Running head: INTEGRATIVE REVIEW 1

Hand Hygiene Efficacy

Amber E. Rose

Bon Secours Memorial College of Nursing

Nursing Research NURS 4122

April 7, 2017

I pledge

Abstract
INTERGRATIVE REVIEW 2

The purpose of this integrative review is to evaluate literature relating to the efficacy of

hand washing versus alcohol based hand hygiene methods. Hand hygiene is a practice

that is constantly evolving and is especially important for those in the medical field.

Without the proper knowledge of efficient hand washing methods, one can potentially

expose their patients to new bacteria. The research design is an integrative review. The

sources used for this integrative review included, PubMed, EBSCO and Google Scholar.

The search of databases yielded 107 results, 15 met the inclusion criteria and 5 were used

for this review. The five articles used support alcohol based hand hygiene methods as the

most efficacious. Limitations to the review included having a limited amount of relevant

articles, a limited amount of articles conducted within the year requirement, and time for

the completion of the assignment. Future research should include more articles pertaining

to nurses and hand hygiene, more studies held in the United States and the expansion of

research into all areas of medicine.

INTERGRATIVE REVIEW 3

Hand Hygiene Efficacy

The purpose of this integrative review is to search for articles and information

related to the efficacy of hand washing versus alcohol based hand hygiene. Lack of

knowledge about proper hand hygiene is cause for worry. Hand hygiene is a critical

component of reducing risk of infection among hospitalized patients. With so many

diverse methods to perform hand hygiene, it can make it hard for one to know which

method is best. Understanding the best method ultimately helps reduce the spread of

infection and disease. Prevention of the transfer of bacteria among nurses and medical

professionals is of the utmost importance. Those individuals are charged with the task to

keep their patients free of any additional illness and the courtesy of keeping a clean and

sterile environment. Therefore the researcher has proposed the following PICO question:

Among hospital nurses, does antibacterial foam decrease bacterial count on hands as

much as soap and water?

Research Design, Search Methods, & Search Outcomes

The research design is an integrative review. This review was written as a class

assignment for a nursing research class in an undergraduate nursing program. The search

for research articles was conducted utilizing computer based search engines PubMed,

EBSCO and Google Scholar. The search terms included, hand washing, hand soap,

alcohol based hand sanitizer, efficacy and hand washing versus hand sanitizer. The

search conducted by databases produced 107 articles. Of those articles, 54 were from

PubMed, 39 from EBSCO and the remaining 14 were produced by Google Scholar. To

maintain and accurate and current approach to the issue, the search was limited to peer-

reviewed articles. Of those peer reviewed articles, they were further limited to
INTERGRATIVE REVIEW 4

quantitative or qualitative nursing research literature, published or translated in English

and written between 2011-2016. All articles needed to pertain to the researchers PICO

question, Among hospital nurses, does antibacterial foam decrease bacterial count on

hands as much as soap and water? The articles were then chosen based on the following

inclusion criteria: hospital nurses, alcohol and water based hand hygiene methods, length

of study, research design and variety of medical specialties. All research articles chosen

were based on inclusion criteria and PICO question relevance. Articles that did not meet

the needed criteria were eliminated from the review. The screening process yielded 5

hospital and nurse hand hygiene based intervention articles, all quantitative.

Findings/Results

The findings and results of four of the five articles reviewed indicate alcohol

based hand washing techniques are more effective than washing hands with soap and

water (Hee-Kyung, Kyung-Mi, & Ho-Ran, 2015; Larson, Cohen, & Baxter, 2012;

Sharma, Dutta, Taneja, & Narang, 2013; Stone et al., 2015). A summary of the research

collected is present in Appendix 1. Burch, Stanger, Mizuguchi, Zurakowski, & Reid,

(2012) indicates that an alcohol only cleanser was not as effective as traditional soap and

water surgical scrub. The researcher framed the review according to the following

categories: bacterial counts with alcohol based hand hygiene products and bacterial

counts with soap and water.

All studies agreed that bacterial collection after encounters with non-sterile

surfaces were important to ensure the most accurate results (Burch et al., 2012, Hee-

Kyung et al 2015, Larson et al 2012, Sharma et al 2013, Stone et al 2015). All reviews

found to support the researchers PICO question are quantitative reviews. Burch stated
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that the best way to get the most concise results were to have each participant rub their

finger tips on the agar plate after patient interaction. All five studies agree the agar plate

is the most efficient way to ensure optimal results for bacterial collection.

