HAND DERMATITIS AND HEALTHCARE UPDATE
Studies have shown that a reason oft-repeated by healthcare workers as to why they aren't always compliant with the Centers for Disease Control and Prevention (CDC)'s "Guideline for Hand Hygiene in Healthcare Settings"1 is because frequent washing causes dry, cracked skin. That's not just an aesthetic problem; it's an occupational hazard for themselves and their patients. Cracks in dry skin provide perfect hiding places for pathogens that can be transferred from Healthcare workers' (HCWs) hands to sick patients in the blink of an eye.
Sprixx hand sanitizers
The problem of hand care is so serious that it garners much attention from high-profile regulatory and advisory agencies. The CDC considers skin dermatitis to be a critical healthcare issue.1 Thejoint Commission on Accreditation for Healthcare Organizations (JCAHO) surveils for compliance with the CDC's hand-hygiene guideline as part of its National Patient Safety Goals.2 The National Institute for Occupational Safety and Health notes that "skin disorders are the number one occupational illness across all occupations and cost $1 billion annually.1 The Association for Professions in Infection Control and Epidemiology Inc., (APIC) advises HCWs to "insist on products that promote and maintain healthy skin, reduce transepidermal water loss, increase skin hydration (moisturization), and have low irritancy potential."4
The stepped-up attention to hand care has industry constantly developing new and improved hand-care products to address this important problem.
What should you look for?
Makers of hand-care products are a source of valuable advice when it comes to effective hand care. They've spent a fortune researching what works before their products go on the market. They're not inclined to risk losing that fortune and potential profits by placing products on the market that they don't have reason to believe will perform. What do these experts have to say about what to look for in hand-care products?
Compatibility
Kirsten M. Thompson, technical service expert, Ecolab, St. Paul, MN, suggested looking for alcohol-based hand rubs and lotions that are compatible with other antimicrobial hand products, providing this example: "Compatibility of hand-care products is important, because persistent antimicrobial activity of chlorhexidine gluconate (CHG) could be diminished if you followed a hand wash containing CHG with a lotion that wasn't CHG-compatible." Steve Rausch, director of marketing, Apollo Corporation, Somerset, WI, concurred: "The most expensive products you can buy are those that don't work."
Skin-friendliness
"It's also important for hand-care products to be skin- friendly," observed Thompson. "If users don't like a product, they won't use it; so, look for a formulation acceptable to most users."
Thompson also advised HCWs to use waterless hand rubs, such as Ecolab's Endure 320 alcohol gel, that have emollients built in. "HCWs may have to wash their hands or rub their hands with a waterless product 40 to 50 times per day. Their hands can become dry and cracked, which hurts. Dry, cracked, bleeding hands are vulnerable to infection, and the bacteria they harbor can be difficult to eradicate. A hand-rub product that leaves an emollient behind not only can kill bacteria, it can preserve the integrity of the skin. The Endure line encompasses the entire spectrum of hand care: soap, alcohol-based hand rubs, surgical scrubs, and lotion, which are formulated to work well together. SkinSynergy is the basis for the Endure line. It's a patented system used to formulate a family of products. The combination of products works as good, if not better, together than each component does separately."
Ecolab hand hygiene products
Healthpoint's Triseptin
Quality
Another point to look for is quality. Rausch advised staying away from "hand-care products loaded with oils, fillers, and thickeners, because they don't perform. When a product doesn't perform, the result can be contact dermatitis and cracked skin that won't heal. A hand-care product should heal, moisturize, hydrate, and contribute to pliability of skin so that it resists drying and cracking. The epidermis is the first line of defense against bacteria. Pliable skin is more resistant to bacteria."
Rausch pointed out that "Many HCWs forget that moisturizing is an important step toward reducing infection. The CDC says that 30% to 40% of all HAIs are due to contaminated hands, and they recommend using a moisturizer to reduce incidence of dry, cracked skin, because moisturized, hydrated skin cuts down the risk of cross- contamination."
