Alcohol-based hand rubs

Selection of alcohol-based hand rub products is the responsibility of individual health care facilities.

It is recommended that alcohol-based hand rub products:

• meet the EN1500 testing standard for bactericidal effect
• have Therapeutic Goods Administration (TGA) approval as a hand hygiene product for a healthcare setting.

Other factors that should also be considered include:

• dermal tolerance
• aesthetic preferences such as fragrance, colour, texture and ease of use
• practical considerations such as availability, convenience and functioning of dispenser, and ability to prevent contamination
• cost.

Alcohol-based hand rubs should be used when hands are visibly clean instead of handwashing because they:

• substantially reduce bacterial count on hands

• require less time than handwashing

• are more accessible

• are self-drying

• are gentler on skin and cause less skin irritation and dryness than frequent soap and water washes, since all hand rubs contain skin emollient (moisturisers).

Handwashing is reserved for situations when hands are visibly soiled, or when gloves have not been worn in the care of a patient with Clostridioides difficile.

Alcohol-based hand rubs have excellent antimicrobial activity against gram-positive and gram-negative vegetative bacteria, and good antimicrobial activity against enveloped viruses. Alcohol solutions containing 60-80% alcohol are most effective. It has been well established that alcohols effectively reduce the bacterial counts on hands better than soap and water.

Alcohol-based hand rubs are more effective against most bacteria and many viruses than either medicated or non-medicated soaps. 

Alcohol-based hand rub is the hand hygiene product of choice for all standard aseptic procedures. Surgical scrub is required for surgical procedures. For definitions on standard versus surgical aseptic technique refer to the Australian Guidelines for the Prevention and Control of Infections in Healthcare.

Alcohol-based hand rub is also the recommended product for the prevention of intravascular catheter-related infections. 

Recent studies have demonstrated minimal rates of cutaneous alcohol absorption such that there should be no concern for healthcare workers. A study suggested that isopropanol might be less likely to be absorbed than ethanol. Healthcare workers who are concerned about absorption for religious or other reasons may elect to use an alcohol-based hand rub that contains isopropanol rather than ethanol.

When implementing a hand hygiene campaign with an alcohol-based hand rub in a healthcare setting, it is important to provide opportunities for healthcare workers to raise concerns about the use of alcohol-based hand rubs for cultural or religious reasons or due to alcohol abuse and help them to understand the evidence underlying its use, and to identify that address their concerns.

Ensuring alcohol-based hand rub is available at the point of care improves hand hygiene compliance.

Alcohol-based hand rub should be easily accessible, generally within arm's reach of where patient care or treatment is taking place. 

Dispensers act as a visual cue for hand hygiene behaviour. Placement of alcohol-based hand rub needs to be consistent and reliable. Clinical staff should assist with the decision-making process regarding placement of alcohol-based hand rub, as they generally best understand the workflow in their area. 

Where possible, alcohol-based hand rub should be placed at the foot of every bed or within each patient cubicle. When designing new healthcare facilities, consideration should be given to appropriate placement of alcohol-based hand rubs so that healthcare workers can easily see and reach them.

Alcohol-based hand rub dispensers should not be placed next to sinks, as this can cause confusion for healthcare workers who may think they need to rinse their hands with water after using alcohol-based hand rub. 

The following locations are suggested for placement of alcohol-based hand rub:

• on the end of every patient bed using either a fixed or removable bracket
• attached to mobile work trolleys, for example, intravenous, drug and dressing trolleys, especially in emergency department and recovery areas
• high staff traffic areas, for example, nurses' station, pan room, medication room and patient room entrance
• all other clinical and patient care areas, such as examination rooms and outpatient consultation rooms
• entrances to each ward, outpatient clinic or department
• public areas such as waiting rooms, reception areas, hospital foyers, near elevator doors in high-traffic areas.

Signage about the appropriate use of alcohol-based hand rubs should be prominently displayed in all clinical areas in all health service organisations.

Health service organisations should clearly document and assign responsibility for replacement of empty alcohol-based hand rub dispensers. For example, workplace agreements or job descriptions may include a requirement for prompt replacement of these dispensers. Alcohol-based hand rub should never be decanted from one bottle to another as this can cause contamination.

