Skip to main content Accessibility help

Prospective, Controlled, Cross-Over Trial of Alcohol-Based Hand Gel in Critical Care Units

  • Mark E. Rupp (a1) (a2), Teresa Fitzgerald (a2), Susan Puumala (a3), James R. Anderson (a3), Rita Craig (a2), Peter C. Iwen (a4), Dawn Jourdan (a2), Janet Keuchel (a2), Nedra Marion (a2), Delayne Peterson (a5), Lee Sholtz (a2) and Valerie Smith (a2)...



There are limited data from prospective studies to indicate whether improvement in hand hygiene associated with the use of alcohol-based hand hygiene products results in improved patient outcomes.


A 2-year, prospective, controlled, cross-over trial of alcohol-based hand gel.


The study was conducted in 2 medical-surgical ICUs for adults, each with 12 beds, from August 2001 to September 2003 at a university-associated, tertiary care teaching hospital.


An alcohol-based hand gel was provided in one critical care unit and not provided in the other. After 1 year, the assignment was reversed. The hand hygiene adherence rate and the incidence of nosocomial infection were monitored. Samples for culture were obtained from nurses' hands every 2 months.


During 17,994 minutes of observation, which included 3,678 opportunities for hand hygiene, adherence rates improved dramatically after the introduction of hand gel, increasing from 37% to 68% in one unit and from 38% to 69% in the other unit (P < .001). Improvement was observed among all groups of healthcare workers. Hand hygiene rates were better at higher workloads when hand gel was available in the unit (P = .02). No substantial change in the rates of device-associated infection, infection due to multidrug-resistant pathogens, or infection due to Clostridium difficile was observed. Culture of samples from the hands of nursing staff revealed that an increased number of microbes and an increased number of microbe species was associated with longer fingernails (ie, more than 2 mm long), the wearing of rings, and/or lack of access to hand gel.


The introduction of alcohol-based gel resulted in a significant and sustained improvement in the rate of hand hygiene adherence. Fingernail length greater than 2 mm, wearing rings, and lack of access to hand gel were associated with increased microbial carriage on the hands. This improvement in the hand hygiene adherence rate was not associated with detectable changes in the incidence of healthcare-associated infection.


Corresponding author

984031 Nebraska Medical Center, Omaha, NE 68198-4031 (


Hide All
1.Jarvis, WR. Selected aspects of the socioeconomic impact of nosocomial infections: morbidity, mortality, cost, and prevention. Infect Control Hosp Epidemiol 1996;17:552557.
2.Alonso-Echanove, J, Gaynes, RRScope and Magnitude of Nosocomial ICU Infections. Boston: Kluwer Academic Publishers; 2002.
3.Pittet, D, Boyce, JM. Hand hygiene and patient care: pursuing the Semmelweis legacy. Lancet Infect Dis 2001;1:919.
4.Voss, A, Widmer, ARNo time for handwashing? Handwashing versus alcoholic rub: can we afford 100% compliance? Infect Control Hosp Epidemiol 1997;18:205208.
5.O'Boyle, CA, Henly, SJ, Larson, E. Understanding adherence to hand hygiene recommendations: the theory of planned behavior. Am J Infect Control 2001;29:352360.
6.Boyce, JM, Pittet, D. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol 2002;23(12 suppl):S340.
7.US Department of Health and Human Services, Centers for Disease Control and Prevention. National Nosocomial Infections Surveillance System Manual. Atlanta, GA: Centers for Disease Control and Prevention; 1999.
8.Paulson, DS, Fendler, EJ, Dolan, MJ, Williams, RA. A close look at alcohol gel as an antimicrobial sanitizing agent. Am J Infect Control 1999;27:332338.
9.Clinical and Laboratory Standards Institute (CLSI). Abbreviated Identification of Bacteria and Yeast: Approved Guideline. Wayne, PA: CLSI; 2002: M35A.
10.Pittet, D, Mourouga, P, Perneger, TV. Compliance with handwashing in a teaching hospital. Infection Control Program. Ann Intern Med 1999;130:126130.
11.Larson, E, Kretzer, EK. Compliance with handwashing and barrier precautions. J Hosp Infect 1995;30(suppl):88106.
12.Watanakunakorn, C, Wang, C, Hazy, J. An observational study of hand washing and infection control practices by healthcare workers. Infect Control Hosp Epidemiol 1998;19:858860.
13.Daniels, IR, Rees, BI. Handwashing: simple, but effective. Ann R Coll Surg Engl 1999;81:117118.
14.Tibballs, J. Teaching hospital medical staff to handwash. Med IA ust 1996;164:395398.
15.Boyce, JM. It is time for action: improving hand hygiene in hospitals. Ann Intern Med 1999;130:153155.
16.Kownatzki, E. Hand hygiene and skin health. J Hosp Infect 2003;55:239245.
17.Bischoff, WE, Reynolds, TM, Sessler, CN, Edmond, MB, Wenzel, RRHandwashing compliance by health care workers: the impact of introducing an accessible, alcohol-based hand antiseptic. Arch Intern Med 2000;160:10171021.
18.Maury, E, Alzieu, M, Baudei, JL, et al.Availability of an alcohol solution can improve hand disinfection compliance in an intensive care unit. Am J Respir Crit Care Med 2000;162:324327.
19.Kohan, C, Ligi, C, Dumigan, DG, Boyce, JM. The importance of evaluating product dispensers when selecting alcohol-based handrubs. Am J Infect Control 2002;30:373375.
20.Widmer, AE, Dangei, M. Alcohol-based handrub: evaluation of technique and microbiological efficacy with international infection control professionals. Infect Control Hosp Epidemiol 2004;25:207209.
21.Recommendations for preventing the spread of vancomycin resistance. Recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep 1995;44(RR-12):113.
22.Muto, CA, Jernigan, JA, Ostrowsky, BE, et al.SHEA guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and enterococcus. Infect Control Hosp Epidemiol 2003;24:362386.
23.Jones, RD, Jampani, HB, Newman, JL, Lee, AS. Triclosan: a review of effectiveness and safety in health care settings. Am J Infect Control 2000;28:184–96.
24.Hoang, TT, Schweizer, HP. Characterization of Pseudomonas aeruginosa enoyl-acyl carrier protein reductase (FabI): a target for the antimicrobial triclosan and its role in acylated homoserine lactone synthesis. J Bacteriol 1999;181:54895497.
25.Chuanchuen, R, Beinlich, K, Hoang, TT, Becher, A, Karkhoff-Schweizer, RR, Schweizer, HP. Cross-resistance between triclosan and antibiotics in Pseudomonas aeruginosa is mediated by multidrug efflux pumps: exposure of a susceptible mutant strain to triclosan selects nfxB mutants overexpressing MexCD-OprJ. Antimicrob Agents Chemother 2001;45:428432.
26.Heath, RJ, Rock, CO. A triclosan-resistant bacterial enzyme. Nature 2000;406:145146.
27.World Health Organization (WHO). World Alliance for Patient Safety. WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft). Geneva, Switzerland: WHO Press; 2006.

Related content

Powered by UNSILO

Prospective, Controlled, Cross-Over Trial of Alcohol-Based Hand Gel in Critical Care Units

  • Mark E. Rupp (a1) (a2), Teresa Fitzgerald (a2), Susan Puumala (a3), James R. Anderson (a3), Rita Craig (a2), Peter C. Iwen (a4), Dawn Jourdan (a2), Janet Keuchel (a2), Nedra Marion (a2), Delayne Peterson (a5), Lee Sholtz (a2) and Valerie Smith (a2)...


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed.