International Journal for Quality in Health Care Advance Access originally published online on March 15, 2006
International Journal for Quality in Health Care 2006 18(2):120-122; doi:10.1093/intqhc/mzi109
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Review Article
One plunge or two?—hand disinfection with alcohol gel
1 Department of Orthopaedic Surgery, Western Infirmary, and 2 Gartnavel General Hospital, Tennents Institute of Ophthalmolgy, Glasgow, UK
Objective. To compare health care workers’ hand surface coverage using two different volumes of alcohol gel for hand disinfection.
Participants and methods. A total of 84 members of staff in our hospital were studied. Subjects were asked to disinfect their hands with alcohol gel containing a clear fluorescent substance. Performance was assessed by using UV light to identify areas which had been missed, and the total surface area missed was calculated. A total of 42 subjects received 3.5 ml of alcohol gel, and 42 age-, sex-, and job-matched subjects received 1.75 ml of alcohol gel.
Results. Significantly less area was missed when hand disinfecting with double the volume of alcohol gel; 1.23 versus 6.35% surface area was missed (P < 0.001).
Conclusion. Doubling the volume of alcohol gel used for hand disinfection significantly improves the efficiency of coverage of the hands with alcohol gel. This may result in lower bacterial count on the hands and may reduce the spread of nosocomial infections including that of methicillin-resistant Staphylococcus aureus.
Keywords: infection control, hospital infection, hand washing
Address reprint requests to Duncan J. M. Macdonald, Department of Orthopaedic Surgery, Western Infirmary, Glasgow, UK. E-mail: djmmacd{at}hotmail.com
Accepted for publication November 10, 2005.
Recent research has demonstrated that alcohol-based hand hygiene products are the most effective antibacterial disinfection agents [1,2], and their use can reduce the spread of infection, including methicillin-resistant Staphylococcus aureus [3]. Hands are recognized as the principle route by which cross-infection occurs, and evidence suggests that health professionals fail to decontaminate their hands as frequently or as thoroughly as they should [4,5]. There is now great emphasis placed on hand disinfection before and after each patient contact. It is important that this is done thoroughly or the risk of infection spread remains [6]. In our opinion, there is a lack of research into improving the effectiveness of health care workers’ hand disinfection.
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Participants and methods |
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A total of 84 clinic and ward staff of our hospital were asked to participate in a trial to compare two volumes of hand disinfectant. In the first week of testing, all 42 staff who worked in a single clinic and ward area were asked to disinfect their hands, as they usually would, using 3.5 ml of an alcohol gel containing a clear fluorescent substance. This volume is the equivalent of two applications as delivered by the alcohol dispenser. No limit was given for the duration of hand rubbing, and the method of hand rubbing was not recorded. Subjects then entered a room and were asked to place their hands into a UV lightbox with their fingers spread. The room lights were then dimmed and the UV light switched on. Subjects’ hands were examined under UV light in order to identify missed areas. This was assessed on both the palmar and dorsal surfaces of the hands by the assessor viewing from directly above. The missed areas were recorded by shading the corresponding area on representative diagrams of dorsal and palmar views of a left and right hand. The same template diagrams were used for all subjects. An initial attempt to use photography to capture the area missed was abandoned because we were unable to adequately capture the images as very low lighting is required to demonstrate the fluorescent substance.
The following week, 42 subjects were selected from staff who worked in a separate clinical area. They were individually matched for age (±5 years), sex, and job description (nurse, doctor, physiotherapist, clerical worker). It was decided to match for these three variables on the basis of a previous study which demonstrated that these factors affected hand disinfection ability [7]. The two groups of staff came from similar departments but did not routinely come into contact with each other in the hospital environment. The second group was tested in exactly the same way as the first group, except they only used 1.75 ml of gel (the equivalent of one application). At the time of the study, the manufacturer (Spirigel, Ecolab Limited, Leeds, UK) recommended only one application for hand disinfection.
Participants were blinded to the nature of the gel, the assessment technique, and the reason for the study. Assessment was performed while participants were at work in their clinical environment. After participation in the study, subjects were requested not to discuss the study with other members of staff. The same assessor was used to assess the hands under the UV lightbox, and they were aware of the group association of the participants. A second blinded assessor analysed the proformas and calculated the percentage area missed for each individual. Each hand diagram covered an area of 1524 mm2 up to a line corresponding to the distal wrist crease. An acetate sheet marked with millimetre square boxes was placed over the hand diagrams, and the shaded areas were counted. Percentage area missed was then calculated. Exactly the same method of assessment was used on every occasion. In order to assess rater reliability, 10 pairs of hands were assessed on two occasions, after the same episode of hand disinfection with 1.75 ml of gel. Using the Bland and Altman method [8], we found that the widest limits of agreement were –0.59 to 0.52%, which is small enough for us to be confident that the assessment method is reliable.
