Alcohol Sanitizers Get Boost from Recommendations
Edition: July 2002 - Vol 10 Number 07
Manufacturers of handwashing products, including soap and alcohol-based sanitizers, are awaiting philosophically the release of new government handwashing guidelines. Those to whom Repertoire spoke say they hope that the guidelines which endorse alcohol-based sanitizers as a useful adjunct to soap and water will encourage caregivers to wash their hands more frequently, regardless of what kind of products they use. If that's the case, not only will caregivers and their patients benefit, but so will manufacturers of both soap and alcohol-based products, they say.
The proposed guidelines were prepared by the Centers for Disease Control and Prevention (CDC), with assistance from the Society for Healthcare Epidemiology of America, the Infectious Diseases Society of America and the Association for Professionals in Infection Control and Epidemiology. The public comment period on the proposed guidelines expired Dec. 24. Final regulations will be released after all the comments are reviewed.
At the heart of the proposed guidelines are these two recommendations:
1. Caregivers should wash hands with a non-antimicrobial soap and water or an antimicrobial soap and water when hands are visibly dirty or contaminated with proteinaceous material, such as blood or feces.
2. If hands are not visibly soiled, caregivers should use an alcohol-based waterless antiseptic agent for routinely decontaminating hands.
Alcohol-based handrubs have been around for years, points out Pat Groziak, director of market development for acute care, Gojo Industries, Akron, OH. In fact, alcohol is recognized as a highly effective antimicrobial.
But until recently, soap has been considered the gold standard for handwashing. In 1975 and 1985, CDC guidelines on handwashing practices in hospitals recommended handwashing with non-antimicrobial soap between most patient contacts and washing with antimicrobial soap before and after performing invasive procedures or caring for high-risk patients. Use of waterless antiseptic agents such as alcohol-based solutions was recommended only in situations where sinks were not available, according to the CDC.
Then, in 1988 and 1995, APIC published guidelines for handwashing and hand antisepsis. Though similar to the CDC guidelines, the 1995 APIC document included more detailed discussion of alcohol-based, waterless antiseptic agents, and supported their use in more clinical settings. In 1995 and 1996, CDC recommended that either antimicrobial soap or a waterless antiseptic agent be used for cleaning hands upon leaving the rooms of patients with multidrug-resistant pathogens such as vancomycin-resistant enterococci and methicillin-resistant Staphylococcus aureus.
The fact is, soap has fallen on hard times. Today, despite their knowledge of the importance of infection control, caregivers fail to wash their hands as frequently as current guidelines recommend they do. Why? According to the CDC, surveys show that about 25 percent of nurses have reported symptoms or signs of dermatitis involving their hands, and as many as 85 percent give a history of having skin problems. Frequent and repeated use of hand hygiene products, particularly soaps and other detergents, is an important cause of chronic irritant contact dermatitis among health personnel.
What's more, although many hospitals have provided personnel with mild, non-antimicrobial soaps in hopes of minimizing dermatitis, frequent use of such products can cause greater skin damage, dryness and irritation than some antiseptic preparations, says the CDC.
Even surgical scrubbing has come under scrutiny. Brushing can shed skin and hence spread organisms from healthcare worker to patient. For that reason, the new recommended guidelines call for healthcare providers to use either an alcohol-based handrub or an antimicrobial soap before donning sterile gloves for surgical procedures. They also recommend that to reduce the number of bacteria that may be released from the hands of surgical personnel, while minimizing skin damage related to surgical hand antisepsis, decontaminate hands without using a brush.
Soap has a couple of other strikes against it. First, healthcare workers resist taking the time to spot the nearest sink, soap up, rinse and then dry their hands before or after coming into contact with patients. Alcohol-based rubs, on the other hand, require no sink or plumbing, and dispensers can be set up next to patient beds or exam tables.
Second, soap can irritate the skin, undermining efforts to get health care workers to wash regularly. Waterless antiseptic agents, on the other hand, contain emollients that are tolerated better by healthcare personnel than non-antimicrobial or antimicrobial soaps, according to the CDC.
A Handwashing Frame of Mind
[The recommendations] won't displace handwashing, but will lead to better hand hygiene compliance for end users, says Groziak, whose company Gojo makes a variety of sanitizers and dispensing systems. Now, the hand sanitizers and handwashing products will sit side
by side. Up until now, hand sanitizers have been locked in the basement.
