Introduction
The aim of this paper is to research “The efficacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap”: randomised clinical trial (Girou et al 2002). According to Garner & Hierholzer 193:250 “Handwashing is the most effective method of reducing infections in hospitals. As this paper highlights and focuses on the prevention of cross contamination and nosocomial infections. The avoidance of infection is paramount in all healthcare setting. Improving hand hygiene reduces the risk of health care associated infection (Pittet et al 2000 citied in Nursing Times October 2004). There are two methods used in this study: soap and alcohol. Soap is a detergent and is used to remove dirt, soil and substances when applied with water. Soap is available is most hospitals in dispensers. Chlorhexidine gluconate was used in this hand wash solution. This is soluble in water but the diguconate form is water soluble (Boyce & Pittet 2002, citied in the Nursing Times October 2004). In this solution there is good activity against Gram positive bacteria, but it is less active against Gram negative bacteria. This chemical has no effect on tubercle bacilli or spores and little effect on viruses. Whilst Alcohol hand decontainants contain propanol. This is available as gels, liquids and many more. Solutions of 60-90% are most effective. The higher the concentration used, the less effective, as the water used in this process weakens the proteins (Gardener & Peel 1996).
The outcome is measurable as the hypothesis is to reduce bacterial of hand contamination. The hospital epidemiologist is a well known author who has written numerous papers concerning infection control; he is highly qualified in this field. This research has been sponsored by a Germany Alcohol gel company “Bode Chemie Gmbh & Co.”, Studies have been completed in the past, however lack of confidence has led to unacceptance in this investigation (Tayor 1978). These studies involved increasing the number of sinks and educating healthcare workers in this method. The framework that I will be using for this paper is “Cormack” from The Research Process in Nursing 4th Edition by Desmond Cormack.
Whilst reviewing this paper the title is minimal. In order to carry out a research study it is vital to identify and emphasis on the environment as it is a contributes factor in its findings. Although it was clear it does not however, explain the environment in which the experiment takes place and with whom. Therefore I have found the title vague. The objective of this paper is evidence based as it is used in clinical practice continuously. For this procedure to be undertaken, knowledge, skills, planning and time are a vital aspect. Research in the healthcare setting is ongoing and is a pathway to new technology. According to Hockey research is “An attempt to increase the sum of what is known, usually referred to as a “body of knowledge” by the discovery of new facts or relationships through a process of systematic scientific enquiry, the research process” (Hockey: 1984:4).
The abstract of this paper did not state the amount of patients included in the research. The methodology is set out to explore handwashing with alcohol based solution versus standard handwashing with antiseptic soap. To explore this statement in more detail a qualitive research design was used. A qualitative approach was used in this study using a participant observation. “By participant observation we mean the method in which the observer participates in the daily life of the people under study, either openly in the role of researcher or covertly in some disguised role, observing things that happen, listening to what is said, and questioning people, over some length of time” (Becker and Geer 1957:200). This type of method is used to aid researchers in understanding people and the process being investigated.
Two clinical studies have been completed in the past. One observational study and one randomised controlled trial with results favouring handrubbing. The randomised study compared handwashing with antiseptic soap versus handrubbing with alcohol based solution. This study resulted in the findings of skin problems as the main issue. The randomised trial focused on patient care using the same procedure. The study took place in June to July 2000 and was undertaken in three intensive care units, although research findings were not published until 2002 in the British Journal of Nursing.
The duration of this study was adequate, since handwashing is used in every day activities within the setting. The study was undertaken in a French hospital with 114 patients and twenty three healthcare workers with a small range of healthcare professionals. Healthcare professionals volunteered for this task and were then selected at random. The participants involved were unaware of being observed. This made it non bias. The participants used were nurses and nursing assistants in this study. Although two occupations were of the same capacity, this created the experiment to be measurable. This provided real life situations as the experiment was carried out within a working hospital setting.
During this task the healthcare workers were given sealed envelopes, which assigned the person to their handwashing technique, this was the use of handwashing with medicated soap or handrubbing with a waterless alcohol based solution. Participants involved in this act had a criteria assigned to them, stating that if their hands became visibly soiled with bodily fluids they would wash their hands with antiseptic soap and the session would come to a end. Whilst having a handrubbing policy the applicants were knowledgeable in the use of alcohol based solutions, introduced by the infection control committee. Literature was available to educate the participants in the work setting, as this was important when using the method of handwashing such as timing of handwashing and hand rubbing.
The sessions were monitored every two to three hours. Routines performed were direct contact with the skin of a patient before and after care, also patients who were with multiresistant bacteria (MRSA). The nature of care was observed and recorded by two observers. These observers were part of the infection control team. The type of care involved included gloves worn, duration of care and the opportunies of hand hygiene during patient activities. All of which are a fundamental of hand hygiene in reducing infection control. The data was collected throughout the procedure by taking imprints of fingertips and palms of all participants, taken before and one minute after the activities. For those who wore gloves, they were removed before this procedure was carried out. Wearing gloves creates a warm, moist environment, which encourages micro-organisms to multiply. Also, gloves may not protect the participants’ hands completely, for example punctures that are hidden allow micro organisms to pass (Hampton 2002). After patient procedures the time spent on handrubbing was enough for decontamination.
