Hand Hygiene in Healthcare: Playing by the New Rules

February 1, 2003

Hand Hygiene in Healthcare: Playing by the New Rules

By Nancy B. Bjerke, RN, MPH, CIC

Handwashing is the most effective means to prevent nosocomialinfections; now hand hygiene with alcohol gels improves healthcare personnelcompliance in the workplace.

OBJECTIVES:

1. Describe the 2002 CDC HICPAC hand hygiene guideline.

2. Suggest a strategy to implement product change to alcohol gels.

3. List the recommendations on hand hygiene.

An assembly of external Centers for Disease Control and Prevention (CDC)experts known as the Healthcare Infection Control Practices Advisory Committee (HICPAC)crafted a completely revised guideline titled hand hygiene, the new term totraditional hand cleansing and washing.1 This guidance includesarticles published since the previous hallmark CDC handwashing guideline of 1985and an Association of Professionals in Infection Control (APIC) guideline onhandwashing and hand antisepsis from 1995.

The format of the 50-page HICPAC document is similar to previous guidelines.Part I reviews the historical and scientific information. Part II states thehealthcare practice recommendations. Part III adds a new element of performanceindicators. The 423 references are followed with a familiar appendix comparingantiseptic agents. This best practice discussion will describe the HICPAC handhygiene document, suggest a strategy to implement any product or practice changeand list the guideline recommendations by rating scale.

Background

Historically,the hand hygiene story begins in 1822 when moistening hands with liquid chloridesolution was advocated for contagious disease interruption. More notably is theIgnaz Semmelweis' work in 1846 when he insisted physicians and students cleantheir hands with a chlorine solution between each clinic patient proving thatcontaminated hands cleansed with an antiseptic agent between patient contactsreduced the transmission of infectious disease and patient fatality moreeffectively than soap and water washing.

The 1950 staphylococcus outbreaks and subsequent investigations led to apreventive strategy focused on healthcare personnel. A series of writtenrecommendations, emphasizing hand cleansing as essential to diseaseinterruption, include the CDC guidelines recommending healthcare practices forimplementation in hospitals followed by APIC recommendations and the use ofalcohol-based hand rinses. This HICPAC guidance advocates alcohol gels as theultimate agent for compliance by healthcare workers (HCWs) performingresponsibilities.

Aside from the normal review of skin flora and physiology, a glossary ofterms defines hand hygiene as handwashing, antiseptic hand-wash and hand-rub, orsurgical hand antisepsis. This is the new all-inclusive term for decontaminatingand degerming the hand skin surface. Fundamental to product regulation andclearance for market are the Food and Drug Administration (FDA) productcategories, defining patient preoperative skin preparation,antiseptic/healthcare worker handwash, and surgical hand scrub.

A dissection of microbe transmission via hands unfolds what has beendiscovered through thoughtful study. Simply stated, microbes reside on skinsurfaces normally and through touch with a reservoir and are easily transmittedto another person directly or indirectly by an object to potentially andrealistically cause colonization and/or infection in that person. The hardinessand survivability of the microbe and the lack of hand hygiene by the person arealso weighty elements in this sequence of events. Published studies indicatethat an evolution is occurring from soap and water hand cleansing for decreasinginfectious transmission to antiseptic agents disinfecting skin surfaces for amore dramatic infection interruption.

Because the FDA has specific, standardized requirements that manufacturersmust meet before their over-the-counter (OTC) drug products are cleared formarket, vendors must provide supporting data that illustrates the achievement ofthese elements. Categorical ratings of I-III delineate safe-to not-safe andefficacious. Alcohol and iodine are considered category I while chlorhexidinegluconate is a category III and would require a new drug application (NDA) withits own FDA requirements. American and European standards for product evaluationdiffer and it is unknown what required log reduction is effective for allmicrobes. It is obvious more research in this area would further clarify therequirements.

The traditional comparative presentation on hand-cleansing agents by chemicalcomponent is narrated and summarized in charts and the appendix basically ranksalcohols and iodine compounds highest with chlorhexidine, tricolsan, phenol, andquaternary ammonium following. Of note, HICPAC states that none of theantiseptic hand agents are sporicidal against Bacillus anthracis or Clostridiumdifficile. This is relevant to the current terrorism activity with massdestruction weapons and healthcare personnel's role in countermeasures.

The discussion on surgical hand scrub progresses from antiseptic agents forskin disinfection to selecting antiseptic products that reduce microbes, arefast-acting and persistent, have non-irritating antimicrobial preparations andhave broad-spectrum activity. The evolution of the scrub procedures moves fromthe addition of brush and sponge to mechanically remove organisms to totalelimination of these additives due to skin damage and increased shedding.Additionally, studies have demonstrated that a traditional 10-minute scrubprocedure is reduced to 5 minute to 2 minute to 1 minute with alcohol gels andno documented or reported increase in surgical site infections.

