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Use of an Alcohol-Based Hand Rub and Quality Improvement Interventions to Improve Hand Hygiene in a Russian Neonatal Intensive Care Unit

  • Samuel M. Brown (a1), Anna V. Lubimova (a2), Natalya M. Khrustalyeva (a3), Svetlana V. Shulaeva (a3), Iya Tekhova (a2), Ludmila P. Zueva (a2), Donald Goldmann (a4) and Edward J. O'Rourke (a4) (a5)...

Hand hygiene (HH) is critical to infection control, but compliance is low. Alcohol-based antiseptics may improve HH. HH practices in Russia are not well described, and facilities are often inadequate.


Four 6-bed units in a neonatal intensive care unit in St. Petersburg, Russia.


Prospective surveillance of HH compliance, nosocomial colonization, and antibiotic administration was performed from January until June 2000. In February 2000, alcohol-based hand rub was provided for routine HH use. Eight weeks later, a quality improvement intervention was implemented, consisting of review of interim data, identification of opinion leaders, posting of colonization incidence rates, and regular feedback. Means of compliance, colonization, and antibiotic use were compared for periods before and after each intervention.


A total of 1,027 events requiring HH were observed. Compliance was 44.2% before the first intervention, 42.3% between interventions, and 48% after the second intervention. Use of alcohol rose from 15.2% of HH indications to 25.2% between interventions and 41.5% after the second intervention. The incidence of nosocomial colonization (per 1,000 patient-days) with Klebsiella pneumoniae was initially 21.5, decreased to 4.7, and then was 3.2 in the final period. Rates of antibiotic and device use also decreased.


HH may have increased slightly, but the largest effect was a switch from soap and water to alcohol, which may have been associated with decreased cross-transmission of Klebsiella, although this may have been confounded by lower device use. Alcohol-based antiseptic may be an improvement over current practices, but further research is required.

