CDC Guidelines Encourage Healthcare to Clean Up
Edition: December 2002 - Vol 10 Number 12
Handwashing with soap and water has been accepted through the ages as a standard of good hygiene. But new guidelines from the Centers for Disease control and Prevention (CDC) recommend the use of alcohol-based hand rubs in addition to traditional handwashing. The guidelines were prepared by the Hand Hygiene Task Force – a group comprised of members from the Healthcare Infection Control Practices Advisory Committee (HICPAC), the Society for Healthcare Epidemiology of America (SHEA), the Association for Professionals in Infection Control (APIC), and the Infections Diseases Society of America (IDSA).
The guidelines reinforce many current practices and propose some new ones. Highlights include:
· Soap and water should be used when healthcare personnel’s hands are visibly soiled.
· The use of gloves does not eliminate the need for hand hygiene. Gloves reduce contamination by 70 percent to 80 percent. Handrubs should be used – and gloves should be changed – before and after patient contact.
· Alcohol rubs should be applied to the total surface of hands and fingers until the hands are dry.
· Alcohol-based handrubs significantly reduce the number of microorganisms on the skin, are fast acting and cause less skin irritation than soap and water.
· Healthcare personnel should avoid wearing artificial nails or natural nails longer than one-quarter inch.
· When considering hand hygiene products for use in healthcare facilities, administrators should keep in mind the efficacy of antiseptic agents against different pathogens, as well as the acceptability of products by personnel. Smell, consistency, color and the effect of dryness on hands are factors that influence how personnel take to an alcohol rub.
· Allergic contact dermatitis caused by alcohol hand rubs is very common, although increased use of these products may lead to occasional reactions.
· Alcohol-based handrubs take less time to use than soap and water.
The CDC recommendations encourage healthcare facilities to develop and implement programs for gauging improvements in adherence to hand hygiene. This may be accomplished through:
· Monitoring hand hygiene adherence.
· Providing healthcare personnel with feedback on its performance.
· Monitoring the volume of alcohol-based handrub used.
· Monitoring adherence to artificial nail policies.
· Assessing the adequacy of hand hygiene adherence when outbreaks of infection occur.
The guidelines offer a comprehensive review of the basic principles of handwashing, including the different products and techniques used to promote hand hygiene.
Soaps – ranging from bar soap to tissue, leaflet and liquid preparations – are detergent-based products containing esterfied fatty acids and sodium or potassium hydroxide. Non-antimicrobial or plain soaps can be beneficial in removing loosely adherent transient flora, according to the guidelines. Handwashing with plain soap and water for 15 seconds is said to remove bacterial counts on the skin by 0.6 to 1.1 log(10). Washing for 30 seconds reduces bacterial counts by 1.8 to 2.8 log(10). Because plain soap has been shown to fail to remove pathogens from the hands, however, using it can lead to an increase in bacterial count. As noted in the guidelines, plain soap on occasion has become contaminated, possibly causing the colonization of hands of workers with gram-negative bacilli.
Most alcohol-based hand antiseptics contain isopropanol, ethanol, n-propanol, or a combination of these products, according to the CDC. Alcohol solutions containing 60 percent to 90 percent alcohol are most effective. Higher concentrations are not as powerful, since proteins are not as easily denatured in the absence of water. The CDC offers the following guidelines to consider when using alcohol-based antiseptics:
· Alcohols have excellent in vitro germicidal activity against gram-positive and gram-negative vegetative bacteria, including multidrug-resistant pathogens.
· Studies show that alcohols effectively reduce bacterial counts on hands.
· Alcohols, when used in concentrations present in alcohol-based handrubs, have in vivo activity against several undeveloped viruses.
· Alcohols are not appropriate for use when hands are visibly dirty or contaminated with proteinaceous material. But, when small amounts of proteinaceous material, such as blood, are present, ethanol and isopropanol may reduce viable bacterial counts on hands more than plain soap or antimicrobial soaps.
· Alcohol can prevent the transfer of healthcare-associated pathogens.
· Alcohol-based products are more effective for standard handwashing or hand antisepsis by healthcare workers than plain or antimicrobial soaps.
· Alcohols are effective for preoperative hand cleaning of surgical personnel.
· The efficacy of alcohol-based hand hygiene products is affected by the type of alcohol used, the concentration of alcohol, contact time, the volume of alcohol used, and whether the hands are wet when the alcohol is applied.
· Alcohol-based handrubs intended for hospital use are available as low-viscosity rinses, gels and foams.
· Frequent use of alcohol-based formulations for hand antisepsis can cause skin to dry unless emollients, humectants, or other skin-conditioning agents are added to the formulations. The drying effect can be reduced or eliminated by adding one percent to three percent glycerol or other skin-conditioning agents.
· Even well-tolerated alcohol handrubs made with emollients can cause a transient stinging sensation at the site of broken skin.
Healthcare personnel must keep in mind that alcohol is flammable. Because it is volatile, the CDC advises storing it in containers that minimize evaporation.
Selecting Hand Hygiene Products
Administrators or product-selection committees must consider factors affecting the efficacy of hand hygiene products, including the effectiveness of antiseptic agents against different pathogens, according to the CDC. If healthcare workers are adverse to a product because of its smell, consistency or color, that too should factor into purchasing decisions.
Studies suggest that the frequency of handwashing or antiseptic handwashing in healthcare settings is influenced by accessibility to hand hygiene facilities, notes the CDC. When too few sinks are available, or sinks are inconveniently located, practitioners are less likely to take advantage of them.
In contrast, dispensers for alcohol-based handrubs do not require plumbing and can be placed next to each patient’s bed and throughout the building. The CDC recommends against placing alcohol handrub dispensers next to sinks, as this may confuse healthcare personnel. Personnel should be informed that it is unnecessary to wash hands with soap and water after each use of an alcohol rub. In fact, this can lead to dermatitis. Rather, healthcare workers should wash their hands after five to 10 applications with an alcohol handrub, since repeated uses can leave them with a feeling of “build-up” of emollients on their hands.
The efficiency of the dispensers that hold the handrub also can affect adherence to hand hygiene. Dispensers that become blocked too easily or do not appropriately deliver the alcohol rub onto the hands may discourage personnel from using them.
When healthcare personnel are unaware of hand hygiene guidelines, do not recognize opportunities for hand hygiene during patient care, or are unaware of the risk of cross-transmission of pathogens, hand hygiene practices break down. Healthcare practitioners must be better informed in order to achieve improvements in hand hygiene practices.