Hand hygiene. It’s perhaps the most funda-mental process performed by healthcare workers (HCWs) as they care for their patients. Soap, water, rubbing, rinsing, toweling or maybe just a quick rub with a squirt of an alcohol-based product. Sounds simple, doesn’t it? If it’s so simple, why is the subject perpetually controversial? Why is compliance with hand-hygiene guidelines consistently below par?

Reasons, excuses, etc., etc.

"There are no easy answers," offered Suzanne Pear, RN, PhD, associate director for scientific affairs and clinical education, Kimberly-Clark, Roswell, GA. "We want a simple answer, but studies show that hand hygiene is a deceptively complex issue. Many components must be in place: system factors, administrative factors, people factors."

Pear pointed out that some factors necessary to successful hand-hygiene compliance are not under the control of healthcare workers (HCWs). For example: "There must be enough staff so that HCWs can focus on more than just tasks. HCWs can’t control staff levels; it’s an administrative issue." Pear, who calls hand hygiene "the basic critical care," said, "Administration needs to be held accountable for having adequate staffing and convenient equipment and supplies; then we need to call HCWs to task for their behavior and hold them accountable. There’s no excuse not to be compliant. Patients can’t afford that. If you go into surgery, there is a 100% expectation that hands will be scrubbed, and I think we need to ask the same thing everywhere care is provided. People live up to expectations, so let’s expect this."

"Generally, there has been a lack of organizational emphasis on the importance of hand hygiene," agreed Trey Howard, vice president of sales and marketing, STERIS Corporation, Mentor, OH. "However, because of increased public awareness, mandatory reporting, and changes in reimbursement, administrators are clearly focusing more on hand hygiene now."

Another factor is time versus technology. "There are competing priorities," explained Pear. "The more complex the care being provided to the patient the more competition there is for behaviors. Hand washing is a basic behavior, but other, more complex priorities, such as monitoring an EKG or a pressure monitor or listening for alarm bells, compete with it."

Then, there’s the perennial favorite issue: good hand hygiene hurts. Simrit Sandhu, product manager for applied infection control, STERIS Corporation, said: "One reason JCAHO [Joint Commission on Accreditation for Healthcare Facilities] cites for low compliance is skin problems caused by hand-hygiene products. Water itself is drying to the hands, as are soap and alcohol. HCWs are required to sanitize or wash hands before and after patient contact, which could be 30 to 70 times per day. It becomes very important that the formulations for your skin are mild but that they work together without inhibiting antimicrobial efficacy."

At a minimum, Pear said, ICU HCWs are expected to perform hand hygiene seven times per hour on average. Skin can become raw, cracked, painful. "There may be a subconscious reluctance because of painful hands that leads to avoidance," said Pear. "You want to prevent breakdown of the skin so there is no hesitancy to perform hand hygiene as often and as thoroughly as they should. When skin breaks down, it increases the likelihood of becoming colonized and transmitting infections to patients."

In its continuing quest to encourage hand hygiene, Kimberly-Clark will soon release a new PPE Dispensing System that offers hand sanitizer and personal protective equipment all in one convenient place. Spring-assisted dispensing of masks and gloves, which can only be pulled out by the cuff so as to prevent contamination of the fingertips, minimizes cross-contamination of products. Icons encourage hand hygiene and proper donning techniques. On the Kimberly-Clark Professional side, the recently released Hand Hygiene Voice Module repeats a message every 2 minutes reminding visitors to restrooms about the importance of handwashing. An internal study found that the module increased handwashing compliance by 12%.

A rose by any other name?

Alcohol-based hand rubs (ABHRs) have proven to be a successful alternative to the traditional soap-and-water wash. Studies have demonstrated that use of ABHRs cause less skin irritation and dryness than frequent handwashing. However, all ABHRs are not created equally. Some are thin, some are viscous; some are heavy on softeners and moisturizers, some not so much, and so on. Many formulations are available, often within the same company.

Kimberly-Clark Hand Hygiene Voice Module

Two formulations in the PURELL line (GOJO Inc, Akron, OH) were tested in a study by Boyce et al.¹  Group 1 used the original PURELL clear formulation, and Group 2 used the new opaque moisturizing PURELL formulation with DERMA-GLYCERIN system during Phase I for 3 weeks. After a 2-week wash-out period, each group switched to the other product for Phase II. The skin condition of participating nurses was assessed before and after each phase; participants filled out a self-assessment questionnaire; and dermatologists measured skin hydration, redness, scaling, and cracking.

