Is Hand washing more effective in Infection Reduction versus Gel Hand Sanitizers?
Is Hand washing more effective in Infection Reduction versus Gel Hand Sanitizers?
Introduction
Today, the burden of health care-associated infections (HCAIs) are drawing attention not only from governments and health care regulatory bodies but also from patients and more so from health care practitioners (HCPs) themselves. This phenomenon is not merely because of the magnitude of the problem regarding the associated incidences of mortality, cost, and complexity of treatment, and morbidity, but also due to the growing recognition and understanding that, most of these complications are preventable. The medical fraternity is thus witnessing in tandem unprecedented improvements in the spread of multi-drug resistant (MDR) pathogen infections as well as the pathophysiology of infectious diseases in healthcare set-ups (Babeluk, Jutz, Mertlitz, Matiasek, & Klaus, 2014). Compounded and driven by the increasing paucity of the availability of new antimicrobials, these factors have necessitated the need for a re-look into the basics of infection prevention and control in the contemporary health care system. Now, there is numerous, and undisputed scientific-based evidence such as Huis et al. (2012) and Wallis (2012) that have established that adherence to hand hygiene (HH) reduces the risk of cross-transmission of infections. With ‘Clean Care is Safer Care’ as one of the principal agendas of the global health care initiative of the World Health Organization (WHO) on patient care safety programs, HH is now regarded as the most fundamental and crucial element of infectious disease control (Nair, Hanumantappa, Hiremath, Siraj, & Raghunath, 2014). Because enough scientific literature supports the observation that HH can significantly reduce and prevent the risk of cross-transmission if properly implemented, this review looks at five of such pieces of evidence akin to answering the questions on which between hand washing and gel hand sanitizers is effective in infection reduction.
Background
Since the early parts of the 19th-century infection prevention and control, experts have recognized HH as one single most important intervention in decreasing the spread and contamination of infections in both community and healthcare settings. The first suggestion that hand decontamination can reduce the risk of infection occurred in the 1840s when Semmelweis established that HH could lessen the incidence of puerperal fever, which was one of the leading causes of maternal mortality at the time (Babeluk et al., 2014). Another landmark study happened in the wake of Staphylococcal epidemics of the 1950s. During this period Mortimer et al. established that direct contact was the primary mode of S. aureus transmission in nurseries and that HCPs hand washing after contact with patients reduced the level of disease acquisition by newborns (Huis et al., 2012). In cognizant of the fact that hands are vectors for the transmission of infectious pathogens between people and contact with inanimate objects in health care settings such as environmental surfaces (like blood pressure cuffs), the Center for Disease Control and Prevention (CDC) has been publishing guidelines on hand washing practices in health care settings since 1975.
Predominantly advocating hand washing with the traditional non-antibacterial soaps and water, both the CDC and World Health Organization (WHO) maintain guidelines to inform HCPs about the proper health care practices of HH. Other than soap and water, alcohol-based hand rubs - though debate continues to rage between which of the two is the most effective - are also widely used. According to Babeluk et al., (2014), while hand washing with soap and water was recommended for HCPs either before or after performing invasive procedures or during the care of high-risk patients, alcohol-based solutions were recommended only in settings where sinks were unavailable. Additionally, patient quality and safety organizations such as HICPAC (Hospital Infection Control Practices Advisory Committee) advocate for the use of antimicrobial soap and water or waterless antiseptic hand gel agents for cleaning hands upon leaving or being in contact with patients infected with MDR pathogens (Wallis, 2012). In its 2002 guidelines for HH, CDC further recommends the use of liquid soap and water for cleaning visibly soiled and contaminated hands. Together with other scientific studies (see Table 1), CDC further recommends the use of alcohol-based hand gels for the decontamination of hands between non-soiling types.
