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By Kathy Dix
The Centers for Disease Control and Prevention (CDC) recently released its long-awaited hand-hygiene guidelines. Infection Control Today spoke with the guidelines' co-author, Didier Pittet, about the root of some of the revised recommendations.
There is a core group of people who are considered global authorities on hand hygiene. Didier Pittet is one of them, renowned for his experience with this fundamental element of infection control. In a recent teleclass, Pittet reviewed the history of hand hygiene and the results of his own promotional strategies to improve compliance with existing recommendations.
Traditional soap-and-water handwashing is going the way of the dodo bird, implied Pittet, at least in terms of between-patient hygiene when there is no visible soil on the hands. "In most situations, conventional handwashing with soap and water will always be relatively inconvenient compared to alcohol-based hand rubs," he noted. In some situations, when healthcare workers (HCWs) are less rushed, there is time for old-fashioned handwashing. But typically, the one- to two-minute handwash is too time-consuming, especially in intensive care units or other sectors that may have up to 35 opportunities for handwashing each hour.
One impetus behind the new guidelines was the inability of HCWs to wash their hands so many times an hour. "People are very busy," Pittet stressed. "There is a shortage of nurses and there are always many things to do. I don't think it would be easy to promote old-fashioned handwashing."
Thus the alcohol-based hand rub. The hand rub is more efficacious than soap-and-water, is more accessible than sinks (it can be carried in a pocket) , and is effective against many microorganisms, even multi-drug resistant pathogens. This has been documented in multiple studies, including one by Pittet published in 1999.1
RESISTANCE: BACTERIAL AND HUMAN
Must we concern ourselves about microbial resistance to alcohol? No, Pittet says. "Nowadays there is no resistance to alcohol; resistance in bacteria has not been demonstrated at all, in contrast to resistance to medicated soaps that have been used for handwashing. There is no mechanism for resistance to alcohol that has been described in bacteria."
However, he says that is a separate issue from some HCWs' resistance to change -- and to the alcohol content of the hand rub. "Some HCWs are reluctant to use alcohol for many reasons, one being that alcohol is alcohol, because people have the impression that they may become alcohol addicts!" said Pittet. "It's completely wrong, but what is in the minds of some people is sometimes difficult to control."
He adds that many HCWs fear developing dry skin from frequent hand rub use. "The problem is that if you ask HCWs to apply in a similar frequency, alcohol vs. soap, the skin is killed a lot more by the soap than by the alcohol," said Pittet. "People will tell you, 'Since using alcohol, my skin is drier than it was before.' But what you need to realize is that people didn't wash their hands before. They were compliant at 10 or 15 percent. With alcohol, they are compliant at 40, 50, 60 even 80 percent." Alcohol-based hand rubs, he added, do less harm to skin than medicated soap in the long run.
A study published by John Boyce ( Pittet's co-author of the CDC guidelines)Â and colleagues demonstrated that hands did not tolerate soap as well as they tolerate alcohol rubs.2 "There will be some reluctance by very old-fashioned doctors and nurses who will not accept that alcohol is more efficacious than medicated soap, just because they learned at medical school or nursing school that medicated soap is the way to go," noted Pittet. In the future, students will be trained in the use of hand rubs rather than just soap and water, but for now, some pockets of resistance may crop up from more seasoned HCWs.
The use of lotions as recommended -- along with emollients included in the hand rubs -- should go a long way toward protecting skin, Pittet said. Even in an ICU where Pittet documented 30 to 35 opportunities for hand hygiene per hour, nurses who applied cream three to five times a day did "very well." "We usually recommend that nurses apply these hand lotions once in the morning, once just before they go to eat, then just once at night. But sometimes they do it a bit more frequently when they're working in high-risk areas," he said.
Noncompliance is an ongoing issue. Group behavior, Pittet said, is extremely important as one approach to encourage handwashing. Since physicians serve as role models for younger colleagues, some chiefs of staff will not begin their rounds if a bottle of hand rub is not included on the cart accompanying the rounds. Others will refuse to begin rounds if everyone does not have a bottle of hand rub in their pockets.
Such examples are central to good hand-hygiene promotion. "Some people say you should reward compliant HCWs; others say that you should punish non-compliers," Pittet commented. "I hate to punish. I would be more favorable to promote the best HCWs and congratulate and be positive." But, he reported, other institutions may emphasize patient safety and take action if proper hand hygiene is not followed.
Although negative reinforcement does not appeal to him, Pittet says there may be a place for it. "Imagine, if you have the chief of surgery telling one of his fellows, 'If you continue to forget to perform hand hygiene at the beside, I will fire you.' I'm pretty sure that the fellow will change his mind!"