Bacteria Count With Soap And Water Count

The study conducted by Larson et al. (2012) was a quantitative, randomized

treatment study. Thirty nurses were selected to participate in this voluntarily consented

study. Participants were required to perform hand washing with soap and water before an

after each task. After each task was completed, four of the participants fingers were

rolled over an agar plate and incubated. After incubation, colonies would then be counted

and documented for further evaluation. Hand washing produced 18% more colonies than

those of other methods.

Sharma et al. (2012) produced a quantitative, randomized, crossover, three armed,

controlled outcome with blinded outcome measurement. The study was made up of 35

NICU nurses. The nurses offered voluntary consent to participate in this study. In order

for nurses to participate, some work requirements needed to be meet. After each activity,

nurses fingers would be cultured to preserve any contamination. After collection,

cultures would be incubated for 24 hours and read by a blinded microbiologist for results.

Colonies from the plate cultured from soap and water had a higher rate of 41.9%. The

results of this study contribute to the body of literature.

Stone et al. (2015) and Hee-Kyung (2012) assessed the efficacy of alcohol based

hand cleaners versus traditional hand washing with soap and water. The studies were

performed in an intensive care unit and measured the presence of MRSA and C-difficile.

Hand washing with soap and water was performed before the start of both studies. The
INTERGRATIVE REVIEW 6

group chosen to use only soap and water after patient interaction would have the right

hand cultured after each patient interaction. The MRSA acquisition rate associated with

Hee-Kyung produced a 10.7% decrease with solely hand washing. C- difficile rates

decreased from 1.88 to .91 in cases per 10,000 bed days. The results produced from the

two studies provide significant research that contributes to this body of this literature.

In the quantitative, blinded controlled study by Burch et al. (2012), participants

were selected from the operating room. Participants scrubbed in with traditional

antiseptic soap and were then required to start pre-operational procedures. 14 participants

produced 49 contamination plates during the study. Results produced from the study

show significantly less contamination from traditional hand washing. This study is the

only study to differ from the other studies mentioned in this research. Although the

results are different this does contribute to the body of literature. Further research is

needed to ensure conclusive evidence of traditional hand washing in the operating room.

Bacteria Count With Alcohol Based Hand Cleanser

Four of the five articles (Hee-Kyung, Kyung-Mi, & Ho-Ran, 2015; Larson,

Cohen, & Baxter, 2012; Sharma, Dutta, Taneja, & Narang, 2013; Stone et al., 2015),

found that alcohol based hand cleansing methods were more effective than traditional

hand washing. All studies required a sample size of 10 or more and must have voluntary

consent from participants. All studies are quantitative and are designed to produce the

most effective outcomes. All four reviews state alcohol based hand hygiene methods are

more effective than traditional soap and water. Hee-Kyung (2014) states a decrease of

17.3 % in the decrease of colonies produced with alcohol based cleanser. The studies

provided contribute significantly to the body of literature.

INTERGRATIVE REVIEW 7

Burch (2012) indicates alternative results and states traditional hand washing is

more effective in preventing the decrease of bacterial transfer. The study was a

quantitative, blinded study performed by participants in the operating room. Participants

were required to use a 62% based alcohol cleanser. Of 49 plates produced by 14 subjects,

16% of the plates had growth, significantly less than the 82% colony growth. The

alternate results produced are significant to this body of research.

Discussions/Implications

The findings of the integrative review address the efficacy of alcohol based hand

cleansers versus traditional soap and water. Therefore all review findings support the

researchers PICO question. The PICO question specifies the setting of the studies must

be healthcare workers in a hospital setting. Four of the five studies (Hee-Kyung, Kyung-

Mi, & Ho-Ran, 2015; Larson, Cohen, & Baxter, 2012; Sharma, Dutta, Taneja, & Narang,

2013; Stone et al., 2015) exhibit significant statistics that support the efficacy of alcohol

based hand cleansers over traditional soap and water. The study initiate by Burch states

that traditional hand washing is more effective than alcohol based methods. Although one

study differs, the decrease of bacterial colonies proves that hand hygiene is an important

part of all healthcare. All studies reviewed allotted an educational period on the positives

of hand hygiene before and after patient care. Education is key and should be taught

throughout the entire health care system to ensure patient safety.

