Product Placement

Critical to the success of the program is having ABHR readily available to HCWs in their work area and near the patient (1). Dispensers act as a visual cue for hand hygiene behaviour, and their strategic and ubiquitous placement makes the product highly accessible for frequent use (19). Placement of ABHR needs to be consistent and reliable. Clinical staff should assist with the decision-making process, as they generally best understand the workflow in their area.

Although this may be time-consuming the benefit of behavioural adherence will be marked.

Where possible ABHR should be placed at the foot of every bed, or within each patient cubicle. An article by Traore (2007) concluded that “availability of a handrub at the point of care increased hand hygiene compliance independently of the type of product used, time of day, professional category and other confounders” (57).

There is no advantage in placing dispensers next to sinks as this can cause confusion for some HCWs who may think they need to rinse their hands with water after using ABHR. 

The following issues should be considered:

Special consideration is necessary when locating ABHR in clinical areas where ingestion or accidental splashing of ABHR is a particular risk (accidental ingestion of ABHR has been reported, but is uncommon (23)).  Such areas include:

  • Paediatrics – ABHR should be located with care near children

  • Mental Health – ABHR should be located with care near psychotic, schizophrenic or suicidal patients, patients undergoing alcohol- or drug-withdrawal, or where there are cognitively impaired patients

  • Public areas - ABHR needs placement in high traffic areas with clear signage regarding appropriate use and the need for parents to carefully supervise their children

  • Bracket design is important since ABHR placement may be affected if ABHR brackets are ill-fitting (e.g. varying sizes of bed rails can affect the efficacy of some ABHR brackets). Consider brackets that are removable, or product that can be removed from brackets easily in case short term patient demands warrant it. Also take into account bracket availability and installation costs, since these expenses can be substantial

Small personal bottles that HCWs carry with them may be more appropriate in the above areas.

The following ABHR placement locations are suggested:
  • On the end of every patient bed (fixed or removable brackets)
  • Affixed to mobile work trolleys (e.g. intravenous, drug and dressing trolleys)
  • High staff traffic areas (e.g. nurse’s station, pan room, medication room and patient room entrance)
  • Other multi-use patient-care areas, such as examination rooms and outpatient consultation rooms.
  • Entrance to each ward, outpatient clinic or Department
  • Public areas – e.g. waiting rooms, receptions areas, hospital foyers, near elevator doors in high traffic areas

A clear decision needs to be made about whose responsibility it will be to replace empty ABHR bottles. Workplace agreements or job descriptions may need to be changed to accommodate prompt replacement of these bottles (11).

There are a number of risks to patients and staff associated with the use of ABHR; however the benefits in terms of its use far outweigh the risks.  A risk assessment should be undertaken and a management plan put in place.  This particularly applies to clinical areas managing patients with alcohol use disorders, and patients at risk of self harm.

 

Paediatric Product Placement

ABHR can be placed in paediatric wards/facilities; however care should be taken in this decision. The placement of ABHR within NICU, SCN, maternity wards, and on cots should follow the HHA recommendations of product placement at point of care. The placement within general paediatric wards should remain within the point of care, except in situations of intellectual impairment or alcohol abuse where the child could unintentionally or intentionally harm themselves. Personal bottles of ABHR could be used in any area where ABHR cannot be placed at the point of care.

Recent research has shown increasing use of ABHRs in the home and community settings, which have corresponded with an increase in the number of calls to poison’s centres regarding children misusing the products. However, Miller et al in 2009 report that ABHRs appear relatively safe when misused by children under six years of age as the exposure invariably occurred as a brief ‘taste’ or accidental ocular or dermal exposure, resulting in little or no toxicity (63). This is supported by anecdotal evidence from Australian Poisons Centres.
 
Further research has shown that use of an ABHR by children in day care centres is safe. Even though children put their hands in their mouth or in contact with other mucous membranes directly after ABHR use, there was nil measurable alcohol detected by breathalyser in any of the children tested (64).