People and Opinions

The Importance of Education: Identifying truth and myths in infection control
by Darcy L. Helder and Medea Myhra

Hand hygiene has been the subject of everything in recent years, from research reports to editorials, from literature reviews to new Guidelines by HICPAC (Healthcare Infection Control Practices Advisory Committee). Are the true messages really getting through to those who need the information?

Identifying truths and myths
Infection Control practices in the field reveal both myths and reality where hand hygiene is involved. It is not only important to educate the health care workers (HCWs) about proper hand hygiene, but it is also important to educate Infection Control Practitioners (ICP’s) about what issues are truly relevant during product selection. One such myth is the claim that thickened alcohol-based hand rubs that contain carbomer will interfere with CHG (Chlorhexidine Gluconate) residual effects. Surgical scrub products are persistent on resident flora up to 6 hours for protection underneath gloves. For this reason, it is important that alcohol based products do not interfere with the effects of CHG if the surgery staff use alcohol products between procedures/surgery.

"It has been well established in the literature that when CHG is converted, wholly or partly, to an insoluble salt, a loss of antibacterial action is to be expected."1 A large company’s literature suggests "When tested in a lab, when a carbomer containing alcohol hand antiseptic is combined with CHG, a white precipitate is formed, thus demonstrating that the CHG has been deactivated." 2

While it is true a white precipitate forms in a test tube when combining CHG and carbomer alone, this does not necessarily inhibit the CHG antimicrobial activity. An independent lab compared the effects of a CHG product and carbomer-containing non-alcohol placebo mixture to a CHG product alone. To avoid having the alcohol bactericidal effect skew the results, the alcohol was removed. Results of this study showed that the carbomer-containing placebo did not reduce the residual effects of CHG.3 (Table 1) To the ICP, this would look to be an important distinguishing factor, when in fact it appears the addition of carbomer should not be a deterrent to selection. Heeg also confirmed this in 2001, comparing both oil-in-water emulsions and water-in-oil emulsions when used with alcohol hand rubs: "the administration of selected products for hand care does not necessarily impair hand disinfection."4

It is true that some compounds may have negative effects on CHG or other antimicrobial ingredients with residual effects5, however the total formula of a product is very important and not just one or two ingredients. Nonionic surfactants or anionic emulsifiers in lotions may interfere with CHG effectiveness. However, it cannot be assumed that products will or will not interfere, therefore, products must be tested in order to make a claim that hand disinfection is not impaired.

As shown in Table 1, the product with carbomer continued to have a greater than 99.999% reduction in bacteria 30 minutes later and greater than 99.9999% reduction in bacteria 90 minutes later, the same as the CHG product alone. The testing was done by an independent laboratory following a written protocol according to ASTM Standard: E 1054-91, Standard Practices for Evaluating Inactivators of Antimicrobial Agents Used in Disinfectant, Sanitizer, Antiseptic, or Preserved Products.

The importance of moisturizing
According to research in the new Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene, the stratum corneum (top layer of the skin) needs a full 6 days for recovery time after a cleansing.5 Although most handwash and alcohol-based hand rubs contain emollients to re-start the moisturizing process, the need for moisturizing still exists. For this reason, nurses should be sure to use moisturizers provided by the health care facility, which are to be selected based on compatibility with gloves and persistent surgical scrub products. If nurses continue to bring in lotions of their own preference, they increase the risk of potential cross-contamination due to interference with antimicrobial products, or the possibility of glove deterioration. For these reasons as well, the new Guideline for Hand Hygiene recommends that moisturizers be made available free of charge for health care workers.

 Test article
#1 Alcohol gel placebo/CHG		 Test article
#2 CHG
Time %
Reduction		 Log10
Reduction		 %
Reduction		 Log10
Reduction
30 min >99.999 >5.99 >99.999 >5.99
90 min >99.9999 >6.00 >99.9999 >6.00

Compatibility of lotions with CHG
Here again, lotions may contain anionic emulsifiers, which could interfere with CHG or other antimicrobial effects. Since lotions are cosmetic products, unregulated by the FDA, companies tend to make claims based on what the competition is saying or what they feel they can get away with…It is vitally important that products be tested together to determine if this claim is possible. One such lotion for health care workers’ hands was studied and found to have no effect on CHG efficacy. The CHG is still allowed to be clinically effective when mixed with this lotion.6

How much product to use?
HCWs also need to be educated as to how much product is needed for each application. The FDA Tentative Final Monograph for Healthcare Antiseptic Drug Products7 —not yet finalized, recommends five (5) grams of product, or around a teaspoon. A teaspoon measurement is easily recognized by people and easy to remember. However, this needs to be translated into nearly a softball-sized portion for foam products due to the air involved. Chances are, HCWs do not realize so much foam product needs to be used, and therefore might not have appropriate coverage and efficacy throughout the course of their shift, putting patients and themselves at risk for infection. It is important to educate about proper usage levels for alcohol-based hand rubs in order to assure correct efficacy. 5

Development of an educational program for increasing hand hygiene adherence by using a no-rinse hand rub
•Purpose/Problem:
Studies have shown adherence to hand hygiene protocols to be as low as 40% on average.5 The Centers for Disease Control and Prevention (CDC) released the Guideline for Hand Hygiene in Health-care Settings in October 2002. As a recommendation, an overall program to improve hand hygiene adherence should include educational materials for health care workers (HCWs).

