The following post is by Rohan Rastogi, an MPH student in Health Policy at the Harvard T.H. Chan School of Public Health and a medical student at the Boston University School of Medicine. He tweets about health policy and medicine at @rorastog.
Your clinician’s hands pose the greatest risk for acquiring an infection while in the hospital. Despite adequate education, clinicians are notoriously non-compliant with hand hygiene guidelines, which recommend frequent use of alcohol-based hand sanitizer.
Though making hand sanitizer more accessible improves compliance, an unexpected antagonist may prevent hospitals from optimally locating dispensers—fire safety codes.
Historically, alcohol-based hand sanitizer was not always recognized as a key component of hospital hand hygiene. The 1983 CDC guidelines recommended using hand sanitizers only in emergency situations where a sink was not readily available.
More recent evidence, however, indicates that using alcohol-based hand sanitizer is usually better than traditional handwashing with soap and water. It’s faster, more accessible than sinks, less irritating to skin, and more effective at reducing transfer of the majority of dangerous bacteria.
Although hand hygiene is considered the single most important strategy to control infection transfer between clinicians and patients, health care workers sanitize less than half as often as they should. With one in every 31 patients acquiring an avoidable infection while in the hospital, understanding how to encourage clinicians to consistently use hand sanitizer has become a billion-dollar question.
In an experiment on behavior change, researchers found that easily accessible hand sanitizer dispensers doubled clinician hand hygiene compliance, while hand hygiene education, feedback, and patient awareness campaigns had no effect. A closer look on accessibility found that improving dispenser placement is more impactful than increasing the number of dispensers. All this to say, the real estate mantra of location, location, location holds true when it comes improving clinician hand sanitizer compliance.
Hand hygiene experts have gone to great lengths to find the perfect hand sanitizer dispenser location. In a particularly notable study, researchers suspended dispensers over patient beds using a trapeze-bar apparatus to improve visibility, which improved compliance compared to a traditional wall-mounted location.
When interviewed, clinicians say that hand sanitizer dispensers have to be in their line of sight, on their workflow route, unobstructed, standardized, within arm’s reach during procedures, and near the patient. A literature review recommended five dispenser locations to improve clinician hand hygiene compliance: outside the patient room, at the room entrance, immediately beside the point of care, immediately adjacent to the patient bed, and at the foot of every patient bed.
It’s unsurprising that placing dispensers as close to patient care activity as possible improves hand sanitizer use. And yet, controversy arose in the early 2000s, when fire marshals began forcing hospitals to move their dispensers.
Given that hand sanitizers must contain at least 60% alcohol by weight to be effective, alcohol-based hand sanitizers are flammable. Isolated incidents, such as the 2013 Oregon case and the 2002 Kentucky case, implicated hand sanitizers in burn injuries when a static spark ignited residual undissolved solution.
Despite these well-publicized events, fires involving alcohol-based hand sanitizer are exceedingly rare. A World Health Organization report states that “although alcohol-based hand rubs are flammable, the risk of fires associated with such products is very low.” The scientific community seems to agree that current hospital fire regulations “represent an abundance of caution.” As such, the minor fire risk must be weighed against the substantial potential benefit for hospital infection safety.
Answering the question of whether fire codes prevent optimal dispenser placement, and thereby hamper hand hygiene, requires a closer look at the codes. The Center for Medicare and Medicaid Services (CMS) and the Joint Commission (JC) adopted sections (18.104.22.168 and 22.214.171.124) of the National Fire Protection Agency’s 2012 Life Safety Code in 2016.
Among the rules: dispensers must be separated from each other by at least 4 feet of space and dispensers cannot be installed within 1 inch of an ignition source (e.g. electrical outlet, appliance, device). According to Dr. Eli Perencevich, an infectious disease physician and researcher from the Iowa Carver College of Medicine, however, these CMS/JC rules may serve as a template for more restrictive state and local fire marshal regulations.
The CMS ruling, in fact, explicitly allows this practice: “States and local jurisdictions may choose to retain stricter codes that prohibit or otherwise restrict the installation of [alcohol-based hand rub] dispensers in health care facilities. Facilities will still be required to comply with those stricter State and local codes.”
The end result—the practice of hospital hand hygiene stops at the patient doorway. A study in Dartmouth’s hospital found that only 37% of hand hygiene events involved in-room dispensers, of which 75% involved the dispenser located just inside the doorway…far away from the patient. This finding led the authors to conclude that there exists “a focus on hand hygiene before and after patient contact but not during patient care.”
In the US, this emphasis on sanitizing upon entering and exiting rooms originates from the most basic compliance monitoring strategy—direct observation at the doorway. The complexities of observing hand hygiene at the point of care have likely exacerbated its neglect.
The red tape of hand hygiene may be hindering hospitals’ ability to protect patients from their clinicians. Some suggest that hospitals should put the power to sanitize back into the hands of clinicians—provide them with personal carry sanitizer bottles. While the idea of sidestepping the wall placement regulations may be enticing, further studies will show whether it improves compliance or reduces infection transmission. Until then…ask your doctor about handwashing.