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A large-scale investigation of alcohol-based handrub (ABHR) volume: hand coverage correlations utilizing an innovative quantitative evaluation system

A large-scale investigation of alcohol-based handrub (ABHR) volume: hand coverage correlations... Background: Current hand hygiene guidelines do not provide recommendations on a specific volume for the clini- cal hand rubbing procedure. According to recent studies volume should be adjusted in order to achieve complete coverage. However, hand size is a parameter that highly influences the hand coverage quality when using alcohol- based handrubs (ABHR). The purpose of this study was to establish a quantitative correlation between applied ABHR volume and achieved hand coverage. Method: ABHR based hand hygiene events were evaluated utilizing a digital health device, the Semmelweis hand hygiene system with respect to coverage achieved on the skin surface. Medical students and surgical residents (N = 356) were randomly selected and given predetermined ABHR volumes. Additionally, hand sizes were calculated using specialized software developed for this purpose. Drying time, ABHR volume awareness, as well spillage aware- ness were documented for each hand hygiene event. Results: Hand coverage achieved during a hand hygiene event strongly depends on the applied ABHR volume. At a 1 ml dose, the uncovered hand area was approximately 7.10%, at 2 ml it decreased to 1.68%, and at 3 ml it further decreased to 1.02%. The achieved coverage is strongly correlated to hand size, nevertheless, a 3 ml applied volume proved sufficient for most hand hygiene events (84%). When applying a lower amount of ABHR (1.5 ml), even peo - ple with smaller hands failed to cover their entire hand surface. Furthermore, a 3 ml volume requires more than the guideline prescribed 20–30 s to dry. In addition, results suggest that drying time is not only affected by hand size, but perhaps other factors may be involved as well (e.g., skin temperature and degree of hydration). ABHR volumes of 3.5 ml or more were inefficient, as the disinfectant spilled while the additional rubbing time did not improve hand coverage. Conclusions: Hand sizes differ a lot among HCWs. After objectively measuring participants, the surface of the small- 2 2 est hand was just over half compared to the largest hand (259 cm and 498 cm , respectively). While a 3 ml ABHR vol- ume is reasonable for medium-size hands, the need for an optimized volume of handrub for each individual is critical, as it offers several advantages. Not only it can ensure adequate hand hygiene quality, but also prevent unnecessary costs. Bluntly increasing the volume also increases spillage and therefore waste of disinfectant in the case of smaller *Correspondence: haidegger@irob.uni-obuda.hu University Research and Innovation Centre (EKIK), Óbuda University, Budapest, Hungary Full list of author information is available at the end of the article © The Author(s) 2021. 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The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Voniatis et al. Antimicrob Resist Infect Control (2021) 10:49 Page 2 of 10 hands. In addition, adherence could potentially decrease due to the required longer drying time, therefore, adjusting the dosage according to hand size may also increase the overall hand hygiene compliance. Keywords: Quality assurance in hand hygiene, ABHR, Hand rubbing technique, Hand coverage, ABHR volume awareness Background issue seems insignificant, as logic dictates that a person Hand hygiene and hand rubbing are unequivocally the with larger hands would apply more disinfectant before first line of defense in patient safety and even social initiating the hand rubbing. However, a recent large-scale safety in a pandemic. Since the ground-breaking discov- study [5] summarizing more than 28 million recorded ery of Ignaz Semmelweis, hand hygiene protocols have hand hygiene events demonstrated how 86% of the hand been created, reassessed, reviewed, and rewritten [1]. In rubbing events only use one push of the disinfectant 2009 the World Health Organisation (WHO) initiated applying apparatus (pump), even if this one push resulted the “SAVE LIVES: Clean Your Hands” program, marking in only 0.75  ml. Furthermore, according to Bansaghi hand hygiene as the cornerstone of infection transmission et al. a clear decrease in volume per push is observed for prevention. Unfortunately, even today, hospital-acquired numerous disinfectant dispensers [11] further indicating infections (HAIs) are dominantly transmitted by hands the presence of a disinfectant application volume issue. [2]. Current research is primarily focused on synthesiz- Variance among institutions and departments is almost ing more effective disinfectant agents and investigating certainly present, as some studies document higher vol- healthcare worker compliance factors [3], however, some umes (3.3─3.4 ml) per hand hygiene event [12] while oth- recent studies have raised questions about whether we ers lower (1.4 ml) ones [13]. are neglecting crucial factors involved in hand rubbing, Consequently, a large population of health care work- and their implications on hand hygiene [4, 5]. A decade ers is: after the WHO Hand Hygiene Guideline, we now possess the technological resources [6] required to re-examine (a) consciously not applying enough disinfectant as and reassess factors, which had been neglected, either they are unable to reliably assess the applied vol- due to their complexity to be measured, or were deemed ume; insignificant and negligible. (b) unconsciously not applying as much disinfectant as In the worldwide-followed WHO guidelines [7, 8], the they think they are; instructions regarding the application of ABHR are clear (c) not applying enough disinfectant for their particu- and explicit: “Apply a palmful of the product in a cupped lar hand size. hand, follow the 6-step protocol for 20–30  s, and cover all hand surfaces.” Initially, it may seem inconsequential, Hand rubbing time or application time is another focus but the absence of an exact volume regarding the applied point concerning hand rubbing quality [14]. While the ABHR led to several issues regarding the clinical appli- WHO guidelines predicate a 20–30  s application time, cation of the guideline. The disinfectant volume does not some studies demonstrated that the 20–30  s application only determine hand coverage, but also application time time is not enough for a 3  ml applied volume to dry on (drying time). To attain the desired microbial reduction the hands [15–17], suggesting a 2 ml applied dosage. This on all hand surfaces, the disinfectant volume and applica- however, may pose drawbacks as a smaller volume could tion time are crucial. potentially result in the decrease of the total disinfected Goroncy-Bermes et  al. [9], demonstrated that an hand surface [17]. In other words, for a part of the HCW ABHR volume of 3  ml is required to obtain a sufficient population, the WHO proposed application time is only microbiological reduction. Surveying the literature, it is feasible when the applied volume is not sufficient to now evident that hand size is an overlooked parameter provide proper microbial reduction. Interestingly, other regarding optimised hand coverage during hand hygiene studies documented that an application time of 15  s is [4, 10]. Zingg et al. [4], although having some limitations, more than enough, and has no significant difference in concluded that for larger hands, even an ABHR volume efficacy [18–20]. of 3 ml might not entirely cover the entire hand surface. Combing in the results of the aforementioned stud- As written in the WHO guidelines, the term “palmful” ies confirms that important open issues still exist can only be considered to be a relative form of quanti- in present hand hygiene protocols, which should be fication, as Healthcare Workers (HCWs) cannot objec - addressed and ultimately solved, as they may have tively quantify the applied volume. At first glance, the serious implications, especially during a pandemic V oniatis et al. Antimicrob Resist Infect Control (2021) 10:49 Page 3 of 10 [21–23]. Proper hand hygiene is paramount to reduce Methods coronavirus transmission and HAI rates alike [22]. A multi-site, prospective randomized study was con- Strictly speaking, a microbial reduction can only ducted involving medical students, surgical residents be considered sufficient once a total hand coverage is and a digital tool for hand hygiene outcome evaluation. achieved, as non-disinfected areas can still transmit The Semmelweis hand hygiene system (HandInScan Zrt., pathogens, or re-contaminate already disinfected hand Debrecen, Hungary) is an innovative digital health tech- areas. In other words, a proper microbial reduction as nology solution that can be utilized to visualize hand seen in laboratory conditions (typically on inanimate coverage after a hand hygiene event. By employing a surfaces) may differ from the clinical setting. Typi- fluorescent handrub, the device can detect the covered cally, improperly disinfected or missed areas include (and theoretically disinfected) areas down to pixel level the fingertips, dorsum of the hands and wrists [24, 25]. resolution with artificial intelligence-based digital image Unfortunately, the information found in the literature processing [28]. The system provides an unprecedented regarding infection transmission models is limited and opportunity for HCWs to directly and immediately visu- no information