Prospective, Controlled, Cross-Over Trial of Alcohol-Based Hand Gel in Critical Care Units

Rupp, Mark E. MD
Fitzgerald, Teresa RN
Puumala, Susan MS
Anderson, James R. PhD
Craig, Rita RN
Iwen, Peter C. PhD
Jourdan, Dawn RN
Keuchel, Janet RN
Marion, Nedra RN
Peterson, Delayne PA
Sholtz, Lee RN
Smith, Valerie RN

From the Department of Internal Medicine (M.E.R.), the Department of Societal and Preventive Medicine (S.P., J.R.A.), the Department of Pathology and Microbiology (P.C.I.), the Department of Pulmonary and Critical Care Medicine (D.P.), University of Nebraska Medical Center, and the Department of Healthcare Epidemiology (M.E.R., T.F., R.C., D.J., J.K., N.M., L.S., V.S.) Nebraska Medical Center, Omaha.

Address reprint requests to Mark E. Rupp, MD, 984031 Nebraska Medical Center, Omaha, NE 68198–4031 ([email protected]).

Presented in part: 14th Annual Scientific Meeting of the Society for Healthcare Epidemiology of America; Philadelphia, Pennsylvania; April 17–20, 2004 (Abstract 351).

Received May 29, 2007; accepted September 25, 2007; electronically published November 21, 2007.

Infection Control and Hospital Epidemiology 29(1):p 8-15, January 2008.

BACKGROUND

There are limited data from prospective studies to indicate whether improvement in hand hygiene associated with the use of alcohol-based hand hygiene products results in improved patient outcomes.

DESIGN

A 2-year, prospective, controlled, cross-over trial of alcohol-based hand gel.

SETTING

The study was conducted in 2 medical-surgical ICUs for adults, each with 12 beds, from August 2001 to September 2003 at a university-associated, tertiary care teaching hospital.

METHODS

An alcohol-based hand gel was provided in one critical care unit and not provided in the other. After 1 year, the assignment was reversed. The hand hygiene adherence rate and the incidence of nosocomial infection were monitored. Samples for culture were obtained from nurses' hands every 2 months.

RESULTS

During 17,994 minutes of observation, which included 3,678 opportunities for hand hygiene, adherence rates improved dramatically after the introduction of hand gel, increasing from 37% to 68% in one unit and from 38% to 69% in the other unit (P<.001). Improvement was observed among all groups of healthcare workers. Hand hygiene rates were better at higher workloads when hand gel was available in the unit (P=.02). No substantial change in the rates of device-associated infection, infection due to multidrug-resistant pathogens, or infection due to Clostridium difficile was observed. Culture of samples from the hands of nursing staff revealed that an increased number of microbes and an increased number of microbe species was associated with longer fingernails (ie, more than 2 mm long), the wearing of rings, and/or lack of access to hand gel.

CONCLUSIONS

The introduction of alcohol-based gel resulted in a significant and sustained improvement in the rate of hand hygiene adherence. Fingernail length greater than 2 mm, wearing rings, and lack of access to hand gel were associated with increased microbial carriage on the hands. This improvement in the hand hygiene adherence rate was not associated with detectable changes in the incidence of healthcare-associated infection.