To achieve a high rate of hand hygiene adherence, HCWs need education, clear guidelines, some understanding of infectious disease risk, and acceptable hand hygiene products.60,197,492,608,609,613,633,634 The selection of hand hygiene products is a key component of hand hygiene promotion, and at the same time a difficult task. The selection strategy requires the presence of a multidisciplinary team (e.g. infection control and prevention professionals, occupational disease professionals, administrative staff, pharmacists, and behavioural scientists) and efforts to evaluate factors related to hand hygiene products and to conduct clinical pilot projects to test these factors.48,58,351,607,610,635,636 The major determinants for product selection are antimicrobial profile, user acceptance, and cost. A decision-making tool for the selection of an appropriate product is available within the Implementation Toolkit (http://www.who.int/gpsc/en/). The antimicrobial efficacy of hand hygiene agents is provided by in vitro and in vivo studies (see Part I, Section 10) which are reproducible and can be generalized. Pilot studies aiming to help select products at the local level should mainly concentrate on tolerance and user acceptability issues. Other aspects such as continuous availability, storage, and costs should also be taken into account on a local basis, so as to guarantee feasibility and sustainability.
15.1. Pilot testing
Pilot testing to assess acceptability is strongly recommended before final selection, aiming at fostering a system change and involving the users in the selection of the product they like most and therefore are most likely to use. Characteristics that can affect HCWs’ acceptance of a hand hygiene product include dermal tolerance and skin reactions to the product, and its characteristics such as fragrance, consistency, and colour,220,493,504,598,610 Structured, self-administered questionnaires may be useful tools to assess HCWs’ acceptability of hand hygiene products. A standardized and validated survey to evaluate acceptability and tolerability among HCWs is available within the Implementation Toolkit (http://www.who.int/gpsc/en/). Such tools should be adapted to the local setting because of differences in sociocultural backgrounds, climate and environmental conditions, and clinical practices among users. Skin reactions to hand hygiene products may be increased by low relative humidity. For example, dry weather during winter months in the northern hemisphere should be taken into account during pilot testing, and the introduction of new products during dry and cold periods with low relative humidity should be avoided. For an efficient test, more than one product should be compared, if possible with products already in use. Each product should be tested by several users for at least 2–3 weeks. A fast track method comparing different products (including the WHO formulations) was tested and validated in high intensity users, such as nurses in intensive care, emergency rooms or postoperative rooms, by the First Global Patient Safety Challenge team.504 The detailed protocol can be obtained from WHO upon request. If comparison is not possible, at least the pre-selected product should be tested for tolerance and acceptance with the above-mentioned tool. Dryness and irritation should be assessed with sufficient numbers of HCWs to ensure that the results can be generalized. If more than one new product is to be tested, either a period with the routine product or, preferably, a minimum of a 2-day washout period should be observed between test periods.504,579 When considering the replacement of a product, the new product should be at least as good as the previous one. An inferior product could be responsible for a decrease in hand hygiene compliance. After careful evaluation of suitable hand hygiene agents, HCWs should be given the option to choose themselves the product for use at their institution. Freedom of choice at an institutional level was rated the second most important feature reported by HCWs to improve hand hygiene compliance in the audit of a successful promotion programme in Victoria, Australia.494 Prior to product pilot testing, the appropriate administrative decision-makers in the institution should determine which products have demonstrated efficacy and which ones can be purchased at the best cost. Only products that have already been identified as efficacious and affordable should be tested by HCWs.
15.2. Selection factors
Factors to be taken into consideration for product selection include:
relative efficacy of antiseptic agents (see
Part I, Section 10) and consideration for selection of products for hygienic hand antisepsis and surgical hand preparation;
dermal tolerance and skin reactions;
cost issues;
aesthetic preferences of HCWs and patients such as fragrance, colour, texture, “stickiness”, and ease of use;
practical considerations such as availability, convenience and functioning of dispenser, and ability to prevent contamination;
time for drying (consider that different products are associated with different drying times; products that require longer drying times may affect hand hygiene best practice);
freedom of choice by HCWs at an institutional level after consideration of the above-mentioned factors.