was found regarding the significance ally observe and evaluate how effective their hand rub - of the size of non-disinfected hand areas. Neverthe- bing technique was (Fig. 1). less, increasing the disinfected hand area can decrease the transient flora, and therefore the infection trans- mission risks. While theoretically simple, defining an Hand coverage measurements exact application time (for a real-life clinical setting) is The participants in this study were 3rd-year medical stu - rather complicated. As a HCW starts the hand rubbing dents (N = 298) and surgical residents (N = 57). After a and the disinfectant is being spread, the disinfectant- brief, yet comprehensive course on hand hygiene theory, volume/area ratio (µl/cm ) is not constant. The ratio participants were assigned individual RFID (Radio Fre- changes during the hand rubbing process as the ABHR quency Identification) cards to record their individual is simultaneously being spread and absorbed while statistical data. Measurements involved giving partici- also evaporating. To further complicate the equa- pants predetermined, randomly assigned exact volumes tion, the evaporation rate is influenced by volume, (1, 1.5, 2, 2.5, 3, 3.5, or 4 ml). The volume range was deter - and chemical composition (e.g., alcohol concentra- mined based on that most professionals’ advice to use a tion) [16] therefore, this dynamic relationship can only 3 ml volume, while surveys found that in practice, smaller be estimated. In  vitro environment application time amounts were commonly used. An investigator using a (time required for the disinfectant to take effect and Dispensette S Analog-adjustable bottle-top dispenser reach the standardized microbial reduction) cannot (Brand GmbH, Germany) gave the participants the exact be identical with the practical in vivo application time (but undisclosed) volume to the centre of their dominant (contact time). In practical terms, and real-life clinical hand’s palm. After performing the hand hygiene event scenarios, application time (time until hand rubbing using a fluorescent dye containing ABHR solution, par - results in dry hands) depends on the applied disinfect- ticipants’ hands were assessed using the Semmelweis ant volume and specific chemical composition of the System. Measurements were performed under the direct handrub, which dominantly dictates the evaporation supervision of an investigator. All measurements were rate. performed with the Semmelweis Training Rub (Hand- The primary objective of this research is the compre- InScan Zrt.) a liquid ABHR containing 70% ethanol and hensive and accurate evaluation of the ABHR volume— a regulatory-wise insignificant amount (i.e., < 0.02%) of coverage area relationship. To our knowledge, no study fluorescent dye. Medical student hand hygiene perfor - of a similar scale exists. In addition, individual dry- mance was evaluated every second week (up to 5 occa- ing times, disinfectant spills and the subject’s ability sions) while residents were evaluated on a daily basis (up to assess volume were also investigated. Ultimately, to 10 occasions). an optimized ABHR volume in addition to a proper rubbing technique would ensure total hand cover- age, and consequently sufficient microbial reduction. Drying time measurements Furthermore, this would also decrease the long-term Drying time (start of hand rubbing until completely dried over-application of disinfectants, which can lead to hands) was measured using a stopwatch. Participants dermatological issues (e.g., skin irritation, contact der- were given a signal to initiate the WHO 6-step hand matitis) [26, 27] for the HCWs and increased costs to rubbing protocol. As soon as participants felt that their the hospitals and institutions. hands are dry, they indicated to the investigator, who recorded and documented the elapsed time in seconds. Voniatis et al. Antimicrob Resist Infect Control (2021) 10:49 Page 4 of 10 Fig. 1 Digital health technology measurement concept employing the Semmelweis hand hygiene system, on the user interface green indicates covered areas, red indicates non-covered areas while a numeric evaluation is additionally provided (Image by HandInScan Zrt.) Hand size determination statistical analysis, R Core Team: R: A Language and Hand size calculation is essential, as the applied ABHR Environment for Statistical Computing (R Foundation for volume/area quotient would be different among different Statistical Computing, Vienna, Austria R Version: 4 0.0 populations. After initial calibration, hand sizes were cal- Released: 2020. 04.24) was used. To concurrently inves- culated digitally by measuring the pixels of the scanned tigate the effect of the person’s experience (student or images [29]. Improperly recorded images were filtered resident), handrub volume, hand size and covered area, and excluded from the calculations. Good quality images a linear mixed-effect model was fitted on the data. The were used for hand size (hand surface area in  cm ) deter- logarithm of the missed area (%) as the outcome variable mination according to an already established Automated was explained by the handrub amount (ml), the hand size Area Assessment Method determined automatically by (cm ), the participant’s experience (student or resident) the Semmelweis System. In some cases, participants were and the interaction effect of handrub volume and hand asked to draw around the outline of their non-dominant size (specific hand coverage). The random intercept was hand on a sheet of paper. Subsequently, the drawings the individual error for participants. Compound sym- were used and hand sizes were also determined by a Digi- metry correlation structure for handrub amount and tal Outline Assessment Method as a control. The results different power variance structure for handrub at differ - using the two methods were compared to examine the ent participants was used to fit the final model. When precision of the Semmelweis System method. examining how handrub volume and hand size affect drying time, a generalized least square regression model was used. Finally, when investigating possible correla- ABHR spill and volume awareness tion between volume awareness (Table  1 Question 2) Both the medical students and the surgical residents were and hand coverage, a chi square test was performed. The given two questions to answer directly before the evalua- questionnaire’s answers (predictor values) and the cov- tion with the Semmelweis System. Important to note that erage results (expected values) were regarded as binary all measurements were performed as blinded studies. Neither the medical students, nor the surgical residents were informed about the exact volume they received dur- Table 1 Hand hygiene event questionnaire completed by all ing the measurements. participants Question Possible answers Statistical analysis Did the disinfectant spill from your Yes/No/I don’t know Where applicable, a statistical analysis of the results was hand during the rubbing? performed. According to the predictor and outcome How did you find the disinfectant Not enough/Just right/Too much variables, different statistical tests were chosen. For the volume? V oniatis et al. Antimicrob Resist Infect Control (2021) 10:49 Page 5 of 10 parameters (Not enough = 0, Just right, Too much = 1, Palm Dorsum while Coverage < 95% = 0, Coverage > 95% = 1). Through - out the analysis, results were designated as significant when p < 0.05. Average missed All area parcipants 0% Results Disinfectant coverage results 2% The assessment methodology proved to be simple and 4% straightforward. The majority of the participants readily 6% understood the concept, and adhered to the measuring 1 ml 8% parameters. After the hand assessment events, 50 meas- handrub 10% urements were filtered and removed due to faulty meas - 12% urements or software-generated artefacts. All events 14% are plotted in Fig.  2, where a direct correlation between 16% disinfectant volume and hand coverage can be observed 18% as increasing the volume results in smaller missed areas. 3 ml The final number of examined hand hygiene events was handrub 42% 1622. The non-covered areas fell to less than 1% only with a dose of 3.5  ml or higher. Interestingly, not everyone Fig. 3 Typically missed areas during the hand hygiene events. covered their hands perfectly (100%) even with a 4  ml (ALL—N = 1557, 1.5 ml—N = 153, 3 ml—N = 724) dose. Noteworthy to mention that when comparing the standardized volumes of 1.5 and 3 ml, it is apparent that half the volume equals less than half of the coverage, thus thumb and the dorsum of the hand. The correlation of volume is not linearly proportional to coverage. volumes and missed areas is exhibited in Fig. 3. Missed areas vary according to the applied ABHR vol ume. Typically missed areas included the fingertips, the Hand size determination Digital hand size assessment results can be observed in Fig.  4. To be as objective as possible for the disinfectant coverage measurements, hand size was calculated by the 8% 7.10% Automated Area Assessment (AAA) method for every single hand hygiene event. Individual hand size values 6% (from the same participant) were then averaged. Results exhibit a bimodal distribution. Comparing the currently 3.85% 4% utilized (Automated Area Assessment) method with a manually determined method (Digital Outline Assess- 1.68% ment) results are almost identical (differences measuring 2% 1.22% 1.02% 0.52% 0.39% 0% 11.5 22.5 33.5 4 35 Male Volume of applied handrub (ml) Female Summarized Le� dorsum Right dorsum Le�p alm