Hand-hygiene: Thumbs up for importance, thumbs down for implementation
by Susan Cantrell, ELS

Hand hygiene for healthcare workers should be a no-brainer. A given. The "A" in the "ABCs" of infection control. But itís not always respected or even practiced. Whatís worse is that too many of us are not even shocked and outraged by that truth.

The value of handwashing is an old and much-proven concept. In 1822, a French pharmacist urged doctors and others who came in contact with patients who had infectious diseases to disinfect their hands with liquid chloride solutions.1 In 1846, Ignaz Semmelweis realized that, when healthcare workers (HCWs) cleansed their hands before touching patients, it reduced morbidity and mortality drastically.2 In 1843, Oliver Wendell Holmes prescribed handwashing after he concluded childbed fever was spread by the hands of HCWs.3 Unfortunately, itís taken a long time for this earth-shaking discovery to sink in. Even now, 182 years down the road, the Centers for Disease Control and Prevention (CDC) still feels compelled to remind us that washing our hands is the single most important thing we can do toward good health, the HCW being no exception.

Reasons ó or excuses ó for noncompliance?
Why do HCWs find such a simple, vital procedure so hard to maintain? Improving compliance with hand hygiene has been tried in a multitude of ways, but usually improvement in rates is only temporary. Is it a concept too simple to be honored in this age of rampant technology? With the advent of waterless hand cleansers, lack of convenient facilities can no longer be given as an excuse not to comply. The CDCís "Guideline for Hand Hygiene in Health-Care Settings," 4 a k a "Everything You Ever Wanted to Know About Hand Washing," takes the guesswork out of virtually any aspect of the hand-hygiene issue. So why are HCWs, from aides to nurses to doctors, still often noncompliant? If a sense of personal responsibility has not been imbued by now, what will it take to effect change?

Changing behaviors, involving patients
"Changing human behavior is no easy task," observed Jeanne Medvick, MT (ASCP), MBA, CIC, clinical studies group manager, STERIS Corp., Mentor, OH. Dr. Maryanne McGuckin, University of Pennsylvania, and STERIS have tackled the problem with their program "Partners in Your Care." Sanja Valentic, senior product manager, applied infection control, STERIS, explained: "HCWs can be convinced to change their behavior in several ways. One way to improve hand-hygiene compliance is through patient intervention. The patient not only has a vested interest in their care, they are a constant in the healthcare equation. HCWs come and go throughout the day, but the patient remains a constant. By getting patients and their families involved in hand hygiene, they become the intervention by asking HCWs, ĎDid you wash or sanitize your hands?í McGuckin has done several studies proving the patient is willing to ask the HCW 90% of the time."5,6

STERIS has an exclusive license with the University of Pennsylvania to use the ĎPartners in Your Careí program as part of our integrated Program of Solutions (POS), according to Valentic. The POS has three parts: A regimen of products, a hand-hygiene compliance-measurement program, and a financial model. The regimen, a combination of soap, alcohol and lotion, facilitates maintenance of the skin-barrier function, minimizes the damaging effects of repeated handwashing or sanitizing, and supports CDC and Joint Commission on Accreditation of Healthcare Organization (JCAHO) requirements. "It has been clinically proven to improve skin quality," she noted. "This is important because, if you have products that improve skin, people will use them, thus increasing compliance, thereby lowering infection rates.

Triad Antiseptic Hand Gel

"We have licensed exclusively a hand-hygieneĖmeasurement program for measuring compliance from the University of Pennsylvania," she continued. "Itís important because JCAHO and the CDC require hospitals to track compliance and infection rates. Also STERIS is offering a financial model to quantify the reduction in your total cost of infections."

Other factors contribute to noncompliance, as well. Valentic points to training issues and a lack of accountability. Meanwhile, Medvick cites reduced staffing,4 increased patient-care responsibilities and "not having enough time in the day to comply in every instance."

Where does good compliance start?
Medvick suggested that education and training can contribute to increased compliance. "HCWs must be given scientifically based information demonstrating a direct relationship between good hand-hygiene practices and lowered healthcare-associated infections, she noted. "Having the healthcare administrator make hand-hygiene compliance a priority helps to create the culture that everyone has a responsibility to practice compliant hand hygiene. Every patient-care manager and department manager should emphasize to employees the importance of complying. It takes a concerted effort on the part of administration, medical staff, and all HCWs to participate in this responsibility. Having a mentor or role model take charge and demonstrate compliance is a powerful incentive to others to act in accord."

Can the right products encourage compliance? The CDC thinks so. The federal agency asserts that, "Alcohol-based products are more effective for standard handwashing or hand antisepsis by HCWs than soap or antimicrobial soaps."4 Early in the evolution of alcohol-based products, there was some resistance by HCWs, because the first generation contained virtually nothing but alcohol and a gelling agent; consequently they were very drying to the skin. These days, most waterless cleansers have emollients, humectants, or other skin-conditioning agents to counteract the drying effect. These components tend to build up after 5 to 10 applications, so itís a good idea to wash hands with soap at that point.

