Patient - Wash Thy Own Hands!

There has been increasing attention over the past decade in engaging patients in patient safety. In infection control this trend has manifest through efforts to have patients monitor and encourage hand hygiene compliance among health care workers. In a related trend, there is also increased interest in patients washing their own hands in a framework called "patient-centered hand hygiene." My understanding of this approach is that having patients clean their own hands could potentially increase their engagement in infection control initiatives including encouraging health care workers to practice hand hygiene. This approach might also have the additional benefit in decreasing the organism burden on patients' hands and interrupting direct or indirect transmission of MDROs in healthcare settings.

It is with this background that Kundrapu and colleagues at CWRU and the Cleveland VA completed a randomized trial of soap and water versus alcohol hand rub in reducing C. difficile spore burden on patients' hands. Forty-four infected or colonized patients were included in the study. Hand cultures were positive in 32% of patients with CDI and 38% of colonized patients prior to hand hygiene. As you can see from the figure below, soap and water significantly reduce the proportion of positive cultures and mean CFUs, while alcohol hand rub did not. Interestingly, around 10% of patients still had C. difficile recovered after washing with soap and water. Seems like a trial is in order to determine the role of patient hands in transmission and whether cleaner patient hands reduces the incidence of CDI and other MDROs in hospital settings. One major limitation is that this intervention could not be implemented in settings where the need is the greatest, namely ICUs, since most patients would be too sick to wash their hands.

Alcohol hand rub prevents rhinovirus infection (despite the authors’ claims) and it can get you really pissed!

This morning, two kind folks independently pointed me to new reports on the efficacy of alcohol hand rub.  The first report in CID by Ronald Turner et al. describes a randomized trial of the efficacy of 62% ethanol hand rub for the prevention of rhinovirus infection.  In the study, 116 volunteers were randomized to the active hand rub group and asked to apply the hand rub after each hand washing episode and also every three hours for 9 weeks. Apparently, there is data showing ethanol hand rub prevents rhinovirus for up to 4 hours. The 96 unblinded controls were asked to practice their usual hand hygiene routine. All enrolled kept a diary of symptoms, had weekly nasal lavage for PCR and two additional nasal lavages if they developed cold symptoms.

The results of the study were somewhat surprising, especially if you just read the abstract and focus on the highlighted p-values.  The authors conclude that "hand disinfection did not reduce rhinovirus infection or rhinovirus-related common cold illnesses."  When you look more closely, only 39% of treated subject developed a confirmed infection versus 49% of untreated. Sure, the p=0.3, but this is just because the study is underpowered. Oh, and reported common cold illnesses were lower in the hand disinfection arm (56% vs 72%, p=0.01). And then read their conclusion - a bit of an over-reach: "the results of our study call into question commonly held assumptions about the route of spread of rhinovirus infection..."  Wow. Do one underpowered study - not blinded, cherry pick the results and then claim rhinovirus might not be spread via hands?

h/t Charlesnika Evans 

The second report highlights the efficacy of hand rub in getting kids wasted.  The MSNBC.com report by Jane Weaver (with Today Show video) describes how 16 LA teens have been treated for intoxication after guzzling 120-proof alcohol hand rub.  Some might even be distilling it first.  Very ingenious.

h/t Mark Vander Weg

From the Department of Unintended Consequences

This morning, one of our infection preventionists came into my office with a bottle of our alcohol-based hand rub and a salt shaker. She poured gel into a plastic cup, dumped a couple teaspoons of salt into it, and voila! The emollients immediately precipitated out, leaving behind a solution that I assume must have been about 120 proof (no, we didn’t drink it….).

This little science experiment was performed as a result of reports we’ve received from another healthcare facility in our region that is having problems with hand rub ingestion using this method of emollient removal—a method that is now available on the interwebs for all to see. Others have reported problems related to hand rub ingestion, and I’ve read many of those reports—however, I was unaware of how easily one could render a disgusting gel into a potable alcohol solution. Here is an interesting report and description of one such use in a prison population, from a Clinical Toxicology meeting in 2006:

Hand Sanitizer Abuse

Roche KM, Barko IR, McDonagh J, Bayer MJ, Sangalli B. Connecticut Poison Control Center, UCONN Health Center, Farmington, CT, USA; Hartford Hospital, Hartford, CT, USA.

Background: Hand sanitizers are often gel-like emulsions, containing high concentrations (>60%) of ethanol. We became aware of correctional facility (CF) inmates using table salt (NaCl) to “break” these emulsions, to generate consumable ethanol. Therefore, a potential for abuse of these products by inmates and others exists. We sought to recreate this procedure and analyzed the resultant liquid for its alcohol concentration. We also surveyed the medical staff and corrections officers (staff) of the state's eighteen correctional facilities to assess their awareness of this practice. Methods: A) Following the method used by CF inmates, four ounces of hand sanitizer was added to a clean cotton sock that was placed over a glass graduated beaker. One teaspoon of NaCl was sprinkled on the gel-like material and within seconds a cloudy liquid filtered into the beaker. The resultant liquid was sent to an independent lab for alcohol analysis using a gas chromatography headspace technique. B) A telephone survey queried the CF staff of each facility (correctional officer (CO) supervisor and nurse) as to: 1) their awareness of this practice in their facility; 2) product availability to inmates, and 3) the value of this information towards changing their institution's policy regarding product availability. Results: A) Laboratory analysis revealed that the submitted liquid contained: ethanol 69.9% v/v; Isopropyl 2.1% v/v. B) Survey Results: 94% (17/18) of the CF staff were not aware of the potential abuse of these products. Inmates had direct access to product in 22% (4/18) of CFs. In one CF, product was removed from the cell blocks as a result of our survey. In 100% (18/18) of CFs, product is used in all medical areas as well as carried by correction officers. Discussion: CF staff found this information both enlightening and beneficial. Surveyed nurses planned on notifying their supervisors and the CO supervisors relayed that they would notify their staff. Conclusion: We discovered the potential for abuse of hand sanitizers in a number of state correctional facilities. More importantly we educated CF staff on the need to control product accessibility to inmates.

What does this mean for prevention? Besides keeping easily accessible products off units where abuse potential is high, education of staff should include awareness of the abuse potential, so that hand rub ingestion is considered when circumstances suggest it as a possibility (e.g. unexplained mental status changes, combined with higher than average product utilization!).

New studies on alcohol-based hand sanitizers

There are two new studies on the use of alcohol for hand hygiene. Antimicrobial Agents and Chemotherapy has a study from the University of Virginia in which volunteers had their hands inoculated with rhinovirus followed by hand hygiene. Water alone removed the virus from 12% of study subjects, soap and water was 31% effective, and alcohol was 81-87% effective.

In the second study, just released by BMC Infectious Disease, researchers found that with the use of alcohol foam, the larger the volume applied, the longer it takes to dry. Makes sense. But the investigators found that the volume of alcohol that would dry by 30 seconds was only slightly better than water alone in removing E. coli that had been inoculated onto the hands. So more is better; a little dab won't do ya.

Too much of a good thing?

A hospital in the UK is removing alcohol gel dispensers at entrances to the building because of instances of homeless persons drinking the gel. The article reports that two deaths in London have been attributed to this. Gel dispensers will remain in other parts of the hospital.