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Frequency and duration of handwashing in an intensive care unit
Frequency and duration of handwashing in an intensive
care
unit
Marie Graham, RN, BScNurs Perth, Western
Australia
The effects on hand lotion in an intensive
decontamination care unit was
of the introduction studied. To obtain
of an antiseptic handrub baseline data, nursing,
medical, physiotherapy, radiology, and orderly staff members were observed. Further observations were carried out after the introduction of the handrub lotion. Patient care activities were classified as high or low, according to the degree of contact with the patients or their equipment. A total of 884 patient contacts and 341 hand decontamination episodes was observed: 440 contacts and 140 handwashes in stage one (32%) and 444 contacts and 201 handwashes in stage two (45%). There was an increase of 13% in hand decontamination frequency after the introduction of the handrub lotion. The data indicate that the frequency of hand decontamination is below levels recommended by infection control authorities. Increasing the accessibility of hand decontamination facilities did result in a slight increase in handwashing compliance. (AM J INFECT CONTROL 1990;18:77-80)
The transfer of microorganisms by the hands of hospital staff members has been identified as a major factor in the transmission of hospital-acquired infection.‘r2 Hand decontamination after patient contact is effective in removing many of these transient microorganisms and is considered to be the most important procedure for the prevention of nosocomial infections?’ 4 Handwashing practices have been extensively studied in the past 10 years. Research on the frequency and duration of handwashing in clinical areas of patient care has suggested that hands are washed too infrequently, and in many cases the handwashing procedure is inadequate.5-7 Research concerning how to From the Clinical Microbiology ner Hospital.
Department, Sir Charles Gaird-
Reprint requests: Marie Graham, RN, Clinical Microbiology Department, Sir Charles Gairdner Hospital, Verdun St., Nedlands, Western Australia 6009. 17/46/13444
increase handwashing sparse. HANDWASHING
compliance,
however,
is
TECHNIQUE
Intensive care unit patients often are severely compromised because of invasive treatments and therapies. Hand decontamination must therefore have priority among health care workers in this area. The Centers for Disease Control recommend a handwash duration of at least 10 seconds (before rinsing) for most patient care activities.* Quraishi et a1.5 studied the duration of handwashing among intensive care unit staff and classified results according to the degree of patient contact before handwashing. Duration did not differ significantly in terms of patienl contact. The mean duration of handwashing was 8.6 seconds. Another study recorded the incidence of handwashing after direct patient contact. The results showed a higher frequency of handwashing in the unit with more sinks for handwashing (p < 0.001). Nurses had a greater frequency of handwashes than did physicians after patient contact.g 77
American
78
Graham
Table
1. Number
INFECTION
of patient
contacts
and hand decontamination Stsge
Occupation
No. of contacts
Nurse Physician Physiotherapist Radiology staff /orderly TOTAL
HANDWASHING
episodes
stage
300 36 26 78 440
PRODUCT8
Hand decontamination agents such as antiseptic foams, gels, and lotions that do not require water are commercially available. Most of these products contain chlorhexidine and alcohol in varying concentrations. AlcohoUchlorhexidine hand rub solutions, if used frequently, have been shown to be effective in reducing bacterial counts on the hands.“-” For frequent use glycerol or other emollients may be added to reduce drying of the skin. Another study that examined the shedding of bacteria and skin squames after handwashing showed that an alcohol (86%) and chlorhexidine (0.02%) solution rubbed onto the hands until dry (approximately 30 seconds) resulted in a lower number of skin squames being released into the air than occurred when soap or antiseptic handwashing agents were used.13 The first aim of this study was to investigate the frequency and duration of handwashing in staff members working in an intensive care unit. The second purpose was to determine whether the introduction of an antiseptic handrub lotion that does not require water, which is placed at each bedside, affects the frequency of hand decontamination. METHOD8 Environment
The study was conducted at the Sir Charles Gairdner Hospital, a 663-bed acute care metropolitan teaching hospital in Perth, Western Australia. The intensive care unit contains 18 beds and consists of two wings of identical design. Each wing contains three single rooms with individual sinks for handwashing and a
(%)
of
by each staff group
one No. of handwashes
Journal CONTROL
No. of contacts
76 (25) 16 (44) 17 (65)
31 (40) 140 (32)
306 47
two No. of handwashes
(%)
106 (35) 28 (59)
15
15 (100)
76 444
52 (68) 201 (45)
bay, with six beds and a sink for handwashing, at each end. Staff members who attend to patients in the middle beds of the bay have to walk to either end to wash their hands. 8ubjects
A nonprobability sample of nursing, medical, physiotherapy, radiology, and orderly staff members who work in the intensive care unit was included in the study. The unit staff members were informed that an audit of infection control procedures would be carried out; however, they were not told that handwashing practices were being specifically observed. Data collection
The study was conducted as an interrupted time series quasi-experiment. In stage one of the study, baseline data were obtained. Handwashing frequency and duration were observed in six observation periods during a 2-week period. Each observation period was of 3 hours’ duration, between 7:30 AM and lo:30 AM. This time was chosen because it was identified to be the time when all staff groups were most likely to be attending the patients. The method of Quraishi et a1.,5 with some modification, was used to classify specific activities before hand decontamination on the basis of the degree of contact with patients or their attached equipment. High-contact activities are those which are more likely to result in contamination of the hands with large numbers of microorganisms. They include invasive procedures such as inserting intravenous or urethral catheters; handling wounds, mucous membranes, and body fluids; touching objects
Volume
18 Number
2
Frequency
April 1990
Table 2. Handwashing
compliance
after patient
No.