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1.Semmelweis, I. The etiology, concept and prophylaxis of childbed fever [excerpts]. In: Buck, C, Llopis, A, Najera, E, Terris, M, eds. The Challenge of Epidemiology: Issues and Selected Readings. Washington, DC: PAHO Scientific Publication; 1988:4659.
2.Rotter, ML. Hand washing and hand disinfection. In: Mayhall, G, ed. Hospital Epidemiology and Infection Control. Baltimore: Williams & Wilkins; 1996:10521068.
3.Jarvis, WR. Handwashing: the Semmelweis lesson forgotten? Lancet 1994;344:13111312.
4.Pittet, D. Improving adherence to hand hygiene practice: a multidisci-plinary approach. Emerg Infect Dis 2001;7:234240.
5.Pittet, D, Mourouga, P, Perneger, TV. Compliance with handwashing in a teaching hospital: infection control program. Ann Intern Med 1999;130:126130.
6.Boyce, JM. It is time for action: improving hand hygiene in hospitals. Ann Intern Med 1999;130:153155.
7.Albert, RK, Condie, F. Hand-washing patterns in medical intensive-care units. N Engl J Med 1981;304:14651466.
8.Dubbert, PM, Dolce, J, Richter, W, Miller, M, Chapman, SW. Increasing ICU staff handwashing: effects of education and group feedback. Infect Control Hosp Epidemiol 1990;11:191193.
9.Larson, E, Killien, M. Factors influencing handwashing behavior of patient care personnel. Am J Infect Control 1982;10:9399.
10.Muto, CA, Sistrom, MG, Farr, BM. Hand hygiene rates unaffected by installation of dispensers of a rapidly acting hand antiseptic. Am J Infect Control 2000;28:273276.
11.Khatib, M, Jamaleddine, G, Abdallah, A, Ibrahim, Y. Hand washing and use of gloves while managing patients receiving mechanical ventilation in the ICU. Chest 1999;116:172175.
12.McGuckin, M, Waterman, R, Porten L, et al.Patient education model for increasing handwashing compliance. Am J Infect Control 1999;27:309314.
13.Preston, GA, Larson, EL, Stamm, WE. The effect of private isolation rooms on patient care practices, colonization and infection in an intensive care unit. Am J Med 1981;70:641645.
14.Kaplan, LM, McGuckin, M. Increasing handwashing compliance with more accessible sinks. Infect Control 1986;7:408410.
15.Harbarth, S, Pittet, D, Grady, L, et al.Interventional study to evaluate the impact of an alcohol-based hand gel in improving hand hygiene compliance. Pediatr Infect Dis J 2002;21:489495.
16.Bischoff, WE, Reynolds, TM, Sessler, CN, Edmond, MB, Wenzel, RP. Handwashing compliance by health care workers: the impact of introducing an accessible, alcohol-based hand antiseptic. Arch Intern Med 2000;160:10171021.
17.Graham, M. Frequency and duration of handwashing in an intensive care unit. Am J Infect Control 1990;18:7781.
18.Conly, JM, Hill, S, Ross, J, Lertzman, J, Louie, TJ. Handwashing practices in an intensive care unit: the effects of an educational program and its relationship to infection rates. Am J Infect Control 1989;76:330339.
19.Donowitz, LG. Handwashing technique in a pediatric intensive care unitam J Dis Child 1987;141:683685.
20.Larson, E, McGeer, A, Quraishi, ZA, et al.Effect of an automated sink on handwashing practices and attitudes in high-risk units. Infect Control Hosp Epidemiol 1991;12:422428.
21.Wurtz, R, Moye, G, Jovanovic, B. Handwashing machines, handwashing compliance, and potential for cross-contamination. Am J Infect Control 1994;22:228230.
22.Larson, EL, Early, E, Cloonan, P, Sugrue, S, Parides, M. An organizational climate intervention associated with increased handwashing and decreased nosocomial infections. Behav Med 2000;26:1422.
23.Pittet, D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol 2000;21:381386.
24.Larson, EL. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 1995;23:251269.
25.Garner, JS. Guideline for isolation precautions in hospitals: The Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1996;17:5380.
26.Larson, EL, Eke, PI, Laughon, BE. Efficacy of alcohol-based hand rinses under frequent-use conditions. Antimicrob Agents Chemother 1986;30:542544.
27.Meers, PD, Yeo, GA, Shedding of bacteria and skin squames after handwashing. Journal of Hygiene (London) 1978;81:99105.
28.Rotter, ML. Hygienic hand disinfection. Infect Control 1984;5:1822.
29.Larson, E. Skin hygiene and infection prevention: more of the same or different approaches? Clin Infect Dis 1999;29:12871294.
30.Boyce, JM. Using alcohol for hand antisepsis: dispelling old myths. Infect Control Hosp Epidemiol 2000;21:438441.
