Episode #35 Everything You Need to Know about Hand Hygiene

Hand hygiene (HH) is a simple task that we perform all day long--or is it? In this episode the Divas review and reveal the basics of HH along with some little known facts and reminders.

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Transcript

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SPEAKER_00 0:08

Welcome. I'm Leslie Cannum. I'm Mary Gavoni. I'm Linda Harvey.

SPEAKER_02 0:14

I'm Olivia Juan. And together we are the Compliance Divas. Hello, everyone. This is Leslie Canham and I am your moderator for this Compliance Diva podcast on hand hygiene. Now, hand hygiene is a household work word these days, and we want to make sure that we provide proper information that is reliable based on CDC guidelines and other research to give you the information you need. We like to bring clarity and simplicity to compliance by navigating regulatory compliance to keep you on course. We encourage you to subscribe to the Compliance Divas podcast through your favorite podcast channel or on our website, thecompliancedevas.com. Again, the resources that we mentioned during our podcast can be found on the compliancedeivas.com website, and we always welcome questions. So please submit your questions to support at the compliancedivas.com. You know, it's interesting, the history of hand hygiene, you would have thought that it would have gone back many, many years. And actually, the uh reason for washing our hands didn't become important until the mid-1800s. Now, today evidence supports the belief that improved hand hygiene can reproduce health care associated infection rates, and failure to perform recommended hand hygiene is actually considered one of the leading causes of health care associated infections. Unfortunately, frequent and repeated use of hand hygiene products, particularly soaps and other detergents, are a primary cause of contact or chronic irritant contact dermatitis among healthcare workers. There's also the issue of discomfort due to irritation that can interfere with adherence to recommended hand hygiene practices. Consequently, it's important to have different types of hand hygiene products and gloves available for use in the dental office. Now, again, as I mentioned, the history of hand hygiene is kind of interesting because it wasn't always considered to be important. Now, the CDC guidelines for hand hygiene were actually developed in 2002. So here we are, almost 20 years from our last update to hand hygiene guidelines. But the concept of cleansing your hands with an antiseptic agent was actually something that emerged as early as 1822 when a French pharmacist demonstrated that solutions containing chlorides of lime or soda could eradicate foul odors associated with human corpses, and that such solutions could be used as disinfectants and antiseptics. In a paper that was published in 1825, it was stated that physicians and other persons attending patients with contagious diseases would benefit from moistening their hands with a liquid chlorine solution or chloride solution. And then the big announcement was made in 1846 when a Hungarian physician, Dr. Ignaz Simelweiss, observed that women whose babies were being delivered by students and physicians at the first clinic in the general hospital of Vienna consistently had a higher mortality rate than those whose babies were born and actually delivered by midwives in a second clinic. And he actually noticed that the students and the physicians would go straight from the autopsy suite to the obstetrics ward without washing their hands. So the history of hand hygiene, actually, we might think it'd be thousands of years old, but the guidelines for healthcare providers really isn't that old. And we rely today on CDC guidelines for hand hygiene and other information from Centers for Disease Control to guide us on the appropriate types of hand hygiene, the products to use and when to use those products. Linda, could you please give us a little bit of uh information on the types of hand hygiene and the criteria for selecting certain types of hand hygiene products?