of handwashing
in an KU
79
contacts
High-level
Occupation
and duration
contacts
Low-level
No. of handwashes
(%)
No.
Nurse Physician Physiotherapist Radiology staff/orderly
yJ
71 (65)
368 66 6 - 44
TOTAL
400
196 (49)
484
238
86 (36)
17
10 (59)
35
29 (83)
such as urinary drainage bags and tracheostomy tubes; and having prolonged patient contact such as in bathing, pressure care, or changing linen. Low-contact activities are those that are less likely to result in the contamination of hands with large numbers of microorganisms. They include taking observations, giving medications, and adjusting linen, leads, lines, and equipment. After the initial 2-week observation period an antiseptic handrub lotion was supplied for all beds in the unit. The lotion contained chlorhexidine gluconate 0.5% and isopropyl alcohol 60% (Hibicol Handrub, Stuart Pharmaceuticals, Wilmington, Del.). The lotion was packaged in a dispenser and did not require water for use because it was rubbed onto the hands until dry. It also contained skin emollients to reduce drying. Instructions on the use of the handrub lotion were made available to all staff members in the unit. The second stage of the study commenced 1 week after the handrub lotion was introduced and involved an additional six 3-hour observation periods during the next 2 weeks. Handwashing frequency was measured by counting the number of handwashes with the use of soap and water or the handrub lotion by each observed staff member. Handwashing duration was measured by a concealed stopwatch. The time period from the wetting of hands with soap and water, or handrub lotion, to completion of rinse or rubbing of hands was measured to the nearest tenth of a second. The same person performed the observations throughout the study.
Statistical
contacts No. of handwashes 96 34 3 12
(%)
(26) (52) (50) (27)
145 (30)
analysis
The Statistical Package for the Social Sciences (SPSS) computer program was used to process the data and generate the statistics. Analysis of variance was used to compare handwashing duration between groups and levels of patient contact. Chi-square analysis was used to compare handwashing duration between stages one and two. RESULTS
A total of 884 patient contacts and 341 hand decontamination episodes was observed. Table 1 shows the number of patient contacts and hand decontamination episodes by each staff group in both stages of the study. In stage one there were 440 patient contacts and 140 handwashes. Handwashing occurred 32% of the time. In stage two, after the introduction of the handrub lotion, there were 444 patient contacts and 201 hand decontamination episodes. Hand decontamination occurred 45% of the time, an increase of 13%. The difference in hand decontamination frequency between stages one and two is statistically significant (p < 0.01). Table 2 shows the number of high- and lowlevel contacts by all staff groups and the number of handwashes.. The difference in handwashing frequency among the staff groups is statistically significant (p < 0.01). The rnean handwash duration time for the entire population was 10 seconds + 0.29 SEM. The shortest handwash was 3 seconds, and the longest was 45.2 seconds. The mean handwash duration time for nurses was 8.8 seconds, physicians 10.2 seconds, physiotherapists 11.3 sec-
American
80
Graham
onds, and radiology/orderly staff members 12.1 seconds. The difference in handwash duration times among the staff groups is statistically significant (p < 0.01). DISCUSSION
The compliance of health care workers with recommended handwashing practices in this study was poor.3, 4 Nurses who had the highest number of patient contacts were also least likely to wash their hands after patient contact. However, this may have been due to the much smaller number of patient contacts observed for the other staff groups. An in-service education program may improve compliance and should emphasize the importance of handwashing, not only between contact with different patients but also after specific activities performed on the same patient. There were many instances in which personnel manipulated the urethral catheter and then immediately afterward handled the tracheostomy tube or central venous cannula. This may lead to the colonization of the tracheostomy wound or intravenous site with virulent gram-negative bacteria.4 The introduction of the handrub lotion in stage two of the study resulted in an increase in handwashing frequency after patient contact. The lotion was conveniently located at each bed area, which allowed staff members to use the product in almost the same time it took for some of them to reach the handwash sink. This also allowed personnel constantly to observe their patients, because they did not have to walk away from the bed to decontaminate their hands. Further observations need to be made during a longer time period to determine whether use of the lotion resulted in a sustained increase in hand decontamination frequency. It was interesting to note the low number of patient contacts observed among the medical staff. They also had more low-level contacts. This may be due to the nature of the work performed by the nursing staff in the unit, who carry out many procedures that in other areas of the hospital normally are performed by medical staff.
