We look at a survey among those responsible for hygiene gaps in the cleaning of dispensers in hospitals – and there are practical alternatives for hygiene management.
Well-practiced hand hygiene is essential for comprehensive patient safety as people are increasingly paying attention to hygiene standards when choosing a hospital.
For thorough washing and disinfection of the hands, hospital staff have access to appropriate hygiene dispensers at multiple locations, and especially in the immediate vicinity of patients. Permanently installed disinfectant dispensers ensure that alcohol-based disinfection can be conveniently achieved without having to travel long distances. This is often a blessing, particularly when dealing with high volumes of people as the workflow does not have to be disrupted. In addition to regular hand hygiene, careful dispenser hygiene plays an important role in infection control as well. This is because dispenser preparation not only ensures perfect functioning, but also effectively prevents possible contamination of the contents.
Critical points during reprocessing
A closer look at the individual components of a hygiene dispenser quickly reveals that the dosing pump is a particular focus when reprocessing. The pump stays in permanent contact with the product, and product residues often adhere inside the suction pipe and at the pump outlet, which can impact dosing. Additives such as re-greasing substances often form at these points during the usage cycle.
When looking at the exterior of a hygiene dispenser, the operating lever is one particular “hot spot” that requires specific attention. Constant contact with the user’s hands, forearms and elbows can quickly lead to cross-contamination and, in the worst case scenario, acquired pathogens can reach patients throughout the facility.
Contaminated hand wash soaps
But how high is the real risk of microbial contamination of the contents? A team led by Dr. Sabine Gleich investigated this question as part of a scientific project at a German university hospital. The researchers found that ten percent of the one hundred liquid soap dispensers were contaminated with bacteria from the environment. However, none of the samples had more than 2 colony-forming units. 
Further studies show that the risk of contamination is particularly high with refilled soap and can lead to outbreaks.  And even with dispenser systems that are operated with disposable bottles, undesirable contamination of the soap can occur if the soap is improperly prepared. 
If one considers the situation with disinfectant dispensers, they are much less critical with regard to microbial colonization than soap dispensers. Nevertheless, failure to clean and care for the dispensers means that the alcohol-based preparations can no longer be dosed correctly, and this undoubtedly has a negative effect on hand hygiene compliance.
The KRINKO perspective
Section 23 of the Infection Protection Act, the Commission for Hospital Hygiene and Infection Prevention (KRINKO), lists detailed recommendations for the prevention of nosocomial infections. The published guidelines are important for hospitals and clinics and should be followed by hygiene management. The recommendation on hand hygiene, which was updated in 2016, describes in detail and extends the requirements for dispenser preparation.
KRINKO has set specific requirements for the dispenser’s exterior as well, such as drip noses at the outlet and removing visible impurities on the housing with disinfectant. According to KRINKO, the operating lever should also be wiped and disinfected daily.
With regard to the scope and frequency of hygiene dispenser cleaning, KRINKO does not define any fixed deadlines and leaves the houses more or less “free play”, regardless of whether soap or disinfectant dispensers are used. However, the individually defined cycles should be put on paper with the in-house hygiene plans which are accessible and reinforced with the staff. Manufacturers typically recommend six months for disinfectant dispensers and six months for soap dispensers for each bottle change.
When looking at dispenser reprocessing there are two types; manual and mechanical. Manual reprocessing involves numerous steps, from cleaning the dosing pump with hot water to disinfecting the housing and assembling the dispenser, and this can take significantly more time than manual dispensers.
Cost: Beyond good and evil
A published statement of costs by Dr. Dr. Otto-Karg from the Klinikum Fulda shows that a half-yearly manual cleaning of 4,000 dispensers can cost 6,800€, something that could be considered at the lower end of the cost spectrum. Logistical processes such as unscrewing or attaching the dispensers, daily surface cleaning and other processes are not taken into account and can add to the cost. In another publication by Stefan Drees from the St. Elisabeth Hospital in Cologne-Hohenlind, costs for proper dispenser preparation were published for each bottle change of up to € 125,000 per year for a 700-bed house. This is an enormous sum and an expenditure which also includes costly labour that will add up over time.
