Infection Control Hotline

By Diane Sosovec, R.N.

Q: When is it appropriate to use hand sanitizers (alcohol-based gels) in lieu of washing with soap and water?

The CDC’s Guideline for Hand Hygiene in Healthcare Settings states that if hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands. Alcohols have excellent in vitro germicidal activity against gram-positive and gram-negative vegetative bacteria, including multidrug-resistant pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE).

When using an alcohol-based hand rub, it is imperative to follow the manufacturer’s directions for use. Hands must be dry and clean; the recommended amount of product should be applied and then rubbed thoroughly until absorbed.

The efficacy of alcohol-based hand hygiene products differ based on the type of alcohol used (Isopropanol, ethanol, n-propanol or a combination of two), concentration of alcohol (60 percent to 95 percent), contact time, amount of alcohol used (1mL is substantially less effective than 3mL) and if the hands are wet when the alcohol is applied. But alcohols have poor activity against bacterial spores, such as Clostridium difficile (C. difficile).

When hands are visibly soiled or when caring for a patient known to harbor C. difficile or other bacterial spores, traditional hand washing with soap and water is recommended.

Q: Does wearing gloves negate the need for hand hygiene?

Gloves do not provide complete protection from hand contamination. They may have a small, undetected defect, or the user may contaminate his hands during glove removal. Hand hygiene must be performed prior to donning gloves and after glove removal. The use of gloves is not a substitute for hand hygiene. This is supported by the CDC, the Association for Professionals in Infection Control and Epidemiology (APIC) and OSHA’s Bloodborne Pathogen Standard.

Q: Does improved hand hygiene reduce the spread of bacteria in health care settings?

Hand hygiene reduces transmission of pathogens and the incidence of health care-associated infections (HAIs). Studies dating back to 1847 have demonstrated that mortality rates of mothers who were assisted with childbirth by hospital staff who cleaned their hands with an antiseptic agent were substantially lower than those deliveries by hospital staff who used only plain soap and water. This study was conducted by Ignaz Semmelweis (who died in 1865), a Hungarian obstetrician who is considered the father of hand hygiene. Studies from the 1960s to the present have consistently demonstrated the relationship of noncompliance with hand hygiene and the increased incidence of HAIs. Recently there has been widespread news coverage of the spread of MRSA in health care settings. In a CDC publication release (MRSA in Healthcare Settings) on Oct. 3, 2007, it was stated that “the main mode of transmission of MRSA to other patients is through human hands, especially health care workers’ hands. Hands may become contaminated with MRSA bacteria by contact with infected or colonized patients. If appropriate hand hygiene such as washing with soap and water or using an alcohol-based hand sanitizer is not performed, the bacteria can be spread when the health care worker touches other patients.”

Q: Some of our staff members complain that their hands are dry and irritated from frequent glove use and hand washing. How can we alleviate this?

Preventing dry skin and reducing the risk of dermal irritation and contact dermatitis should be the goal of every health care employer and employee. Skin moisturizers are used to help prevent dryness and restore dry skin to its normal condition.

The CDC’s Guideline for Hand Hygiene in Healthcare Settings recommends that health care workers be provided with products that will minimize the occurrence of irritant dermatitis associated with hand antisepsis or hand washing. Individuals who experience dry or irritated skin are less likely to be 100 percent compliant with routine hand hygiene.

Health care workers need to be provided with appropriate moisturizing products. It should be noted that not all lotions, moisturizers and creams are compatible with hand hygiene products. Over-the-counter products (personal products brought in from home) should never be used in the clinical environment. Moisturizing agents that are approved for use in the clinical environment are available as hand lotions, as a component of hand hygiene products and as inner coatings on medical and surgical gloves.

Health care practitioners should consult with the organization’s infection control professional to determine product efficacy, compatibility and end-user acceptance. It also is advisable to require written documentation that supports all product claims from the manufacturer’s representative relative to product compatibility, efficacy and appropriate use.

