Nosocomial Infections and Handwashing

¶ … hygiene techniques with traditional soaps may or may not be more effective than using alcohol-based solutions concerning reduction in nosocomial infection rates in acute hospitals. With recent usage of alcohol-based solutions, use of traditional antibacterial soaps may be outdated and take longer. Nosocomial infections present as a major issue for acute care hospitals and require research in identifying the most effective way to sterilize hands to avoid increasing infection rates. While traditional handwashing with antibacterial soaps have been done for years, water availability and time taken to perform handwashing may not promote efficiency among hospital staff. Alcohol-based solutions require no water and additional washing or scrubbing. This research paper will focus on recent articles and studies that highlight which method works best.

Integration and Synthesis of the Evidence

Many articles and studies the past and in recent years attest to the effectiveness and efficiency of alcohol-based solutions. One 2012 studied noted the efficacy of all sanitizers used in relation to soap. "All sanitizers sufficiently inactivated the test viruses in the suspension test whereas two soaps were active only against vaccinia virus and BVDV. In the modified fingerpad test a povidone-iodine-containing soap was superior to the sanitizers whereas two soaps showed no activity" (Steinmann et al., 2012, p. 277). The only soap that tested better than the sanitizers was the povidone-iodine-containing soap. The availability of sanitizers is much higher than the povidone-iodine-containing soap. Therefore, regardless of effectiveness of such soap over sanitizers, the ease and convenience, the availability of sanitizers, points to alcohol-based solutions as the potential better choice for hand sanitation and reduction of nosocomial rates.

Another study discussed dry-fast antisepsis, an alcohol-based solution as having a longer lasting effect than traditional handwashing. "The results showed that the use of dry-fast antisepsis has a better persistent effect (P = 0.001), more nurses chose dry-fast antisepsis than surgeons (P = 0.012)... The dry-fast technique has the advantage of being less irritating to the skin and less time consuming" (Chen et al., 2013, p. 179). Additionally, handwashing as noted by the authors, is time-consuming and leads to drier, more irritated skin. The article discusses availability of new alcohol-based solutions that are not as drying to the skin as traditional handwashing and dry faster than older alcohol-based solutions.

An article by Howard, Jowett, Faoagali, & Mckenzie (2014) shares the efficacy of alcohol solution to a conventional scrub and cites the same level of efficacy even after 30 minutes. "Several studies have shown that rubbing hands with an alcohol/chlorhexidine solution provides equivalent microbial decontamination to a conventional surgical scrub using aqueous chlorhexidine. An alcohol/chlorhexidine hand rub was found to be as efficacious as a traditional scrub after 30 min" (Howard, Jowett, Faoagali, & Mckenzie, 2014, p. 78). This means that while one technique (the surgical scrub) takes a long time to perform, the other technique (use of alcohol/chlorhexidine solution) does not and is just as effective. The article further supports the idea that alcohol-based solutions are the way to go to provide the level of hand hygiene needed to promote a decrease in nosocomial infections.

While some articles not the same level of efficacy for traditional handwashing and alcohol-based solutions, one study highlighted the overall superiority of alcohol-based antiseptic solutions. "Alcohol-based antiseptic solutions are superior in terms of reducing the incidence of colonization" (Siddiqui et al., 2016, p. 1). The authors explained the alcohol-based solution was easier and faster to use and promoted reduced bacterial colonization even after a certain amount of time passed (30 minutes to 1 hour). While the study could have included a greater variety of antibacterial soaps, the study further supports the use of alcohol-based solutions over traditional handwashing (with antibacterial soaps).

Alcohol-based solutions offer superior guard against bacteria even when compared to ozone handwashing. "Post-wash bacterial counts were determined from one hand (immediate effect), and from the other hand that had been gloved for 3h (delayed effect). The investigation indicated that ozone is inferior to propan-1-ol 60% hand rub for hand asepsis" (Appelgrein, Hosgood, Dunn, & Schaaf, 2016, p. 340). The level of convenience and ease of use are also factors in being able to maintain a reduced rate of bacterial growth on hands thanks to faster and easier reapplication. Because handwashing takes time and is shown to not be as effective or is as effective, the literature points to the best option being alcohol-based solutions.

