vw polo gti changing hand hygiene behaviour at the point of care

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Q: Why is WHO placing great emphasis on alcohol based handrubs, at the point of care, and promoting them as the international standard for hand hygiene?

A: The availability of a product which renders the hands safe in terms of transmission of pathogens, and which can be used at the very place where pathogens are transmitted, has revolutionized hand hygiene improvement strategies in the modern age. For this reason, alcohol based handrubs are considered to fulfil the highest standards of safety in relation to the prevention of cross infection.

At the present time, the most efficacious, well tolerated and well researched product which can be placed ergonomically and safely at the point of care is an alcohol based handrub. This system change facilitates the right action to occur at the right time and in the right way. It is unlikely, although not impossible, that running water, soap and towels will be installed right next to each patient’s bed, or be available at the point of care in an affordable and practical way. Soap and water handwashing is however less efficacious, more time consuming, and less well tolerated by skin than alcohol based handrubbing.

In countries where access to sinks is limited or non existent, alcohol based handrubs offer a method of preventing cross infection which can be implemented in the short term alongside a longer term strategy of sink installation.

A: No. The Guidelines promote hand hygiene compliance per se. The facts are as follows: when an alcohol based handrub is available, it should be used as the first choice for hand hygiene (of non soiled hands) since it enables health care workers to optimally comply with recommended indications at the point and moment of care.

However, the Guidelines and all training materials emphasize that hands need to be washed with soap and water when they are visibly dirty or when exposure to potential spore forming organisms is strongly suspected or proven, or after using the lavatory.

There will always be a need for health care staff to clean their hands with soap and water at certain times, but for the routine and regular contacts which staff have with patients every day (corresponding to the Five Moments) alcohol based handrubs at the point of care provide a constant safety net. This protects patients from the multitude of microbes which can spread silently, but with devastating consequences, from one patient to another, or from one body site to another in the same patient. Therefore, the WHO supports sink installation programmes and access to water supplies, soap, and towels, within health care settings.

Q: Is it true that alcohol based handrubs are not effective against some important pathogens, for example, Clostridium difficile and norovirus?

Clostridium difficile: no agent used in hand hygiene preparations, including alcohol based handrubs,
vw polo gti changing hand hygiene behaviour at the point of care
is effective against the spores of Clostridium difficile. During outbreaks of C. difficile related infections it is preferable to wash hands with soap and water following glove removal after caring for patients with diarrhoea. Alcohol based handrubs can then be used after handwashing in these instances.

Norovirus: the efficacy of alcohol based handrubs against noroviruses varies with type and concentration of alcohol in the formulation, with a minimum 60% (v/v) concentration of ethanol required for good activity. WHO experts recommend the use of alcohol based handrubs during outbreaks of noroviral gastroenteritis.

Whether alcohol is effective against microbes such as Clostridium difficile and norovirus can divert attention from a much overlooked issue. Alcohol based handrubs play a critical role in mass behaviour change and health improvement. Discouraging their widespread use in response to diarrhoeal infections, will only jeopardize overall patient safety in the long term. Appropriate use and removal of gloves is crucial when dealing with patients with diarrhoeal illness, followed by hand washing with soap and water in case of C. difficile outbreaks.

Alcohol based handrub should be used in all other instances, providing a constant safety net to protect patients from the multitude of harmful resistant and non resistant organisms transmitted by the hands of health care workers.

Q: Is it correct that WHO is promoting alcohol based handrubs in the form of liquids rather than gels and foams?

A: No. The Guidelines promote alcohol based handrubs at the point of care. The WHO is aware that across the globe various formulations of alcohol based handrubs are in use and there is no suggestion that locally selected products should change, as long as they meet international efficacy standards, or are validated by a WHO approved laboratory, and they have proven satisfactory skin tolerability. Staff preference is crucial for success of any strategy.

Q: What does ‘point of care alcohol based handrub’ mean in practice?

Making alcohol based handrub available at the point of care means making it available at the exact place where care or treatment involving physical contact between a patient and a health care worker takes place (as illustrated within the Five Moments). Point of care products should be accessible without leaving the patient environment (Five Moments). This enables staff to make hand hygiene habitual and quickly and easily take action to ensure compliance in relation to the indications corresponding to the Five Moments, thus killing the pathogens and preventing their spread. it must be within the dotted line denoting the patient zone as illustrated through the Five Moments posters). Point of care is usually achieved through staff carried handrubs (pocket bottles) or handrubs fixed to the patient’s bed, bedside table or to the wall next to the patient’s bed. trolleys, or dressing or medicine trays which are taken into the patient environment, can also fulfil this definition, if they are reliably taken into the patient zone in anticipation of contact.

Q: Should hand hygiene be performed prior to donning non sterile gloves?

Hand hygiene should be performed regardless of the use of gloves (whether non sterile or sterile) when an indication for hand hygiene applies. That means: hand hygiene must be performed before donning gloves, if the following care activity implies both an indication for hand hygiene, such as “before patient contact” or “before aseptic task”, and for using gloves.

The fact of donning gloves by itself does not constitute an indication for hand hygiene (for example, you may put on gloves just to handle contaminated material for your own protection, without touching the patient or undertaking an aseptic task).

It is important to clarify also that glove use should be limited only to real indications. Gloves are often overused and consequently a “false” sense of security might induce the health care worker to omit hand hygiene when indicated. Glove use indications were reviewed by the WHO and summarized in Fact Sheet 6 and the Hand Hygiene Brochure.

Q: Can alcohol be used on Gloved hands?

It is very important that staff allow the alcohol to dry properly before donning gloves, and that they clean their hands again after removing them, if indicated. It is not recommended that staff use the alcohol based handrub whilst gloves are on their hands.

Q: If staff are not familiar with alcohol based handrubs at the point of care what approach should be taken to convince them of its effectiveness?

A: In the early days of alcohol based handrub, there was a perception amongst some health care workers that this was a less effective way to clean the hands than, for example, using soap and water. In fact, some health care workers will have been exposed to the recommendation that hands should be washed with soap and water prior to applying alcohol. Today, the evidence very clearly supports the view that it is perfectly acceptable and indeed preferable to use an alcohol based handrub on its own (without a prior handwash) as long as the hands are clean to the naked eye, and there has not been contact with body fluids.

Alcohol based hand rubs are efficacious, time saving and kinder to the skin than soap and water. They increase the reliability and likelihood of compliance occurring, and have a high impact on reducing the burden of HAI.

In summary, many studies have compared alcohol based handrubs and antibacterial soap and water. In 90% of such studies,
vw polo gti changing hand hygiene behaviour at the point of care
alcohol rubs reduced bacterial and viral counts on the hands to a greater degree than antimicrobial soaps.

About the Author

Ralph Lauren