Benefits of Alcohol Based Gel over Soap Based Scrub in Preventing Nosocomial Infection in Care Facility - Essay Example

Benefits of alcohol based gel over soap based scrub in preventing nosocomial infection in critical care facility Multiple physical contacts of healthcare workers (HCW), as part of their occupation, has prospect for transfer of microorganisms among contact subjects as well as objects, and hand hygiene is considered paramount in eliminating the microorganisms that colonize superficial layers of skin. With the popularization of hand washing as simple, easiest method for checking the chances of contamination and prevention of infection hand hygiene products with or without antimicrobial activity are flooding the market. A comprehensive search for evidence based practice and recent findings on the efficacy of alcohol-based hand rub, and its suitability as a hand hygiene product for use in a clinical setting, reveals that the gel is associated with better skin condition, superior acceptance, and a trend toward improved compliance, will be appropriate to prevent occupational contact dermatitis as well as nosocomial infection. Although guidelines on hand hygiene procedures are abundant, variety in hand washing products, such as type of antimicrobial agents (e.g., alcohol, chlorhexidine, iodine, triclosan, hexachlorophene) and their concentration, different procedures of hand hygiene, and time required to practice the procedure are found to be more confusing and adversely affecting hand hygiene practice. In this context, an attempt has been made to identify different aspects of hand hygiene principles and their applicability in a health care facility that is in the grip of nosocomial infection. Story behind the scene: On successful completion of graduate nurse practitioner training I got selected in Chamberlain hospital [a fictitious title open to change] which has multi-specialty services. After few weeks of assuming charge as nurse in-charge of neonatal intensive care unit I had dryness, itching, and color change on my hands. My personal experience was shared with colleagues and they also expressed similar symptoms. It was found that most of the health care workers posted in other wards of the facility also had similar irritant hand syndrome. It prompted me to search for associated reasons as well as to enquire from the records the rate of infection, length of hospital stay, and readmission rates that are main components in quality health care, to substantiate my apprehensions about the probable cause of inappropriate hand wash practice and associated nosocomial infection. Though it has been noted that the hand washing practice being followed in the facility was not in line with the one I was following earlier and the facility was not adhering to standard hand hygiene guidelines not much importance was paid to the subject due to heavy work load, till I had irritant hand. The hand hygiene policy being followed in the facility was hand scrub with soap and water, for fifteen seconds, between attending patients. Alcohol based rubs were not being used by the staff as it was of the opinion of hospital administration that the standard practice of hand scrub with soap and water is cheapest, effective, and is the accepted method for decades. Literature on hand hygiene and research evidence suggests that strict adherence to guidelines will help reduce infection in health care facilities and alcohol based hand rubs are effective than conventional soap and water scrub. In addition, time taken for hand wash with soap and water, drying the hands, and wearing gloves are also important in achieving maximum hand hygiene. Since the practice being followed is not according to standard approved guidelines and it was observed that there exist lack of awareness among administrators as well as inadequacy of training among health care workers it was proposed that a change is inevitable to improve quality of health care in the facility. As such, I was prompted to initiate change and convince administration with research evidence on the subject for effective implementation of efficient hand hygiene practice that will be beneficial for all stake holders, such as the facility, health care workers, and the patients. The Problem: It is observed that hospital acquired infections are on the rise among patients requiring intensive care in acute-care facilities, surgical centers, as well as outpatient settings where clinical procedures are performed. Along with dramatic changes in health care provisions in the United States there is proportionate increase in hospital acquired infections in patients requiring intensive care, particularly after surgery. It is opined that even after improving operating room ventilation, sterilization methods, barriers, surgical technique, and availability of antimicrobial prophylaxis surgical sight infection (SSI) is