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

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<strong>WHO</strong> GUIDELINES ON HAND HYGIENE IN HEALTH CARE incident underscores the fact that, following the application of alcohol-based handrubs, hands should be rubbed together until all the alcohol has evaporated. In the USA, shortly after publication of the 2002 CDC/HICPAC hand hygiene guideline, fire marshals in a number of states prohibited the placement of alcohol-based handrub dispensers in egress corridors because of a concern that they may represent a fire hazard. On 25 March 2005, the Center for Medicare and Medicaid Services adopted a revised version of the USA National Fire Protection Agency’s Life Safety Code that allows such dispensers to be placed in egress corridors. The International Fire Code recently agreed to accept alcohol-based handrubs in corridors. In addition, the CMS 3145-IFC (Fire Safety Requirement for Certain Health Care Facilities, Alcohol- Based Hand Sanitizer and Smoke Detector Amendment) was published in March 2005, addressing this issue. 990 23.6.2 Other safety-related issues Accidental and intentional ingestion and dermal absorption of alcohol-based preparations used for hand hygiene have been reported. 599,778-780 Acute, severe alcohol intoxication resulting from accidental ingestion of an unknown quantity of alcoholbased handrub was recently reported in the United Kingdom, resulting in the unconsciousness of an adult male patient (Glasgow Coma Scale 3). 778,781 This unusual complication of hand hygiene may become more common in the future, and security measures are needed. These may involve: placing the preparation in secure wall dispensers; labelling dispensers to make the alcohol content less clear at a casual glance and adding a warning against consumption; and the inclusion of an additive in the product formula to reduce its palatability. In the meantime, medical and nursing staff should be aware of this potential risk. Alcohol toxicity usually occurs after ingestion. It is primarily metabolized by an alcohol dehydrogenase in the liver to acetone. Symptoms and signs of alcohol intoxication include headache, dizziness, lack of coordination, hypoglycaemia, abdominal pain, nausea, vomiting, and haematemesis. Signs of severe toxicity include respiratory depression, hypotension, and coma. Among alcohols, isopropyl alcohol appears to be more toxic than ethanol, but less so than methanol. Blood isopropyl alcohol levels of 50 mg/dl are associated with mild intoxication and 150 mg/dl with deep coma. Apparently, isopropyl alcohol has no adverse effects on reproduction and is not genotoxic, teratogenic, or carcinogenic. 991 In addition to accidental ingestion, alcohols can be absorbed by inhalation and through intact skin, although the latter route (dermal uptake) is very low. Any absorption exceeding certain levels may result in toxicity and chronic disease in animals 992 and humans. 780 Recently, the Health Council of the Netherlands 993 suggested to classify ethanol as carcinogenic and to include it in skin notation because of the fear of an increased risk of breast and colorectal cancer in persons with an occupational exposure to ethanol. While the Dutch Social and Economic Council advised the Ministry of Social Affairs and Employment to consider an exception for the use of alcoholbased handrubs in health-care settings, the Ministry of Social Affairs and Employment rejected such an exception and set the maximum amount of occupational absorbed ethanol at such a low level that the decision could possibly lead to a ban of ethanol-containing handrubs in the Netherlands if upheld. Obviously, such a decision would be disastrous for health-care settings and could induce other countries to consider similar measures. Indeed, while there are no data to show that the use of alcohol-based handrub may be harmful – and studies evaluating the absorption into blood show that it is not – reduced compliance with hand hygiene will lead to preventable HCAIs. Data used by the Dutch Heath Council estimated the absorption level after spraying of the total body under occlusive circumstances and after exposure times of up to 24 hours, although this is obviously not relevant for the application of handrubs. Furthermore, they estimated a worst case dermal uptake of 30 mg ethanol after a single application to hands and forearms, and a daily uptake of 600 mg/day after 20 applications per day, an estimate that has been proven wrong by several new studies. 782,784,994,995 In practice, absorption of ethanol from a handrub would be by a combination of dermal absorption and inhalation. In a study using a solution of 44% ethanol sprayed on the skin and left for 15 minutes, there was no positive identification of ethanol in any of the blood samples taken (limit of detection was 9 mg/litre). 