Infection Control Today - 06/2004: Clinical Requirements

Clinical Requirements of Body-Worn Hand Sanitation
Accessibility is the Key to Hand Hygiene Compliance

By Ron Cagle

Since the October 2002 update of theCenters for Disease Control and Prevention (CDC)s hand hygiene guidelines forhealthcare settings, wall-mounted alcohol handrub dispensers have been going upin hospitals across the country. These programs will surely have a dramaticimpact on lowering infection rates; however, the questions remain: Is this thebest we can do? Are wall mounts as accessible as they need to be to meet thecritical objectives? And what about body-worn hand sanitizers that have morerecently become available? Body-worn hand sanitizers promise to redefineaccessibility and move hand hygiene practices much closer to the hand-hygienegoals of the CDC as well as Patient Safety Goal No. 7, reducinghealthcare-acquired infections (HAIs), mandated by the Joint Commission on theAccreditation of Healthcare Organizations (JCAHO).

The Critical Scope of the Problem

Weve all read the statistics, but the need for ways toprevent HAIs cannot be overemphasized. According to the CDC, HAIs are the fourthleading cause of death in the U.S. There are 2.2 million nosocomial infectionsannually resulting in more than 80,000 fatalities. The annual economic burden ofnosocomial infections to the U.S. healthcare system is $5.2 billion. Multi-drugresistant pathogens are an emerging contributor and threaten to perpetuallyraise the stakes even further.

Focus on Hands

Weve known about the role hands play in infection controlfor 150 years, yet the problem persists. Hand hygiene is considered to be theNo.1 preventive measure against the spread of infection. At least20,000 of the annual nosocomial infection fatalities are attributed directly toinadequate hand hygiene. The old handwashing model did not account for thereality of todays conditions. For example, studies show that healthcareworkers (HCWs) can wash their hands every time they should, or do their jobs,but not both! Another factor is that constant handwashing is far too damaging tohands. Clearly, HCWs need realistic answers.

CDC Recommends Accessibility

Given the magnitude of the problem and the practical realitiesfacing todays HCWs, the CDC updated its hand-hygiene guidelines. The mostnotable recommendation is to use an alcohol-based handrub when hands are notvisibly soiled.¹ This allows hand sanitation to no longer be restricted to asink and makes possible a variety of more accessible options. Going farther toemphasize accessibility, the guidelines recommend that HCWs carry individualpocket-sized containers in areas of anticipated high-intensity patient care.

Much of the groundwork of the updated guidelines point toaccessibility as the key to compliance. CDC guideline co-author Didier Pittet,MD, concludes, Strategies to improve compliance with hand hygiene practicesshould be multi-modal and multi-disciplinary, and easy access to fast-actinghand hygiene agents should be viewed as the main tool of the strategy. ²Bischoff and associates, in their April 2000 study, offered a supporting view:Accessibility may eventually be shown to be the most reliable variable predicting handwashing rates. ³

Got Compliance?

The question of compliance remains. Will wall-mounted systemsend hand-transmitted infection in healthcare settings and therefore eliminatethe need for additional innovations, tools, and programs? The factorscontributing to non-compliance point to the answer:

• Placement.Wall mounts cannot be everywhere they will beneeded. As Pittet points out, To ask a busy HCW to walk away from apatients bed ... to obtain an antiseptic solution enhances the risk fornoncompliance with recommendations.1 Regardless of placement, situations willarise that require the HCW to walk.

• Time Constraints.Studies found that the higher the demandfor hand hygiene, the lower the compliance.⁴ Any tool that takes time will notcompletely overcome this core compliance factor. Although less so than with handwashing, wall mount use does require dedicated time.

• Interruptions.In virtually every case, using awall-mounted alcohol hand sanitizer requires a workflow interruption. A HCW muststop, see the dispenser, go to it, use it, and return. The more steps, the moreattention, and the more thought that is required, will ultimately effectcompliance.

Body-Worn Critical Requirements

Since the release of the CDC updated guidelines, a new breedof bodyworn hand sanitizers has been introduced. Although they dispense similaralcohol hand-sanitizing agents, the critical requirements are significantlydifferent from wall-mounted and other delivery systems:

• Body-worn. Clipped on clothing or belt, a body-worn handsanitizer is always within reach.

• Second-nature habit. A body-worn hand sanitizer thatoperates with one hand offers the capability of becoming a second-nature habit.

• High-intensity access. Using a hand sanitizer that operatesas a second- nature habit is the only realistic way hand-hygiene compliance canbe maintained during high intensity patient care situations.

• Time savings. According to prominent ER physician AngeloSalvucci, Second-nature hand sanitizers save me up to an hour in anine-hour shift. I no longer spend time hunting down a wall-mounted dispenser orsink. In fact, I virtually do not have to spend any additional time sanitizingmy hands.

• Eliminated interruptions. A second-nature hand sanitizerdoes not require a workflow interruption. It can easily be used within the flowof most tasks.

• Patient care. A second-nature hand sanitizer allows HCWs tofocus on patient care. I no longer have to break patient eye contact tosanitize my hands, explains Salvucci. The time and thought I save can gointo what Im here for quality patient care.

• Visibility. Body-worn hand sanitizers act as visiblereminders to the user, other staff, and patients that hand sanitation is apriority. It brings the sanitizer out where the action is and where everyone canshare in the reminder.

• Personal commitment. When a wall mount unit is broken, itis an institutional problem (i.e., someone elses concern). A personal handsanitizer is always a personal commitment.

Lessons of Semmelweis

Semmelweis taught us that it shouldnt require 50 years totake the next logical step in hand sanitation compliance. Body-worn handsanitizers warrant a closer look by virtually every healthcare setting. Theintent of the CDC guidelines call for opening the review process to newinnovations.

The process should include:

• New product category. Body-worn hand sanitizers warrant anew category with its own set of clinical requirements. This includesquestioning current assumptions/practices and looking at new solutions outsideexisting purchasing confines.

• Trials now. Virtually every ICU and ER will benefit from acloser clinical look at a tool that not only promises better compliance ratesbut time savings.

• Clinical leadership. Leadership starts by example. Thedaily use of a body-worn hand sanitizer is the easiest and most potent way tohelp others understand the importance of this issue.

• Cost perspective. It is the severity of the problem beingaddressed that lends the proper perspective to potential new solutions. Asstated in the CDC guidelines, The cost of hand-hygiene products should not bethe primary factor influencing product selection. Further, second-nature handhygiene holds the promise of savings that will dwarf the costs of the program.Again from the guidelines, Thus, hospital administrators must consider thatby purchasing more effective or more acceptable hand-hygiene products to improvehand-hygiene practices, they will avoid the occurrence of nosocomial infections; preventing only a limited number of additionalhealth-care-associated infections per year will lead to savings that will exceedany incremental costs of improved hand-hygiene products.

• Studies. Addressing the subject of changing behavior ofHCWs, Pittet calls for action: Carefully designed studies dealing withbehavior change should be viewed as worthy candidates for grant support byfunding agencies. Peer-reviewed journal editorial boards and facilitychairpersons also need to reconsider their positions on this subject.Second-nature hand sanitation certainly falls within this intent.

The change in culture called for in the updated guidelineswill benefit from tools worthy of the paradigm shift. The accessibility ofwall-mounted and body-worn alcohol hand sanitizers together will lend strengthto administrative and educational program components. Higher expectations can beset and achieved given realistic accessibility to hand hygiene agents.

Ron Cagle is the business development manager for HarborMedical, Inc. of Santa Barbara, Calif.