Does the Availability of Alcohol-Based Hand Sanitizer Increase Hand Hygiene Compliance Levels?

Part I: Problem Identification

Background and Need for Research

The practice problem addressed in this paper is: For nurses in critical care/intensive care units, does the availability of alcohol-based hand sanitizer increase hand hygiene compliance levels? Hand hygiene refers to the ability to clean hands to make sure they are free of dirt and germs. Traditionally, hand hygiene in a hospital setting was cared for by washing hands with soap and water but, in recent years, alcohol-based hand sanitizers are often used to accomplish the same purpose. Regardless of the method used, nurses realize the importance of preventing the spread of germs, especially in acute settings such as critical or intensive care units. Hospitals now typically make hand sanitizers available in most locations since they are convenient to use and allow nurses and other medical staff to practice good hand hygiene when soap and water are not practical. The wide availability of hand sanitizer provides an opportunity to eliminate (or minimize) the spread of germs and may actually improve overall compliance with protocols designed to accomplish that purpose.

While most health care workers, including nurses, are well aware of the benefits of hand sanitizers they are still not regularly used. Research indicates that compliance with hand hygiene protocols and adherence to a consistent pattern of usage is alarmingly low; in some cases in the 20 to 40 percent range (Kheder, Eltayeb, & Shaddad, 2010). In many cases, working conditions and location determine the level of hand sanitizer use and overall hand hygiene. Soap and water are becoming less preferred in most settings as the primary method of hand hygiene for a variety of reasons, including inconvenience and skin irritation (McArdle, Lee, Gibb, & Walsh, 2006). In contrast, hand sanitizers are extremely convenient and should improve compliance in most cases. Nurses that utilize hand sanitizer have a demonstrably higher level of hygiene rates in health care settings (Hilburn, Hammond, Fendler, & Groziak, 2003). Since this is the case in general health care settings, it is logical to assume that increased use of hand sanitizers by nurses assigned to critical care/intensive care units will similarly benefit.

Significance of the Problem

Hand hygiene in a hospital setting is acknowledged as a simple but effective method of preventing infections such as C. Difficile. In recent years, widespread initiatives at the domestic and international level attempt to educate health care leadership to emphasize compliance with hand hygiene programs (Pittet, Allegranzi, & Boyce, 2009). One of the most important success factors in improving the level of compliance is simply making sure that hand sanitizer is widely available in a health care setting. Now that hand sanitizer is a common sight throughout hospitals for use by visitors and others, it seems logical that increased availability of hand sanitizer in critical care areas of the hospital is even more worthwhile (Sax et al., 2009). Of course, availability does not necessarily mean increased usage by the nursing staff, so a study of this topic is beneficial for all stakeholders in the hospital environment.

In light of the importance of hand hygiene in a hospital setting, it is important to identify the most effective methods for encouraging compliance with hygiene policies, especially within critical care and intensive care units. Hand hygiene may be cared for using standard soap and water or alcohol-based hand cleaners. While it is now recognized that the latter is just as effective as soap and water as well as quicker and more convenient to use, the question of whether nurses are consistently using hand sanitizer needs further research. The literature reveals several studies indicating that the availability of hand sanitizer improves compliance with hand hygiene protocols.

Part II: Review of the Literature

The literature indicates the possibility of improving the frequency with which nurses and other health care professionals use hand sanitizer. Numerous studies exist that support a connection between various interventions and a higher level of hand hygiene compliance (see, e.g., Helder et al., 2010; Marra et al., 2010a; Rosenthal et al., 2009), but there is limited evidence of improving compliance over 90 percent (e.g., Cromer et al., 2009; Duggan et al., 2009; Lederer, Best, & Hendrix, 2009). The problem with these studies, however, is that only Lederer et al. utilized a methodology designed well enough to allow the observance of long-term improvement. This is a consistent theme in the literature. While some studies report improvements in the use of hand sanitizer and more effective hand hygiene, it is unclear whether these improvements are sustainable.