The survey states that the participant’s duration for handwashing and handrubbing was thirty seconds to one minute. This time period was sufficient for handrubbing with alcohol based solution however it may be not long enough for handwashing with antiseptic soap. Whilst handrubbing is quick and a fast method to use, the alcohol must be applied in all areas and the hands then rubbed vigorously until dry. Alcohol effectively reduces microbial counts in clean hands. However, handwashing takes and needs time for the procedure to be completed accurately. The handwashing technique should take at least 30 seconds to one minute. (Gould 1994). Handwashing techniques are not always effective. The use of soap can increase the bacterial skin on hands (Larson et al 1986). Health care workers can also develop skin conditions, such as dry or cracked skin. Particular areas of the hands are thumbs, fingernails, fingertips, and the wrists are often missed.
Was this literature read by the participants before conducting this experiment? I would have felt more comfortable knowing that the participants received accurate training in hand hygiene. Since the manner in which they wash their hands would affect the outcome. Although it is part of all healthcare professionals training, good practice becomes forgotten (Paulson et al). In order for this experiment to be effective all participates would need to demonstrate typical hand washing strategies. The data indicates alcohol based solution reduces hand contamination than handwashing with antiseptic soap. In total there was a total of 114 patient care activities, this included 59 in handrubbing and 55 in handwashing amongst 23 healthcare workers, 12 were assigned to handrubbing and 11 to handwashing. The activities designated to the groups were equivalent. The bacterial results were lower after hand hygiene was completed for both groups. The reduction of bacterial contamination accomplished for each participant involved in this study for handrubbing was higher than handwashing. 83% for handrubbing and 58% for handwashing resulting in a range of 26%. During the observation of the hand hygiene activities, handrubbing is the most effective method especially when you take into account the duration of the procedures for example, 65% procedures of hand hygiene using antiseptic soap was only used for 30 seconds. The finding in this study focusing on time was not suffient for all results of bacteria to be acknowledged after decontamination. Whilst handrubbing was also 30 seconds.
Whereas anlyaising this paper it has come to my knowledge that the tasks performed were fair, this involved ten hand samplings, five samples before and five after hand cleaning. The activities involved direct contact with the skin before and after care. Those using gloves and in contact with bodily fluids were excluded therefore making this study more accurate. The data collected during study was detailed knowledge. The amount of people chosen in this survey was sufficient. Using a larger number may cause complications.
Conclusion
At present Super bugs is a major concern in hospitals. New infections are continuous. Research has been going on for a number of years. There are strains of bacteria occurring all the time and research companies need to be update with their knowledge. From this research handrubbing with alcohol based solution is more effective than handwashing with antiseptic soap. The process of handwashing is more complicated than the use of alcohol. There are more points of contact contamination through the procedure of handwashing, such as touching taps and drying hands correctly. Although handrubbing is practical, quick and easy to use with less points of contact contamination. Also remembering alcohol based solutions is more economical. A study completed in a Geneva hospital Switzerland, are also more in favour of alcohol based solutions and nosocomil infections have decreased.
This survey could be perceived bias as the company carrying out the survey would look favourable on their own product as they wish to sell it. Therefore it could be seen as an advertising promotion rather than an independent survey. Perhaps different departments could have been used. Why was the survey completed in three intensive care units? Intensive care units have more complex illnesses and hygiene is an utmost in these units. Different methods and departments in the survey could have being used. Furthermore the University hospital used in this study was a training hospital. Therefore the participants in the study should be 100% in hand hygiene methods. Further study needs to be carried out in this research, as it is not conclusive. Good hand hygiene is vital in health care. Health care workers should be engaged in a variety of procedures and methods, as the conformity will be weak if the products are unpopular.
Reference
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Websites:
http:// Department of Health
http:// www. Nursingtimes.net/ntclinical/handwashing _what _ is_the_best_solution.html
http://www.bmj.com/cgi/content/full325/7360/362
Journals
Alcohol hand rubs: hygiene and hazard
John R H Archer, David M Wood, Zoe Tizzard, Alison L Jones, & Paul I Dargan
BMJ 2007 335: 1154-1155.
Alcohol handrubs v soap
BMJ 2003 326:50.
Girou E.& Loyeau Legrand S et al. Efficacy of handrubbing with alcohol based solution
versus standard handwashing with antiseptic soap. BMJ 2002;325:362 (17 August).
Juhani Ojajarvi, Arti Thakerar, & Collin Goodbourn.
Lancet 2000 Oct 14 (9328) 1307-12 11073019. More staff are using alcohol base solution. Nosocomil infections have decreased.