The Advantages of Using Alcohol-based Hand Rubs in Healthcare

According to an article in Clinical Infectious Diseases, "scientific evidence and ease of use support the use of a hand rub" as an alternative to conventional hand washing for the routine hand hygiene for healthcare workers (HCWs).

Hand Hygiene

Hand hygiene, or the removal or destruction of microorganisms on the hands, is "the single most important factor in preventing nosocomial infections." Traditionally, hand hygiene has been achieved through hand washing, which "suspends microorganisms and mechanically removes them by rinsing with water," or removes and kills microorganisms when one uses a soap containing an antimicrobial ingredient.

Drawbacks of Hand Washing

The Centers for Disease Control and Prevention (CDC) "has recommended hand washing for hand hygiene for decades," and proper hand washing for at least fifteen seconds has been demonstrated to be effective. Unfortunately:

  • Employee compliance with hand washing procedures "rarely exceeds 40% in the situations in which hand washing is deemed necessary," a trend which has shown no sustained improvement for the last twenty years
  • When HCWs do practice hand washing, they commonly do so for less than 10 seconds
  • Despite the effectiveness of hand washing, "journals continue to publish reports of outbreaks of disease transmitted by contaminated hands, which suggests that the current recommendations for hand hygiene are not always followed"
  • Hand washing is time consuming, and "HCWs may just not have the time necessary to wash their hands"
  • Washing one's hands correctly requires 1-2 minutes
  • One mathematical model estimates that, in order to achieve 100% compliance, an ICU would have to devote ~16% of its available nursing time to hand washing
  • A clinical trial found the time required for proper hand washing to be even greater than that estimated by the above model
  • Although limited access to hand washing "has been shown to be an important risk factor for poor compliance," sinks are costly and can not practically be installed at locations convenient to HCWs
  • Soaps may become "contaminated during use and trigger an outbreak"
  • Due to the possibility that hands may be contaminated by the faucet or splashes from the trap or sink, and that plumbing systems may become contaminated, "recontamination with waterborne bacteria after hand washing is a concern"
  • Finally, some evidence indicates that "hand washing is not always sufficient to prevent cross-transmission of pathogens"
Advantages of Including an Alcohol-based Hand Rub in Hand Hygiene Regimens

Using an alcohol-based hand rub is fundamentally different from hand washing. While such rubs do not remove dirt and debris, and are therefore not an option if hands are visibly soiled or contaminated with proteins or organic matter, they have proven advantageous over hand washing in a number of ways.

  • Compliance with hand hygiene procedures has been shown to improve significantly when a hand rub is used in place of hand washing
  • Numerous in vitro studies and in vivo studies have shown that disinfectants, such as alcohol-based hand rubs, offer bacteria-killing activity that is superior to hand washing, a conclusion which has been "validated in a randomized crossover clinical trial of preoperative hand scrubs."; in fact, one recent review "favored the use of the hand rub for hand hygiene before invasive procedures"
  • In some instances, hand rubs are more effective against viruses than hand washing
  • Using an alcohol-based hand rub saves time
  • Preliminary data indicates that using a hand rub takes 18-27 seconds, rather than the 1-2 minutes needed for proper hand washing
  • The same mathematical model that projected ~16% of available nursing time would have to be dedicated to hand washing before an ICU achieved 100% compliance also found that switching to "a hand rub would decrease the necessary time to 26% of that needed for regular hand washing"
  • One of the risks inherent in hand washing, the possibility of recontamination due to both contaminated plumbing systems and contact with the faucet and/or sink, is "intrinsically excluded by the use of an alcohol hand rub"
  • Side effects caused by using a hand rub "are rare and are mainly related to dryness of the skin."; In fact, one institution, a 1,000-bed tertiary care center, compiled a database – covering a span of over 10 years and including more than 3,500 HCWs – that "did not identify a single case of documented allergy" to the hand rub the facility used
  • Hand washing dries the skin, "whereas alcohol compounds only redistribute lipids"
When one considers all of the advantages, it is probably not surprising that most countries in Northern Europe use hand rubs as the standard for hand hygiene.

Nor is it surprising that Widmer concludes that the use of an alcohol-based hand rub is "an excellent alternative to hand washing when antimicrobial efficacy, time for the procedure, and limited access to sinks are of concern."