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Alcohol preparations, outlined by the WHO (2009) as containing either ethanol, isopropanol or n-propanol, or a combination, have become an increasingly common site in many western healthcare settings. They offer an efficient

1997). ABHR have been tested for efficacy against a myriad of pathogens (e.g. see Boyce et al., 2002, pp. S10; WHO, 2009, pp. 32 for detailed overviews), with the overall summary that it is effective as a counter-measure to gram-positive and gram-negative vegetative bacteria (e.g. MRSA and VRE), however is not effective as a counter to bacterial spores (e.g. CDI). Work by Pittet et al. (1999b) further confirmed the effectiveness of ABHR in comparison to unmedicated soap and water as a method for reducing bacterial contamination on hand surfaces.

In a much cited paper, Voss and Widmer (1997) concisely offer a rationale for the use of ABHR as a time-saving alternative to hand hygiene using a soap and water, with a standardised setting of an ICU for context. Their calculation delivers a proposed time saving of 13.3 hours per shift within the ICU setting studied (based on 12 healthcare professionals working), by switching to ABHR rather than using a soap and water approach. This striking result, from the extreme of their

comparison calculations (using an assumed 100% compliance rate), led the authors to suggest that, amongst other benefits, hand hygiene compliance may be positively affected by the time saving promise of ABHR.

Since the publication of Voss and Widmer (1997) ABHR has become

commonplace throughout the NHS. It was a cornerstone of the Cleanyourhands Campaign (CYHC), whereby the availability of ABHR at points of care (i.e. Patient bedsides) and ward entrances was a core intervention (National Patient Safety Agency, 2004). The recent evaluation of the CYHC (Stone et al., 2012) revealed dramatic rises in procurement of ABHR (3.4 to 26.0 mL per Patient bed day), attributed by the authors, in the main, to the campaign aims. Encouragingly, results presented by the authors indicated a trend in the last four quarters of the

campaign (Jul 07 - Jun 08 inclusive) interpreted asan estimated reduction in MRSA bacteraemia of 1%...for each additional mL used per bed day(pp. 3, and Table 3, pp. 9). Furthermore Stone et al. (2012) cite the publication of the Health Act (2006) as being associated with a significant rise of ABHR procurement. This act included specific guidance on the use of ABHR, including the stipulation thatAn NHS body must, with a view to minimising the risk of HCAI, ensure that…. (e) there is adequate provision of suitable hand wash facilities and antibacterial hand rubs(pp. 5). By comparing the study period prior to the act publication date against the remaining period following publication the CYHC data found ABHR procurement rose post-publication: from 0.68mL per bed day to 0.99mL per bed day.

Concern has been raised about an increasing recourse to ABHR leading to a reduction in soap and water decontamination. Such behaviour could be potentially catastrophic in cases where HCAI pathogens are unaffected by ABHR, as in the case of CDI (Gould et al., 2007). However, in response to the concern of Gould et al. (2007), which directly addressed the CYHC, Stone et al. (2007) cited the Geneva Study (Pittet et al., 2000). This study found that despite the introduction of ABHR, recourse to soap and water hand decontamination remained stable. A similar finding was subsequently found at the evaluation stage of the CYCH (Stone et al., 2012).The acknowledged increase in ABHR procurement was not found to be at the expense of soap procurement, which itself increased

dramatically: from 17.4 to 33.8 mL per bed day.

Such a trend was also noted by Whitby and McLaws (2007) who proposed a behavioural explanation for continued soap and water decontamination in the face

of potentially time-saving ABHR use. To be discussed later, their view is based upon the proposition that hand hygiene can be separated into two components: Inherent and Elective. Inherent relates to a sense of “automatic” hand hygiene, linked to perceptions of self-risk, performed when hands are visibly dirty, feel sticky, or in response to contact with an emotionally dirty trigger (e.g. armpit). Elective relates to remaining instances of hand decontamination, whereby an element of learning of appropriate hand hygiene behaviour is required. Whitby and McLaws(2007) suggest ABHR may be more strongly linked to Elective hand hygiene. This isdue to the automatic, long-standing association between soap and water decontamination and reduction of perceived self-risk (i.e. Inherent hand hygiene). They suggest an increased use of ABHR is seen due to increased hand hygiene following Elective hand hygiene triggers, perhaps partly due to new interventions (i.e. CYHC posters, availability of ABHR). However, hand hygiene following Inherent hand hygiene triggers is unaffected by new interventions, due to its well-established, self-protection base. Recourse to soap and water is more automatic, therefore levels of soap procurement (as an indicator of soap and water use) remain unaffected by alternate methods of hand hygiene being introduced. Whilst final evaluations of the CYHC (Stone et al., 2012) do show soap

procurement increase, contrary to the original suggestions of Whitby and McLaws (2007), this may be explained by the accompanying spike in CDI cases in theUK during the CYHC (see 1.2.). This may have led to institutional-wideemphasis on hand hygiene with soap and water, in addition to heightened perceptions of self- risk, further increasing recourse to soap and water.