Kathleen Louden

October 29, 2013

SAN FRANCISCO — Physicians and nurses on an acute pain service increased compliance rates with their hospital's hand-disinfection policy by nearly 30% by wearing a personal container of antibacterial hand rub, a new study finds.

The simple intervention used a 2-oz (59-mL) bottle of alcohol-based hand sanitizer and a clamp (both Purell, Gojo Industries) that attached to a pocket, belt, or hospital identification badge.

Wearing the individual hand-decontamination product improved overall application of the hand gel from a mean of 34% before the intervention to 63% after the intervention, reported lead study author Colby Parks, MD, from the University of Wisconsin Hospitals and Clinics, Madison.

"It's a lot more difficult to forget [to apply hand sanitizer] in a busy healthcare environment when it's on your ID badge," Dr. Parks, a third-year anesthesiology resident, told Medscape Medical News.

He presented these findings as a scientific poster here at the American Society of Anesthesiologists (ASA) 2013 Annual Meeting.

According to Dr. Parks, the university hospital has a "gel in, gel out" policy requiring proper hand hygiene by applying hand sanitizer before and after each patient contact. Wall-mounted dispensers of antibacterial hand rub are available throughout patient care areas, as are randomly placed self-standing bottle dispensers.

Personal hand sanitizer dispenser. Courtesy of Colby Parks, MD

In an attempt to improve hand-hygiene compliance, which Dr. Parks called "less than ideal," a quality improvement study was conducted in the hospital's nerve block team over 18 days. Study participants included approximately 15 attending physicians, physician trainees, and nursing staff, with 7 to 8 providers on the block team on any given day.

Researchers observed the team members during normal work activities for 9 nonconsecutive days before the intervention and recorded their compliance with the institutional hand-hygiene policy before and after 146 patient-clinician encounters. When the healthcare providers individually received the personal hand sanitizer to wear, they were given information about how to use the dispenser and the reason for the intervention. Subsequently, their hand-hygiene compliance was again recorded for 9 nonconsecutive days during 161 patient encounters.

Compliance (application) rates rose from 23% to 53% before a patient encounter and from 43% to 72% after a patient encounter, according to the abstract.

Table. Effect of Personal Hand Sanitizer on Compliance With Hand-Hygiene Policy

Type of Healthcare Provider Before Intervention (n = 146) (%) [a] After Intervention (n = 161) (%) [a]
Attending physicians 33 42
Resident physicians 54 79
Fellows 56 72
Nurses 12 49
Overall 34 63[b]

[a]Patient encounters

[b]Significant difference at P < .001 (z test of independent proportions)


Compliance Poor for Nurses

Unlike previous findings, which showed the best rates of hand hygiene among nurses on a multidisciplinary healthcare team, the present study showed that nurses had the worst compliance rate before the intervention. In response to a question from the audience, Dr. Parks said the initial low compliance rate of 12% might have been because the wall-mounted hand gel dispensers were not in locations convenient to the nurses, who must repeatedly move between direct patient contact and a computer or supply cart.

Attending physicians also reportedly had poorer compliance with using hand sanitizer than residents and fellows, which Dr. Parks attributed to their supervisory role and less frequent direct patient contact.

Contamination of the patient care area and the patient was not studied. However, past research demonstrates that use of a hand sanitation device worn on the healthcare worker decreases intraoperative transmission of bacteria (Anesthesiology. 2009;110:978-985). That device (Sprixx GJ, Sprixx Inc) gives an audible alarm to remind the wearer to use the hand sanitizer gel.

The device that Dr. Parks and coworkers used did not have an alarm, but he said the easy accessibility of the attachable personal dispenser might act as a reminder on its own.

He also noted that study participants were aware they were being observed before and after the intervention, which may have affected results. Observation was necessary because the gel dispenser that the researchers used did not automatically record gel use, as is the case with a commercially available electronic "smart" dispenser (Sprixx).

Prolonged Use Unclear

An anesthesiologist reviewing Dr. Parks' poster, Thomas Sinclair, MD, said he wears a personal dispenser of sanitizing hand gel at his institution, Hoag Memorial Hospital Presbyterian in Newport Beach, California.

"It's now automatic to reach for it," Dr. Sinclair, who was not involved in the study, told Medscape Medical News.

Whether that happened in the new study was not clear, however. John Dombrowski, MD, a pain specialist based in Washington, DC, who was also asked by Medscape Medical News to comment on the research, said he would like to see a longer observation period after the intervention than 9 days.

"It would be interesting to see how long the compliance will last and if hand hygiene becomes a habit," said Dr. Dombrowski, who did not participate in the study.

It is the anesthesiologist's responsibility to use hand sanitizer whether it's on the wall or on your body. Dr. John Dombrowski

Although it is important to find and test ways to combat the problem of nosocomial infection, Dr. Dombrowski said hand sanitizer is readily available in patient care areas.

"It is the anesthesiologist's responsibility to use hand sanitizer whether it's on the wall or on your body," Dr. Dombrowski stated.

Acknowledging that every healthcare facility has a different workflow, Dr. Parks said personally worn hand sanitizer may not be the best hand-hygiene technique in all hospital environments.

"An effort needs to be made to make hand hygiene convenient regardless of the method," Dr. Parks said.

This study was funded by the University of Wisconsin Health, Madison. Dr. Parks, Dr. Dombrowski, and Dr. Sinclair have disclosed no relevant financial relationships.

American Society of Anesthesiologists (ASA) 2013 Annual Meeting. Abstract #2309. Presented October 13, 2013.


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