the most common nosocomial infection (NI) causing morbidity and mortality among hospitalized patients all over the world. Since the patient population admitted in such facilities are severely ill and immunocompromised “prevention of infections and other adverse events is a major component of providing quality care.” (Merging infectious diseases, 2001, p.174). Investigations revealed that inefficient hand hygiene by health care workers, spread of anti-microbial resistant bacteria in health care facilities, and frequency of bacterial transfer among patients impede quality health care. Statistical evidence projects that prevalence of nosocomial infections (NIs) in the United States is between “3.5 and 9.9%” and ‘approximately 2 million NIs occur annually. (Kalmf, & Kramer, 2004). Stake holders and initiative for change: Obviously the stakeholders are primarily the patients as they are at risk of either contracting infection themselves or transmitting to others interacts with them. Health care workers as well as caregivers are also at increased risk of contamination. It is seen that major route of contamination in hospital settings is through hands of health care workers, particularly nursing personnel. It is possible that nursing care personnel may contaminate their hands while negotiating patients and may forget to wash hands, or hastily wash their hands due to work load. This may lead to microbial colonization that could either cause dermatological hazards to themselves or infection of patients or both. But, frequent washing of hands with soap and water leads to skin irritation, hardening of the skin, dryness of hands, or even abnormal skin conditions due to chemical reactions of soap. An interview with longest staying nurse in the facility was arranged to know the hand hygiene guidelines, practice, and attitude of authorities towards hand hygiene as well as to understand individual opinion for brining changes to existing system. It derived that she considered herself to be hard-pressed for time, being called upon to provide care and attention to many patients at a time. She found it difficult to even attend to writing work that make it difficult to indulge in washing hands after seeing each patient, which takes away lot of time that could otherwise be used for patient care. Moreover, wash rooms or basins located at far away places makes it more inconvenient and consume much time (about 20 seconds) for just going and coming back after each wash. It is opined that wash facility at distant places burns out productive time and provision of alcohol gel near bed of patient, provided at close proximity at different places of nurse room, and also at wards could save time and provide more opportunity to follow hand asepsis. Boyce quote that in an observational study “nurses needed an average of 62 seconds to walk to a sink, wash and dry their hands, and return to the patient’s bed” (Boyce, 2001, p.1) and if nurses obtain alcohol hand disinfectant from a bedside dispenser and 15 seconds is required for drying, 100% compliance would require 4 hours of nursing time per shift rather than 16 hours of nursing time per shift required for hand washing in an identical situation. (Boyce, 2001). In addition, waterless scrubs are easy to carry, convenient to handle, speedier, skin friendly, and more effective in infection control than conventional soap and water solution. It may be construed that the nursing faculty is in favor of introduction of non-soap use in the facility. The incidence of skin problems among health care workers, increased prevalence of infections in different wards, cost benefits of changes to alcohol based hand rubs, and associated benefits have been brought to the notice of infection control unit, and administrative authorities with substantiating evidence, since nurse practitioners have to act as leaders of change as well. Relevance of better hand hygiene: The skin is a “dynamic structure that has primary function to reduce water loss, provide protection against abrasive action and microorganisms, and act as a permeability barrier to the environment.” (Boyce, & Pittet, 2002, p.4). Normal skin is generally colonized with bacteria and hands of health care workers (HCWs) more easily get colonized with “pathogenic flora (e.g., S. aureus), gram-negative bacilli, or yeast.” (Boyce, & Pittet, 2002, p.4). A breach in skin integrity results in “a decrease in time available for 1) uptake of nutrients (e.g., essential fatty acids), 2) protein and lipid synthesis, and processing of the precursor molecules required for skin-barrier function.” (Boyce, & Pittet, 2002, p.5). Hence, hand hygiene that retains healthy skin flora is considered paramount for health care workers to prevent increased risk of infection from one patient to another via the hands of HCWs. “Hand washing has traditionally been identified as the most important