Handy advice: CDC asks physicians to come clean with gels

Alcohol-based hand rubs are considered easier to use and more efficient at killing germs that often cause serious infections.

By Susan J. Landers, amednews staff. Nov. 18, 2002.

Washington -- Although somewhat surprising, and even a bit embarrassing, evidence shows that physicians, nurses and other health care workers don't always adequately wash their hands.

In 34 hand-washing studies, these professionals really cleaned up only 40% of the time, according to the hand hygiene resource center at the Hospital of Saint Raphael in New Haven, Conn. The shortcoming is attributed to heavy workloads and hectic schedules. "Health care personnel are always on the go, which sometimes makes hand washing with soap and water difficult," said Steve Solomon, MD, acting director of Centers for Disease Control and Prevention's health care quality promotion division.

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But their oversight is linked to the transmission of infection within the health care system. The CDC estimates that each year nearly 2 million patients in the United States get an infection in hospitals, and about 90,000 of die as a result.

In an effort to reverse these outcomes, the CDC issued new hand hygiene guidelines last month that will prove useful in the hospital, the clinic and even in physicians' offices.

Central to the directive is the regular use of alcohol-based hand rubs, and the message is clear: Even the busiest physician should be able to find time to use these products for a between-patient cleanup.

"These hand rubs should help promote hand hygiene because they are much more accessible than sinks, take less time to use and cause less skin irritation and dryness than many soaps," Dr. Solomon said.

Specifically, using an alcohol-based hand rub requires about 15 seconds of time, versus approximately 60 seconds to go to a sink and wash, according to studies.

Findings also indicate that the alcohol-based hand rubs reduce the number of bacteria on the hands more effectively than does washing with soap and water.

But despite their effectiveness, they can't take the place of this traditional approach if hands are soiled with blood or other material, said CDC Director Julie L. Gerberding, MD, MPH. "Alcohol preps are not going to deal with that aspect of hand hygiene."

The use of gloves is also still recommended, especially for situations in which people are coming into contact with blood or other body fluids or when they are conducting sterile procedures.

Many physicians also may be surprised by the findings of a recent study that hand cleaners labeled "antibacterial" are no better at killing germs than is regular soap and water.

But one piece of information is constant. "Clean hands are the single most important factor in preventing the spread of dangerous germs and antibiotic resistance in health care settings," Dr. Gerberding said.

2 million patients a year get hospital-acquired infections; 90,000 die.

This is not just a concern for hospitals and nursing homes. Physicians' offices also play a role in the spread of disease, said John Boyce, MD, co-author of the new guidelines. "When patients who have been in and out of hospitals come into the office, they continue to carry resistant bacteria on their skin, such as vancomycin-resistant enterococci or methicillin-resistant Staphylococcus aureus," he said.

"We are even seeing some people who have acquired the methicillin-resistant Staphylococcus aureus in the community," Dr. Boyce said.

Many doctors who work with Dr. Boyce have begun using the alcohol products in their offices. "The alcohol hand rubs are faster, more convenient and easier on your hands," said Dr. Boyce, section chief of infectious diseases at the Hospital of Saint Raphael in New Haven, Conn. Dr. Boyce created the hand hygiene resource center on the hospital's Web site.

The hand rubs will also prove useful in emergency situations that might occur during high-risk procedures or in intensive care units, when there might not be time for everyone to line up at a sink for hand washing, Dr. Gerberding said.

In fact, many hospitals already use the products. They were introduced several years ago at Vanderbilt University Hospital, said William Shaffner, MD, who represented the Infectious Diseases Society at a CDC briefing on the guidelines. The convenience of the products has increased compliance with hand hygiene at his hospital, he said.

Benefits outweigh costs

Any additional cost of alcohol hand-cleaning products is easily outweighed in hospitals by cutting costly patient infections. In offices, the products' cost, which has yet to be documented, might be offset by eliminating the need to pay for water and paper towels, Dr. Boyce said.

Many physicians already make hand hygiene an office priority. For example, Cincinnati family physician William Sawyer, MD, is a champion of hand washing, and he sees the CDC's new guidelines as a great boon to his hand hygiene awareness campaign. "To me, what's most important about all of this is raising everybody's awareness of the role their hands play in the spread of disease."

Alcohol-based hand rubs take only 15 seconds to use.

For the past few years, Dr. Sawyer has been aided in his effort by the large and yellow Henry the Hand, a most noticeable presence at schools and meetings, including the AMA House of Delegates.

Dr. Sawyer practices what he preaches and always stops at the sink after exiting an exam room. "It's an ingrained habit," he said. But "if you can't wash your hands between patients, then sanitize them with an alcohol-based hand rub."

Melvyn Sterling, MD, a member of the AMA Council on Scientific Affairs, is also a practitioner of exemplary hand hygiene. "I make it very visible in my office," he said. "I wash my hands in the sink in the exam room, in the presence of patients."

Dr. Sawyer also promotes the four basic principles of hand awareness to all people -- big and little. The principles, which are endorsed by the AMA, are: Wash your hands when they are dirty and before eating; don't cough into your hands; don't sneeze into your hands; and do not put your fingers into your eyes, nose or mouth.

"Coughing or sneezing into your hands is a great way to carry germs through the hospital," he said.

"You can wash and sanitize your hands all the time and still contaminate somebody, something or yourself if you aren't aware of what you're doing with your hands at all times," Dr. Sawyer added.

ADDITIONAL INFORMATION:

4 rules to keep clean

The AMA also endorses the four principles of hand awareness:

Wash you hands when they are dirty and before eating.
Do not cough into your hands.
Do not sneeze into your hands.
Above all, do not put your fingers into your eyes, nose or mouth.

The diligent cleaning of hands with soap and water or an alcohol-based product will be celebrated during National Hand Washing Awareness Week, Dec. 8 to Dec. 14.

Hand hygiene highlights

Use of alcohol-based hand rubs is recommended for patient care -- these products are more convenient than thoroughly washing hands with soap and water between patients.
Physicians and other health care personnel should still use soap and water when their hands are visibly soiled.
The use of gloves does not eliminate the need for hand hygiene. Hand rubs should be used before and after each patient just as gloves should be changed before and after each patient.
Improved adherence to hand hygiene has been shown to terminate outbreaks in health care facilities, reduce the transmission of antimicrobial-resistant organisms and reduce overall infection rates.

Source: Centers for Disease Control and Prevention