Modified from University of Wisconsin-Madison Ebling Library (2016)
While HH is a critical exercise in reducing the risk of morbidity, mortality, and costs associated with the treatment of HCIAs across the entire health care profile, a systematic review of hand washing finds that sanitizing and hand-washing compliance are also weighty in decreasing and preventing the risk of HCAIs among the hemodialysis settings. As such, the current CDC and the general nursing practice and policy require hand sanitizing or washing with a gel sanitizer containing 70% alcohol/alcohol antiseptics. Staffs have an obligation to cleanse hands between patients, before and after eating, before and after using the bathroom, and before and after patient care. Even though there is no guideline on the number of times HCPs are required to cleanse, soap and water hand washing is only required when there is contact with bodily fluids or visibly soiled hands. However, such guideline can be vulnerable to laxity, and therefore the current practice needs to be revised or changed because given the option (as it currently is), many staff members have admittedly gone for hours into a shift without conducting a gel hand sanitizer or soap and water hand washes. This practice thus increases the risk of infection in the hemodialysis health care settings, which is the primary complication among dialysis patients.
Regarding the main players in the sector, the key stakeholders within the outpatient dialysis clinic are the staff and charge nurses, dialysis technicians, dieticians, and social workers. These officers encounter patients in each treatment (three times a week) for several hours in each encounter (3-4 hours per treatment). Concerning individual roles, dialysis technicians set up dialyzer machines and handle blood tubing and process dialyzers. While providing care for hemodialysis, technicians compromise the patient’s first line of defense. The nurses do this when they break through the skin while cannulating the patients’ access. The role of charge nurses is to complete the assessment of patients and assure that patients are stable to provide safe dialysis treatment. Nurses also collect and interpret laboratory draws, administer medication, as well as supervise the technicians. On the other hand, dieticians and social workers undertake frequent weekly contact with patients to evaluate their nutritional and coping status. Even though this group of staffs has less direct contact transmission risk with patients, they are still required to use gel sanitizer pre and post meeting with patients.
Because nurses constitute the largest percentage of HCW (health care workers) and are the ‘nucleus of our contemporary health care system,' several studies recognize that hand decontamination and sanitization is more vital in preventing the spread of disease among patients. One such study is the 2005 Larson et al. analysis that pit the effect of antiseptic handwashing against alcohol sanitizer on HCAIs in neonatal intensive care units. Working on the CDC recommendation on the use of waterless alcohol hand products instead of the traditional soap and water hand washing, the authors compared the effect of two HH regiments: an alcohol hand sanitizer and a conventional antiseptic hand wash in neonatal intensive care. The study design comprised of a clinical trial using a crossover strategy in two intensive care units (ICUs) in Manhattan in a random order for the period March 1, 2001, to January 31, 2003 (Larson et al., 2005). The study participants included 2,932 neonatal hospital admissions (52,760 in-hospital patient days) and 119 nurses. In random order, each of the two HH regiments was used for 11 consecutive months in each of the ICU settings.
After adjusting for the various study variables – follow-up times, study site, surgery, and birth weight – Larson et al. (2015) found no significant efficacy differences between the two hand decontamination products nor neonatal infections between the products. Compared to hand washing, Larson et al. (2015) found the odd ratios for alcohol for the tested diseases as 0.98 (95% confidence interval [CI]) and 0.99% (95% CI, 0.77-1.33) for bloodstream infection (Larson et al., 2005). For pneumonia and soft tissue infections, the authors established an odd ratio of 1.61 (95% CI, 0.57-5.54) and 1.78 (95% CI, 0.94-3.37). For central nervous system (CNS) infections (CI, 0.42-3.76) the study found a 1.26 (95%) odd ratio (Larson et al., 2005). Moreover, the study established that while the skin condition for the participating nurses significantly improved during the alcohol phase (P=.02 for observer and P=.049 for self-assessments), there were no significant differences recorded in the mean microbial counts on the nurses’ hands. Larson et al. (2015) found the microbial counts on the hands of nurses to be 3.21 and 3.11log colony-forming units for hand washing and alcohol, respectively (P=.38).
Even though Larson et al. (2015) found the rates of infection as well as the total microbial counts on the nurses’ hands to be equivalent during both the traditional hand washing using soap and alcohol phases, the study found an improvement in the skin conditions of the nurses in the latter. Still, the authors acknowledge the difficulty in assessing the impact on infection rates of a single intervention due to the multiple effects of various contributory factors such as staff behavior, unit design settings, and patient risk levels. Other practices such as the frequency and quality of staff HH were also identified as likely to be as significant as a product in reducing the risk of microbial cross-transmission (Larson et al., 2005).