infection control intervention to prevent disease transmission and is recommended before and after contact with patients, body fluids, and dirty material; between dirty and clean procedures on the same patient; before and after performing invasive procedures; and after using the washroom.” (Langley, 2002). French pharmacist who propagated that “solutions containing chlorides of lime or soda could eradicate foul orders associated with human corpses and that such solutions could be used as disinfectants and antiseptics.” (Boyce, & Pittet, 2002, p.3). as early as 1822, and stated in 1825 that “physicians and other persons attending patients with contagious diseases would benefit from moistening their hands with a liquid chloride solution.” (Boyce, & Pittet, 2002, p.3). has to be considered as the founder of hand hygiene and antisepsis concept (P.1). Subsequent evidence based observations and seminal works by Ignaz Semmelweis and Oliver Wendell Holmes during 1850s gave credibility and acceptance for handwashing as one of the prime measures for preventing transmission of pathogens in health-care facilities. Hand washing with soap and water for 1-2 minutes before and after patient contact was the standard practice for generations, and written guidelines on hand washing practices in hospitals were published by Centers for Disease Control and Prevention (CDC) in 1975 and 1985. Further guidelines on the subject by the Association for Professionals in Infection Control (APIC), similar to those of CDC guidelines, were issued in 1988 and 1995, in which 1995 guidelines contained more detailed discussions of alcohol-based hand rubs. The Healthcare Infection Control Practices Advisory Committee (HICPAC) in 1995 and 1996 recommended that “either antimicrobial soap or a waterless antiseptic agent be used for cleaning hands upon leaving the rooms of patients with multidrug-resistant pathogens (e.g., vancomycin-reistant eneterococci [VRE] and methicillin-resistant staphylococcus aureus [MRSA].” (Boyce, & Pittet, 2002, p.4). Now, alcohol based hand rub is the practice most recommended to prevent infection through hands of health care workers. Possible contraindications: Studies indicate that “regular and repetitive use of cleansing and antiseptic products for hand hygiene in medical settings is typically at risk for inducing irritant contact dermatitis (ICD)” (Xhauflaire-Uhoda, Macarenko, Denooz, Charlier, & Pierard, 2008). A Review Article by Kampf and Loffler(2007) to develop evidence-based procedures, safe and effective in preventing nosocomial infection by the hand, found that noncompliance with hand hygiene guidelines and practice of frequent hand washing with soap and water by health care workers rather with alcohol-based hand rub not only increases skin irritation but also increases risk of infection. It is found that prevalence of hand dermatitis, an occupational skin disease, is highest in health care workers (HCW). Hand dermatitis, with symptoms of itching, burning, tickling, pain, tightening and smarting of skin, develops due to frequent contact with water, gloves, disinfectants and detergents and topically applied skin care products, which breaches skin barrier. The prophylactic measure for minimizing this risk, among other things, is application of skin protection creams (SPC). Though alcohol-based formulations have much acceptance for hand hygiene, there is concern about possible health consequences, cultural and religious precepts that prohibit alcohol use, and “potential systemic diffusion of alcohol or its metabolites following dermal absorption or airborne inhalation related to its use” (Kramer, Below, Bieber, Kampf, Toma, Huebner, & et al, 2009) that make it unsuitable for some health care workers In this context Kramer and team conducted a study to assess ethanol absorption during hygiene and surgical hand disinfection and to quantify absorption levels in humans. The experiment using three different alcohol-based hand rubs containing 95%, 85%, and 55% ethanol (classified into A, B, and C ) was conducted in 12 volunteers selected using predefined criteria. Hygienic hand disinfection was performed after a proven or anticipated contamination of hands. The highest median concentration found with hand rub A was 20.95 mg/L (equivalent to 0.02% ethanol); with hand rub B 11.45 mg/L (equivalent to 0.011%) and 6.90 mg/L with hand rub C (equivalent to 0.007% ethanol). The amount of absorbed ethanol was 1365 mg with hand rub A, 630 mg with hand rub B, and 358 mg with hand rub C having proportion of absorbed ethanol at 2.3%, 1.1%, and 0.9% respectively for hand rub A, B, and C. On the basis of study findings Kramer et al (2007) conclude that “under clinical conditions the use of ethanol-based hand rubs does not lead to intoxicating levels of alcohol in the peripheral blood.” (Kramer, Below, Bieber, Kampf, Toma, Huebner, & et al 2009). and its