Maximizing Hand-Hygiene Compliance to Improve Outcomes:

November 1, 2001

Maximizing Hand-Hygiene Compliance to Improve Outcomes:
A New Tool for Infection Control

By Eleanor J. Fendler, PhD, MD and Patricia A.Groziak, MS

Hospital-acquired infections are a major concern in healthcare facilities,affecting at least 2 million patients annually and resulting in extendeddurations of care and substantial morbidity.1 Such infections areestimated to cause or contribute to 88,000 deaths annually in the US, as well asrequiring nearly $5 billion in treatment costs.1 The incidence ofinfections in acute care facilities is about 9.8 infections per 1,000 patientcare days and in long-term care facilities, approximately 7.2 infections per1,000 resident care days.2,3 Because infections are a major cause ofmorbidity and mortality, and the threat of antibiotic-resistance is becoming aserious public health concern, attempts to control the spread of infections inhealthcare has demanded increasing attention. The Centers for Disease Controland Prevention (CDC) states one-third of these infections can be prevented byimplementing better infection control programs, and that hand hygiene is themost important measure to prevent the spread of infection.4

Compliance with handwashing procedures by healthcare workers (HCWs) continuesto be at 20-50%.2, 5-8 Studies have shown that deterrents to handhygiene compliance include the amount of time required for soap-and-waterhandwashing with heavy workloads, skin irritation, and dryness caused byfrequent handwashing with soap and water, and poor access to sinks.2,9-13

Use of waterless alcohol-based hand sanitizers instead of soap-and-waterhandwashing has been demonstrated to overcome these barriers to compliance.11-16Alcohols, in the form of both rinses and gels, are one of the most effectiveagents for reducing the number of viable pathogens on the hands18-21including under artificial fingernails.22 Hand disinfection with analcohol gel hand sanitizer containing emollients causes less skin irritation anddryness of the hands than handwashing.12 Introduction of easilyaccessible dispensers with an alcohol-based waterless handwashing antisepticalso has been demonstrated to lead to significantly higher hand hygiene ratesamong HCWs.8 Improving compliance of HCWs with recommended handhygiene measures can reduce transmission of hospital-acquired pathogens16,17and result in decreased infection rates.17

Alcohols for Hand Disinfection

Alcohols have been used for skin antisepsis in healthcare for more than acentury. Ethanol is the only Category 1 (safe and effective) antimicrobialingredient in the FDA Tentative Final Monograph (TFM), covering handwashes,surgical hand scrubs, and hand antiseptics in the US. Ethanol (ethyl alcohol) at60-95% concentration by weight has very rapid, broad spectrum antimicrobialefficacy for gram-positive and gram-negative bacteria, including theantibiotic-resistant microorganisms, as well as for some fungi and viruses.Evaluations of both the immediate and persistent antimicrobial effects of theproduct on the hands over the course of 10 consecutive microbialcontamination/product application cycles show high efficacy. The irritationpotential of the product measured over the course of 15 additional productcycles using the standard visual scoring showed no skin irritation.

Contrary to popular opinion, alcoholic products seem to be quite acceptableto users.12,23 Newer formulations containing emollients eliminate thedrying effects of alcohol on skin and significantly increase acceptability.24-33Intermittent use of an alcohol hand gel containing emollients was found toreduce the soap-induced skin irritation of HCWs and to improve their skincondition (cracking, scaling, and redness) and maintain normal skin hydration.34Similar results were found in Finland where use of alcoholic preparationscontaining emollients instead of soap or detergents are recommended to preventskin problems especially during the winter months.14

Impact of Alcohol Hand Sanitizers on Clinical Outcomes

Numerous obstacles to handwashing compliance have been documented, includinghigh workloads, inconvenient sink locations, skin irritation and dryness, andinadequate knowledge of hand hygiene guidelines or protocols. Despite a varietyof interventions designed to increase compliance, including training, education,and patient awareness programs, handwashing compliance among HCWs has remainedpoor--typically less than 50%. Recently published studies on the benefits ofalcohol that document efficacy and improved clinical outcomes support therecommendation in the proposed draft of the CDC's Healthcare Infection ControlPractices Advisory Committee (HICPAC) 2002 Hand Hygiene Guidelines that alcoholhand rubs be considered the leading tool for hand disinfection whenever handsare not visibly soiled.35

Improvement in clinical outcomes through the use of alcohol hand sanitizershas been documented in the areas of skin condition, hand hygiene compliance,absenteeism, and infection rates.

  • Improved skin condition. Boyce and coworkers12 conducted a study to compare the frequency of skin irritation and dryness associated with using an alcohol hand gel regimen for hand antisepsis vs. soap and water handwashing. This prospective, randomized trial with crossover design compared an alcohol hand gel with plain soap-and-water handwashing among 29 nurses working on three hospital wards. Irritation and dryness were evaluated by self-assessment and visual assessment by a study nurse. The authors concluded that a well-formulated alcohol gel containing moisturizers is well tolerated by HCWs and does not cause the skin irritation and dryness resulting from plain soap-and-water handwashing.12

  • Increased hand hygiene compliance. Bischoff and coworkers8 investigated the efficacy of three hand hygiene interventions--an education/feedback intervention, patient awareness program, and the placement of a new and accessible alcohol hand gel--on handwashing compliance. This 6-month study compared the efficacy of these three interventions using direct observation of handwashing for 1,575 potential opportunities during 120 hours randomized for both time of day and bed location. Alcohol hand sanitizer dispensers were available in a ratio of 1:4 patients and subsequently 1:1 patient. The researchers found that the introduction of an alcohol hand sanitizer was the only intervention that resulted in significantly higher hand hygiene rates. Compliance improved as accessibility was enhanced, from 19% to 41% with a 1:4 dispenser:patient ratio, and 23% to 48% with 1:1 ratio. Education/feedback intervention and patient awareness programs failed to improve handwashing compliance.8

Scientific evidence supports the use of alcohol hand sanitizers as effectivetools to overcome the obstacles associated with poor handwashing compliance.Successfully incorporating alcohol hand sanitizers into routine clinicalpractice will positively impact hand hygiene behavior, thereby improving patientsafety and quality of care and reducing the financial and human costs associatedwith hospital-acquired infections.

Dr. Eleanor J. Fendler is the director of skin care technology for GOJOIndustries of Akron, Ohio. She has more than 20 years of experience in productformulation, infection control, and dermatology. Patricia A. Groziak, M.S., isthe acute care market director for GOJO Industries. She has more than 20 yearsof experience in the healthcare industry.