Q: Does the way in which people put on and take off gloves have an impact on cross-contamination?

Yes. When donning gloves, a key factor in personal protection is that the correct size of glove is worn. Too small of a glove will be tight and can tear easily. Too large of a glove will not fit properly around the wrist, and loose, baggy fingertips may snag and tear. If a selection of appropriately sized gloves is not available, health care workers are less likely to use gloves. Strict attention must be paid when removing gloves so that the outer surface of the glove does not contact exposed skin. Gloves should be removed by slowly pulling them down, one at a time and turning them inside out. (See photos.) This will reduce skin exposure to any potential contaminant on the outside surface. Upon removal, gloves should be disposed of in a designated biohazard container or receptacle.

Q: If all gloves are designed to provide an effective barrier, why does it matter what material the gloves are made of?

All medical-grade gloves are designed to provide effective two-way barrier protection. Examination and surgical gloves may be made of natural rubber latex or synthetic materials.

Not all glove materials are designed to meet the requirements of all clinical tasks and procedures, which is a primary concern when selecting an examination glove.

The industry trend with exam gloves is moving away from natural rubber latex, which historically was considered the gold standard in barrier protection.

Today, vinyl and nitrile exam gloves have a 65 percent share of the acute care market. It is critical to note that there are recommendations for appropriate use of vinyl and nitrile exam gloves because vinyl as a barrier has limitations.

Vinyl exam gloves

• Are appropriate for short-term tasks (less than 15 minutes), involving minimal stress or manipulation of the glove and low risk of exposure to blood and other potentially infectious materials.
• Are not recommended for use when there is a moderate to high risk of exposure to blood or body fluids, nor are they appropriate for contact with chemicals or with preparation or administration of chemotherapeutic agents. They should not be worn by individuals with known or suspected sensitivity to vinyl compounds.
• Vinyl exam gloves are not recommended as the only option in high-risk clinical departments such as the OR, ER, ICU or labor and delivery.

Nitrile exam gloves

• Are appropriate for all aspects of direct patient care. 
• Many, but not all, are approved for use with chemotherapeutic agents and commonly used chemicals. Health care workers should check with the manufacturer for supporting documentation and testing data.

Q: What is the best way for a facility to evaluate the various hand hygiene products available?

The most successful way to evaluate hand hygiene products is by direct feedback from end users after a reasonable trial/evaluation period.

This process must be led in collaboration with the infection control department. Not all hand hygiene products are “dermal friendly,” and some may cause skin irritation. 

Below are recommendations for hand hygiene product evaluation:

• All products must be initially screened for the efficacy of the antiseptic agents against various pathogens.
• A trial for a two-week period or a time frame recommended by the product’s manufacturer.
• A trial in a clinical unit or units with high use (ICU) is recommended.
• Provide comprehensive education on product use by an industry representative.
• Complete evaluation forms by individual end users.
• Do not evaluate more than one hand hygiene product at a time.
• Do not evaluate hand hygiene products at the same time as glove products.
• Try to avoid product evaluation during the winter months, when skin may be compromised due to environmental factors.
• Validate that all hand hygiene products are compatible with other product offerings such as gloves.
• Request that all product claims be provided in writing and with appropriate testing data.

Q : Is there a link between skin health and health care-associated infections?

A factor that influences hand hygiene behavior is the condition of the skin. One study published in the April 2000 issue of the American Journal of Infection Control reported that frequent and scheduled use of an oil-containing lotion improved skin condition and led to a 50 percent increase in hand-washing frequency among health care providers.

Reports from these studies emphasize the need to educate personnel regarding the value of regular, frequent use of hand-care products.  

About thie column

This column presents answers and practical guidance to some of the most commonly asked questons of suppliers and educators in the infection control and sterile processing communities. To submit a question to the column, e-mail Bob Kehoe, executive editor, at [email protected].

This article first appeared in the February 2008 issue of Materials Management in Health Care.

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