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By Deb Paul-Cheadle, RN, CIC
Waterless alcohol rubs have replaced soap and water as the leadingrecommended tool for hand disinfection, as stated by the Centers for DiseaseControl and Prevention (CDC)'s revised Guideline for Hand Hygiene. This mindsetchange occurred after multiple studies showed that handwashing protocols bear noresemblance to what actually occurs in healthcare settings.
Education and re-education were thought to be the solution, but in allfairness to healthcare professionals, the reason we are not washing correctly isnot due to a deficiency in knowledge. The time demand, inconvenience of repeatedhandwashing, a desire to prevent or not aggravate hand dermatitis, poor accessto sinks or sinks that are blocked by patient equipment are usually thecontributors to low rates of handwashing compliance.
Studies show that the time it takes to effectively degerm your hands withsoap and water is between 10 and 60 seconds. It takes the active antimicrobialingredients in soaps up to 60 seconds to destroy most organisms. The idealduration for handwashing is not known. Handwashing for 15 seconds removes mosttransient organisms. If hands are visibly soiled, more time is required forhandwashing. The observed average handwashing time is 7 to 10 seconds. Thistells us that when you think your hands are clean, they are not. The beauty ofthe alcohol degermers is the time factor -- five seconds and 99 percent of theorganisms on your hands are killed. This includes viruses. Alcohol rubs alsoprovide improved access, as there is no need for sinks or water. Another perk isthat the newer degermers have emollients that actually improve the skin, andafter initial stinging, if used on hands with dermatitis and open cracks,significant improvement with actual clearing of problems can be achieved.
My experience with the waterless degermers began in 1999. We were looking forsomething other than soap that we could try on the hands of healthcare workers (HCW)complaining of dermatitis. We had 27 HCWs with significant dermatitis who wereunder the care of dermatologists. We had been unsuccessful with different soaps.The HCWs were each given an alcohol-based waterless degermer with emollients touse instead of soaps. Every HCW experienced dramatic improvement, with completeresolution of dermatitis and skin excoriation in 25 HCWs. The other two HCWs sawgreat improvement, but with underlying eczema, they continue to see theirdermatologists for creams they only use when not working.
With this success in the healing of damaged hands, it was decided to trialthe degermer in the Neonatal Intensive Care Unit. Not only were the HCWspleased, we also saw a reduction in babies with Staphylococcus aureus andmethicillin-resistant Staph aureus (MRSA). It was decided to place the productat every isolette. Within the month, the MRSA population dropped to zero, withno recurrence. A study was also conducted to look at the cost of usage. Resultsshowed an actual savings, as the cost of the product was far outweighed by thereduction in use of paper towels, lotions and waste management. Needless to say,the hospital implemented the product institution-wide. The only drawback was theminimal persistence the degermer provided, in comparison with antimicrobialproducts.
The following review provides an overview of how certain agents work, andwhat organisms they are active against. Once I understood the mechanisms ofaction, it became easy to embrace the revolution in hand hygiene that is takingplace in the healthcare world today.
These are very effective antimicrobial agents. When used in concentrationsgreater than 61 percent, alcohols act by rapidly denaturating DNA, RNA and lipidbiomolecules that are essential for microbial growth and development. Alcoholdoes not harm skin cells, as the body rapidly re-supplies intra-cellular waterthat is lost in denaturing. Alcohols are very effective against gram-negativeand gram-positive bacteria, fungi, viruses, including hepatitis B and C, HIV,RSV, CMV, influenza and the herpes family. Alcohol application provides thefastest and greatest reduction in microbial counts on the skin, and bacterialresistance to alcohol is non-existent. Alcohol is considered to be the safesttopical antiseptic to use.
Chlorehexidine Gluconate (CHG)
This agent works by disrupting cell membranes, which is why it is veryimportant to rinse hands thoroughly after use. GHG is considered broad spectrumbut it is not as effective against gram-negative bacteria. CHG has minimalaction against Tubercule bacilli and mycobacterium species and it has a fairfungicidal action. CHG is effective against HIV, herpes, CMV and influenza. CHGis better at "sticking" to the skin, therefore providing persistence,but it is not as rapid or extensive as the alcohols. The activity of CHG is verypH dependent, (5.5-7.0). Bacterial resistance to CHG has been reported. Acuteskin irritations, contact dermatitis, anaphylaxis from allergic reactions,Ototoxixity and corneal damage have been reported with CHG use, therefore, theFDA categorizes CHG containing formulations as drug products requiring formalapproval.
Preparations containing iodine work by releasing free iodine into theinterior of a microorganism, which causes toxic oxidation and substitutionreactions within the cells. Iodine has a wide range of activity, includingspores, gram-negative and gram-positive bacteria, fungi, viruses andtuberculosis. It works rapidly, but has poor persistence. It is rapidlyneutralized by blood and organic material. Iodine is generally considered a safeproduct, although skin irritation has been reported. The skin and mucousmembranes can absorb iodine and iodophores. Induction of hypothyroidism innewborns has been documented. These products also need FDA approval.
Trizenol Technology Products
These are alcohol and zinc combinations. This combination providespersistence for hours after use. They can be used with or without water, andthis capability makes the removal of surface dirt and organic material possiblewhen needed. Trizenol products provide broad spectrum and rapid antimicrobialaction (the same as alcohol, as this is the active ingredient), with excellentantimicrobial persistence (up to six hours). Emollients have been added tomaintain skin integrity. These abilities make this an exciting breakthrough inhand hygiene. This product is classified as a cosmetic, and does not need FDAapproval.
The CDC would like to see waterless degermers outside of every patient room.Fire marshals do not want to see it in the hallways. Safety department personnelhave concerns regarding the product being in patient rooms. This has been aninteresting dilemma, and we are working on solutions that are not costprohibitive. Alcohol products that come in pocket-size containers are aconvenient but expensive approach to this roadblock. The manufacturer isexploring the use of a fireproof wall mount.
The use of alcohol hand rubs is a fundamental change in the way hospitalscomply with hand-hygiene imperatives. It is a change that will ultimately allowhealthcare professionals to do the right thing more frequently. By making goodhand hygiene easier, compliance rates will go up and infection rates will godown. The CDC has gone so far as to actually say, "Stop trying to gethealthcare workers to wash their hands! Start giving them alcohol handrubs."
Deb Paul Cheadle, RN, CIC, works in infection control for Spectrum Healthin Grand Rapids, Mich.