WHO Guidelines on Hand Hygiene in Health Care - Safe Care ...

<strong>WHO</strong> GUIDELINES ON HAND HYGIENE IN HEALTH CARE
23.5.2 Sinks
While not all settings have a continuous water supply, tap
water (ideally drinkable, is preferable for handwashing (see Part
I, Section 11.1). In settings where this is not possible, water
“flowing” from a pre-filled container with a tap is preferable to
still-standing water in a basin. Where running water is available,
the possibility of accessing it without the need to touch the
tap with soiled hands is preferable. This may be achieved by
taps that are opened by using an elbow or foot. In settings
without budget restrictions, sensor-activated taps may be used
for handwashing, although it must be noted that the system
reliability is paramount since its failure completely prevents any
access to handwashing facilities. In summary, manual or elbowor
foot-activated taps could be considered the optimal standard
within health-care settings. Their availability is not considered
among the highest priorities, however, particularly in settings
with limited resources. Of note, recommendations for their use
are not based on evidence.
To avoid water splashes, the water stream should not be
directed straight into the drain, and taps should be fitted with
an aerator screen. The mesh of the aerator screen should be
sufficiently wide to ensure that no water remains on top of the
aerator screen, as this may lead to bacterial contamination and
consequent spread of microbes. 982
23.5.3 Dispensers
In most health-care facilities, alcohol-based handrub dispensers
have historically been located close to the sink, often adjacent
to the wall-mounted liquid soap. Part of their function was to
dispense pre-set amounts of handrub (mostly 1. 5 ml, half of
what was needed according to older guidelines). Frequently,
these dispensers were designed to allow the user to apply
handrub without using their contaminated hands to touch the
dispenser (elbow-activated). While wall-mounted dispensers
at the sink seemed a logical place to start promoting hand
antisepsis with rubs over handwashing, the main advantage of
handrubs is the fact that they can (and should) be used at the
point of care, for example at the end of the bed. Placement of
handrubs exclusively at the sink therefore disregards one of their
unique features and is not aligned with promoting hand hygiene
at the five moments when it is required in health care.
The advantages and disadvantages of the different dispenser
systems are discussed below and summarized in Table
I.23.3. Although the same wall-mounted dispensers are used
frequently for handrubs and liquid soaps, this section will focus
on handrub dispersion. It is obvious that economic constraints
as well as local logistics have a major influence on the choice
of dispensing system. Furthermore, in many settings, the
different forms of dispensers, such as wall-mounted and those
for use at the point of care, should be used in combination to
achieve maximum compliance. Some of the prerequisites for all
dispensers and their placement are given in Table I.23.4. Some
examples of dispensers for use at the point of care are shown in
Figure I.23.5.
23.5.3.1 Wall-mounted systems
Wall-mounted soap dispensing systems are recommended
to be located at every sink in patient and examination rooms,
when affordable. Wall-mounted handrub dispensers should be
positioned in locations that facilitate hand hygiene at the point of
care, in accordance with the concept of the “My five moments
for hand hygiene”. Careful consideration should be given to the
placement of these dispensers in areas with patients who are
likely to ingest the product, such as disoriented elderly patients,
psychiatric patients, young children, or patients with alcohol
dependence. In patient areas where beds are geographically in
very close proximity, common in developing countries, wallmounted,
alcohol-based handrubs can be placed in the space
between beds to facilitate hand hygiene at the point of care.
Some institutions have customized dispensers to fit on carts or
intravenous-pools to ensure use during care delivery.
Splashes on the floor from wall-mounted dispensers have
been reported as a potential problem, as this may lead to the
discolouration of certain floor surfaces or even result in the floor
surface becoming slippery. Some manufacturers in developed
countries offer dispensers with a splash-guard intended to
catch splashes and droplets to avoid these problems.
Dispensers should be mounted on the wall in a manner that
allows unrestricted, easy access (i.e. not in corners or under
hanging cupboards). They should be used preferably with
disposable, transparent containers of a standardized size,
thus allowing the use of products from different suppliers (e.g.
Euro-dispenser for standardized 500 ml and 1000 ml bottles).
The product should be placed in the dispenser in such a way
that the label and content is visible to ensure timely replacement
of empty containers by housekeeping or maintenance staff.
Dispersion of the handrub should be possible in a “nontouch”
fashion to avoid any touching of the dispenser with
contaminated hands, e.g. “elbow-dispensers” or pumps that
can be used with the wrist. 58 Despite the fact that ease of
access may lead to increased use, as shown by Larson and
colleagues 654 when comparing the frequency of handrub use
of manually operated and touch-free dispensers in a paediatric
ICU, robust mechanical systems are preferable over electronic
“non-touch systems” that are more susceptible to malfunction,
more costly, and frequently only usable with the supplier’s own
hand hygiene formulation. In general, the design and function
of the dispensers that will ultimately be installed in a healthcare
setting should be evaluated, because some systems were
shown to malfunction continuously, despite efforts to rectify the
problem. 983
23.5.3.2 Table-top dispensers (pumps)
A variation of wall-mounted dispensers are holders and frames
that allow placement of a container that is equipped with a
pump. The pump is screwed onto the container in place of the
lid. It is likely that this dispensing system is associated with
the lowest cost. Containers with a pump can also be placed
easily on any horizontal surface, e.g. cart/trolley or night
stand/bedside table. Several manufacturers have produced
dispenser holders that allow positioning of the handrub onto
a bed frame, thus enabling access to the handrub at the
point of care. A disadvantage of these “loose” systems is the
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