The new guidance focuses on the human aspect of hand hygiene in itsdescription of dermatitis conditions and their resolution with new alcohol basedgels containing emollients. Detergent harshness, water temperature, repeatedproper or improper hand cleansing, various side effects of antiseptic agents,climatic conditions, lotions and cream compositions and applications, andsensitivities to product formulations and glove materials are some of thecausative factors toward dermatitis. The conversion to alcohol gels is reportedto cure dermatological conditions due to the emollient additives. While alcohollacks persistency, HICPAC espouses that frequent use of alcohol gel productswill mount a cumulative effect through routine use. A reprimand in the guidelinedirects that personnel need not routinely wash their hands after eachapplication or multiple applications of an alcohol hand rub. Additionally, bothsoaps and alcohol waterless agents are not placed adjacent to sinks to avoidconfusion on which product is used according to the HICPAC guideline. Cautionshould be exercised in selection and use of hand lotions and creams, especiallythose containing oil and their effect on glove materials. Yet, HICPAC furtherrecommends that free skincare lotion be available because increased use ofhand-hygiene agents might be associated with skin dryness; this is acontradiction to the whole advocacy of alcohol hand rubs.

The new criteria for hand-hygiene product selection are very subjective;personnel assess the products by smell, feel, consistency and color. Objectivecharacteristics would focus on the time duration for alcohol to dry, skinintegrity after use initially and long term, dispensing methods, and cost.Facility product evaluation committees would benefit from pre-established,written objective characteristics for assessing potential new hand cleansing anddisinfecting agents. Conducting a structured evaluation process would includespecific units, quantity of product, vendor inservicing prior to trial,documented evaluation sheets, specified timeframe, etc. The intent is anunbiased assessment of the products under consideration. An analysis of theevaluation sheets summarizes the pros and cons of each agent before an informeddecision is made for the institution. A follow-up assessment once the selectedproduct has been in use for some time (three to six months, for example) wouldvalidate whether personnel are using the product appropriately and for all thedesignated situations.

The education and research discussion in the guideline outline what contentof instruction should include, who should be instructed, how performance andobservations could be conducted, what barriers to adherence to hand hygienepractices would be addressed, to name a few. The specific aspects for researchproposals are identified thus, suggesting what evidence-based studies arenecessary to further strengthen the recommendations of this guideline.

The HICPAC guidance briefly addresses fingernails, artificial nails, glovingpolicies and jewelry. The nail discussion minimizes the contribution that naillength and artificial nail have in serious bacterial outbreaks' most notable isthe 17 neonatal deaths reported by CDC in February 2000. According to thedocument, the application of nail polish is only a problem when it is chipped.Regarding gloves, the document reinforces the federal law that states handsshould be decontaminated or washed after removing gloves. Gloves are not washedor reused. Petroleum-based hand lotions/creams may adversely affect gloveintegrity. Some alcohol rubs interact with residual powder in gloves. Gloveremoval is required in between patients. For jewelry, authors state more studiesare needed.

Recommendations

Part II of the guidance lists the recommendations based on a five-pointrating scale: Category IA (do this); Category IB (can do this;) Category IC(must do); Category II (suggested); and no recommendation, no consensus reached.The following priority list is a condensed version per rating scale, using theactual number before each recommendation as identified in the guideline.

Category IC Must Do:

6.C. Wear gloves for bodily fluid contact.

8.C. Store alcohol hand rubs in flammable materials cabinets.

Category IA Do This

1.A. Wash visibly dirty hands with soap and water.

1.B. Use alcohol hand rubs to clean hands.

1.G. Decontaminate hands after body fluid contact if hands not visiblysoiled.

4.E. Prevent topping off partially empty soap dispensers

5.A. Provide HCWs with hand lotions/creams for dermatitis.

6.A. No artificial fingernails or extenders in ICUs or ORs.

7.B. Monitor HCWs' compliance and give feedback on hand hygiene practices.

8.C. Provide HCWs with alcohol hand rubs.

8.D. Provide alcohol hand rubs at entrance to patient's room, bedside, andfor HCW pocket.

Category IB Can Do This

1.B. Wash hands with antimicrobial soap and water, if not using alcohol handrubs.

1.C. Decontaminate hands before patient contact.

1.D. Decontaminate hands before donning sterile gloves for central IVcatheter insertions.

1.E. Decontaminate hands before urinary, IV, and other non-surgical catheterinsertions.

1.F. Decontaminate hands after patient contact.

1.J. Decontaminate hands after glove removal.

1.K. Wash hands with soap and water before eating and after using restroom.

1.L Antimicrobial towelettes are a substitute for soap and water cleansingonly.

2.A. Apply alcohol hand rubs to palm, rubbing over entire hand surface untildry.

