Hand Hygiene in Healthcare: Playing by the New Rules

Hand Hygiene in Healthcare: Playing by the New Rules

By Nancy B. Bjerke, RN, MPH, CIC

Handwashing is the most effective means to prevent nosocomial infections; now hand hygiene with alcohol gels improves healthcare personnel compliance in the workplace.

An assembly of external Centers for Disease Control and Prevention (CDC) experts known as the Healthcare Infection Control Practices Advisory Committee (HICPAC) crafted a completely revised guideline titled hand hygiene, the new term to traditional hand cleansing and washing.¹ This guidance includes articles published since the previous hallmark CDC handwashing guideline of 1985 and an Association of Professionals in Infection Control (APIC) guideline on handwashing and hand antisepsis from 1995.

The format of the 50-page HICPAC document is similar to previous guidelines. Part I reviews the historical and scientific information. Part II states the healthcare practice recommendations. Part III adds a new element of performance indicators. The 423 references are followed with a familiar appendix comparing antiseptic agents. This best practice discussion will describe the HICPAC hand hygiene document, suggest a strategy to implement any product or practice change and list the guideline recommendations by rating scale.

Background

Historically, the hand hygiene story begins in 1822 when moistening hands with liquid chloride solution was advocated for contagious disease interruption. More notably is the Ignaz Semmelweis' work in 1846 when he insisted physicians and students clean their hands with a chlorine solution between each clinic patient proving that contaminated hands cleansed with an antiseptic agent between patient contacts reduced the transmission of infectious disease and patient fatality more effectively than soap and water washing.

The 1950 staphylococcus outbreaks and subsequent investigations led to a preventive strategy focused on healthcare personnel. A series of written recommendations, emphasizing hand cleansing as essential to disease interruption, include the CDC guidelines recommending healthcare practices for implementation in hospitals followed by APIC recommendations and the use of alcohol-based hand rinses. This HICPAC guidance advocates alcohol gels as the ultimate agent for compliance by healthcare workers (HCWs) performing responsibilities.

Aside from the normal review of skin flora and physiology, a glossary of terms defines hand hygiene as handwashing, antiseptic hand-wash and hand-rub, or surgical hand antisepsis. This is the new all-inclusive term for decontaminating and degerming the hand skin surface. Fundamental to product regulation and clearance for market are the Food and Drug Administration (FDA) product categories, defining patient preoperative skin preparation, antiseptic/healthcare worker handwash, and surgical hand scrub.

A dissection of microbe transmission via hands unfolds what has been discovered through thoughtful study. Simply stated, microbes reside on skin surfaces normally and through touch with a reservoir and are easily transmitted to another person directly or indirectly by an object to potentially and realistically cause colonization and/or infection in that person. The hardiness and survivability of the microbe and the lack of hand hygiene by the person are also weighty elements in this sequence of events. Published studies indicate that an evolution is occurring from soap and water hand cleansing for decreasing infectious transmission to antiseptic agents disinfecting skin surfaces for a more dramatic infection interruption.

Because the FDA has specific, standardized requirements that manufacturers must meet before their over-the-counter (OTC) drug products are cleared for market, vendors must provide supporting data that illustrates the achievement of these elements. Categorical ratings of I-III delineate safe-to not-safe and efficacious. Alcohol and iodine are considered category I while chlorhexidine gluconate is a category III and would require a new drug application (NDA) with its own FDA requirements. American and European standards for product evaluation differ and it is unknown what required log reduction is effective for all microbes. It is obvious more research in this area would further clarify the requirements.

The traditional comparative presentation on hand-cleansing agents by chemical component is narrated and summarized in charts and the appendix basically ranks alcohols and iodine compounds highest with chlorhexidine, tricolsan, phenol, and quaternary ammonium following. Of note, HICPAC states that none of the antiseptic hand agents are sporicidal against Bacillus anthracis or Clostridium difficile. This is relevant to the current terrorism activity with mass destruction weapons and healthcare personnel's role in countermeasures.

The discussion on surgical hand scrub progresses from antiseptic agents for skin disinfection to selecting antiseptic products that reduce microbes, are fast-acting and persistent, have non-irritating antimicrobial preparations and have broad-spectrum activity. The evolution of the scrub procedures moves from the addition of brush and sponge to mechanically remove organisms to total elimination of these additives due to skin damage and increased shedding. Additionally, studies have demonstrated that a traditional 10-minute scrub procedure is reduced to 5 minute to 2 minute to 1 minute with alcohol gels and no documented or reported increase in surgical site infections.