SPEAKER_01 4:43

Sure, Leslie, thank you. You know, while hand hygiene is a household word, as you just said, I think it's something that we all end up taking for granted, even though we don't mean to. For example, we've all learned how to wash our hands as children, and then it was reinforced when we were in school by our teachers. And then again, when we were in dull assistinguish and hygiene school, we had to pass a hand hygiene evaluation by our instructor in order to move to the next step in our learning process. But when you think about hand hygiene, it has really evolved over the past number of decades and centuries. But to order to think about the types of products to have in your practice, we have to think about the types of hand hygiene that we're performing, because that influences the types of hand hygiene products that you would buy and keep in your practice. And actually, there are four different types of hand hygiene that I want to review, Leslie, this today. First is routine hand wash. So when we're performing a routine hand wash, that's water with non-antimicrobial soap. In other words, we're just using plain soap and water because the purpose here is to remove soil and just remove the transient organisms. And I'd like to distinguish a little bit what the transient organisms are, because I'm going to talk about some a different kind of organism in just a minute. But a transient organism is think of it as the transient bacteria that gets on our hands from contacting a surface that has some kind of microorganism on it. It's a temporary bacteria or temporary flora, such as when we touch something and it's contaminated with the norovirus and we contract the stomach flu as a result. So routine hand wash can remove that kind of transient bacteria and soil. Whereas the second type of hand hygiene method is antiseptic hand wash. This is water along with antimicrobial soap, such as a chlorohexidine. Now, the main distinction between the routine hand wash and antiseptic is that now we're not only removing soil and bacteria, but we are destroying the transient microorganisms and we're reducing the resident flora. So, to talk about what is resident flora, what is that bacteria? Well, this is a bacterial flora that lives longer on our hands, but normally it doesn't cause disease. So now, if we're going into this antiseptic hand wash, we have the ability to reduce the amount of resident flora because of the persistent activity and whatever the product is for the antiseptic hand wash. Now, with both of these types of hand hygiene, Leslie, routine or antiseptic, we're still washing all surfaces of the hands and fingers, and it has to be for a minimum of 15 seconds. Now, let's talk about the third type of hand hygiene. This is antiseptic hand rub. This is where our alcohol-based hand rubs come in. And the fact that when we evaluate the product we're using here, we always be sure that we're using a professional grade product and not an over-the-counter product. The purpose of an antiseptic hand rub, will remove or destroy the transient bacteria microorganisms, and reduce the resident floor as well. We still have to make sure we're sanitizing and moistening, moistening with this with the rub all surfaces of our hands and fingers. And we do that until the hands are dry, when that's at least 15 seconds. So the times that we can use this alcohol-based hand rub are when our hands are not visibly soiled. And the CDC also states that when before we eat, after we go to the restroom, those are the perfect times to be using some type of soap and water. But in between times, when our hands are not visibly soiled, using an antiseptic hand rub is fine. Now, the fourth level is the surgical antisepsis. This hand hygiene technique is a little bit more involved. We think of this for our surgical procedures. Water and antimicrobial soap are used here as well, just like they are with the antiseptic hand wash. And the same result or purpose is to remove or destroy the transient microorganisms and to reduce the resident bacterial flora. One of the differences between the surgical antisepsis and the antiseptic hand wash is that with the surgical antiseptis hand hygiene, we are now washing our forearms in addition to all surfaces of our hands and fingers. And we're washing longer instead of a minimum of 15 seconds. Now it's between two and six minutes long. So that's pretty important to distinguish between that time frame. And this is when surgical procedures are being performed. This is the hand hygiene technique that's preferred. Leslie, I'd like to circle back though, just briefly to the routine hand wash and the antiseptic hand wash because how would our listeners know which one is best to use and when? So these are fine for routine exams, either one of these, whether it's antibacterial soap or not, pardon me, non-antibacterial microbial soap or microbial soap. So either one of these is fine for routine exams and any procedures that are non-surgical in nature. So that helps our listeners to kind of know when to use which hand hygiene technique when. So, Leslie, overall, there are four levels, and I think it's important for our listeners to distinguish between the two because then they understand why it's important to use professional grade products. And I'd like to make one other point, Leslie, about the surgical antisepsis. In addition to using, there's two actually two strategies you can use with that. I mentioned the water and the antimicrobial soap, but you can also use water and non-antimicrobial soap, but you must follow that with an alcohol-based surgical hand product, hand scrub product that has persistent activity. So, in other words, not something over the counter. And those are two different options that anybody who's performing an oral surgery procedure or any other surgical procedure in dental history could use a surgical hand antisepsis. So, Lisa, I think that pretty much covers these four.

SPEAKER_02 10:50

That's great, Linda. You've given us a great idea of what kind of hand washing technique we should use for what type of procedures we're performing. And I want to just distinguish between the 15 seconds hand washing for healthcare providers that there's a difference between what we're hearing uh just on public service announcements to wash your hands for 20 seconds. And I think that uh the difference really is that when people hear 20 seconds, they'll probably wash their hands for 15 seconds. I get a little tired of washing, standing at the sink. I'm ready to get on to the next thing. And I actually uh timed myself one time just to see how long it would take me, just for regular at-home washing my hands, a routine hand wash. And I felt like I was done after about seven seconds. I actually had to force myself to stay at the sink a little bit longer. And then I do time sometimes dental teams when they're washing their hands for routine hand wash, uh, just in setting up the stage for how long do you wash your hands prior to seeing a patient for routine procedures? And it seems like we fall around anywhere between about 35 and 45 seconds is how long we feel that we need to spend to do a good job washing our hands. So 15 seconds is an absolute bare bones minimum. Doesn't mean that you can't spend more time, and we certainly do spend more time, but then spending time hand washing can lead to irritation on hands. It's not just the uh the components of the hand hygiene product that should sometimes irritate our hands. Sometimes it's it's the multiple times that we're washing our hands or the temperature of the water. Mary, can you talk to us a little bit about skin irritation related to hand hygiene products or gloves?