use is safe in humans. Another problem is poor compliance with hand hygiene guidelines as data obtained by Kampf & Loffer (2007), through observation of HCWs, indicate that “almost 50% of all hand hygiene procedures in clinical practice are hand washes,” but with inadequate wash time. Fuls et al observe that bacterial reductions are significantly affected by wash time, product type, and soap volume. (Fuls, Rodgers, Fischler, Howard, Patel, Weidner, & et al, 2008). “Even water on its own, is a known irritant” (Kampf & Loffler, 2007, p.3), and washing hands is indicated in exceptional cases. It is experienced that “proportions of hand washing among all hand hygiene procedures is probably far higher than it should be.” (Kampf & Loffler, 2007, p. 647). Although guidelines specify strict adherence to hand wash/rub time, observational evidence suggests poor compliance by health care workers, which adversely affect hand hygiene. Proof for efficacy of alcohol based gel: Alcohol-based hand rub(ABHR) is “an alcohol-containing preparation designed for application to the hands for reducing the number of viable microorganisms on the hands that usually contain 60%-95% ethanol or isopropanol. Studies suggest that ABHR are “better suited than soap and water to render hands safe after known or suspected contamination with potentially pathogenic microorganisms,” and “hand rubs use an antiseptic or topical antimicrobial agent to reduce a substantial part of the transient flora by killing rather than removing the flora.” (Gruendemann, & Mangum, 2001, p. 106). In addition, it is a most cost effective germicide and rapid acting skin antiseptic that is readily available, with less time consuming process, and easy to handle. Hand rub techniques recommends “rubbing 3 to 5 ml of a fast-acting antiseptic on both hands until dry, or for a preset duration recommended by the manufacturer—usually 30 seconds to 1 minute. All areas of the hands should be covered, and the subungual spaces cleaned by rubbing the fingertips on the antiseptic-covered palms.” (Gruendemann, & Mangum, 2001, p.105). A prospective controlled trail of alcohol-based hand gel carried out by Rupp and colleagues (2007) found that “there is significant and sustained improvement in the rate of hand hygiene adherence when hand gel was available in the unit.” (Rupp, Fitzgerald, Puumala, Anderson, Craig, Iwen, & et al, 2007). So far as cost comparisons of different hand wash products are concerned, it is pointed out that “2% chlorhexidine gluconate detergent was 1.7 times as expensive as the non medicated soap, and the alcohol-based hand gel was twice as expensive.” (Boyce, 2001, p.232). However, it is pointed out that “the excess hospital expenses associated with four or five nosocomial infections of average severity is equal to the entire annual budget for soap and alcohol products used for hand hygiene and inpatient care areas.” (Boyce, 2001, p. 232). Since ‘hands contaminated with microbes’ require disinfection, evidence suggest that alcohol based hand rub should be used extensively in clinical situations. Though many nurses complain about burning sensation on application of alcohol based hand rubs, investigations using 60% n-propanol solution revealed that “alcohol based hand rubs rarely provoke relevant irritation on intact skin.” (Kampf & Loffler, 2007) The burning sensation after alcohol application is indicative of serious impairment to the skin barrier of the user that necessitates prompt prevention to check further deterioration of skin flora. But burning sensation caused by alcohol-based hand rub is misinterpreted as its ‘aggressiveness’ leading to ‘increased hand washing,’ which disrupt skin barrier causing severe hand dermatitis and imminent occupational disability. (Kampf & Loffler, 2007) recommends that “a 3-step concept (consisting of skin protection before work, cleaning and skin care after work).” (Kampf & Loffler, 2007, p.6). and “a more aggressive focus on the teaching of evidence-based hand hygiene practice” (Kampf & Loffler, 2007, p.6) will be appropriate to prevent occupational contact dermatitis and “key for future success” in hand hygiene practice. Comparison of intervention: “The important considerations in evaluating the suitability of a hand hygiene product for use in a clinical setting are its efficacy in preventing the transmission of microorganisms, adverse consequences (odor, skin damage) for health care providers, ease of access for users, affordability, and concerns about the induction of resistant bacteria, adverse consequences (odor, skin damage) for health care providers, ease of access for users, affordability, and concerns about the induction of resistant bacteria.” (Langley, 2002). Major disadvantages of hand scrub with soap and water are “lower efficacy, a decreased dermal tolerance, higher potential for impaired efficacy due to an incorrect performance