2.B. Wet hands with water, apply recommended product dose, rub vigorously 15seconds over surface, rinse with water, dry thoroughly with paper towel; turnfaucet off with towel. Avoid hot water which increases dermatitis risk.

3.C. Use antimicrobial soap or alcohol hand rub for surgical scrub beforedonning sterile gloves.

3.D. Perform surgical scrub with antiseptic and water for manufacturer'sstated 2-6 minutes time only.

3.E. Use alcohol surgical hand scrubs per manufacturer's instruction.Pre-wash with soap and water and dry thoroughly before alcohol surgical scrub;dry thoroughly before donning sterile gloves.

4.A. Provide HCWs with efficacious, low irritancy hand hygiene products.

4.B. Obtain HCW input on products regarding feel, fragrance and skintolerance; cost is not a primary factor in product selection.

5.B. Solicit manufacturer information on interactions among hand lotions,creams, alcohol rubs and antimicrobial soaps used in the facility.

6.D. Remove gloves after each patient; do not reuse or wash gloves.

8.A. Make hand hygiene adherence a priority in the facility, providingadministrative support and finances.

8.B. Implement multidisciplinary program for HCW compliance to hand hygienepractices.

Category II Suggested

1.H. Decontaminate hands if moving from contaminated to clean body site.

1.I. Decontaminate hands after contact with inanimate objects near patients.

1.M. Wash hands with plain or antimicrobial soap and water for Bacillusanthracis (anthrax) spore exposure.

2.C. Liquid, bar, leaflet or powdered plain soap are acceptable non-antimicrobialforms for washing hands. Use soap racks for bar soap; use small bars.

2.D. Eliminate multiple use hanging or roll cloth towels in healthcare.

3.A. Remove rings, watches and bracelets before doing surgical hand scrub.

3.B. Remove debris underneath fingernails with a nail cleaner under runningwater.

4.C. Solicit manufacturer information regarding interactions among handcleansing products, skin care products and glove types used in the facility.

4.D. Evaluate dispenser systems for function and dosing prior to purchase.

6.B. Keep natural nail tips less than 1/4 inch long.

6.E. Change gloves if moving from contaminated to clean body site duringpatient care.

7.A. Educate HCWs about hand contamination activities and pros and cons ofcleansing methods.

7.C. Encourage patients and families to remind HCWs about decontaminatingtheir hands.

No recommendation, No consensus reached

1.N. Routine use of non-alcohol hand rubs for hand hygiene in healthcare.

6.F. Wearing rings in healthcare.

Note: 2.A. Follow the manufacturer's recommendations regarding the volume ofproduct to use. This statement in the HICPAC document appears to sanctionviolation of federal law, namely non-compliance with FDA labeling requirements,as it is without a rating.

Performance Indicators

Part III on performance indicators is a new addition to the HICPAC format.Here it focuses on four aspects for measuring HCW hand hygiene compliance:

1) Survey compliance of performance quantity over quantity of opportunitiesby ward or by service, providing feedback to HCWs;

2) Calculate the volume of alcohol product used per 1,000 patient days;

3) Monitor artificial nail wearing compliance with written policy; and

4) Assess HCW hand hygiene compliance during outbreaks.

The 2002 HICPAC Guideline on Hand Hygiene espouses the advent of alcohol gelsas the answer to HCW compliance deficits while requesting statistical researchdata for strengthening evidence-based references for alcohol based hand hygienepractices. It behooves anyone who has or is about to implement this guidance tothoroughly and thoughtfully read this entire document. Employ critical thinkingskills when assessing its intent and its recommendations as they apply to theunique healthcare delivery system or facility. Conducting objective productevaluations within the facility with a multidisciplinary group provides asystematic method for informed decision-making. Instruct HCWs and adhere to thelabeling and storage requirements of the products selected. Remember handcleansing and disinfecting with skin care and antiseptic products requiremultiple steps, mechanical friction being the most important to rid the surfaceof microbes.

TEST QUESTIONS: TRUE OR FALSETF
1. Artificial nail extenders must be polished when worn during patient care.  
2. Chlorhexidine is a category I according to FDA.  
3. Semmelweis recommended triclosan as the first hand antiseptic solution.  
4. Alcohol hand rubs are the primary antiseptic for surgical hand scrubs.  
5. Moving from a contaminated to a clean body site requires only new gloves.  
6. Iodophors are the recommended agents for disinfecting post anthrax exposure.  
7. Alcohol hand rubs require 15 seconds for drying time.  
8. Add additional product to partially empty soap dispensers.  
9. Alcohol products are stored in clean storage closets with other antiseptics.  
10. Petroleum hand creams combat dermatitis and safeguard glove integrity  

ANSWERS

1. F
2. F
3. F
4. F
5. F
6. F
7. F
8. F
9. F
10. F