INTRODUCTION

Healthcare-associated infections (HAIs) increase patient morbidity and mortality and are the object of attention by the Hospital Infection Control Commissions (HICC)¹. Hand hygiene (HH) is directly associated with a reduction in infection rates, and it is a relatively simple measure. Despite this, there is not great compliance by professionals, which is a challenge for infection control.^2,3,4 Since 2004, the World Health Organization (WHO) has identified HAI as a patient safety issue, launching the “Clean Care is Safer Care” campaign in 2005,⁵ and in 2009, the Multimodal Strategy was defined and disseminated to encourage compliance with HH,² ratifying the use of alcoholic preparations as a standard solution for hand antisepsis⁶.

Since then, one of the nine main WHO recommendations on HH in health services is the provision of access for health professionals to alcohol preparation at the point where care is provided,⁶ guidance that was regulated in Brazil by RDC 42 of October 25, 2010,⁷ and later by Technical Note 01/2018 GVIMS/GGTES/ANVISA.⁸

The use of alcoholic preparations is widely recommended, due to the ease of their distribution in the institution, and some studies indicate that their use increased health professionals’ compliance with HH.⁶ This increase may be related to advantages such as: elimination of most microorganisms (including viruses); short period of time to sanitize hands (20 to 30 seconds); product availability at the service point; good skin tolerability; no need for any special infrastructure, such as a clean water supply network, washbasin, among others.^9,10

Furthermore, alcoholic preparations act quickly and have excellent bactericidal and fungicidal activity when compared to other agents used in HH. For these reasons, when alcohol-based hand rub is available, it should be adopted as the first choice product (when there is no visible dirt on the hands), being, in short, a recommendation with level of evidence IB in the WHO Guidelines on Hand Hygiene in Healthcare Services Health⁶. However, the elimination of the microbial load after HH with alcoholic preparation is directly related to the correct technique.^10,11,12

The Multimodal Strategy also makes it mandatory to monitor HH practices through indicators, providing employees with feedback on performance and results.¹³ In Brazil, the Protocol for the Practice of Hand Hygiene in Health Services, which is based on the Multimodal Strategy, defines the following indicators for measuring compliance: mandatory indicators: a) consumption of alcohol-based hand rub: monitoring of the volume of alcohol-based hand rub used for every 1,000 patients/day; b) soap consumption: monitoring the volume of liquid soap with or without antiseptic used for every 1,000 patients/day. Recommended indicator: c) percentage (%) of compliance: number of HH actions carried out by health professionals/number of opportunities for HH, multiplied by 100.¹³ Measuring the degree of professionals’ compliance with processes based on scientific evidence is necessary to demonstrate whether the efforts undertaken by the organization led to significant changes in the performance scenario. Monitoring makes health care more transparent as well as providing information to direct improvement initiatives.¹⁴

Monitoring the volume of alcohol preparation is an indirect method that helps institutions to monitor professionals’ compliance with HH associated with direct observation, which is considered the gold standard.¹⁵ It must be calculated using the formula: amount of alcoholic product used in the month in milliliters (ml) divided by the number of patients/day.^13,16 As for the ideal minimum consumption, the WHO, in the document Hand Hygiene Self-Assessment Framework 2010, brings in item 3.3c of the assessment and feedback questionnaire the following question: alcohol consumption for hands is at least 20 L per 1,000 patients/day?¹⁷ Since then, health services have used the reference 20 ml per patient/day as a minimum goal to be achieved, as seen in studies related to the subject.^{15, 18}

In 2014, the Collaborating Center for Quality and Patient Safety (Proqualis)¹⁸ published the “Alcoholic Hand Preparation Consumption Sheet”. In it, we can find the definition of patient/day as the patient care provided by a hospital day.¹⁹ Therefore, the Standardization of Hospital Census Nomenclature manual, published by the Ministry of Health, defines “hospital day” as a 24-hour period between two consecutive hospital censuses. The censuses, in turn, are the counting and registration, each hospital day (24 hours), of the number of occupied and vacant beds in inpatient units and hospital services.²⁰ Regarding outpatient clinics, they are not considered hospital beds, since patients are treated on a non-hospitalization basis.

Given the fact that, currently, there is no guidance regarding the profile for application of the reference published by the WHO for many health institutions, the study sought to analyze information available in the scientific literature to support the definition of alcoholic preparation consumption for HH in outpatient institutions and Day Hospitals.

