Good hand hygiene is your best defense against healthcare-acquired infections, but there's more to it than scrubbing in for surgery or squirting some alcohol-based sanitizer onto your hands. Here's a look at the products and protocols appropriate for each area of your facility.

Non-clinical areas
The CDC has approved alcohol-based hand washes for clinical areas, but this doesn't rule out your using them in non-clinical areas. Besides, non-clinical staff are just as capable of spreading microorganisms as clinical staff, though it's admittedly less likely those viruses and bacteria will end up compromising the patient. But when you consider the efficacy of alcohol hand washes, giving all staff access to them is a worthy idea. As long as you follow the appropriate building codes, you can install dispensers in the reception area, office areas and the break room, among other places.

Remember, just because a sink may be located nearby, that doesn't mean that staff will have time to get up to wash their hands after each little cough or sneeze. It's not just during cold and flu season, either, as people who have allergies can suffer year-round from congestion, coughing and sneezing. Your reception staff will have, at the very least, some indirect patient contact, usually touching the same papers and pens during the admissions process.

Bathrooms, stairwells and, in the case of hospitals, cafeterias are also good places to make alcohol-based hand washes available. This placement can help encourage patients and their escorts to think about hand hygiene. I've heard of hospitals passing out personal bottles of hand sanitizer along with literature on infections and self-care in an effort to prevent self-infection. While no research to my knowledge has explored the possibility that visitors' poor hand hygiene in the facility leads to an increased risk of healthcare-associated infection, making the tools for proper hygiene available certainly can't hurt. In addition, placement in staff bathrooms is a good reminder that you should wash with soap and water first (visible soil) and rub with alcohol second (microorganism kill) in clinical areas as well.

If a product containing CHG is the formulation of choice for clinical areas, I recommend you make a plain alcohol product available in non-clinical areas to avoid potential negative skin reactions to CHG. Overall, the more alcohol-based rubs are available, the more they're likely to be used, and it's the duty of infection control practitioners to think about preventive measures throughout the facility, not just in the most critical areas.

Pre- and post-op
Your pre-op and recovery areas are two places it's important to have a protocol that includes both soap and water and alcohol-based rubs. Changes made to the NFPA 101 Life Safety Code last year let you now mount dispensers in hallways, so there's no excuse now. When you consider the efficacy of rubs in clinical practice, you'd be silly to not add them. 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."[1]

Soap and water should be used to remove visible soil, while the rubs can be used for spot cleaning between patient contacts and healthcare-worker-to-healthcare-worker contacts. According to CDC guidelines, the rub you choose should be 60 percent to 95 percent alcohol and should contain an agent, such as CHG or iodophors, for persistence of activity. Do not be swayed by cheaper formulations that contain less than 60 percent alcohol because they are cheaper - such rubs are not effective for healthcare purposes and therefore would be a waste of money.

Whether you choose gels, foams or rinses (the substance of choice in Europe) is up to your staff's preferences, input from infection control and the results of any trials you may conduct. While wall-mounted dispensers are best, as they are maintained by environmental services and are less likely than portable containers to be contaminated, you may also want to look into providing staff with personal-sized (0.5 ounces to 4 ounces) containers.

If you decide it would encourage compliance, buy products that come with devices to hold the small bottles on belt clips or lanyards. This prevents healthcare workers from having to reach into pockets - which may be dirty themselves, or contain other objects that the worker would contaminate when retrieving the gel bottle. To reduce the risk that workers will use contaminated gel, have a policy that calls for bottles to be thrown away when they are empty.

The OR
The gloves that you'll be wearing in the OR don't preclude the need for good hand hygiene habits. In fact, studies show that flora will multiply more quickly on gloved hands than on ungloved hands, making it all the more crucial that you follow proper protocol.

That means a three-minute to five-minute scrub with comfortably warm-to-hot water - longer scrubs under uncomfortably hot water will damage skin, increasing microbial load and microorganism shedding. Traditionally, non-antiseptic soap has been used for surgical scrubbing, but with the advent of brushless, alcohol-based scrubs (different from the quick-kill alcohol-based rubs I've already discussed), there has been some debate over which to use. The CDC guidelines allow for either, but recommend that healthcare workers pre-wash with non-antimicrobial soap, then completely dry their hands and arms before applying the alcohol-based product according to manufacturers' instructions.

One study published in the British Journal of Dermatology (September 2000) found alcohol-based formulations were more effective and better tolerated than non-antiseptic soap, which actually posed a risk of spreading contamination. Researchers theorized that the alcohol scrubs, also known as brushless or waterless scrubs, were more effective because healthcare workers are more likely to scrub properly when their skin is comfortable.

It seems that the trend now is toward performing a traditional soap scrub for the first case of the day and using brushless or water-aided scrubs for subsequent cases. About two-thirds of respondents to a recent Outpatient Surgery Magazine survey employed this tactic, the thinking being that the traditional scrub first thing in the morning will more effectively reduce any gross contamination brought in from outside. Even if brushless scrubs are the norm in your facility, you may want to make soap available, as surgeons and nurses sometimes feel that alcohol-based products build up, making donning gloves more difficult, and they like to go the traditional route to remove this.

You can encourage hand hygiene compliance in your anesthesia providers by keeping personal alcohol rub containers (non-foam) in each of your anesthesia carts. They don't pose a fire hazard when kept in drawers, but will still be in a convenient spot should your anesthesia provider need it.

Working in concert
Remember that, despite the convenience and effectiveness of alcohol-based products for all areas of your facility, they're not a panacea.

• Alcohol doesn't kill spores.
• High concentrations (95 percent) are needed to kill some viruses (though you're unlikely to encounter such viruses in outpatient surgery).
• It's not persistent, despite its quick kill rate.
• It's ineffective against gross contamination (only mechanical soap-and-water washing will help you there).

Reference
1. 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.