Hand Hygiene Methods: Soap vs. Alcohol-Based Sanitizers

Introduction and Problem Statement

According to Ho et al. (2015), statistics indicate that approximately 20% to 40% of healthcare-associated infections have been linked to cross-infection through the hands of healthcare workers. Efficacious hand hygiene is imperative to prevent the transmission of healthcare-associated pathogens. A great deal of hand hygiene programs in healthcare settings emphasize compliance among healthcare personnel, because transitory contamination of their hands is deemed to be the primary basis for pathogen transmission (Kundrapu et al., 2014).

The use of alcohol-based hand sanitizers in health units has become prevalent since their recommendation by the Centers for Disease Control and Prevention (CDC) in 2002. This recommendation was made in light of patient interaction, particularly when hands are not visibly soiled. However, alcohol-based hand sanitizers are not efficacious against all classifications of pathogens (Carter, 2013). The problem identified is: in healthcare settings, is the use of alcohol-based hand rubs more effective or less effective than soap-and-water techniques in reducing hospital-acquired infection statistics?

Nursing Care Model and Leadership Context

My mentored practicum experience took place in an Acute Rehabilitation and Brain Center. Nursing care can be delivered through a mixture of organizational approaches, and the model of care delivery varies widely from one healthcare facility to another and from one patient population to another. The model applied in my practicum experience is progressive patient care — a system in which patients are placed in units based on their healthcare needs as determined by the severity of illness (Current Nursing, 2012). Our unit comprised 10 nurse assistants and 8 registered nurses.

The primary approach my nurse manager proposed to address the hand hygiene problem was using alcohol-based hand sanitizers five times before washing hands with soap and water. Operating under a dictatorial style of leadership, the decision-making process employed by the manager failed to incorporate the perspectives of staff members or other internal and external sources. This approach has an adverse impact on patient outcomes. Because alcohol-based hand sanitizers are not fully effective in eradicating certain bacteria — particularly Clostridium difficile — this solution contributes to substandard patient care (Carter, 2013). Ultimately, this can give rise to patient dissatisfaction and reduced employee motivation, as staff have no sense of input and their opinions are not taken into account.

Evidence-Based Intervention Proposals

I believe this problem could be resolved differently from the manager's proposal. My proposal entails washing hands with soap and water as the primary method. Moreover, if hospital infection statistics remain low for a period of six months, personnel should receive financial bonuses and a written commendation in their personal file.

Kundrapu et al. (2014) determined that the hands of patients with Clostridium difficile infection (CDI) and asymptomatic carriers were repeatedly contaminated with C. difficile bacteria. This contamination could potentially lead to transmission or recurrence of CDI when bacteria on the hands are ingested. The study indicated that soap-and-water handwashing was efficacious for reducing the rate of recurrence of positive cultures and the presence of bacteria on hands, while alcohol hand rub was not. The results suggest that patient handwashing could be a beneficial and simple adjunct to standard control measures for C. difficile.

Carter (2013) assesses the ideal balance between handwashing and hand sanitizers, considering whether over-reliance on alcohol-based hand sanitizers has contributed to disease outbreaks or to the emergence of more infectious pathogen strains. The author draws on insights from experts including Aron Hall, an epidemiologist at the CDC's Viral Diseases Division, and Clifford McDonald, an authority on C. difficile and a senior adviser for science and integrity at the CDC's Health Quality Promotion Division. Both experts agree that there is no evidence that alcohol-based hand sanitizers have contributed to strain selection or outbreak events. Their recommendation is to avoid further modifications to CDC guidelines so that the substantial gains achieved through increased use of alcohol-based hand sanitizers — namely reductions in healthcare-associated infections — are not lost. Overall, the proper balance for hand hygiene includes increased adherence to appropriate technique, achieved through education and consistently reminding staff to scrub all hand surfaces for at least 40 to 60 seconds with soap and water, or for 20 to 30 seconds using 3 to 5 mL of alcohol-based product.

The research study by Edmonds et al. (2013) sought to determine whether surrogate organisms can predict activity against C. difficile bacteria, and compared the effectiveness of various hand hygiene processes against C. difficile. The findings show that C. difficile bacteria were much harder to remove through handwashing than surrogate bacterial species, a result consistent with prior research. These outcomes indicate that surrogate organisms should not be used to predict the effectiveness of hand hygiene against C. difficile. Furthermore, the results demonstrate that prevailing hand hygiene interventions have limited effectiveness against C. difficile spores. Consequently, healthcare workers should continue to adhere to recommendations for handwashing with soap and water and emphasize contact precautions when caring for patients with CDI.

According to Ho et al. (2015), the use of alcohol hand rub is acknowledged as the gold standard for hand hygiene of non-visibly soiled hands and is considered to reduce the time required for hand hygiene. The World Health Organization (WHO) recommends applying alcohol hand rub following the same 7-step procedure used for handwashing with antimicrobial soap and water, while the CDC recommends applying alcohol to cover all surfaces of both hands and fingers until the hands are dry. The study by Ho et al. (2015) assessed the efficacy of three hand hygiene procedures in reducing hand carriage of methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive Staphylococcus aureus (MSSA) among healthcare workers. Results demonstrated that alcohol hand rub — whether applied covering all hand surfaces in no particular order or following the 7-step procedure — and chlorhexidine handwashing were equally efficacious in eliminating hand carriage of both MRSA and MSSA.

According to Tuladhar et al. (2015), human norovirus is the leading cause of acute gastroenteritis, affecting individuals of all age groups. The virus spreads either directly through person-to-person contact or indirectly through contaminated food, water, and environmental fomites. A large proportion of norovirus outbreaks are linked to person-to-person spread, and hands are considered a primary vehicle for viral transmission — directly or indirectly. Human norovirus and other pathogenic infections can remain communicable on human hands for hours. The study by Tuladhar et al. (2015) tested the effectiveness of alcohol-based hand antiseptics against human enteric and respiratory infections and compared this with handwashing using soap and water against norovirus. The authors concluded that washing hands with soap and water is more effective than alcohol-based hand antiseptics in eliminating noroviruses from hands. For this reason, soap-and-water handwashing is the preferred intervention to prevent hand-mediated transmission in healthcare environments and food preparation facilities.

Other facilities address this problem differently. One alternative approach involves applying alcohol to cover all surfaces of both hands and fingers until hands are dry. I believe the better solution is to employ the 7-step technique for handwashing with antimicrobial soap and water. In addition, I consider staff education and training to be a long-term solution to this problem. Personnel education enables staff to better understand why soap-and-water handwashing is the most efficacious approach for eradicating bacteria and preventing hospital-acquired infections (Ho et al., 2015).

References

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Carter, D. (2013). The right balance between hand sanitizers and handwashing. AJN The American Journal of Nursing, 113(7), 13.

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Ho, H. J., Poh, B. F., Choudhury, S., Krishnan, P., Ang, B., & Chow, A. (2015). Alcohol hand rubbing and chlorhexidine handwashing are equally effective in removing methicillin-resistant Staphylococcus aureus from health care workers' hands: A randomized controlled trial. American Journal of Infection Control, 43(11), 1246–1248.

Kundrapu, S., Sunkesula, V., Jury, I., Deshpande, A., & Donskey, C. J. (2014). A randomized trial of soap and water hand wash versus alcohol hand rub for removal of Clostridium difficile spores from hands of patients. Infection Control and Hospital Epidemiology, 35(2), 204–206.

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