INFECTION
Journal
of
CONTROL
In studies that evaluate the effectiveness of handwashing in the eradication of transient microbial flora, handwashing durations between 15 and 30 seconds are recommended.3 In this study the duration of handwashing is below the recommended level. There was a slight increase in handwashing duration after high-level contact activities; however, there is a need for further studies to evaluate the effectiveness of hand decontamination agents at shorter handwash times. One limitation of the study was associated with the method used to collect the data. There was a concern that some staff members may have “guessed” the real reason for the observations, which, however, was not reflected in the rate of handwashing observed. In addition, all observations were carried out at the same time of day, and all staff members may not have been observed. It also was not possible to ascertain if personnel observed in stage one were the same persons as those observed in stage two. CONCLUSION
This study suggests that in-service education of health care workers regarding handwashing habits must be continuously reinforced to achieve optimal compliance with recommended handwashing policies. This issue was highlighted in an earlier study of handwashing practices.’ In addition, the evaluation of hand decontamination agents at short duration times (10 to 15 seconds) is needed. Increasing the availability of hand decontamination facilities by the provision of either more handwash sinks or handrub lotions also may result in an increase in handwashing compliance. I thank Nursing, Australia,
Carol Bradburn, RN, formerly Lecturer, Cm-tin University of Technology, Perth, for her assistance.
School of Western
References 1. Reybrouck G. Role of the hands in the spread of nosocomial infections. I. J Hosp Infect 1983;4:103-10. 2. Larson E. A causal link between handwashing and risk of infection? Examination of the evidence. Infect Control Hosp Epidemiol 1988;9:28-36. 3. Steere AC, Mallison GF. Handwashing practices for the prevention of nosocomial infections. Ann Intern Med 1975;83:683-90.
Volume
18 Number
2
April 1990
4. Daschner FD. Useful and useless hygienic techniques in intensive care units. Intensive Care Med 1985;ll: 280-3. 5. Quraishi ZA, McGuckin M, Blais FX. Duration of handwashing in intensive care units: a descriptive study. AM J INFECT CONTROL 1984;11:83-7. 6. Fox MK, Langner SB, Wells RW. How good are hand washing practices? Am J Nurs 1974;74:1676-8. 7. Albert RK, Condie F. Hand-washing patterns in medical intensive-care units. N Engl J Med 1981;304: 1465-6. 8. Centers for Disease Control. Guidelines for handwashing and hospital environmental control. Infect Control 1986;7:231-43. 9. Kaplan LM, McGuckin M. Increasing handwashing
Frequency
10.
11. 12.
13.
and duration
of handwashing
in an ICU
81
compliance with more accessible sinks. Infect Control 1986;‘7:408-10. Morrison AJ, Gratz J, Cabezudo I, Wenzel RP. The efficacy of several new handwashing agents for removing non-transient bacterial flora from hands. Infect Control 1986;‘7:268-72. Larson EL, Eke PI, Laughon BE. Efficacy of alcoholbased hand rinses under frequent-use conditions. Antimicrob Agents Chemother 1986;30:542-4. Tanaka K, Kumon K, Hirata T, Yamamoto F, Fujita T. Evaluation of rapid drying hand disinfectant preparations in the intensive care unit. Crit Care Med 1988;16:540-2. Meers PD, Yeo GA. Shedding of bacteria and skin squames after handwashing. J Hyg 1978;81:99-105.