Rightpalm 8.4% 3.7% 4.7% 11.3% Uncoveredhandsurface: 7.0% Hand surface(cm ) Fig. 2 a Hand coverage (percent of the total hand surface missed during hand hygiene event). b Example of the computed outcome: Fig. 4 Hand size calculation results, provided by the Semmelweis missed areas at 7% uncovered surface System’s software (automated area assessment method) Uncovered hand surface Ss ample ize <260 260–270 270–280 280–290 290–300 300–310 310–320 320–330 330–340 340–350 350–360 360–370 370–380 380–390 390–400 400–410 410–420 420–430 430–440 440–450 450–460 460–470 470–480 480–490 >490 Voniatis et al. Antimicrob Resist Infect Control (2021) 10:49 Page 6 of 10 8% 7% 6% rd 3 grade medical 5% students 4% Surgical 3% residents 2% 200 1% <2 2–2.52.5–3 3–3.53.5–4 4–4.5>4.5 100 1:1 rao Applied handrub (μl/cm ) Linear trendline Fig. 6 Specific Hand Coverage in the case of 3rd grade medical (y=0.82x+51.2) 0 students, who recently learned proper hand disinfection technique, 0100 200300 400500 and surgical residents, who have several years of experience. Applying enough ABHR, medical students reached similar results as Hand size determined by Automated Area 2 surgical residents. When suboptimal volumes were used experience Assessment method (cm ) had indeed an impact Fig. 5 Comparing the two different hand size determination methods. Note: Average hand size difference between the two methods was 10.1% Drying time Drying time results confirm that by increasing the dis - 10%) (Fig. 5) confirming therefore that software provided infectant volume, the application time (drying time) machine-based automated hand size calculations can be increases as well. At a 3 ml volume, a plateau is reached considered reliable. Interesting to note that the differ - in the mean values (Fig.  8). Important to note that these ences between the two methods were documented when results concern an ABHR with a 70% ethanol concentra- larger hands were assessed. Inaccuracies in the digital tion, differences, may be observed using other products. outline assessment method, most likely resulted by the Furthermore, the resulted relatively wide variances indi- experimental settings, i.e., participants were asked to cate that (apart from hand size) other intrinsic or extrin- draw around their hands, and not all participants put the sic factors can potentially influence drying times as well. same effort resulting in significantly lower precision. Disinfectant spill and volume awareness The increase in the applied ABHR volume (while being Specific hand coverage (μl/cm ) undisclosed) was generally consciously detected among In order to objectively assess the effect of ABHR volume the participants. However, it was clearly shown that par- on hand coverage, specific hand coverage was deter - ticipants cannot precisely assess the given volumes, as mined to calculate the disinfectant volume per hand sur- even with a 3  ml dose (on average-sized hands resulting face area ratio. According to our results, the average total hand size area was 372.9 cm while the median hand size was 370.2 cm . When 3 ml of handrub is distributed on a pair of on average-sized hands (372.9 cm each) it equals 2 100% a 4.02  μl/cm specific hand coverage. In Fig.  6, it can be 90% seen that surgical residents performed considerably bet- 80% ter than 3rd-year medical students. Thus, if a 4.02  μl/ 70% cm is regarded as sufficient for an average hand, the 3 ml Hand surface 60% (cm ) volume seems to be a valid approximation as to what a 50% 40% <340 medium hand-sized person should apply. 30% 340–380 Regarding hand size and applied disinfectant cover- 20% age, Fig.  7 visually demonstrates how at a smaller dose 380–420 10% the difference between covered areas due to hand sizes >420 0% becomes evident. As the volume of the applied disinfect- 11.5 22.5 33.5 4 ant increases, the gap between the hand sizes decreases. Volume of applied handub (ml) Fig. 7 Hand size (hand surface)—uncovered area correlation measurements Hand size determined by Digital Outline Assessment method (cm ) Ro ate f appropiate Nd ot cd overe he an surfac hand hs ygiene event V oniatis et al. Antimicrob Resist Infect Control (2021) 10:49 Page 7 of 10 Did the handrub drop off yourhand? a 80 100% 80% 60% 40  Yes 40% I'm not sure 20% No 0% 0 0.51 1.52 2.53 3.54 <2 2–2.52.5–3 3–3.53.5–4 4–4.5>4.5 1 1.5 22.5 33.5 4 11.5 22.5 33.5 4 Applied handrub (μl/cm ) Handrub (ml) Fig. 10 Handrub spillage results (Handrub spillage refers to the ABHR spillage during a hand hygiene event). Note: 1.5 ml and 3 ml ABHR volumes on an average sized hand resulted in 2.51 and 4.01 μl/cm , respectively same disinfectant-volume/area ratio values the partici- pants felt that the given volume was not enough and yet the disinfectant was dripping from their hands. A further remark is that investigators reported, that although some participants did not report dripping, some spill was still observed. Arguably, dripping can occur without the par- Handrub (μl/cm ) ticipants noticing it therefore, the actual results are prob- Fig. 8 Results of drying time measurements. a Drying time and volume correlation without taking hand size into consideration ably an underestimation compared to the questionnaire. b Drying time and Specific Hand Coverage correlation (hand size taken into consideration). Note: WHO guidelines mention that hand Statistical analysis results rubbing should take 20–30 s, while the typically prescribed 2.5–3 ml ABHR volume requires longer time to dry According to the data analysis, the handrub volume (p < 0.0001), hand size (p < 0.0001), and participant’s experience (medical student or surgical resident) (p = 0.003) have a significant effect on the non-covered The amount of handrub felt... area. In addition, the disinfectant volume/hand size ratio 100% also has a significant effect on the size of the missed area (p = 0.0339). Regarding drying times disinfectant volume 80% More is a significant factor (p < 0.0001), while hand size is not than 60% enough (p = 0.083). Finally, participant volume awareness seems 40%  Just right to correlate with achieving the predetermined (> 95%) hand coverage (p = 0.034). Not 20% enough 0% <2 2–2.52.5–3 3–3.53.5–4 4–4.5>4.5 Discussion Applied handrub (μl/cm ) This is the first objective, digital health technology sup - Fig. 9 Volume awareness results ( Volume awareness refers to the ported, large-scale investigation regarding disinfectant ability of the participants to assess the ABHR volume given to them). volume and hand coverage correlations. Unlike several Note: 1.5 ml and 3 ml ABHR volumes on an average sized hand result other studies where the observer or examiner calculated in 4.02 and 2.51 μl/cm or evaluated the disinfectant-covered areas manually, during our investigation evaluations were all performed using an objective computerised and automated elec in a 4.02  µl/cm specific hand coverage) a significant tronic system [6]. number of students (more than 30%) (Fig.  9) felt that Comparing the performance of medical students and the given ABHR volume was not enough. It is also evi- surgical residents it is clear that experience and proce- dent that increasing the volume of the applied disinfect- dural memory are key to perfect the hand rubbing tech- ant increases the hand rubbing volume losses during nique and hand hygiene protocol (Fig. 5). Nevertheless, a the WHO 6-step protocol (Fig.  10). Interestingly, at the perfect score (0% missed areas) was rarely achieved. An R( esponses %) D rying me (sec) D rying me (sec) R( esponses %) Voniatis et al. Antimicrob Resist Infect Control (2021) 10:49 Page 8 of 10 important condition was that measurements occurred individual is seemingly the best option [10] as just plainly always under the direct supervision of an investigator. increasing the volume also increases spillage and there- u Th s, the overall performance is significantly (yet uni - fore a waste of disinfectant in the case of smaller hands. formly) influenced by the Hawthorne effect. In a real- Apart from the material (and therefore financial) waste, world clinical setting, the performance should be worse the findings of Greenaway et al. and others [18, 30] sug- not only due to less attention being given to the WHO gest that compliance also decreases with higher applied 6-step protocol but due to the often decreased applied volumes (due to longer application time). According to disinfectant volume as well [11]. our results, applied ABHR volumes are relative to the Regarding disinfectant volume and hand coverage cor- same volume for small-handed people the volume feels relations, our results indicate that a volume of 1.5  ml is excessive while for large-handed ones feel just right. inadequate as it leaves on average 4% of the total hand Therefore, adjusting the dosage according to hand size surface bare of disinfectant. As Goroncy-Bermes et  al. could also increase the overall compliance with the pro- [9] suggested, a volume of 3 ml seems rather appropriate tocol. In addition to an optimized volume, simplifying as according to our findings the missed area falls under the hand hygiene steps could also decrease the spillage 1%. While increasing the disinfectant dose to 3, 3.5 and while also increasing compliance [31]. 