of the procedure, the necessity of a wash basin, and the longer time spent for the procedure” (Kramer, Below, Bieber, Kampf, Toma, Huebner, & et al 2009). For supporting this observation experience from a neonatal care ICU is cited here. Newborns in neonatal intensive care units (NICUs) are at increased risk of health care associated infections because of “a combination of innate characteristics including their fragile integumentary and underdeveloped immune system.” (Cohen, Saiman, Cimiotti, & Larson, 2003). as well as the frequent need for staff contact for various procedures. An observational study was conducted in two university-affiliated New York City Level III and IV NICU facilities that were following similar infection control practices. The product used for hand hygiene in first unit was an alcohol-based hand rub and that for second unit was traditional antimicrobial soap with 2% chlorhexidine gluconate. It was observed that the frequency of touching neonates with unclean or ungloved hands by staff members on the unit using alcohol products were significantly less than staff on the units using a traditional antimicrobial soap. Depending on the observational outcomes Cohen et al suggests that “an intervention which includes the adoption of the newer alcohol-based products accompanied by strong administrative support has the potential to improve hand hygiene practices.” (Cohen, Saiman, Cimiotti, & Larson, 2003). Outcome: Though hand decontamination using antimicrobial soap was general practice, on the suggestion of CDC this widely accepted practice was changed to alcohol-based handrubs in October 2002. This change was based on ‘better invitro and invivo efficacy of alcohol-based handrubs compared with antimicrobial soaps against drug-resistant bacteria. (Gordin, Schultz, Huber, Gill, 2005). An effective outcome of this approach has been well analyzed by Gordin and colleagues. Since there have been less clinical impact data on effectiveness of alcohol-based handrubs (ABHR), Gordin and colleagues conducted an observational survey from 1998 to 2003 at the Veterans Affairs Medical Center, Washington, DC that initiated alcohol-based handrub since October 2000. They compared the changes for first three years where there was no ABHR use with the three years following, when ABHR was provided for hand decontamination. Even though hospital employees were instructed to use alcohol-based hand rub ( with 62.5% ethyl alcohol) before and after any patient contact that was available in all inpatient and outpatient clinic rooms, no change was made in the type of soap available for hand scrub. For determining newly acquired nosocomial infection cases screening criteria was prescribed and trained infection control practitioners evaluated all patients with selected drug-resistant organisms. During the study period neither attempts at decolonization of patients with resistant bacteria nor infection control measures and change in antibiotic use were taken. Gordin et al (2005) found reduced incidence of “nosocomially acquired drug-resistant bacteria,” (Gordin, Schultz, Huber, Gill, 2005, p.650). particularly MRSA and VRE, during the three years following implementation of an alcohol-based handrub, which validated the CDC recommendation in favor of alcohol-based hand rubs. Planning the change: Since product acceptability by HCWs is viewed as a crucial step for compliance with good hand hygiene practice, an intervention study was conducted by Traore and team in the medical intensive care unit (ICU) of the University of Geneva Hospitals to analyze this aspect. (Traore, Hugonnet, Lübbe, Griffiths, & Pittet, 2007). The study was conducted in two phases, in which during phase I all ICU staff used the alcohol-based liquid formulation (Hopirub), which contains 75% isopropyl alcohol, 0.5% chlorhexidine gluconate, and isopropyl myristate. During phase II the liquid was replaced by the gel formulation, with similar constituents of liquid formulation, but in gel form. Both formulations were easy to carry and widely available at every vantage point. The participants were given formal training and validation during a pilot phase, and patient care activities and indications for hand hygiene that encompass activities with varying degrees of contamination risk were recorded. The participants’ skin condition was assessed using Larson’s Skin Self-Assessment Rating Scale. Though there was low compliance with hand hygiene recommendations, introduction of gel formulation and availability of handrub at the point of care for immediate access was found to increase compliance. It is observed that hand washing for less than 30 seconds does not clean all bacteria, and thorough washing for more than 30seconds is essential to remove known infection agents and microorganisms that cause rapid infection. Hand washing, in the professional point of view of hospital health