A survey carried out in October 2018 among specialist staff during the Freiburg Infectious Diseases and Hygiene Congress provided interesting insights into the cleaning behaviour of German clinics and hospitals. The results published in the Journal Infection Control & Hospital Epidemiology demonstrate that every third institution only cleans visibly contaminated disinfectant dispensers adequately. This carries the risk that dispensers and dosing pumps are rated as clean from the outside but are soiled inside and are therefore not properly prepared. 15 percent even say never to reprocess. 
Practical alternatives to reprocessing
As we have learned, the cleaning behaviour of soap dispensers can have a negative effect on dispenser hygiene. Here KRINKO has a solution ready and endorses the use of disposable pumps, which are aimed at those who shy away from the effort of continuous reprocessing.
“For dispensers of hand wash preparations, it is therefore advantageous to use disposable pumps on the container that are discarded with the empty container.Excerpt from the KRINKO recommendation, 2016
The German Society for Hospital Hygiene’s (DGKH) recommendation on the requirements for soap and hand disinfectant dispensers in health care facilities is in line with the information with KRINKO with regard to the use of disposable pumps. The DGKH recommendation is “in the same horn” as the KRINKO and even advocates their use in disinfectant dispensers. 
“Soap and hand disinfectant dispensers with disposable pump heads that are disposed of with the empty container are preferred. If the pump heads are used for subsequent containers, the manufacturer must provide detailed processing instructions”.Extract from the DGKH recommendation, 2011
This recommendation from two well-known institutions is being promoted by more and more hospitals. One example is the Oberammergau Clinic, where innovative Disposable Hygiene Pumps (DHP) have been used since the beginning of the year in all patient rooms in acute care areas, as well as in heavily frequented therapy areas. Another example is a North Rhine-Westphalian clinic which relies on the advantages of the practical DHP disposable pumps, particularly in hygiene-sensitive intensive care units.
Medical facilities typically use one exclusive manufacturer for the formula that they use to provide consistency. The Euro bottle standard guarantees the user the greatest possible flexibility and is recommended by KRINKO and DGKH for safe and hygienic dispensing.
 Gleich, S., Vieweg, C., & von Baum, H. (2015). Untersuchung der mikrobiellen Kontamination von Waschlotionsspendern aus unterschiedlichen Risikobereichen. Hyg Med, 40(6), 236-241.
 Buffet-Bataillon, S., Rabier, V., Bétrémieux, P., Beuchée, A., Bauer, M., Pladys, P., … & Jolivet-Gougeon, A. (2009). Outbreak of Serratia marcescens in a neonatal intensive care unit: contaminated unmedicated liquid soap and risk factors. Journal of Hospital Infection, 72(1), 17-22.
 Trautmann, M., Notburga, P., & Bobic, R. (2013). Reinigungs-und Desinfektionsleistung eines Aufbereitungsprogramms für die routinemäßige Reinigung von Dosierspendern im Krankenhaus. Hyg Med, 38(11), 468-472.
 Spender für Händedesinfektionsmittel und Seifenlösungen ein Hygienerisiko? Empfehlungen : Klare Rahmenbedingungen und deren Umsetzung? Dr. Dr. I. Otto-Karg. Krankenhaushygiene Klinikum Fulda gAG Universitätsmedizin Marburg. Presentation.
 Aufbereitung von Händedesinfektionsmittel- und Seifenspendern aus Sicht der Hygienefachkraft. Stefan Drees. St. Elisabeth-Krankenhaus Köln-Hohenlind. Presentation.
 Schulz-Stübner, S., Volkmann, A., Ebner, W., & Hauer, T. (2019). Practice and attitudes toward alcohol-based hand disinfection among German infection control teams. Infection Control & Hospital Epidemiology, 40(5), 609-612.
 Assadian, O., Kramer, A., Christiansen, B., Exner, M., Martiny, H., Sorger, A., & Suchomel, M. (2011). Empfehlung zu Anforderungen an Seifen-und Händedesinfektionsmittelspender in Einrichtungen des Gesundheitswesens. Hygiene und Medizin, 36(10), 407.