Growing use of alcohol-based hand cleansers makes it easier to comply with handwashing guidelines," Valentic said. However, HCWs still need to wash their hands with soap to remove visible soil. Frequent handwashing can damage skin. Skin health has a significant impact on HCWsí compliance. We know that when someoneís hands become damaged, they stop washing and sanitizing; their skin becomes irritated, red, and dry; barrier function is impaired, which can increase the skinís bacterial load. Products need to be mild and have minimal impact on the skinís natural moisturizing factor."

The CDC guideline also points out that how long an alcohol-based hand rub takes to dry, how the product feels, fragrance, and how well dispensers work also can affect user acceptance.4

Qualities desirable in a waterless hand-hygiene product
"Alcohol solutions containing 60% to 95% alcohol are most effective," according to the CDC guideline.4 Mark Stecker, director of sales and marketing, Triad Disposables, Brookfield, WI, noted, "We were very fortunate to have essentially the formulation of choice that the CDC outlined in the hand-hygiene guideline. Triad brand antiseptic hand gel is a 70% ethyl alcohol formulation."

STERIS Alcare Plus Handrub

But the bottom line on alcohol solutions is the kill factor, Stecker contends. "With the alcohol-based products, what it really comes down to is the kill profile. It kills the germs," he said. "It would have to be something frightening that could survive alcohol. Ethyl alcohol continues to be one of the oldest and most commonly used antiseptics. You can stack it up against any other antiseptic on the market. As a hand-hygiene product, I canít think of anything better."

The CDC states that, in addition to efficacy against pathogens, acceptance of hand-hygiene products by personnel should be considered in selecting the products.1 Triad Disposables took the smart route and asked the end users ó the nurses ó what they wanted in a waterless hand cleanser. "Our research strongly indicated a few things that we really took to heart when we designed our product: First, the nurses absolutely wanted a clear product, no dyes, nothing that didnít need to be there; second, they wanted it thick, a high viscosity, so that itís easy to work with; third, they wanted an emollient that you could feel left behind, a softening or moisturizing agent to offset the drying effect of alcohol, Stecker said.

"The nurses really helped us design this product, even in the sizes," he continued. "We try to make it as accessible as possible by offering it in a variety of sizes and packaging. I think weíre the only company that offers a single-dose foil pack. You can carry the packs in your pocket, tear one open, squeeze the gel out, throw the package way, and youíre done. We also have 4-oz and 8-oz bottles and a 16-oz pump dispenser for the walls," he added..

The CDC guideline further states, "Alcohols are rapidly germicidal when applied to the skin, but they have no appreciable persistent (i.e., residual) activity.4 However, regrowth of bacteria on the skin occurs slowly after use of alcohol-based hand antiseptics, presumably because of the sublethal effect alcohols have on some of the skin bacteria."

Persistence is the ability to remain on the skin, continuing to kill pathogens after the hand rub is finished. It is mentioned most often with surgical hand antisepsis, but it also can be appropriate for standard use. "People should at least consider persistence in the equation, along with skin friendliness, and cost-effectiveness," said Steve Owens, marketing director for the surgical division of Healthpoint Ltd, Fort Worth, TX.

"Triseptin Water-Optional is the only alcohol-based, chlorhexidine gluconate-free hand-hygiene product with residual effect. Itís the addition of zinc pyrithione that gives Triseptin Water-Optional its persistence," Owens noted. "By containing an antimicrobial that has persistent and residual effect, the product provides an insurance policy in the event of noncompliance. In the real world, the doctor gets busy, runs between procedures, runs between patients, forgets to wash his hands, or maybe has bad dermal condition and chooses not to wash. The persistent effect has real value in these cases, because the product continues to kill pathogens between hand rubs. It really differentiates our product."

Another practical aspect is that, being water-optional, when a handwash rather than a hand rub is in order, HCWs donít need to put away the alcoholic gel and pull out the soap; they can just rub with Triseptin Water-Optional, then rinse with water, washing the germs down the sink drain.

"A childrenís hospital brought to our attention that when thereís a Clostridium difficile outbreak, the first thing they do is pull the alcohol-based gels and switch to washing with soap," Owens related. "The reason for the switch is that alcohol-based gels, including ours, generally just inactivate the germ; they donít actually get rid of the C difficile, itís just put in a vegetative state. So, they switch to the rinse-off products, or the soaps, because they want to wash the pathogen off, totally remove it from their hands. With Triseptin Water-Optional, they donít have to change hand cleansers, they simply change the way itís used."

Personalize this
As a purchaser of hand-hygiene products for an institution, you want to make the best choices possible for your staff, coworkers, and patients. As you know, that means research, research, research. Start with the CDCís guideline. But itís also important to take it down to a more personal level.