METHOD

This is an integrative review (IR) study, following the steps: 1) theme identification and research question selection; 2) establishment of criteria for inclusion and exclusion of studies; 3) definition of the information to be extracted from the chosen studies; 4) assessment of included studies; 5) interpretation of results; 6) review presentation.^{21, 22}

The PICo (Problem, Interest and Context) strategy was used, where P: ideal consumption volume of alcoholic preparation for HH; I: evidence available for determination; Co: outpatient clinics and Day Hospitals. Thus, the research question was defined: what evidence is available in the scientific literature to define the value of alcohol consumption for HH in outpatient clinics and Day Hospitals?

To carry out the search in the databases, the following keywords were chosen, according to the structured and multilingual vocabulary of Descriptors in Health Sciences (DeCS): "Segurançado Paciente", "Higienedas Mãos", "Anti-Infecciosos Locais". The following Medical Subject Headings (MeSH) descriptors were also used: "Hand Hygiene"[Mesh], "Patient Safety"[Mesh], "Anti-Infective Agents, Local"[Mesh], "Infection Control"[Mesh]. Articles in Portuguese, English and Spanish, with content available in full, online and free of charge, published between 2010 and 2021, which were in accordance with the pre-established theme, were included. The choice of this period was due to the launch of the Multimodal Strategy to improve compliance with HH practices by the WHO. Editorials and news as well as articles in other languages, not available in full or free of charge, and that did not have thematic significance for the objectives of work, were excluded.

Materials published in events/conferences, technical materials and articles from the following journal databases of the Coordination for the Improvement of Higher Education Personnel (CAPES - Coordenaçãode Aperfeiçoamento de Pessoal de Nível Superior) were selected (www.periodicos.capes.gov.br) as follows: Scopus; Web of Science; SciELO; PubMed/MEDLINE; Cumulative Index to Nursing and Allied Health Literature (CINAHL); BDENF - Nursing Database (BDENF); and Latin American and Caribbean Literature on Health Sciences (LILACS), through the Virtual Health Library: VHL (BIREME). The search strategies used were organized with the help of a librarian and are described in Chart 01.

Searches in the databases were carried out by two researchers independently, between May and June 2021, and resulted in a total of 1069 articles. For selection, the analysis criteria shown in Flowchart 01 were used.

This process was carried out through a thorough reading of titles and abstracts, so that the studies that met the defined inclusion criteria, in addition to meeting the proposed objective, were selected for the final selection. For the final selection of the articles, a critical and detailed analysis was carried out in which we sought to identify what information was used to define the value of alcoholic preparation consumption for HH and the amount of ml used on average to perform an HH.

RESULTS AND DISCUSSION

Five articles that address the theme were selected, but no article was found that specifically addressed outpatient clinics or Day Hospital. The English language was predominant, being presented in all publications. Two studies took place in a research environment in Hungary, and the others were conducted in other countries, covering Europe and Asia. As for the databases, one study was published in VHL, one in Scopus, one in CINAHL, and two in PubMed, with publications beginning in 2010 (1), and the others in 2013 (1), 2015 (2) and 2020 (1).

Subsequently, a synoptic table (Table 01) was elaborated, in order to synthesize the main information, and the articles were divided according to the variables related to the objective of this review, as ml of alcoholic preparation for each HH and consumption of alcoholic preparation per patient/day.

Although the studies do not contemplate contexts similar to Day Hospital and/or outpatient care, they provide relevant information to support the definition of alcoholic preparation consumption for HH and which were divided into two variables: ml of alcoholic preparation for each HH and alcoholic preparation consumption per PD. Of the five articles, two contained information related to both analytical categories: one only about the number of milliliters to be used for proper HH and two only about the alcoholic preparation consumption for HH identified in the institutions.

Through the analysis of the three articles that mention the amount of ml of alcoholic preparation for each HH, it was identified that the average volume predicted for a correct procedure is 3 ml,^22,23,24however there is a caveat that for large hands this volume may be inadequate.^25,26 This brings a responsibility for professionals to judge, at the end of the HH technique, whether the amount of alcoholic preparation used was sufficient to cover the entire hand. If not, care should be taken to use a larger amount than that commonly available in dispensers. The NHSScotland National Infection Prevention and Control Manual states that the volume of alcohol preparation used should, in the absence of manufacturer instructions, be approximately 3 ml to ensure full coverage. The authors state that this volume is based on a series of experimental and observational studies, however the same study demonstrated that, in practice, the volume of alcoholic preparation used per HH opportunity in the National Health Service (NHS) is probably closer to 1 ml.²⁷

