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Wringing Our Hands
CDC Proceeds Slowly in Writing Updated Guidelines
By Kelli M. Donley
Handwashing, once a simple task, has developed into a monumental chore toregulate. Millions of dollars are spent educating, promoting and urginghealthcare workers (HCWs) to wash their hands diligently.
But with what? There are waterless-handwashing products, brushless-products,products to be used before treating patients in ICU, products to be used beforewearing gloves and the traditional sink and soap approach.
There is nothing simple about handwashing these days. The action of removingpotential pathogens from the palms of hospital workers is no longer a matter ofproviding bars of soap, a clean sink and towels.
The time spent, frequency, method, cleansing product and chemical of choiceused to wash those digits has become a source of controversy, with medicalorganizations and healthcare companies in a shouting match to whose opinion maybe heard first, and ultimately recorded in the much awaited update of Center forDisease Control and Prevention's (CDC) Guideline for Hand Hygiene in HealthcareSettings.
The guidelines, which are under review and being written currently, arerumored to be released in 2003. Other sponsors of the update include the Societyfor Healthcare Epidemiology of America (SHEA), the Association for Professionalsin Infection Control and Epidemiology (APIC) and the Infectious Diseases Societyof America (IDSA).
With so many cooks in the kitchen, there is no wonder what is taking so longto produce the new information, longed for by many in infection control.
The current CDC guidelines were written in 1987 by Julia S. Garner, RN, MN,and Martin S. Favero, PhD. There is also a long list of contributing expertsfrom the Hospital Infections Program at the Center for Infectious Diseases.Considering these guidelines are 15 years old, it is easier to point out what ismissing, rather than what must have been revolutionary at the time. The report,which was an update itself from the previous Guideline for HospitalEnvironmental Control, written in 1983, discusses the difference betweenmechanical and chemical removal of microorganisms. However, officials did nottake a stance on antimicrobial products. At the time, they note well-controlledstudies highlighting the need for antimicrobial products were not available. Thelack of research inhibited their ability to judge the necessity for suchproducts.
Instead, the report reads, "Handwashing with plain soaps and detergentsis effective in removing many transient microbial flora. Resident microorganismsin the deep layers may not be removed by handwashing with pain soaps anddetergents, but usually can be killed or inhibited by handwashing with productsthat contain antimicrobial ingredients."1
The use of antimicrobial products when water and soap is not availablereceived a category III recommendation. In other words, there was researchshowing this may be appropriate, but the evidence was not substantial enough tomerit strong support.
Additionally, HCWs are guided to wash their hands before performing invasiveprocedures, between contact with high-risk patients and after touching objectsthat could be potentially contaminated with pathogens.
APIC Speaks Up
Elaine Larson, RN, PhD, FANN, CIC, wrote APIC's updated handwashingguidelines in 1994. The Guideline for Hand Washing and Hand Antisepsis inHealth-Care Settings was an update from the organization's previousrecommendations, APIC Guideline for Use of Topical Antimicrobial Agents.
APIC's update, written some seven years after the CDC's guideline, discusseshandwashing issues in more depth. Topics not discussed by the CDC but outlinedby APIC include: specific antiseptic agents, surgical scrub, nails (nail polish,artificial nails), jewelry, lotion-use, storage of handwashing supplies andcompliance.
Larson writes, "Two major dilemmas facing infection controlpractitioners in healthcare settings today are when to use antiseptic agents andwhich agents to use."2
The report uses research conducted by Lilly and Lowbury in 1979 showing skinantiseptic provides a maximum level of bacteria count reduction. 2
It is unapparent why this research, used by APIC, was not considered in 1987by Garner and Favero. Rather, the CDC Guidelines cite Lilly and Lowbury researchpublished in 1964.
Larson uses the 1979 research, along with 238 other references, to concludesoap and water may not be the best option in all situations. Instead, shewrites, the choice between soap and water, an antiseptic soap or an antisepticrub should be dependent on the patient and the circumstances. The report statesantimicrobial soap should be used when a HCW is performing and invasiveprocedure or when coming in contact with immuno-compromised patients.
The choice of antimicrobial product is also up for discussion. Larson writes,"Each is different and none is ideal for all uses." The reportsuggests HCWs should review the characteristics of antimicrobial ingredients(i.e., alcohols, chlorhexidine gluconate, hexachlorophene, iodine/iodophors,para-chloro-meta-xylenol, Triclosan) before selecting their choice ofhandwashing product.