Patty Taylor, RN, marketing vice president, healthcare, GOJO, said that "subjective and objective measurements showed that the skin condition of nurses’ hands was better when using the opaque formulation, and a majority of nurses preferred it to the traditional clear formula." How well nurses like a formula is important, according to Taylor. "We believe, as the CDC does, that, if you provide a product that HCWs like, they’ll be more likely to use it."

GOJO offers a variety of formulations and recently released a PURELL non-
aerosol, alcohol-based, instant hand-sanitizer foam. To complement this product, they also released a new touch-free dispenser. The attraction of the dispenser, explained Taylor, is that "it reduces contact transmission, and it’s been proven to increase hand-hygiene compliance."²

Taylor Oldroyd, Vienna, VA, independent distributor for PureWorks, Salt Lake City, UT, agreed that "HCWs will not use products that dry out, crack, and inflame their skin. Oldroyd related that "Under the direction of Dr. David N. Wright, at the AORN meeting in Washington, D.C. last February, we interviewed over 400 nurses and some hospital staff department heads about their compliance to hand-hygiene protocol. Almost without exception, they responded that they ‘hated’ how their skin feels following use of the products supplied for them by their hospitals and that this is the primary reason for not complying 100% with the protocol recommendations."

Oldroyd believes the following components are the keys to good hand care:

• Products should make the skin feel good

• Products should not cause negative reactions in fragrance-sensitive users

• Products should not be flammable

• Products should have persistent germ-kill over a long period of time, if possible

• Product ingredients should be hypo-allergenic

• Product ingredients should moisturize and condition the skin

• Products must be compliant with
FDA published monographs on skin care

STERIS family of hand hygiene products

How do you measure hand hygiene?

Measuring hand-hygiene compliance is tricky business. For one thing, there’s been no unified approach, so there’s often no way to determine if compliance is improving, getting worse, or staying the same. GOJO is the sole sponsor of a project designed to change that. The Joint Commission on Accreditation of Healthcare Organizations, in partnership with major infection control organizations in the United States and abroad, will conduct the 18-month project to identify the best ways to measure compliance with hand-hygiene guidelines. At the time of the announcement, Jerod M. Loeb, PhD, executive vice president, division of research, said "Effective measurement will help healthcare organizations target interventions, which in turn should improve hand hygiene practices by healthcare workers, and ultimately result in fewer healthcare-associated infections [HAIs]."

Compatibility for effectiveness

Hand-hygiene formulations that work together effectively is the thrust of STERIS’s message on hand hygiene. "STERIS is taking a different approach," Sandhu told HPN. "We say that compliance itself is not enough. What’s needed is effective compliance: frequent washing with the right products. A combination of products is needed. An HCW may use an ABHR four or five times, then wash with soap, and finally use a lotion. All these products should work together. Our products have been tested by a third-party institution, the University of Cincinnati Skin Sciences Institute."

Backing up product claims with scientific findings is vital. STERIS believes in the importance of scientific data. "Results of these tests are slated for publication in a supplement that will appear in an upcoming issue of AJIC (Association for Professionals in Infection Control and Epidemiology’s peer-reviewed journal)," advised Howard. "We thought the study was an important investment, because no one else thinks of it this way. Not all hand-hygiene products work well together."

"We have different types of ABHRs to meet the needs of our customers," continued Howard. "Some customers like a thicker gel-type product, but thickeners inhibit residual activity (persistence) of CHG [chlorhexidine gluconate]. Users need to know that. They’re paying more for the CHG because they need a higher level of care, say in a high-risk area, but using a mid-priced gel could be ruining the antimicrobial activity of the CHG product.

"Efficacy shouldn’t be assumed; some products don’t do what people assume they do," explained Howard. "Some HCWs bring products from home, but they need to know that those products are not the most efficacious for the healthcare setting. Proper hand hygiene has the potential to eliminate one-third of all HAIs. Hand hygiene is on the front line in the war against HAI, and we need to make sure we equip the front line with the best possible solutions so as to have the greatest impact. Proper hand hygiene has the potential to eliminate one-third of all HAIs."

"It’s little things that make large differences," observed Sandhu. "An act as simple as handwashing can create a huge difference in reducing the incidence of HAIs. If HCWs hands hurt, they may not wash. We provide products that promote healthy skin."