SPEAKER_00 12:35

Absolutely, Leslie. And you are so right because we are repetitively washing our hands all throughout the day, and there's all kinds of opportunities for dental health care workers to develop some kind of irritation or dermatitis. But it's important to understand what the underlying cause is, because contact dermatitis can either be caused by an irritant, a chemical, um, some kind of a component of a glove, or it can be allergic dermatitis, allergic contact dermatitis. And so if any dental health care professional develops this dermatitis, they need to have some type of a structured plan for trying to get to the bottom of what is causing the irritation. It could be changing the hand wash product that you is used, it could be changing the type of gloves that are used. But if the problem persists, there's two challenges. One, it could be irritant or allergic contact dermatitis, which should be diagnosed by a physician. And then there's precautions, obviously, that need to be taken to prevent it from becoming a type one life-threatening allergic reaction. But also, you need to make sure that you are not working clinically or having hands in contact with potential pathogens if you have open and um perhaps even weeping sores on your hands. Just putting gloves on over that is certainly not going to protect the hands. So again, contact dermatitis can simply be a local irritant, or it could manifest itself as a contact with some kind of an allergen, whether it is latex, and there are some practices still using latex gloves in some cases, or it could be another type of chemical, for example, in a nitrile type of glove, um, but it could be any of the other chemicals that we work with in dentistry. Beyond that, some of the things that I think you sort of touched on this earlier, Leslie, is we don't need to use really hot water while we're washing our hands. Number one, it's kind of uncomfortable, but it's very drying to the skin. It dries out the natural oils that are in the skin by using too much hot water. The CDC uh guidance for or guidelines for hand hygiene and healthcare settings say to use tepid water. So kind of um lukewarm, not really super hot water for washing our hands. And looking at using products that are designed for use in healthcare. Even if what you want to use is a plain soap for a routine hand wash, there are those that are designed specifically for healthcare that don't have potential irritants in them, like dyes or perfumes like might be contained in some over-the-counter products. There was a big um push, I think, in the early 1990s during a lot of the HIV and hepatitis B concern in the beginning of the bloodborne pathogen standard to use really stringent antimicrobial hand washes, and in many practices would use something like a chlorhexidine hand wash product for all their routine hand washes. And what we saw were a lot of people who were developing skin irritation. So we need to look at that. Um, the other thing to keep in mind is that in 2016, the Food and Drug Administration banned the use of any type of powdered gloves. Powder was used as a lubricant, primarily in latex gloves, but it was also added into non-latex gloves to make them easier to don and doff. But that has been banned by the FDA for a number of years now. And the reason is that that powder, when those gloves are taken off, can become airborne and it can contain particles such as latex that could then be inhaled not only by a dental health care worker, but by a patient who might be sensitive and not know that they have a sensitivity to latex. So having a specific hand hygiene protocol in a practice is a good thing, following along the information that Linda shared with us. When can we use a plain soap? When do we need to use an antimicrobial hand um soap or a hand rub? And when do we do surgical hand and bicepsis? And then looking for products that may decrease the amount of irritation, and also finding products such as hand creams that are compatible with our glove material, but that can help overcome the dryness or potential irritation.

