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

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE
evaluation 197,221,264,326,327,329,405,495,504,608,610,613,636 (see Part I, Section
14). Some studies have confirmed that these assessment
techniques correlate well with other physiological measures
such as transepidermal water loss or desquamation, tests which
are not practical to use in clinical settings. 264,326,405,495,549,577,613,636
An example of a tolerability assessment framework for use in
the clinical setting is included in Appendix 3 220,504,572 and is part
of the <strong>WHO</strong> alcohol-based handrub tolerability and acceptability
survey (Implementation Toolkit available at http://www.who.
int/gpsc/en/) (see also Part I, Section 14). Dermal tolerance is
one of the main parameters leading to the product acceptability
by HCWs that influences directly the compliance with hand
hygiene. It is demonstrated that dermal tolerance of alcoholbased
handrubs is related to the addition and the quality of
emollient in the product; 504,580,627 even alcohols, frequently used
in alcohol-based handrubs, are known to generate a minor
skin irritant effect compared with handwashing with soap and
water. 548,583
15.2.2 Aesthetic preferences
Fragrance.
Products with a strong fragrance may lead to discomfort and
respiratory symptoms in some HCWs allergic to perfume or
fragrances. Many patients complain about perfumed products,
especially in oncology. Therefore, consideration should be given
to selecting a product with mild or no added fragrances.
Consistency (texture).
Handrubs are available as gels, solutions or foams. Dermal
tolerance and efficacy were not considered as they are not
affected by consistency. 203,495 Although more expensive than
solutions, gels have recently become the most popular type
of alcohol-based handrub preparation in many countries.
Due to their formulations, some gels may produce a feeling of
humectant “build-up”, or the hands may feel slippery or oily
with repeated use. This difference in consistency has not been
associated with better objective tolerance or higher compliance
with hand cleansing in a controlled study. 579 A prospective
intervention study and a comparison study have shown that
the use of a gel formulation was associated with better skin
condition, superior acceptance, and a trend towards improved
compliance. 493,496 Nevertheless, it is worth recalling that first
generations of gel formulations have reduced antimicrobial
efficacy compared with solutions. 205,218 A recent study suggests
that the antibacterial efficacy of alcohol-based gels may
depend mainly on concentration and type of alcohol in the
formulation. 496
Solutions generally have a consistency similar to water while
some are slightly viscous. They often dry more quickly than
gels or foams (a potential advantage) and may be less likely to
produce a feeling of humectant “build-up”. They are more likely
to drip from the hands onto to the floor during use, and it has
been reported that these drips have created spots on the floor
under the dispensers in some hospitals. Solutions often have a
stronger smell of alcohol than do gels. 495,636
manufacturers of foams recommend the use of a relatively large
amount of product for each application, and HCWs should be
reminded to follow the manufacturer’s recommendation.
15.2.3 Practical considerations
Product accessibility.
Several studies suggest that the frequency of hand
cleansing is determined by the accessibility of hand hygiene
facilities. 335,486,492,493,497,498,637-639 A reliable supplier (industrial
or local at the health-care facility) is essential to ensure
a continuous supply of products. If industrial products
are not available or are too expensive, products may be
produced within the local setting (see also Part I, Section 12).
<strong>WHO</strong> identified and validated two different alcohol-based
formulations, and a Guide to Local Production (Implementation
Toolkit, available at http://www.who.int/gpsc/en/). However,
even if a simple method is proposed, it is difficult to regulate the
quality control of locally made products, and more sophisticated
but feasible methods to monitor quality are needed.
Issues related to infrastructure necessary to ensure continuous
access to hand hygiene products and equipment are specifically
dealt with in Part I, Section 23.5.
Risk of contamination.
Alcohol-based rubs have a low risk of contamination, 338 but
soap contamination is more common. 160,640-644 Multiple-use
bar soap should be avoided because it is difficult to store
bar soap dry at a sink, with a subsequent increase in the risk
of contamination. 640-642 Although liquid soaps are generally
preferred over bar soaps for handwash, the risk for either
intrinsic 643 or extrinsic 160,644 microbial contamination still exists.
15.2.4 Cost
The promotion of hand hygiene is highly cost effective (see
Part III, Section 3), and the introduction of a waterless system
for hand hygiene is a cost-effective measure. 329,645,646 While
the cost of hand hygiene products will continue to be an
important issue for departments responsible for purchasing
such products, the level of acceptance of products by HCWs is
even more important. An inexpensive product with undesirable
characteristics may discourage hand hygiene among HCWs and
the resulting poor compliance will not be cost effective.
Financial strategies to support programmes designed to
improve hand hygiene across a nation may benefit from a
centralized design and production of supporting materials.
This strategy may be more cost effective to the overall health
economy (see also Part III, Section 3).
Foams are used less frequently and are more expensive. Similar
to gels, they are less likely to drip from the hands onto the
floor during application, but may produce stronger “build-up”
feeling with repeated use and may take longer to dry. Some
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