Patient Safety Tip of the Week
July 18, 2017
Another Hazard from Alcohol-Based Hand Gels
Along with soap and water, alcohol-based hand gels are a key
component of our hand hygiene programs. But occasionally we have seen
unexpected consequences from these.
In our April 2013 What's New in the Patient Safety World column “Reminder:
Hand Sanitizers Are Flammable” we noted a very unusual hospital fire injuring a young girl in Oregon (Budnick
2013). It was suspected that an alcohol-based hand sanitizer from a
wall-mounted dispenser was the key fuel in this fire. The fire began on the
shirt of an 11 y.o. girl, who suffered third degree
burns over multiple parts of her body. The report
of the fire marshal who investigated the fire determined through discovery
and analysis of circumstantial evidence and elimination of other ignition
sources that static electricity had likely been the ignition source. The girl
had apparently been scuffing her feet and rubbing her bed linens in attempt to
create sparks on her sheets. The fuel source was determined to be an
alcohol-based hand sanitizer, which the girl had apparently spread on her
bedside table and shirt. The alcohol content of the hand sanitizer was 50-70%.
In addition, there was olive oil on the girl’s shirt and hair. This apparently
had been used to remove glue from EEG electrodes that had been used for
monitoring. It was noted that some olive oil dripped on her shirt while it was
combed through her hair and that the girl also wiped her hands on her shirt
after touching her hair. The fire marshal tested the hypothesis regarding the
oil and hand sanitizer on her shirt and the ignition source and confirmed burn
patterns that matched those in the actual case. Notably, he determined that
ignition source would not have been adequate to ignite just the olive oil
without the presence of the hand sanitizer.
Those who are
familiar with surgical fires know that the alcohol-based skin preps used in the
OR are commonly identified as the fuel in surgical fires. But that was the
first time we’d heard of the hand sanitizers found in most hospital rooms as a
potential fuel. But they certainly have the same types of volatile alcohols in
high concentrations that we see in the surgical skin preps that have been
associated with surgical fires. This fire did not even require an oxygen-rich
environment. But static electricity is ubiquitous and the fumes from the
alcohol-based hand sanitizer obviously were enough to generate this fire.
But, beside fires, there are other potential unexpected consequences
from hand sanitizers. Now a report from the UK describes another unintended
consequence of alcohol-based hand sanitizers: a patient death from drinking
substantial amounts of an alcohol-based hand gel (75% ethyl alcohol
concentration). Though the case apparently occurred in 2015, it just began to
receive attention this year. The 76 y.o. patient
apparently had dementia and was confused and drank large amounts of the
sanitizer, which was at the end of his bed (Burke
2017). The amount of alcohol in his blood was six times the legal limit (Wooler
2017).
In response to the UK incident, some hospitals have
introduced lockable wall mounted dispensers and issued staff with personal mini
bottles of hand wash (Coggan
2017).
This is not the first time ingestion of hand gel for its
alcohol content has been problematic in the UK. Previously there were reports
of patients and visitors drinking hand gel from public areas of hospitals. A
number of hospitals in the north of England have removed hand gel from public
areas because some patients and visitors were drinking it for its alcoholic
content (Barbour
2012).
Gormley and colleagues described a
case of coma due to ingestion of an ethanol-based hand sanitizer in a medical
inpatient in the US (Gormley
2012). The teenage patient complained of dizziness and then became
comatose on the sixth day of a hospitalization. After the patient was admitted
to the ICU, a nurse from the patient’s floor found an empty 500 mL bottle of hand
sanitizer in the patient’s wastebasket, covered with a towel. Another clue to
the underlying etiology was in serum osmolarity
(alcohol is highly osmotic and is included in most formulas for calculating osmolarity but is usually assumed to be zero). In this
case, the calculated osmolarity was 304 mOsm/kg and measured osmolarity
was 388 mOsm/kg. That led to measurement of serum ethanol
level, which returned as 720 mg/dL when drawn more
than 6 hours after onset of symptoms. He was treated with hemodialysis and,
after regaining consciousness, admitted to infusing the hand sanitizer into his
gastrostomy tube because he wanted to “get a buzz” though he denied any
suicidal intent. He also admitted to several ingestions during the past year of
other ethanol-based hand sanitizers, mouthwash and alcoholic beverages through
his gastrostomy tube.