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function Ads_PopUp() {}
Apollo's lotions are different, said Rausch, because they aren't oil-based. " oil-based lotions simply coat the skin and only lock in moisture already present in the skin. Thera 5 lotion and Thera 10 cream contain urea and lactic acid, chemicals produced naturally by the body. Urea attracts moisture to dry skin cells and increases the water-binding capacity of the stratum corneum, the outermost layer of the epidermis. Lactic acid is a humectant that holds moisture in the stratum corneum. oil-based lotions don't attract moisture; they only provide a barrier to hold in whatever moisture is available in the skin. If the skin is dehydrated when the barrier goes on, there won't be any moisture to retain; so, the skin is unable to re- hydrate. Every time HCWs wash their hands with soap and water, Thera 5 or Thera 10 draws moisture into the skin to rehydrate the epidermis."
Health Care Logistics Infection control training CD
Other advantages of the Thera line cited by Rausch are that "they don't leave a heavy, greasy layer on the skin; there are no dyes or mineral oil to irritate skin or erode the structure of latex gloves, as petroleum-based products can; and the lotion or cream only need be reapplied after several hand washings."
Delivery
HCWs are always pressed for time, which is one reason alcohoi- based cleaners are so popular: an alcohol rub is quicker to complete than an effective hand wash. Ron Cagle, business development manager, Sprixx, Santa Barbara, CA, cited another advantage: Studies show that hand washing is more damaging to skin than alcohol."
"The CDC hand-hygiene guidelines recommend wall-mounted containers and individual pocket-sized containers," noted Cagle. Sprixx's focus is delivery systems for alcohol-based cleansers, making the product conveniently available to HCWs so that use becomes "a second-nature habit," said Cagle. "Alcoholbased cleansers need to be more accessible to become a second-nature habit. Cleaning hands by using a wall mount when entering or leaving a patient room is good, but it's not enough; it must be done at point-of-care. We champion the idea of body-worn, second-nature tools. Having a personal container changes the paradigm from an institutional policy or problem to a personal commitment. It changes how you think about hand hygiene fundamentally, from something impersonal to something very personal."
A beeper-sized personal container, called the Sprixxer, sprays 63% ethyl alcohol with an emollient added. It clips onto a belt or clothing and can be sprayed into the palm with one hand. "It deploys quickly, and the spray won't drip," explained Cagle.
If bought in bulk, each dispenser costs $4.95, and a 1.35-ounce replacement cartridge costs $1.25. A 0.5-ounce bottle with a reusable clip costs $1.15 per unit. Also available is a 2.36-ounce spray bottle that fits into a holster, with the holster cost at $3 and the replacement bottle at $2.10. There are currently two alcohol- based formulas with different scents, and the company has 10 new formulas with different scents, consistencies, emollients, and active ingredients in the making; however, no release date has been set for them yet.
Persistence
Lawton Seal, senior program manager, research and development, Surgical Division, HEALTHPOINT, Fort Worth, TX, added persistence to a list of qualities that should be sought by users of hand cleansers. "The Food and Drug Administration (FDA) has a category with specific requirements for HCW personnel handwash products that must be met for vendors to be compliant. If products don't meet these standards, they don't perform the way people think they are, and the user has a false sense of security."
HEALTHPOINT's water-optional hand wash exceeds FDA requirements.5 It employs 61% alcohol for quick kill combined with zinc pyrithione for prolonged kill. A study by Seal et al found that "the product provides antimicrobial persistence, and residual effects and repeated use contribute positively to overall skin conditioning."
"It all goes back to product efficiency," said Steve Owens, marketing director, Surgical Division, HEALTHPOINT." Sixty-two percent ethanol has good quick-kill ability, but 2 or 3 hours later, the microbes have returned. Used as often as needed, the skin may dry or crack, and microbes could grow in these niches. You need sustained, prolonged kill plus skin-conditioning properties that can replace moisture and fats removed by alcohol to maintain a barrier. oil (fat) has microbiocidal properties, too," said Owens.
Education
Most companies provide inservice when introducing their products to facilities, but some companies go far beyond that. Medline Industries Inc,Mundelein, IL, promotes education with its new "Innovations in Hand Hygiene: A Continuing Education Program" for HCWs on DVD. They also have a new awareness campaign, "Germ Stoppers," designed to educate patients and visitors, as well as HCWs, about the importance of hand hygiene. The "Germ Stoppers" campaign empowers patients to question hospital staff entering their room as to whether they've sanitized their hands. The campaign includes instructions for cleaning hands with Medline's no-rinse sanitizer.