SPEAKER_02 17:59

Thank you, Mary. That's really a great explanation of uh the types of skin irritation and um information on products to choose for preventing irritation. Olivia, who is one of our fellow Deveras, is not here with us today, but she wanted to make sure that uh she has a little bit of information for you on jewelry and nail care. And the CDC guidelines for hand hygiene, the ones that were printed in uh 2002, uh actually have a pretty good section on uh hand hygiene related to nails and artificial nails and nail polish and jewelry. So, first of all, short nails are always easier to keep clean than longer nails. If you have longer nails, there's certainly a lot more under the, I guess you could say under the hood area, surface area to clean out. And uh when it comes to nail polish, it's interesting that freshly applied nail polish does not increase the number of bacteria that's recovered from under the skin, but chip nail polish or under the nails, I should say, chip nail polish may support the growth of larger numbers of organisms found on fingernails. And the concept of hand washing is to remove the debris, and alcohol hand sanitizers have a different uh way of they kill the debris, but they don't remove debris. And when your hands are smooth and and uh not cracked, uh you don't have lots of uh areas of compromise or calluses, smooth surfaces are very easy to clean, whereas rough surfaces are more difficult to clean. And if you can think about your nail bed, if you wear nail polish, and as your nail grows, there becomes a little gap between the polish and the cuticle of your nail. And I like to say that's like the grand canyon for uh these transient flora and other organisms to hide in and make it more difficult for you to wash your hands. Another thing that uh makes it more difficult to wash hands is jewelry. So I can understand that if you have a wedding ring and you don't want to take it off every day to go to work, I relate to that because I my theory is that if I take off my wedding ring, I'm gonna lose it. It's not a matter of if, it's a matter of when it will happen. So I don't want to take my ring off every day. So I have to spend extra time making sure that I get underneath that ring and clean really well when I'm performing hand hygiene. There are several studies that have demonstrated that skin underneath rings is more heavily colonized, uh, more than the comparable areas of the skin with uh on fingers without rings. And one study that CDC uh cites says that 40% of nurses harbored gram-negative bacteria on skin underneath underneath their rings. And some of those nurses carried that same organism under their rings for several months. So when it comes to performing hand hygiene, it is certainly important to uh make sure that you take care of your nails, keep them short, uh, avoid nail polish. My dad is a dentist and uh he loved to have his nails look nice and trim and clean. He also liked his nail beds to look shiny, but instead of using nail polished, he would uh he purchased a little chamois buffer that he got at the beauty supply store. And uh he would keep his cuticles trim, he would keep his nails short, and he would also buff his nail beds to give that nice shiny uh sheen that almost looked like nail polish. But the secondary benefit of having his nails always look good. And by the way, um this was pre-gloves days. So we were wet finger dentistry, and so it was important for the appearance of our nails to be acceptable so that patients wouldn't see, for example, a little line of dirt under the fingernails. That was his pet peeve. But it also would help him when he was washing his hands to make sure that he had a smooth surface. So when a hand wash occurred, he could very quickly remove that the bacteria and organisms and transient flora that would reside on the skin. And also, of course, between patient and patient appropriate hand hygiene. Another study was conducted with artificial nails, and they found that there was an outbreak that actually occurred with Pseudomonas originosa in a neonatal intensive care unit that where there were two nurses who had artificial nails. And the artificial nails actually help to have transmission go from one infant to the other. So I know today we say, well, gee, you know, we wear gloves over our hands. And so what does it matter whether we have artificial nails or whether we have nail polish or long nails? When you don gloves, you sometimes will poke a hole through the gloves with the nails if they're a little bit on the longer side. Also with jewelry, uh, you know, a ring, if you have the gemstone on it, it can also puncture your gloves. And then there's something else that's little known. I think most people give gloves more credit than they are due when it comes to glove integrity. There are oftentimes uh microperforations and pinholes that we cannot see. And when we don our gloves, we can actually enlarge those microperforations and pinholes, which means that fluid from the patient's mouth can actually wake to the inside of the gloves. So our nails and our hands can become contaminated even while we're wearing gloves through these microperforations and pinholes. And then on top of that, when we remove our gloves, sometimes what's on the outside of the glove lands back on our hands or and on our nails. So, of course, hand hygiene is important to perform not only before donning gloves, but every time gloves are removed as well. So I thank uh Olivia for uh bringing that topic up for us. And I just thought I'd just spend a couple of minutes uh talking about some of the other uh points that Miri mentioned about keeping your hands uh you know from irritation and soreness. That CDC does recommend that we use some kind of a hand lotion uh or moisturizer on our skin to keep our skin in good condition. Uh, but something to be aware of is that we should be using a professional strength product when it comes to our hands. Uh, as healthcare workers, we wash our hands multiple times a day. It is different than washing our hands a couple of times a day. And uh so using an alcohol hand sanitizer, if it's the kind of product that's commercially available for everybody, it may not have the emollients and the moisturizers that are needed to put back into your skin what comes out from using it frequently during the day. And at the end of the day, after washing hands with either sober water or using alcohol hand sanitizer, a hand lotion can also help to uh improve skin condition. But make sure when you're on the job, if you do use a hand lotion, don't use a product with a petroleum-based product in it, because petroleum can actually interfere with glove integrity as well. But at this point, what I'd like to do is turn the conversation over to the other divas and talk about some of the uh stories of hand uh conditions that we've come across as dental consultants in our career. Who would like to go first?