And after we began writing this column, an AHRQ WebM&M presented yet another case of a patient becoming
unconscious from alcohol intoxication related to drinking hand sanitizer (Stewart 2017). The patient had
a history of alcohol abuse and severe depression and had been hospitalized with
pneumonia. When found unconscious, her blood alcohol level was 530 mg/dL. Several empty containers of alcoholic foam hand sanitizer
were found and the patient later admitted drinking the sanitizer.
Poisoning from hand sanitizing solutions has been increasing
recently. In Canada there have been deaths reported due to ingestion of such
agents, which may also contain methanol which is even more toxic (CBC
2013). CDC recently reported on exposure of children aged ≤12 years
in the US to hand sanitizers (Santos 2017),
using data from the National Poison Data System (NPDS). From 2011 to 2014, a
total of 70,669 hand sanitizer exposures in children aged ≤12 years were
reported to NPDS, 92% of which were exposures to alcohol-based hand sanitizers.
Exposures were somewhat less common during summer months and it was speculated
that there might be greater access to hand sanitizers during the school year.
The major route of exposure was ingestion and the majority of intentional
exposures to alcohol hand sanitizers occurred in children aged 6–12 years.
Alcohol hand sanitizer exposures were associated with worse outcomes than were nonalcohol hand sanitizer exposures. The CDC article points
out that younger children have decreased liver glycogen stores, which increases
their risk of developing hypoglycemia, and have various pharmacokinetic factors
which make them more susceptible to developing toxicity from alcohol. The
report concludes that caregivers and health care providers should be aware of
the potential dangers associated with hand sanitizer ingestion and that children
using alcohol hand sanitizers should be supervised and these products should be
kept out of reach from children when not in use.
The fact that older children are more likely to be exposed
suggests to the CDC authors that many such exposures are intentional. The above-mentioned
Canadian report noted there are many online videos featuring teenagers
ingesting hand sanitizers to get intoxicated (CBC
2013).
So what, if anything, should hospitals and other healthcare
facilities do regarding this risk? First of all, remember that the overall risk:benefit ratio for alcholol-based sanitizers is overwhelmingly in favor of a
net benefit. In so many of our columns on hand hygiene we’ve stressed the
importance of ready availability of dispensers to promote compliance with hand
hygiene. So no one would advocate widespread removal of these products from
hospitals and clinics.
But there probably are a few things that might be done.
First is a risk assessment for the
patient. Patients who have a history of alcohol abuse or are at risk for
alcohol withdrawal or are confused, delirious or demented might be considered
at-risk for ingestion of the products. In such cases, it might be possible to
utilize methods of dispensing only small amounts of alcohol-containing
sanitizer.
The AHRQ article (Stewart 2017) cites as
potential solutions dispensers that yield a small dose with a refractory period
between doses or dispensers that alarm when used multiple times in a short
period. But Stewart notes that these machines are likely to be expensive and
thus impractical. As noted above, some UK hospitals have begun use of lockable
wall mounted dispensers and issued staff with personal mini bottles of hand
wash. Some hospitals are already using hand sanitizing systems that
electronically capture the amounts dispensed in order to assess staff compliance
with recommended hand hygiene practices. Most of those measure volumes dispensed
over 24 hours or longer periods but theoretically they could be programmed to
alarm if a certain amount is exceeded within a specified timeframe (keeping in
mind that the same amount that would be appropriately dispensed for a healthcare
rounding team in a patient room could be enough to seriously harm a patient who
ingested that amount).
What about psychiatric patients? A review of intentional
ingestions of ethanol-containing hand sanitizers (Gormley
2012) noted that many published case reports describe intentional ingestions
that frequently occurred in the emergency department or psychiatric wards, with
goals of intoxication or suicide.
What about those psychiatric patients admitted to medical or
surgical services? We’ve done numerous columns on the risk of suicide on med/surg units and other non-behavioral health units. When you
have to house a potentially suicidal patient or patient with significant
psychiatric conditions on a medical or surgical unit, you need to perform a
thorough environmental risk assessment. While hanging or jumping out of windows
are probably the most common ways such patients may attempt suicide on those
units, exposure to chemicals or other hazardous materials is another risk. And
what hazard could be closer than the hand sanitizer dispenser in the patient’s
room? Since the availability of such dispensers on such units is important for
infection control purposes, this might be one situation where the type of “alarming”
dispenser mentioned by Stewart might be appropriate.
What about pediatric patients? From the recent CDC report it
is clear that children are at highest risk for exposure to hand sanitizers and
we’d expect hospitalized children are also likely at high risk.
