Current trends in hospital hand disinfection

Günter Kampf
MD
Consultant Hospital Epidemiologist

Surgical site infections are among the most frequently observed preventable hospital-acquired infections (HAIs). In a bid to keep them under control, preoperative hand treatment has become a global standard. Appropriate treatment can reduce the number of pathogens on hands to a minimum. Antiseptic treatment is strictly necessary as 18% of surgical gloves become perforated ­during surgical procedures, and any bacteria and yeast on the surgeon’s hands could enter the surgical wound.(1)

There are two principal options for preoperative hand treatment: antimicrobial soap, based on chlorhexidine digluconate or povidone iodine, or alcohol-based handrub, based on ethanol or ­propanol. Scrubbing is usually less effective than rubbing and can lead to more skin irritation. Rinsing with tap water can also recontaminate surgeons’ hands. A surgical scrub is also slower than a rub, as the ­commonly used active agents need time to exhibit their antimicrobial efficacy.(2)

Short application time for handrubs
In 2005, a one-and-a-half minute propanol-based handrub was described as equally effective as both a three-minute rub and the European reference procedure.(6,7) A one-minute application time, however, did not meet efficacy requirements.(6) For the first time, an evidence-based application time for an alcohol-based handrub was found.

Handwash prior to disinfection
Other studies indicate that handwashing immediately before applying a handrub actually has its disadvantages. Washing significantly increases the water content in the upper layer of the skin for almost 10 minutes and causes the handrub to be less effective.(8,9) In addition, washing also tends to enhance skin irritation.(10) That is why hands should be washed only when visibly soiled. When hands appear clean, washing is not justified.

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Both developments can impact on care provision without reducing treatment efficacy. Their main advantage is they do not waste healthcare workers’ valuable time. It has been calculated that, under ideal conditions, a shorter disinfection time can save 2,500 hours for a university hospital with 25,000 ­operations a year.(11) Up to 5,000 hours can be saved when hands are not routinely washed before ­applying a handrub.(11) Product savings (both handrub and liquid soap) add to this economic ­evaluation.

National policies do not require a minimum application time for surgical handrubs as long as they fulfill the relevant efficacy requirements and are approved for surgical hand disinfection.(4,5) But it is still recommended that hands be washed prior to application of the handrub, at least before the first ­operation of the day.(4,5) We are likely to see a revision of this recommendation due to a lack of supporting evidence and increasing evidence showing that routine handwashing has clear disadvantages.

Conclusion
Hospitals should take a critical look at their surgical hand disinfection routines. There is clear potential to save valuable time and reduce product consumption by implementing an evidence-based protocol for surgical hand disinfection. Hospitals should remove the routine handwash and select the most ­effective handrub in order to achieve the shortest possible but equally effective application time for surgical hand disinfection.

References

1. Kralj N, et al. Surgical gloves – how well do they protect against infections? Gesundheitswesen 1999;61(8-9):398-403.
2. Kampf G, et al. Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs. Clin Microbiol Rev 2004;17(4):863-93.
3. Parienti JJ, et al. JAMA 2002;288(6):722-7.
4. Boyce JM, et al. Guideline for hand hygiene in healthcare settings. Recommendations of the healthcare infection control practices advisory committee and the HICPAC/SHEA/APIC/IDSA hand hygiene task force. MMWR 2002;51:1-45.
5. Anonymous. Händehygiene. Bundesgesundheitsblatt 2000;43(3):230-3.
6. Kampf G, et al. J Hosp Infect 2005;59(4):304-10.
7. Kampf G, et al. Appl Environ Microbiol 2006;72(6):3856-61.
8. Hübner N-O, et al. Int J Hyg Environ Health 2006;209(3):285-91.
9. Hübner NO, et al. BMC Microbiology 2006;6:57.
10. Löffler H, et al. Br J Dermatol 2007;157:74-8.
11. Kampf G, et al. Unpublished data.