One exception to this trend was a study conducted by Linam, Margolis, Atherton, and Connelly (2011) which reported improved compliance over an extended period of time based on an intervention that included education on the use of hand sanitizer and reminders provided by leadership in the hospital setting. In the view of Linam and associates, improved compliance in hand sanitizer usage requires more than just the availability of the product. Rather, their results indicated that increased availability should be accompanied by individual feedback and active encouragement, which resulted in a compliance rate of 90 percent Linam et al., 2011). The addition of feedback is also significant for increased compliance within specifically targeted groups in a health care setting that have a critical role in the treatment of patients, such as nurses.

The literature is consistent in presenting evidence that increased availability of hand sanitizer relates to an increased level of hand hygiene compliance. Another issue that is addressed is the amount of time saved by using hand sanitizer in contrast with soap and water. That topic was addressed by Voss and Widmer (cited in Kheder et al., 2010) who determined that washing hands with soap and water takes over five times as long as using hand sanitizer. This additional time is significant, as the cited study—based in an ICU—reported that traditional hand washing required a total of 16 hours each day for the 12 nurses included in the study while using hand sanitizer consumed just three hours. Based on this earlier study, additional research found that convenient access to hand sanitizer in an ICU improved hand hygiene compliance (Omer, Khedir, & Elkhawad, 2010). Clearly, the benefits of hand sanitizer make it the choice of nurses in critical care settings.

While the ultimate goal of hand hygiene programs is 100 percent compliance, there is nothing in the literature to indicate that the goal is attainable. One study that addressed that issue is Kheder et al. (2010) which determined that full compliance is unrealistic. Nevertheless, any improvement in the level of compliance is beneficial, especially among nurses working in critical care environments. This study, as well as most of the literature, indicates that greater availability of hand sanitizer is the first—and most important—step in improving hand hygiene compliance levels. The benefit of hand sanitizer is self-evident since it can be placed near the beds of patients in critical care/intensive care units to increase the ease of access. Studies such as Kheder et al. (2010) support the hypothesis that greater (and more convenient) availability of hand sanitizer creates an environment of greater compliance especially for busy nurses who do not want to engage in practices that unnecessarily take time away from their critical duties and patient care.

Not all studies that support the use of hand sanitizer focus on specific groups of health care workers. One such study (Rupp et al., 2008) provided evidence of an improvement in hand hygiene in the general workforce of health care workers. The key element involved, according to that study, was increased availability of hand sanitizer at various locations throughout the facility. One of the groups included in the study was nurses who tested at lower levels of microbial flora on their hands. Rupp and associates did not attempt to determine if increased levels of compliance with hand sanitation were related to decreased levels of patient infections since that was beyond the scope of the research. However, such a relationship was suggested for future research.

Many of the improvements in hand hygiene that are reported on in the literature are the result of specific efforts to improve quality to health care settings. In Russia, a study by Brown et al. (2003) focused on how such a quality improvement included the increased provision of hand sanitizer in health care settings. The results of this study were not as impressive as many undertaken elsewhere (especially in Western countries) since there was only slight improvement observed in compliance with a hand hygiene program following the addition of hand sanitizer in more locations than were previously available. Brown and colleagues (2003) obtained results similar to those found in the research conducted earlier in Switzerland (Pittet et al., 2000) that noted an improvement in compliance, but not to the levels desired. Nevertheless, it must be noted that any improvement in hand hygiene compliance is beneficial and may eventually expand to others as those benefits are recognized.

