Clinical effectiveness of alcohol-based products in increasing hand hygiene compliance and reducing infection rates: a systematic review

Summary

Reducing the incidence of healthcare-associated infection represents a major challenge. This systematic review of the evidence base considers the clinical effectiveness of incorporating an alcohol-based hand hygiene product into procedures aimed at improving compliance with hand hygiene guidelines, and thereby reducing the incidence of healthcare-associated infections. Multi-component interventions that included alcohol-based products were as effective as those that did not, both in achieving sustained hand hygiene compliance and in reducing infection rates. However, a number of difficulties were encountered in assessing hand hygiene studies: the problem of attributing efficacy to an alcohol-based product when used in a multi-component intervention; the variability inherent in the design of such studies; and how to use data from uncontrolled, unblinded studies in the assessment.

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.