4 ml decreases the missed area to approximately 1%, 0.7% and 0.5%, respectively, and the average drying time for Limitation of the study these volumes was well above the recommended 20─30 s Due to the natural distribution among a popula- according to the current WHO guideline, which may put tion, larger and smaller handed people are fewer than unnecessary load on the HCWs during clinical practice. medium-size handed people therefore the number of Our results concur with the results of Macinga et al. and recorded measurements per hand size is not truly equal. Suchomel et al. [14, 16] who also documented increased Therefore, the volume of the disinfectant spill (while drying times. A drying time of 20 s was uncommon even probably different for the two populations) was not quan - in the cases of 1  ml applied volumes. Contradictions in tified and was additionally overshadowed by the aver - the literature exist as Paula et  al. findings [19] demon - age values. Consequently, the actually applied volume strate how hand wettability is statistically equal after a (actual volume = given volume − spillage) was different 15 or 30 s application time. However, as they stated their for the two hand sized populations. In addition, the effect results may have been obscured due to the small popu- of alcohol type and concentration was not investigated lation they examined (N = 20), the effect of the continu - in this study, only a 70% ethanol containing handrub ous training, or that hand size was not used to normalize was tested. Handrubs with different alcohol concentra - results among participants. Further investigating the tions can have different characteristics. Finally, medical results, it can be seen that drying times even when made students and surgical residents participated in the study independent from hand size demonstrate a large vari- thus intermediate experience level was not investigated. ance. This suggests that other intrinsic factors are influ - encing the results (e.g., skin temperature, skin hydration). Furthermore, application time and microbiological Conclusions reduction should be re-examined as controversy still According to our results, the covered area during a hand exists in the current research. For example, Pires et al. or hygiene event strongly depends on the applied ABHR Harnoss et  al. [18] investigated the application time and volume. At small volumes (i.e., 1–1.5  ml), the covered bacterial reduction relationship. Their results suggest area deficit is more evident, as people with larger hands that no significant difference was found between 15 and fail to cover the entire hand surface. A 3 ml applied vol- 30 s application time. Their studies included a rather lim - ume is sufficient for medium size hands to achieve full ited and probably experienced study population (N = 32 coverage, however, this volume requires more than the and 14 respectively), whilst no hand size measurements instructed 20–30  s to be thoroughly applied. In addi- were taken into consideration, and only the microbiologi- tion, this volume can be insufficient for larger hands, but cal sampling on fingertips was performed. wasteful for smaller ones as not only the disinfectant loss When incorporating hand size in the evaluations, our (spillage) will increase. Notably, the additional rubbing results demonstrate how hand size does matter. 1.5  ml (drying) time is disadvantageous, since hand coverage of disinfectant is clearly not sufficient for larger hands. will not increase. The optimal applied ABHR volume is At 3  ml volume, smaller and larger handed participants therefore relative. The implementation of an optimised, achieved almost the same percentage of disinfected areas. clinical set, hand size depended protocol would ben- As results show, 3  ml is a good approximation for efit future hand hygiene guidelines, as it would not only medium size hands yet an optimized volume for each increase the speed and efficiency of hand hygiene events, V oniatis et al. Antimicrob Resist Infect Control (2021) 10:49 Page 9 of 10 5. Kenters N, Eikelenboom-Boskamp A, Hines J, McGeer A, Huijskens EGW, but also improve compliance and adherence rates while Voss A. Product dose considerations for real-world hand sanitiser effi- keeping the disinfectant wastes and costs to a minimum. cacy. Am J Infect Control. 2020;48(5):503–6. https ://doi.org/10.1016/j. ajic.2019.12.001. 6. Lehotsky A, Szilágyi L, Bánsághi S, Szerémy P, Wéber G, Haidegger Abbreviations T. Towards objective hand hygiene technique assessment: valida- ABHR: alcohol-based handrub; HCW: healthcare workers; WHO: World Health tion of the ultraviolet-dye-based hand-rubbing quality assessment Organization. procedure. J Hosp Infect. 2017;97(1):26–9. https ://doi.org/10.1016/j. jhin.2017.05.022. Acknowledgements 7. Pittet D, Allegranzi B, Boyce J. The World Health Organization Guide- The authors would like to give thanks to all the participants contributing lines on hand hygiene in health care and their consensus recommen- to the study. Special thanks to Lilla Gorbay Nagy for her assistance in the dations. Infect Control Hosp Epidemiol. 2009;30(7):611–22. https ://doi. measurements and Daniel Sandor Veres for his guidance in the statistical org/10.1086/60037 9. analysis. We are also grateful to the employees of the “George Berci” Surgical 8. Tarka P, Gutkowska K, Nitsch-Osuch A. Assessment of tolerability Research and Training Laboratory, and the Department of Surgery of Sem- and acceptability of an alcohol-based hand rub according to a WHO melweis University. We would also like to thank HandInScan Zrt. For providing protocol and using apparatus tests. Antimicrob Resist Infect Control. us the Semmelweis System for the study. T. Haidegger is a Bolyai fellow of the 2019;8(1):1–8. https ://doi.org/10.1186/s1375 6-019-0646-8. Hungarian Academy of Sciences. 9. Goroncy-Bermes P, Koburger T, Meyer B. Impact of the amount of hand rub applied in hygienic hand disinfection on the reduction of Authors’ contributions microbial counts on hands. J Hosp Infect. 2010;74(3):212–8. https ://doi. CV, SB, and TH contributed to the study design. Data collection was carried org/10.1016/j.jhin.2009.09.018. out by CV and SB. Data analysis was carried out by SB. Project supervision was 10. Bellissimo-Rodrigues F, Soule H, Gayet-Ageron A, Martin Y, Pittet D. provided by FA and TH. All authors read and approved the final manuscript. Should alcohol-based handrub use be customized to healthcare work- ers’ hand size? Infect Control Hosp Epidemiol. 2016;37(2):219–21. https Funding ://doi.org/10.1017/ice.2015.271. CV is supported by the ÚNKP-20-3-II-SE-29, and SB is supported by the ÚNKP- 11. Bánsághi S, Soule H, Guitart C, Pittet D, Haidegger T. Critical reliability 20-3-II-SE-24 New National Excellence Program of the Ministry for Innovation issues of common type alcohol-based handrub dispensers. Antimicrob and Technology from the source of the National Research, Development and Resist Infect Control. 2020;9(1):90. https ://doi.org/10.1186/s1375 6-020- Innovation Fund. 00735 -4. 12. Kramer A, Pittet D, Klasinc R, et al. Shortening the application time of Availability of data and materials alcohol-based hand rubs to 15 seconds may improve the frequency The datasets used and/or analysed during the current study are available from of hand antisepsis actions in a neonatal intensive care unit. Infect the corresponding author on reasonable request. Control Hosp Epidemiol. 2017;38(12):1430–4. https ://doi.org/10.1017/ ice.2017.217. Ethics approval and consent to participate 13. ICPIC Proceedings. Abstracts from the 5th international conference on Not applicable. prevention and infection control (ICPIC 2019). Antimicrob Resist Infect Control. 2019;8(S1):1–201. https ://doi.org/10.1186/s1375 6-019-0567-6. Consent for publication 14. Suchomel M, Leslie RA, Parker AE, Macinga DR. How long is enough? Not applicable. Identification of product dry-time as a primary driver of alcohol-based hand rub efficacy. Antimicrob Resist Infect Control. 2018;7(1):1–6. https :// Competing interests doi.org/10.1186/s1375 6-018-0357-6. TH is founder of HandInScan Zrt., manufacturer of the Semmelweis System. SB 15. Kampf G, Marschall S, Eggerstedt S, Ostermeyer C. Efficacy of ethanol- is employee of HandInScan Zrt. based hand foams using clinically relevant amounts: a cross-over controlled study among healthy volunteers. BMC Infect Dis. 2010. https :// Author details doi.org/10.1186/1471-2334-10-78. Laboratory of Nanochemistry, Department of Biophysics and Radiation 16. Macinga DR, Shumaker DJ, Werner HP, et al. The relative influences of Biology, Semmelweis University, Budapest, Hungary. Department of Surgi- product volume, delivery format and alcohol concentration on dry-time cal Research and Techniques, Semmelweis University, Budapest, Hungary. and efficacy of alcohol-based hand rubs. BMC Infect Dis. 2014;14(1):1–8. Department of Epidemiology, Semmelweis University, Budapest, Hun- https ://doi.org/10.1186/1471-2334-14-511. gary. University Research and Innovation Centre (EKIK), Óbuda University, 17. Wilkinson MAC, Ormandy K, Bradley CR, Fraise AP, Hines J. Dose consid- Budapest, Hungary. Austrian Center for Medical Innovation and Technology erations for alcohol-based hand rubs. J Hosp Infect. 2017;95(2):175–82. (ACMIT ), Wiener Neustadt, Austria. https ://doi.org/10.1016/j.jhin.2016.12.023. 18. Harnoss JC, Dancer SJ, Kaden CF, et al. Hand antisepsis without decreas- Received: 10 December 2020 Accepted: 26 February 2021 ing efficacy by shortening the rub-in time of alcohol-based handrubs to 15 seconds. J Hosp Infect. 2020;104(4):419–24. https ://doi.org/10.1016/j. jhin.2019.09.004. 19. Paula H, Becker R, Assadian O, Heidecke CD, Kramer A. Wettability of hands during 15-second and 30-second handrub time intervals: References a prospective, randomized crossover study. Am J Infect Control. 1. 