The implications of the findings suggest the use of alcohol-based cleansers can

greatly decrease the presence of bacteria. Education by the hospital and CDC can also

help decrease the spread of nosocomial infections.

Limitations
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Limitations by the researcher are vast in quantity. These limitations have

ultimately influenced this integrative review. The review assigned is a final class

assignment solely produced and conducted by the researcher. The researcher is a full time

student with limited time and resource availability. The researcher commutes two hours,

is married and had other commitments. The research was also affected by the assignment

limitations such as, the quantity of articles, article timeframe restrictions and assignment

due dates. This integrative review was a first for the author. Due to the lack of

experience, this reviewer does not have the knowledge needed to give the best results.

Conclusion

The findings of this integrative review prove the importance of effective hand

hygiene. All but one article concluded alcohol based hygiene methods are the most

efficacious. Beneficial findings found in the study include: decreased colony counts of

MRSA with proper hand hygiene, decreased episodes of C-difficile and over cleanliness

of health care providers. Only one article states that traditional hand washing is more

effective when in the operating room. Although the article did not coincide with other

reviews, all methods of hand hygiene are essential to the reduction of bacteria and

infection. Education from hospital officials and healthcare organizations are key to

reducing the spread of infection. Nurses can be the forerunners of this movement since

nurses are the first mode of contact with patients. Educating nurses and healthcare staff

are key to prevention.

INTERGRATIVE REVIEW 9

References

Burch, T. M., Stanger, B., Mizuguchi, K. A., Zurakowski, D., & Reid, S. D. (2012). Is

alcohol-based hand disinfection equivalent to surgical scrub before placing a

central venous catheter?. Anesthesia And Analgesia, 114(3), 622-625.

doi:10.1213/ANE.0b013e31824083b8

Hee-Kyung, C., Kyung-Mi, K., & Ho-Ran, P. (2014). Effects of hand hygiene education

and individual feedback on hand hygiene behaviour, MRSA acquisition rate and

MRSA colonization pressure among intensive care unit nurses. International

Journal Of Nursing Practice, 21(6), 709-715. doi:10.1111/ijn.12288

Larson, E. L., Cohen, B., & Baxter, K. A. (2012). Analysis of alcohol-based hand

sanitizer delivery systems: efficacy of foam, gel, and wipes against influenza A

(H1N1) virus on hands. American Journal Of Infection Control, 40(9), 806-809.

doi:10.1016/j.ajic.2011.10.061

Sharma, V. S., Dutta, S., Taneja, N., & Narang, A. (2013). Comparing hand hygiene

measures in a neonatal ICU: a randomized crossover trial. Indian Pediatrics,

50(10), 917-921

Stone, S. P., Fuller, C., Savage, J., Cookson, B., Hayward, A., Cooper, B., & Charlett,

A. (2012). Evaluation of the national Cleanyourhands campaign to reduce

Staphylococcus aureus bacteraemia and Clostridium difficile infection in hospitals

in England and Wales by improved hand hygiene: four year, prospective,

ecological, interrupted time series study. BMJ (Clinical Research Ed.), 344e3005.

doi:10.1136/bmj.e3005
Running head: INTEGRATIVE REVIEW 10

First Author Sharma, VS (2013)

(Year)/Qualifications
Department of Pediatrics and Microbiology, Postgraduate Institute of Medical

Education and Research, India

Background/Problem Hand hygiene is one of the oldest and most fundamental practices to reduce the risk of
Statement
transmission of bacteria.

With time, the CDC has found it medically acceptable to use alcohol based hand

cleansers.

The CDC acknowledges there is a need for better trials for this argument.

This experiment is designed to prove which method of hand hygiene is better, hand

washing or alcohol based hand rubs.

Conceptual/theoretical Researchers wanted to solidify the CDC original recommendation that alcohol based
Framework
hand hygiene was just as effective as hand washing with soap.

Design/ Quantitative experiment

Method/Philosophical
Underpinnings Randomized, crossover, three-armed, controlled trial with blinded outcome

measurement
INTERGRATIVE REVIEW 11

During the experiment, nurses could only care for one child.

