VOL: 101, ISSUE: 20, PAGE NO: 46
Annette Jeanes, MSc, RGN, SCM, DipIC, DipN, is lead nurse, infection control, University Lewisham Hospital, London
It has been known for many years that dirty or contaminated hands can transmit micro-organisms that may cause infection, and that cleaning the hands reduces this risk. Good hand hygiene is therefore beneficial for society. It is an important and simple infection control intervention, compliance with which can reduce the risk of health care-associated infection (Pittet et al, 2000).
Traditional hand-washing techniques take time and can have detrimental effects on the skin of health care workers (Larson, 1986). The unwanted effects of washing include dry, cracked or red skin. Furthermore, it is sometimes difficult to be able to wash one’s hands because of water, soap or towels not being available. Alcohol-based hand rubs are a quick and accessible alternative. They are, however, not appropriate for all situations and should not be used when hands are visibly soiled.
Patient safety alert
A patient safety alert was issued by the National Patient Safety Agency in 2004, which recommended using an alcohol-based decontaminant at the bedside to enhance hand hygiene compliance (NPSA, 2004). The ‘cleanyourhands’ campaign is the current initiative by the National Patient Safety Agency to improve hand hygiene in NHS trusts: (www.npsa.nhs.uk/cleanyourhands)
What are alcohol-based hand decontaminants?
These are solutions which, when rubbed over the surface of the hand, rapidly destroy micro-organisms on the skin. They do not remove dirt or debris and are therefore not suitable for use on soiled hands.
They are commonly known as ‘hand rubs’ and are produced as liquids, gels and foams. The standard container may be used from a wall dispenser, at the bedside or at the bed end. Many manufacturers now produce personal dispensers for the pocket or to clip at the waist.
The formulation and presentation of the products vary, as does their provision and availability. Ultimately, the product should enable staff to work safely and protect patients from infection.
The NHS Purchasing and Supply Agency undertook a comprehensive review of alcohol-based hand decontaminants in England, which resulted in the selection of three main products (see: www.pasa.nhs.uk/consumables/shared/domestics/handhygiene Each was selected to conform to EN1500, a European efficacy standard and dermatological criterion. However, many other products are available and these may be used to good effect.
What do alcohol-based hand decontaminants contain?
The decontaminants contain one or a combination of the following:
- Ethyl alcohol (ethanol);
- Isopropyl alcohol (isopropanol);
- N-propanol alcohol
Using 100 per cent alcohol is not as effective as solutions containing 60-90 per cent alcohol. This is because the addition of water is required to denature proteins (change their structure). An emollient is usually added to reduce the effects of drying, and antiseptics may also be added to provide a residual effect after the hand rub has been used (Gardener and Peel, 1996).
How do alcohol-based hand decontaminants work?
In gel formulations, the gel liquefies as it warms on the skin. The liquid then fills the skin crevices and evaporates as it is being spread over the skin. Micro-organisms on the skin surface are rapidly destroyed by this action. Bacteria are reduced in greater numbers using this method than by washing just with soap and water (Ojajarvi,1980). There is a broad spectrum of antimicrobial activity but there may be limited effects on some viruses (Boyce and Pittet, 2002).
Some products that contain additional antiseptics may have a residual antibacterial activity.
The presence of dirt or debris may protect micro-organisms from being destroyed and a weak solution of alcohol may act only as a bacteriostatic; that is, it is capable of inhibiting the reproduction of bacteria.
When should alcohol-based hand decontaminants be used?
These decontaminants should be used when the hands are visibly clean and before carrying out a basic clinical intervention.
Box 1 lists examples of when alcohol-based hand rubs should be used.
Disadvantages of alcohol-based hand decontaminants
There are disadvantages of using these types of decontaminants (Box 2), but these are generally outweighed by the benefits of access and the time saved by not having to wash the hands. However, it is important to recognise that hand-washing is still required in many circumstances and that some staff may not wish to use hand rubs.
Applying alcohol-based hand decontaminants
The rapid evaporation of alcohol-based hand rubs means that a simple, quick application is necessary in order to cover the hands. The hand hygiene liaison group (www.handhygiene.co.uk/) developed a technique that begins by covering the finger tips with the hand rub, including the nails, and then rapidly covering the remaining parts of the hands. The action of spreading the hand rub increases evaporation and drying. The process ends when the hands feel dry, the whole operation taking less than a minute to complete (see Footnote about forthcoming Practical Procedures).
The nozzles of dispensers may become clogged or blocked if they are not used frequently. They should therefore be checked regularly and any blockage or debris removed. To avoid potential contamination, the container and the nozzle unit should be replaced when the container is empty. Dispensers should be replenished regularly and be accessible. Responsibility for this should be allocated to specific team members.
Surgical hand disinfection
Some alcohol hand decontaminants are suitable for hand disinfection before surgery. This is a two-stage procedure consisting of a surgical hand wash, followed by the application of an alcohol-based solution for up to five minutes (Rotter, 1999). The hands should then be air dried before putting on the surgical gloves.
Alternatives to alcohol-based solutions
Hand decontaminants that do not contain alcohol are available and include tea tree oil, aloe vera, and water-based solutions.
Alcohol-based hand rubs are a quick and simple alternative to hand-washing. Soiled hands should be washed and the decontaminant used on visibly clean hands.
The provision of alcohol-based hand rubs increases opportunities for hand decontamination in health care settings and, it is hoped, hand hygiene compliance.
A series of Practical Procedures on hand hygiene will be published in Nursing Times’ clinical section, beginning on June 28.