Medline also is busy developing a self-assessment tool, called the "Hand Hygiene, Skin, and Glove-Use Survey," designed to evaluate compliance with the CDC's hand-hygiene guidelines. "Dr. Denise Korniewicz, a well-known barrier expert, and Dr. Elaine Larson, editor of the American Journal of Infection Control, designed this survey that asks questions whose answers uncover factors behind behavior and attitudes specific to each facility that result in noncompliance," said Stephen Cervieri, vice president of education and research, Medline. "The usual way to test for compliance is 'supervisory observation,' anonymously. It takes time to observe and get results, sometimes a year. Our tool will imrnediately reveal problems and challenges that need to be resolved in a particular facility, such as inconveniently located sinks or dry skin." The tool is being pilot tested at selected facilities now.
Medline's Aloetouch exam gloves
In the second phase of the tool's development, the same facilities will participate in a trial that tests Medline's aloe- coated medical gloves as a therapy for dry, cracked skin. "This product is a breakthrough," said Tripp Amdur, president of Medline's Accucare Division. "It's a patented solution that's brought the handcare product into the glove. HCWs have to wear gloves anyway, so they might as well get treatment at the same time." An added attraction: "The aloe-coated gloves can eliminate the need for lotions and the extra time needed to apply them; they can eliminate the risk of crossinfection presented when a bottle of lotion is used by more than one HCW; and they eliminate the space needed to store lotions in supply closets. Sales have exploded over the past year. We have hundreds of letters of testimony, just an overwhelming response to the aloe-coated gloves' effect on skin, and they cost less than a penny more than a glove without an aloe coating.
Whimsy
Health Care Logistics, Circleville, OH, is a medical products distribution company that also promotes hand-hygiene, but they do it with "a whimsical approach," said Ken Bober, consultant, market research and business development. Their "Just Say NOsocomial" infection control training program uses six characters, Handy the Hand Washing Octopus, Freddy the Fomite, Perry the Pathogen, Gordon the Glove, Sophie Soap and Water, and Anti Annie Septic, to motivate HCWs to practice good hand hygiene. "Infection control personnel must continually be sensitized to the importance of hand washing," observed Bober. "These humorous characters present infection control measures in a way that hospital employees will remember when conducting their jobs."
Apollo's Thera 5 moisturizing lotion
The training program includes a CD PowerPoint presentation that is intended to stimulate discussion; a binder with a copy of each slide, with talking points; 30 copies of six different posters that highlight each character and its message, for posting throughout the institution; and 25 copies of the training brochure, recapping what's on the posters. The healthcare professional who presents the program is provided with giveaways, such as hand-sanitizer spray pens and "Just Say NOsocomial" silicone bracelets and magnets, for attendees as visible reminders to practice proper handwashing techniques.
The initial cost for the 'Just Say NOsocomial" package is $110. Additional components are sold in packs of 25 at quantity discounts.
Most importantly ...
No matter which products you choose for your facility, here are some important words to keep in mind from Owens: "Take care in selecting products. Keep the standard high with regard to hand hygiene."
JCR Introduces hand hygiene buttons
Joint Commission Resources (JCR) announced the release of hand hygiene buttons designed to promote staff handwashing. JCR is an affiliate of Joint Commission on Accreditation of Healthcare Organizations. The hand hygiene buttons encourage patients to ask and remind healthcare staff to wash their hands before and after patient encounters. These colorful buttons instantly communicate to patients the healthcare organization's commitment to stopping the spread of infections. They are available in packs of 10 in English or Spanish for $5. Custom orders are available in quantities of 100, 250, 500, and 1,000 for the following languages: Arabic, Brazilian Portuguese, Chinese, Czech, French, German, Italian, and Japanese. For more information or to order the hand hygiene buttons, call JCR Customer Service toll-free at 877-223-6866, 8
REFERENCES
1 .Centers for Disease Control and Prevention. Guideline for hand hygiene in Healthcare settings. MMWR Recomm Rep 200Z;51(RR16):1-44.
2.JCAHO. National Patient Safety Goals, http:// www. jcipatientsaf ety.org/show.asp? durki=9721 &site=164&return=9344.
3. National Institute for Occupational Safety and Health. NORA allergic and irritant dermatitis. December 1998. http:// www.cdc.gov/ niosh/topics/skin.
4. Association for Professionals in Infection Control and Epidemiology, Inc. Healthy Skin: An Ounce of Prevention for Your front Line of Defense. Washington., DC: APIC; 2005.
