Maximizing Hand-Hygiene Compliance to Improve Outcomes:
A New Tool for Infection Control
By Eleanor J. Fendler, PhD, MD and Patricia A. Groziak, MS
Hospital-acquired infections are a major concern in healthcare facilities, affecting at least 2 million patients annually and resulting in extended durations of care and substantial morbidity.1 Such infections are estimated to cause or contribute to 88,000 deaths annually in the US, as well as requiring nearly $5 billion in treatment costs.1 The incidence of infections in acute care facilities is about 9.8 infections per 1,000 patient care days and in long-term care facilities, approximately 7.2 infections per 1,000 resident care days.2,3 Because infections are a major cause of morbidity and mortality, and the threat of antibiotic-resistance is becoming a serious public health concern, attempts to control the spread of infections in healthcare has demanded increasing attention. The Centers for Disease Control and Prevention (CDC) states one-third of these infections can be prevented by implementing better infection control programs, and that hand hygiene is the most important measure to prevent the spread of infection.4
Compliance with handwashing procedures by healthcare workers (HCWs) continues to be at 20-50%.2, 5-8 Studies have shown that deterrents to hand hygiene compliance include the amount of time required for soap-and-water handwashing with heavy workloads, skin irritation, and dryness caused by frequent handwashing with soap and water, and poor access to sinks.2,9-13
Use of waterless alcohol-based hand sanitizers instead of soap-and-water handwashing has been demonstrated to overcome these barriers to compliance.11-16 Alcohols, in the form of both rinses and gels, are one of the most effective agents for reducing the number of viable pathogens on the hands18-21 including under artificial fingernails.22 Hand disinfection with an alcohol gel hand sanitizer containing emollients causes less skin irritation and dryness of the hands than handwashing.12 Introduction of easily accessible dispensers with an alcohol-based waterless handwashing antiseptic also has been demonstrated to lead to significantly higher hand hygiene rates among HCWs.8 Improving compliance of HCWs with recommended hand hygiene measures can reduce transmission of hospital-acquired pathogens16,17 and result in decreased infection rates.17
Alcohols for Hand Disinfection
Alcohols have been used for skin antisepsis in healthcare for more than a century. Ethanol is the only Category 1 (safe and effective) antimicrobial ingredient in the FDA Tentative Final Monograph (TFM), covering handwashes, surgical hand scrubs, and hand antiseptics in the US. Ethanol (ethyl alcohol) at 60-95% concentration by weight has very rapid, broad spectrum antimicrobial efficacy for gram-positive and gram-negative bacteria, including the antibiotic-resistant microorganisms, as well as for some fungi and viruses. Evaluations of both the immediate and persistent antimicrobial effects of the product on the hands over the course of 10 consecutive microbial contamination/product application cycles show high efficacy. The irritation potential of the product measured over the course of 15 additional product cycles using the standard visual scoring showed no skin irritation.
Contrary to popular opinion, alcoholic products seem to be quite acceptable to users.12,23 Newer formulations containing emollients eliminate the drying effects of alcohol on skin and significantly increase acceptability.24-33 Intermittent use of an alcohol hand gel containing emollients was found to reduce the soap-induced skin irritation of HCWs and to improve their skin condition (cracking, scaling, and redness) and maintain normal skin hydration.34 Similar results were found in Finland where use of alcoholic preparations containing emollients instead of soap or detergents are recommended to prevent skin problems especially during the winter months.14
Impact of Alcohol Hand Sanitizers on Clinical Outcomes
Numerous obstacles to handwashing compliance have been documented, including high workloads, inconvenient sink locations, skin irritation and dryness, and inadequate knowledge of hand hygiene guidelines or protocols. Despite a variety of interventions designed to increase compliance, including training, education, and patient awareness programs, handwashing compliance among HCWs has remained poor--typically less than 50%. Recently published studies on the benefits of alcohol that document efficacy and improved clinical outcomes support the recommendation in the proposed draft of the CDC's Healthcare Infection Control Practices Advisory Committee (HICPAC) 2002 Hand Hygiene Guidelines that alcohol hand rubs be considered the leading tool for hand disinfection whenever hands are not visibly soiled.35
Improvement in clinical outcomes through the use of alcohol hand sanitizers has been documented in the areas of skin condition, hand hygiene compliance, absenteeism, and infection rates.
- Improved skin condition. Boyce and coworkers12 conducted a study to compare the frequency of skin irritation and dryness associated with using an alcohol hand gel regimen for hand antisepsis vs. soap and water handwashing. This prospective, randomized trial with crossover design compared an alcohol hand gel with plain soap-and-water handwashing among 29 nurses working on three hospital wards. Irritation and dryness were evaluated by self-assessment and visual assessment by a study nurse. The authors concluded that a well-formulated alcohol gel containing moisturizers is well tolerated by HCWs and does not cause the skin irritation and dryness resulting from plain soap-and-water handwashing.12
- Increased hand hygiene compliance. Bischoff and coworkers8 investigated the efficacy of three hand hygiene interventions--an education/feedback intervention, patient awareness program, and the placement of a new and accessible alcohol hand gel--on handwashing compliance. This 6-month study compared the efficacy of these three interventions using direct observation of handwashing for 1,575 potential opportunities during 120 hours randomized for both time of day and bed location. Alcohol hand sanitizer dispensers were available in a ratio of 1:4 patients and subsequently 1:1 patient. The researchers found that the introduction of an alcohol hand sanitizer was the only intervention that resulted in significantly higher hand hygiene rates. Compliance improved as accessibility was enhanced, from 19% to 41% with a 1:4 dispenser:patient ratio, and 23% to 48% with 1:1 ratio. Education/feedback intervention and patient awareness programs failed to improve handwashing compliance.8
Scientific evidence supports the use of alcohol hand sanitizers as effective tools to overcome the obstacles associated with poor handwashing compliance. Successfully incorporating alcohol hand sanitizers into routine clinical practice will positively impact hand hygiene behavior, thereby improving patient safety and quality of care and reducing the financial and human costs associated with hospital-acquired infections.
Dr. Eleanor J. Fendler is the director of skin care technology for GOJO Industries of Akron, Ohio. She has more than 20 years of experience in product formulation, infection control, and dermatology. Patricia A. Groziak, M.S., is the acute care market director for GOJO Industries. She has more than 20 years of experience in the healthcare industry.