Is more better?

by Lorri Downs, RN, BSN, MS, CIC

As healthcare providers work to eliminate hospital-acquired infection, hand hygiene has become a focus of that effort. It is simplicity itself; no less groundbreaking than when Pasteur interrupted the assembly at the Académie Royale de Médecine to plead his case for clean hands. Yet today, hospital-acquired infections occur in upwards of 15 percent of admitted patients. The questions are, naturally, “Why do new infections continue to happen in acute care settings?” and “How can they be stopped?”

Protocol, Product and Practice

If the goal of a hand hygiene program is reducing transmission of disease, then the ultimate measurement of any such program is the observed infection rate at that facility. Every hospital-acquired infection is not the result of a dirty hand, but we do know that the preponderance of HAIs are related to suspect hand hygiene technique, thanks to modern epidemiologists standing on the shoulders of Semmelweis, Lister and Pasteur. And in response, infection prevention and hand hygiene have become inexorably linked.

Hand hygiene programs have three common, interdependent elements:

• Protocol involves the when, why, and where hand hygiene activities must be performed.
• Product is about the antiseptic agents and supplies used for hand antisepsis, including the “how” of their appropriate use.
• Practice brings the “who” into the picture through organization-wide training and individual action, as measured by the compliance rate of care giving individuals in the facility.

Of these three elements, protocols are the most stable and agreed upon. They may vary in minor ways, but there is universal understanding (supported by both professional and regulatory organizations) that before and after patient contact, after toileting, before eating, after extensive public contact and after “catching” a sneeze or cough are minimally acceptable times for performing hand hygiene. In the United States alone, following existing hand washing protocols could prevent as many as 20,000 deaths each year.

Practice is the most troubling element of a hand hygiene program because results are so disappointing. According to Dr. Didier Pittet, director of infection control programs at the University of Geneva Hospitals, it is not uncommon to encounter hand hygiene compliance as low as 20 percent in individual wards and units, barely half the still-disappointing 40 percent compliance cited by the WHO globally. The CDC and Joint Commission Center for Transforming Healthcare have reported similar statistics. There have also been many works identifying barriers or impediments to compliance along with recommendations for improvement. These have been both structural, such as ensuring sufficient sinks and sanitizing stations at points-of-need and behavioral, such as changing cultural norms with “no one excused” levels of scrutiny and expectation.

Product is arguably the least discussed element of a comprehensive hand hygiene plan, yet is probably the element with the most variation in approach and least agreement on what is best. Cleansers and soaps may contain antimicrobial ingredients such as triclosan or CHG (chlorhexidine gluconate), but may have none at all. Waterless hand sanitizers generally contain a form of alcohol—isopropyl or ethyl—but concentrations vary widely as do product forms; gels, liquids, sprays and foams.

Adding to the confusion of what the right sanitizer formulation may be is the fact that standards vary significantly. European and North American (ASTM) standards do not specify product alcohol concentrations, but rather demonstrated efficacy in immediate microbial kill and persistence. European standards are more stringent than the North American ones. And while the WHO Guidelines for Hand Hygiene in Healthcare specifies a concentration of at least 80 percent ethyl alcohol or 75 percent isopropanol to ensure efficacy, today, with a few notable exceptions, products in the United States do not meet this standard.

Dr. Pittet, a key contributing author to both the 2002 CDC and 2009 WHO guidelines, touched on the issue during a recent Prevention Above All forum presentation in Washington, D.C. noting that “some products in the U.S. with alcohol volumes as low as 60-62 percent may pass the ASTM standards, though such a low ethanol concentration would never pass the European efficacy norms.”

The varying standards raise a series of questions. Why is Europe holding themselves to a higher standard of care? What do they know that we, in America, have yet to recognize? Might the evidence suggest we ask ourselves if we should be using higher alcohol-concentration products with good emollient technology?

Whether the product is delivered as a foam, liquid or gel may make a difference as well, according to Dr. Günter Kampf, a member of the German Association for Infection Control. “Foams that I have seen contain around 60-62 percent ethanol. If you have a 30 second time for the hands to be covered by the foam, you need a rather small amount, which is 1.6 grams. You have two problems to face. One is the concentration of ethanol is too low, and the other is that the total amount of foam which is applied is in addition too low.”

In effect, using current foams in a practical way (30 seconds) will not yield bactericidal results consistent with the FDA’s Tentative Final Monograph for Healthcare Antiseptics requirements and using an application volume of current foams to meet those requirements results in an impractical amount of time spent performing hand hygiene.

Another point of debate is whether ingredients beyond alcohol are necessary for persistence in a surgical hand antisepsis preparation. CHG (chlorhexidine gluconate) is the most frequently added ingredient in these products. “When you look at the WHO guidelines for hand hygiene, [60 percent] concentrations are too low for use in hospitals,” said Dr. Kampf. This may be why, in the United States in particular, some surgical scrub products include. When looking at a WHO/European standard alcohol product, though, he concluded “the data I have seen is not convincing in terms of an additional benefit when you have chlorhexidine in addition to ethanol in the formulation.” Many products meet surgical antisepsis guidelines without skin irritating agents like CHG, and those options should be seriously considered as an alternative to CHG containing options.

What, then, about soap and water? “In the ICU, nurses had at least 20 opportunities to clean their hands for every hour of patient care. It will take you almost half an hour every hour to clean your hands,” stated Dr. Pittet. Alcohol-based hand rubs solve the time constraint on sanitizing hands at clinically appropriate times. As alcohol removes less of the lipids that keep moisture in skin, it is actually less drying than soaps. “It’s a lot better for your hands.”

So, what does this mean to the person in the U.S. market choosing a sanitizer? “When you choose a product,” explained Dr. Pittet, “you are better off to choose a product with a higher content in alcohol. It will be much more effective on some microorganisms that require a higher content in alcohol like some viruses.”

Hand sanitizing products are only one part—an important part—of the picture when it comes to organization-wide efforts to control infection. Hand hygiene is one of the easiest factors to control; it only makes good sense to equip yourself with the best possible products. Likewise, you should work to ensure your protocols and practices are implemented, monitored and targeted toward excellence. Without all three—product, protocol and practice—in place, you’re just hoping for success.

Lorri Downs, RN, BSN, MS, CIC is a board certified infection preventionist and vice president of Infection Prevention at Medline Industries Inc. Ms. Downs possesses a diverse portfolio of more than 25 years in the nursing profession. Her expertise has focused on infection prevention surveillance at large acute care organizations, plus ambulatory and public health settings. Ms. Downs has crafted hospital infection control programs, local emergency preparedness plans as well as lectured on various infection prevention topics.