It’s in your hands-unintended consequences of a hand hygiene product change

Mrs Jacqueline Meyer1, Associate Professor Rhonda L Stuart1

1Monash Health, Clayton, Australia


Effective hand hygiene (HH) is an important measure in reducing hospital-acquired infections (HAI). However, inappropriate product use may have unintended adverse consequences.


When our new 64-bed neonatal intensive care unit (NICU) was opened, a change of alcohol-based hand rub product from a solution to a gel occurred. The thicker consistency of the gel-based product was aimed at decreasing staining and splashing on the new floors.

In the following 12 months the unit experienced a spike in coagulase negative staphylococcus (CoNS) line-associated blood stream infections. A bundle approach to reducing these infections was adopted, including addressing aseptic technique, and line management. Contemporaneously, increased staff reported hand irritation and skin damage to infection prevention (IP). To investigate, IP looked at the unit’s HH product use and performed a survey of hand health.


In a 7-month period, 19 line-related infections were reported, 16 involved CoNS.

Multiple HH products were identified in use and HH compliance was decreasing. 40-50% of survey respondents experienced hand peeling, cracking or flacking, with over 20% using an inappropriate product pre-procedure, and 50% dissatisfied with the current product available.

A change in HH product was introduced along with an increased focus around product use for moment 2 of HH. Following the intervention hand health improved and line related infections decreased.


Health services should be mindful that hand hygiene is important in decreasing HAI, however inappropriate HH may lead to poor hand health and increased risk of infection transmission. Education and vigilance is vital.


Infection control consultant at Monash Health since 2014.

With previous positions in both adult and paediatric Intensive Care, and a transfusion nurse consultant for Monash Health.

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