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Suen LKP, Wong JWS, Lo KYK, Lai TKH. The use of hand scanner to standardized measurement technique. In: CINTI 2020, 20th IEEE interna- enhance hand hygiene practice among nursing students: a single- tional symposium on computational intelligence and informatics. 2020. blinded feasibility study. Nurse Educ Today. 2018;2019(76):137–47. https https ://doi.org/10.1109/CINTI 51262 .2020.93058 30. ://doi.org/10.1016/j.nedt.2019.01.013. 30. Greenaway RE, Ormandy K, Fellows C, Hollowood T. Impact of hand sani- 25. Lehotsky Á, Morvai J, Szilágyi L, Bánsághi S, Benkó A, Haidegger T. Hand tizer format (gel/foam/liquid) and dose amount on its sensory properties hygiene technique assessment using electronic equipment in 26 Hun- and acceptability for improving hand hygiene compliance. J Hosp Infect. garian healthcare institutes. Orv Hetil. 2017;158(29):1143–8. https ://doi. 2018;100(2):195–201. https ://doi.org/10.1016/j.jhin.2018.07.011. org/10.1556/650.2017.30792 . 31. Tschudin-Sutter S, Sepulcri D, Dangel M, Ulrich A, Frei R, Widmer AF. Sim- 26. García-Gavín J, Lissens R, Timmermans A, Goossens A. Allergic contact plifying the World Health Organization Protocol: 3 steps versus 6 steps dermatitis caused by isopropyl alcohol: a missed allergen? Contact Der- for performance of hand hygiene in a cluster-randomized trial. Clin Infect matitis. 2011;65(2):101–6. https ://doi.org/10.1111/j.1600-0536.2011.01936 Dis. 2019;69(4):614–20. https ://doi.org/10.1093/cid/ciy94 8. .x. 27. Birnbach DJ, Mckenty NT, Rosen LF, Arheart KL, Everett-Thomas R, Lindsey Publisher’s Note SF. Does adherence to world health organization hand hygiene protocols Springer Nature remains neutral with regard to jurisdictional claims in pub- in the operating room have the potential to produce irritant contact lished maps and institutional affiliations. dermatitis in anesthesia providers? Anesth Analg. 2019;129(6):E182–4. https ://doi.org/10.1213/ANE.00000 00000 00411 2. 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A large-scale investigation of alcohol-based handrub (ABHR) volume: hand coverage correlations utilizing an innovative quantitative evaluation system

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Abstract

Background: Current hand hygiene guidelines do not provide recommendations on a specific volume for the clini- cal hand rubbing procedure. According to recent studies volume should be adjusted in order to achieve complete coverage. However, hand size is a parameter that highly influences the hand coverage quality when using alcohol- based handrubs (ABHR). The purpose of this study was to establish a quantitative correlation between applied ABHR volume and achieved hand coverage. Method: ABHR based hand hygiene events were evaluated utilizing a digital health device, the Semmelweis hand hygiene system with respect to coverage achieved on the skin surface. Medical students and surgical residents (N = 356) were randomly selected and given predetermined ABHR volumes. Additionally, hand sizes were calculated using specialized software developed for this purpose. Drying time, ABHR volume awareness, as well spillage aware- ness were documented for each hand hygiene event. Results: Hand coverage achieved during a hand hygiene event strongly depends on the applied ABHR volume. At a 1 ml dose, the uncovered hand area was approximately 7.10%, at 2 ml it decreased to 1.68%, and at 3 ml it further decreased to 1.02%. The achieved coverage is strongly correlated to hand size, nevertheless, a 3 ml applied volume proved sufficient for most hand hygiene events (84%). When applying a lower amount of ABHR (1.5 ml), even peo - ple with smaller hands failed to cover their entire hand surface. Furthermore, a 3 ml volume requires more than the guideline prescribed 20–30 s to dry. In addition, results suggest that drying time is not only affected by hand size, but perhaps other factors may be involved as well (e.g., skin temperature and degree of hydration). ABHR volumes of 3.5 ml or more were inefficient, as the disinfectant spilled while the additional rubbing time did not improve hand coverage. Conclusions: Hand sizes differ a lot among HCWs. After objectively measuring participants, the surface of the small- 2 2 est hand was just over half compared to the largest hand (259 cm and 498 cm , respectively). While a 3 ml ABHR vol- ume is reasonable for medium-size hands, the need for an optimized volume of handrub for each individual is critical, as it offers several advantages. Not only it can ensure adequate hand hygiene quality, but also prevent unnecessary costs. Bluntly increasing the volume also increases spillage and therefore waste of disinfectant in the case of smaller *Correspondence: haidegger@irob.uni-obuda.hu University Research and Innovation Centre (EKIK), Óbuda University, Budapest, Hungary Full list of author information is available at the end of the article © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Voniatis et al. Antimicrob Resist Infect Control (2021) 10:49 Page 2 of 10 hands. In addition, adherence could potentially decrease due to the required longer drying time, therefore, adjusting the dosage according to hand size may also increase the overall hand hygiene compliance. Keywords: Quality assurance in hand hygiene, ABHR, Hand rubbing technique, Hand coverage, ABHR volume awareness Background issue seems insignificant, as logic dictates that a person Hand hygiene and hand rubbing are unequivocally the with larger hands would apply more disinfectant before first line of defense in patient safety and even social initiating the hand rubbing. However, a recent large-scale safety in a pandemic. Since the ground-breaking discov- study [5] summarizing more than 28 million recorded ery of Ignaz Semmelweis, hand hygiene protocols have hand hygiene events demonstrated how 86% of the hand been created, reassessed, reviewed, and rewritten [1]. In rubbing events only use one push of the disinfectant 2009 the World Health Organisation (WHO) initiated applying apparatus (pump), even if this one push resulted the “SAVE LIVES: Clean Your Hands” program, marking in only 0.75  ml. Furthermore, according to Bansaghi hand hygiene as the cornerstone of infection transmission et al. a clear decrease in volume per push is observed for prevention. Unfortunately, even today, hospital-acquired numerous disinfectant dispensers [11] further indicating infections (HAIs) are dominantly transmitted by hands the presence of a disinfectant application volume issue. [2]. Current research is primarily focused on synthesiz- Variance among institutions and departments is almost ing more effective disinfectant agents and investigating certainly present, as some studies document higher vol- healthcare worker compliance factors [3], however, some umes (3.3─3.4 ml) per hand hygiene event [12] while oth- recent studies have raised questions about whether we ers lower (1.4 ml) ones [13]. are neglecting crucial factors involved in hand rubbing, Consequently, a large population of health care work- and their implications on hand hygiene [4, 5]. A decade ers is: after the WHO Hand Hygiene Guideline, we now possess the technological resources [6] required to re-examine (a) consciously not applying enough disinfectant as and reassess factors, which had been neglected, either they are unable to reliably assess the applied vol- due to their complexity to be measured, or were deemed ume; insignificant and negligible. (b) unconsciously not applying as much disinfectant as In the worldwide-followed WHO guidelines [7, 8], the they think they are; instructions regarding the application of ABHR are clear (c) not applying enough disinfectant for their particu- and explicit: “Apply a palmful of the product in a cupped lar hand size. hand, follow the 6-step protocol for 20–30  s, and cover all hand surfaces.” Initially, it may seem inconsequential, Hand rubbing time or application time is another focus but the absence of an exact volume regarding the applied point concerning hand rubbing quality [14]. While the ABHR led to several issues regarding the clinical appli- WHO guidelines predicate a 20–30  s application time, cation of the guideline. The disinfectant volume does not some studies demonstrated that the 20–30  s application only determine hand coverage, but also application time time is not enough for a 3  ml applied volume to dry on (drying time). To attain the desired microbial reduction the hands [15–17], suggesting a 2 ml applied dosage. This on all hand surfaces, the disinfectant volume and applica- however, may pose drawbacks as a smaller volume could tion time are crucial. potentially result in the decrease of the total disinfected Goroncy-Bermes et  al. [9], demonstrated that an hand surface [17]. In other words, for a part of the HCW ABHR volume of 3  ml is required to obtain a sufficient population, the WHO proposed application time is only microbiological reduction. Surveying the literature, it is feasible when the applied volume is not sufficient to now evident that hand size is an overlooked parameter provide proper microbial reduction. Interestingly, other regarding optimised hand coverage during hand hygiene studies documented that an application time of 15  s is [4, 10]. Zingg et al. [4], although having some limitations, more than enough, and has no significant difference in concluded that for larger hands, even an ABHR volume efficacy [18–20]. of 3 ml might not entirely cover the entire hand surface. Combing in the results of the aforementioned stud- As written