Practice and attitudes toward alcohol-based hand disinfection among German infection control teams

To the Editor—Recent publications have discussed the microbiological effectiveness of 15 seconds of alcohol-based hand disinfection and of reducing the time recommendations for alcohol-based hand disinfection in standard operating procedures to increase compliance,¹ the reprocessing of conventional hand disinfection dispensers,² and the technical failure rate of automatic hand disinfection dispensers,³ and the problems related to using alcohol-containing tissue wipes rather than conventional dispensers.⁴

We designed an anonymous survey and distributed it during the 2018 Freiburg congress of infectious diseases and infection control (Freiburger Infektiologie- und Hygienekongress) to analyze the attitudes of German infection control teams regarding those issues and the integration of patients into hand disinfection programs.

Material and Methods

Congress participants were asked to deposit the filled out data sheets in exit-door drop boxes. Data were collected without personal identifiers according to the EU General Data Protection Regulation (GDPR). Therefore this is not human research and the data analysis did not require the review of an institutional review board. Predefined subgroup analyses included nurse infection control practitioners (NICP) and physician members (PM) of the infection control team (either hygiene-link physicians or certified specialists in hospital hygiene). The Fisher exact test was used to test for significance between groups; P < .05 was considered statistically significant.

Results

In total, 385 surveys were returned (mean age, 50 years; range, 24–66). Of all respondents, 20% were from hospitals with <200 beds, 25% were from hospitals with 201–400 beds, 18% were from hospitals with 401–600 beds, 19% were from hospitals with >600 beds, 13% were from rehabilitation hospitals, and 5% were from elsewhere (“other”). Among all respondents, 96 were in the PM group and 223 were in the NICP group; the remaining respondents were link nurses, public or occupational health physicians, and medical technicians. Table 1 shows the answers to the survey questions.

Table 1. Itemized Summary of Survey Items and Answers [translated from German]

Note. NICP, nurse infection control practitioner; PM, physician member of the hygiene team

^a P = .00001 (Fisher exact test) between NICP and PM, with “agree” and “partially agree” answers counted as “yes” answers and “partially disagree” and “disagree” answers counted as “no” answers for statistical analysis.

The only statistically significant difference (P = .00001) between physician and nurse members of the infection control team was found regarding the need for using the elbow to activate the dispenser mechanism rather than touching the dispenser with undisinfected hands, which is favored by 52% of physicians compared to 20% of nurses (agree and partially agree answers were counted together, respectively). All other differences between the 2 professional groups were not significant.

Discussion

For most items, we did not find significant differences in the attitudes and preferences of physician and nurse members of the infection control team. Only elbow use of dispensers was significantly more important for physicians than for nurses, although there is no evidence for its practical value despite a theoretical rationale of less contamination of the dispenser itself.

Most infection control preventionists report that their institutional standard operating procedures define the time needed for hand disinfection as the 30 seconds indicated by the WHO Five Moments and still favor 30 seconds for alcohol-based hand disinfection. However, they acknowledge that in daily practice disinfection times of 30 seconds are almost never reached and that most disinfect their hands <15 seconds. However, most infection control preventionists think that a more realistic time requirement would increase the motivation of staff and overall adherence to hand hygiene policies, which is in accordance with the findings of Kramer et al¹ in their observational study in a neonatal intensive care unit. The reported preference of 30 seconds but with an expectation of higher adherence with shorter times might be a sign of reluctance to change long-standing formal rules, which is a barrier in the conceptual frame of change management and implementation science.⁵ This theory is underscored by the fact that two-thirds of the respondents agreed with the statement that you need a buffer between the formal requirement in a standard operating procedure SOP and scientifically sound minimum to generate an additional safety corridor. Although this concept is often used to define technical safety limits, it can be deleterious in behavioral psychology because it undermines trust in the scientific base of infection control recommendations.

In most institutions patients are specifically targeted in hand hygiene programs, although <20% of hospitals have a formal “speak up” campaign. Most survey respondents indicated that they would use alcohol-containing wipes as an alternative mode for hand disinfection for patients only and not for use by staff, and this idea is supported by the findings of Ory et al.⁴

The respondents described many different ways that alcohol-based hand disinfectant is provided in their respective institutions. Most described conventional wall-mounted dispensers, which leaves improvement potential for bedside-mounted systems that might better facilitate work flow. Technical problems with automatic systems seem to be a relevant issue, which supports the findings by Roth et al.²

We observed great variance in the way dispenser systems are cleaned and maintained: To do nothing, as reported by 15% of all respondents, is clearly unacceptable, whereas cleaning triggered by visual inspection is done by a weak majority and is supported by the literature.³

In summary, our survey indicated some improvement potentials regarding the infrastructure as well as the use of alcohol-based hand disinfection in German hospitals. We noted a certain amount of resistance by members of the infection control team irrespective of professional affiliation toward changing established formal practice patterns, despite new scientific evidence.