourced from poor hand hygiene.¹ An even less impressive figure is the $4.5 billion in treatment costs per year.

“Approached from an infection control point of view, hand hygiene is a front-line strategy for protecting against any hospital-acquired infection (HAI), particularly between patients,” says Cynthia Halvorson, RN, MSN, CNOR, with the Medical Center of Aurora in Aurora, Colo. “Hand hygiene is considered a job expectation. It is certainly included in annual competency reports.”

The whirlwind of activity HCWs weather each day as their shifts pound on leaves no room for surprise that time is the No. 1 deterrent for adherence to guidelines. Studies find in every eight-hour shift, the time spent washing hands is equal to the loss of one nurse.² Handwashing with soap and water, based on seven 60-second episodes per hour, averaged 56 minutes spent per shift, per worker. One study conducted in an intensive care unit (ICU) demonstrated that it took nurses an average of 62 seconds to leave a patient’s bedside, walk to a sink, wash their hands and return to patient care.³

All that time spent and the use of plain soap and water has been found to be the least effective of all hand-hygiene methods.⁴

Efficacy is an important factor when considering new products that save time and increase adherence. Rest assured, researchers and handhygiene product manufacturers are offering many solutions.

“The biggest change we’re seeing now is moving to the alcohol-based products and things that require less time and a different application due to the effectiveness of the agent,” Halvorson points out. At the top of the efficacious list are alcohol-based handrubs and wipes. Alcohol-based handrubs significantly reduce the number of microorganisms on skin, are fast-acting and cause less skin irritation.5 These formulas also have been shown to be significantly more efficient in reducing hand contamination than handwashing with antiseptic soap.⁶

More impressive to its abilities is the considerable time difference — a mere 18 minutes — spent per eight-hour shift when using an alcohol-based handrub.⁷

Halvorson says she has found the rubs beneficial in saving time and getting the job done.

“Certainly the agents you can put on that do not require water” save time, she says. “Just put it on, rub it in for the required time and go.”

Carol Imes, director of nursing at Mentor Surgery Center in Mentor, Ohio agrees. There is a “need to use friction with soap and water, and you need to rub 15 seconds for effectiveness,” she adds. “Some people think just a quick wash is sufficient.” Imes’ facility uses hand gels in patient areas. She says alcohol-based hand rubs are the quickest, most effective way for HCWs to ensure good hand hygiene on the go.

Alcohol-based hand antiseptics contain isopropanol, ethanol, n-propanol, or a combination. The antimicrobial activity of alcohols consists of their ability to denature proteins. Alcohol solutions containing 60 percent to 95 percent alcohol are most effective.⁸ Alcohols have excellent in vitro germicidal activity against gram-positive and gram-negative vegetative bacteria, including multidrug-resistant pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin- resistant Enterococcus faecium (VRE), Mycobacterium tuberculosis, and various fungi. One study found alcoholic preparations, particularly n-propanol and isopropanol, were most effective in combating such organisms as Escherichia coli (E. coli).⁹ Certain enveloped (lipophilic) viruses such as herpes simplex virus, human immunodeficiency virus (HIV), influenza virus, respiratory syncytial virus (RSV) and vaccinia virus, also are susceptible to alcohols when tested in vitro.¹⁰ Despite its effectiveness against these organisms, alcohols have very poor activity against bacterial spores, protozoan oocysts, and certain nonenveloped (nonlipophilic) viruses. Researchers have found alcohol preparations to have little or no residual effect.¹¹

Addition of substances such as chlorhexidine gluconate (CHG), a cationic bisbiguanide, is quite common in alcohol-based preparations. CHG has substantial residual activity and is used to increase lasting efficacy of the alcohol-based products.

Halvorson swears by the addition of CHG to alcohol preparations. “Certainly the ones with an alcohol/chlorhexidine combo are most effective,” she says, and there is some available research to back her. Ohio-based Hill Top Research, Inc., for instance, tested the efficacy of a waterless surgical hand preparation containing 1 percent CHG and 61 percent ethyl alcohol for antimicrobial removal in comparison with a standard 4 percent CHG surgical scrub and a 61 percent ethyl alcohol control.