Purell Instant hand sanitizer from GOJO

Killing persistently

Alcohol is a great quick-acting germ killer, but it lacks "persistence," the ability to continue killing pathogens for a time following application. Germ Pro Products (Tampa, FL) offers an alcohol-free, hand-sanitizing lotion combined with a surface disinfectant, both of which are persistent. Wayne Albright, president, told HPN: "Germ Pro’s Persistent Action Plan is based on the belief that products capable of persistently killing pathogens, when used in addition to compliance with HICPAC [Healthcare Infection Control Practices Advisory Committee] guidelines, will significantly reduce nosocomial infections."

"Independent laboratory tests show that Germ Pro’s Hand Sanitizing Waterless Wash/Lotion continues to kill pathogens for up to 4 hours and does not wash off easily," said Albright. "HCWs apply the lotion at the beginning of the work day and reapply every 3 to 4 hours or after a hard scrub. This helps the hands from becoming re-infected between hand washings. Our lotion forms a polymeric film on the hands that is not water-soluble, helping to provide protection against the harsh effects of alcohol washes. Vitamin E and other emollients are part of the formula to moisturize and help heal the hands. Some HCWs have to wash their hands more than 50 times per day, and their hands become so dry and cracked that they don’t comply with handwashing guidelines. Germ Pro’s features allow HCWs to have better compliance because their hands don’t hurt."

Because HCWs’ hands often are contaminated by pathogens that live on surfaces in the patient environment, Germ Pro developed Surface Disinfectant, also possessing the quality of persistence, to be used in tandem with the lotion. "Independent tests indicate that the Surface Disinfectant kills pathogens, including methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus, for up to 28 days. Results of a test conducted by Kansas State University show that it even kills Clostridium difficile and its spores," noted Albright. "A persistent surface disinfectant should be applied to doors, light switches, bed rails, telephones, remote controls, toilets, countertops, wheelchairs, and other surfaces to help prevent HCWs, patients, and visitors from picking up pathogens and contaminating other surfaces."

PureWorks also offers products with persistence. "The active ingredient in the skin-disinfecting lotion and foam, benzethonium chloride, was formulated with other ingredients to stay on the surface of the skin, continuing to kill germs for hours following each application. The time it remains depends on skin condition and environmental factors, such as presence of moisture," explained Oldroyd. "Skin conditioners and emollients were added to condition and moisturize the skin. The more the products are used, the better conditioned and moisturized the skin becomes."

The hand in the glove

Another component of hand hygiene that can be detrimental to skin health is the constant use of gloves. The trend has been away from powdered gloves, because they can be drying and abrasive to the skin. Cardinal Health (McGaw Park, IL) has gone a step farther and incorporated a coating inside their gloves that can help to restore damaged skin and can replace the need for lotion.

Esteem glove with Neu-Thera
from Cardinal Health

Deborah Davis, technical and clinical marketing director for gloves business, told HPN, "Neu-Thera gloves have been clinically proven to heal skin. We’ve talked to some customers who were in danger of losing their jobs because of poor hand health due to frequent scrubbing with soap or rubbing with an alcohol-based product. They were able to continue after using these gloves. When hands are not compromised, it encourages handwashing."

"Gloves are ubiquitous in healthcare delivery," observed Davis. "HCWs wear perhaps 20 to 30 pairs per day. Neu-Thera gloves leave a protective barrier on the skin that reduces moisture loss. The formulation is glycerin-based. It softens and moisturizes and can take the place of lotion. The ingredient panthenol helps to repair damaged skin. Healthy, intact skin is the first line of defense against infection."

It’s all about life

Hand hygiene is basically an HCW issue, but it’s important because how well it’s performed can make a monumental difference in patient lives. Pear neatly summed up the bottom line: "We need to realize that we have all these facts and figures, but behind those facts and figures are people, people who mean a lot to other people. When someone dies of infection, lives are changed irrevocably." HPN

References

1. Boyce JM, Gallardo C, Watsky KL. Prospective, randomized clinical trial of the effects of two alcohol-based hand rub products on skin condition of nurses’ hands. In: The 16th Annual Scientific Meeting of the Society for Healthcare Epidemiology of America; March 2006; Chicago, IL. Abstract 06-A-341-SHEA.

2. Larson EL, Albrecht S, O’Keefe M. Hand hygiene behavior in a pediatric emergency department and a pediatric intensive care unit: comparison of use of 2 dispenser systems. Am J Crit Care 2005;14:304-312.