What about using non-alcohol-based sanitizers? These are
less potentially risky than alcohol-based ones but they are also less effective
from an infection control standpoint. So don’t expect any significant move away
from the alcohol-based hand sanitizers. However, if you have a unit that has a
historically low prevalence of infections (eg. a
behavioral health unit), these might be an option.
We admit that none of these proposed solutions is ideal. The
response in the UK to the case noted above indicates that product redesign may
be necessary but is also looking for expert input into potential solutions.
While efforts to prevent ingestion of hand-sanitizers may be
suboptimal currently, it is equally important to have early recognition of the
resultant intoxication so that adequate support can be provided. Management
includes the usual supportive care we’d provide any obtunded or comatose
patient. But some patients may require dialysis to avoid end organ damage.
Therefore, a high level of suspicion is needed if you find a patient obtunded
or comatose. As noted above, serum osmolarity may be
a clue. If there is a disparity between the calculated osmolarity
and the measured one, get a serum ethanol level. Obviously, when we are
confronted with a patient with altered level of consciousness and a picture
compatible with a “metabolic encephalopathy” we consider intoxications as potential
etiologies. But we often forget about that possibility in patients who develop
this clinical picture after admission to the hospital. So when there is no
obvious other “metabolic” derangement as a likely explanation for the patient’s
clinical status, get a toxicology screen. But while you are waiting for that tox screen to come back from the lab, don’t forget a simple
inexpensive step: “Search the trash!”. Look in the trash receptacles in the patient’s room or
any other locations he/she may have recently been.
Lastly, don’t forget that the dangers to the “at-risk”
patient extend beyond the patient’s room. They can easily find hand sanitizer
dispensers when you send them to the radiology suite or multiple other areas of
the hospital. You might, therefore, even consider adding a warning on your “Ticket
to Ride” for intra-hospital transports.
Spreading awareness of the risks associated with
alcohol-based hand sanitizers, regardless of how infrequent, is an important
first step. However, we need evidence for strategies that mitigate the risks
yet help maintain the critical role in infection control that these sanitizers
provide. Please send us your comments about any steps you’ve taken at your
facilities or other logical interventions that might be undertaken.
References:
Budnick N. Portland hospital fire
investigated; hand sanitizer link suspected in girl's injuries. The Oregonian
February 18, 2013
http://www.oregonlive.com/health/index.ssf/2013/02/portland_hospital_fire_investi.html
State of Oregon. Office of the Fire Marshal. Fire and Life
Safety Supplemental Investigation Report. February 5, 2013
http://media.oregonlive.com/health_impact/other/OHSU%20Feb%2002%20Report%20Final.pdf
Burke D. NHS warned over 'future deaths' after dementia
patient, 76, dies after drinking hand sanitiser in
hospital. Daily Mail (UK) 2017; 3 June 2017
Wooler S. OAP OD’s On Hand Gel. Elderly
dementia patient dies from alcohol poisoning after downing a bottle of hospital
hand sanitizer. The Sun (UK) 2017; 3 June 2017
https://www.thesun.co.uk/living/3712643/elderly-dementia-patient-dies-from-alcohol-poisoning/
Coggan A. Keogh unveils safety steps after patient dies from
drinking alcohol gel. Health Service Journal 2017; 8 June 2017
Barbour S. Patients 'drinking alcohol hand gel'. BBC News
2012; 19 Nov 2012
http://www.bbc.com/news/av/health-20404541/patients-drinking-alcohol-hand-gel
Gormley NJ, Bronstein AC, Rasimas JJ, et al. The Rising Incidence of Intentional
Ingestion of Ethanol-Containing Hand Sanitizers. Crit
Care Med. 2012; 40(1): 290-294
Stewart S. Cases & Commentaries. AHRQ WebM&M. The Hidden Harms of Hand Sanitizer. Published
July 2017
https://psnet.ahrq.gov/webmm/case/415
CBC. Hand sanitizer ingestion linked to 2 Ontario deaths. Bodico brand contained toxic ingredient methanol. CBC News
2013; Posted: Oct 25, 2013
http://www.cbc.ca/news/canada/toronto/hand-sanitizer-ingestion-linked-to-2-ontario-deaths-1.2252046
Santos C, Kieszak S, Wang A, et al.
Reported adverse health effects in children from ingestion of alcohol-based
hand sanitizers - United States, 2011-2014. MMWR Morbidity Mortality Weekly
Report 2017; 66(8): 223-226
https://www.cdc.gov/mmwr/volumes/66/wr/mm6608a5.htm
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