SPEAKER_00 25:45

Mary. Well, one thing I just wanted to mention, which may be a motivator for some um women out there who like to wear their wedding wedding rings, especially an engagement ring to work, is that constant putting on and taking off your gloves can actually wear down the prongs on your setting. And I can't tell you over the years how many um dentists, assistants, hygienists I've talked to that said they looked down at their ring one day and found out that the stone was missing or something felt weird and the stone was missing. So either don't wear that, maybe just have a smooth wedding band if you need to wear it to work. Um, be careful. And I agree with you, Leslie. If I took it off, I it would probably get lost. I never recommend putting it in your pocket at work. That's a very bad thing to do, leave it home, or just make sure that you have it checked at a jeweler frequently to make sure that your prongs are intact. I'm so glad you mentioned, Leslie, the idea about um the micro perforations and micro tears and gloves. As I that's one of my pet peeves as I'm observing folks in practices, they finish with their patients, they take their gloves off and they write on the chart if it's a paper chart or they go to the keyboard or they walk out of the room. And the first thing they need to do after they take those gloves off is wash their hands. And that's when I typically recommend a soap and water wash as opposed to an alcohol hand rub, because you may have some debris on your hand from those microperforations.

SPEAKER_02 27:31

That is so true. And Mary, you know, when I take off my gloves, I know that uh there's perspiration inside the glove. My hands are usually a little bit wet. And uh I like to remind myself that all that moisture that might not all be me. That might be some of the fluid that had wicked to the inside of the glove from the patient's oral cavity. And I think if people can uh you know keep in mind the concept that their hands are contaminated after they remove their gloves, that it would make uh washing hands an automatic next step. And I'm oftentimes surprised at when I visit a dental practice while they're seeing patients, I have personally observed hands not being washed not only after glove removal, but before going to another patient and donning gloves again. And I don't I understand you know how we could forget something as basic as hand washing. And today, with our patients all so familiar with the word hand hygiene and PPE, that our patients will be looking to see if we're washing our hands. That the in direct observation, if they don't see that, then I think they might be worried that uh if we're not washing our hands, what else are we forgetting to do? Linda, you wanted to add something.

SPEAKER_01 28:50

Oh, certainly did, Leslie. The story that you just shared about the you know, not washing our hands after we take off our gloves. It's got the perfect example. A number of years ago, this is BC before COVID, right? But as you already said before then, our patients were aware of PPE and H hand hygiene, although they may not have known the acronyms. This was in a pediatric dental practice with, of course, the open bays, and the dentist had left one patient and stepped over to the next bay to another patient. And the mother observed that the doctor did not wash his hands before put donning the new set of gloves. And it just so happened that the mother was a nurse. So she was infuriated. She snatched her child out of the chair, from what I'm told, and told the doctor she was going to be reporting him. And she knew he did not do the proper hand hygiene. So our patients have always been watching us, even before COVID. So making sure that we don't skip a step along the way is so important for maintaining our health as well as our patients' health.

SPEAKER_02 29:52

That's right. Patient perception is so important these days, and many of our patients are still a little bit leery about coming back to the practice. Something else that I think we don't uh recognize is that in some of our dental offices, we have a sink that's located just outside of the treatment room or behind the patient's uh line of sight. And or if we use alcohol hand sanitizer and it's not something that is performed in the line of sight of the patient, they may think that we didn't wash our hands. So it would be a good idea if in either one of those two circumstances that we step around in front of the patient and then continue to dry our hands with a paper towel while the patient is watching us, or continue to rub in the hand sanitizer and explain that I've used a professional strength alcohol hand sanitizer on my hands to make sure my hands are clean prior to putting on gloves and treating you. And so, you know, that way a patient might feel more assured, whether it's an adult patient or a child, and you'd be surprised at how observant uh kids are and how they will come back and say the darnedest things to their parents. So it is important that they are clear on that. I also want to spend just another minute talking about on alcohol hand sanitizer, how important it is to rub that hand sanitizer all the way in until it's dry. There is a case study that was published in the CDC guidelines for hand hygiene about a nurse who had applied alcohol hand sanitizer to her hands, and then she at the same time removed an isolation gown before the sanitizer was dried. She had touched a doorknob to leave the room, and the metal caused a spark. The spark uh and the static electricity from her isolation gown um actually ignited the alcohol hand sanitizer in her hand. So she had a little fire in her hands. So while you might think, you know, gee, alcohol hand sanitizer, yeah, quick, get it on quick. We have take uh after gloves come off, just real quickly slap it on. Remember to rub it all the way in until it's dry. Um, another kind of uh funny story that I want to share is uh in California, we have hand hygiene regulations. So we have we follow CDC guidelines, but there are specific regulations, uh, partly that allude to what Mary was talking about with any kind of contact dermatitis. We have we have a weeping dermatitis or exudative lesions on our skin, on our hands. We can't provide care for dental patients because of the chance of opportunistic infection. And so that means no handling uh patients, no handling patient care items or processing instruments, or pretty much you're you're on the sidelines until your hands heal. In that same hand hygiene guideline, there's an interesting statement about making sure that your hands are completely dry after washing with soap and water before you put on gloves. And I thought to myself, you know, if you've ever tried to put on gloves with wet hands, you only do that once because it's darn near impossible to don gloves when your hands are still a little bit wet. So make sure that you dry your hands altogether, completely dry, and with alcohol hand sanitizer, uh, rub it in until it's dry. And before donning gloves, of course, you want to make sure that that sanitizer is dry because not only do you want to make sure that it's working well for you, but uh wet hand sanitizer may have an effect on the integrity of the gloves as well. Now let's see, are there any other comments? Yeah, Mary, you had something you wanted to share.

