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s healthcare providers work to eliminate hospital-acquiredinfection, hand hygiene has become a focus of that effort.It is simplicity itself; no less groundbreaking than when

Pasteur intemrpted the assembly at the Acaddmie Royale de Mddecineto plead his case for clean hands. Yet today, hospital-acquired infec-tions occur in upwards of 15 percent of admitted patients. The ques-tions are, naturally, "Why do new infections continue to happen inacute care settings?" and "How can they be stopped?"

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If the goal of a hand hygiene program is reducing transmission ofdisease, then the ultimate measurement of any such program is theobserved infection rcte at that facility. Every hospital-acquired infec-tion is not the result of a dirty hand, but we do know that thepreponderance of HAIs are related to suspect hand hygiene technique,thanks to modern epidemiologists standing on the shoulders ofSemmelweis, Lister and Pasteur. And in response, infection preventionand hand hygiene have become inexorably linked.

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Hand hygiene programs have three common, interdependent elements:Protocol involves the when, why, and where hand hygiene activitiesmust be performed.Product is about the antiseptic agents and supplies used for handantisepsis, including the oohow" of their appropriate use.Practice brings the "whon' into the picture through organization-wide training and individual action, as measured by the compliancerate of care giving individuals in the facility.Of these three elements, protocols are the most stable and agreed

upon. They may vary in minor ways, but there is universal understanding(supported by both professional and regulatory organizations) thatbefore and after patient contact, after toileting, before eating, after exten-sive public contact and after "catching" a sneeze or cough are minimallyacceptable times for performing hand hygiene. In the United Statesalone, following existing hand washing protocols could prevent as manyas 20,000 deaths each year.

Practice is the most troubling element of a hand hygiene programbecause results are so disappointing. According to Dr. Didier Pittet,director of infection control programs at the University of GenevaHospitals, it is not uncommon to encounter hand hygiene compliance aslow as 20 percent in individual wards and units, barely half the still-disappointing 40 percent compliance cited by the WHO globally. TheCDC and Joint Commission Center for Transforming Healthcare havereported similar statistics. There have also been many works identifyingbarriers or impediments to compliance along with recommendations forimprovement. These have been both structural, such as ensuring suffi-cient sinks and sanitizing stations at points-of-need and behavioral, suchas changing cultural norms with "no one excused" levels of scrutiny andexpectation.

Product is arguably the least discussed element of a comprehensivehand hygiene plan, yet is probably the element with the most variation inapproach and least agreement on what is best. Cleansers and soaps may

contain antimicrobial ingredients such astriclosan or CHG (chlorhexidine gluconate),but may have none at all. Waterless hand sani-tizers generally contain a form of alcohol-isopropyl or ethyl-but concentrations varywidely as do product forms; gels, liquids,sprays and foams.

Adding to the confusion of what the rightsanitizer formulation may be is the fact thatstandards vary significantly. European andNorth American (ASTM) standards do notspecify product alcohol concentrations, butrather demonstrated efficacy in immediatemicrobial kill and persistence. European stan-dards are more stringent than the NorthAmerican ones. And while the WHOGuidelines for Hand Hygiene in Healthcarespecifies a concentration of at least 80 percentethyl alcohol or 75 percent isopropanol toensure efficacy, today, with a few notableexceptions, products in the United States donot meet this standard.

Dr. Pittet, a key contributing author to boththe 2002 CDC and 2009 WHO guidelines,touched on the issue during a recent PreventionAbove All forum presentation in Washington,D.C. noting that "some products in the U.S.with alcohol volumes as low as 6O-62 percentmay pass the ASTM standards, though such alow ethanol concentration would never pass theEuropean efficacy norms."

The varying standards raise a series ofquestions. Why is Europe holding themselvesto a higher standard of care? What do theyknow that we, inAmerica, have yet to recognize?Might the evidence suggest we ask ourselves ifwe should be using higher alcohol-concentra-tion products with good emollient technology?

Whether the product is delivered as afoam, liquid or gel may make a difference aswell, according to Dr. Giinter Kampf, amember of the German Association forInfection Control. "Foams that I have seencontain around 60-62 percent ethanol. If youhave a 30 second time for the hands to becovered by the foam, you need a rather smallamount, which is 1.6 grams. You have twoproblems to face. One is the concentration ofethanol is too low. and the other is that the totalamount of foam which is applied is in additiontoo low."

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In effect, using current foams in a practical way (30 seconds)will not yield bactericidal results consistent with the FDA s TentativeFinal Monograph for Healthcare Antiseptics requirements and usingan application volume of current foams to meet those requirementsresults in an impractical amount of time spent performing handhygiene.

Another point of debate is whether ingredients beyond alcoholare necessary for persistence in a surgical hand antisepsis prepara-tion. CHG (chlorhexidine gluconate) is the most frequently addedingredient in these products. "When you look at the WHO guidelinesfor hand hygiene, [60 percent] concentrations are too low for use inhospitals," said Dr. Kampf. This may be why, in the United States inparticular, some surgical scrub products include. When looking at aWHO/European standard alcohol product, though, he concluded "thedata I have seen is not convincing in terms of an additional benefitwhen you have chlorhexidine in addition to ethanol in the formula-tion." Many products meet surgical antisepsis guidelines without skinirritating agents like CHG, and those options should be seriouslyconsidered as an alternative to CHG containing options.

What, then, about soap and water? "In the ICU, nurses had atleast 20 opportunities to clean their hands for every hour of patientcare. It will take you almost half an hour every hour to clean yourhands," stated Dr. Pittet. Alcohol-based hand rubs solve the timeconstraint on sanitizing hands at clinically appropriate times. Asalcohol removes less of the lipids that keep moisture in skin, it isactually less drying than soaps. "It's a lot better for your hands."

So, what does this mean to the person in the U.S. marketchoosing a sanitizer? "When you choose a product," explained Dr.Pittet, "you are better off to choose a product with a higher content inalcohol. It will be much more effective on some microorganisms thatrequire a higher content in alcohol like some viruses."

Hand sanitizing products are only onepart-an important part-of the picture when itcomes to organization-wide efforts to controlinfection. Hand hygiene is one of the easiestfactors to control; it only makes good sense toequip yourself with the best possible products.Likewise, you should work to ensure yourprotocols and practices are implemented,monitored and targeted toward excellence.Without all three-product, protocol and prac-tice-in place, you're just hoping for success.*

Lorri Downs, RN, BSN, MS, CIC is aboard certified infection preventionist and vicepresident of Infection Prevention at MedlineIndustries Inc, Ms, Downs possesses a diverseportfulio of more than 25 years in the nursingprofession. Her expertise has focused on infec-tion prevention surveillance at large acute careorganizations, plus ambulatory and publichealth settings. Ms. Downs has crafted hospitalinfection control programs, local emergencypreparedness plans as well as lectured onva rious infection prevention topics.

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