Critical evaluation of a research paper ‘Efficacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinic
IntroductionThe objective of the study was to compare the efficacy of hand rubbing with an alcohol-based solution versus conventional hand washing with antiseptic soap in reducing hand contamination during routine patient care. It was designed as a randomised controlled trial during daily nursing sessions of 2-3 hours. The study concluded that hand rubbing with an alcohol-based solution is more efficient in reducing hand contamination than hand washing with antiseptic soap.
Unique features of the study and advantages over other studies
- Sampling methods: Imprints were taken from the dominant hand fingertips and palm, one minute before and after the procedure. If the participant wore gloves during the procedure, it was removed before sampling was carried out. Each fingertip and the palm were pressed on contact agar plates containing neutralisers. The hands were sampled during routine patient care. 75% alcohol was used.
- The study design was planned in such a way that it did not interfere with regular patient care activities.
In another study by Larson et al, the product tested contained less alcohol (61%) and contained another antiseptic compound. In addition, it was not clear whether the hands were sampled during patient care activities. The sampling method used was the glove juice technique, which is difficult to perform during routine patient care activities.
Limitations of the study
- Although the glove juice technique is difficult to perform during routine care activities, it may be more effective in recovering the whole bacterial burden on hands. Therefore, this study may have underestimated the degree of hand contamination.
In routine hospital practice, compliance with hand rubbing with an alcohol-based solution is still very low. Some attempts like increasing the number of accessible sinks and educating healthcare workers have been made to improve compliance. Still, none of these interventions led to any significant improvement in compliance. After following the routine practice for many years, enforcement of an alcohol-based solution as a substitute continues to be a real challenge for infection control teams.
Some of the reasons attributed by health-care workers for not adhering with recommendations include, “skin irritation, inaccessible supplies, interference with worker-patient relation, patient needs perceived as priority, wearing gloves, forgetfulness, ignorance of guidelines, insufficient time, high workload and understaffing, and lack of any scientific information demonstrating the impact of improved hand hygiene on hospital infection rates.” (Didier Pittet)
Some reasons may be related to the institution i.e., lack of institutional priority for hand hygiene, and lack of an institutional attitude that encourages safety. In addition to the reasons mentioned above, the most frequently reported reasons are “inconveniently located or insufficient numbers of sinks, low risk for acquiring infection from patients belief that the use of gloves obviates need for hand hygiene and ignorance of or disagreement with guidelines and protocols.”(Didier Pittet)
Alcohol-based solutions in clinical practice
The rapid efficacy of alcohol-based solutions and their availability at the bedside make these solutions an ideal substitute for conventional hand washing and should help in achieving increased compliance with hand hygiene during patient care. Improving hand hygiene compliance can reduce the rates of nosocomial infection and development of multi-resistant bacteria.
The role of infection control department
Specific information on correct cleaning processes and the appropriate products to use for each hospital or clinic area is usually provided by the infection control department. Hand hygiene is the single most effective means of preventing the spread of nosocomial infections among hospital patients and personnel. (Kelly Patterson.)
Advantages of alcohol-based hand rubs.
- It is waterless, therefore there is no need for a sink or paper towels.
- The action of an alcohol-based hand rub is twice as fast compared to traditional hand washing.
- They are gentler on hands than soap and water.
However, they are highly flammable and the greaest challenge is to find an appropriate place for the dispensers. It is best to put them near the door. (Kelly Patterson.)
Strategies for successful promotion of hand hygiene in hospitals
Some of the important strategies are: staff education and motivation, routine observation and feedback, making alcohol-based hand rub readily available, patient education, reminders in the workplace, administrative sanctions and rewards, promoting and facilitating skin care for health care workers, obtaining active participation at individual and institutional level, avoiding overcrowding, understaffing and excessive workload, ensuring institutional safety climate, enhancing individual and institutional self-efficacy. (Didier Pittet)
Evaluating the efficacy of hand wash
Hand washes are evaluated by using a standardised method (Food and Drug Administration). 5 ml of a standardized suspension of Serratia marcescens are applied to the hands and then rubbed over the surfaces of the hands before baseline bacterial sampling and before each wash with the test material. A specified volume of the test material is dispensed into the hands and is spread over the hands and lower one-third of the forearms. Hands are completely lathered after adding tap water for a specified time, covering all hand surfaces and the lower third of the forearms. Then the hands and forearms are rinsed for 30 seconds in tap water at a temperature of 40ºC. Ten washes with the test formulation are required. After the first, third, seventh, and tenth washes, rubber gloves or polyethylene bags used for sampling are placed on the right and left hands and 75 ml of sampling solution is added to each glove. The gloves are then secured above the wrist. A one-minute massage of all surfaces of the hand is done. Samples are obtained aseptically for quantitative culture. No neutralizer of the antimicrobial is added to the sampling solution, but if dilution of the antimicrobial in the sampling fluid does not result in demonstrable neutralization, a neutralizer specific for the test formulation is added to the sampling solution. TFM criteria for efficacy are as follows: a 2-log10 reduction of the indicator organism on each hand within 5 minutes after the first use, and a 3-log10 reduction of the indicator organism on each hand within 5 minutes after the tenth use.
New method for determination of efficacy of hand wash products.
A mixture of E coli and S marcescens is inoculated in the fingernail areas of the hands of volunteers and the areas are dried for a standard time. After routine hand washing, each fingernail region is individually scrubbed with an electric toothbrush into the collection fluid in a petri dish. The test bacteria in the fluid are then evaluated. This method has several advantages over the frequently used glove juice technique (Mahl MC)
- Large numbers of volunteers, multiple sampling sites and many hand wash products may be performed.
- Ten sampling sites (fingers) are available, versus the two-gloved hands. 3. Efficiency is almost 3. 100% in the recovery of spore tracers placed on the fingernails.
Conclusion: It is clear that alcohol-based solutions may be more beneficial in reducing hand contamination when compared to routine methods. However, the compliance rate among health care workers is still low. Strategies for successful implementation have to be seriously pursued in institutions by the various methods outlined. The efficacy of the new method should also be routinely monitored.
Didier Pittet, 2001. Improving Adherence to Hand Hygiene Practice: A Multidisciplinary Approach. October 20, 2005.
Food and Drug Administration. Tentative final monograph for healthcare antiseptic drug products; proposed rule. Federal Register 1994;59:31441-52.
Kelly Patterson, 2003. Infection control in medical facilities: a microcosm of the unprecedented health and safety demands on today’s housekeepers. October 20, 2005.
Mahl MC, 1989. New method for determination of efficacy of health care personnel hand wash products. J Clin Microbiol. 1989 October; 27(10): 2295–2299.