Another study that weighed significantly on the importance of HH in the prevention of infection in health care settings was Kaya et al. (2015). Performed in Diyarbakir Training and Research Hospital in May 2013, the objective of the study was to investigate the practices as well as the knowledge levels of HCWs about HH in the selected study setting. The survey relied on the understanding that HH is a fundamental measure of the control of hospital-acquired infections (HAIs) and is motivated by the realization that continued compliance with HH in most HCWs is poor. Using the Statistical Package for Social Sciences (SPSS) 16.0 program to evaluate the study data, this investigation used a questionnaire to assess the knowledge and practices on HH of 179 HCWs (Kaya et al., 2015).
In the first part of the survey, the demographic information of the study environment was collected. Of the 179 participants, 123 (68.7%) were found to be male, and 56 (31.3%) were female. Among the participants, 127 (70.9%) were nurses, and 17 (9.5%) were specialist physicians. Moreover, 14 (7.8%), 8 (4.5%), 7 (3.9%), 3 (1.7%), 2 (1.1%) and 1 (0.6%) were health officers, paramedics, cleaning staff, emergency medical technicians, midwives, and practicing physician respectively (Kaya et al., 2015). Regarding training, 133 (74.3%) of the interviewed workers stated that they had trained on HH after graduation, out of which 131 (73.2%) emphasized the need for more education on the same. The authors further found that 14 (8%) of the participating HCWs provided HH before contacting a patient while 118 (66.5%) provided HH after contacting a patient.
Of the study participants, 113 (63.6%) mentioned that they practiced HH after contacting body fluid while 27 (15.2%) practiced HH before an aseptic procedure (Kaya et al., 2015). 65 HCWs (36.3%) further stated that they paid attention to HH after contacting the family of patients. On the other hand, 161 HCWs (89.9%) specified that they did not practice HH after taking off gloves and 134 (74.9%) did not practice before wearing one. Regarding the method used, 50 (28%) reported using normal soap and water, 82 (46%) used antiseptic soap and water, and 47 (26%) used alcohol-based antiseptic hand gel. Regardless of the method, Kaya and colleague determined that the knowledge levels of practice of the participants on HH were inadequate (Kaya et al., 2015). Of the workers who did not use hand gel antiseptics, the reasons for using soap and water instead include distrust, restricted time, the feeling of stickiness, and routine workload (Kaya et al., 2015).
Nazari, Hasani, and Khazaeinejad (2015) is another study that contributes to the literature on the importance of HH in the prevention of HAIs. This investigation examined the effect of involuntary motivational factors on HH by HCPs. Despite being both a low-cost and a convenient measure highly recommended to all HCPs in the prevention of nosocomial infections, Nazari et al. (2015) found that HCWs commonly neglect the importance of this practice in their workplace settings. This detailed, analytical investigation was conducted on randomly selected 153 HCPs to evaluate the effect of involuntary motivational factors on HH compliance by HCPs. The authors used questionnaires based on the theory of planned behavior (TPB) to collect data that was later analyzed in SPSS using descriptive and inferential statistics, Pearson’s correlation coefficient, and T-test (Nazari et al., 2015).
The results of the Nazari et al. (2015) study showed that with a mean age of 29.28±8.24 years, 125 participants (81.7%) were female while the rest were male. The self-reports disclosed that the participants washed their hands in 52.29% (SD=29.36) of cases only before contacting patients. There was also an 80.40% (SD=21.59) of hand washing cases only after contacting patients, and 55.64% (SD=29.84) cases for both before and after contact with patients (Nazari et al., 2015). While there were several correlations between the underlying factors and attitude of HCPs towards HH compliance such as behavioral, normative, subjective, and general attitudinal beliefs, the mean score obtained in the study was indicative of a positive attitude towards HH for a majority of participants. The authors found that the majority of participants accepted hand washing both before and after contact with patients as the norm in the medical practice (score: 6.12±1.20) (Nazari et al., 2015).