in the WHO guidelines, the term “palmful” ies confirms that important open issues still exist can only be considered to be a relative form of quanti- in present hand hygiene protocols, which should be fication, as Healthcare Workers (HCWs) cannot objec - addressed and ultimately solved, as they may have tively quantify the applied volume. At first glance, the serious implications, especially during a pandemic V oniatis et al. Antimicrob Resist Infect Control (2021) 10:49 Page 3 of 10 [21–23]. Proper hand hygiene is paramount to reduce Methods coronavirus transmission and HAI rates alike [22]. A multi-site, prospective randomized study was con- Strictly speaking, a microbial reduction can only ducted involving medical students, surgical residents be considered sufficient once a total hand coverage is and a digital tool for hand hygiene outcome evaluation. achieved, as non-disinfected areas can still transmit The Semmelweis hand hygiene system (HandInScan Zrt., pathogens, or re-contaminate already disinfected hand Debrecen, Hungary) is an innovative digital health tech- areas. In other words, a proper microbial reduction as nology solution that can be utilized to visualize hand seen in laboratory conditions (typically on inanimate coverage after a hand hygiene event. By employing a surfaces) may differ from the clinical setting. Typi- fluorescent handrub, the device can detect the covered cally, improperly disinfected or missed areas include (and theoretically disinfected) areas down to pixel level the fingertips, dorsum of the hands and wrists [24, 25]. resolution with artificial intelligence-based digital image Unfortunately, the information found in the literature processing [28]. The system provides an unprecedented regarding infection transmission models is limited and opportunity for HCWs to directly and immediately visu- no information was found regarding the significance ally observe and evaluate how effective their hand rub - of the size of non-disinfected hand areas. Neverthe- bing technique was (Fig. 1). less, increasing the disinfected hand area can decrease the transient flora, and therefore the infection trans- mission risks. While theoretically simple, defining an Hand coverage measurements exact application time (for a real-life clinical setting) is The participants in this study were 3rd-year medical stu - rather complicated. As a HCW starts the hand rubbing dents (N = 298) and surgical residents (N = 57). After a and the disinfectant is being spread, the disinfectant- brief, yet comprehensive course on hand hygiene theory, volume/area ratio (µl/cm ) is not constant. The ratio participants were assigned individual RFID (Radio Fre- changes during the hand rubbing process as the ABHR quency Identification) cards to record their individual is simultaneously being spread and absorbed while statistical data. Measurements involved giving partici- also evaporating. To further complicate the equa- pants predetermined, randomly assigned exact volumes tion, the evaporation rate is influenced by volume, (1, 1.5, 2, 2.5, 3, 3.5, or 4 ml). The volume range was deter - and chemical composition (e.g., alcohol concentra- mined based on that most professionals’ advice to use a tion) [16] therefore, this dynamic relationship can only 3 ml volume, while surveys found that in practice, smaller be estimated. In  vitro environment application time amounts were commonly used. An investigator using a (time required for the disinfectant to take effect and Dispensette S Analog-adjustable bottle-top dispenser reach the standardized microbial reduction) cannot (Brand GmbH, Germany) gave the participants the exact be identical with the practical in vivo application time (but undisclosed) volume to the centre of their dominant (contact time). In practical terms, and real-life clinical hand’s palm. After performing the hand hygiene event scenarios, application time (time until hand rubbing using a fluorescent dye containing ABHR solution, par - results in dry hands) depends on the applied disinfect- ticipants’ hands were assessed using the Semmelweis ant volume and specific chemical composition of the System. Measurements were performed under the direct handrub, which dominantly dictates the evaporation supervision of an investigator. All measurements were rate. performed with the Semmelweis Training Rub (Hand- The primary objective of this research is the compre- InScan Zrt.) a liquid ABHR containing 70% ethanol and hensive and accurate evaluation of the ABHR volume— a regulatory-wise insignificant amount (i.e., < 0.02%) of coverage area relationship. To our knowledge, no study fluorescent dye. Medical student hand hygiene perfor - of a similar scale exists. In addition, individual dry- mance was evaluated every second week (up to 5 occa- ing times, disinfectant spills and the subject’s ability sions) while residents were evaluated on a daily basis (up to assess volume were also investigated. Ultimately, to 10 occasions). an optimized ABHR volume in addition to a proper rubbing technique would ensure total hand cover- age, and consequently sufficient microbial reduction. Drying time measurements Furthermore, this would also decrease the long-term Drying time (start of hand rubbing until completely dried over-application of disinfectants, which can lead to hands) was measured using a stopwatch. Participants dermatological issues (e.g., skin irritation, contact der- were given a signal to initiate the WHO 6-step hand matitis) [26, 27] for the HCWs and increased costs to rubbing protocol. As soon as participants felt that their the hospitals and institutions. hands are dry, they indicated to the investigator, who recorded and documented the elapsed time in seconds. Voniatis et al. Antimicrob Resist Infect Control (2021) 10:49 Page 4 of 10 Fig. 1 Digital health technology measurement concept employing the Semmelweis hand hygiene system, on the user interface green indicates covered areas, red indicates non-covered areas while a numeric evaluation is additionally provided (Image by HandInScan Zrt.) Hand size determination statistical analysis, R Core Team: R: A Language and Hand size calculation is essential, as the applied ABHR Environment for Statistical Computing (R Foundation for volume/area quotient would be different among different Statistical Computing, Vienna, Austria R Version: 4 0.0 populations. After initial calibration, hand sizes were cal- Released: 2020. 04.24) was used. To concurrently inves- culated digitally by measuring the pixels of the scanned tigate the effect of the person’s experience (student or images [29]. Improperly recorded images were filtered resident), handrub volume, hand size and covered area, and excluded from the calculations. Good quality images a linear mixed-effect model was fitted on the data. The were used for hand size (hand surface area in  cm ) deter- logarithm of the missed area (%) as the outcome variable mination according to an already established Automated was explained by the handrub amount (ml), the hand size Area Assessment Method determined automatically by (cm ), the participant’s experience (student or resident) the Semmelweis System. In some cases, participants were and the interaction effect of handrub volume and hand asked to draw around the outline of their non-dominant size (specific hand coverage). The random intercept was hand on a sheet of paper. Subsequently, the drawings the individual error for participants. Compound sym- were used and hand sizes were also determined by a Digi- metry correlation structure for handrub amount and tal Outline Assessment Method as a control. The results different power variance structure for handrub at differ - using the two methods were compared to examine the ent participants was used to fit the final model. When precision of the Semmelweis System method. examining how handrub volume and hand size affect drying time, a generalized least square regression model was used. Finally, when investigating possible correla- ABHR spill and volume awareness tion between volume awareness (Table  1 Question 2) Both the medical students and the surgical residents were and hand coverage, a chi square test was performed. The given two questions to answer directly before the evalua- questionnaire’s answers (predictor values) and the cov- tion with the Semmelweis System. Important to note that erage results (expected values) were regarded as binary all measurements were performed as blinded studies. Neither the medical students, nor the surgical residents were informed about the exact volume they received dur- Table 1 Hand hygiene event questionnaire completed by all ing the measurements. participants Question Possible answers Statistical analysis Did the disinfectant spill from your Yes/No/I don’t know Where applicable, a statistical analysis of the results was hand during the rubbing? performed. According to the predictor and outcome How did you find the disinfectant Not enough/Just right/Too much variables, different statistical tests were chosen. For the volume? V oniatis et al. Antimicrob Resist Infect Control (2021) 10:49 Page 5 of 10 parameters (Not enough = 0, Just right, Too much = 1, Palm Dorsum while Coverage < 95% = 0, Coverage > 95% = 1). Through - out the analysis, results were designated as significant when p < 0.05. Average missed All area parcipants 0% Results Disinfectant coverage results 2% The assessment methodology proved to be simple and 4% straightforward. The majority of the participants readily 6% understood the concept, and adhered to the measuring 1 ml 8% parameters. After the hand assessment events, 50 meas- handrub 10% urements were filtered and removed due to faulty meas - 12% urements or software-generated artefacts. All events 14% are plotted in Fig.  2, where a direct correlation between 16% disinfectant volume and hand coverage can be observed 18% as increasing the volume results in smaller missed areas. 