Study: Increased hand gel use not reducing hospital infections

Mark Rupp, M.D.

Improved hand hygiene among health-care workers thanks to increased use of anti-bacterial gels is not reducing hospital infection rates, a UNMC study indicates.

But the study’s leader, UNMC’s Mark Rupp, M.D., said the results do not negate the importance of proper hand hygiene — noting that the problem of hospital infection is complicated and extends well beyond the issue of hand washing.

“Although we did not see a dramatic reduction in hospital-acquired infections corresponding to the increase in hand hygiene, these results should not be interpreted to mean that hand hygiene is not important,” said Dr. Rupp, professor of infectious diseases at UNMC and medical director in the department of healthcare epidemiology at The Nebraska Medical Center. “There are many factors that influence the development of hospital-acquired infections. It would be naive to think that a single, simple intervention would fix this problem.”

The rate of hospital infection was low before the study and so documenting the impact of increased hand hygiene was a difficult task, Dr. Rupp said.

Anti-bacterial hand gels are quickly catching on with consumers. They also are becoming the norm among health care professionals who often disinfect their hands up to 50 times a day.

The UNMC study was conducted to evaluate whether the use of anti-bacterial hand gels would reduce the rate of hospital-acquired infections — called nosocomial infections.

According to the U.S. Centers for Disease Control and Prevention (CDC), an estimated 1.7 million hospital-acquired infections occur in the United States each year with 99,000 associated deaths. Some of these deaths may be related to poor hand hygiene in health professionals.

Though researchers found a doubling in the rate of hand hygiene compliance associated with the use of hand gel, researchers did not see a corresponding reduction in hospital-acquired infections.

The use of anti-bacterial hand gels, shown as effective at killing germs as soap and water, has been instituted in health care facilities across the country as a more convenient way to sanitize hands.

More about hand gels Alcohol-based hand gels significantly reduce the number of microorganisms on skin, are fast acting and cause less skin irritation. They take less time to use than traditional hand washing. In an eight-hour shift, an estimated one hour of an ICU nurse’s time will be saved by using an alcohol-based handrub, according to the U.S. Centers for Disease Control and Prevention (CDC). Anti-bacterial hand gels, said Teresa Fitzgerald, infection control specialist, The Nebraska Medical Center, are a boon to health care professionals, some of who wash their hands up to 50 times a day. She said the traditional use of soap and water, and paper towels, causes hands to chap and dry out, sometimes causing cracked skin. In addition, gel can be used on the go. “Hand-gel has been a real blessing,” Fitzgerald said. “Sometimes you’re going in and just fluffing a pillow or straightening a sheet and using hand gel really saves on chapped hands. The gels also contain an emollient that helps soften hands.” She added hands should be washed with soap and water if they are visibly soiled.

The study, one of the largest and most rigorous examinations of hand hygiene to date, is published in the January issue of the journal Infection Control and Hospital Epidemiology. It observed health care workers for 300 hours over two years in two separate medical-surgical adult intensive care units at The Nebraska Medical Center, UNMC’s hospital partner. Hand cultures were performed on nurses every 60 days during the two-year study.

Dr. Rupp said the message of the study is that hand hygiene is only one aspect of the prevention of hospital-acquired infections. The national average rate of hand-washing compliance among health professionals in hospitals is about 40 percent.

“We were able to dramatically increase hand hygiene. Our hand-washing rate doubled from 38 percent to about 70 percent,” Dr. Rupp said. “Although this was a great improvement, it isn’t nearly what we should be achieving. In more recent studies, we have some units achieving 85 to 90 percent hand hygiene compliance.”

Federal guidelines call for health professionals to sanitize hands with soap and water or hand gels, before and after contact with patients, Dr. Rupp said. Hand hygiene also should be done even before donning gloves because of the risk of contaminating gloves by hands.

“Gloves are not a substitute for hand hygiene,” he said. “There’s a misperception that if you have gloves on, the patient is protected, but gloves can get contaminated when putting them on and can easily carry germs from patient-to-patient if they are not changed between patients.”

The other thing researchers learned in the study was an increased number of microbes are present with fingernail length greater than 2 millimeters (one-eighth of an inch). Microbes include bacteria, fungi and viruses.

The Nebraska Medical Center sets guidelines for its health care employees when it comes to fingernails and rings. Artificial nails are banned, nails should be kept short and rings kept to a minimum.

Dr. Rupp said those in the community concerned about preventing infection should do the same.

Fingernails are too long if when looking at palm of your hand, you can see nails above the skin of your fingers, he said.

The Nebraska Medical Center has launched several initiatives over the years to improve hand hygiene, including encouraging patients and family members to speak up.

“Patients have every right to ask if health professionals have washed their hands,” Dr. Rupp said. “We encourage them to do this. We also ask patient’s families to play that role.”

Most recently, the hospital initiated a program that calls for recruiting and training observers in hospital units to monitor hand hygiene. The feedback is provided to the department of healthcare epidemiology, which shares the information with hospital units.

Dr. Rupp said the program, which has been successful in increasing hand hygiene in test units, will be rolled out to all areas of the hospital.