Handwashing: what is the best solution?

There is a link between poor hand hygiene and infection - contaminated hands can transmit micro-organisms that may cause infection. The prevention of harm to patients is a fundamental concept in health care and therefore the prevention of infection is important. Improving hand hygiene reduces the risk of health-care-associated infection (Pittet et al, 2000).

As the value of hand hygiene has increased, hand-hygiene products have developed. Traditional handwashing takes time and can have effects on the skin of health-care workers such as dry or cracked skin and contact dermatitis. Products such as alcohol hand rubs are quick and accessible but not always appropriate.

In health-care establishments the provision of products and facilities vary, often influenced by cost and space. In some community settings traditional handwashing may not be possible. In each situation needs will vary but ultimately the product used should enable staff to work safely and protect patients from infection.

The National Patient Safety Agency's Clean Your Hands Campaign has called for the use of hand rubs at the bed side in all hospitals, following a successful pilot involving six acute trusts. It is now appointing implementer sites, with a view to rolling out the campaign in five phases over the next year (see Box, page 44).

Preparations
The main products currently in use are:

- Soap

- Aqueous antiseptic handwash solutions

- Alcohol-based hand rubs

- Others including emollient soap substitute, tea tree-oil based solutions, water-based solutions and hand wipes.

Product choice
The product required may vary in different circumstances. Individuals should ask the following questions:

- Why am I cleaning my hands?

- How dirty are they?

- Are hand-drying facilities available?

- How much time do I have?

Hands that are contaminated with body fluids or which are visibly dirty will require washing with soap and water. Some procedures such as a surgical operations may require handwashing. In many situations where hands are visibly clean applying an alcohol hand rub may be sufficient before a basic clinical intervention.

Gloves should be worn where soiling with body substances is possible.

Product selection criteria
In each preparation type there is a range of products available. When selecting a product to purchase and use, its acceptability to the user, including any perfume and consistency, is important.

The dermatological effects of the product will also affect people's desire to use it. Knowledge that a product has a residual bactericidal effect may encourage use. Ease of use, including the design of dispenser or holder and suitability of holders, fittings or fixings will be significant. Space and access issues will be of importance, as will the cost, including initial outlay and any maintenance or servicing costs.

Soap
Soap is detergent-based and suitable for removing dirt, soil and organic substances when applied with water. Products may contain preservatives and/or bacteriostatic agents in order to minimise or prevent bacterial growth. Perfumes and emulsifiers may also be added.

Soap is available in a bar, liquid, leaves or leaflets. It has minimal antimicrobial activity but will remove loosely adherent flora. The use of soap can increase the bacterial skin count of hands following use (Larson et al, 1986).

The main advantages of soap are as follows:

- It is simple to use where sinks and towels are available

- Most staff are familiar with the product and technique required

- The time taken is an opportunity to pause and think

- Staff may report that they 'feel clean' after the procedure.

Disadvantages of using soap include:

- Staff normally need to stay at the sink to wash hands, which may take several minutes including travelling time to and from sinks

- Bars can slip from fingers, and can get stuck under nails and rings

- Bars and containers can become contaminated

- Washing hands with soap and water can cause skin irritation and dryness - this can be offset by adding emulsifiers, but is exacerbated by poor hand drying

- Perfumes are often added which may not appeal to all users and may cause allergies.

Soap is by far the preferred method for routinely washing soiled hands.

The construction and design of the dispenser is important, to minimise the risk of contamination and optimise the ability to get soap easily. To avoid potential contamination of dispensers, disposable rather than refillable cartridges should be used, and wall, foot or elbow-operated dispensers chosen where possible. Dispensers should be checked and maintained regularly.

Soft, good-quality, absorbent disposable towels should be used to dry hands. Hot-air hand dryers are not suitable for clinical areas due to the noise they create and their inability to dry hands thoroughly and quickly.

Antimicrobial handwash solutions
There are three main types of solution: chlorhexidine gluconate, povidone iodine and triclosan.

Chlorhexidine gluconate: Chlorhexidine gluconate is incorporated in a number of hand-hygiene products. Chlorhexidine alone is minimally soluble in water but the digluconate form is water-soluble (Boyce and Pittet, 2002). It is available in aqueous or detergent liquid formulations of 0.5-4%. Its antimicrobial effect relates to the attachment and disruption of cytoplasmic membranes.

The specific effects are complex. There is good activity against Gram-positive bacteria but it is less active against Gram-negative bacteria, fungi and some virus groups.

There is little activity against tubercle bacilli and it is not sporicidal (Boyce and Pittet, 2002). It acts well in the presence of organic matter, including blood. Activity can be reduced in the presence of natural soaps and hand creams containing anionic emulsifying agents. There is some residual activity.

Advantages include:

- Versatile and widely available.

- Skin irritation is unlikely.

- Residual activity.

Disadvantages include:

- Limited antimicrobial effect

- Although there is minimal absorption by the skin, eye contact can cause conjunctivitis or corneal damage. It should not be used in ear or brain surgery due to toxic effects on tissue.

Iodine and iodophours: Iodophours have largely replaced iodines due to the potential for skin irritation and discoloration. Iodophours contain iodine, iodide or triiodide and a polymer carrier. This increases the solubility of the iodine, promotes sustained release and reduces irritation (Boyce and Pittet, 2002).