The researchers concluded the combination of 1 percent CHG and 61 percent ethanol had significantly greater microbial reduction than either the scrub or the control.¹²

The antimicrobial activity of CHG is likely attributable to attachment to, and subsequent disruption of, cytoplasmic membranes, resulting in precipitation of cellular contents.¹³ CHG has good activity against gram-positive bacteria, somewhat less activity against gram-negative bacteria and fungi, and only minimal activity against tubercle bacilli. It has in vitro activity against the enveloped viruses herpes simplex virus, HIV, cytomegalovirus, influenza, and RSV, but substantially less activity against such nonenveloped viruses as rotavirus, adenovirus, and enteroviruses.

(For more information on additional agents used in hand-hygiene products, visit www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm) Wava Truscott, PhD, director of scientific affairs and clinical education at Roswell, Ga.- based Kimberly-Clark Health Care, says a proper technique must be observed when using hand sanitizers. “To perform their function of killing microorganisms, hand sanitizers must be allowed to dry on the hands before proceeding.

This is not only critical to ensure efficacy of antimicrobial activity, it is also important in preventing glove barrier compromise. If the alcohol is still liquid when the glove is donned, most glove materials will be susceptible to rapid degradation.”

It has been recommended that alcohol-based hand sanitizers be available at each bedside for proper hand disinfection.¹⁴ However, alcohol-based rubs and gels are not always the best choice for the long term. Studies have shown alcohol-based handrubs, compared with other products, demonstrate better efficacy after a single episode of hand hygiene, but that wasn’t the case after 10 episodes.¹⁵ According to CDC guidelines, alcohols are not appropriate for use when hands are visibly dirty.

“Studies have shown that alcohol hand gels are effective in killing the bacteria, but do not remove the dirt and soil,” adds Joann Reilly, director of marketing at Orangeburg, N.Y.-based Professional Disposables International (PDI), “because of the natural friction caused by the wiping action, an important function rub-in alcohol handwashes cannot achieve.” Studies have shown PDI’s Sani-Dex® ALC Antimicrobial Alcohol Gel Hand Wipes is effective at killing 99.99 percent of harmful bacteria and removes more dirt and soil than a rub. Sani-Dex ALC comes in convenient quick-pull 135-count wipe canisters and 100-count pocket packets for quick on-the-go sanitizing. Additionally, a medium locking Sani-Bracket is available for wall and mobile equipment attachment.

Research suggests alcohol wipes are an acceptable alternative to soap-and-water handwashing, and has found less skin irritation reported with the alcohol wipes than other products.¹⁶ Repeated washing with alcohol-laden wipes result in reductions in bacterial colony counts comparable with nonmedicated soap, sufficient to prevent transmission of pathogens by the hands in most situations that arise in nonacute healthcare settings.¹⁷

“It is very important to wash hands in a hospital setting, in between patients or handling equipment in order to prevent the spread of germs and diseases,” adds Reilly. “However, there are times when sinks are unavailable. Wipes are ideal for those times. Nurses, emergency medical staff and other staff on the run who are looking for an effective bacteria who are looking for an effective bacteria killing solution can carry the sanitizing wipes with them throughout the day to effectively disinfect hands before treating patients.”

“Having the hand sanitizer always within reach and operated by one hand removes the logistical barriers to hand hygiene compliance,” says Ron Cagle, business development manager of Santa Barbara, Calif.-based Sprixx.

Besides bedside dispensers, pocket dispensers are available and their use is on the rise. Sprixx, for example, developed the Sprixx XE, or the “Sprixxer,” which looks like a beeper and takes a replacement cartridge that holds 1.35 ounces of alcohol hand sanitizer; the Sprixx HP — which uses a holster with a 2.36 ounce replacement spray bottle; and the Sprixx LT — which uses a small, light half-ounce spray bottle with a reusable clip.