3 ml The final number of examined hand hygiene events was handrub 42% 1622. The non-covered areas fell to less than 1% only with a dose of 3.5  ml or higher. Interestingly, not everyone Fig. 3 Typically missed areas during the hand hygiene events. covered their hands perfectly (100%) even with a 4  ml (ALL—N = 1557, 1.5 ml—N = 153, 3 ml—N = 724) dose. Noteworthy to mention that when comparing the standardized volumes of 1.5 and 3 ml, it is apparent that half the volume equals less than half of the coverage, thus thumb and the dorsum of the hand. The correlation of volume is not linearly proportional to coverage. volumes and missed areas is exhibited in Fig. 3. Missed areas vary according to the applied ABHR vol ume. Typically missed areas included the fingertips, the Hand size determination Digital hand size assessment results can be observed in Fig.  4. To be as objective as possible for the disinfectant coverage measurements, hand size was calculated by the 8% 7.10% Automated Area Assessment (AAA) method for every single hand hygiene event. Individual hand size values 6% (from the same participant) were then averaged. Results exhibit a bimodal distribution. Comparing the currently 3.85% 4% utilized (Automated Area Assessment) method with a manually determined method (Digital Outline Assess- 1.68% ment) results are almost identical (differences measuring 2% 1.22% 1.02% 0.52% 0.39% 0% 11.5 22.5 33.5 4 35 Male Volume of applied handrub (ml) Female Summarized Le� dorsum Right dorsum Le�p alm Rightpalm 8.4% 3.7% 4.7% 11.3% Uncoveredhandsurface: 7.0% Hand surface(cm ) Fig. 2 a Hand coverage (percent of the total hand surface missed during hand hygiene event). b Example of the computed outcome: Fig. 4 Hand size calculation results, provided by the Semmelweis missed areas at 7% uncovered surface System’s software (automated area assessment method) Uncovered hand surface Ss ample ize <260 260–270 270–280 280–290 290–300 300–310 310–320 320–330 330–340 340–350 350–360 360–370 370–380 380–390 390–400 400–410 410–420 420–430 430–440 440–450 450–460 460–470 470–480 480–490 >490 Voniatis et al. Antimicrob Resist Infect Control (2021) 10:49 Page 6 of 10 8% 7% 6% rd 3 grade medical 5% students 4% Surgical 3% residents 2% 200 1% <2 2–2.52.5–3 3–3.53.5–4 4–4.5>4.5 100 1:1 rao Applied handrub (μl/cm ) Linear trendline Fig. 6 Specific Hand Coverage in the case of 3rd grade medical (y=0.82x+51.2) 0 students, who recently learned proper hand disinfection technique, 0100 200300 400500 and surgical residents, who have several years of experience. Applying enough ABHR, medical students reached similar results as Hand size determined by Automated Area 2 surgical residents. When suboptimal volumes were used experience Assessment method (cm ) had indeed an impact Fig. 5 Comparing the two different hand size determination methods. Note: Average hand size difference between the two methods was 10.1% Drying time Drying time results confirm that by increasing the dis - 10%) (Fig. 5) confirming therefore that software provided infectant volume, the application time (drying time) machine-based automated hand size calculations can be increases as well. At a 3 ml volume, a plateau is reached considered reliable. Interesting to note that the differ - in the mean values (Fig.  8). Important to note that these ences between the two methods were documented when results concern an ABHR with a 70% ethanol concentra- larger hands were assessed. Inaccuracies in the digital tion, differences, may be observed using other products. outline assessment method, most likely resulted by the Furthermore, the resulted relatively wide variances indi- experimental settings, i.e., participants were asked to cate that (apart from hand size) other intrinsic or extrin- draw around their hands, and not all participants put the sic factors can potentially influence drying times as well. same effort resulting in significantly lower precision. Disinfectant spill and volume awareness The increase in the applied ABHR volume (while being Specific hand coverage (μl/cm ) undisclosed) was generally consciously detected among In order to objectively assess the effect of ABHR volume the participants. However, it was clearly shown that par- on hand coverage, specific hand coverage was deter - ticipants cannot precisely assess the given volumes, as mined to calculate the disinfectant volume per hand sur- even with a 3  ml dose (on average-sized hands resulting face area ratio. According to our results, the average total hand size area was 372.9 cm while the median hand size was 370.2 cm . When 3 ml of handrub is distributed on a pair of on average-sized hands (372.9 cm each) it equals 2 100% a 4.02  μl/cm specific hand coverage. In Fig.  6, it can be 90% seen that surgical residents performed considerably bet- 80% ter than 3rd-year medical students. Thus, if a 4.02  μl/ 70% cm is regarded as sufficient for an average hand, the 3 ml Hand surface 60% (cm ) volume seems to be a valid approximation as to what a 50% 40% <340 medium hand-sized person should apply. 30% 340–380 Regarding hand size and applied disinfectant cover- 20% age, Fig.  7 visually demonstrates how at a smaller dose 380–420 10% the difference between covered areas due to hand sizes >420 0% becomes evident. As the volume of the applied disinfect- 11.5 22.5 33.5 4 ant increases, the gap between the hand sizes decreases. Volume of applied handub (ml) Fig. 7 Hand size (hand surface)—uncovered area correlation measurements Hand size determined by Digital Outline Assessment method (cm ) Ro ate f appropiate Nd ot cd overe he an surfac hand hs ygiene event V oniatis et al. Antimicrob Resist Infect Control (2021) 10:49 Page 7 of 10 Did the handrub drop off yourhand? a 80 100% 80% 60% 40  Yes 40% I'm not sure 20% No 0% 0 0.51 1.52 2.53 3.54 <2 2–2.52.5–3 3–3.53.5–4 4–4.5>4.5 1 1.5 22.5 33.5 4 11.5 22.5 33.5 4 Applied handrub (μl/cm ) Handrub (ml) Fig. 10 Handrub spillage results (Handrub spillage refers to the ABHR spillage during a hand hygiene event). Note: 1.5 ml and 3 ml ABHR volumes on an average sized hand resulted in 2.51 and 4.01 μl/cm , respectively same disinfectant-volume/area ratio values the partici- pants felt that the given volume was not enough and yet the disinfectant was dripping from their hands. A further remark is that investigators reported, that although some participants did not report dripping, some spill was still observed. Arguably, dripping can occur without the par- Handrub (μl/cm ) ticipants noticing it therefore, the actual results are prob- Fig. 8 Results of drying time measurements. a Drying time and volume correlation without taking hand size into consideration ably an underestimation compared to the questionnaire. b Drying time and Specific Hand Coverage correlation (hand size taken into consideration). Note: WHO guidelines mention that hand Statistical analysis results rubbing should take 20–30 s, while the typically prescribed 2.5–3 ml ABHR volume requires longer time to dry According to the data analysis, the handrub volume (p < 0.0001), hand size (p < 0.0001), and participant’s experience (medical student or surgical resident) (p = 0.003) have a significant effect on the non-covered The amount of handrub felt... area. In addition, the disinfectant volume/hand size ratio 100% also has a significant effect on the size of the missed area (p = 0.0339). Regarding drying times disinfectant volume 80% More is a significant factor (p < 0.0001), while hand size is not than 60% enough (p = 0.083). Finally, participant volume awareness seems 40%  Just right to correlate with achieving the predetermined (> 95%) hand coverage (p = 0.034). Not 20% enough 0% <2 2–2.52.5–3 3–3.53.5–4 4–4.5>4.5 Discussion Applied handrub (μl/cm ) This is the first objective, digital health technology sup - Fig. 9 Volume awareness results ( Volume awareness refers to the ported, large-scale investigation regarding disinfectant ability of the participants to assess the ABHR volume given to them). volume and hand coverage correlations. Unlike several Note: 1.5 ml and 3 ml ABHR volumes on an average sized hand result other studies where the observer or examiner calculated in 4.02 and 2.51 μl/cm or evaluated the disinfectant-covered areas manually, during our investigation evaluations were all performed using an objective computerised and automated elec in a 4.02  µl/cm specific hand coverage) a significant tronic system [6]. number of students (more than 30%) (Fig.  9) felt that Comparing the performance of medical students and the given ABHR volume was not enough. It is also evi- surgical residents it is clear that experience and proce- dent that increasing the volume of the applied disinfect- dural memory are key to perfect the hand rubbing tech- ant increases the hand rubbing volume losses during nique and hand hygiene protocol (Fig. 5). Nevertheless, a the WHO 6-step protocol (Fig.  10). Interestingly, at the perfect score (0% missed areas) was rarely achieved. An R( esponses %) D rying me (sec) D rying me (sec) R( esponses %) Voniatis et al. Antimicrob Resist Infect Control (2021) 10:49 Page 8 of 10 important condition was that measurements occurred individual is seemingly the best option [10] as just