The the benefits to patients and staff of the use of alcohol-based hand rub outweigh the risks. A risk assessment should be undertaken and a management plan put in place for all clinical areas, and particularly for areas that manage patients with alcohol use disorders, patients at risk of self harm and patients such as children who may be at risk of accidental ingestion. 

The following factors should be considered in relation to safe placement of alcohol-based hand rub:

• The maximum size of an individual alcohol-based hand rub dispenser should not exceed 500 mls
• No more than 80 individual alcohol-based hand rub dispensers (each with a maximum capacity of 500 mls) should be installed within a single smoke compartment
• Dispensers should not project more than 15 cm into corridor egress
• Wall-mounted brackets should be located at a height of between 92 cm and 122 cm above the floor (avoid placing at eye level)
• Dispensers should not be located over carpeted areas, unless the area is protected by active sprinklers
• Dispensers should not be located over or directly adjacent to ignition sources such as electrical switches, power points, call buttons, or monitoring equipment
• Dispensers should be separated from heat sources and electric motors
• Dispensers should be installed according to manufacturer’s recommendations and to minimise leaks or spills
• Regular maintenance of dispensers and brackets should occur in accordance with manufacturer’s guidelines
• Product usage signs should be clearly visible and laminated
• Regular monitoring of each area is recommended for misuse or removal of product
• Each facility should take adequate care with the placement of each dispenser so as to protect vulnerable populations, for example in psychiatric units, drug and alcohol units, paediatric units and units caring for cognitively impaired patients
• Alcohol-based hand rub bottles should be designed to minimise evaporation due to the volatile nature of alcohols
• Site-specific instructions should be developed to manage adverse events, such as alcohol-based hand rub ingestion, eye splashes or allergic reactions
• Bracket design is important, as alcohol-based hand rub placement may be affected if brackets are ill-fitting (for example, varying sizes of bed rails can affect the efficacy of some brackets)
• Brackets that are removable, or product that can be removed from brackets easily, to accommodate short term patient demands 
• Bracket availability and installation costs.

The placement of alcohol-based hand rub needs to be aligned with risk assessment of the individual patients or patient populations. For example, clinical areas where ingestion or accidental splashing of alcohol-based hand rub is a particular risk, such as:

• paediatrics – locate with care near children (see below)
• mental health – locate with care near mental health patients, patients undergoing alcohol- or other drug-withdrawal, or where there are cognitively impaired patients
• public areas - place in high traffic areas with clear signage about appropriate use and the need for parents to carefully supervise their children.

Small personal bottles that healthcare workers carry with them may be more appropriate in some of the above areas.

Alcohol-based hand rub can be placed in paediatric wards. The placement of alcohol-based hand rub within neonatal intensive care units, special care nurseries, maternity wards and on cots should follow the recommendations for product placement at the point of care. 

Placement in general paediatric wards should be at the point of care, except in situations where intellectual disability or alcohol abuse or where the child could unintentionally or intentionally harm themselves. Personal bottles of alcohol-based hand rub should be used in any area where alcohol-based hand rub cannot be placed at the point of care.

In some situations washing hands with soap and water is preferable to use of alcohol-based hand rub. 

Bacterial spores

Alcohol has virtually no activity against bacterial spores. Washing hands with soap and water is preferred in this situation because it is the best method of physically removing spores from the hands. However, the vegetative form of Clostridiodes difficile is highly sensitive to alcohol-based hand rub.

The November 2018 ASID/AICA position statement on Infection Control Guidelines for Patients with Clostridiodes difficile Infection (CDI) in Healthcare Settings recommends the primary use of alcohol-based hand rub in accordance with the WHO 5 Moments for Hand Hygiene when caring for patients with CDI. Gloves should be used during the care of patients with CDI, to minimise spore contamination, and if hands become soiled, or gloves have not been used, then hands must be washed with soap and water.

Non-enveloped (non-lipophilic) viruses

Alcohol has a poor activity against some non-enveloped viruses. (for example: rotavirus, norovirus, polio, hepatitis A). However, there is conflicting evidence suggesting that alcohol-based hand rub is more effective than soaps in reducing virus titres on finger pads. Thus, in norovirus outbreaks it is usually best to reinforce the use of alcohol-based hand rub, unless hands are visibly soiled, in which case handwashing with soap and water is preferred.

Other organisms

Alcohol has a poor activity against tropical parasites, and protozoan oocysts. Handwashing soap and water is preferred.