“Sprixx is an ergonomically designed hand sanitizer that you wear and use on the go,” Cagle adds. “It is always at your side and always there when and where you need it the most. Unlike wall-mounted alcohol hand sanitizer dispensers, Sprixx makes it possible for doctors and nurses to never have to skip even the smallest hand hygiene opportunity. When you have to cross the room to use a wall dispenser, small hand hygiene opportunities such as rubbing your ear or pulling up a chair tend to be ignored out of practicality. Studies show that infections are most likely spread when healthcare workers are at their busiest. The key was identified by the CDC — accessibility is paramount.”

Akron, Ohio-based GOJO Industries manufactures Purell® and Provon® skin care products designed for hand hygiene, bathing, moisturizing and perineal care. Purell Instant Hand Sanitizers are alcohol-based hand rubs with an active ingredient of 62 percent ethyl alcohol. Bruce J. Van Deman, GOJO’s director of healthcare marketing, acute care, says both skin care products are dispensed in state-of-the-art dispensing systems, manual or electronic, hands-free dispensers. The dispensers are conformant with fire safety standards.

“Our dispensing systems have a full range of accessories, commercially available, that are designed to enhance dispenser installation and simplify dispenser service and maintenance issues,” he explains. Examples of the accessories include Tru-Fit™ Wall Plate, At-A-Glance™ Refill Alert and the FMX™ Utility Shelf.

Other potentially useful products to provide incentive to healthcare workers are products such as Circleville, Ohio-based Health Care Logistics, Inc.’s Personal Protection Belt. The belt features removable hook-and-loop pockets, holsters and pouches; perfect for lotions, hand sanitizers, gloves, sprays and wipes.

When evaluating hand-hygiene products for potential use in healthcare facilities, the CDC advises that administrators or product selection committees consider the relative efficacy of antiseptic agents against various pathogens and the acceptability of the products by personnel. Characteristics of a product can greatly affect acceptance and therefore usage. It is imperative to take into consideration any deterrents your staff has vocalized. These may include skin irritation or allergy, dispensing issues and convenience and accessibility concerns. Delivery system, cost per use, reliable vendor support and supply all are additional considerations.

Visibility also is important, according to Cagle. Products worn on the worker, such as the Sprixxer, “helps remind other staff to sanitize hands as well as being a visible symbol for the patient that the best infection control measures are a priority,” he says.

The CDC notes additional barriers to adherence of hand-hygiene practice include skin irritation, inaccessible supplies, interference with healthcare worker-patient relationships, priority of care (i.e., the patients’ needs are given priority over hand hygiene), wearing of gloves, forgetfulness, lack of knowledge of the guidelines, insufficient time for hand hygiene, high workload and understaffing.

“There are practical issues too of the type of dispenser and what that means to the organization of putting it on a wall or sitting on a ledge,” adds Halvorson. “All the maintenance and logistics of it come into play. How often does it have to be refilled, whose job is it, will the device hold up over time with multiple users and nonstop use all day long? If those things crop up, there tends to be not a lot of patience or tolerance for that.”

“With all of them it’s truly a matter of the end user understanding the principle behind it,” Halvorson says. “I think that is where the concern comes in, ‘Is it being properly used in order for it to be effective?’ I suppose the concern with, for instance, the wipe, could be proper education of the staff. ‘X quantity of the wipes does contain the effective amount of the agent.’ “Agents used as a surgical scrub by the OR staff can take really good initial education and follow-up to really ensure it is being used appropriately,” she continues. “That’s what it boils down to on almost anything, that the end user is really clear on, ‘this is what it’s indicated for and if it is used to its specifications, than it is effective.’”

Educational information and resources also is imperative, according to Halvorson. “This includes good educational information either through the vendor or through articles that keep those of us on the frontline aware of new developments.”

