By Thomas Kovach, MA
Revised handwashing and hand rinse guidelines adopted in October 2002 by the Centers for Disease Control and Prevention (CDC)'s Healthcare Infection Control Practices Advisory Committee (HICPAC) and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force are as follows:
1."Caregivers should wash hands with a non-antimicrobial soap and water or an anti-microbial soap and water when hands are visibly dirty or contaminated with proteineous material, such as blood or feces" (Recommendation 1)
2."If hands are not visibly soiled, caregivers should use an alcohol-based waterless antiseptic agent for routinely decontaminating hands"
(CDC Guideline for Hand Hygiene in Healthcare Settings: Recommendation 2)
These key CDC recommendations will no doubt add to the usage of alcohol hand sanitizers in the healthcare environment, continuing the trend we've seen in the last several years. Every year for the past 17 years, Kovach & Associates Inc. has conducted a scientific survey of hand washing and waterless antiseptic hand rinse use, tracking volumes as well as handwashing and hand rinsing practices.
Since 2001, the number of hospitals using any type of waterless alcohol hand sanitizer has doubled. Also, and more importantly, the number of handwashing episodes in hospitals that use waterless alcohol hand sanitizers has increased significantly since 2001. So, both the number of hospitals using and the volume of alcohol hand sanitizers inside of user-hospitals has increased rapidly between 2001 and 2002, and will continue into 2003. These findings apply to nurses washing hands during routine patient-care activities on the general patient floor as well as to pre-op surgical preparation and post-op hand washing in the hospital operating recovery room.
Waterless Alcohol Hand Sanitizers: Advantages and Disadvantages
In the new guidelines, the CDC continues to urge the use of antimicrobial hand soaps when hands are visibly soiled and possibly harboring transient pathogenic microorganisms. Hence, the use of a healthcare personnel hand wash with Triclosan, PCMX or CHG, for example, as the active ingredient continues to be important to maintain residual log reduction activity on caregiver hands during the patient-care day. However, hand wash compliance levels have hovered in the current 40 percent to 50 percent range for several years. Thus, the adoption of the aforementioned guidelines on waterless alcohol hand sanitizers adds a new dimension in handwashing and could be expected to lead to higher hand-hygiene compliance levels and improved infection control practices. This is due to the ease and convenience of using a waterless alcohol hand sanitizer as an adjunct to soap and water and/or current antimicrobial hand wash formulations.
Most alcohol hand sanitizers contain isopropanol, ethanol, n-propanol or a combination of these ingredients. Alcohol has an excellent initial antimicrobial log reduction activity because of its ability to denature proteins. Most alcohol hand sanitizer formulations offer excellent initial log reduction of gram-positive and gram-negative bacteria, fungi and multi-drug resistant pathogens such as vancomycin-resistant Enterococcus (VRE) and methicillin-resistant Staphylococcus aureus (MRSA). However, alcohol does not have the residual ability to inhibit microorganisms over the entire patient day. So it would be important that healthcare practitioners use a waterless alcohol hand sanitizer before and after each patient handling episode during the entire patient handling day to fully utilize alcohol's excellent initial log reduction activity.
Also, not all alcohol hand sanitizer formulas are the same. For example, variance occurs in actual formulations with some alcohol hand sanitizers varying in the amount of alcohol from 60 percent to 95 percent. More alcohol is not necessarily better, as less water content in the formulation can actually hinder the effectiveness of alcohol in denaturing proteins.
Alcohol hand sanitizers are available in several formats: liquids, thick gels and foams. Foams are not widely used, as they are significantly more expensive. Thicker alcohol gel formats seem better than the liquid form, as they tend not to spill as easily. Open-ended comments from Kovach & Associates' annual survey of handwashing and hand rinses from 120 directors of housekeeping suggest that waterless alcohol gels are probably better than liquids, "as thick gels are more easy to control volume when applying-- thereby reducing the potential of spillage on wax floors which causes spot damage to the floor."
Fragrance and Color in the Formulation
Some manufacturers add fragrance to their alcohol hand sanitizer formulation. Their logic is that the formulation is more appealing to caregivers and patients. However, a review of advantages and disadvantages listed in Kovach & Associates' annual survey of 120 directors of nursing across the United States would suggest otherwise. Fragrance becomes a problem due to the potential among caregivers and patients for allergic reactions to different fragrances. Directors of nursing cited fragrance as a factor in causing nausea in both patients and caregivers. A fragrance-free product is preferable. Similar survey comments regarding fragrance in the healthcare environment were seen in quotes associated with healthcare personnel hand washes, lotions and liquid body soaps. Hand rinses, healthcare personnel hand washes and lotions are all regarded as having a degree of personal use preference, so high fragrance levels can become a problem for caregivers and patients.
We have also heard some objections to the use of dyes in some formulations. These can leave stains or residue on caregiver and patient hands and clothes. It would be best to use a product that has no color additives or dyes in its formulation to avoid staining and possible skin irritation.
The use of waterless alcohol hand sanitizers will enhance hand hygiene programs. This conclusion is due to their ease and convenience of using in conjunction with plain or antimicrobial soaps and water, thereby increasing hand hygiene compliance levels. In addition, alcohol hand sanitizers usually have excellent initial log reduction of gram-positive and gram-negative bacteria, fungi and multi-drug resistant pathogens. When choosing an alcohol hand sanitizer for your facility, consider that foams can be more expensive than gels or liquids. There are advantages to a thick gel formulation over a thinner liquid. A fragrance- and dye-free alcohol hand sanitizer may have advantages as well. Keep in mind, however, that since alcohol is not able to maintain residual log reduction activity during the course of the normal patient care day, using healthcare personnel hand wash formulations containing Triclosan, PCMX and CHG as active ingredients are also important to the caregiver and should also be used during the day.
Thomas Kovach is president of Kovach & Associates Inc., a St. Louis general management-consulting firm that specializes in handwashing, infection control, skin care and wound care topics. Kovach has been in the infection control industry for 25 years.