Nurses were mandated to start with 2 minute hand washing, then they would continue

the rest of the day with assigned method of hand hygiene.

After performing activities that required hand hygiene, each nurses hands were

cultured one minute before and after each activity.

Sample/ Setting/Ethical 35 NICU nurses employed for more than a year

Considerations
Level 3 NICU

Nurses with history of iodine allergy were excluded from study

Nurses underwent a 14- day neutral period where they received instruction on proper

hand hygiene.

Nurses were provided lists of items to avoid during this neutral period.

Study was approved by Institutional Ethics Committee

Staff nurses had a requirement of 1 year of work in ICU

Major Variables Studied Nurses were asked to avoid direct contact with know infected surfaces or any other
(and their definition), if
appropriate grossly soiled material to decrease the risk of elevated hand contamination.
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Nurses performed the hygiene methods based on number random sequence of 3 hand-

washing methods.

Dependent variable- nurses with stable hand flora

Independent variable- randomization of hand hygiene technique

Measurement Tool/Data
Collection Method After performing activities that required hand hygiene, each nurses hands was
cultured

Data Analysis The microbiologist was blinded to the study of each hand hygiene used

Contaminated plates would be counted for colonies

Findings/Discussion Soap and water was found to be less helpful than alcohol based methods

Soap had 41.9% of plates with colonies while alcohol had 36.5%

Appraisal/Worth to This study is in favor of the CDCs original recommendations.

practice
INTERGRATIVE REVIEW 13

First Author Larson, Elaine L. (2012)

(Year)/Qualifications
School of Nursing, Mailman School of Public Health, Colombia University, New York, NY

Background/Problem Minimal research has been done to prove the efficacy of soap and water over alcohol
Statement
based agents.

This study is to determine which hand washing agent will be more effective in

destroying the H1N1 virus.

Conceptual/theoretical None were noted

Framework

Design/ Quantitative experiment

Method/Philosophical
Underpinnings Randomized treatment

Logs of personnel hands were created after patient interaction.

Participants were required to be between the ages of 18-65, male or non-pregnant

female.

Participants were required to be in good health, free of any skin issues.

Sample/ Setting/Ethical 30 nurses were selected to participate.

Considerations
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Set in New York Outpatient clinic

All formulations of hand products were approved by CDC

This study did not state any ethical approvals.

10 participants were randomized to each hygiene effort.

Major Variables Studied Hands were washed with plain soap and water and after drying ethyl was applied to
(and their definition), if
appropriate participants hands

Independent variable: hand washing techniques

Dependent variable: culture

Measurement Tool/Data
Collection Method Two fingers pads were used as test product and the other two finger pads were used as

controls in a randomized fashion.

To retrieve the count of virus on fingers pads, a solution was placed on fingers and

collected in a vile.

After collection of contamination, the participants hands were washed with a bleach

solution.
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Data Analysis
Log counts were retrieved form each participants 4 treated and 4 untreated finger

pads.

Log differences were calculated and averaged from the group

Used Student t test for paired data to compare the counts between treated and

untreated

Findings/Discussion All alcohol products were shown to show significant reductions in bacteria

Little differences were found between alcohol-based wipes and alcohol based gel

methods.

Appraisal/Worth to This study proves the efficacy of alcohol-based methods over soap and water.
practice
INTERGRATIVE REVIEW 16

First Author Burch, Thomas Michael (2012)

(Year)/Qualifications
Cardiothoracic Anesthesiology and Microbiology, Wake Forest University School of

Medicine, Bostons Childrens Hospital, Boston, Ma

Background/Problem Alcohol-only hand cleaners have been shown to decrease the spread of infections in
Statement
hospitals.

The researchers have hypothesized that alcohol only based cleansers would work just

as well if not better than hand washing with soap and water.

Conceptual/theoretical Not stated in this article.

Framework

Design/ Quantitative
Method/Philosophical
Underpinnings Trial Controlled

Blinded study

Sample/ Setting/Ethical No patients were involved with this study.

Considerations

Major Variables Studied Independent Variable: Which hand washing procedure done by each participant?
(and their definition), if
appropriate Dependent Variable: How many cultures grew after each hand washing method was
INTERGRATIVE REVIEW 17

done?

