Product Placement

Ensuring alcohol-based handrub is available at the "point-of-care" improves hand hygiene compliance.

Point-of-care: is the place where three elements come together:

  • The patient
  • The healthcare worker
  • The care or treatment involving contact with the patient

A hand hygiene product should be easily accessible, generally within arms reach of where patient care or treatment is taking place.

Products should be accessible without having the leave the patient zone.

Dispensers act as a visual cue for hand hygiene behaviour, and their strategic and ubiquitous placement makes the product highly accessible for frequent use. Placement of alcohol-based handrub 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 alcohol-based handrub 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”.

The placement of alcohol-based handrub can have a significant effect on the hand hygiene compliance of healthcare workers. In a study by Birnbach et al, medical staff had 54% hand hygiene compliance when alcohol-based handrub was in their line of sight on entering a patient’s room, compared to 11.5% when they couldn’t see the alcohol-based handrub dispenser. When designing new healthcare facilities, consideration should be given to appropriate placement of alcohol-based handrubs.

The placement of  dispensers next to sinks is strongly discouraged as this can cause confusion for some healthcare workers who may think they need to rinse their hands with water after using alcohol-based handrub. 

The following alcohol-based handrub 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
  • Entrances 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 alcohol-based handrub bottles. Workplace agreements or job descriptions may need to be changed to accommodate prompt replacement of these bottles. Never pour alcohol-based handrub from one bottle into another as this can cause contamination.

Safe ABHR Placement

There are a number of risks to patients and staff associated with the use of alcohol-based handrub; 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, see Generic ABHR OH&S Risk Assessment Form

Placement recommendations

  • The maximum size of an individual alcohol-based handrub dispenser should not exceed 500mls
  • No more than 80 individual alcohol-based handrub dispensers (each with a maximum capacity of 500ml) should be installed within a single smoke compartment
  • Corridors should have at least 1.8m wide with at least 150cm between each alcohol-based handrub dispenser
  • Dispensers should not project more than 15cm into corridor egress
  • Wall mounted brackets should be located at a height of between 92cms and 122 cm above the floor (avoid placing at eye level)
  • Dispensers should not be located over carpeted areas, unless the area is protected by active sprinklers
  • Dispensers should not be located over, or directly adjacent to ignition sources (e.g. electrical switches, power points, call buttons, or monitoring equipment)
  • Alcohol-based handrub dispensers should be separated from heat sources and electric motors
  • Dispensers should be installed according to manufacturer’s recommendations and to minimise leaks or spills
  • Regular maintenance of dispensers and brackets should occur in accordance with manufacturer’s guidelines
  • Product usage signs should be clearly visible and laminated
  • Regular monitoring of each area is recommended for misuse, or removal of product
  • Each facility should take adequate care regarding the placement of each dispenser so as to protect vulnerable populations, for example in psychiatric units, drug and alcohol units, paediatric units and units caring for cognitively impaired patients
  • Alcohol-based handrub bottles should be designed so as to minimise evaporation due to the volatile nature of alcohols
  • Site-specific instructions should be developed to manage adverse events, such as alcohol-based handrub ingestion, eye splashes or allergic reactions
  • Bracket design is important since alcohol-based handrub placement may be affected if alcohol-based handrub 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.

 

Clinical area placement considerations

Special consideration is necessary when locating alcohol-based handrub in clinical areas where ingestion or accidental splashing of alcohol-based handrub is a particular risk (accidental ingestion of alcohol-based handrub has been reported, but is uncommon). The placement of alcohol-based handrub needs to be aligned with the risk assessment of the individual patient, or patient population.

Such areas include:

  • Paediatrics – should be located with care near children (see below)
  • Mental Health – should be located with care near mentally ill patients, patients undergoing alcohol- or drug-withdrawal, or where there are cognitively impaired patients
  • Public areas - needs placement in high traffic areas with clear signage regarding appropriate use and the need for parents to carefully supervise their children

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

Paediatric Product Placement

ABHR can be placed in paediatric wards/facilities. The placement of alcohol-based handrub 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 alcohol-based handrub could be used in any area where alcohol-based handrub cannot be placed at the point of care.

Recent research has shown increasing use of alcohol-based handrubs 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 alcohol-based handrubs 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, and recent publication from an American Poisons centre.

Further research has shown that use of an alcohol-based handrub 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 alcohol-based handrub use, there was nil measurable alcohol detected by breathalyser in any of the children tested.