ReviewClinical effectiveness of alcohol-based products in increasing hand hygiene compliance and reducing infection rates: a systematic review
Introduction
One of the biggest challenges facing healthcare services is to reduce the incidence of healthcare-associated infections (HAIs). An HAI, or nosocomial infection, is defined as an infection that was not present at the time of hospital admission but was acquired via the provision of healthcare.1 HAIs are endemic worldwide and their prevalence in Scotland is comparable with that in other European countries, where the estimated incidence ranges from 6 to 10%.2 In Scotland, HAIs are a major factor in an estimated 457 deaths each year, and are a contributory factor in a further 1372 deaths, claiming more lives than traffic accidents, drug-related deaths and acquired immune deficiency syndrome.3 HAI can also complicate treatment of the condition that required hospitalization, cause patient distress, slow recovery, increase the duration of hospital stay and cause disability.4 The economic burden of HAI is substantial, with the annual cost to NHS Scotland estimated as £186 million.3
As healthcare staff often play a role in the spread of HAI, good hand hygiene practices are important in reducing the incidence of such infections.5, 6 However, compliance with hand hygiene guidelines and standards is unsatisfactory, and various initiatives have been developed to improve the situation. One approach involves the use of alcohol-based hand hygiene products, which, unlike soap and water, do not require access to a sink, and are also quicker to use.7 Whilst alcohol-based products do not replace handwashing for visibly soiled hands, these products have a role in improving hand hygiene in other situations where the hands may be contaminated.7
The systematic review described here was carried out by NHS Quality Improvement Scotland, as part of a Health Technology Assessment (HTA) entitled ‘The provision of alcohol-based products to improve compliance with hand hygiene’ in May 2005.8 NHS Quality Improvement Scotland is a Special Health Board, established by the Scottish Executive in 2003 to improve the quality of healthcare delivered by NHS Scotland. One of its roles is to provide evidence-based advice to the NHS in Scotland.
The review aimed to assess the clinical effectiveness of alcohol-based hand hygiene products, in terms of improvements in hand hygiene compliance and/or associated HAI rates. As these products are usually introduced as part of multi-component interventions, it is often not possible to evaluate their effects independently from those of the other intervention components. Therefore, literature assessing the clinical effectiveness of multi-component interventions that did not include alcohol-based hand hygiene products was also reviewed.
Section snippets
Methods
A systematic literature search was performed between May and November 2004. The search strategy combined terms for the concept of ‘handwashing’ with those relating to ‘infection’, ‘alcohol cleanser’ or ‘compliance’. Studies were excluded if they were conducted in dental surgeries, considered to be surgical scrubbing, aimed to improve hand hygiene solely or primarily as a universal precaution (i.e. to protect healthcare workers from infection), examined handwashing technique or duration as the
Interventions to improve compliance with hand hygiene
Twenty-six studies met the inclusion criteria. Of these, 20 were uncontrolled prospective studies, five were prospective studies with non-randomized parallel control groups, and one employed a cross-over design. Hand hygiene compliance was assessed by self-reporting (one study), hand hygiene product usage (two studies), or direct observation (23 studies). There was considerable variation in the indication for hand hygiene; some studies required the procedure before and/or after each patient
Discussion
Alcohol-based hand hygiene products are usually introduced as part of multi-component interventions to improve hand hygiene compliance and infection rates, rather than in isolation. The evidence showed that multi-component interventions that include alcohol-based products are as effective as those that do not, both in achieving sustained hand hygiene compliance and in reducing the incidence of HAI.
However, a number of difficulties were encountered in assessing hand hygiene studies and in
Acknowledgements
Julie Eastgate provided assistance with preparation of the manuscript.
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