Feds are fired up in clearing the way for alcohol handrubs
Feds are fired up in clearing the way for alcohol handrubs
Risk of infection outweighs risk of fire
Preaching with the enthusiasm of the newly converted, federal regulators are clearing the way for widespread installation of alcohol-based handrubs in hospitals and ambulatory surgery centers.
The Centers for Medicare & Medicaid Services (CMS) was downright enthusiastic — as government agencies go — in deciding to allow the installation of the hand-hygiene dispensers in so-called egress corridors or fire exit routes. In issuing an interim final rule that becomes effective May 24, 2005, the CMS agreed with many ICPs who have long argued that the risk of infection outweighs the risk the alcohol-based gels will spark or accelerate a fire.1
"Any fire safety concerns are, we believe, more than offset by the potential for health care facilities to improve their infection control practices," the CMS stated in the March 25, 2005, Federal Register. "As the availability of alcohol-based handrubs (ABHRs) increases in a facility, so does the rate of hand-hygiene compliance. An increase in hand-hygiene compliance rates results in a decrease in health care-acquired infections. We believe that the public will benefit from more ABHR dispensers being available in more places because the increased availability of ABHR dispensers will likely decrease the number of health care-acquired infections."
Indeed, the CMS rule states that the use of ABHRs has been associated with improved adherence to recommended hand-hygiene practices. "Adherence is directly tied to access," the CMS states. "The highest possible adherence to hand-hygiene practice is achieved when ABHR dispensers are in readily accessible locations such as the corridor near the patient room entrance and inside patient rooms."
With the fire-regulation snag cleared, the CMS ruling is seen as a way to revitalize the hand-hygiene issue and draw new attention to it as a critical component of patient safety.
"This has been long awaited and is going to make a major difference, particularly because there was the unexpected expansion beyond the hospital into ambulatory care," says Judene Bartley, MS, CIC, a clinical consultant in Beverly Hills, MI, and a member of the Association for Professionals in Infection Control and Epidemiology. "That was an additional element."
The hope is that the ease and access of alcohol rubs will help ICPs overcome the historically poor compliance with hand hygiene by harried health care workers.
"It makes it so much easier to have these [dispensers] in the corridor just outside the door," Bartley says. "There is the immediate reminder to the staff as they walk into the door, particularly with physicians that are doing rounds and go from room to room. It makes it very easy for everyone to get a dollop of the gel as they walk in. The second issue is that then the patient can see the staff cleaning their hands as they walk in."
Attacking an historic problem
Still, anyone involved with infection control for very long knows than an endless succession of guidelines and all manner of carrots and sticks have been used to improve compliance with the cardinal principle of infection control. But if you’re a patient, the best guess right now is that you have about a 50-50 chance that the health care workers providing you care have decontaminated their hands.
"Everyone understands that there are limits," Bartley says. "This isn’t the only solution; we are still dealing with human behavior. But the idea that we have one less barrier, one more opportunity to improve hand hygiene, is pretty exciting to many people. The focus, the outcome we want, is the reduction of infections. We want improvement of compliance with hand hygiene, but the larger goal is to reduce transmission among staff and patients."
Going from patient to patient, the unwashed hands of health care workers become vectors for cross-transmission of pathogenic organisms. Patients become colonized, and subsequently some develop hospital-acquired infections. The current estimates are that some 2 million patients are infected in hospitals each year, and some 90,000 die from those infections. Thus, alcohol handrubs are intended as a primary intervention against a problem of enormous magnitude.
"We have been waiting on CMS to make a change," says Mary Hiott, MT CIC, infection control practitioner at St. Francis Hospital in Charleston, SC. "How many people are dying from nosocomial infections compared to how many people die in hospital fires? Really, what is the risk of these alcohol gels causing a hospital fire? We don’t think it is near the same risk as people getting hospital-acquired infections."
In that regard, a growing body of studies indicates that use of the alcohol rubs will actually lower infection rates. In a newly published study of pediatric hospitals, the use of alcohol hand gel was strongly and independently associated with a reduction in gastrointestinal infections.
"The frequency of hand hygiene that must be done to even get close to what we think is ideal absolutely requires a product like this," says Danielle M. Zerr, MD, MPH, author of the aforementioned study and infection control director at Children’s Hospital in Seattle. "This takes little time and can be used when you are talking to a patient’s family or walking down the hall. Institutions that aren’t yet using the gel really need to consider using alcohol hand sanitizers because issues like ease of use, time savings, and skin [protection] are real."