care
unit
Marie Graham, RN, BScNurs Perth, Western
Australia
The effects on hand lotion in an intensive
decontamination care unit was
of the introduction studied. To obtain
of an antiseptic handrub baseline data, nursing,
medical, physiotherapy, radiology, and orderly staff members were observed. Further observations were carried out after the introduction of the handrub lotion. Patient care activities were classified as high or low, according to the degree of contact with the patients or their equipment. A total of 884 patient contacts and 341 hand decontamination episodes was observed: 440 contacts and 140 handwashes in stage one (32%) and 444 contacts and 201 handwashes in stage two (45%). There was an increase of 13% in hand decontamination frequency after the introduction of the handrub lotion. The data indicate that the frequency of hand decontamination is below levels recommended by infection control authorities. Increasing the accessibility of hand decontamination facilities did result in a slight increase in handwashing compliance. (AM J INFECT CONTROL 1990;18:77-80)
The transfer of microorganisms by the hands of hospital staff members has been identified as a major factor in the transmission of hospital-acquired infection.‘r2 Hand decontamination after patient contact is effective in removing many of these transient microorganisms and is considered to be the most important procedure for the prevention of nosocomial infections?’ 4 Handwashing practices have been extensively studied in the past 10 years. Research on the frequency and duration of handwashing in clinical areas of patient care has suggested that hands are washed too infrequently, and in many cases the handwashing procedure is inadequate.5-7 Research concerning how to From the Clinical Microbiology ner Hospital.
Department, Sir Charles Gaird-
Reprint requests: Marie Graham, RN, Clinical Microbiology Department, Sir Charles Gairdner Hospital, Verdun St., Nedlands, Western Australia 6009. 17/46/13444
increase handwashing sparse. HANDWASHING
compliance,
however,
is
TECHNIQUE
Intensive care unit patients often are severely compromised because of invasive treatments and therapies. Hand decontamination must therefore have priority among health care workers in this area. The Centers for Disease Control recommend a handwash duration of at least 10 seconds (before rinsing) for most patient care activities.* Quraishi et a1.5 studied the duration of handwashing among intensive care unit staff and classified results according to the degree of patient contact before handwashing. Duration did not differ significantly in terms of patienl contact. The mean duration of handwashing was 8.6 seconds. Another study recorded the incidence of handwashing after direct patient contact. The results showed a higher frequency of handwashing in the unit with more sinks for handwashing (p < 0.001). Nurses had a greater frequency of handwashes than did physicians after patient contact.g 77
American
78
Graham
Table
1. Number
INFECTION
of patient
contacts
and hand decontamination Stsge
Occupation
No. of contacts
Nurse Physician Physiotherapist Radiology staff /orderly TOTAL
HANDWASHING
episodes
stage
300 36 26 78 440
PRODUCT8
Hand decontamination agents such as antiseptic foams, gels, and lotions that do not require water are commercially available. Most of these products contain chlorhexidine and alcohol in varying concentrations. AlcohoUchlorhexidine hand rub solutions, if used frequently, have been shown to be effective in reducing bacterial counts on the hands.“-” For frequent use glycerol or other emollients may be added to reduce drying of the skin. Another study that examined the shedding of bacteria and skin squames after handwashing showed that an alcohol (86%) and chlorhexidine (0.02%) solution rubbed onto the hands until dry (approximately 30 seconds) resulted in a lower number of skin squames being released into the air than occurred when soap or antiseptic handwashing agents were used.13 The first aim of this study was to investigate the frequency and duration of handwashing in staff members working in an intensive care unit. The second purpose was to determine whether the introduction of an antiseptic handrub lotion that does not require water, which is placed at each bedside, affects the frequency of hand decontamination. METHOD8 Environment
The study was conducted at the Sir Charles Gairdner Hospital, a 663-bed acute care metropolitan teaching hospital in Perth, Western Australia. The intensive care unit contains 18 beds and consists of two wings of identical design. Each wing contains three single rooms with individual sinks for handwashing and a
(%)
of
by each staff group
one No. of handwashes
Journal CONTROL
No. of contacts
76 (25) 16 (44) 17 (65)
31 (40) 140 (32)
306 47
two No. of handwashes
(%)
106 (35) 28 (59)
15
15 (100)
76 444
52 (68) 201 (45)
bay, with six beds and a sink for handwashing, at each end. Staff members who attend to patients in the middle beds of the bay have to walk to either end to wash their hands. 8ubjects
A nonprobability sample of nursing, medical, physiotherapy, radiology, and orderly staff members who work in the intensive care unit was included in the study. The unit staff members were informed that an audit of infection control procedures would be carried out; however, they were not told that handwashing practices were being specifically observed. Data collection
The study was conducted as an interrupted time series quasi-experiment. In stage one of the study, baseline data were obtained. Handwashing frequency and duration were observed in six observation periods during a 2-week period. Each observation period was of 3 hours’ duration, between 7:30 AM and lo:30 AM. This time was chosen because it was identified to be the time when all staff groups were most likely to be attending the patients. The method of Quraishi et a1.,5 with some modification, was used to classify specific activities before hand decontamination on the basis of the degree of contact with patients or their attached equipment. High-contact activities are those which are more likely to result in contamination of the hands with large numbers of microorganisms. They include invasive procedures such as inserting intravenous or urethral catheters; handling wounds, mucous membranes, and body fluids; touching objects
Volume
18 Number
2
Frequency
April 1990
Table 2. Handwashing
compliance
after patient
No.
