Wringing Our Hands
CDC Proceeds Slowly in Writing Updated Guidelines
By Kelli M. Donley
Handwashing, once a simple task, has developed into a monumental chore to regulate. Millions of dollars are spent educating, promoting and urging healthcare workers (HCWs) to wash their hands diligently.
But with what? There are waterless-handwashing products, brushless-products, products to be used before treating patients in ICU, products to be used before wearing gloves and the traditional sink and soap approach.
There is nothing simple about handwashing these days. The action of removing potential pathogens from the palms of hospital workers is no longer a matter of providing bars of soap, a clean sink and towels.
The time spent, frequency, method, cleansing product and chemical of choice used to wash those digits has become a source of controversy, with medical organizations and healthcare companies in a shouting match to whose opinion may be heard first, and ultimately recorded in the much awaited update of Center for Disease Control and Prevention's (CDC) Guideline for Hand Hygiene in Healthcare Settings.
The guidelines, which are under review and being written currently, are rumored to be released in 2003. Other sponsors of the update include the Society for Healthcare Epidemiology of America (SHEA), the Association for Professionals in Infection Control and Epidemiology (APIC) and the Infectious Diseases Society of America (IDSA).
With so many cooks in the kitchen, there is no wonder what is taking so long to produce the new information, longed for by many in infection control.
The current CDC guidelines were written in 1987 by Julia S. Garner, RN, MN, and Martin S. Favero, PhD. There is also a long list of contributing experts from the Hospital Infections Program at the Center for Infectious Diseases. Considering these guidelines are 15 years old, it is easier to point out what is missing, rather than what must have been revolutionary at the time. The report, which was an update itself from the previous Guideline for Hospital Environmental Control, written in 1983, discusses the difference between mechanical and chemical removal of microorganisms. However, officials did not take a stance on antimicrobial products. At the time, they note well-controlled studies highlighting the need for antimicrobial products were not available. The lack of research inhibited their ability to judge the necessity for such products.
Instead, the report reads, "Handwashing with plain soaps and detergents is effective in removing many transient microbial flora. Resident microorganisms in the deep layers may not be removed by handwashing with pain soaps and detergents, but usually can be killed or inhibited by handwashing with products that contain antimicrobial ingredients."1
The use of antimicrobial products when water and soap is not available received a category III recommendation. In other words, there was research showing this may be appropriate, but the evidence was not substantial enough to merit strong support.
Additionally, HCWs are guided to wash their hands before performing invasive procedures, between contact with high-risk patients and after touching objects that could be potentially contaminated with pathogens.
APIC Speaks Up
Elaine Larson, RN, PhD, FANN, CIC, wrote APIC's updated handwashing guidelines in 1994. The Guideline for Hand Washing and Hand Antisepsis in Health-Care Settings was an update from the organization's previous recommendations, APIC Guideline for Use of Topical Antimicrobial Agents.
APIC's update, written some seven years after the CDC's guideline, discusses handwashing issues in more depth. Topics not discussed by the CDC but outlined by APIC include: specific antiseptic agents, surgical scrub, nails (nail polish, artificial nails), jewelry, lotion-use, storage of handwashing supplies and compliance.
Larson writes, "Two major dilemmas facing infection control practitioners in healthcare settings today are when to use antiseptic agents and which agents to use."2
The report uses research conducted by Lilly and Lowbury in 1979 showing skin antiseptic provides a maximum level of bacteria count reduction. 2
It is unapparent why this research, used by APIC, was not considered in 1987 by Garner and Favero. Rather, the CDC Guidelines cite Lilly and Lowbury research published in 1964.
Larson uses the 1979 research, along with 238 other references, to conclude soap and water may not be the best option in all situations. Instead, she writes, the choice between soap and water, an antiseptic soap or an antiseptic rub should be dependent on the patient and the circumstances. The report states antimicrobial soap should be used when a HCW is performing and invasive procedure or when coming in contact with immuno-compromised patients.
The choice of antimicrobial product is also up for discussion. Larson writes, "Each is different and none is ideal for all uses." The report suggests HCWs should review the characteristics of antimicrobial ingredients (i.e., alcohols, chlorhexidine gluconate, hexachlorophene, iodine/iodophors, para-chloro-meta-xylenol, Triclosan) before selecting their choice of handwashing product.