994 Turner and colleagues evaluated the dermal absorption through HCW’s intact skin 599 :3 ml of an isopropyl alcohol-containing handrub (52.6% (w/w) isopropyl alcohol) were applied to HCWs’ hands every 10 minutes over a 4-hour period. A blood sample was taken 5 minutes after the final application of handrub and blood isopropyl alcohol levels were measured. In 9 out of 10 participants, a rise in the blood isopropyl alcohol level was noted at very low levels (the highest observed level was 0.18 mg/dl), much less than the levels achieved with mild intoxication (50 mg/dl). More recently, Miller and colleagues conducted two studies in which large amounts of an ethanol-based handrub were used very frequently over periods of several hours; they found that blood alcohol levels at the end of the trial periods were below the level of detection. 782,995 Brown and colleagues exposed HCWs to intensive use (30 times/hour) of ethanoland isopropanol-based handrub solutions and found only extremely low concentrations of ethanol in the blood (far too low to cause symptoms) and that blood isopropanol levels were undetectable. 783 Similarly, insignificant levels of ethanol were detected in the breath of a few study participants and no trace of isopropanol. Kramer and colleagues studied the intensive use of handrub solutions containing 55–95% ethanol and found that blood ethanol concentrations were far below levels that would result in any noticeable symptoms. For example, the highest median blood ethanol concentration after intensive use of a 95% ethanol hand rub was 20.95 mg/litre, whereas levels of 200– 500 mg/litre are needed to impair fine motor coordination, and levels of 500–1000 mg/litre are needed to impair judgement. 784 The presence of ethanol in the blood of human beings can also have other origins. Ethanol can be found in ripe fruit with concentrations of 0.6% or higher as a product of fermentation by natural yeasts. 996 A very small amount of ethanol is present as an endogenous substance in the blood, probably resulting from microbial production in the gastrointestinal tract. Studies have shown concentrations ranging from 0 mg/litre to1.6 136
PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE mg/litre. 997,998 In rare instances, much higher endogenous concentrations have been reported (> 800 mg/litre) in Japanese subjects with serious yeast infections; endogenous ethanol appears to have been produced after they had eaten carbohydrate-rich foods. 997 Studies to measure both alcohol and acetone levels in subjects chronically exposed to topical alcohols are required to investigate further this issue. Based on work emerging from the United Kingdom,Table I.23.5 lists the risks and recommended mitigation measures. 999,1000 Table I.23.1 Indications for gloving and for glove removal Indication Glove use 1) before a sterile condition 2) anticipation of a contact with blood or another body fluid, regardless of the existence of sterile conditions and including contact with non-intact skin and mucous membrane 3) contact with a patient (and his/her immediate surroundings) during contact precautions Glove removal 1) as soon as gloves are damaged (or non-integrity suspected) 2) when contact with blood, another body fluid, non-intact skin and mucous membrane has occurred and has ended 3) when contact with a single patient and his/her surroundings, or a contaminated body site on a patient has ended 4) when there is an indication for hand hygiene Table I.23.2 A question-frame to capture practical conditions for appropriate and safe glove use Before donning gloves When to wear gloves When to remove gloves – Is there any indication for glove use? – What is this indication? – What type of gloves is required? – Are gloves still in their original packaging? – When does the exact moment to put on gloves apply? – How do they protect the patient, the HCW, the environment? – Is any hand hygiene action indicated before donning gloves? – If any indication for hand hygiene, was handwashing or handrubbing performed? – Was it performed immediately before donning gloves? – Have both hands to be gloved? – Has the gloving technique been respected? – Does the indication for use of gloves still remain? – Does any indication for glove removal occur? – When does the exact moment for removing glove apply? – Has the technique to remove gloves been respected? – Have gloves been properly disposed? – Has hand hygiene been performed immediately after glove removal? – Have hands been washed if soiled with blood or another body fluid after glove removal? 137
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