Doctors and nurses on the go often skip soap and water in favor of an alcohol-based hand gel, thinking the quick-acting goo will kill bacteria on their hands and curb the spread of infection.
It turns out that's not enough.
In a Nebraska hospital, medical workers nearly doubled their use of the alcohol-based gel, but their generally cleaner hands had no bearing on the rate of infections among patients.
The doctor who studied the problem pointed to many villains: Rings and fingernails that are too long and hard to clean, poor handling of catheters and treatment areas that aren't sanitized.
"Hand hygiene is still important, but it's not a panacea," said Dr. Mark Rupp, an infectious disease specialist at the University of Nebraska Medical Center. He led the study at the adjoining Nebraska Medical Center.
The results of his study appear to contradict hospital guidelines from the Centers for Disease Control and Prevention that say better hand hygiene — through frequent washing or use of hand gels — has been shown to cut the spread of hospital infections.
The spread of infection-causing germs in U.S. hospitals is a huge health problem, accounting for an estimated 1.7 million infections and 99,000 deaths each year, according to the CDC. These include drug-resistant staph, urinary tract infections and ventilator-associated pneumonia, among others.
"There are many factors that influence the development of hospital-acquired infections. It would be naive to think that a single, simple intervention would fix this problem," Rupp said.
His study appears in the January issue of Infection Control and Hospital Epidemiology.
Research has shown alcohol-based hand gels are more effective, faster and easier to use than soap and water. The findings of the new study were based on 300 hours of hand hygiene observations of nurses and doctors in two comparable intensive care units over a two-year period.
More gel dispensers were put in the units, and usage rose from 37 percent to 68 percent in one unit and from 38 percent to 69 percent in the other. Compliance for hand washing of any kind in most hospitals is estimated to be about 40 percent, according to experts, although some hospitals do better.
Every two months, bacteria samples were taken from health workers' hands, which were found to be cleaner when using the alcohol gel.
The infection rates in both ICUs were "relatively low," the study said. And researchers found "no significant relationship" between rates of hand gel use and infections among patients. In fact, in one unit the infection rate rose when the hand gel was widely available and its use promoted.
Rupp found the results surprising. However, he said hospital-borne infections cannot be stopped by better hand hygiene alone because infections aren't limited to person-to-person contact.
He suggested hand gels be combined with other measures, such as better cleaning of hospital units, proper insertion and maintenance of catheters, and doctors prescribing antibiotics only when necessary so more drug-resistant bacteria don't pop up.
Trim fingernails and take off rings
He also said hospital workers shouldn't wear rings and should trim their fingernails even more than the CDC recommendation of no longer than a quarter of an inch. Rupp said bacteria showed up when nails extended just beyond the fingertip.
Mike Bell, who deals with infection control at the CDC, said that while he didn't agree that hand gels do little to reduce infection, Rupp was right to say they were just one part of the solution.
"If they don't do everything else right, having clean hands is not enough," he said.
Both Bell and Dr. David Hooper of Massachusetts General Hospital in Boston suggested that Rupp's study would have shown a reduction in infections if it was conducted over a longer period.
Hooper said the compliance rate for hand hygiene at Massachusetts General has been about 90 percent for the past several years. The number of drug-resistant staph cases was cut in half and continues to decline, he said.