To record the functional areas that were being neglected, we divided the palmar surface of the hand diagrams into three regions. ‘Fingers’ corresponded to the area from the metacarpal phalangeal joint line to the tip of the index, middle, ring, and little fingers on the left and right hand; ‘thumbs’ was from the metacarpal phalangeal joint to the tip of both thumbs; ‘palms’ was the remainder of the palm of the hands up to the distal wrist crease. We considered these areas as the most likely to come into contact with patients and potentially act as vectors for the transfer of infective organisms.
Statistical analysis
Groups were compared using a paired t-test.
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Results |
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There were 30 females and 12 males in each group, with a mean age of 36.9 years in the group using 3.5 ml of gel and 36.5 years in the group using 1.75 ml of gel. Each group comprised of 24 nurses, 11 doctors, 5 clerical staff, and 2 physiotherapists.
All members of staff were considered ‘trained’ in hand washing through a poster campaign over the preceding 12 months, which recommended one plunge of gel and clearly described six stages of hand rubbing with the gel in order to completely cover the hands. The alcohol gel used in the study had been in use in the hospital in all clinical areas for the previous 12 months.
Both groups demonstrated a wide variation in the percentage area missed on individuals’ hands with a range from 0 to 5.9% in the group using 3.5 ml of gel and from 0.3 to 18.7% in the group using 1.75 ml of gel. Only three subjects achieved complete coverage of their hands in the group using 3.5 ml of gel. The group using 3.5 ml of gel performed significantly better than the group using 1.75 ml; mean area missed was 1.23 versus 6.35%; P < 0.001, 95% CI for difference of means: 3.28–6.96%.
The group using 3.5 ml of gel completely covered the whole of the palmer surface of their hands with alcohol gel significantly more often than the group using 1.75 ml (32/42 versus 10/42, P < 0.001). The 3.5 ml group also consistently completely covered more of their fingers (39/42 versus 23/42, P < 0.001), thumbs (41/42 versus 31/42, P < 0.0034), and palms (41/42 versus 19/42, P < 0.001) when compared with the group using 1.75 ml of gel.
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Discussion |
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Alcohol-based hand hygiene products are now the recommended form of hand antisepsis [3]. It is apparent that health care workers are not achieving complete coverage of their hands when disinfecting with alcohol gel. This study indicates that efficiency of hand coverage with alcohol gel is significantly improved by using a larger volume of alcohol gel. This effect may be because the larger volume of gel encourages staff to spend longer rubbing their hands and also to cover all areas of their hands in order to disperse the gel. The time spent rubbing and the method of rubbing were not recorded in this study and would merit further investigation. It is recognized that poor hand disinfection technique results in less bacterial decontamination of hands [6]. We have not demonstrated a clinical impact of the difference in coverage of hands with the two volumes of alcohol; if our staff however use only a single plunge of gel, it is likely that hand disinfection is currently inadequate. This means that health care workers may be acting as potential vectors of nosocomial infection even if they remember to disinfect their hands between patient contacts. The significant improvement in the coverage of these functional areas when using a larger volume of gel may be critically important in the process of infection control.
As this study was not randomized, there are concerns regarding selection bias and comparability of groups. However, we matched for the variables which influence hand-washing performance. The assessment method may be more reliably performed electronically, and this would also enable the study to be double blinded. A further limitation is that different alcohol-based hand hygiene products vary in viscosity, and it is possible that this may also affect the distribution over the hands. For this reason, an optimal volume of solution may need to be sought for each product available for hand disinfection.
For staff who are expected to disinfect their hands regularly throughout the day, there may be a reluctance to use a larger volume of gel if this takes a longer time for the hands to dry. There are also concerns about the potential side effects of alcohol-based solutions which can cause skin irritation, and this may be more likely if a larger surface area is covered [9]. It has however been suggested that this irritation is due to breaks in the epidermal surface which can be prevented by the use of emollients within alcohol-based hand rubs [10]. Further studies could investigate if hand hygiene compliance is influenced by the amount of alcohol gel used. It would be useful to determine if the observed difference in coverage of the hands with different volumes of alcohol gel had any effect on the quantity of skin flora.
Previous research has focussed on studying the frequency of health care workers’ hand disinfection, and education and public health policy is widely aimed at encouraging the physical act of hand disinfection [11]. This is of great importance, but it is essential that when hands are disinfected, it is done effectively. Hospital-acquired infections cost the NHS in excess of £1 billion per year, approximately 8% of all hospitalized patients are affected with obvious associated morbidity and a human cost of 5000 lives per year [12]. Reducing these figures through effective hand disinfection would probably save more than the added cost of using double the volume of alcohol gel when hand disinfecting.
The more effective coverage of hands with alcohol gel observed by increasing the amount of alcohol gel used has potential advantages for improving hand disinfection without the need for specific training and could be introduced simply by promoting the use of ‘two plunges’. This method might be particularly suitable for patients’ visitors to hospital wards who are also now being asked to disinfect their hands.
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Conclusion |
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Using a larger volume of alcohol gel leads to more thorough coverage of hands when hand disinfecting, and this may help reduce the spread of nosocomial infections.
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References |
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