Nearly one-tenth of hospital admissions are the result of hospital-acquired infections, but prevention is in your hands. Literally. Simple, well-done hand hygiene ' washing and surgical scrubbing ' can terminate outbreaks in healthcare facilities, reduce transmission of harmful organisms and, without a doubt, reduce overall infection rates. Here's a report on recent hand hygiene advances.

New products and practices
In addition to old-fashioned soap and water, you now have the option of alcohol-based rubs and scrubs, which were introduced to the hand care market in the 1980s as an adjunct to soap-and-water hand washing.

The Centers for Disease Control and Prevention (CDC) and the Association for periOperative Registered Nurses are throwing their weight behind antiseptics containing isopropanol, ethanol or n-propanol as critical to good hand hygiene in healthcare.

Yet a recent Outpatient Surgery infection control survey (n=101) found less than one-fifth (17.8 percent) of facilities were using alcohol-based rubs after scrubbing in with soap and water. Nearly two-thirds (66.3 percent) of respondents used the rubs between patient contact. But 15 percent said they never use alcohol-based rubs.

"It's taken hold in some areas of the country," says Marsha A. Miller, RN, MEd, CNOR, manager of professional education and training for Advanced Steriliza-tion Products. "In fact, it's kind of facility-dependent; Stanford uses it throughout its hospital, but [the University of California at San Francisco] does not."

Compelling evidence
The facilities that haven't incorporated alcohol-based rubs may want to consider doing so because science supports their efficacy. According to the CDC's 2002 "Guidelines for hand hygiene in health-care settings," the rubs reduce bacteria on hands more rapidly than antimicrobial soaps or detergents, and they kill the most organisms.1 A 2002 study found that, with alcohol-based hand rubs, the median reduction in bacterial contamination was 83 percent versus 58 percent with hand washing. The researchers concluded that, "during routine patient care, handrubbing with an alcohol-based solution is significantly more efficient in reducing hand contamination than hand washing with antiseptic soap."2 A study in an acute-care facility and one in an extended-care facility suggest alcohol rubs can reduce urinary tract, surgical site and respiratory tract infection rates by about one-third.3,4

In addition, JCAHO is watching. "JCAHO is going to enforce [the recommendations]," says Judene Bartley, MS, MPH, CIC, a clinical consultant for the Premier Safety Institute. "In fact, hand-hygiene issues are going to be receiving a lot more attention from the JCAHO than anyone would have thought."

Here's what you need to know to integrate them.

The right combination
The CDC report and fact sheet cite alcohol products as the answer to nearly every clinical hand hygiene need, pointing to their especially remarkable power at simply killing patho-gens and other microorganisms. Absolutely, they're valuable. But they're not the only answer, says Nancy Bjerke, RN, MPH, CIC, an independent consultant with Infection Control Associates in San Antonio.

"[Alcohol] has a place in certain situations, but I do not believe it is the answer to all hand-washing opportunities," says Ms. Bjerke. "It does do a quick kill, but what if you have buildup on your hands? Actual hand washing is important."

The CDC report does warn alcohol-based rubs are not appropriate for hands "visibly dirty or contaminated" with proteinaceous materials such as dirt or blood. In this instance, wash with soap and water.

The most important factor, then, is to differentiate between when to use soap and water and when to use an alcohol rub.

The CDC recommends you "use alcohol hand rubs to clean hands" but also says you should "wash visibly dirty hands with soap and water"; these are both 1A, the second-strongest recommendations. In the February AORN Journal, AORN printed its "Recommended Practices for Surgical Hand Antisepsis/Hand Scrubs," which says you should follow soap and water for surgical scrubbing with an alcohol rub and that you should "sanitize hands with an alcohol-based rub" if they aren't visibly dirty.5 (See "Help Picking an Alcohol-based Rub" on page 14 for more from the AORN.)

Boosting frequency
But even if healthcare professionals are sanitizing their hands correctly ' the right product for the situation ' they're simply not doing it enough, says Ms. Bjerke. Hand-washing compliance is generally reported from 10 percent to 50 percent in many studies. Ms. Bjerke says Infection Control Associates sees similar results in its compliance surveys.

"In reality," she says, "compliance is very lax."

Time constraints and inconvenient sink locations ' probably the biggest factors impeding hand-washing compliance ' will almost inevitably continue to exist, but facility administrators can boost compliance by offering the easiest possible access to the kind of products their employees want to use. According to the 2002 CDC report, here are the factors most affecting whether your staff will accept and use hand-hygiene products:

• comparison of products,
• relative smell,
• consistency,
• color and
• drying effect on hands.

