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Abstract & Commentary
Synopsis: The availability of rinse-free alcohol gel from wall-mounted dispensers resulted in a 32.8% increase in the rate of hand antisepsis 2-6 weeks after installation.
Source: Earl ML, et al. Am J Nurs. 2001;101(3):26-33.
Although it is common knowledge that the hands of health care workers can carry disease-causing organisms from one patient to another, compliance with hand antisepsis guidelines remains poor. During the past decade, rinse-free alcohol-based antiseptic gels that require neither soap nor water have been developed as an alternative means of hand cleansing. Earl and colleagues postulated that ready access to such gels would increase rates of compliance with hand antisepsis guidelines.
The study was conducted in 2 units, a 20-bed SICU and 13-bed MICU, located in a university-affiliated tertiary care facility. Phase I established baseline rates of compliance. During 30 days of observation, 1090 episodes were observed that required hand antisepsis and compliance was 39.6%. Subsequently, in Phase II, 73 gel dispensers (Kimcare Instant Hand Sanitizer, Kimberly-Clark Corp.) were installed inside and outside patient rooms, and observations were conducted to establish the short-term effect of the intervention. During 25 days, 1091 episodes were observed that required hand antisepsis, and the overall rate of compliance increased 32.8%, with the rate of hand antisepsis increasing significantly (P < 0.001) in the SICU. Rates also increased in the MICU but not significantly (P = 0.09). Slightly more than half of all observed instances of hand antisepsis involved the use of gels (62.8% nursing personnel, 61.6% physicians, 52.4% ancillary personnel). Gel dispensers located in the hallways were 30 times more likely to be used than those mounted inside patient rooms.
Phase III was conducted 10-14 weeks after the dispensers were installed to test long-term effects of the intervention. Over 30 days, 834 episodes were observed that required hand antisepsis. Compliance increased an additional 8.4% to 43.9% above baseline. In all phases of the study, ancillary personnel had the highest compliance with hand antisepsis (83.5%), followed by nursing personnel (56.9%) and physicians (43.7%).
Comment by Leslie A. Hoffman, PhD, RN
Waterless alcohol-based hand hygiene products are available in a variety of different formulations, including gels, rinses, and foams. In Europe, where they are known as hand gels, they have been used in health care facilities for many years. Typically containing an alcohol compound plus an emollient, gels are thought to work against microorganisms by denaturing proteins, thereby destroying cell walls. When used at full strength, they are the most effective and fastest way to reduce microbial counts on the skin. Reluctance to use these gels largely results from the belief that they are drying to the skin, but studies reveal that they are actually less drying than soap and water cleansing.
In this study, the simple action of placing gel dispensers inside and outside of patient rooms increased compliance with hand antisepsis 43.9% above baseline (soap and water only). More importantly, this increase was sustained over the 3-month observation interval. While the study lacks blinding, knowledge of the study did not appear to be a factor motivating improved rates of hand antisepsis. Compliance rates were determined by 5 observers, all public health graduate students, who recorded episodes of patient contact and noted whether hand washing occurred. Observation sessions were scheduled at varied times of the day and night in order to obtain an accurate representation of all shifts. Unit managers, but not unit staff, were informed about the purpose of the study. If asked, the observers stated they were conducting an infection control study for the epidemiology unit.
Several findings suggest that convenience may have been the primary factor motivating change. Sinks in patient rooms were located a distance from the bed area. Gel dispensers were placed in convenient locations on the wall next to each bed and just outside the door. Of note, gel dispensers located outside the room were 30 times more likely to be used than those inside the room were. Finding a sink and washing the hands with soap and water requires more time than using a conveniently placed gel dispenser. Findings of this study support that gel dispensers placed at opportune locations—eg, inside and just outside patient rooms—may be a practical method of encouraging hand antisepsis by ICU personnel and, thereby, reducing nosocomial infection rates.
Leslie Hoffman is Professor, Medical-Surgical Nursing Chair, Department of Acute/Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, Penn.