ABHR Placement for Improved HHC

Critical to the success of the program is having ABHR readily available to HCWs in their work area and near the patient, at the point of care (1). Dispensers act as a visual cue for HH 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 HHC independently of the type of product used, time of day, professional category and other confounders” (57).
 
The placement of ABHR can have a significant effect on the HHC of HCWs. In a study by Birnbach et al (73), medical staff had a HHC rate of 54% when the ABHR was in their line of sight on entering a patient’s room, compared to 11.5% when they couldn’t see the ABHR dispenser. When designing new healthcare facilities, consideration should be given to appropriate placement of ABHRs.
 
The placement of  dispensers next to sinks is strongly discouraged as this can cause confusion for some HCWs who may think they need to rinse their hands with water after using ABHR. 
 
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
  • 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 ABHR bottles. Workplace agreements or job descriptions may need to be changed to accommodate prompt replacement of these bottles (11). Never pour ABHR 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 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 (see HHA OH&S Risk Assessment).

Placement recommendations

  • The maximum size of an individual ABHR dispenser should not exceed 500mls (44-45)
  • No more than 80 individual ABHR 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 ABHR dispenser (43-45)
  • Dispensers should not project more than 15cm into corridor egress (41, 44-45)
  • Wall mounted brackets should be located at a height of between 92cms and 122 cm above the floor (avoid placing at eye level) (41-42)
  • Dispensers should not be located over carpeted areas, unless the area is protected by active sprinklers (43)
  • Dispensers should not be located over, or directly adjacent to ignition sources (e.g. electrical switches, power points, call buttons, or monitoring equipment) (41, 43-44)
  • ABHR dispensers should be separated from heat sources and electric motors (41, 44)
  • Dispensers should be installed according to manufacturer’s recommendations and to minimise leaks or spills (43)
  • Regular maintenance of dispensers and brackets should occur in accordance with manufacturer’s guidelines (43)
  • 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 (44)
  • ABHR 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 ABHR ingestion, eye splashes or allergic reactions

Clinical area placement considerations

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 (see below)
  • Mental Health – ABHR should be located with care near mentally ill 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 some of the above areas.

Paediatric Product Placement

ABHR can be placed in paediatric wards/facilities. 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, and recent publication from an American Poisons centre (72).
 
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).