Most iodophour preparations for hand hygiene are 7.5-10% povidone iodine. It has a broad range of antibacterial activity including Gram-negative and positive bacteria, fungi, certain spores, mycobacteria and viruses. There is some residual bactericidal activity but is quickly deactivated by organic matter or skin secretions, particularly in lower concentrations (Gardener and Peel, 1996).

It main advantage is its broad-spectrum antibacterial activity, while its disadvantages include sensitivity and allergies. Its absorption may also cause side-effects.

Triclosan: This is a diphenyl ether. Triclosan solution replaced hexachlorophene in many areas. It is available as a soap or liquid solution of 0.2-2%.

It acts by affecting cytoplasmic membrane and synthesis of RNA, fatty acids and proteins. It has a broad range of activity as a bacteriostatic but is more effective against Gram-positive than Gram-negative organisms. Some residual activity remains on the skin after use.

It is not affected by organic matter (Boyce and Pittet, 2002), is poorly absorbed and has low toxicity. Allergic reactions are rare. Its main disadvantage is it bacteriastatic properties.

There is a potential of the reduced susceptibility of micro-organisms to antiseptics (Boyce and Pittet, 2002. These solutions may become contaminated while in use. Similar precautions are required to those taken with soap dispensers. Good hand-drying is important to prevent sore or cracked hands.

Alcohol solutions
Alcohol hand decontaminants contain one or a combination of the following: ethyl alcohol (ethanol), isopropyl (isopropanol) and N-propanol.

Solutions of 60-90% are most effective. Higher concentrations are less effective as water is required to denature proteins. An emollient is usually added to reduce the effects of drying. Antiseptics may be added to provide a residual effect (Gardener and Peel, 1996).

Alcohol-based hand decontaminants are available as rubs, liquid, gels and foams from wall dispensers, personal dispensers (tottles) and other holders at bedsides and bed-ends.

Alcohol denatures proteins. Micro-organisms on the skin surface are rapidly destroyed but these solutions do not remove dirt or debris.

Advantages include:

- Simple and fast to use - dispense into hands and rub vigorously all over until hands are dry or alcohol has evaporated

- Helpful when handwashing is not possible

- Causes less skin irritation or damage than handwashing

- Greater reduction of bacteria than by handwashing

- Portable.

The disadvantages of alcohol solutions are:

- They can be used on only visibly clean hands

- They have a broad spectrum of activity but may have limited effect on some viruses

- Hands can get sticky with repeated use

- The smell of alcohol can be off-putting

- May sting if hands are cut or cracked

- Flammable

- Artificial nails may be affected.

Surgical hand scrub: Some formulations are suitable for a surgical hand scrub and rub. This is a two-stage procedure using a short scrub with an antiseptic detergent followed by applying an alcohol solution for about two minutes. This is reported to be as effective as a full traditional surgical scrub (Boyce and Pittet, 2002).

Other products: Other options include emollient soap substitute, tea tree oil-based solutions, water-based solutions and hand wipes.

Conclusion
Good hand hygiene is vital in health care. Several products are available which may vary in their suitability and efficacy. Staff should be involved in any selection process, as compliance will be poor if products are disliked.

Guidance on hand hygiene
- A patient safety alert was issued by the National Patient Safety Agency in September this year (NPSA, 2004) which recommended bedside alcohol decontaminant to enhance hand hygiene compliance (See box, The National Patient Safety Agency's Clean Your Hands campaign, page 44).

- In England the NHS Purchasing and Supply Agency has undertaken a comprehensive review of alcohol hand decontaminants, resulting in the selection of three companies to provide these products in England. Each was selected to conform to EN1500 - a European efficacy standard and dermatological criterion.

- Fifty-four per cent of English trusts had bedside alcohol hand rubs in place before the NPSA alert was issued.

The National Patient Safety Agency's Clean Your Hands campaign
THE PILOT

- A pilot study by the National Patient Safety Agency (NPSA) between July 2003 and January 2004 showed that hand cleaning by health-care staff can be trebled by introducing simple, practical changes

- Initial findings from the evaluation of the six-month pilot showed how staff at the six acute trusts went from cleaning their hands between each patient contact an average of 28% of times to 76%

TOOLKIT

- As part of the campaign the NPSA developed a toolkit for trusts to make hand hygiene an integral part of day-to-day health care. Key elements included alcohol hand rubs, promotional posters that changed every two weeks, and posters and leaflets for patients

THE NEXT STAGE

- The NPSA in September put out a call for acute NHS trusts to become implementer sites for the campaign, which will be implemented across the acute NHS in five phases

KEY ISSUES

- An economic assessment by the Department of Health estimates that if the success of the pilot is replicated nationally 450 lives and £140 million a year will be saved. For a trust with 500 beds, this would mean savings of £460 000 a year, or a reduction in 1540 bed days

- Supplies of disinfectant rubs can be ordered through a new NHS PASA national contract for an improved range of products that have been rigorously tested

- The NHS Purchasing and Supply Agency (NHS PASA) has to date found that over 50% of trusts in England have already begun introducing alcohol-based disinfectants at the point of care, and a further 20% plan to implement this in the near future.

Source: www.npsa.nhs.uk/cleanyourhands

Author's contact details
Annette Jeanes, Lead Nurse, Infection Control, University Hospital Lewisham, Lewisham High Street, London SE13 6LH. Email: annette.jeanes@uhl.nhs.uk

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