31.Rotter, ML. Arguments for alcoholic hand disinfection. J Hosp Infect 2001;48(suppl A):S4S8.
32.Boyce, JM, Kelliher, S, Vallande, N. Skin irritation and dryness associated with two hand-hygiene regimens: soap-and-water hand washing versus hand antisepsis with an alcoholic hand gel. Infect Control Hosp Epidemiol 2000;21:442448.
33.Larson, E, Silberger, M, Jakob, K, et al.Assessment of alternative hand hygiene regimens to improve skin health among neonatal intensive care unit nurses. Heart Lung 2000;29:136142.
34.Paulson, DS, Fendler, EJ, Dolan, MJ, Williams, RA. A close look at alcohol gel as an antimicrobial sanitizing agent. Am J Infect Control 1999;27:332338.
35.Maki, DG. The use of antiseptics for handwashing by medical personnel. J Chemother 1989;1(suppl 1):311.
36.Teare, EL, Cookson, B, French, GL, A et al.UK handwashing initiative. J Hosp Infect 1999;43:13.
37.Larson, E. Hygiene of the skin: when is clean too clean? Emerg Infect Dis 2001;7:225230.
38.Boyce, JM, Rotter, ML. Hospital hygiene procedures: areas of consensus and ongoing controversies. J Hosp Infect 2001;48(suppl A):S1S92.
39.Pittet, D, Hugonnet, S, Harbarth, S, et al.Effectiveness of a hospital-wide programme to improve compliance with hand hygiene: infection control programme. Lancet 2000;356:13071312.
40.Harbarth, S, Martin, Y, Rohner, P, Henry, N, Auckenthaler, R, Pittet, D. Effect of delayed infection control measures on a hospital outbreak of methicillin-resistant Staphylococcus aureus. J Hosp Infect 2000;46:4349.
41.Nettleman, MD, Mcintosh, SL, Mcintosh, TJ, Wenger, J, Geerdes, H. Infection control in the Russian Federation: review of a tertiary care hospital. Infect Control Hosp Epidemiol 1994;15:200202.
42.DiCarlo, JV, Zaitseva, TA, Khodateleva, TV, et al.Comparative assessment of pediatric intensive care in Moscow, the Russian Federation: a prospective, multicenter study. Crit Care Med 1996;24:14031407.
43.Pittet, D, Dharan, S, Touveneau, S, Sauvan, V, Perneger, TV. Bacterial contamination of the hands of hospital staff during routine patient care. Arch Intern Med 1999;159:821826.
44.Harbarth, S, Pittet, D, Grady, L, Goldmann, DA. Compliance with hand hygiene practice in pediatric intensive care. Pediatr Crit Care Med 2002;2:311314.
45.Casewell, M, Phillips, I. Hands as route of transmission for Klebsiella species. Br Med J 1977;2:13151317.
46.Larson, EL, McGinley, KJ, Foglia, A, et al.Handwashing practices and resistance and density of bacterial hand flora on two pediatric units in Lima, Peru. Am J Infect Control 1992;20:6572.
47.Robinton, ED, Mood, EW. A study of bacterial contaminants of cloth and paper towels. Am J Public Health 1968;58:14521459.
48.Haley, RW, Bregman, DA. The role of understaffing and overcrowding in recurrent outbreaks of staphylococcal infection in a neonatal special-care unit. J Infect Dis 1982;145:875885.
49.Pettinger, A, Nettleman, MD. Epidemiology of isolation precautions. Infect Control Hosp Epidemiol 1991;12:303307.
50.Larson, E, McGinley, KJ, Grove, GL, Leyden, JJ, Talbot, GH. Physiologic, microbiologic, and seasonal effects of handwashing on the skin of health care personnel. Am J Infect Control 1986;14:5159. Carvalho, M, Lopes, JM, Pellitteri, M. Frequency and duration of handwashing in a neonatal intensive care unit. Pediatr Infect Dis J 1989;8:179180.
52.Tenorio, AR, Badri, SM, Sahgal, NB, et al.Effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant enterococcus species by health care workers after patient care. Clin Infect Dis 2001;32:826829.
53.Freeman, J, Epstein, MF, Smith, NE, Platt, R, Sidebottom, DG, Goldmann, DA. Extra hospital stay and antibiotic usage with nosocomial coagu-lase-negative staphylococcal bacteremia in two neonatal intensive care unit populations. Am J Dis Child 1990;144:324329.
54.Townsend, TR, Wenzel, RP. Nosocomial bloodstream infections in a newborn intensive care unit: a case-matched control study of morbidity, mortality and risk. Am J Epidemiol 1981;114:7380.
55.Jarvis, WR, Selected aspects of the socioeconomic impact of nosocomial infections: morbidity, mortality, cost, and prevention. Infect Control Hosp Epidemiol 1996;17:552557.
56.Craig, CP, Connelly, S. Effect of intensive care unit nosocomial pneumonia on duration of stay and mortality. Am J Infect Control 1984;12:233238.
57.Leu, HS, Kaiser, DL, Mori, M, Woolson, RF, Wenzel, RP. Hospital-acquired pneumonia: attributable mortality and morbidity. Am J Epidemiol 1989;129:12581267.
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