Manufacturers can help caregivers identify incompatibilities with hand-hygiene products and techniques by providing materials that help educate clinicians about the various types of reactions and the proper steps to take if an irritation is present. A good example is the Kimberly-Clark Knowledge Network which helps clinicians identify whether an irritation is glove-associated or caused by other factors such as improper hand hygiene or incompatibility with soaps and other disinfectants.

Widespread compliance is making leaps and bounds in the hand-hygiene arena, but much work is left to be done. Companies such as Sprixx and Surfacine Development Co. are working on advanced formulations for further efficacy. “We have heard that Clostridium difficile requires a higher degree of efficacy — along the lines of a 70 percent alcohol formula — we are developing such a formula,” Cagle adds.

Surfacine®, a silver compound used for a long-lasting antimicrobial effect, also is being integrated into healthcare associated hygiene and infection control products (for more information, visit www.infectioncontroltoday.com).

“We’re kind of creatures of habit and sometimes it is hard to move us out of that comfort zone. I think eventually we can keep ourselves very open minded and keep up with the latest and greatest changes that are based on sound principles and are evidence-based,” Halvorson says. “The more streamlined, simple and straightforward the application is, is always the best.”

Works Cited

1. Hand Hygiene Resource Center, www.handhygiene.org, accessed May 10, 2005.

2. Voss A and Widmer AF. No Time For Handwashing!? Handwashing versus alcoholic rub: can we afford 100% compliance? Infect Control Hosp Epidemiol 1997;18:205-8.

3. Voss A and Widmer AF. No Time For Handwashing!? Handwashing versus alcoholic rub: can we afford 100% compliance? Infect Control Hosp Epidemiol 1997;18:205-8.

4. Kampf G, Kramer A. Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs. Clin Microbiol Rev. 2004 Oct;17(4):863-93.

5. Centers for Disease Control “Hand Hygiene Guidelines Fact Sheet” www.cdc.gov/od/oc/media/pressrel/fs021025.htm

6. Girou E, et. al. Efficacy of handrubbing with alcohol-based solution versus standard handwashing with antiseptic soap: randomized clinical trial. BMJ. 2002 Aug 17;325(7360):362.

7. Voss A and Widmer AF. No Time For Handwashing!? Handwashing versus alcoholic rub: can we afford 100% compliance? Infect Control Hosp Epidemiol 1997;18:205-8.

8. Boyce, JM, Pittet, D 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 Part I. Review of the Scientific Data Regarding Hand Hygiene Review of Preparations Used for Hand Hygiene October 25, 2002 / 51(RR16);1-44. www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm

9. Ayliffe GA, et. al. Hand disinfection: a comparison of various agents in laboratory and ward studies. J Hosp Infect. 1988 Apr;11(3):226-43.

10. Boyce, JM, Pittet, D 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 Part I. Review of the Scientific Data Regarding Hand Hygiene Review of Preparations Used for Hand Hygiene October 25, 2002 / 51(RR16);1-44. www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm

11. Ayliffe GA, et al. Hand disinfection: a comparison of various agents in laboratory and ward studies. J Hosp Infect. 1988 Apr;11(3):226-43.

12. Mulberry G, et al. <I>Evaluation of a waterless, scrubless chlorhexidine gluconate/ethanol surgical scrub for antimicrobial efficacy.<$> Am J Infect Control. 2001 dec;29(6):377-82.

13. Boyce, JM, Pittet, D 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 Part I. Review of the Scientific Data Regarding Hand Hygiene Review of Preparations Used for Hand Hygiene October 25, 2002 / 51(RR16);1-44. www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm

14. Bonten MJ. Infection in the intensive care unit: prevention strategies Curr Opin Infect Dis. 2002 Aug;15(4):401-5.

15. Sickbert-Bennett EE, et al. Comparative efficacy of hand hygiene agents in the reduction of bacteria and viruses. Am J Infect control. 2005 Mar;33(2):67-77.

16. Butz AM, et al. Alcohol-impregnated wipes as an alternative in hand hygiene. Am J Infect Control. 1990 Apr;18(2):70-6.

17. Ibid.