And that's the real value of quick, water-free rubs: high acceptance among rushed healthcare workers. A study in 2000 by the Department of Internal Medicine at the Medical College of Virginia performed in a medical ICU, cardiac surgery ICU and general medical ward in a 728-bed teaching facility found that while education programs boosted compliance only minimally, the installation of vast numbers of hand-rub dispensers (initially one for every four patients; eventually one-to-one) improved a 23 percent compliance rate to 48 percent.

Once a new NFPA 101 Life Safety Code is in place (probably this summer), healthcare facilities will have more options regarding placement of alcohol-based hand rub dispensers.

"It will increase access to hand hygiene," says Ms. Bartley. "Instead of having a lineup of people at the sink, 10 people can take a squirt of alcohol in 30 seconds."

When it comes to improving soap-and-water washing compliance, encourage staff to use common sense. APIC guidelines say hands should be washed with non-anti-microbial soap and water "when visibly soiled" and with an alcohol-based rub before and after patient contact and after any possible contact with body fluids and substances, mucous membranes, broken skin or contaminated objects. APIC recommends anti-microbial cleansing products before surgery or placement of invasive devices, when antimicrobial activity is desired and "when it is important to reduce ... skin flora in addition to transient microorganisms." You should also provide lotions (to prevent skin dryness from repeated hand washing) and single-use paper towels or a blow dryer nearby, but out of reach of splash contamination, says Ms. Bjerke. If you use a blow dryer, activate it with your elbow to avoid recontaminating hands.

Proper technique
Second to frequency in the hand-washing hierarchy is technique. Both cleansing methods have recommended procedures.

For a water-free, alcohol-based hand rub, apply the correct amount to one dry palm and rub the hands together. Cover all surfaces of hands and fingers and wipe until dry.

When using soap and water, the longer hands are wetted and lathered, the better a product will perform ' though you shouldn't go longer than about six minutes, because you'll risk irritating your skin, which can open it up for infection. The APIC recommends you rub hands "vigorously" for 10 seconds to 15 seconds with a "plain, non-anti-microbial soap" in bar, leaflet, liquid or powder form. Other guidelines, such as AORN's, prefer anti-microbial soap to improve transient-organism kill.

For pre-surgery scrubbing, wash hands and forearms, clean under fingernails and apply an antimicrobial agent "with friction" to wet hands and forearms for two minutes to six minutes.

Not a panacea
Proper hand hygiene doesn't end with hand washing. Facility managers should be vigilant about employees' habits; long nails, for instance, should be kept to a minimum because of an increased risk of trapped bacterium. The CDC says artificial nails, which can tear gloves, should be avoided entirely, with natural nails no longer than a quarter-inch "if [the provider cares] for patients at high risk of acquiring infections."

"More organizations are making statements about anything not natural," says Ms. Bartley, "and that could include nail polish, too. Because that opens you up to the possibility of chipped polish and infection."

Gloves should also be worn for all contact with bodily fluids, but the CDC has warned against reliance on gloves in lieu of washing, or vice versa. Even though leading gloves have been proven to reduce pathogen contact with the skin by 70 percent to 80 percent, according to the CDC, they are not perfect, and cleaning the skin underneath is necessary to maintain a sanitary facility.

Added bonus
Beyond all else, though, simple hand washing is the most important part of hand hygiene. Done correctly and enough, it is the biggest factor in keeping some of the most easily prevented infections out of the healthcare workplace. In addition, says Ms. Bjerke, frequent and conspicuous compliance with at least basic hand washing reinforces patients' confidence, even in cases of non-invasive contact.

"It basically tells patients that healthcare worker respects them enough not to transmit any infectious material to them," she says.

References
1. Centers for Disease Control and Prevention, "Guidelines for hand hygiene in health-care settings, Recommendations and reports," Morbidity and Mortality Weekly Report 51 (RR-16). 25 Oct 2002.
2. Girou E, Loyeau S, et al. Efficacy of handrubbing with alcohol based solution versus standard hand washing with antiseptic soap: Randomised clinical trial. BMJ. 17 Aug 2002;325(7360):362.
3. Hilburn J, Hammond BS, et al. Use of alcohol based hand sanitizer as an infection control strategy in an acute care facility. American Journal of Infection Control. 31 April 2003(2):109-16
4. Fendler EJ, Ali Y et al. The impact of alcohol hand sanitizer use on infection rates in an extended care facility. American Journal of Infection Control. 30 June 2002(4):226-33.
5. Association for periOperative Registered Nurses, "Reco-mmended Practices for Surgical Hand Antisepsis/Hand Scrubs," AORN Journal Vol 79, No 2. Feb 2004;416-31.