5. Seal LA, Rizer RL, Maas-lrslinger, R. A unique water optional health care personnel hand wash provides antimicrobial persistence and residual effects while decreasing the need for additional products. XIm JInfectConfro/2004;33:207-216.
by Susan Cantrell, ELS
Copyright KSR Publishing Nov 2005
Sprixx hand sanitizers
The problem of hand care is so serious that it garners much attention from high-profile regulatory and advisory agencies. The CDC considers skin dermatitis to be a critical healthcare issue.1 Thejoint Commission on Accreditation for Healthcare Organizations (JCAHO) surveils for compliance with the CDC's hand-hygiene guideline as part of its National Patient Safety Goals.2 The National Institute for Occupational Safety and Health notes that "skin disorders are the number one occupational illness across all occupations and cost $1 billion annually.1 The Association for Professions in Infection Control and Epidemiology Inc., (APIC) advises HCWs to "insist on products that promote and maintain healthy skin, reduce transepidermal water loss, increase skin hydration (moisturization), and have low irritancy potential."4
The stepped-up attention to hand care has industry constantly developing new and improved hand-care products to address this important problem.
What should you look for?
Makers of hand-care products are a source of valuable advice when it comes to effective hand care. They've spent a fortune researching what works before their products go on the market. They're not inclined to risk losing that fortune and potential profits by placing products on the market that they don't have reason to believe will perform. What do these experts have to say about what to look for in hand-care products?
Compatibility
Kirsten M. Thompson, technical service expert, Ecolab, St. Paul, MN, suggested looking for alcohol-based hand rubs and lotions that are compatible with other antimicrobial hand products, providing this example: "Compatibility of hand-care products is important, because persistent antimicrobial activity of chlorhexidine gluconate (CHG) could be diminished if you followed a hand wash containing CHG with a lotion that wasn't CHG-compatible." Steve Rausch, director of marketing, Apollo Corporation, Somerset, WI, concurred: "The most expensive products you can buy are those that don't work."
Skin-friendliness
"It's also important for hand-care products to be skin- friendly," observed Thompson. "If users don't like a product, they won't use it; so, look for a formulation acceptable to most users."
Thompson also advised HCWs to use waterless hand rubs, such as Ecolab's Endure 320 alcohol gel, that have emollients built in. "HCWs may have to wash their hands or rub their hands with a waterless product 40 to 50 times per day. Their hands can become dry and cracked, which hurts. Dry, cracked, bleeding hands are vulnerable to infection, and the bacteria they harbor can be difficult to eradicate. A hand-rub product that leaves an emollient behind not only can kill bacteria, it can preserve the integrity of the skin. The Endure line encompasses the entire spectrum of hand care: soap, alcohol-based hand rubs, surgical scrubs, and lotion, which are formulated to work well together. SkinSynergy is the basis for the Endure line. It's a patented system used to formulate a family of products. The combination of products works as good, if not better, together than each component does separately."
Ecolab hand hygiene products
Healthpoint's Triseptin
Quality
Another point to look for is quality. Rausch advised staying away from "hand-care products loaded with oils, fillers, and thickeners, because they don't perform. When a product doesn't perform, the result can be contact dermatitis and cracked skin that won't heal. A hand-care product should heal, moisturize, hydrate, and contribute to pliability of skin so that it resists drying and cracking. The epidermis is the first line of defense against bacteria. Pliable skin is more resistant to bacteria."
Rausch pointed out that "Many HCWs forget that moisturizing is an important step toward reducing infection. The CDC says that 30% to 40% of all HAIs are due to contaminated hands, and they recommend using a moisturizer to reduce incidence of dry, cracked skin, because moisturized, hydrated skin cuts down the risk of cross- contamination."
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function Ads_PopUp() {}
Apollo's lotions are different, said Rausch, because they aren't oil-based. " oil-based lotions simply coat the skin and only lock in moisture already present in the skin. Thera 5 lotion and Thera 10 cream contain urea and lactic acid, chemicals produced naturally by the body. Urea attracts moisture to dry skin cells and increases the water-binding capacity of the stratum corneum, the outermost layer of the epidermis. Lactic acid is a humectant that holds moisture in the stratum corneum. oil-based lotions don't attract moisture; they only provide a barrier to hold in whatever moisture is available in the skin. If the skin is dehydrated when the barrier goes on, there won't be any moisture to retain; so, the skin is unable to re- hydrate. Every time HCWs wash their hands with soap and water, Thera 5 or Thera 10 draws moisture into the skin to rehydrate the epidermis."
