Healthcare facilities strive to hand infections defeat
by Susan Cantrell, ELS
There is an old Lebanese proverb that still offers
sound advice for us today: "Hygiene is two thirds of health." Never is that
truer than in the healthcare setting.
It is common knowledge that good hand hygiene is a
key to wellness, both at home and in the medical setting. That’s why the results
of a study published in December 2011 in the American Journal of Infection
Control is so disturbing.1 Eighty-five medical students were
surveyed in their third year of study, their first year with clinical contact.
Seven scenarios, of which 5 were correct hand-hygiene indications, were given:
before patient contact, before preparation of infusions, after removal of
gloves, after contact with the patient’s bed, and after contact with vomit.
Sadly, only 33% of the students correctly identified all 5 true indications, and
only 21% correctly identified all 5 true and 2 false indications. If these 85
students are a typical representation of our future healthcare workers (HCWs),
we could be in trouble.
Scientific evidence on the value of clean hands has
been accumulating since the early 1800s. Centers for Disease Control and
Prevention (CDC) has been publishing handwashing guidelines since 1975. J.
Hudson Garrett, Jr., PhD, MSN, MPH, FNP-BC, CSRN, VA-BC, senior director,
clinical affairs, PDI Inc., Orangeburg, NY, noted, "Hand hygiene is widely
accepted as the most critical infection-prevention intervention in modern
medicine." Yet, compliance with hand-hygiene protocol remains an issue.
One reason for noncompliance that always floats to
the top when hand hygiene is under discussion is skin damage caused by frequent
hand cleansing. That is a genuine concern. Skin damage is painful, making
compliance less likely. The skin can become so dry that it feels like it is
burning; it can appear red and feel rough to the touch. Skin damage presents an
infection risk because dry, fissured skin offers hiding and breeding places for
pathogenic organisms that can be transferred from the caregiver to the patient
or the environment.
The CDC’s hand-hygiene guideline states,
"...approximately 25% of nurses report symptoms or signs of dermatitis involving
their hands, and as many as 85% give a history of having skin problems. Frequent
and repeated use of hand-hygiene products, particularly soaps and other
detergents, is a primary cause of chronic irritant contact dermatitis among HCWs."
The good news from CDC is "The potential of detergents to cause skin irritation
can vary considerably and can be ameliorated by the addition of emollients and
humectants."
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Ecolab Revitalizing Skin Lotion |
For the caregiver
Industry grasps the problem. Linda Homan, RN, BSN,
CIC, senior manager, clinical and professional service,
Ecolab, St. Paul, MN
stated, "One of the most important factors driving hand-hygiene compliance is
providing products that are not harsh or damaging to the skin, so HCWs want to
use them. At Ecolab, we formulate our hand sanitizers, such as our Quik-Care
Foam Waterless Hand Sanitizer, and soap products to include skin conditioners
and emollients that help moisturize and improve skin health with continued use.
We also recommend that healthcare facilities provide hospital-grade hand lotions
to prevent skin damage. For example, our Revitalizing Skin Lotion is a CHG [chlorhexidine
gluconate]-compatible moisturizing lotion that does not compromise the
antimicrobial efficacy of CHG scrubs and is compatible with latex and non-latex
gloves."
One complaint often heard by users is that they do
not like how a product feels on their hands, so they do not want to use it.
Ecolab heard that complaint and responded. "Ecolab hand sanitizers are
formulated to dry within seconds and not leave a sticky feeling on skin, which
reduces application time and encourages use," said Homan. "In addition to
products that are gentle but effective, we have found that a combination of
products, dispensers, education, training, and a monitoring system that provides
immediate feedback and positively reinforces behavior without interfering with
an HCW’s daily routine, also drives compliance."