In a multimodal intervention in South Africa, the reference of 3 ml per HH opportunity was also used for measurement²⁸ and, likewise, in the context of Primary Care in the Faranah region, Guinea. In this analysis, a clear underutilization was identified, with an average of 0.77 ml per consultation, compared to the recommended minimum amount of 3 ml per HH²⁹. The authors inferred that, as low consumption was accompanied by relatively high compliance in terms of the number of HH actions, the most plausible explanation for the general underuse of alcoholic solution was due to the use of a small amount of alcoholic solution per HH action, and not a few HH actions per consultation, which could be explained by the lack of knowledge of the required amount or the desire not to ‘waste’, for fear of interruption of supply³⁰. This point evokes the need for greater disclosure of the minimum amount of alcoholic preparation for effective HH and its relationship with the assessment of the representativeness of consumption measured by the HICC.

When assessing the findings on the average alcoholic preparation consumption per PD, it is noticed the prevalence of studies in general hospitals in ICU and non-ICU, which may be related to the fact that patients of greater complexity demand more care and interventions. Only one study brought a different perspective, related to alcoholic preparation consumption in a Hungarian NH, but the measurement used different markers, being by “health professional” and not by “PD”. It is worth mentioning that none of the authors mentioned the goal of 20 ml PD, published by the WHO in the document Hand Hygiene Self-Assessment Framework 2010 (HHSAF).¹⁷

Analyzing other studies on alcoholic preparation consumption, it was identified that, in the Neonatal Intensive Care Unit (NICU) of the largest maternity hospital in the state of Bahia, the monthly average use of alcoholic preparation for HH was 16.341 ml. The authors report that the HICC carried out the monthly calculation of the minimum expected consumption in ml, according to WHO criteria, and the value 46.640 ml was used as a reference parameter¹⁷, however, they did not explain the method they used to define this reference higher than that predicted by the WHO, but we can infer that, in this sector, the opportunities for HH are greater than in the others.

In a pre-hospital emergency service in Goiás,³⁰ a consumption of 2.071 ml of alcoholic preparation was found for an average of 750 occurrences assisted, about 2.76 ml per service provided, slightly below the amount of ml minimum for a proper HH. After the educational activity proposed in the referenced article, there was an increase to about 6.02 ml of alcoholic preparation per visit, suggesting the performance of two HH. However, considering that emergency medical service professionals work minimally in pairs, the “5 moments for HH” and the goal published by the WHO, we can infer that compliance with HH by professionals is low, which may be related to the challenges due to the structural conditions of ambulances and the service profile. As in the case of outpatient clinics and Day Hospitals, this report makes us reflect on how assertively the WHO consumption reference is applicable to the most diverse health services, since HH opportunities differ according to the type of service and complexity.

In 2007, a voluntary electronic surveillance tool was introduced in German healthcare institutions to record alcoholic preparation consumption and determine consumption trends between 2007 and 2018. Thus, 75.2% of intensive care hospitals in Germany (N = 1,460) participated. In 2018, the average consumption results obtained were: in the ICUs (n =1,998), 137.4 ml per PD; in intermediate care units (N = 475); 70.6 ml per PD; and in the wards, 32.6 ml per PD³¹. It is noticed that, the greater the complexity of care, the more opportunities for HH there are, reflecting on the increase in alcoholic preparation consumption by PD.

In a retrospective analysis comparing the results of two surveillance systems implemented (WHO HHSAF and alcoholic solution consumption) in 40 hospitals in the Piedmont region of Italy, there was a positive correlation between the HHSAF score and the chance of belonging to the high alcohol consumption group, mainly for cut-offs of 19 to 23 ml per PD. Two alcohol solution consumption peaks were identified at approximately 10 and 22 ml per PD, corresponding to median scores of 353.75 and 375 points, respectively³².

The maximum score considered for the HHSAF is 500 points. The article makes us reflect on authors’ assertion that both surveillance systems are consistent and that the HHSAF score “may function as a reasonable predictor of compliance with HH in health settings”.³²

In the African study, carried out between 2020 and 2021 on a multimodal intervention in a NICU, the baseline volume of alcoholic preparation use was 70 ml per PD, about 23 HH actions per PD and 73 ml per PD after the intervention. The initial HHSAF score was 165, classifying the unit as a “basic” level, evolving to 262.5, becoming classified as an “intermediate” level”.²⁷ This shows us that a high score level on the HHSAF does not necessarily reflect on compliance with HH.

