by Nancy Andrews, RDH, BS
New CDC recommendations suggest that soap and water are important for cleaning but not as the only protocol to prevent cross-contamination. Most offices should be using waterless alcohol hand sanitizers in their daily routine due to their very effective antimicrobial activity. The new products and protocol for hand hygiene will be more successful because they are easier to comply with.
Medical and dental discoveries have brought fantastic new treatments as well as new hope of health and beauty. Equally important is that the standards and methods of performing those procedures more aseptically continue to develop so that patients and clinicians can be protected from health-care-associated infections. The ongoing process of improving safety standards involves learning new ideas, employing new habits, and using new products. Because research shows that previously accepted practices of hand hygiene are inadequate for patient and operator safety, the Centers for Disease Control issued updated hand hygiene recommendations in 2002 and again in the recently issued CDC Guidelines for Infection Control in Dental Health Care Settings, Dec. 2003. By this time, every dental professional should be using the new, recommended hand hygiene practices. Do your practices reflect these new professional standards?
2002 CDC hand hygiene recommendations
1) Perform hand hygiene with (either nonantimicrobial or antimicrobial) soap and water when hands are visibly dirty or contaminated with blood or other potentially infectious material (OPIM). If hands are not visibly soiled, an alcohol-based hand rub can also be used. Follow the manufacturer's instructions.
2) Perform hand hygiene:
• When hands are visibly soiled
• After barehanded touching of any object likely to be contaminated by blood, saliva, or respiratory secretions or OPIM
• Before and after treating each patient
• Before donning and immediately after removing gloves
3) For oral surgical procedures, perform surgical hand antisepsis before donning sterile surgeon's gloves. Use either an antimicrobial soap and water or soap and water, dry hands, and apply an alcohol-based surgical hand-scrub product with persistent activity.
4) Prevent contamination of hand hygiene products by storing liquid products in disposable or reusable, closed containers that can be cleaned. Do not "top off" partially empty dispensers.
5) Use hand lotions and antiseptic products that are compatible with gloves. Avoid petroleum or oil emollients which can affect the integrity of gloves.
6) Keep fingernails short and smoothly filed to prevent damage to gloves and to promote hand hygiene.
7) Artificial fingernails are not generally recommended, and definitely not recommended for direct treatment of high-risk patients.
8) Do not wear hand or nail jewelry that might compromise the donning, fit, or integrity of gloves.
• What are the differences between the previous and new recommendations? Previous recommendations were to wash with (plain or antimicrobial) soap and water, unless no clean water was available (in which case waterless alcohol antimicrobial hand rubs were recommended). Antimicrobial soaps offered added chemical antisepsis to physical removal of organisms and debris.
The new recommendations suggest that soap and water are important for cleaning, but not as the only protocol to prevent cross-contamination. Physical cleaning with soap and water is essential to remove physical matter and debris, while alcohol solutions offer very effective antimicrobial activity on skin that is free of debris and "matter." Dental personnel must understand when to wash and when to use waterless rubs.
• What are the reasons for the new recommendations? Hand hygiene is considered the most important factor in disease transmission prevention today. Yet, convincing research cited by the CDC links poor hand hygiene practices to health-care-associated infections (any infections associated with a medical or surgical intervention). Professional hand hygiene practices must, therefore, be improved, and the use of alcohol hand sanitizers is likely to provide the method to overcome most or all of the reasons for past poor hand hygiene practices.
Studies of hospital practices found that workers were not following recommended handwashing practices (using soap, water, sinks, and paper towels thoroughly and at the appropriate times). The main factors recognized as contributors to noncompliance (and, therefore, poor hand hygiene) were:
1) Lack of awareness of when cross-contamination exposure occurs
2) Misconception that using gloves reduces the need for hand asepsis
3) Inconvenient or unavailable sink locations
4) Infrequent washing
5) Short handwashing times
The most common reasons given for infrequent washing and/or short handwashing times were found to be numbers one through three above as well as concern for skin sensitivity to soap, antimicrobials and water, heavy schedules, long hours, and lack of time. Additional conditions such as jewelry, fingernail conditions, and false fingernails or ornamentation were found to reduce hand hygiene effectiveness, because removal or deactivation of microbes was significantly reduced and gloves might be compromised.
• What are the benefits of waterless hand sanitizers? Alcohol rubs have been found to have greater antimicrobial effect than both antimicrobial and plain soap. Fortunately, most health-care workers find using the new products and protocol much easier and faster, so compliance is likely to greatly improve. Waterless dispensers may also be placed in more accessible locations, and since the alcohol solutions dry rapidly and contain emollients, skin chapping and irritation are reduced. Dental infection control has been dealt a winning hand!
• Which alcohol hand sanitizers are recommended?
These five product features describe optimal waterless hand sanitizers, as recommended by the CDC:
* Choose ethanol rather than isopropyl. Ethyl alcohol offers the following advantages:
• Ethanol has greater activity against viruses than isopropanol.
• Isopropanol is more fat-soluble and more drying to the skin than ethanol.
* The alcohol content should be between 60 and 95 percent for maximum effectiveness.
* Persistent activity. The product should contain an antimicrobial ingredient that remains on the skin after the alcohol dries, providing residual antimicrobial activity.
* Added emollients to prevent skin dryness. The emollient should be compatible with latex gloves.
* A well-designed dispenser. The dispenser should be easy to use, reliable, and designed to avoid cross-contamination. Nontouch dispensers are an example of technology that discourages cross-contamination.
Most offices should be using waterless alcohol hand sanitizers in their daily routine based on the recent CDC recommendations. The 2003 CDC Infection Control Guidelines also recommended evaluating the success of office asepsis protocol.
Use the charts in this article to evaluate your office's compliance with current hand hygiene recommendations. Keep a record of this exercise, and use it to review and train your dental office team annually. Appropriate integration of traditional handwashing protocol with use of high-alcohol antiseptic hand rubs should be every office's goal.
Once dental-care workers are introduced to waterless hand rubs, most seem to value their reliability as highly effective antimicrobials, while finding them significantly faster and easier. The bottom line is that the new products and protocol for hand hygiene will be more successful because they are easier to comply with.References
• Guidelines for Infection Control in Dental Health-Care Settings-2003, CDC. Morbidity and Mortality Weekly Report, Dec 19, 2003; Vol 52/No RR-17.
• Palenik, C.J. "Hand Hygiene; Bring on the Alcohol Rubs" Dentistry Today December 2003;44-49.
• Organization for Safety & Asepsis Procedures. Hand hygiene, new CDC guidelines expand options to healthcare facilities. Infection Control in Practice; 2003:2(1):1-8.
• Andrews, N. Wash your hands less often for better infection prevention. The Journal of Practical Hygiene. Jan-Feb 2003: 13-15.Nancy Andrews, RDH, BS, is a dental educational consultant. She received her BSDH from University of Southern California, practiced clinical dental hygiene for 20 years, and has provided leadership to individual dental practitioners, large facilities, and dental laboratories as a consultant in clinical safety. She has been employed by corporations for product and educational development, management, marketing and education, training and promotion. Ms. Andrews has had numerous articles published in peer-reviewed professional journals and has presented more than 300 seminars on clinical safety and dental hygiene practice.