The goal of the guidelines is to improve [hand hygiene] compliance, says Joann Reilly, director of marketing for Orangeburg, NY-based PDIProfessional Disposables International, which makes alcohol-based wipes. If this is achieved, they will assist epidemiologists in reducing the spread of nosocomial infections.
We fully support the new guidelines and what they are trying to accomplish, she continues. We feel that clean, sanitized hands are one of the most important ways to avoid spreading infection from patient to patient. What's more, she says, We feel we have one of the best methods of helping healthcare workers comply with the guidelines.
John Russell, director of healthcare sales for Dial Corp., echoes Reilly's comments. These recommendations do not tell you not to wash your hands, he says. Hand sanitizers are an adjunct to handwashing. We believe that hand sanitizers will add to the market, not take it away. That would be good news for Scottsdale, AZ-based Dial, which makes a variety of soaps as well as alcohol-based sanitizing products. In fact, at the most recent convention of the Association for Professionals in Infection Control and Epidemiology, the company introduced Dial Complete, an antimicrobial soap that is delivered as a foam via a dispenser.
The bottom line is that hand sanitizers will drive people to be more compliant [with hand hygiene recommendations], says Russell. The regulations will drive usage of soap as well as [alcohol-based sanitizers], because people will be in the handwashing mode.
Hand Hygiene Key Recommendations
Following are some key recommendations from the CDC's ''Draft Guidelines for Hand Hygiene in Healthcare Settings.'' The public comment period on the proposed guidelines expired Dec. 24. Final regulations will be released after all the comments are reviewed. Each recommendation is categorized on the basis of existing scientific data, theoretical rationale, applicability, and economic impact. The CDC system for categorizing recommendations is as follows:
Category IA. Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.
Category IB. Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale.
Category IC. Required for implementation, as mandated by federal and/or state regulation or standard.
Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale.
Indications for Handwashing and Hand Antisepsis
A. Wash hands with a non-antimicrobial soap and water or an antimicrobial soap and water when hands are visibly dirty or contaminated with proteinaceous material. (IA)
B. If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands in all other clinical situations described in items I.C. through I.K. (See Page 18). (IA)
C. On nursing units where an alcohol-based waterless antiseptic agent is available, provide personnel with a non-antimicrobial soap for use when hands are visibly dirty or contaminated with proteinaceous material. It is not necessary, and may be confusing to personnel, to have both an alcohol-based waterless antiseptic agent and an antimicrobial soap available on the same nursing unit. (II)
D. Although waterless antiseptic agents are highly preferable, hand antisepsis using an antimicrobial soap may be considered in settings where time constraints are not an issue and easy access to hand hygiene facilities can be ensured, or in rare instances when a care giver is intolerant of the waterless antiseptic product used in the institution. (IB)
E. Decontaminate hands after contact with a patient's intact skin (as in taking a pulse or blood pressure, or lifting a patient). (IB)
F. Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings, as long as hands are not visibly soiled. (IA)
G. Decontaminate hands if moving from a contaminated body site to a clean body site during patient care. (II)
H. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. (II)
I. Decontaminate hands before caring for patients with severe neutropenia or other forms of severe immune suppression. (II)
J. Decontaminate hands before donning sterile gloves when inserting a central intravascular catheter. (IB)
K. Decontaminate hands before inserting indwelling urinary catheters or other invasive devices that do not require a surgical procedure. (IB)
L. Decontaminate hands after removing gloves. (IB)
M. To improve hand hygiene adherence among personnel in units or instances where high workloads and high intensity of patient care are anticipated, make an alcohol-based waterless antiseptic agent available at the entrance to the patient's room or at the bedside, in other convenient locations, and in individual pocket-sized containers to be carried by healthcare workers. (IA)
Selection of Hand Hygiene Agents
A. Provide personnel with efficacious hand hygiene products that have low irritancy potential, particularly when used multiple times per shift. (IB)
B. To maximize acceptance of hand hygiene products by health personnel, solicit input from caregivers regarding the feel, fragrance, and skin tolerance of any products under consideration. The cost of hand hygiene products should not be the primary factor influencing product selection. (IB)
C. Prior to making purchasing decisions, evaluate the dispenser systems of various product manufacturers or distributors to ensure that dispensers function adequately and deliver an appropriate volume of product. (II)
D. Do not add soap to a partially empty soap dispenser. This practice of ''topping off'' dispensers may lead to bacterial contamination of soap. (IA)