Assessment of two hand hygiene regimens for intensive care unit personnel Elaine L. Larson, RN, PhD, FAAN, CIC; Allison E. Aiello, MSPH; Jed Bastyr, BS; Chris Lyle, MS; Julie Stahl, BS; Alicia Cronquist, RN, MPH; Lena Lai, BA; Phyllis Della-Latta, PhD, ABMM, FAMM T he hands of healthcare person- nel frequently serve as vectors for the transmission of organ- isms between patients. Al- though hand hygiene is one of the most important interventions in reducing transmission of potentially infectious agents, healthcare professionals wash less often and for shorter durations than rec- ommended, and efforts to change their behavior have not been effective. There- fore, it is important to develop new ap- proaches to improve hand hygiene. There is no national standard for hand hygiene products, but antiseptic detergents are most commonly used in adult and pedi- atric critical care settings (1). The need for frequent handwashing and the glove changing required among staff in high-risk, high-volume patient care areas such as intensive care units (ICUs) causes skin damage and dermato- logical problems among staff who prac- tice appropriate hand hygiene vigorously. This skin damage leads to changes in normal bacterial hand flora, shedding of more organisms into the environment, and potentially increased risk of nosoco- mial transmission of pathogens from the hands of personnel to patients (1–3). The challenge is therefore to maximize the antimicrobial effectiveness of hand hygiene practices while minimizing changes to skin health or microflora in an effort to reduce nosocomial infection rates. The purpose of this study was to compare the effects of two hand-care reg- imens—a 2% chlorhexidine gluconate (CHG)-containing traditional antiseptic wash (Foam Care, Ballard, Draper, UT) and a waterless handrub containing 61% ethanol with emollients (ALC) (Avagard, 3M Health Care, St. Paul, MN)— on skin microbiology and skin condition among ICU personnel. MATERIALS AND METHODS This was a 4-wk prospective, randomized clinical trial. Subjects and Setting Subjects were eligible for the study if they worked full time (30 hrs/wk) in the medical or surgical ICU of a large medical center in northern Manhattan, were aged 18 – 65, were free from known allergy to study products, were not currently receiving topical or sys- temic steroids or antibiotics, and had no diag- nosed current dermatologic conditions such as psoriasis. Subjects who reported a latex allergy were eligible for the study if they re- frained from using latex products during the study. The sample size was determined by the numbers required to detect a difference in the Visual Skin Scaling form (see description be- low). Previous studies have provided a SD esti- mate of 1.2 (4, 5). To have 80% power to detect a difference of 1 on the scale at a 0.05 level of significance, 19 subjects were required per group (6). To account for potential dropouts and poststudy exclusions, 25 subjects were recruited into each treatment group. From the Columbia University School of Nursing, New York, NY (E.L.L.); the Columbia University School of Public Health, New York, NY (A.E.A., A.C.); 3M Health Care, St. Paul, MN (J.B., C.L., J.S.); Columbia Presby- terian Medical Center, Clinical Microbiology Labora- tory, New York, NY (L.L.); and the Department of Clinical Pathology, Columbia University Medical Center, New York, NY (P.D.-L.). Supported, in part, by 3M Health Care, St. Paul, MN. Copyright © 2001 by Lippincott Williams & Wilkins Objective: To compare skin condition and skin microbiology among intensive care unit personnel using one of two randomly assigned hand hygiene regimens: a 2% chlorhexidine gluconate (CHG)-containing traditional antiseptic wash and a waterless hand- rub containing 61% ethanol with emollients (ALC). Design: Prospective, randomized clinical trial. Setting: Two critical care units (medical and surgical) in a large, metropolitan academic health center in Manhattan. Subjects: Fifty staff members (physicians, nurses, housekeepers, respiratory therapists) working full time in the intensive care unit. Interventions: One of two hand hygiene regimens randomly assigned for four consecutive weeks. Measurements and Main Results: The two outcomes were skin condition (measured by two tools: Hand Skin Assessment form and Visual Skin Scaling form) and skin microbiology. Samples were obtained at baseline, on day 1, and at the end of wks 2 and 4. Participants in the ALC group had significant improvements in the Hand Skin Assessment scores at wk 4 (p  0.04) and in Visual Skin Scaling scores at wks 3 (p  0.01) and 4 (p  0.0005). There were no significant differences in numbers of colony-forming units between participants in the CHG or ALC group at any time period. The ALC regimen required significantly less time than the CHG regimen (mean: 12.7 secs and 21.1 secs, respectively; p  0.000) and resulted in a 50% reduction in material costs. Conclusions: Changes in hand hygiene practices in acute care settings from the traditional antiseptic wash to use of plain, mild soap and an alcohol-based product should be considered. Further research is needed to examine the association between use of antiseptic products for hand hygiene of staff and reductions in nosocomial infection rates among patients. (Crit Care Med 2001; 29:944 –951) KEY WORDS: antisepsis; handwashing; infection control; noso- comial infections; critical care; skin; hygiene; alcohol; chlorhexi- dine gluconate 944 Crit Care Med 2001 Vol. 29, No. 5