Health Care Logistics Infection control training CD
Other advantages of the Thera line cited by Rausch are that "they don't leave a heavy, greasy layer on the skin; there are no dyes or mineral oil to irritate skin or erode the structure of latex gloves, as petroleum-based products can; and the lotion or cream only need be reapplied after several hand washings."
Delivery
HCWs are always pressed for time, which is one reason alcohoi- based cleaners are so popular: an alcohol rub is quicker to complete than an effective hand wash. Ron Cagle, business development manager, Sprixx, Santa Barbara, CA, cited another advantage: Studies show that hand washing is more damaging to skin than alcohol."
"The CDC hand-hygiene guidelines recommend wall-mounted containers and individual pocket-sized containers," noted Cagle. Sprixx's focus is delivery systems for alcohol-based cleansers, making the product conveniently available to HCWs so that use becomes "a second-nature habit," said Cagle. "Alcoholbased cleansers need to be more accessible to become a second-nature habit. Cleaning hands by using a wall mount when entering or leaving a patient room is good, but it's not enough; it must be done at point-of-care. We champion the idea of body-worn, second-nature tools. Having a personal container changes the paradigm from an institutional policy or problem to a personal commitment. It changes how you think about hand hygiene fundamentally, from something impersonal to something very personal."
A beeper-sized personal container, called the Sprixxer, sprays 63% ethyl alcohol with an emollient added. It clips onto a belt or clothing and can be sprayed into the palm with one hand. "It deploys quickly, and the spray won't drip," explained Cagle.
If bought in bulk, each dispenser costs $4.95, and a 1.35-ounce replacement cartridge costs $1.25. A 0.5-ounce bottle with a reusable clip costs $1.15 per unit. Also available is a 2.36-ounce spray bottle that fits into a holster, with the holster cost at $3 and the replacement bottle at $2.10. There are currently two alcohol- based formulas with different scents, and the company has 10 new formulas with different scents, consistencies, emollients, and active ingredients in the making; however, no release date has been set for them yet.
Persistence
Lawton Seal, senior program manager, research and development, Surgical Division, HEALTHPOINT, Fort Worth, TX, added persistence to a list of qualities that should be sought by users of hand cleansers. "The Food and Drug Administration (FDA) has a category with specific requirements for HCW personnel handwash products that must be met for vendors to be compliant. If products don't meet these standards, they don't perform the way people think they are, and the user has a false sense of security."
HEALTHPOINT's water-optional hand wash exceeds FDA requirements.5 It employs 61% alcohol for quick kill combined with zinc pyrithione for prolonged kill. A study by Seal et al found that "the product provides antimicrobial persistence, and residual effects and repeated use contribute positively to overall skin conditioning."
"It all goes back to product efficiency," said Steve Owens, marketing director, Surgical Division, HEALTHPOINT." Sixty-two percent ethanol has good quick-kill ability, but 2 or 3 hours later, the microbes have returned. Used as often as needed, the skin may dry or crack, and microbes could grow in these niches. You need sustained, prolonged kill plus skin-conditioning properties that can replace moisture and fats removed by alcohol to maintain a barrier. oil (fat) has microbiocidal properties, too," said Owens.
Education
Most companies provide inservice when introducing their products to facilities, but some companies go far beyond that. Medline Industries Inc,Mundelein, IL, promotes education with its new "Innovations in Hand Hygiene: A Continuing Education Program" for HCWs on DVD. They also have a new awareness campaign, "Germ Stoppers," designed to educate patients and visitors, as well as HCWs, about the importance of hand hygiene. The "Germ Stoppers" campaign empowers patients to question hospital staff entering their room as to whether they've sanitized their hands. The campaign includes instructions for cleaning hands with Medline's no-rinse sanitizer.
Medline also is busy developing a self-assessment tool, called the "Hand Hygiene, Skin, and Glove-Use Survey," designed to evaluate compliance with the CDC's hand-hygiene guidelines. "Dr. Denise Korniewicz, a well-known barrier expert, and Dr. Elaine Larson, editor of the American Journal of Infection Control, designed this survey that asks questions whose answers uncover factors behind behavior and attitudes specific to each facility that result in noncompliance," said Stephen Cervieri, vice president of education and research, Medline. "The usual way to test for compliance is 'supervisory observation,' anonymously. It takes time to observe and get results, sometimes a year. Our tool will imrnediately reveal problems and challenges that need to be resolved in a particular facility, such as inconveniently located sinks or dry skin." The tool is being pilot tested at selected facilities now.