Still, thinking about the HHSAF’s education pillar, a study conducted at NHO Shimoshizu national hospital, with 440 beds, located in Chiba, Japan, identified that the 5-year initiative implemented resulted in an eightfold increase in alcoholic solution consumption, from 4.2 to 34.4 ml per PD.³³ Even if the HHSAF is not a tool that correctly explains professionals’ compliance, its application is essential as a strategic basis to generate a favorable environment and culture for this to happen, which is its main purpose.¹⁷

Assessing the final consumption achieved after the initiative, three other studies corroborate the result, showing an average consumption of approximately 35 ml per PD in Japanese intensive care services,³⁴ 32 ml per PD in three ICUs of a private hospital in Minas Gerais³⁵ and 36.4 ml per PD in a Sub-Intensive Care Unit of an Italian general hospital³⁶.

In the same context, an analysis carried out at Faranah Regional Hospital to assess the WHO HH improvement strategy’s feasibility and effectiveness in this resource-poor setting, identified that the mean monthly alcohol consumption for the entire hospital increased after the intervention, from 2.2 L at baseline to 28.0 L at follow-up³⁷. A total of 24 months of HH data were reviewed, and converted to liters per 1000 PD. The total consumption of alcoholic solution was 18,693 L, ranging from 30.1 to 72.6 ml per PD per ward³⁸. The Multimodal Hand Hygiene Improvement Strategy is clearly a way to encourage the creation of a HH culture in health organizations⁶.

The heterogeneity of alcoholic preparation consumption in the different sectors of health establishments is evident (lower consumption identified in studies: 2.76 ml per service provided; higher consumption identified in the studies: 137.4 ml PD), and even in those that reach better levels, it is not possible to state that consumption is adequate. There is a latent need to define the minimum consumption of alcoholic solution expected in all types of health services based on the “5 moments for HH”, in order to make the correlation of these data with practice more and more reliable. This logic was applied in a study carried out at The Ottawa Hospital, in Ontario, which aimed to estimate the total volume of alcoholic preparation needed for HH during a year, based on the estimated number of HH indications at each point of care.³⁸ The definition of opportunities was carried out through the number of HH indications signaled in the audits and through interviews with frontline professionals, bringing more reliable data for comparison between current and ideal consumption. In another article, researchers reported that, in France, the alcoholic preparation consumption index is calculated considering the actual HH expected per day and per patient category, and, based on a volume of 3 ml per HH, an expected annual consumption is calculated³⁹. Measuring volumetry in isolation, without a reference that considers the minimum HH opportunities expected during a given service, does not add real value to practice. Through this data, it is possible to understand where one is, but not where one intends to go and how far away we are. In this way, the identification of the expected minimum consumption of alcohol preparation can contribute to greater assertiveness in the planning of actions to increase the compliance of professionals with HH in all health services, including outpatient clinics and Day Hospitals. Moreover, investments in infrastructure, provision of alcohol preparation at the point of care, training and adequate sizing of employees are necessary. It is possible that the results presented by health institutions are less than ideal, due to the imbalance between these crucial factors.

CONCLUSION

Alcoholic preparation consumption for HH is still a controversial subject. when discussing the minimum consumption by health services, and with scarce information, when it comes to outpatient clinics and Day Hospitals. The study sought to analyze the information available in the literature to support the definition of alcoholic preparation consumption for HH in these institutions, but no articles were found in relation to this specific context. However, the data identified on the minimum amount of ml of alcoholic preparation for each HH pave the way for further research on the subject, which can be associated with the mapping of HH opportunities in each care situation.

This need is evident, especially in the outpatient and Day Hospital scope, since the published studies are commonly related to general hospitals and concentrated in sectors with a higher risk of infection. However, less complex environments also present risks and require evidence to support best practices, subsidizing the critical analysis of the success of implemented infection prevention actions, such as HH.

The main limitation of this study was the use of restricted descriptors, which may have interfered with the findings. However, we understand that this text brings up an important discussion for assistance in health services in general, not just for outpatient clinics and Day Hospital, opening doors for primary studies. Therefore, it is suggested that studies relating the type of health unit, the profile of patients and the “5 moments for HH” be carried out, bringing assertiveness and reliability regarding the minimally expected alcoholic preparation consumption, allowing institutions to better measure the efforts necessary for its achievement.

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IR