of handwashing
in an KU
79
contacts
High-level
Occupation
and duration
contacts
Low-level
No. of handwashes
(%)
No.
Nurse Physician Physiotherapist Radiology staff/orderly
yJ
71 (65)
368 66 6 - 44
TOTAL
400
196 (49)
484
238
86 (36)
17
10 (59)
35
29 (83)
such as urinary drainage bags and tracheostomy tubes; and having prolonged patient contact such as in bathing, pressure care, or changing linen. Low-contact activities are those that are less likely to result in the contamination of hands with large numbers of microorganisms. They include taking observations, giving medications, and adjusting linen, leads, lines, and equipment. After the initial 2-week observation period an antiseptic handrub lotion was supplied for all beds in the unit. The lotion contained chlorhexidine gluconate 0.5% and isopropyl alcohol 60% (Hibicol Handrub, Stuart Pharmaceuticals, Wilmington, Del.). The lotion was packaged in a dispenser and did not require water for use because it was rubbed onto the hands until dry. It also contained skin emollients to reduce drying. Instructions on the use of the handrub lotion were made available to all staff members in the unit. The second stage of the study commenced 1 week after the handrub lotion was introduced and involved an additional six 3-hour observation periods during the next 2 weeks. Handwashing frequency was measured by counting the number of handwashes with the use of soap and water or the handrub lotion by each observed staff member. Handwashing duration was measured by a concealed stopwatch. The time period from the wetting of hands with soap and water, or handrub lotion, to completion of rinse or rubbing of hands was measured to the nearest tenth of a second. The same person performed the observations throughout the study.
Statistical
contacts No. of handwashes 96 34 3 12
(%)
(26) (52) (50) (27)
145 (30)
analysis
The Statistical Package for the Social Sciences (SPSS) computer program was used to process the data and generate the statistics. Analysis of variance was used to compare handwashing duration between groups and levels of patient contact. Chi-square analysis was used to compare handwashing duration between stages one and two. RESULTS
A total of 884 patient contacts and 341 hand decontamination episodes was observed. Table 1 shows the number of patient contacts and hand decontamination episodes by each staff group in both stages of the study. In stage one there were 440 patient contacts and 140 handwashes. Handwashing occurred 32% of the time. In stage two, after the introduction of the handrub lotion, there were 444 patient contacts and 201 hand decontamination episodes. Hand decontamination occurred 45% of the time, an increase of 13%. The difference in hand decontamination frequency between stages one and two is statistically significant (p < 0.01). Table 2 shows the number of high- and lowlevel contacts by all staff groups and the number of handwashes.. The difference in handwashing frequency among the staff groups is statistically significant (p < 0.01). The rnean handwash duration time for the entire population was 10 seconds + 0.29 SEM. The shortest handwash was 3 seconds, and the longest was 45.2 seconds. The mean handwash duration time for nurses was 8.8 seconds, physicians 10.2 seconds, physiotherapists 11.3 sec-
American
80
Graham
onds, and radiology/orderly staff members 12.1 seconds. The difference in handwash duration times among the staff groups is statistically significant (p < 0.01). DISCUSSION
The compliance of health care workers with recommended handwashing practices in this study was poor.3, 4 Nurses who had the highest number of patient contacts were also least likely to wash their hands after patient contact. However, this may have been due to the much smaller number of patient contacts observed for the other staff groups. An in-service education program may improve compliance and should emphasize the importance of handwashing, not only between contact with different patients but also after specific activities performed on the same patient. There were many instances in which personnel manipulated the urethral catheter and then immediately afterward handled the tracheostomy tube or central venous cannula. This may lead to the colonization of the tracheostomy wound or intravenous site with virulent gram-negative bacteria.4 The introduction of the handrub lotion in stage two of the study resulted in an increase in handwashing frequency after patient contact. The lotion was conveniently located at each bed area, which allowed staff members to use the product in almost the same time it took for some of them to reach the handwash sink. This also allowed personnel constantly to observe their patients, because they did not have to walk away from the bed to decontaminate their hands. Further observations need to be made during a longer time period to determine whether use of the lotion resulted in a sustained increase in hand decontamination frequency. It was interesting to note the low number of patient contacts observed among the medical staff. They also had more low-level contacts. This may be due to the nature of the work performed by the nursing staff in the unit, who carry out many procedures that in other areas of the hospital normally are performed by medical staff.