In the study, Nazari, Hasani, and Khazaeinejad established that HCPs tend to believe in controlling factors for standard HH (5.31±1.20). Regarding outcome, the authors observed the existence of a significant correlation between normative beliefs of participants (r=0.619) and subjective norms about HH standards (r=0.608). However, the study found that the relationship between the incentive of participants and their intention to comply with HH standards was not significant (r=0.133) (Nazari et al., 2015). According to the findings of this study, therefore, HCPs tend to have a positive attitude towards HH compliance. Nonetheless, owing to the impact of involuntary motivational factors, the drive for this behavior could significantly be jeopardized, and as such, it is necessary that medical authorities identify and implement policy and practice initiatives for such possibility of behavioral change and laxity among HCPs.
Another pertinent study is Scheithauer et al. (2012) that examined the need for improving HH compliance rates in hemodialysis settings as constituting more than just hand rubs. In the study, a prospective, three-phase, observational intervention probe was conducted on HH during hemodialysis treatments. The primary method of the survey was the compilation and implementation of the optimized HH SOPs for dialysis connections and disconnections during a two predefined intervention period. In the study, the authors identified 8,897 indications for HH (Phase I: 2376, Phase II: 3413, Phase III: 3108). They also performed a combined 4,520 indication-specific hand rubs (HRs) (Phase I: 875, Phase II: 1684, Phase III: 1961) (Scheithauer et al., 2012). In analyzing the observed HR indications during Phase 1, the authors identified a recurrent number of avoidable HR signs and preventable ‘systematic mistakes’ in the workflow such as not performing HR immediately before aseptic task or recontaminations after HR practice.
After training and subsequently implementing HH-optimized SOPs, the mean number of observed HR indications during a single phase of hemodialysis procedure declined by 29% with the authors recording significant additional reduction from both Phases I to Phase II and from Phase II to Phase III (both P < 0.001). In parallel, the study found that 107% significantly improved HH compliance following the implementation of the SOPs that saw a substantial reduction in the number of HR indications but an increase in the performed HR for each subsequent individual hemodialysis procedure (Scheithauer et al., 2012). Immediately following the implementations of the SOPs, Scheithauer et al. (2011) reported an increase in HH compliance rates and a decrease in the number of recontaminations due to non-optimized workflow. Specifically, the study reported an improvement in compliance with HH beyond connections and disconnections from 47% (460/977), 56% (770/1380), and finally to 65% (745/1144) during the three observation phases (Scheithauer et al., 2012).
Related to the above study are the 2013 Scheithauer, Eitner, Häfner, Floege, and Lemmen study that examined the sustainability of HH improvements particularly in the hemodialysis setting. This study was a follow-up observational survey to the 2011 Scheithauer et al. investigation in the same hemodialysis unit of a tertiary care Centre located at the RWTH Aachen University Hospital (Division of Nephrology) to assess the sustainability. With no HH-related interventions performed in the one year between the studies, the main outcome of this follow-up investigation was a significant HH compliance with opportunities per hemodialysis procedure (Scheithauer, Eitner, Häfner, Floege, & Lemmen, 2013).
During this follow-up observational study, Scheithauer et al. (2013) observed 1,574 HH opportunities and 871 HR. Overall, the study finds the compliance to be 55%, which was significantly lower than that at the end of the first survey (62%) but meaningfully higher than that at the start of the first study (37% and 49 %). The study further found that both the decrease in HH opportunities and the corresponding increase in HR were sustained over the course of the investigation. Thus, in the 320 (20%) opportunities, the authors examined gloves being worn instead of HR performed, representing 46% of the missed HR (Scheithauer et al., 2013).
Throughout this follow-up study (Phase IV), Scheithauer et al. (2013) identified 1,574 opportunities for all the HH cases observed, out of which 871 prompted the need for HRs thus resulting in a compliance rate of 55%. In the study, the mean number of the observed HR opportunities for one hemodialysis procedure was higher than that previously observed in Phase III of the 2011 study but remained lower than that seen in Phases I and II (Scheithauer et al., 2013). A technical analysis of the main finding of the prospective three-phase observational intervention study in the first survey was that there was a decrease of avoidable HR opportunities due to ‘Systematic mistakes’ and unnecessary re-contamination. Even though the systematic errors remained the same in the present study as at the end of the previous survey, Scheithauer et al. (2013) reported lower connections compared to Phase III, thus indicating the sustained success of the implemented HH SOPs.