Measurement Tool/Data After a hand washing method was commenced, the participant had a 15-minute
Collection Method
window to resume normal activities.

After 15 minutes the participants fingers minus the thumb would be gently swiped

over an agar plate for collection.

The plates would then be cultured for 24 hours at 37 degrees C.

Data Analysis Results were interpreted by blind microbiologist into two labels, growth or no growth

82% vs. 16 % growth seen on alcohol versus traditional hand wash surgical scrub soap.

Traditional hand scrub in with soap and water was the more effective cleanser.

Findings/Discussion The alcohol based products used were not as effective as plain surgical hand scrub.

Appraisal/Worth to This is the only study to not agree with the original thought that alcohol based products
practice
are better than soap and water.

This study proves that more trials are needed to be run in different parts of the hospital

to determine which is the best method in each department.

INTERGRATIVE REVIEW 18

First Author Hee-Kyung, Chun, RN, MSN, ICAPN (2014)

(Year)/Qualifications
Infection control nurse, department of infection control, Kyung Hee University Medical

Center, Seoul, South Korea

Background/Problem Assess the influence of hand hygiene practices against the presence of MRSA in the
Statement
MICU.

Conceptual/theoretical
Framework

Design/ Quasi-experimental Study

Method/Philosophical
Underpinnings Blind and Randomized

Quantitative

Methods were scored based on: hand hygiene agent, rubbing time, area, and drying

method.

Sample/ Setting/Ethical Study was approved by the Institutional Review Board of the Catholic University of
Considerations
Korea College of Medicine

24 nurses form the MICU were included in the study, all nurses have given voluntary
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consent.

69 nursing activities were documented and hand cultured were retrieved after each

activity.

The right hand of each participant would be cultured using hand plate and incubated

for 24-48 hours.

Major Variables Studied Independent Variable: hand hygiene agent, rubbing time, area, and drying method.
(and their definition), if
appropriate Dependent Variable: Cultures measures from the 69 nursing activities

Measurement Tool/Data Each method was monitored to make sure each nurse was cooperating with her
Collection Method
assigned method.

Individual reports of observed hand hygiene, appropriateness of hand hygiene

methods and hand culture results were taken.

MICU patients were given nasal swab culture to measure the transfer of bacteria.

MRSA colonies formed on plates were counted by a blinded microbiologist

Data Analysis Reduction in spread of MRSA in MICU noted by the decreased presence of MRSA by

nasal swabs
INTERGRATIVE REVIEW 20

MRSA colonization decreased by 8.6 % with hand washing and 14.9 % with alcohol

based methods

Findings/Discussion Hand hygiene is one of the most fundamental methods to reduce the spread of

nosocomial infections

Nurses are the healthcare workers who are mostly like to carry these diseases due to

the increased direct patient contact.

Appraisal/Worth to Alcohol based methods have been proven to decrease the travel of harmful bacteria
practice
INTERGRATIVE REVIEW 21

First Author Stone, S., (2012)

(Year)/Qualifications Senior lecturer, stroke physician, and general physician for older people

Background/Problem Improved hand hygiene reduces infection in a wide variety of settings

Statement England has rolled out a Cleanyourhands Campaign aimed to educate hospital workers

and reduce the presence of MRSA.

Conceptual/theoretical Study wants to evaluate the impact of the Cleanyourhands Campaign in Englands

Framework hospitals

Design/ Prospective, ecological, interrupted time series study at trust level

Method/Philosophical Quantitative

Underpinnings

Sample/ Setting/Ethical 187 acute trusts in England and Wales

Considerations
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Major Variables Studied Independent: hand hygiene agent and method

(and their definition), if Dependent: decrease in C. diff

appropriate

Measurement Tool/Data Quarterly measurement rates for each trust of hospital procurement

Collection Method To record infection rates, the study had access to the database for the national

mandatory reporting scheme.

Data Analysis Data was counted at the national database and reported quarterly to the study.

Findings/Discussion MRSA cases decreased 1.88 to .91

C diff cases decreased 16.75 to 9.49

Alcohol based products were independently associated with reduced MRSA and C diff

Appraisal/Worth to Significant to studies and proves hand hygiene is necessary to prevent the spread of

practice disease.
INTERGRATIVE REVIEW 23