When hand washing with antimicrobial soap and water is not available, which method can be used?

Regularly washing your hands is an important measure for preventing the spread of germs which cause diseases. In most situations, washing your hands with soap and water according to the correct technique, is enough to leave them hygienically clean. However, many people do not wash their hands properly, even if they do use soap and water. It’s important to be familiar with the correct technique so you know how to remove germs effectively each time you wash.

Correct hand washing technique with soap and water

To wash your hands correctly:

• Before washing hands, remove rings as well as jewellery like bangles you wear on your wrists. Plain rings can be left on, but you should remove all other jewelry, including your wristwatch;
• Ensure any cuts on your hands or wrists are covered with a waterproof dressing like a plaster (band-aid);
• Wet your hands thoroughly with water. Either hot or cold water can be used as evidence suggests that they are equally effective for removing germs from the hands;
• Apply liquid or bar soap to your hands. Use enough soap so that it creates a thick lather over your hands when you rub them together. If using an alcohol based wash instead of soap and water, you’ll need a palmful to wash your hands properly;
• Rub your hands together to lather the soap. While lathering move your hands away from the running water to ensure the soap is not washed away before it has time to wash away the germs on your hands. This is important as the soapy lather works to suspend dirt and germs so they can be easily washed away. Lather the back and front of your hands, your wrists and your fingernails, ensuring you don’t miss any spots. Commonly missed spots include finger tips, between fingers, thumbs and wrists;
• Wash all parts of your hands thoroughly for 15-20 seconds;
• Rinse your hands thoroughly under running water so the germs wash away. Do not use a bowl of stagnant water for rinsing. Keep your hands down to ensure that the contaminated rinse water drains down the sink and does not run up your wrists and elbows;
• If the tap needs to be turned off manually, cover your hand with a disposable paper towel to turn off the tap. This helps prevent your hands from being re-contaminated with germs on the tap.

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It is also important to thoroughly dry your hands after each wash, as wet hands are more likely to pick up germs from the environment. The best way to dry your hands is to:

• Use a disposable paper towel;
• Pat your hands dry, don’t rub them. Rubbing your hands can cause skin damage;
• Do not use a multiple use towel as the towel may harbor germs which can re-contaminate your hands;
• Hot air dryers which are commonly found in public toilets may also be used to dry your hands. However, they are not recommended if you work in healthcare settings such as a hospital, unless their design has been proven to prevent the spread of germs.

The hand washing procedure should take 40-60 seconds.

Washing with antimicrobial soap

If you are a nurse, doctor or other healthcare professionals, you may need to wash your hands with antimicrobial soap before touching a patient. To wash with antimicrobial soap you should follow the above steps, but use a soap with antimicrobial activity instead of normal soap. You will need to lather and wash your hands with the anti-microbial soap for 60 seconds (not 15-20 seconds as per the standard procedure).

Other tips which may help ensure your hands are hygienic include:

• Keep your finger nails short and clean. Artificial or long fingernails make hand hygiene difficult because dirt and germs get caught under the fingernails. Ideally nails should be trimmed to <0.5 cm long so that soap can get under the nails during hand washing;
• If you use sponges or clothes for washing your hands they must be washed frequently with bleach. Clothes and sponges provide moist surfaces, ideal for the growth of micro-organisms.

References

1. South Australian Health Infection Prevention and Control. Hand Hygiene Guideline. 2010. [cited 4 August 2013]. Available from: [URL Link]
2. Utah Department of Health. Hand Washing Information. 2005. [cited 22 Feb 2011]. Available from: [URL Link]
3. World Alliance for Patient Safety. WHO Guidelines on hand hygiene in healthcare (Advanced Draft)- a Summary- Clean hands are safer hands. 2005. [cited 2 March 2011]. Available from: [URL Link]
4. National Health and Medical Research Council. Handwashing. In Preventing Infectious Diseases in Childcare. 4th Ed. 2006. [cited 22 Feb 2011]. Available from: [URL Link]
5. Clinical Excellence Commission. Hand hygiene with artificial nails and wrist jewellery. 2006. [cited 20 August 2013]. Available from: [URL Link]

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Selection of alcohol-based handrub products is the responsibility of individual health care facilities.