The final article notes the use of unfiltered water as a potential factor in less efficacy concerning handwashing. "Bacterial counts were markedly reduced after hand hygiene with ABHR (1.4 log10; P < .0001) and 4% chlorhexidine gluconate with filtered water (0.8 log10; P < .0001). Use of unfiltered water was associated with minimal nonsignificant bacterial reduction" (Salmon, Truong, Nguyen, Pittet, & Mclaws, 2014, p. 178). If filtered water plays a role in how much bacteria remains on the hands post handwashing, this proves that alcohol-based solutions are far superior than traditional handwashing. This article revealed a potential factor in the decreased efficacy of handwashing. Many hospitals do not have filtered water for handwashing. The easiest solution for reduction of nosocomial infections would be to use alcohol-based solutions.

The themes across the articles demonstrate clearly that handwashing is inconvenient, takes too long, and is as or not as effective as alcohol-based solutions. The articles also demonstrate alcohol-based solutions keep working over a marked period. Furthermore, handwashing appears to require certain factors to maintain effectiveness concerning bacterial growth on hands. For example, hands must be washed for a certain time to decrease bacterial presence on skin.

Comparative Evaluation of the Evidence to Practice

My own experience with alcohol-based solutions is very positive. It is so much easier to reapply hand sanitizer to keep my hands clean versus using the traditional method of handwashing with antibacterial soaps. It would take me at least 2 minutes to wash my hands and one minute to dry. I would have to go to a sink and wash my hands. However, with use of hand sanitizers that are available at many key points in and around the hospital, I find it is much easier to keep my hands free of bacteria.

As Chen et al. (2013) explained in their study, there are variations of alcohol-based solutions available that are quick drying and do not dry the hands. When I use traditional handwashing, my hands become very dry and I find I must apply lotion to keep them moisturized. Howard, Jowett, Faoagali, & Mckenzie (2014) stated alcohol-based solutions are just as effective as traditional surgical scrubs. The staff working in the hospital used hand sanitizers or other alcohol-based scrubs have noted a reduction in nosocomial infections because they reapply frequently and keep their hands clean longer than traditional handwashing.

Acute care hospitals often have patients that have wounds that could lead to infections and complication from infections if exposed to bacteria. Persistent use of alcohol-based solutions by medical staff leads to a decreased chance of exposure to potential infection-causing pathogens. It seems the answer is to use alcohol-based solutions for most hand hygiene needs.

In terms of feasibility of changing practice, the alcohol-based solution is an easy solution to carry out. Many hospitals already position hand sanitizer dispensers throughout their facilities, especially in patient rooms, near elevators, and in or near bathrooms. If hospital staff are instructed to use alcohol-based solutions instead of traditional handwashing, it would most likely be taken well given the ease and convenience of such a solution. These kinds of solutions promote convenience and ease of use and feasibility very likely.

Any barriers of change would be lack of availability of alcohol-based solutions (real) and desire to stick to traditional handwashing (perceived). People that use alcohol-based solutions do so because they are nearby. If there is no alcohol-based solution nearby, a hospital staff member will go to a sink and wash his or her hands with soap. He or she will not go outside and look for hand sanitizer to sanitize hands. This is a real barrier that is a potential means of decreasing use of alcohol-based solutions. It can even extend to alcohol-based solution dispensers not being refilled in a timely manner. If a dispenser is empty, the person wishing to use it will do the next best thing, wash his or her hands.

A perceived barrier is people believing handwashing is more effective than alcohol-based solutions. Because it is a traditional means of hand hygiene, surgeons, doctors, or nurses may feel it is the most effective way. They may not feel as clean simply applying hand sanitizer as they would from scrubbing for several minutes with antibacterial soap. While evidence points to the efficacy of alcohol-based solutions, many do not follow evidence-based practice and so the perception of traditional handwashing may still linger showing the potential perceived barrier of handwashing versus alcohol-based solutions.