An emphasis on alcohol-based hand disinfection was the centerpiece for new hand-hygiene guidelines issued by the Centers for Disease Control and Prevention in 2002. Citing efficacy studies of use of the products in Europe, the CDC argued that highly accessible alcohol rubs should be the new weapon against a constant threat to patient safety — the contaminated hands of health care workers. However, the paradigm shift from sink and soaps to waterless hand gels has been undercut by fire safety concerns because many of the products are flammable.
"[They were] prohibited in exit corridors. The underlying issue had to do with egress in case of fire," Bartley says. "So they have been [installed] inside rooms and they have been permitted in areas where you had internal corridors that weren’t fire exits — areas that we would typically call suites, like an ICU. The concern was the normal patient corridors that go directly into a patient room. Those corridors have the exit signs leading outside in case there was a fire. That’s where they were prohibited."
The initial ruling may seem prudent, but some ICPs say the prohibition blocked them from putting the dispensers in the most convenient, highly trafficked areas where they would most likely be used. The CMS interim final rule renders the issue moot because the fire concerns have now been addressed.
"Although ABHR dispensers were once considered to be a fire safety risk when placed in egress corridors, they are no longer considered by fire safety experts to pose a significant risk to patient safety," the CMS stated. "... ABHR dispensers can be safely installed in egress corridors if they meet certain specifications, such as being placed at least 4 feet apart and not being placed over carpet in an unsprinklered smoke compartment."
The ABHRs are most commonly found in a gel form contained in a single-use disposable bag that is inserted into a wall-mounted dispenser, similar in appearance to wall-mounted hand-soap dispensers. The dispenser compresses the bag to dispense the gel. During normal operation and replacement, the dispenser remains a closed system, meaning that vapors are not released into the atmosphere. "The relatively small quantity of gel in each dispenser combined with the absence of vapor release means that these dispensers, when properly installed and used, pose little fire risk in health care facilities," the CMS concluded.
Check your state and local laws
While the CMS action removes a considerable obstacle, individual states may still adhere to stricter standards. The CMS decision was seen as a critical factor in getting those states to amend their own stances regarding alcohol dispensers. "Some of the states were very clear about not making a move until there was language [from CMS]," Bartley says. "That varies across the states. For that reason, this is very significant, because hospitals are not going to risk a citation that could threaten their licensure."
The CMS action gives ICPs the ammunition they need to convince state and local fire marshals of the safety and patient benefits of the alcohol gels.
"It will play a big role for us," Hiott says. "We have a very strict state fire marshal who has absolutely forbidden us to put in any alcohol handrubs in any egress. In every single one of our operating rooms, the hallways have an egress. We have surgeons that desperately want us to put the waterless alcohol scrubs in our ORs. They are not as hard on their hands and they do just as good a job. That is not an issue for other people because not all operating room hallways have egresses; it just happens that ours do."
Amid the momentous shift to alcohol handrubs, Bartley adds one caveat: Don’t do away with sinks. "Soap and water and sinks are still essential because of contamination of hands with blood or body fluids."
Indeed, there have discussions about downplaying sinks in architectural plans for hospitals due to the increasing use of waterless handrubs, notes Bartley. Traditional hand washing is still the standard recommendation if hands are visibly soiled. "[Alcohol rubs are] an enormous step forward but it is not a total equivalency because there are times when hands are soiled, and that is most likely to happen in the care of the patient," she says. "We need all of these elements as part of the armorarium to reduce infections."
[Editor’s note: Though it appears the CMS ruling was issued in near-final form, there is still a comment period concerning the federal action. Comments must be received no later than 5 p.m. on May 24, 2005. In commenting, please refer to file code CMS-3145-IFC. You may submit electronic comments on specific issues in the regulation to www.cms.hhs.gov/regulations/ecomments. You may mail written comments (one original and two copies) to the following address: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-3145-IFC, P.O. Box 8018, Baltimore, MD 21244-8018.]
Reference
- Centers for Medicare & Medicaid Services. Fire safety requirements for certain health care facilities; amendment. Interim final rule. 70 Fed Reg 15,229-15,239 (Mar. 25, 2005).