Performance feedback is one method used in many of the studies reported in the literature. However, most of the studies taking that approach focus simply on feedback provided at a later time or based on aggregate assessments of overall compliance (Linam et al., 2011). In contrast, it is more beneficial to encourage health care workers, including nurses, to make personal assessments of their compliance with hand hygiene protocol, including expanded use of hand sanitizer. This method enables the nurse to recognize at the time whether or not hand sanitizer was used, and that information can be used to improve subsequent behavior (Linam et al., 2011). Linam and colleagues utilized real-time identification and mitigation in the study to identify the most effective assessment methods. The conclusions of this study included the benefit of having hand sanitizer readily available in health care settings since that is what the professionals identified as the most critical factor contributing to an improved perception of the need for hand hygiene. External feedback also aided this process, especially when it was carried out as encouragement rather than criticism.

Some of the studies included in this review of the literature have specific weaknesses based on their methodology. For example, the use of a cross-sectional study by Kheder et al. (2010) allowed the study to only measure compliance in a very limited time frame, rather than an assessment of thorough compliance over an entire year. Therefore, actual compliance levels may not have been accurately identified. Moreover, while the nurses involved in that study were not supposed to be aware that their use (or non-use) of hand sanitizer was being observed, it is possible that they suspected it, which may have altered their behavior as a result. Consequently, the validity of the results may be in doubt.

Another study (Marra et al., 2010b) had similar limitations. Results of any study based at one location only may not be generalizable to other locations. While electronic counters were utilized by the researchers to track hand sanitizer usage, these participants may likewise have been aware that they were being observed and adjusted behavior to appear to be more in compliance with hand hygiene guidelines.

Part III: Discussion

Final Analysis

There were several themes observed in the literature review all pointing to the general conclusion that the availability of hand sanitizer improves hand hygiene in health care settings. For nurses working in critical care units, this conclusion carries additional weight since they are directly treating patients with compromised health who are more susceptible to infections. In addition to simply providing hand sanitizer in additional locations, the literature also indicated that performance feedback was useful—at both the external and personal levels. Finally, it was also observed that 100 percent compliance is unlikely, but that significant improvements are possible if dedicated measures are undertaken and nursing staff is fully committed to a hand hygiene program.

There is little doubt, based on the literature presented here for a review that increased availability of hand sanitizer results in higher compliance with the goal of improved hand hygiene. Since hand hygiene in a hospital setting is understood to be one of the most basic actions that nurses can take to reduce the spread of germs it is important to identify the most effective methods for encouraging compliance with hygiene policies. Nurses that work in critical care and intensive care units are likely more aware of the need for hand hygiene but the literature still indicates that compliance is low in many hospitals. Clearly, the wide availability of hand sanitizer provides an opportunity to eliminate (or minimize) the spread of germs and may actually improve overall compliance with protocols designed to accomplish that purpose. Measurement of success in hand hygiene compliance for a future study should be based on a percentage of improvement over the baseline, which needs to be established prior to the start of any study. The goal of any study is to improve compliance levels among nursing professionals.

Future research should be based specifically in critical care units in multiple hospitals, perhaps in one large city or, if feasible, two or three cities. The population included in the study should be the critical care nurses working in these respective units. Additionally, a longitudinal study should be established in order to thoroughly examine compliance behavior over an extended period of time. From a practical standpoint, the study could be limited to a 12 month period. The study would involve observation of behavior in such a way that the nurses were unaware that they were being observed. This might be accomplished by using existing employees in the hospitals involved in the study as observers in order to minimize the risk of nurses recognizing that they are being observed.

An additional feature of the methodology is a comparison between two study groups. One group of nurses would simply be observed to see if they were taking advantage of increased availability of hand sanitizer in critical care/intensive care units. The second group (also working in critical care/intensive care units) would have similar availability to hand sanitizer, but would also be involved in feedback and education related to the benefits of hand hygiene in general and hand sanitizer in particular. These dual groups are suggested for the research based on the literature, which indicated that the availability of hand sanitizer alone results in improved compliance in many cases (but not all), while feedback interventions are also successful in certain settings. Therefore, the thesis for this future research is that increased access to hand sanitizer is beneficial for compliance with hand hygiene protocol, but it is likely that the availability of hand sanitizer in combination with feedback and education will result in greater improvement that may be more sustainable.

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