Prospective, controlled, cross-over trial of alcohol-based hand gel in critical care units

BACKGROUND. There are limited data from prospective studies to indicate whether improvement in hand hygiene associated with the use of alcohol-based hand hygiene products results in improved patient outcomes. DESIGN. A 2-year, prospective, controlled, cross-over trial of alcohol-based hand gel. setting. The study was conducted in 2 medical-surgical ICUs for adults, each with 12 beds, from August 2001 to September 2003 at a university-associated, tertiary care teaching hospital. METHODS. An alcohol-based hand gel was provided in one critical care unit and not provided in the other. After 1 year, the assignment was reversed. The hand hygiene adherence rate and the incidence of nosocomial infection were monitored. Samples for culture were obtained from nurses' hands every 2 months. RESULTS. During 17,994 minutes of observation, which included 3,678 opportunities for hand hygiene, adherence rates improved dramatically after the introduction of hand gel, increasing from 37% to 68% in one unit and from 38% to 69% in the other unit (P < .001). Improvement was observed .001 among all groups of healthcare workers. Hand hygiene rates were better at higher workloads when hand gel was available in the unit (P = .02). No substantial change in the rates of device-associated infection, infection due to multidrug-resistant pathogens, or infection due to Clostridium difficile was observed. Culture of samples from the hands of nursing staff revealed that an increased number of microbes and an increased number of microbe species was associated with longer fingernails (ie, more than 2 mm long), the wearing of rings, and/or lack of access to hand gel. CONCLUSIONS. The introduction of alcohol-based gel resulted in a significant and sustained improvement in the rate of hand hygiene adherence. Fingernail length greater than 2 mm, wearing rings, and lack of access to hand gel were associated with increased microbial carriage on the hands. This improvement in the hand hygiene adherence rate was not associated with detectable changes in the incidence of healthcare-associated infection.