• Objectives:
To develop an educational program for infection control hand hygiene. Educational programs for hand hygiene have been shown to be effective at increasing hand hygiene adherence and connected with reductions of nosocomial infection rates. 5,8,9 The CDC Guideline for Hand Hygiene recommends the educational program include the following:

1. Rationale for hand hygiene
2. Indications for hand hygiene
3. Techniques for hand hygiene
4. How to maintain skin health by moisturizing which can prevent or minimize xerosis (dry skin)
5. Patient Care Managers/Adminstrators expectations to have policies in place and role models in the facility
6. Indications for and limitations of Glove Use

Methods & results:
A literature review and telephone interviews were completed to understand current infection control practices, techniques, educational level, awareness of new guidelines, and selection of appropriate products (indications). Of the interviews completed in October 2002, all ICPs were aware of the new CDC Guideline for Hand Hygiene. However, 83% stated the healthcare workers in their institution were not yet aware of these guidelines or were just minimally familiar with them. 50% of respondents suggested video training would be beneficial. Other comments included: anything to make it easier for the staff to comply, short, concise, easy to use, dramatic impression to drive home the importance, based in reality or they will dismiss it and not follow it, on-going reminders. It is expected that more HCWs are now aware of the Guideline now that it is finalized, but education is still an important part of the implementation of a good hand hygiene program.

Based on the survey feedback, a comprehensive educational program was developed for infection control practices including an educational video to educate staff about the importance of hand washing, proper procedures and product usage. An accompanying pamphlet highlights the key points of the video and serves as a pocket reminder. Audit worksheets are available for ICPs to determine how much product is needed and where hand washing products should be placed throughout the facility. This not only encompasses the alcohol-based hand gels, but also antimicrobial soap for use with water, plain liquid soap and a moisturizer. Hand washing reminder posters were also created and are distributed to healthcare facilities, in order to sustain the awareness level.

CDC Guideline recommendation Educational Program Application
7.A. Educate personnel regarding types of patient-care activities that can result in hand contamination and the advantages of various methods used to clean hands Video and pocket guide read-along-pamphlet
7.B. Monitor HCW’s adherence with recommended hand hygiene practices and provide personnel with information regarding their performance Audit spreadsheet and Quality Review worksheet
7.C. Encourage patients and their families to remind HCWs to decontaminate their hands New posters for staff, patients & visitors

Conclusion
This new educational program will help Infection Control professionals educate HCWs about the rationale, indications and techniques for hand hygiene, in order to stay compliant with the recommendations of the new CDC guideline. Table 2 demonstrates how this educational program meets the guideline requirements.

ICP’s should request support data from manufacturers, and manufacturers, in turn, should make sure products are tested and represented or promoted appropriately. The efficacy of this new educational program in helping educate HCWs about the rationale, indications and techniques for hand hygiene remains to be formally explored. HPN

References
1. Senior, N, Some observations on the formulation and properties of chlorhexidine. J. Soc. Cosmet. Chem, 24 259-278(1973).
2. 3M Avagard D Frequently Asked Questions. http://www.3m.com
3. Independent Laboratory, Data on file, Coloplast Corp.
4. Heeg P, J Hosp Infect 2001 Aug 48 Suppl A:S37-9.
5. Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health Care Setting: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002:51 (No. RR-16, 13 & 22-24).
6. Independent Laboratory, Data on file, Coloplast Corp.
7. Food and Drug Administration. Tentative final monograph for healthcare antiseptic drug products; proposed rule. Federal Register 1994; 59:31443.
8.Pittet D, Hugonnet S, Harbarth S, et.al, Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000:356;1307-12
9. Pittet D, Compliance with hand disinfection and its impact on hospital-acquired infections. J Hosp Inf. 2001;48 (Supplement A); S40-S46.

About t he authors:Darcy Helder holds a B.S. in Business Administration with a concentration in Marketing from Minnesota State University, Mankato, and has worked for Coloplast Corp. for 9 years in the fields of marketing research and development. usdlh@coloplast.com
Medea Myhra has a B.A. in General Distributive Science with an emphasis in Biology and Chemistry from Gustavus Adolphus College, St. Peter, MN and has over 17 years of laboratory experience in different fields, including the past 3 ½ years as a Formulation Chemist in R&D at Coloplast Corp.
The authors of this article are employees of Coloplast Corp., Skin Care Division in North Mankato, MN, Some of this information has been presented at Symposium on Advanced Wound Care and Medical Research Forum on Wound Repair, Las Vegas, Nevada, 2003 and Wound, Ostomy, Continence Conference, Cincinnati, OH, 2003.

 

February 2005