If you or someone you care about is a patient in a healthcare facility, donít be passive about your wishes; itís all-important to be assertive when your health is at stake. You absolutely should ask any HCW who wants to touch you, "Did you wash or sanitize your hands?" Donít let them touch you if you hear any response less than a solid "Yes!" Donít waste one moment fretting about offending the HCW. Itís the HCWsí job to wash their hands to help reduce the risk of transmitting an infection to patients, and they know it. Remember the Hippocratic oath: "First, do no harm." If their hands transmit a nosocomial infection, harm can be done. It may take only one exposure to transfer the infection to a patient. If the patient dies from the infection, you wonít get the opportunity to ask a second time. Think how you would feel knowing that, if you had only spoken up, someone you loved might not have died. There really are times when hand hygiene can make the difference between life and death. The life a simple handwash saves may be your own or someone you love. Isnít that worth leaving your comfort zone, risking irritating an HCW by simply asking them to do what theyíre supposed to have done already? Do it ó without fail. Take responsibility. No excuses.

1. Labarraque AG. Instructions and Observations Regarding the Use of the Chlorides of Soda and Lime. Porter J, ed. [French] New Haven, CT: Baldwin and Treadway; 1829.
2. Semmelweis I. Etiology, Concept, and Prophylaxis of Childbed Fever. Carter KC, ed. 1st ed. Madison, WI: The University of Wisconsin Press; 1983.
3. Rotter M. Hand washing and hand disinfection [chapter 87]. In: Mayhall CG, ed. Hospital Epidemiology and Infection Control. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1999.
4. Centers for Disease Control and Prevention. Guideline for hand hygiene in health-care settings: 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):[inclusive page numbers].
5. McGuckin M, Waterman R, Storr IJ, Bowler IC, Ashby M, Topley K, et al. Evaluation of a patient-empowering hand hygiene programme in the U.K. J Hosp Infect 2001;48:222-227.
6. McGuckin M, Waterman R, Porten L, Bello S, Caruso M, Juzaitis B, et al. Patient education model for increasing handwashing compliance. Am J Infect Control 1999;27:309-314.

Hand-Hygiene Resources
www.hopisafe.ch: University of Geneva Hospitals, Geneva Switzerland
www.cdc.gov/ncidod/hip: Centers for Disease Control and Prevention, National Center for Infectious Diseases, Atlanta, GA
www.jr2.ox.ac.uk/bandolier/band88/b88-8.html: Bandolier journal, United Kingdom
www.med.upenn.edu, University of Pennsylvania, Philadelphia

Moisturizers & Lotions: Pros and Cons
by Tom Berry, Materials Management Director, Childrenís Hospital of The Kingís Daughters, Norfolk, VA

Moisturizers and other hand care products can be effective in treating hand problems. However, many over-the-counter hand-care products can become contaminated with infectious microorganisms that thrive in the occlusive environment of medical gloves. In addition, consumer products often contain fragrances and other additives that may prove irritating or incompatible with clinical hand-hygiene products.

Approved moisturizers, however, can help prevent dehydration, damage to lipid barrier properties and desquamation (excessive skin cell shedding), as well as restore the water-holding capacity of the keratin layer. Several controlled trials have demonstrated that regular use of hand lotions or creams helps prevent and treat irritant contact dermatitis and there is biological evidence that emollients may help protect against cross-infection.

CDC hand-hygiene guidelines specifically call for provision of "efficacious hand hygiene products that have low irritancy potential, particularly when these products are used multiple times per shift."

What constitutes effective protection? Glycerin has been shown to attract moisture into skin, maintain skin lipids and oils, and normalize desquamation (skin shedding). It moisturizes and plasticizes the stratum corneum, and is used in a range of living organisms to maintain the correct osmotic pressure in living cells.

Gluconolactone is an alphahydroxyacid (AHA) that is less irritating than other AHAs such as lactic and glycolic acid and is known to minimize flakiness. It is often used to treat photodamaged skin.

Chitosan, which is widely used in dressings for wound healing, is a carbohydrate that promotes regeneration of injured tissues. Used alone, it can bind to skin or hair and act as a protective film. In composition with other skin-care product ingredients, it can bind water and other molecules for delivery, and increase skinís moisture retention.

Panthenol/Provitamin 5, more familiar as Vitamin B5, can play an important role in protecting aging skin when applied topically. This is particularly relevant in nursing, where the majority of practicing nurses are more than 40 and the average age of an operating room nurse is 50.

Substantial data has been compiled over the years to demonstrate that topically applied vitamins can be beneficial to skin when they are absorbed into the epidermis or upper dermis.

Even with the proper ingredients in optimal proportions, however, a skin-care product requires regular, frequent and proper use to be effective. Numerous articles note that failure to use supplemental lotions is a factor that contributes to dermatitis. Additionally, whether through lack of time or simple misunderstanding of proper application techniques, many clinical personnel do not adequately protect their hands even when they use the proper lotions or creams.