15.2.1. Dermal tolerance and skin reactions
Several studies have published methods to evaluate dermal tolerance such as dryness or irritation220,577, either by self-assessment or by expert clinical evaluation197,221,264,326,327,329,405,495,504,608,610,613,636 (see Part I, Section 14). Some studies have confirmed that these assessment techniques correlate well with other physiological measures such as transepidermal water loss or desquamation, tests which are not practical to use in clinical settings.264,326,405,495,549,577,613,636 An example of a tolerability assessment framework for use in the clinical setting is included in Appendix 3220,504,572 and is part of the WHO alcohol-based handrub tolerability and acceptability survey (Implementation Toolkit available at http://www.who.int/gpsc/en/) (see also Part I, Section 14). Dermal tolerance is one of the main parameters leading to the product acceptability by HCWs that influences directly the compliance with hand hygiene. It is demonstrated that dermal tolerance of alcohol-based handrubs is related to the addition and the quality of emollient in the product;504,580,627 even alcohols, frequently used in alcohol-based handrubs, are known to generate a minor skin irritant effect compared with handwashing with soap and water.548,583
15.2.2. Aesthetic preferences
Fragrance
Products with a strong fragrance may lead to discomfort and respiratory symptoms in some HCWs allergic to perfume or fragrances. Many patients complain about perfumed products, especially in oncology. Therefore, consideration should be given to selecting a product with mild or no added fragrances.
Consistency (texture)
Handrubs are available as gels, solutions or foams. Dermal tolerance and efficacy were not considered as they are not affected by consistency.203,495 Although more expensive than solutions, gels have recently become the most popular type of alcohol-based handrub preparation in many countries. Due to their formulations, some gels may produce a feeling of humectant “build-up”, or the hands may feel slippery or oily with repeated use. This difference in consistency has not been associated with better objective tolerance or higher compliance with hand cleansing in a controlled study.579 A prospective intervention study and a comparison study have shown that the use of a gel formulation was associated with better skin condition, superior acceptance, and a trend towards improved compliance.493,496 Nevertheless, it is worth recalling that first generations of gel formulations have reduced antimicrobial efficacy compared with solutions.205,218 A recent study suggests that the antibacterial efficacy of alcohol-based gels may depend mainly on concentration and type of alcohol in the formulation.496
Solutions generally have a consistency similar to water while some are slightly viscous. They often dry more quickly than gels or foams (a potential advantage) and may be less likely to produce a feeling of humectant “build-up”. They are more likely to drip from the hands onto to the floor during use, and it has been reported that these drips have created spots on the floor under the dispensers in some hospitals. Solutions often have a stronger smell of alcohol than do gels.495,636
Foams are used less frequently and are more expensive. Similar to gels, they are less likely to drip from the hands onto the floor during application, but may produce stronger “build-up” feeling with repeated use and may take longer to dry. Some manufacturers of foams recommend the use of a relatively large amount of product for each application, and HCWs should be reminded to follow the manufacturer’s recommendation.
15.2.3. Practical considerations
Product accessibility
Several studies suggest that the frequency of hand cleansing is determined by the accessibility of hand hygiene facilities.335,486,492,493,497,498,637–639 A reliable supplier (industrial or local at the health-care facility) is essential to ensure a continuous supply of products. If industrial products are not available or are too expensive, products may be produced within the local setting (see also Part I, Section 12). WHO identified and validated two different alcohol-based formulations, and a Guide to Local Production (Implementation Toolkit, available at http://www.who.int/gpsc/en/). However, even if a simple method is proposed, it is difficult to regulate the quality control of locally made products, and more sophisticated but feasible methods to monitor quality are needed.
Issues related to infrastructure necessary to ensure continuous access to hand hygiene products and equipment are specifically dealt with in Part I, Section 23.5.
Risk of contamination
Alcohol-based rubs have a low risk of contamination,338 but soap contamination is more common.160,640–644 Multiple-use bar soap should be avoided because it is difficult to store bar soap dry at a sink, with a subsequent increase in the risk of contamination.640–642 Although liquid soaps are generally preferred over bar soaps for handwash, the risk for either intrinsic643 or extrinsic160,644 microbial contamination still exists.
15.2.4. Cost
The promotion of hand hygiene is highly cost effective (see Part III, Section 3), and the introduction of a waterless system for hand hygiene is a cost-effective measure.329,645,646 While the cost of hand hygiene products will continue to be an important issue for departments responsible for purchasing such products, the level of acceptance of products by HCWs is even more important. An inexpensive product with undesirable characteristics may discourage hand hygiene among HCWs and the resulting poor compliance will not be cost effective.
Financial strategies to support programmes designed to improve hand hygiene across a nation may benefit from a centralized design and production of supporting materials. This strategy may be more cost effective to the overall health economy (see also Part III, Section 3).