plainly always under the direct supervision of an investigator. increasing the volume also increases spillage and there- u Th s, the overall performance is significantly (yet uni - fore a waste of disinfectant in the case of smaller hands. formly) influenced by the Hawthorne effect. In a real- Apart from the material (and therefore financial) waste, world clinical setting, the performance should be worse the findings of Greenaway et al. and others [18, 30] sug- not only due to less attention being given to the WHO gest that compliance also decreases with higher applied 6-step protocol but due to the often decreased applied volumes (due to longer application time). According to disinfectant volume as well [11]. our results, applied ABHR volumes are relative to the Regarding disinfectant volume and hand coverage cor- same volume for small-handed people the volume feels relations, our results indicate that a volume of 1.5  ml is excessive while for large-handed ones feel just right. inadequate as it leaves on average 4% of the total hand Therefore, adjusting the dosage according to hand size surface bare of disinfectant. As Goroncy-Bermes et  al. could also increase the overall compliance with the pro- [9] suggested, a volume of 3 ml seems rather appropriate tocol. In addition to an optimized volume, simplifying as according to our findings the missed area falls under the hand hygiene steps could also decrease the spillage 1%. While increasing the disinfectant dose to 3, 3.5 and while also increasing compliance [31]. 4 ml decreases the missed area to approximately 1%, 0.7% and 0.5%, respectively, and the average drying time for Limitation of the study these volumes was well above the recommended 20─30 s Due to the natural distribution among a popula- according to the current WHO guideline, which may put tion, larger and smaller handed people are fewer than unnecessary load on the HCWs during clinical practice. medium-size handed people therefore the number of Our results concur with the results of Macinga et al. and recorded measurements per hand size is not truly equal. Suchomel et al. [14, 16] who also documented increased Therefore, the volume of the disinfectant spill (while drying times. A drying time of 20 s was uncommon even probably different for the two populations) was not quan - in the cases of 1  ml applied volumes. Contradictions in tified and was additionally overshadowed by the aver - the literature exist as Paula et  al. findings [19] demon - age values. Consequently, the actually applied volume strate how hand wettability is statistically equal after a (actual volume = given volume − spillage) was different 15 or 30 s application time. However, as they stated their for the two hand sized populations. In addition, the effect results may have been obscured due to the small popu- of alcohol type and concentration was not investigated lation they examined (N = 20), the effect of the continu - in this study, only a 70% ethanol containing handrub ous training, or that hand size was not used to normalize was tested. Handrubs with different alcohol concentra - results among participants. Further investigating the tions can have different characteristics. Finally, medical results, it can be seen that drying times even when made students and surgical residents participated in the study independent from hand size demonstrate a large vari- thus intermediate experience level was not investigated. ance. This suggests that other intrinsic factors are influ - encing the results (e.g., skin temperature, skin hydration). Furthermore, application time and microbiological Conclusions reduction should be re-examined as controversy still According to our results, the covered area during a hand exists in the current research. For example, Pires et al. or hygiene event strongly depends on the applied ABHR Harnoss et  al. [18] investigated the application time and volume. At small volumes (i.e., 1–1.5  ml), the covered bacterial reduction relationship. Their results suggest area deficit is more evident, as people with larger hands that no significant difference was found between 15 and fail to cover the entire hand surface. A 3 ml applied vol- 30 s application time. Their studies included a rather lim - ume is sufficient for medium size hands to achieve full ited and probably experienced study population (N = 32 coverage, however, this volume requires more than the and 14 respectively), whilst no hand size measurements instructed 20–30  s to be thoroughly applied. In addi- were taken into consideration, and only the microbiologi- tion, this volume can be insufficient for larger hands, but cal sampling on fingertips was performed. wasteful for smaller ones as not only the disinfectant loss When incorporating hand size in the evaluations, our (spillage) will increase. Notably, the additional rubbing results demonstrate how hand size does matter. 1.5  ml (drying) time is disadvantageous, since hand coverage of disinfectant is clearly not sufficient for larger hands. will not increase. The optimal applied ABHR volume is At 3  ml volume, smaller and larger handed participants therefore relative. The implementation of an optimised, achieved almost the same percentage of disinfected areas. clinical set, hand size depended protocol would ben- As results show, 3  ml is a good approximation for efit future hand hygiene guidelines, as it would not only medium size hands yet an optimized volume for each increase the speed and efficiency of hand hygiene events, V oniatis et al. Antimicrob Resist Infect Control (2021) 10:49 Page 9 of 10 5. Kenters N, Eikelenboom-Boskamp A, Hines J, McGeer A, Huijskens EGW, but also improve compliance and adherence rates while Voss A. Product dose considerations for real-world hand sanitiser effi- keeping the disinfectant wastes and costs to a minimum. cacy. Am J Infect Control. 2020;48(5):503–6. https ://doi.org/10.1016/j. ajic.2019.12.001. 6. Lehotsky A, Szilágyi L, Bánsághi S, Szerémy P, Wéber G, Haidegger Abbreviations T. Towards objective hand hygiene technique assessment: valida- ABHR: alcohol-based handrub; HCW: healthcare workers; WHO: World Health tion of the ultraviolet-dye-based hand-rubbing quality assessment Organization. procedure. J Hosp Infect. 2017;97(1):26–9. https ://doi.org/10.1016/j. jhin.2017.05.022. Acknowledgements 7. Pittet D, Allegranzi B, Boyce J. The World Health Organization Guide- The authors would like to give thanks to all the participants contributing lines on hand hygiene in health care and their consensus recommen- to the study. Special thanks to Lilla Gorbay Nagy for her assistance in the dations. Infect Control Hosp Epidemiol. 2009;30(7):611–22. https ://doi. measurements and Daniel Sandor Veres for his guidance in the statistical org/10.1086/60037 9. analysis. We are also grateful to the employees of the “George Berci” Surgical 8. Tarka P, Gutkowska K, Nitsch-Osuch A. Assessment of tolerability Research and Training Laboratory, and the Department of Surgery of Sem- and acceptability of an alcohol-based hand rub according to a WHO melweis University. We would also like to thank HandInScan Zrt. For providing protocol and using apparatus tests. Antimicrob Resist Infect Control. us the Semmelweis System for the study. T. Haidegger is a Bolyai fellow of the 2019;8(1):1–8. https ://doi.org/10.1186/s1375 6-019-0646-8. Hungarian Academy of Sciences. 9. Goroncy-Bermes P, Koburger T, Meyer B. Impact of the amount of hand rub applied in hygienic hand disinfection on the reduction of Authors’ contributions microbial counts on hands. J Hosp Infect. 2010;74(3):212–8. https ://doi. CV, SB, and TH contributed to the study design. Data collection was carried org/10.1016/j.jhin.2009.09.018. out by CV and SB. Data analysis was carried out by SB. Project supervision was 10. Bellissimo-Rodrigues F, Soule H, Gayet-Ageron A, Martin Y, Pittet D. provided by FA and TH. All authors read and approved the final manuscript. Should alcohol-based handrub use be customized to healthcare work- ers’ hand size? Infect Control Hosp Epidemiol. 2016;37(2):219–21. https Funding ://doi.org/10.1017/ice.2015.271. CV is supported by the ÚNKP-20-3-II-SE-29, and SB is supported by the ÚNKP- 11. Bánsághi S, Soule H, Guitart C, Pittet D, Haidegger T. Critical reliability 20-3-II-SE-24 New National Excellence Program of the Ministry for Innovation issues of common type alcohol-based handrub dispensers. Antimicrob and Technology from the source of the National Research, Development and Resist Infect Control. 2020;9(1):90. https ://doi.org/10.1186/s1375 6-020- Innovation Fund. 00735 -4. 12. Kramer A, Pittet D, Klasinc R, et al. Shortening the application time of Availability of data and materials alcohol-based hand rubs to 15 seconds may improve the frequency The datasets used and/or analysed during the current study are available from of hand antisepsis actions in a neonatal intensive care unit. Infect the corresponding author on reasonable request. Control Hosp Epidemiol. 2017;38(12):1430–4. https ://doi.org/10.1017/ ice.2017.217. Ethics approval and consent to participate 13. ICPIC Proceedings. Abstracts from the 5th international conference on Not applicable. prevention and infection control (ICPIC 2019). Antimicrob Resist Infect Control. 2019;8(S1):1–201. https ://doi.org/10.1186/s1375 6-019-0567-6. Consent for publication 14. Suchomel M, Leslie RA, Parker AE, Macinga DR. How long is enough? Not applicable. Identification of product dry-time as a primary driver of alcohol-based hand rub efficacy. 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