Homan also cited scientific evidence in support of
Ecolab’s product claims. "A poster presented at the APIC [Association for
Professionals in Infection Control and Epidemiology Inc.] annual conference in
June described how the combination of the right products and automated
monitoring can drive improvement. Working with Ecolab, Southern Alabama’s
Andalusia Regional Hospital implemented a hand-hygiene monitoring system that
tracked use of both hand sanitizer and soap. Over a 6-month period, hand
sanitizer and soap dispenses increased by 82.6%. In addition, patient responses
to a question about their perception of HCW hand cleansing demonstrated a 9%
increase in the perception that HCWs ‘always’ performed hand hygiene."2
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Kindest Kare Foamed Antiseptic Handrub
from
STERIS |
STERIS Corporation, Mentor, OH, also believes in
the power of emollients. STERIS Kindest Kare Foamed Antiseptic Handrub with
Enhanced Emollients is a high-performance formulation designed specifically for
healthcare professionals, to encourage frequent use in hospitals and health
facilities. It is a mild yet effective foamed handrub that moisturizes hands, as
well as a lotion, while eliminating 99.9999% of most common organisms. It
contains 62% ethyl alcohol, and, when tested on human skin, this exclusive
professional healthcare formula meets Food and Drug Administration (FDA)’s
Healthcare Personnel Handwash and Surgical Scrub criteria on both the first and
the tenth wash. It is used with either a manual or touchless wall-mounted
dispenser that creates quality foam.
Laura Ball, infection prevention product manager,
Kimberly-Clark, Roswell, GA, talked to
Healthcare Purchasing News about some of their moisturizing hand-care products. "Kleenex ULTRA Moisturizing
Foam Hand Sanitizer uses natural cucumber and green tea extracts to moisturize
skin for up to 2 hours after application. In addition, tests show that it
improves skin hydration by 30%, and it is clinically proven to improve skin
condition in less than 5 days, leaving skin feeling soft and smooth, while
maintaining efficacy against the most common bacteria that can contaminate
surfaces and cause infection. Research conducted by Kimberly-Clark found that
two out of three nurses prefer the Kleenex ULTRA Moisturizing Foam Hand
Sanitizer over Purell Advanced Skin Nourishing Foam."
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Kleenex Ultra Moisturizing Foam Hand Sanitizer
from Kimberly-Clark |
Ball mentioned other advantages of Kleenex ULTRA
Moisturizing Foam Hand Sanitizer that make it attractive to HCWs. It "dries
fast, and the proprietary moisturizing formula reduces the sticky feel users
experience after multiple uses with other hand sanitizers, while improving skin
hydration to leave hands feeling nourished and healthy. It is compatible with
latex, nitrile, and vinyl gloves and has a 70% alcohol content, which is
effective against the most common bacteria and fungi that can contaminate
surfaces and cause infection. It is cost-effective, as it delivers nearly twice
the number of shots as gel products of the same size."
fiteBac SkinCare, LLC, Fort Worth, TX, a subsidiary
of Kimmerling Holdings Group, LLC, recently launched a new hand sanitizer,
fiteBac SkinCare Germicidal Hand Softening Gel, which they believe will
help reverse the trend of skin damage associated with frequent handwashing.
Former Dow Corning chemist John Blizzard wanted to create a sanitizer that
lacked the harmful side effects linked to other traditional hand sanitizers.
fiteBac Gel is paraffin-free, water-free, unscented, petroleum-free, and
alcohol-free. The patent-pending technology is comprised of a non-alcohol–based
antimicrobial formulation and a silicone-based cross polymer that provides
hydrophobic properties to improve the skin’s moisture barrier and keep the skin
soft, even after frequent handwashing or glove use.
Germgard Lighting, LLC, Dover, NJ, does not yet
ship commercialized products, but it is working on a different approach to hand
cleansing. Their goal is to provide a suite of less expensive, faster working,
and better infection-prevention and contamination-control solutions. The
products under development employ UV-C technologies and optical materials for
sanitation of both bare and gloved hands. Germgard Lighting’s UV-C hand
sanitizer and its suite of hand-protection products is expected to have the
potential to improve upon the efficacy, lengthy application time, and irritation
associated with handwashing.