The new guidance focuses on the human aspect of hand hygiene in its description of dermatitis conditions and their resolution with new alcohol based gels containing emollients. Detergent harshness, water temperature, repeated proper or improper hand cleansing, various side effects of antiseptic agents, climatic conditions, lotions and cream compositions and applications, and sensitivities to product formulations and glove materials are some of the causative factors toward dermatitis. The conversion to alcohol gels is reported to cure dermatological conditions due to the emollient additives. While alcohol lacks persistency, HICPAC espouses that frequent use of alcohol gel products will mount a cumulative effect through routine use. A reprimand in the guideline directs that personnel need not routinely wash their hands after each application or multiple applications of an alcohol hand rub. Additionally, both soaps and alcohol waterless agents are not placed adjacent to sinks to avoid confusion on which product is used according to the HICPAC guideline. Caution should be exercised in selection and use of hand lotions and creams, especially those containing oil and their effect on glove materials. Yet, HICPAC further recommends that free skincare lotion be available because increased use of hand-hygiene agents might be associated with skin dryness; this is a contradiction to the whole advocacy of alcohol hand rubs.

The new criteria for hand-hygiene product selection are very subjective; personnel assess the products by smell, feel, consistency and color. Objective characteristics would focus on the time duration for alcohol to dry, skin integrity after use initially and long term, dispensing methods, and cost. Facility product evaluation committees would benefit from pre-established, written objective characteristics for assessing potential new hand cleansing and disinfecting agents. Conducting a structured evaluation process would include specific units, quantity of product, vendor inservicing prior to trial, documented evaluation sheets, specified timeframe, etc. The intent is an unbiased assessment of the products under consideration. An analysis of the evaluation sheets summarizes the pros and cons of each agent before an informed decision is made for the institution. A follow-up assessment once the selected product has been in use for some time (three to six months, for example) would validate whether personnel are using the product appropriately and for all the designated situations.

The education and research discussion in the guideline outline what content of instruction should include, who should be instructed, how performance and observations could be conducted, what barriers to adherence to hand hygiene practices would be addressed, to name a few. The specific aspects for research proposals are identified thus, suggesting what evidence-based studies are necessary to further strengthen the recommendations of this guideline.

The HICPAC guidance briefly addresses fingernails, artificial nails, gloving policies and jewelry. The nail discussion minimizes the contribution that nail length and artificial nail have in serious bacterial outbreaks' most notable is the 17 neonatal deaths reported by CDC in February 2000. According to the document, the application of nail polish is only a problem when it is chipped. Regarding gloves, the document reinforces the federal law that states hands should be decontaminated or washed after removing gloves. Gloves are not washed or reused. Petroleum-based hand lotions/creams may adversely affect glove integrity. Some alcohol rubs interact with residual powder in gloves. Glove removal is required in between patients. For jewelry, authors state more studies are needed.

Recommendations

Part II of the guidance lists the recommendations based on a five-point rating scale: Category IA (do this); Category IB (can do this;) Category IC (must do); Category II (suggested); and no recommendation, no consensus reached. The following priority list is a condensed version per rating scale, using the actual number before each recommendation as identified in the guideline.

Category IC Must Do:

6.C. Wear gloves for bodily fluid contact.

8.C. Store alcohol hand rubs in flammable materials cabinets.

Category IA Do This

1.A. Wash visibly dirty hands with soap and water.

1.B. Use alcohol hand rubs to clean hands.

1.G. Decontaminate hands after body fluid contact if hands not visibly soiled.

4.E. Prevent topping off partially empty soap dispensers

5.A. Provide HCWs with hand lotions/creams for dermatitis.

6.A. No artificial fingernails or extenders in ICUs or ORs.

7.B. Monitor HCWs' compliance and give feedback on hand hygiene practices.

8.C. Provide HCWs with alcohol hand rubs.

8.D. Provide alcohol hand rubs at entrance to patient's room, bedside, and for HCW pocket.

Category IB Can Do This

1.B. Wash hands with antimicrobial soap and water, if not using alcohol hand rubs.

1.C. Decontaminate hands before patient contact.

1.D. Decontaminate hands before donning sterile gloves for central IV catheter insertions.