It is recommended that alcohol-based handrub products:

• Meet the EN1500 testing standard for bactericidal effect
• Have Therapeutic Goods Administration (TGA) approval as a hand hygiene product for a healthcare setting.

Other factors that should also be considered include:

• Dermal tolerance
• Aesthetic preferences such as fragrance, colour, texture and ease of use
• Practical considerations such as availability, convenience and functioning of dispenser, and ability to prevent contamination
• Cost issues.

When to use alcohol-based handrub

Alcohol-based handrubs should be used (when hands are visibly clean) instead of handwashing because they:

• Substantially reduce bacterial count on hands

• Require less time than handwashing

• Are more accessible

• Are self-drying

• Are gentler on skin and cause less skin irritation and dryness than frequent soap and water washes, since all handrubs contain skin emollient (moisturisers).

Handwashing is reserved for situations when hands are visibly soiled, or when gloves have not been worn in the care of a patient with Clostridium difficile.

Alcohol-based handrubs have excellent antimicrobial activity against gram-positive and gram-negative vegetative bacteria, and good antimicrobial activity against enveloped viruses. Alcohol solutions containing 60-80% alcohol are most effective. It has been well established that alcohols effectively reduce the bacterial counts on hands better than soap and water.

Alcohol-based handrubs are more effective against most bacteria and many viruses than either medicated or non-medicated soaps. 

Alcohol-based handrub is the hand hygiene product of choice for all standard aseptic procedures. Surgical scrub is required for surgical procedures. For definitions on standard versus surgical aseptic technique refer to the Australian Guidelines for the Prevention and Control of Infections in Healthcare.

Alcohol-based handrub is also the recommended product for the prevention of intravascular catheter-related infections. 

Cutaneous absorption of alcohol

Recent studies have demonstrated minimal rates of cutaneous alcohol absorption such that there should be no concern for healthcare workers. A study suggested that isopropanol might be less likely to be absorbed than ethanol. Thus, healthcare workers who are concerned about absorption for religious or other reasons may elect to use an alcohol-based handrub that contains isopropanol rather than ethanol.

When implementing a hand hygiene campaign with an alcohol-based handrub in a healthcare setting, it is important to provide opportunities for healthcare workers to raise concerns about the use of alcohol-based handrubs for cultural or religious reasons or due to alcohol abuse and help them to understand the evidence underlying its use, and to identify that address their concerns.

Alcohol-based handrub placement

Ensuring alcohol-based handrub is available at the point-of-care improves hand hygiene compliance.

Alcohol-based handrub should be easily accessible, generally within arm's reach of where patient care or treatment is taking place. 

Dispensers act as a visual cue for hand hygiene behaviour. Placement of alcohol-based handrub needs to be consistent and reliable. Clinical staff should assist with the decision-making process regarding placement of alcohol-based handrub, as they generally best understand the workflow in their area. 

Where possible, alcohol-based handrub should be placed at the foot of every bed or within each patient cubicle. When designing new healthcare facilities, consideration should be given to appropriate placement of alcohol-based handrubs so that healthcare workers can easily see and reach them.

Alcohol-based handrub dispensers should not be placed next to sinks, as this can cause confusion for healthcare workers who may think they need to rinse their hands with water after using alcohol-based handrub. 

The following locations are suggested for placement of alcohol-based handrub:

• On the end of every patient bed (fixed or removable brackets)
• Affixed to mobile work trolleys (for example, intravenous, drug and dressing trolleys)
• High staff traffic areas (for example, nurses' station, pan room, medication room and patient room entrance)
• Other multi-use patient-care areas, such as examination rooms and outpatient consultation rooms
• Entrances to each ward, outpatient clinic or department
• Public areas such as waiting rooms, receptions areas, hospital foyers, near elevator doors in high traffic areas.

A clear decision needs to be made about whose responsibility it is to replace empty alcohol-based handrub bottles. Workplace agreements or job descriptions may need to be changed to accommodate prompt replacement of these bottles. Alcohol-based handrub should never be decanted from one bottle into another as this can cause contamination.

Safe placement of alcohol-based handrub

There are a number of risks to patients and staff associated with the use of alcohol-based handrub, however, the benefits far outweigh the risks. A risk assessment should be undertaken and a management plan put in place. This particularly applies to clinical areas that manage patients with alcohol use disorders, and patients at risk of self harm. 

