Quantity of Research Available
A total of 250 citations were identified in the literature search. Following screening of titles and abstracts, 249 citations were excluded and one potentially relevant report from the electronic search was retrieved for full-text review. Four potentially relevant publications were retrieved from the grey literature search. Of these potentially relevant articles, two publications were excluded for various reasons, while three publications met the inclusion criteria and were included in this report. Appendix 1 describes the PRISMA flowchart of the study selection.
Additional references of potential interest are provided in Appendix 5.
Summary of Study Characteristics
A tabular description of the included study characteristics is provided in Appendix 2.
Study Design
Three evidence-based guidelines4–6 were identified that included recommendations regarding hand antisepsis procedures.
One guideline5 followed a National Institute for Health and Care Excellence (NICE) accredited process for guideline development, using comprehensive a literature search. The evidence quality of included studies was evaluated according to the Scottish Intercollegiate Guideline Network (SIGN), and a strength of recommendation was reported for each statement.
A guideline from NICE6 was developed in accordance with the NICE guidelines methodology, using a comprehensive literature search. Evidence quality was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE), and a strength of recommendation was reported for each statement.
A third guideline, by the Public Health Agency of Canada (PHAC)4 was also identified. The guideline did not provide a detailed methodology, nor were details of the literature search provided. Evidence quality was graded using PHAC’s own grading system, and a strength of recommendation was reported for each statement.
Country of Origin
The included guidelines were from the UK5,6 and Canada.4
Intended Users and Target Population
The three included guidelines focused on health care workers in hospital and acute care settings (Loveday et al.),5 primary health care and community settings (NICE),6 and any health care settings (PHAC).4
Interventions and Comparators
All three guidelines4–6 aimed to provide information regarding hand antisepsis. All of the guidelines4–6 provided recommendations on hand antisepsis techniques, two guidelines5,6 provided recommendations on best practice for hand drying, and one guideline4 provided recommendations of the use of hand wipes.
Outcomes
The guidelines provided evidence-based recommendations for techniques and products for hand antisepsis,4–6 best practice for hand-drying,5,6 and the use of hand wipes.4 The outcomes considered by the guidelines were focused on preventing and controlling healthcare associated infections.4–6
Summary of Critical Appraisal
A tabular description of the critical appraisal is provided in Appendix 3.
The guidance by Loveday et al.5 followed a rigorous methodology by NICE. It included a systematic literature search, clearly described scope and purpose, key recommendations, and editorial independence. The guidance clearly describes selection criteria and evidence is linked to the recommendations. There are few limitations to this guideline. It is unclear if views and preferences of the target population were sought, a procedure for updating the guideline was not provided, there are no tools or advice provided for implementation, and no monitoring or auditing criteria are provided.
The NICE guidance6 followed rigorous methodology, including a systematic literature search, and clear descriptions of scope and purpose, key recommendations, and editorial independence. The guidance clearly describes selection criteria and evidence is linked to the recommendations. The only limitation identified was a lack of auditing criteria provided in the guideline.
The guidance by PHAC4 is clearly presented in the areas of scope and purpose, key recommendations, and editorial independence and there are explicit links between the evidence and recommendations. It is unclear if systematic methods were used to search for evidence, criteria for selecting the evidence were not described, the views and preferences of the target population (patients and public) were not sought, there is no procedure provided for updating the guidelines, and there are no tools or advice provided for implementing recommendations.
Summary of Findings
The main findings and guideline recommendations are provided in tabular format in Appendix 4.
What are the evidence-based guidelines regarding optimal techniques and products for hand antisepsis in hospital or residential care settings?
All three guidelines4–6 provided recommendations regarding optimal techniques and products for hand antisepsis in hospital or residential care settings.
All three guidelines4–6 recommended that hands must be decontaminated immediately before each episode of direct patient contact or care and after each episode of direct patient contact or care, after removing gloves, and any contact with fluids, objects, or equipment that are at risk of becoming contaminated based on moderate4,5 to high-quality4 evidence. They also recommended an alcohol-based hand rub for the decontamination of hands before and after patient contact and clinical care, unless hands are visible soiled or contaminated with body fluids or if the patient is excreting bodily fluids in which care soap and water must be used based on high-quality evidence.4,5 An alcohol-based hand rub solution was recommended to come into contact with all surfaces of the hand and hands were recommended to be rubbed together vigorously until the solution has evaporated and the hands are dry based on high-quality evidence.4,5
One guideline6 recommended that an effective handwashing technique involves three stages: preparation, washing and rinsing, and drying. According to the guideline,6 preparation requires wetting hands under running water before applying the hand solution. They also stated that the handwash solution must come into contact with all surface of the hand and the hands must be rubbed together vigorously for a minimum of 10–15 seconds before drying with paper towels. These recommendations were based on a previous version of the guideline, which has since been withdrawn; therefore, the level of evidence the original recommendation was based on was unclear.
One guideline4 recommended that hand hygiene using soap and water should be used to remove visible soil and/or organic material, when a buildup of alcohol-based hand rub feels uncomfortable after multiple applications, after point-of-care with an infectious patient, during outbreaks, or immediately after using toilet facilities. It also recommended that alcohol-based hand rubs with alcohol concentration should be between 60–90% depending on the use and status of the clinical care unit. These recommendations are based on moderate to high-quality evidence.
What are the evidence-based guidelines regarding best practice for hand-drying post hand-washing in hospital or residential care settings?
Two guidelines5,6 provided recommendations regarding best practice for hand-drying post hand-washing in hospital or residential care settings. Both guidelines5,6 recommended that good-quality paper towels (paper towel quality was not defined) should be used to dry the hands thoroughly. This recommendation is based on low-quality evidence.5
What is the evidence-based guidelines regarding the use of hand wipes in hospital or residential care settings?
One guideline4 recommended hand wipes impregnated with plain soap, antimicrobials, or alcohol should not be used as an alternative to alcohol-based hand rub or antimicrobial soap for hand antisepsis. The guideline stated that hand wipes may be used as an alternative to soap and water when hands are visibly soiled and a handwashing sink is not immediately available or when a handwashing sink is unsuitable. This recommendation is based on high-quality evidence.
Limitations
Three evidence-based guidelines were identified.4–6 One of the guidelines5 provided some recommendations based on low quality research studies and/or expert opinion. One of the guidelines6 used recommendations based on a previous version of the guideline which has since been withdrawn. We were unable to determine the level of evidence the original recommendations were based on. One of the guidelines4 included manufacturer’s recommendations, which were not graded or critically appraised. The same guideline4 did not provide explicit details on a literature search strategy and methodology. Two of the guidelines5,6 were produced in the UK, making them less likely to be applicable to the Canadian context.