Medline's Aloetouch exam gloves
In the second phase of the tool's development, the same facilities will participate in a trial that tests Medline's aloe- coated medical gloves as a therapy for dry, cracked skin. "This product is a breakthrough," said Tripp Amdur, president of Medline's Accucare Division. "It's a patented solution that's brought the handcare product into the glove. HCWs have to wear gloves anyway, so they might as well get treatment at the same time." An added attraction: "The aloe-coated gloves can eliminate the need for lotions and the extra time needed to apply them; they can eliminate the risk of crossinfection presented when a bottle of lotion is used by more than one HCW; and they eliminate the space needed to store lotions in supply closets. Sales have exploded over the past year. We have hundreds of letters of testimony, just an overwhelming response to the aloe-coated gloves' effect on skin, and they cost less than a penny more than a glove without an aloe coating.
Whimsy
Health Care Logistics, Circleville, OH, is a medical products distribution company that also promotes hand-hygiene, but they do it with "a whimsical approach," said Ken Bober, consultant, market research and business development. Their "Just Say NOsocomial" infection control training program uses six characters, Handy the Hand Washing Octopus, Freddy the Fomite, Perry the Pathogen, Gordon the Glove, Sophie Soap and Water, and Anti Annie Septic, to motivate HCWs to practice good hand hygiene. "Infection control personnel must continually be sensitized to the importance of hand washing," observed Bober. "These humorous characters present infection control measures in a way that hospital employees will remember when conducting their jobs."
Apollo's Thera 5 moisturizing lotion
The training program includes a CD PowerPoint presentation that is intended to stimulate discussion; a binder with a copy of each slide, with talking points; 30 copies of six different posters that highlight each character and its message, for posting throughout the institution; and 25 copies of the training brochure, recapping what's on the posters. The healthcare professional who presents the program is provided with giveaways, such as hand-sanitizer spray pens and "Just Say NOsocomial" silicone bracelets and magnets, for attendees as visible reminders to practice proper handwashing techniques.
The initial cost for the 'Just Say NOsocomial" package is $110. Additional components are sold in packs of 25 at quantity discounts.
Most importantly ...
No matter which products you choose for your facility, here are some important words to keep in mind from Owens: "Take care in selecting products. Keep the standard high with regard to hand hygiene."
JCR Introduces hand hygiene buttons
Joint Commission Resources (JCR) announced the release of hand hygiene buttons designed to promote staff handwashing. JCR is an affiliate of Joint Commission on Accreditation of Healthcare Organizations. The hand hygiene buttons encourage patients to ask and remind healthcare staff to wash their hands before and after patient encounters. These colorful buttons instantly communicate to patients the healthcare organization's commitment to stopping the spread of infections. They are available in packs of 10 in English or Spanish for $5. Custom orders are available in quantities of 100, 250, 500, and 1,000 for the following languages: Arabic, Brazilian Portuguese, Chinese, Czech, French, German, Italian, and Japanese. For more information or to order the hand hygiene buttons, call JCR Customer Service toll-free at 877-223-6866, 8
REFERENCES
1 .Centers for Disease Control and Prevention. Guideline for hand hygiene in Healthcare settings. MMWR Recomm Rep 200Z;51(RR16):1-44.
2.JCAHO. National Patient Safety Goals, http:// www. jcipatientsaf ety.org/show.asp? durki=9721 &site=164&return=9344.
3. National Institute for Occupational Safety and Health. NORA allergic and irritant dermatitis. December 1998. http:// www.cdc.gov/ niosh/topics/skin.
4. Association for Professionals in Infection Control and Epidemiology, Inc. Healthy Skin: An Ounce of Prevention for Your front Line of Defense. Washington., DC: APIC; 2005.
5. Seal LA, Rizer RL, Maas-lrslinger, R. A unique water optional health care personnel hand wash provides antimicrobial persistence and residual effects while decreasing the need for additional products. XIm JInfectConfro/2004;33:207-216.
by Susan Cantrell, ELS
Copyright KSR Publishing Nov 2005
posted by Madison @ 12:08 PM
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