For the patient
Patients often cannot ambulate to a sink to clean
their hands. Garrett described how PDI’s products take into consideration their
needs. "Sani-Hands Instant Hand Sanitizing Wipes contain aloe and vitamin E,
which has been clinically proven to moisturize the skin with repeated use. The
antimicrobial gel rub is enhanced by the friction of the wipe, physically
removing more soil from hands than traditional gels and foams, without leaving a
sticky or greasy residue. Sani-Hands contain 65.9% alcohol, which exceeds CDC
and WHO [World Health Organization] requirements for alcohol content in
hand-hygiene products in healthcare settings, and kills 99.99% of bacteria."
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PDI Sani-Hands wipes family |
Sani-Hands Instant Hand Sanitizing Wipes are
packaged in quick-pull canisters and individual packets, which make them
convenient for meal trays and overbed tables. "The Sani-Hands Bedside Pack is
specifically designed to aid patients, whether bedbound or ambulatory, in proper
hand hygiene," said Garrett. "Each pack contains 20 large wipes, ideal for an
average patient stay of 3 days in most inpatient facilities. All Sani-Hands are
fragrance-free and dye-free, which allow them to be used on the most sensitive
patient populations; are FDA Food Code-compliant, making them safe for
use prior to eating; and contain moisturizers and emollients to ensure that
hands are not dried out with repeated use."
"PDI also offers optional point-of-care/-use dispensing accessories for use with Sani-Hands products, including Sani-Bracket wall and mobile-equipment brackets and Infection Prevention Pak," said
Garrett. "These are designed to aid in compliance with regulatory and
accreditation requirements for engaging the patient and their family in their
own care."
"Sani-Hands has been used by hospitals to support a
patient hand-hygiene program to reduce the spread of healthcare-acquired
infections," said Garrett. He related an experience that took place in 2009 at a
100+ bed, high-acuity, long-term–care facility in Pennsylvania, which
implemented a multidisciplinary infection-prevention program that targeted a
thorough environmental-disinfection program using Super Sani-Cloth/Sani-Cloth
Bleach and also a healthcare provider-/resident-centered hand-hygiene program
using Sani-Hands. "The 6-month study resulted in HAI rates dropping by 77%, a
decrease in acute-care transfers due to infection treatment needed by 22
transfers, and, most significantly, a $33K decrease in the costs of antibiotics
for treatment of resident infections as compared to the previous year," said
Garrett. "This program not only resulted in decreased costs, but also became
part of the facility’s antimicrobial stewardship program."
For the OR
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Surgicept Waterless Surgical Hand Scrub
from CareFusion |
Susie Wolf, senior product manager of hand-scrub
solutions, CareFusion,
San Diego, CA, also highlighted the importance of selecting products liked by
staff, because staff preference can have a great impact on compliance with
hand-hygiene protocol. "A study has shown that, if healthcare practitioners
don’t feel comfortable with a product, they are not likely to use it
consistently," said Wolf.3
"A nationwide blind study of healthcare
professionals showed the ingredients and formulation of Surgicept may address
some of the factors related to the failure to adhere to surgical hand-scrub
protocols. Nearly 80% of the surgeons and OR [operating room] staff preferred
Surgicept to the current leading waterless surgical hand antiseptic
(Surgical-scrub comparison market research, Bernstein-Rein, 2010). Participants
found Surgicept to be significantly more appealing and noted its soft, smooth
feel and quick drying time. Surgicept dried two times faster than the
comparative product. In addition to overall preference, more participants
favored Surgicept on specific attributes that could have a positive effect on
compliance, including easier gloving, quicker dry time, less residue on the
skin, and an easier application process. The faster dry time leads to shorter
overall application time, which can lead to better adherence to hand-hygiene
guidelines."
"We developed the Surgicept formulation to address
the complaints from surgical staff about the feel, longer drying time, and
stickiness of current surgical-scrub products," said Shanta M. Modak, PhD,
research scientist, Columbia University Medical Center, New York, NY, and
inventor of Surgicept. "I believe that Surgicept will make hand hygiene more
comfortable for healthcare professionals and therefore has the potential to
increase compliance."