The other study relevant to the study of HH in health care practice is the 2013 Figueiredo, De Siqueira, Poli-de-Figueiredo, and D'Avila investigation on a comparison of 2 techniques in peritoneal dialysis patients in reducing the number of colony-forming units (CFUs) on the hands of patients undergoing PD. In this particular study, the authors examined 22 participants in a controlled clinical trial that were subjected to a two-hand evaluation treatment for microbiologic flora. The two treatments were a simple soap and water HH and antiseptic hand hygiene, in which the participants rubbed their hands primarily with 70% ethyl alcohol gel until thoroughly dry (Figueiredo et al., 2013).
Of the 22 participants enrolled in the Figueiredo et al., (2013) study, 54.5% were men with a mean study age of 50.3 ±16 years (range: 21 – 76 years). While the study showed no differences in the growth of coagulase-negative Staphylococcus (CNS) between sexes or type of dialysis, the authors depicted a correlation of age and time on the dialysis with CNS growth. With both groups, the study found a moderate and a positive correlation with age in both groups (SHH+AHH: r = 0.365, p < 0.050; AHH: r = 0.315, p < 0.050) (Figueiredo et al., 2013). Nevertheless, the study found that the CFU count for both hands of the 22 participants was significantly higher in the regular soap and water group than in the alcohol-based gel-only group (69.0 CFU vs. 9.0 CFU, p < 0.010). Overall, among the patients undergoing PD, the study showed that using 70% ethyl alcohol gel to cleanse hands might be more effective in reducing cross-transmission of infections than following the regular hygiene recommendations in reducing microbial populations.
Therefore, based on the body of evidence, particularly in Figueiredo et al., (2013) one particular best practice in reducing health care settings is the use of alcohol gel in HH techniques. Previous studies comparing the antimicrobial efficacy of alcohol gel or liquid alcohol-based hand sanitizers with that of a non-antimicrobial soap for hand washing demonstrated that alcohol gel hand sanitizers significantly reduced (>99.9%) colonization by transient microbes (Figueiredo et al., 2013). One practice model that is more appropriate to the application of the alcohol-based hand sanitizer gels proposed practice change is the implementation of WHO multimodal hand hygiene improvement strategy. The justification for the selection of this model is that studies such as Huis et al., (2012) have demonstrated that successful and sustained HH improvement is achieved and realized by the implementation of multi-approach tactic to tackling different obstacles and behavioral barriers. Based on the recent updated WHO guidelines on HH in health care settings, the application of this model follows the implementation of the various components that the make the strategy. Some of the essential practical tools (application toolkit) to be used for the implementation of this practice change include (1) system change, and (2) training and education. Others are (3) evaluation and feedbacks, and (4) constant reminders in the workplace environment on the centrality of the HH (Wallis, 2012).
Changing established behavior and codes of practice of any kind is difficult and is especially true in the healthcare setting due to the complex relationships between the broad range of caregivers, patients, organizations, and professionals. Some of the possible barriers to the successful implementation of the proposed practice change include perverse incentives, inhibiting environment, poor project management, playing safe, stifling innovations, and poor workforce planning. Even though the implementation of the proposed change model relies heavily on individual HCP’s consent, some of the possible ethical connotations that may arise during the planning or implementation of the model revolve around the issues of political and ideological philosophies as well as those of distributive justice.
Conclusion
In conclusion, although it is highly recommended and well accepted that HH is a critical patient safety practice for reducing HAIs, compliance with this practice is often low. Well-developed tools such as the WHO multimodal HH improvement strategy are available for implementing HH interventions. Regarding the technique to be used for hand sanitizing, reviews have found that HH compliance interventions are mixed. However, a recent analysis by Figueiredo and colleagues in 2013 found that alcohol-based sanitizers are more effective in infection reduction than the traditional hand washing using soap and water.
References
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