Stephanie Rees, Kenneth Igwe and John Glen
Betsi Cadwaladr University Health Board
Background
Chlorhexidine (Status Quo)
- Harsh on skin – 27.8% report dermatitis related to chlorhexidine.(1)
- High use of clean water – >1 million litres of water per year in Glan Clwyd Hospital.
- Not removed in water treatment – persists into the oceans and water table.
- Toxic to aquatic life – affects fish behavior and primary producer numbers. (2)
Alcohol-Based Hand Rubs (ABHRs)
- Use no clean water – if hands not visibly soiled and have been washed that day.
- 2 minutes for sterile hand preparation – Hand must remain wet for 2 minutes.
- Prolonged antimicrobial action – suppressed microbial growth within surgical gloves for up to 6 hours. (3)
- Recommended by the Royal College of Surgeons – in the ‘Intercollegiate Green Theatre Checklist’. (4)
- Improved skin hydration – reduced cracking and fissuring. (5)
Aims and Objectives
- Implementation: Transition to ABHRs for all sterile procedures within 12 months.
- Education: Provide training for all clinicians, integrated into hospital inductions.
- Monitoring: Audit compliance and infection rates post-implementation.
Methodology
- Introduced ABHRs (Sterillium) to the Intensive Care Unit to evaluate feasibility in a controlled environment.
- Delivered drop-in sessions, bedside teaching, and visual “memory aids” to address technique changes.
Outcomes
The pilot was successfully established in ICU, though wider rollout faced cultural and logistical hurdles.
Impact
Before ABHR (n=12)
- 50% rated scrub stations outside of theatre as inadequate.
- 30% reported skin irritation from chlorhexidine hand scrubs.
- 20% were familiar with ABHRs or had used them previously.
Do you have any concerns about the use of alcohol-based hand rubs?
“Dry hands, skin peeling off.”
“Does not feel as thorough. No good if visibly soiled. Not sure if it’s effective for all pathogens.”
“Need assurance comparable to standard scrub with water and chlorhexidene/betadine.”
After ABHR (n=13)
- 100% reported ABHRs as easy to use.
- 93% reported increased ease of adherence to hand hygiene practices for sterile procedures.
- 85% reported no change or improved skin condition.
- 93% were either ‘satisfied’ or ‘very satisfied’ with the introduction of ABHRs in ICU.
What changes have you noticed in hand hygiene practices since the introduction of alcohol-based hand rubs?
“Easier and less mess.”
“Hand washing for aseptic technique is much easier, quicker and less messy (compared to soap and water). No need to worry about non-sterile towels to dry your hands. Gloves easier to put on as alcohol rub dries completely, whilst it can be difficult to dry hands completely after using soap and water.”
What could be done to improve the implementation of alcohol-based hand rubs in your department?
“To consolidate and disseminate information about safety and efficacy.”
“Continue to introduce across other areas of the hospital, including the ED.”
Conclusions
- High satisfaction (93%) suggests that initial resistance can be overcome through education and evidence.
- Despite implementation hurdles, the ICU pilot proved ABHRs are a practical, cost-saving, and eco-friendly alternative.
View the project poster and slides from the Cohort 9 Bevan Exemplar Showcase
References:
1) Barnes S, Stuart R, Redley B. Health care worker sensitivity to chlorhexidine-based hand hygiene solutions: A cross-sectional survey. Am J Infect Control. 2019 Aug;47(8):933-937. doi: 10.1016/j.ajic.2019.01.006. Epub 2019 Feb 12. PMID: 30765146.
2) Lawrence JR, Zhu B, Swerhone GDW, Topp E, Roy J, Wassenaar LI, et al. Community-Level Assessment of the Effects of the Broad-Spectrum Antimicrobial Chlorhexidine on the Outcome of River Microbial Biofilm Development. Appl Environ Microbiol 2008;74:3541. https://doi.org/10.1128/AEM.02879-07
3) Hennig TJ, Werner S, Naujox K, Arndt A. Chlorhexidine is not an essential component in alcohol-based surgical hand preparation: a comparative study of two handrubs based on a modified EN 12791 test protocol. Antimicrob Resist Infect Control 2017;6:96. https://doi.org/10.1186/S13756-017-0258-0.
4) https://www.rcseng.ac.uk/-/media/images/rcs/about-rcs/sustainability/greentheatrecompendiumofevidence.pdf
5) Lopes AER, Menegueti MG, Gaspar GG, Tartari E, da Silva Canini SRM, Pittet D, et al. Comparing surgeons’ skin tolerance and acceptability to alcohol-based surgical hand preparation vs traditional surgical scrub: A matched quasi-experimental study. Am J Infect Control 2022;50:1091–7. https://doi.org/10.1016/J.AJIC.2022.01.028.