SPEAKER_00 33:40

I did. We have said several times during this episode that dental practices should make sure they're using professional grade um hand hygiene products. And that is also true of um alcohol hand rubs because the over-the-counter hand rubs are required by the FDA to have at least 60% um alcohol. But in the CDC guidelines, it states they should be 70 or above. So that um means that it needs to be something that you buy through your dental distributor or through a medical distributor that has a higher level. And keep in mind that ethyl alcohol is less drying than propanolol or isopropyl alcohol that's in some products. So make sure you buy products that are well researched, just simply using an over-the-counter that you might use for patient safety when they come in to sanitize their hands is not necessarily the appropriate product to be used in the treatment rooms.

SPEAKER_02 34:43

Thank you, Mary. And you know, that brings to mind another topic. During the pandemic, we have seen an increase in the use of alcohol hand sanitizers. I know for myself, uh, going in in 2020, I purchased uh alcohol hand sanitizers when I could find them. And I also found that they were missing from a lot of the store shelves for my personal use at home. And I followed CDC guidelines. I would sanitize my hands frequently during the day. I sanitized them if I had to go out to the market or to the post office, and you know, before I get back in my car and touch anything, I'd sanitize my hands. I realized that I had sort of um a burning sensation on the palms of my hands, of both hands, after a few weeks. And I really didn't know what that burning sensation was. It felt like I had laid both of my palms on a hot cookie sheet. So I was quite concerned about it. And then I realized that the only thing that was different in my life was that I was using alcohol hand sanitizers, uh, pretty, I guess you could say overuse. And when I realized that, I switched over to one of the professional strength products that's sold by my dental dealer, and uh my irritation issues went away pretty quickly. Another thing that comes to mind are uh during the alcohol hand sanitizer shortage, as you, if you will, there was a lot of home-brewed alcohol hand sanitizers. A lot of companies that uh had the ability to make alcohol hand sanitizers were making them and putting them out on the market for people. In fact, uh, my own family had brought home a gallon jug of alcohol hand sanitizer, and uh I said, nope, we're absolutely not going to use that because I don't know really what's in it and how it was made. I don't know if it's safe. Uh, but there was also something that was uh coming out of uh the areas in Mexico they were uh producing an alcohol hand sanitizer that had methanol in it, and methanol is toxic. And uh the poison line got several calls that toddlers that were uh having alcohol hand sanitizer placed on their hands were having a severe reaction. And so it's actually toxic to ingest, it's toxic to have on your skin. So you want to make sure that you're using an alcohol-based hand sanitizer that is not only uh for healthcare providers, but in your own environment for commercial for household use, you want to make sure that you're using a product that doesn't have any of the toxic chemicals in it. So, in closing out this hand hygiene podcast, let's everyone take a look at the products that we're using. Let's take a look at the amount of time that we're spending washing our hands, and let's take note of any irritation that occurs and recognize that we might need to seek the opinion of a healthcare provider if we are experiencing anything like any kind of irritant dermatitis or allergic dermatitis that might occur. With that, I'd like to close our podcast and remind everyone that we bring clarity and simplicity to compliance by navigating regulatory compliance to keep you on course. Please submit your questions to support at the compliancedevas.com and be sure and look for the resources on our website for this hand hygiene podcast.