What are the guidelines for using Alcohol-Based Hand Rubs (ABHRs) in healthcare settings?

Guidelines for Alcohol-Based Hand Rubs (ABHRs) in Healthcare Settings

Alcohol-based hand rubs should be the primary method for routine hand hygiene in healthcare settings, used for 20-30 seconds until hands are dry, except when hands are visibly soiled or after suspected exposure to bacterial spores. 1, 2

When to Use ABHRs

Mandatory Indications

• Before touching a patient to protect them from harmful microorganisms on your hands 2
• Before any clean or aseptic procedure, including insertion of urinary catheters, intravascular catheters, central lines, or other invasive devices 1, 2
• After body fluid exposure risk, including contact with body fluids, mucous membranes, or non-intact skin 2
• After touching a patient, even if only intact skin contact occurred 2
• After touching patient surroundings, including medical equipment and inanimate objects in the patient zone 2
• Immediately after removing gloves, as gloves do not provide complete protection and hands become contaminated during removal 3, 2
• When moving from a contaminated body site to a clean body site on the same patient to prevent cross-contamination 2

Critical Contraindications

• Do NOT use ABHRs when hands are visibly soiled - soap and water handwashing is required 1, 4
• Do NOT use for suspected or proven exposure to bacterial spores (e.g., Clostridioides difficile) - ABHRs have poor activity against spores and soap and water is necessary 1

Proper Application Technique

Correct Method

• Apply 3 mL of product (approximately one full pump or palmful) to the palm of one hand 2
• Rub hands together vigorously, covering all surfaces including backs of hands, between fingers, and under fingernails 2
• Continue rubbing for 20-30 seconds or until hands are completely dry, whichever is longer 2
• The myth that ABHRs require >60 seconds is FALSE - they are highly effective at 20-30 seconds 1, 2

Common Mistakes to Avoid

• Never wash hands immediately before using ABHR - this is unnecessary and causes skin irritation 5
• Never wash hands immediately after using ABHR - this removes beneficial emollients and defeats the purpose 5
• Do not apply ABHR to wet or damp hands - water dilutes the alcohol and reduces efficacy 5, 6
• Avoid using insufficient product - inadequate volume prevents coverage of all hand surfaces 2

Antimicrobial Efficacy

Spectrum of Activity

• ABHRs have excellent activity against: gram-positive bacteria, gram-negative bacteria, mycobacteria, fungi, and enveloped viruses 1, 2
• ABHRs have poor activity against: bacterial spores (e.g., C. difficile, Bacillus species) 1
• ABHRs achieve 3.5-5.0 log₁₀ bacterial reduction within 30 seconds, which is superior to plain soap and water 2, 4

Advantages Over Soap and Water

Microbiological Benefits

• More effective bacterial reduction than plain soap and water handwashing 1, 4
• Faster application - requires significantly less time than traditional handwashing 1
• Better accessibility - can be placed at point of care without need for sinks 1

Skin Health Benefits

• Cause less skin irritation and dryness than soap and water when formulated with emollients 1, 5
• Improve skin condition when replacing frequent handwashing, provided they contain moisturizers 5
• Initial burning sensation may occur in healthcare workers with pre-irritated skin from previous frequent handwashing, but this typically resolves with continued use 5

Strategies to Improve Compliance

System-Level Interventions

• Provide individual containers of ABHR to each healthcare worker for personal use 1
• Make ABHRs more accessible than handwashing facilities by placing dispensers at point of care 1
• Provide regular feedback to personnel regarding their hand hygiene adherence and performance 1
• Supply hand lotions or creams to prevent and treat occupational hand dermatitis 1

Product Selection Considerations

• Choose formulations with emollients to minimize skin irritation 5
• Gel and foam formats are generally more acceptable than liquids to healthcare workers 7
• The 1.5 mL dose provides optimal balance between efficacy and user acceptability, though 3 mL is recommended for complete coverage 2, 7
• Key desirable properties include: fast absorption, soft/moisturized hand feel, non-sticky texture, clean feel, and low odor 7

Special Considerations

Surgical Hand Antisepsis

• ABHRs are appropriate for preoperative surgical hand preparation and have not been associated with increased surgical site infections 1
• A 5-minute scrub is as effective as a 10-minute scrub for reducing bacterial counts 1
• Brushes or sponges are NOT required when using ABHRs for surgical hand preparation 1

Frequency of Use

• Nurses in intensive care units use ABHRs up to 141 times per shift (15 times per hour in 95% of shifts), demonstrating that frequent use is both necessary and feasible 8
• Hand hygiene is ALWAYS necessary even when gloves are worn - gloves do not eliminate the need for hand hygiene 1, 3

Skin Barrier Considerations

• Extensive skin hydration may increase susceptibility to ABHR-induced irritation 6
• Occupational hand dermatitis occurs in up to 30% of healthcare workers, primarily from detergent use rather than ABHRs 5
• Select low-irritating formulations and educate staff on proper use to prevent the vicious cycle of increased handwashing and decreased ABHR use 5