Wolf added that Surgicept’s formula exceeds
FDA-required surgical hand-scrub testing standards for immediate, persistent,
and cumulative reductions in resident and transient flora.
Those working in the OR traditionally scrub their
hands and nails with a brush or sponge, which can contribute to skin damage.
Greg F. Skorczewski, technical specialist,
3M, St. Paul, MN, explained how their
products can offer an advantage over the traditional approach. "In the OR, skin
damage can occur from traditional surgical-scrub methods that use a brush or
sponge. 3M developed Avagard (chlorhexidine gluconate 1% solution and ethyl
alcohol 61% w/w) Surgical and Healthcare Personnel Hand Antiseptic with
Moisturizers as a fast and effective alternative to a traditional 6-minute
surgical scrub. The unique formulation combines alcohol for immediate
antimicrobial kill and chlorhexidine gluconate for persistence, and is delivered
in an emollient-rich lotion base to help maintain skin integrity."
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3M Avagard Hand Antiseptic with Moisturizers in
hands-free wall dispenser |
"The Avagard Surgical Antiseptic application is a
three-step process that is performed in a fraction of the time of a traditional
scrub," continued Skorczewski. "In addition, its dual active formulation of
alcohol and active levels of chlorhexidine gluconate provides cumulative and
superior persistent antimicrobial activity as compared to products whose only
active ingredient is alcohol."4
"3M also provides Avagard D Instant Hand Antiseptic
with Moisturizers as a personnel healthcare handwash option," said Skorczewski.
"With the increased awareness and emphasis on sustained hand-hygiene compliance,
HCWs have been faced with a significant increase in hand-hygiene opportunities.
Avagard D Instant Hand Antiseptic has a unique advanced liquid-crystalline
moisturizing formulation that helps prevent dryness and maintain skin
integrity."
Compliance monitoring
Some facilities have boosted their performance by
monitoring HCWs for compliance at hand-hygiene opportunities. There are a number
of monitoring systems, including the traditional one of observance. The trend
now is toward technological solutions. "Direct observation has many
disadvantages," said Paul Alper, vice president, strategy and business
development, Deb Worldwide Healthcare Inc., Charlotte, NC. "It only captures a
small sampling of hand-hygiene events; people act differently when they know
they are being watched, the Hawthorne Effect; it is not timely; and it is
expensive."
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DebMed GMS hand-hygiene compliance reports
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Alper explained how their solution works. "The DebMed GMS (group monitoring system) is the world’s first electronic monitoring
system to report hand-hygiene compliance rates based on the WHO’s Five Moments
for Hand Hygiene," said Alper. "When a soap or sanitizer dispenser is used, a
wireless signal is sent, indicating that a hand-hygiene event has occurred. The
hand-hygiene events are compared to how many hand-hygiene events should have
taken place, based on the breakthrough ‘HOW2 Benchmark Study,’ published in the American Journal of Infection Control in February 2011.5 This
research established statistically significant numbers of hand-hygiene
opportunities in various types of units in different hospital settings.
Proprietary data from each hospital using the system is added to this
calculation to ‘calibrate’ the compliance rate so that it is specific to that
hospital. Compliance reports are available via the Web."
Other advantages of the DebMed GMS is that "the
system does not require a real-time location system or radio-frequency
identification infrastructure, does not interfere with existing systems, and
requires no capital investment," said Alper. "The DebMed GMS captures 100% of
hand-hygiene events, eliminates the Hawthorne Effect, provides compliance
reports in real-time, and is the most cost-effective system on the market. The
system monitors compliance at the group level to encourage collaboration, rather
than singling out individuals, and includes an online toolkit to help support
behavior change."