The question remains, what will final guidelines cover? Will they include more information or specifics about artificial nails? Brushless scrubs? Alcohol-based gels?
The previous guidelines included a draft that was sent before printing to 150 scientists and infection control practitioners to review for comment. The guidelines being written currently were also sent out for review. The comment period has since elapsed. Information on the CDC Web site says comments from the reviews are being processed and will be noted.
Greg Carter, RN, CIC, is the manager of infection control and central processing at Kettering Medical Center in Kettering, Ohio. Carter, known as the "Germinator" by colleagues, says although he did not have a chance to review the proposed changes, there are alterations he expects.
"The standard time difference for washing, from 10 to 15 seconds (may change)," he says.
Product advances, he says, should also be noted.
"Waterless hand cleaners have revolutionized handwashing compliance," he says. "With these being more available than most sinks are, healthcare workers, including physicians, are using (these products)."
Carter notes that the events of the last year have brought the importance of diligent infection control to light for many in the industry.
"I think for the first time, infection control professionals are being recognized for what they are really educated to do," he says. "In the past, most administrators know they were suppose to have one, but did not know really what the practitioner could really accomplish if allowed -- epidemiology, education, outbreak investigation, patient/staff safety, knowledge of the regulatory requirements and biological incident experts. Since Sept. 11, people are really depending on us as the bioterrorism experts for their facility. In the words of someone along the way, 'We've come a long way baby!'"
Dial Corporation director of healthcare sales John Russell says after reviewing proposed changes in the handwashing guidelines there is a possibility that facilities will use more handwashing supplies as there will be greater awareness of the importance of handwashing.
"The new guidelines recommend use of a hand sanitizer as a supplement to handwashing," he says. "The new proposed guidelines state that unless your hands are visibly soiled, you don't need to wash your hands. However most healthcare facilities will probably use more hand hygiene products in the future than they have used in the past because of the increased usage of hand sanitizers. The mix of products will vary by facility."
Additionally Russell feels that infection control specialists, not manufacturers, are responsible for making necessary changes to the proposed update.
"As a manufacturing corporation, we are not the expert in creating infection control handwashing guidelines," he says. "We are going to read the guideline once it is finalized and we have or will have products that will satisfy the guidelines' recommendations."
Shawn Gentry, director of marketing and product development in the infection prevention division of Healthpoint says waterless scrub use, as described in the CDC draft guideline, may be confusing to HCWs.
" As manufactures of alcohol-based products, we support the use of waterless products in the healthcare setting; however, their clinical in-use should follow their approved label claim," he says. "After reading the Draft Guidelines, one could confuse the use of healthcare personnel handwashes
for surgical scrubs. In the FDA's Tentative Final Monograph for Healthcare Antiseptic Drug Products, antiseptic products generally fall into three categories each with separate testing criteria: surgical scrubs, patient preoperative skin preparations and healthcare personnel handwash.
A concern is that ICP's, OR Staff and Industry could view the Guidelines (if the draft version goes final as written) as approval to use waterless products (Healthcare Personnel Handwashes) as surgical scrubs.
Gentry says this confusion could lead to problems in handwash compliance.
"The efficacy requirements for surgical scrubbing is clearly defined and established fora purpose. Per the AORN's Recommended Practices for Surgical Hand Scrubs, the purpose of a surgical scrub is to remove, reduce and inhibit microbial presence and regrowth (summarized). If one uses waterless scrub product, they will not be able to remove the microorganisms without first performing a prewash (with soap and water). The use of a prewash combined with a waterless scrub product will add several steps to the scrubbing process which is already being abbreviated. One concern is this could result in a decrease in compliance and lower the standard of care in the surgical scrubbing arena. There is little doubt that alcohol-based products offer superior antimicrobial activity (fast acting and broad spectrum); however, one should make sure that the alcohol-based product they are evaluating or using meets the FDA's TFM testing criteria for surgical scrubs and includes a prewash to remove dirt and transient microorganisms between every procedure. In this rapidly evolving product category, there should be a choice of brush-free scrubs that offer superior efficacy compared to current practices, include a prewash (water-aided) and provide a cost effective solution for the surgical market."
Officials from the CDC did not return calls for comment on when the new guidelines would be published.