This is not necessarily the proper tone to take, Pittet says, but many options for effectiveness remain untested, and these, he adds, may be explored in the future for refractory noncompliers. "I think most of the time you will correct the poor compliance with hand hygiene simply by making some changes in the system -- in particular, introducing an alcohol-based hand rub, and using a multi-modal promotion campaign with a few items that will work."
MAKING HAND HYGIENE WORK
Pittet's multi-modal campaign included the following factors:
THE NITTY GRITTY
Some experts disagree with the CDC recommendations. At one time, Pittet disagreed with them himself, when soap-and-water handwashing was the recommended action rather than hand rubs. "Some people completely disagree with the indications or the circumstances that were used as recommendations for hand hygiene. It had to be reviewed and re-discussed and we reviewed the literature to try to make it clear. Some said they had never been convinced by looking at the literature that successful hand hygiene promotion could reduce transmission of either resistant bacteria or nosocomial infections."
Indirect evidence was available in the literature, and old evidence was available from the original research by Semmelweis in the 19th century, but Pittet's study in 2000 directly linked hand hygiene to reduced nosocomial infection rates. That report -- and later research -- generated a progressive change in the perspective of the "holdouts."
"Not everyone is convinced that drops in infection rates were due to hand hygiene," he adds. "Some disagree with the high frequency necessary; they say that 'Even if we improve the compliance by a little bit, you will decrease the infection rate, so why must I be 100 percent compliant to make a drop?'" reported Pittet. "I say, 'You don't have to be one hundred percent. I would recommend that you have that goal -- to be 100 percent.'"
Two problems can contribute to this "refractory" attitude: under-education and over-education. Some people, Pittet said, are "too educated and not educated by the right person on the specific issue of hand hygiene, or they are not educated on the right topic." But neither group will properly comply with hand hygiene recommendations. "I have met worldwide experts in the field of infectious diseases and bacteria and they don't understand the very simple concept of bacterial transmission at the bedside," Pittet says. Researchers whose work is restricted to the laboratory do not realize what patient care encompasses. Because they cannot visualize patient care, they cannot visualize the ease with which nosocomial transmission can occur.
Some HCWs have asked Pittet why it is necessary to try to achieve 100 percent compliance if even 60 percent compliance could affect the infection rate. "It's clear that it's certainly better to be 100 percent compliant than 80 percent or 60 percent compliant, but if you ask me to translate that into the risk for cross-transmission, we don't have that data in the literature," added Pittet. "I can tell you that improving our average compliance rate from 48 percent to 70 percent decreased our nosocomial transmission rate by 50 percent. We have monitored HCWs that are currently working ICUs who are very close to 100 percent, so it is possible."
Q: How do long or artificial fingernails, broken fingernails and nail polish affect hand hygiene?
A: "In our institution, artificial nails are not allowed. There is a recommendation for working with nails that are not too long. Is there a reduction in the activity of the use of medicated soap or hand rub with HCWs who use nail polish? There is not definitive study in the literature. It would not be recommended in the guidelines that nail polish be removed before coming to work, as there is no clear study about this topic."
Q: Is there a recommendation as to how many times you should use the hand rub before washing with soap and water?
A: "I know there have been several people giving a recommendation to do that, but there is no reason to do so. You can use hand rub every time you need to as long as you need to, and there is absolutely no need for the use of handwashing between any hand rubbing action. Several of the hand rubs, gels in particular, tend to leave trace residue on the skin prompting some people to handwash from time to time."
Q: Is alcohol hand gel effective against Clostridium difficile?
A: "When we talk C. difficile we are talking spores, and there is absolutely no disinfectant against spores. The only thing effective is chlorine, but it has to be in too high a concentration. During the treatment of a C. diff patient, use gloves, and then use handwashing or hand rubbing or whatever to kill other bugs."
Q: Most of the hand rubs contain 60 to 63 percent alcohol. Is 70 percent the absolute?
A: "What we recommend is between 60 and 80 percent. When you use isopropyl alcohol, you can use lower concentrations than with ethyl alcohol. In the U.S., when you speak of alcohol-based hand rub, you speak of gels, since there are few rinses. The higher the content of alcohol in gel, the more efficacious it is, but gels are less effective than rinses -- but still more effective than medicated soaps."
Q: What about antimicrobial hand wipes?
A: "The problem with the wipes is that none of them has been really investigated in powerful studies, and we are not exactly sure of the efficacy of the wipes. They could be useful in specific uses for specific indications, but we will not recommend the systematic use of those wipes, because the amount of alcohol spreading from wipes to hands is unknown. Studies should demonstrate the log reduction in bacteria. The ultimate goal would be to use the wipes at the bedside and control and count the infection rates. Personally I would not do such a study because of the inconvenience of such wipes."