care, is needed to remove germs and bacteria acquired from one patient, to take necessary steps to counteract and destroy germs within health care practitioners, called resident flora that is more obdurate kind, and to ensure that proper washing is done to avoid germ activities in settings. Traore et al observe that on comparing the use of an alcohol-based liquid versus a gel formulation on hand hygiene “the gel was associated with better skin condition, superior acceptance, and a trend toward improved compliance.” (Traore, Hugonnet, Lubbe, Griffiths, & Pittet, 2007) Hence, it is suggested that an observational pilot study similar to this case study model, may be tried in two different wards where there is report of severe contamination and infection. Framing PICO question and selection of articles for evidence base: Since research evidence suggests that alcohol-based hand rub is more effective in preventing nosocomial infections in clinical settings an attempt has been made to locate significant articles related to hand hygiene practice. The problem identified is erroneous hand hygiene practice in a health care facility, the intervention proposed is alcohol based hand rub as an alternative for soap and water scrub, and the ultimate objective is prevention of nosocomial infection with active involvement of nurse practitioner for bringing quality health care. Based on these terms PICO question ‘Is alcohol based gel effective than soap based scrub in preventing nosocomial infection?’ has been used to search data bases of PubMed Central and Google Scholar. A comprehensive search strategy for all English articles from Pubmed Central and Google Scholar with the terms hand hygiene, soap scrub, alcohol based gel and nosocomial infection was used to locate articles of relevance. Of the 349 articles retrieved from Google scholar published during 2002 to 2008, restricting the search for recent articles retrieved 281 articles, and further restriction to randomized controlled trials retrieved 132 articles. From these 132 scholarly articles that are perceived more important ones to the topic has been chosen manually after reading brief to the topic.. While searching PubMed Central database, the search was limited to free full text, randomized controlled trials, and journal article that is in English and connected to nursing journal. Finally, few articles from both data bases related to hand hygiene with alcohol based hand rub and soap and water scrub, their cost effectiveness, efficacy, and clinical experience in similar situation has been used for analyzing the topic, before arriving at the conclusions and suggestion for change. Summary and conclusions: Research evidence suggests that poor hand hygiene is associated with “nosocomial infections with drug-resistant bacteria” that leads to high rates of “morbidity and increased healthcare costs” (Gordin, Schultz, Huber, Gill, 2005). It is found that on effective implementation of evidence based practices (EBPs) “patient outcomes improve and resource use decline.” (Everett, & Titler, 2005, p. 295). For achieving this goal appropriate use of hand disinfectants is an integral part of individual prevention measures that has to be learned during professional training and “ease of access to antiseptic agents and level of acceptance of products by personnel can influence compliance with recommended hand hygiene practice.” (Boyce, 2001, p. 233). The experience of Cohen of team that compared efficacy of alcohol based hand rub versus soap and water hand scrub in a neonatal intensive care unit is an appropriate model for our clinical facility. Analyses of select articles reveal that hand wash with alcohol-based preparations and adherence to guidelines on the subject will help prevent nosocomial infections in clinical settings, and thereby improve quality of care. References Boyce, J M. (2001). Special issue: Antiseptic technology: Access, affordability, and acceptance: Conclusion. Retrieved June 9, 2009, from http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=2631717&blobtype=pdf Boyce, J M. (2001). Special issue: Antiseptic technology: Access, affordability, and acceptance: Access. Retrieved June 9, 2009, from http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=2631717&blobtype=pdf Boyce, J M., & Pittet, D. (2002). Guideline for hand hygiene in health-care settings: Recommendation of the healthcare infection control practices advisory committee and the HICPAC/SHEA/APIC/IDSA/V hand hygiene task force: Physiology of normal skin. MMWR: Morbidity and Mortality Weekly Report. 4. Retrieved June 9, 2009, from http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf Boyce, J M., & Pittet, D. (2002). Guideline for hand hygiene in health-care settings: Recommendation of the healthcare infection control practices advisory committee and the HICPAC/SHEA/APIC/IDSA/V hand hygiene task force: part1.review of the scientific data regarding hand hygiene: Historical perspective. MMWR: Morbidity and Mortality Weekly Report. 