The question remains, what will final guidelines cover? Will they includemore information or specifics about artificial nails? Brushless scrubs?Alcohol-based gels?
The previous guidelines included a draft that was sent before printing to 150scientists and infection control practitioners to review for comment. Theguidelines being written currently were also sent out for review. The commentperiod has since elapsed. Information on the CDC Web site says comments from thereviews are being processed and will be noted.
Greg Carter, RN, CIC, is the manager of infection control and centralprocessing at Kettering Medical Center in Kettering, Ohio. Carter, known as the"Germinator" by colleagues, says although he did not have a chance toreview the proposed changes, there are alterations he expects.
"The standard time difference for washing, from 10 to 15 seconds (maychange)," he says.
Product advances, he says, should also be noted.
"Waterless hand cleaners have revolutionized handwashingcompliance," he says. "With these being more available than most sinksare, healthcare workers, including physicians, are using (these products)."
Carter notes that the events of the last year have brought the importance ofdiligent infection control to light for many in the industry.
"I think for the first time, infection control professionals are beingrecognized for what they are really educated to do," he says. "In thepast, most administrators know they were suppose to have one, but did not knowreally what the practitioner could really accomplish if allowed -- epidemiology,education, outbreak investigation, patient/staff safety, knowledge of theregulatory requirements and biological incident experts. Since Sept. 11, peopleare really depending on us as the bioterrorism experts for their facility. Inthe words of someone along the way, 'We've come a long way baby!'"
Dial Corporation director of healthcare sales John Russell says afterreviewing proposed changes in the handwashing guidelines there is a possibilitythat facilities will use more handwashing supplies as there will be greaterawareness of the importance of handwashing.
"The new guidelines recommend use of a hand sanitizer as a supplement tohandwashing," he says. "The new proposed guidelines state that unlessyour hands are visibly soiled, you don't need to wash your hands. However mosthealthcare facilities will probably use more hand hygiene products in the futurethan they have used in the past because of the increased usage of handsanitizers. The mix of products will vary by facility."
Additionally Russell feels that infection control specialists, notmanufacturers, are responsible for making necessary changes to the proposedupdate.
"As a manufacturing corporation, we are not the expert in creatinginfection control handwashing guidelines," he says. "We are going toread the guideline once it is finalized and we have or will have products thatwill satisfy the guidelines' recommendations."
Shawn Gentry, director of marketing and product development in the infectionprevention division of Healthpoint says waterless scrub use, as described in theCDC draft guideline, may be confusing to HCWs.
" As manufactures of alcohol-based products, we support the use ofwaterless products in the healthcare setting; however, their clinical in-useshould follow their approved label claim," he says. "After reading theDraft Guidelines, one could confuse the use of healthcare personnel handwashes
for surgical scrubs. In the FDA's Tentative Final Monograph for HealthcareAntiseptic Drug Products, antiseptic products generally fall into threecategories each with separate testing criteria: surgical scrubs, patientpreoperative skin preparations and healthcare personnel handwash.
A concern is that ICP's, OR Staff and Industry could view the Guidelines (ifthe draft version goes final as written) as approval to use waterless products(Healthcare Personnel Handwashes) as surgical scrubs.
Gentry says this confusion could lead to problems in handwash compliance.
"The efficacy requirements for surgical scrubbing is clearly defined andestablished fora purpose. Per the AORN's Recommended Practices for Surgical HandScrubs, the purpose of a surgical scrub is to remove, reduce and inhibitmicrobial presence and regrowth (summarized). If one uses waterless scrubproduct, they will not be able to remove the microorganisms without firstperforming a prewash (with soap and water). The use of a prewash combined with awaterless scrub product will add several steps to the scrubbing process which isalready being abbreviated. One concern is this could result in a decrease incompliance and lower the standard of care in the surgical scrubbing arena. Thereis little doubt that alcohol-based products offer superior antimicrobialactivity (fast acting and broad spectrum); however, one should make sure thatthe alcohol-based product they are evaluating or using meets the FDA's TFMtesting criteria for surgical scrubs and includes a prewash to remove dirt andtransient microorganisms between every procedure. In this rapidly evolvingproduct category, there should be a choice of brush-free scrubs that offersuperior efficacy compared to current practices, include a prewash (water-aided)and provide a cost effective solution for the surgical market."
Officials from the CDC did not return calls for comment on when the newguidelines would be published.