The following factors should be considered in relation to safe placement of alcohol-based handrub:

• The maximum size of an individual alcohol-based handrub dispenser should not exceed 500 mls
• No more than 80 individual alcohol-based handrub dispensers (each with a maximum capacity of 500 mls) should be installed within a single smoke compartment
• Dispensers should not project more than 15 cm into corridor egress
• Wall-mounted brackets should be located at a height of between 92 cms and 122 cm above the floor (avoid placing at eye level)
• Dispensers should not be located over carpeted areas, unless the area is protected by active sprinklers
• Dispensers should not be located over, or directly adjacent to, ignition sources such as electrical switches, power points, call buttons, or monitoring equipment
• Alcohol-based handrub dispensers should be separated from heat sources and electric motors
• Dispensers should be installed according to manufacturer’s recommendations and to minimise leaks or spills
• Regular maintenance of dispensers and brackets should occur in accordance with manufacturer’s guidelines
• Product usage signs should be clearly visible and laminated
• Regular monitoring of each area is recommended for misuse or removal of product
• Each facility should take adequate care regarding the placement of each dispenser so as to protect vulnerable populations, for example in psychiatric units, drug and alcohol units, paediatric units and units caring for cognitively impaired patients
• Alcohol-based handrub bottles should be designed so as to minimise evaporation due to the volatile nature of alcohols
• Site-specific instructions should be developed to manage adverse events, such as alcohol-based handrub ingestion, eye splashes or allergic reactions
• Bracket design is important, since alcohol-based handrub placement may be affected if brackets are ill-fitting (for example, varying sizes of bed rails can affect the efficacy of some brackets)
• Brackets that are removable, or product that can be removed from brackets easily, should be considered in case short term patient demands warrant it 
• Bracket availability and installation costs also require consideration.

Clinical area placement considerations

Special consideration is necessary when locating alcohol-based handrub in clinical areas where ingestion or accidental splashing of alcohol-based handrub is a particular risk. The placement of alcohol-based handrub needs to be aligned with the risk assessment of the individual patient or patient population.

Such areas include:

• Paediatrics – locate with care near children (see below)
• Mental health – locate with care near mental health patients, patients undergoing alcohol- or drug-withdrawal, or where there are cognitively impaired patients
• Public areas - place in high traffic areas with clear signage regarding appropriate use and the need for parents to carefully supervise their children.

Small personal bottles that healthcare workers carry with them may be more appropriate in some of the above areas.

Paediatric product placement

Alcohol-based handrub can be placed in paediatric wards. The placement of alcohol-based handrub within neonatal intensive care units, special care nurseries, maternity wards and on cots should follow the recommendations for product placement at point-of-care. 

Placement within general paediatric wards should remain within the point-of-care, except in situations of intellectual impairment or alcohol abuse where the child could unintentionally or intentionally harm themselves. Personal bottles of alcohol-based handrub could be used in any area where alcohol-based handrub cannot be placed at the point-of-care.

Limitations of alcohol-based handrub

In some situations washing hands with soap and water is preferable to use of alcohol-based handrub. 

Bacterial spores

Alcohol has virtually no activity against bacterial spores. Washing hands with soap and water is preferred in this situation because it is the best method of physically removing spores from the hands. However, the vegetative form of Clostridium difficile is highly sensitive to alcohol-based handrub.

The November 2018 ASID/AICA position statement on Infection Control Guidelines for Patients with Clostridium difficile Infection (CDI) in Healthcare Settings recommends the primary use of alcohol-based handrub in accordance with the WHO 5 Moments for Hand Hygiene when caring for patients with CDI. Gloves should be used during the care of patients with CDI, to minimise spore contamination, and if hands become soiled, or gloves have not been used, then hands must be washed with soap and water.

Non-enveloped (non-lipophilic) viruses

Alcohol has a poor activity against some non-enveloped viruses. (for example: rotavirus, norovirus, polio, hepatitis A). However, there is conflicting evidence suggesting that alcohol-based handrub is more effective than soaps in reducing virus titres on finger pads. Thus, in norovirus outbreaks it is usually best to reinforce the use of alcohol-based handrub, unless hands are visibly soiled, in which case handwashing with soap and water is preferred.

Other organisms

Alcohol has a poor activity against tropical parasites, and protozoan oocysts. Handwashing soap and water is preferred.