Splish splash ...: adding alcohol-based handrubs to hand hygiene routines contributes to patient safety, saves lives and adds to operational efficiency.

You might think that keeping your hands clean with good-old-fashioned soap and water could never be improved upon. But, it can.

According to the Centers for Disease Control and Prevention (CDC), using alcohol-based handrubs as an addition to soap and water and gloves win add to patient safety and save more lives. Incorporating these handrubs into your facility's daily routine may involve a little work--mainly some basic training and changing practices.

The Rhode Island Veterans Home in Bristol, R.I., found success with alcohol rubs 14 years ago.

"From the start, we placed these gels where sinks were not available, such as on isolation carts, linen carts, medication carts and resident kitchens," said Adrienne Camara, infection control nurse for the veterans' home and chair of the Long Term Care section of the Association for Professionals in Infection Control and Epidemiology, an international organization with more than 110 chapters in the United States.

"We gave them to residents on precautions [of] who can be taught to use them, so they have them in their rooms," Camara said. "We placed them by the cafeteria lines, the break rooms and the dining rooms."

Even though a formal study has not been performed at the facility, anecdotal information does suggest that the hand gels have served their purpose. "I can say a gentleman with chronic eye infections that could not use the bathroom alone was given the gel and he has had far fewer eye infections," she said.

Some dos and don'ts

View alcohol rubs as another tool, not a substitute for hand washing or gloves, according to the CDC.

Use alcohol rub or soap and water for routine cleaning if hands are not visibly soiled.

Use soap and water if the hands are visibly dirty or contaminated with proteinaceous material, visibly soiled with blood or other body fluids.

Wash with soap and water before eating and after restroom use.

Use gloves when contact with blood and body fluids becomes necessary, and for performing sterile procedures. Gloves reduce hand contamination by 70 percent to 80 Perc ent, according to the CDC. Gloves also prevent cross-contamination and protect residents and staff from infection.

Ruba a dub dub ...

Lack of handwashing by healthcare workers is a well-documented problem. In more than 30 studies conducted by the CDC during the past 20 years, handwashing has been found to be as low as 20 percent. But compliance requires only a 15-to-30 second procedure. It is easily timed by singing a slow-paced rendition of Yankee Doodle or the first verse of Happy Birthday to You.

Reasons for skipping handwashing include time constraints, skin irritation and dryness caused by frequent handwashing, and poor access to sinks, according to "The Impact of Alcohol Hand Sanitizer Use on Infection Rates in an Extended Care Facility," published in the June 2002 issue of American Journal of Infection Control.

Handwashing is still the single most effective way of preventing institution-acquired, or nosocomial, infections in health care settings. According to Intensive Surveillance for Infections in the Three-Year Study of Nursing Home Patients, published in the 1992 American Journal of Epidemiology, approximately 7.2 infections occur during every 1,000 resident care days in long term care facilities.

"Research into elderly patients and nursing homes is lacking," said Michael Ernst, Pharm. D., an assistant professor at the College of Pharmacy at the University of Iowa in Iowa City, Iowa. In a paper published in the September 1999 issue of the journal Pharmacotherapy and summarized on the University of Iowa Healthcare Web site, "Infections in nursing home patients due to physical changes and environment," Ernst noted that more than 1.5 million infections occur annually in American nursing homes, with around 10-20 infections per 100 residents each month. "This means about 1-2 infections for each resident each year, and these figures are most likely underreported," he said

Meanwhile, other studies identified increased compliance and decreased infection rates when alcohol-based rubs were incorporated into hand hygiene. In one American Journal of Infection Control study spanning 34 months at Regency Manor, a 275-bed facility in Columbus, Ohio, the use of alcohol rubs on selected units reduced infection rates by 30.4 percent compared to units where handwashing alone was used.

Operating well

Putting handrubs into hand hygiene routines actually supports staff by giving them effective and time-saving methods, according to Dr. Carol O'Boyle, assistant professor at the University of Minnesota School of Nursing, a member of the CDC review committee and author of the currently unpublished study, Is There Enough Time?