4. Retrieved Jun 9, 2009, from http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf Boyce, J M., & Pittet, D. (2002). Guideline for hand hygiene in health-care settings: Recommendation of the healthcare infection control practices advisory committee and the HICPAC/SHEA/APIC/IDSA/V hand hygiene task force: Normal bacterial skin flora. MMWR: Morbidity and Mortality Weekly Report. 4. Retrieved Jun 9, 2009, from http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf Cohen, B., Saiman, L., Cimiotti, J., & Larson, E. (2003). Factors associated with hand hygiene practices in two neonatal intensive care units. NIH Public Access: Author Manuscript, 22 (6), 494-499. PubMedCentral. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=12799504 Cohen, B., Saiman, L., Cimiotti, J., & Larson, E. (2003). Factors associated with hand hygiene practices in two neonatal intensive care units: Introduction. NIH Public Access: Author Manuscript, 22 (6), 494-499. PubMedCentral. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=12799504 Cohen, B., Saiman, L., Cimiotti, J., & Larson, E. (2003). Factors associated with hand hygiene practices in two neonatal intensive care units: Discussion. NIH Public Access: Author Manuscript, 22 (6), 494-499. PubMedCentral. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=12799504 Everett L Q., & Titler M G. (2005). Chapter 19: making EBP part of clinical practice: The lowa model. Springer Publishing Company. 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Reduction in nosocomial transmissions of drug- resistant bacteria after introduction on an alcohol based handrub. Infection Control and Hospital Epidemiology. Retrieved Jun 9, 2009, from http://www.journals.uchicago.edu/doi/pdf/10.1086/502596?cookieSet=1 Gordin, F.M., Schultz, M.E., Huber, R.A., Gill, J.A. (2005). Reduction in nosocomial transmissions of drug- resistant bacteria after introduction on an alcohol based handrub: Conclusion. Infection Control and Hospital Epidemiology. Retrieved Jun 9, 2009, from http://www.journals.uchicago.edu/doi/pdf/10.1086/502596?cookieSet=1 Kramer, A., Below, H., Bieber, N., Kampf, G., Toma, C D., Huebner, N., & et al. (2009). Quantity of ethanol absorption after excessive hand disinfection using three commercially available hand rub is minimal and below toxic levels for humans: Discussion. BMC Infectious Diseases. 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Prevention of irritant contact dermatitis among health care workers by using evidence–based hand hygiene practices: A review: Evidence based hand hygiene and irritant hand dermatitis. Retrieved June 9, 2009, from http://www.jstage.jst.go.jp/article/indhealth/45/5/645/_pdf Kampf, G., & Loffler, H. (2007). Prevention of irritant contact dermatitis among health care workers by using evidence–based hand hygiene practices: A review: The role of skin care. 6. Retrieved June 9, 2009, from http://www.jstage.jst.go.jp/article/indhealth/45/5/645/_pdf Kampf, G., & Loffler, H. (2007). Prevention of irritant contact dermatitis among health care workers by using evidence–based hand hygiene practices: A review: Conclusion for clinical practice. 6. Retrieved June 9, 2009, from http://www.jstage.jst.go.jp/article/indhealth/45/5/645/_pdf Langley, J. (2002).From soap and water, to waterless agents: Update on hand hygiene in health care settings: Considerations for use. The Canadian Journal of Infectious Diseases, 13 (5), 285-286. PubMedCentral. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=18159403 Merging infectious diseases: A pear reviewed journal tracking and analyzing disease trends: Conclusions. (2001). 174. EID Online. Retrieved Jun 9, 2009, from http://www.cdc.gov/ncidod/eid/vol7no2/pdfs/v7n2.pdf Rupp, M E., Fitzgerald, T., Puumala, S., Anderson, J R., Craig, R., Iwen P C., & et al. (2007). Prospective, controlled, cross-over trial of alcohol-based hand gel in critical care units. Infection Control & Hospital Epidemiology, 29, 8-15. doi: 10.1086/524333 Traore, O., Hugonnet, S., Lübbe J., Griffiths W., & Pittet D. (2007). Liquid versus gel handrub formulation: A prospective intervention study. The Critical Care Forum, 11 (3), R52. PubMedCentral. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=17477858 Traore, O., Hugonnet, S., Lübbe J., Griffiths W., & Pittet D. (2007). Liquid versus gel handrub formulation: A prospective intervention study: Conclusion. The Critical Care Forum, 11 (3), R52. PubMedCentral. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=17477858 Xhauflaire-Uhoda, E., Macarenko, E., Denooz, R., Charlier, C., & Pierard, G E. (2008). Skin protection creams in medical settings: successful or evil?: Introduction. Journal of occupational medicine and toxicology, 3, 15. doi: 10.1186/1745-6673-3-15 Read More