Infection Control Today - 06/2004: Clinical Requirements

Clinical Requirements of Body-Worn Hand Sanitation
Accessibility is the Key to Hand Hygiene Compliance

By Ron Cagle

Since the October 2002 update of the Centers for Disease Control and Prevention (CDC)s hand hygiene guidelines for healthcare settings, wall-mounted alcohol handrub dispensers have been going up in hospitals across the country. These programs will surely have a dramatic impact on lowering infection rates; however, the questions remain: Is this the best we can do? Are wall mounts as accessible as they need to be to meet the critical objectives? And what about body-worn hand sanitizers that have more recently become available? Body-worn hand sanitizers promise to redefine accessibility and move hand hygiene practices much closer to the hand-hygiene goals of the CDC as well as Patient Safety Goal No. 7, reducing healthcare-acquired infections (HAIs), mandated by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO).

The Critical Scope of the Problem

Weve all read the statistics, but the need for ways to prevent HAIs cannot be overemphasized. According to the CDC, HAIs are the fourth leading cause of death in the U.S. There are 2.2 million nosocomial infections annually resulting in more than 80,000 fatalities. The annual economic burden of nosocomial infections to the U.S. healthcare system is $5.2 billion. Multi-drug resistant pathogens are an emerging contributor and threaten to perpetually raise the stakes even further.

Focus on Hands

Weve known about the role hands play in infection control for 150 years, yet the problem persists. Hand hygiene is considered to be the No.1 preventive measure against the spread of infection. At least 20,000 of the annual nosocomial infection fatalities are attributed directly to inadequate hand hygiene. The old handwashing model did not account for the reality of todays conditions. For example, studies show that healthcare workers (HCWs) can wash their hands every time they should, or do their jobs, but not both! Another factor is that constant handwashing is far too damaging to hands. Clearly, HCWs need realistic answers.

CDC Recommends Accessibility

Given the magnitude of the problem and the practical realities facing todays HCWs, the CDC updated its hand-hygiene guidelines. The most notable recommendation is to use an alcohol-based handrub when hands are not visibly soiled.1 This allows hand sanitation to no longer be restricted to a sink and makes possible a variety of more accessible options. Going farther to emphasize accessibility, the guidelines recommend that HCWs carry individual pocket-sized containers in areas of anticipated high-intensity patient care.

Much of the groundwork of the updated guidelines point to accessibility as the key to compliance. CDC guideline co-author Didier Pittet, MD, concludes, Strategies to improve compliance with hand hygiene practices should be multi-modal and multi-disciplinary, and easy access to fast-acting hand hygiene agents should be viewed as the main tool of the strategy. 2 Bischoff and associates, in their April 2000 study, offered a supporting view: Accessibility may eventually be shown to be the most reliable variable predicting handwashing rates. 3

Got Compliance?

The question of compliance remains. Will wall-mounted systems end hand-transmitted infection in healthcare settings and therefore eliminate the need for additional innovations, tools, and programs? The factors contributing to non-compliance point to the answer:

  • Placement.Wall mounts cannot be everywhere they will be needed. As Pittet points out, To ask a busy HCW to walk away from a patients bed ... to obtain an antiseptic solution enhances the risk for noncompliance with recommendations.1 Regardless of placement, situations will arise that require the HCW to walk.
  • Time Constraints.Studies found that the higher the demand for hand hygiene, the lower the compliance.4 Any tool that takes time will not completely overcome this core compliance factor. Although less so than with hand washing, wall mount use does require dedicated time.
  • Interruptions.In virtually every case, using a wall-mounted alcohol hand sanitizer requires a workflow interruption. A HCW must stop, see the dispenser, go to it, use it, and return. The more steps, the more attention, and the more thought that is required, will ultimately effect compliance.

Body-Worn Critical Requirements

Since the release of the CDC updated guidelines, a new breed of bodyworn hand sanitizers has been introduced. Although they dispense similar alcohol hand-sanitizing agents, the critical requirements are significantly different from wall-mounted and other delivery systems:

  • Body-worn. Clipped on clothing or belt, a body-worn hand sanitizer is always within reach.
  • Second-nature habit. A body-worn hand sanitizer that operates with one hand offers the capability of becoming a second-nature habit.
  • High-intensity access. Using a hand sanitizer that operates as a second- nature habit is the only realistic way hand-hygiene compliance can be maintained during high intensity patient care situations.
  • Time savings. According to prominent ER physician Angelo Salvucci, Second-nature hand sanitizers save me up to an hour in a nine-hour shift. I no longer spend time hunting down a wall-mounted dispenser or sink. In fact, I virtually do not have to spend any additional time sanitizing my hands.
  • Eliminated interruptions. A second-nature hand sanitizer does not require a workflow interruption. It can easily be used within the flow of most tasks.
  • Patient care. A second-nature hand sanitizer allows HCWs to focus on patient care. I no longer have to break patient eye contact to sanitize my hands, explains Salvucci. The time and thought I save can go into what Im here for quality patient care.
  • Visibility. Body-worn hand sanitizers act as visible reminders to the user, other staff, and patients that hand sanitation is a priority. It brings the sanitizer out where the action is and where everyone can share in the reminder.
  • Personal commitment. When a wall mount unit is broken, it is an institutional problem (i.e., someone elses concern). A personal hand sanitizer is always a personal commitment.

Lessons of Semmelweis

Semmelweis taught us that it shouldnt require 50 years to take the next logical step in hand sanitation compliance. Body-worn hand sanitizers warrant a closer look by virtually every healthcare setting. The intent of the CDC guidelines call for opening the review process to new innovations.

The process should include:

  • New product category. Body-worn hand sanitizers warrant a new category with its own set of clinical requirements. This includes questioning current assumptions/practices and looking at new solutions outside existing purchasing confines.
  • Trials now. Virtually every ICU and ER will benefit from a closer clinical look at a tool that not only promises better compliance rates but time savings.
  • Clinical leadership. Leadership starts by example. The daily use of a body-worn hand sanitizer is the easiest and most potent way to help others understand the importance of this issue.
  • Cost perspective. It is the severity of the problem being addressed that lends the proper perspective to potential new solutions. As stated in the CDC guidelines, The cost of hand-hygiene products should not be the primary factor influencing product selection. Further, second-nature hand hygiene holds the promise of savings that will dwarf the costs of the program. Again from the guidelines, Thus, hospital administrators must consider that by purchasing more effective or more acceptable hand-hygiene products to improve hand-hygiene practices, they will avoid the occurrence of nosocomial infections; preventing only a limited number of additional health-care-associated infections per year will lead to savings that will exceed any incremental costs of improved hand-hygiene products.
  • Studies. Addressing the subject of changing behavior of HCWs, Pittet calls for action: Carefully designed studies dealing with behavior change should be viewed as worthy candidates for grant support by funding agencies. Peer-reviewed journal editorial boards and facility chairpersons also need to reconsider their positions on this subject. Second-nature hand sanitation certainly falls within this intent.

The change in culture called for in the updated guidelines will benefit from tools worthy of the paradigm shift. The accessibility of wall-mounted and body-worn alcohol hand sanitizers together will lend strength to administrative and educational program components. Higher expectations can be set and achieved given realistic accessibility to hand hygiene agents.

Ron Cagle is the business development manager for Harbor Medical, Inc. of Santa Barbara, Calif.

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