In the study, O'Boyle compared the time involved in conventional handwashing to using gels by observing the routine in an intensive care step-down unit. The average time taken for washing--involving walking to the sink, running water, soaping, rubbing, rinsing and drying--clocked in at 30 seconds to a minute each time. An average routine of a 30-second hand wash, four times per hour totaled 16 minutes per shift, or four hours for a 15-staff unit. By contrast, a staff person could dispense gel while walking past a dispenser, continue walking while rubbing in the gel, and save considerable time in the process.

Going shopping

A wide variety of products and dispensing modes allow facility managers to select one that is most effective and most convenient for staff and residents. The CDC advises considering the efficacy of the agents against various pathogens and such factors as smell, consistency, color and drying.

Camara, at the Rhode Island Veteran's Home, said that she changed products because the first one turned out to be too messy, stained hands and caused skin reactions. In general, however, alcohol handrubs cause less skin irritation and allergic contact dermatitis, according to the CDC.

Dispensing modes range from small, personal-size bottles with flip or pump tops for individual staff use to larger, portable pump bottles or wall-mounted dispensers for strategic location throughout the facility.

At Walker Senior Services in Minneapolis, Infection Control Nurse Carla Mackedanza conducted a pilot study to determine which type of containers staff accepted and used more readily and how many might be needed.

On the two 50-bed units studied, dispensers were mounted just inside resident room doors on one unit, and at convenient, but unobtrusive, locations on another unit. Staff and visitors preferred the dispensers inside the doorways because they were convenient and eliminated long walks.

For staff members who prefer small individual bottles but find them inconvenient because they can get misplaced, facilities can invest in a breakaway neck lanyard or a retractable clip, which attaches easily to clothing.

Camara's staff preferred 16-ounce pump bottles to wall-mounted dispensers, which were frequently broken. She personally replaced the pump bottles so she can monitor use. Camara noted that the staff moves the larger bottles to where they are needed--increasing use.

Facilities considering use of wall-mounted dispensers should make sure they comply with the requirements of the National Fire Protection Association, specifically Standard 101 of the Life Safety Code, according to James Loveland, P.E., a program manager at the Minnesota Department of Health.

The Center for Medicare and Medicaid Services has adopted the Life Safety Code as a condition of participation in Medicare and Medicaid, and has determined that the mounting of alcohol-based hand sanitizers in a hallway or pathway out of the building is a violation of that Code. State survey agencies have been instructed to issue a deficiency in this case, Loveland said.

Some guidelines for wall-mounted dispensers:

Make sure none of the hand sanitizer dispensers extend more than 3.5 inches from the wall to safeguard residents.

Monitor residents carefully to make sure they don't eat the handrub.

Space wall-mounted dispensers far enough apart to prevent spread of flames in case of ignition.

Dispensers should not be mounted near a source of ignition.

Dispensers may be in rooms, nursing stations or other areas that are not considered a hallway or pathway out of the facility.

Check with your state fire marshal to ensure compliance with any local restrictions, Loveland said.

Proper Use Of Handrubs

A portion of the complete set of guidelines, taken from www.cdc.gov/handhygiene, follow. The guidelines were developed by the Healthcare Infection Control Practices Advisory Committee, in collaboration with the Society for Healthcare Epidemiology of America, the Association of Professionals in Infection Control, and the Infectious Disease Society of America.

Apply product to palm of one hand, following manufacturers recommendations for volume.

Rub hands together covering all surfaces of hands and fingers.

Continue rubbing until hands are dry.

How to Track Usage as Part of a Facility's Quality Check

Periodically observe hand hygiene adherence.

Provide feedback to personnel regarding performance.

Measure volume of handrub used every 1,000 patient days

Monitor hands to ensure no artificial nails are being worn, especially in high-risk areas.

Assess your hand hygiene routine whenever infections occur.

Source: CDC "Hand Hygiene Guidelines Fact Sheet"