INFECTION
Journal
of
CONTROL
In studies that evaluate the effectiveness of handwashing in the eradication of transient microbial flora, handwashing durations between 15 and 30 seconds are recommended.3 In this study the duration of handwashing is below the recommended level. There was a slight increase in handwashing duration after high-level contact activities; however, there is a need for further studies to evaluate the effectiveness of hand decontamination agents at shorter handwash times. One limitation of the study was associated with the method used to collect the data. There was a concern that some staff members may have “guessed” the real reason for the observations, which, however, was not reflected in the rate of handwashing observed. In addition, all observations were carried out at the same time of day, and all staff members may not have been observed. It also was not possible to ascertain if personnel observed in stage one were the same persons as those observed in stage two. CONCLUSION
This study suggests that in-service education of health care workers regarding handwashing habits must be continuously reinforced to achieve optimal compliance with recommended handwashing policies. This issue was highlighted in an earlier study of handwashing practices.’ In addition, the evaluation of hand decontamination agents at short duration times (10 to 15 seconds) is needed. Increasing the availability of hand decontamination facilities by the provision of either more handwash sinks or handrub lotions also may result in an increase in handwashing compliance. I thank Nursing, Australia,
Carol Bradburn, RN, formerly Lecturer, Cm-tin University of Technology, Perth, for her assistance.
School of Western
References 1. Reybrouck G. Role of the hands in the spread of nosocomial infections. I. J Hosp Infect 1983;4:103-10. 2. Larson E. A causal link between handwashing and risk of infection? Examination of the evidence. Infect Control Hosp Epidemiol 1988;9:28-36. 3. Steere AC, Mallison GF. Handwashing practices for the prevention of nosocomial infections. Ann Intern Med 1975;83:683-90.
Volume
18 Number
2
April 1990
4. Daschner FD. Useful and useless hygienic techniques in intensive care units. Intensive Care Med 1985;ll: 280-3. 5. Quraishi ZA, McGuckin M, Blais FX. Duration of handwashing in intensive care units: a descriptive study. AM J INFECT CONTROL 1984;11:83-7. 6. Fox MK, Langner SB, Wells RW. How good are hand washing practices? Am J Nurs 1974;74:1676-8. 7. Albert RK, Condie F. Hand-washing patterns in medical intensive-care units. N Engl J Med 1981;304: 1465-6. 8. Centers for Disease Control. Guidelines for handwashing and hospital environmental control. Infect Control 1986;7:231-43. 9. Kaplan LM, McGuckin M. Increasing handwashing
Frequency
10.
11. 12.
13.
and duration
of handwashing
in an ICU
81
compliance with more accessible sinks. Infect Control 1986;‘7:408-10. Morrison AJ, Gratz J, Cabezudo I, Wenzel RP. The efficacy of several new handwashing agents for removing non-transient bacterial flora from hands. Infect Control 1986;‘7:268-72. Larson EL, Eke PI, Laughon BE. Efficacy of alcoholbased hand rinses under frequent-use conditions. Antimicrob Agents Chemother 1986;30:542-4. Tanaka K, Kumon K, Hirata T, Yamamoto F, Fujita T. Evaluation of rapid drying hand disinfectant preparations in the intensive care unit. Crit Care Med 1988;16:540-2. Meers PD, Yeo GA. Shedding of bacteria and skin squames after handwashing. J Hyg 1978;81:99-105.