Alper also talked about cost savings experienced by
users of DebMed. "A study conducted at Duke University Medical Center, published
in Infection Control and Hospital Epidemiology, showed that minimal
improvements in compliance lead to substantial savings, concluding that a 1%
increase in hand-hygiene compliance would result in annual savings of $39,650 to
a 200-bed hospital.6 One DebMed user, the Greenville Hospital System,
Greenville, SC, was able to increase unit-based hand-hygiene compliance
significantly upon implementing the program."
Irisys was awarded a contract from U.K. National
Institute for Health Research last year to develop sensors to improve handwash
compliance rates. The compliance monitoring system, currently being trialed in
the United Kingdom, uses thermal sensors to detect movement of people, around
the clock and without invading their privacy, and determines an accurate count
of handwash opportunities. It then compares those opportunities with handwash
occurrences. Use of sanitizing gel hand-rub or soap dispensers also is
monitored. Combined with communication and reporting systems, the resulting
solution is expected to be an affordable, non-intrusive technology that could
cut infection rates.
UltraClenz (Jupiter, FL) Patient Safeguard System
offers a real-time monitoring system. Here’s how it works. The system is
comprised of a badge, a dispenser beacon, and a wireless communication system.
The badge communicates with the dispenser beacon, and the information is sent to
the Bentley Wireless Communication System. Notification of the caregiver’s
hand-hygiene status is communicated to the floor supervisor on a computer or
tablet device. The badge displays whether the caregiver is compliant (green
light), needs to be aware that a situation requires compliance (yellow light),
or whether the caregiver is noncompliant (red light). The caregiver’s badge
displays a green light when he or she sanitizes or washes his or her hands. The
yellow light comes on, as a reminder, when the caregiver approaches a patient’s
bed. If the caregiver does not clean his or hands at appropriate times, a red
light flashes on the badge and a repetitive, audible alert is sounded. For more
detailed information on the UltraClenz Patient Safeguard System, go to
http://www.ultraclenz.com.
Complex yet simple
While the topic of hand hygiene in healthcare is
definitely not child’s play, it is so simple a concept that even children can
convey this important message effectively. During their recent annual meeting,
APIC awarded first place in their second annual Film Festival to the video
"Scrub-a-Dub Dub," performed by rapping 10-year-old twin brothers Jerry and
Josie Herman. Jerry spent several months as an intensive-care patient at All
Children’s Hospital in St. Petersburg, FL, the source of the video. The video
reinforces proper hand-hygiene technique for healthcare professionals and
encourages patients and families to be involved in this important
infection-prevention strategy. The video’s chorus says, "We don’t care if you’re
a doctor, a parent, or nurse; if you’ve got patient contact, you wash your hands
first!" The video concludes with step-by-step instructions in best practices for
handwashing. To see the video, go to
http://www.youtube.com/watch?v=ItPrIK5eh-Q&feature=youtu.be.
References
1. Graf K, Chaberny IF, Vonberg R-P. Beliefs about
hand hygiene: a survey in medical students in their first clinical year. Am J
Infect Control 2011;39(10):885-888.
2. Northey CB, Improving hand hygiene practice
through utilization of automated hand hygiene monitoring and feedback
technology. Poster presented at the Annual Association of Professionals in
Infection Control and Epidemiology Educational Conference and International
Meeting; June 2012; San Antonio, TX.
3. 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].
4. Olson LK, Morse DJ, Duley C, Savell BK.
Prospective, randomized in vivo comparison of a dual-active waterless
antiseptic versus two alcohol-only waterless antiseptics for surgical hand
antisepsis. Am J Infect Control 2012;40(2):155-159.
5. Steed C, Kelly JW, Blackhurst D, Boeker S,
Diller T, Alper P, et al. Hospital hand hygiene opportunities: where and when
(HOW2)? The HOW2 Benchmark Study. Am J Infect Control 2011;39(1):19-26.
6. Cummings KL, Anderson DJ, Kaye KS. Hand hygiene noncompliance and the cost
of hospital-acquired methicillin-resistant Staphylococcus aureus
infection. Infect Control Hosp Epidemiol. 2010;31(4):357-364.