1.E. Decontaminate hands before urinary, IV, and other non-surgical catheter insertions.

1.F. Decontaminate hands after patient contact.

1.J. Decontaminate hands after glove removal.

1.K. Wash hands with soap and water before eating and after using restroom.

1.L Antimicrobial towelettes are a substitute for soap and water cleansing only.

2.A. Apply alcohol hand rubs to palm, rubbing over entire hand surface until dry.

2.B. Wet hands with water, apply recommended product dose, rub vigorously 15 seconds over surface, rinse with water, dry thoroughly with paper towel; turn faucet off with towel. Avoid hot water which increases dermatitis risk.

3.C. Use antimicrobial soap or alcohol hand rub for surgical scrub before donning sterile gloves.

3.D. Perform surgical scrub with antiseptic and water for manufacturer's stated 2-6 minutes time only.

3.E. Use alcohol surgical hand scrubs per manufacturer's instruction. Pre-wash with soap and water and dry thoroughly before alcohol surgical scrub; dry thoroughly before donning sterile gloves.

4.A. Provide HCWs with efficacious, low irritancy hand hygiene products.

4.B. Obtain HCW input on products regarding feel, fragrance and skin tolerance; cost is not a primary factor in product selection.

5.B. Solicit manufacturer information on interactions among hand lotions, creams, alcohol rubs and antimicrobial soaps used in the facility.

6.D. Remove gloves after each patient; do not reuse or wash gloves.

8.A. Make hand hygiene adherence a priority in the facility, providing administrative support and finances.

8.B. Implement multidisciplinary program for HCW compliance to hand hygiene practices.

Category II Suggested

1.H. Decontaminate hands if moving from contaminated to clean body site.

1.I. Decontaminate hands after contact with inanimate objects near patients.

1.M. Wash hands with plain or antimicrobial soap and water for Bacillus anthracis (anthrax) spore exposure.

2.C. Liquid, bar, leaflet or powdered plain soap are acceptable non-antimicrobial forms for washing hands. Use soap racks for bar soap; use small bars.

2.D. Eliminate multiple use hanging or roll cloth towels in healthcare.

3.A. Remove rings, watches and bracelets before doing surgical hand scrub.

3.B. Remove debris underneath fingernails with a nail cleaner under running water.

4.C. Solicit manufacturer information regarding interactions among hand cleansing products, skin care products and glove types used in the facility.

4.D. Evaluate dispenser systems for function and dosing prior to purchase.

6.B. Keep natural nail tips less than 1/4 inch long.

6.E. Change gloves if moving from contaminated to clean body site during patient care.

7.A. Educate HCWs about hand contamination activities and pros and cons of cleansing methods.

7.C. Encourage patients and families to remind HCWs about decontaminating their hands.

No recommendation, No consensus reached

1.N. Routine use of non-alcohol hand rubs for hand hygiene in healthcare.

6.F. Wearing rings in healthcare.

Note: 2.A. Follow the manufacturer's recommendations regarding the volume of product to use. This statement in the HICPAC document appears to sanction violation of federal law, namely non-compliance with FDA labeling requirements, as it is without a rating.

Performance Indicators

Part III on performance indicators is a new addition to the HICPAC format. Here it focuses on four aspects for measuring HCW hand hygiene compliance:

1) Survey compliance of performance quantity over quantity of opportunities by ward or by service, providing feedback to HCWs;

2) Calculate the volume of alcohol product used per 1,000 patient days;

3) Monitor artificial nail wearing compliance with written policy; and

4) Assess HCW hand hygiene compliance during outbreaks.

The 2002 HICPAC Guideline on Hand Hygiene espouses the advent of alcohol gels as the answer to HCW compliance deficits while requesting statistical research data for strengthening evidence-based references for alcohol based hand hygiene practices. It behooves anyone who has or is about to implement this guidance to thoroughly and thoughtfully read this entire document. Employ critical thinking skills when assessing its intent and its recommendations as they apply to the unique healthcare delivery system or facility. Conducting objective product evaluations within the facility with a multidisciplinary group provides a systematic method for informed decision-making. Instruct HCWs and adhere to the labeling and storage requirements of the products selected. Remember hand cleansing and disinfecting with skin care and antiseptic products require multiple steps, mechanical friction being the most important to rid the surface of microbes.

ANSWERS

1. F
2. F
3. F
4. F
5. F
6. F
7. F
8. F
9. F
10. F