Nurses' hand decontamination practice: results of a local study

Multidrug-resistant bacteria infection control: study of compliance with isolation precautions in a Paris university hospital

Isolation practices in a university hospital were analyzed for 137 patients with multidrug-resistant bacteria. Isolation was ordered in writing by physicians for 40% and instituted by nurses for 60%; 74% were isolated. Compliance depended on physician ordering in writing (odds ratio, 36.3; 95% confidence interval, 4.8-274.9). Nurses complied best with hand washing.

The health professional's role in preventing nosocomial infections

Despite their best intentions, health professionals sometimes act as vectors of disease, disseminating new infections among their unsuspecting clients. Attention to simple preventive strategies may significantly reduce disease transmission rates. Frequent hand washing remains the single most important intervention in infection control. However, identifying mechanisms to ensure compliance by health professionals remains a perplexing problem. Gloves, gowns, and masks have a role in preventing infections, but are often used inappropriately, increasing service costs unnecessarily. While virulent microorganisms can be cultured from stethoscopes and white coats, their role in disease transmission remains undefined. There is greater consensus about sterile insertion techniques for intravascular catheters-a common source of infections-and their care. By following a few simple rules identified in this review, health professionals may prevent much unnecessary medical and financial distress to their patients.

Increase in hand-alcohol consumption among medical staff in a general hospital as a result of introducing a training program and a visualization test

To assess the impact of training programs, including a visualization test for hand disinfection, we monitored the hand-alcohol consumption of medical staff. The consumption increased steadily from 5.7 L of hand alcohol per capita per year in 1990 to 9.1 L in 1998. There was no significant increase in skin problems.

Innovations in hand hygiene: Manugel from SSL International

Hand hygiene is the single most effective method of preventing cross-infection. Barriers to performing effective hand hygiene include lack of time and the poor cosmetic acceptability of many of the available hand decontaminants. These problems are exacerbated in domiciliary nursing care where conditions in some homes may prevent adequate decontamination, especially when drying hands. Damp hands transfer bacteria more effectively than dry ones. The availability of newer alcoholic hand gels is helping to overcome these problems and the introduction of single-use sachets is of particular benefit in domiciliary care.

A comparison of soap, alcohol and glove use during the nappy-changing procedure in a special care baby unit

This study was conducted in a special care baby unit (SCBU) in a district general hospital and concentrated on hand decontamination and glove-wearing during the nappy-changing procedure. The aims were to determine whether or not nurses were adhering to existing infection control policies and guidelines, and to determine the most appropriate product to be used for hand decontamination.

Nurses were observed carrying out nappy changes to determine their existing hand-washing and glove-wearing practices. A microbiological analysis of nurses' hands during the nappy change was performed in order to compare the effectiveness of soap, alcohol, and glove use in eliminating bacteria from the hands.

The observation study demonstrated that not all nurses were adhering to existing infection control policies and guidelines. The microbiological analysis found that on the majority of occasions, alcohol was better than soap at removing bacteria from the hands but that gloves provided the best protection overall for both babies and nurses by preventing the acquisition of bacteria.

Together these findings suggest that nurses' hands may be providing a route for the transmission of hospital-acquired infection in the SCBU. Ideally, nurses should be wearing gloves during the nappy-changing process and using alcohol to decontaminate their hands.

Skin tolerance and effectiveness of two hand decontamination procedures in everyday hospital use

BACKGROUND

Hand decontamination is crucial to control nosocomial infections. The utility of hand decontamination is related not only to its antimicrobial effectiveness, but also to its acceptability by hospital staff.

OBJECTIVES

We aimed to assess skin tolerance and antimicrobial effects of two widely accepted hand hygiene measures under in-use conditions.

METHODS

Fifty-two nurses were randomly assigned for an 8-day period to either an alcohol-based disinfectant or a hand wash with a non-antiseptic soap. At baseline and at the end of the test period, microbiological hand samples were obtained both before and after a hand hygiene procedure, and skin tolerance was assessed using clinical scores and measurement of transepidermal water loss.

RESULTS

Self-assessment of skin condition and grade of skin damage worsened significantly more in the group using soap than in the group using alcoholic disinfectant (P = 0.004 and P = 0.01, respectively). The alcohol-based rinse was significantly more effective than liquid soap in removing transient contaminant micro-organisms (P = 0.016). Twenty of 50 hand washes with non-antiseptic soap apparently resulted in bacterial contamination of the hands. At the end of the study, the total bacterial count increased with the increasing number of hand washes in the soap group (P = 0.003), and with the degree of skin damage (P = 0.005) in the antiseptic group.

CONCLUSIONS

In everyday hospital practice, alcohol-based disinfectant is more effective and better tolerated than non-antiseptic soap; soap is at risk of spreading contamination; and skin comfort strongly influences the number and the quality of hand hygiene procedures.

Relevance of carcass palpation in lambs to protecting public health

We recently reviewed the Food Safety and Inspection Service's (FSIS's) inspection procedures for lambs. As a result, FSIS published a Federal Register notice informing the public of its intent to change from an inspection system that requires extensive carcass palpation to an inspection system that requires no carcass palpation for lambs. This decision was based on the following three points. (i) Extensive carcass palpation in lambs does not routinely aid in the detection of food safety hazards that result in meat-borne illnesses. (ii) Hands are capable of spreading or adding contamination to the carcasses. (iii) FSIS inspection systems must reflect science-based decisions as they pertain to meat-borne illnesses consistent with a Pathogen Reduction/Hazard Analysis and Critical Control Point environment.

The efficacy of cotton cover gowns in reducing infection in nursing neutropenic patients: an evidence-based study

This pilot study aimed to investigate the routine use of cotton cover gowns in the care of neutropenic patients and whether the rate of infection would increase if they were not used. Patients were randomly placed into alternate groups on admission and nursed with or without gowns. The patients' rates of infection were noted with no significant difference in infection rates. Using evidence from a systematic review of the literature, cover gowns have now been removed as a method of protecting neutropenic patients. 'Simple' and effective hand-washing, together with the use of broad-spectrum antibiotics, has been shown to be sufficient protection for these patients.

Infection control in wound care: a study of fatalism in community nursing

As part of a study of community nurses' perceptions of quality in nursing care, the author conducted in-depth qualitative interviews with seven community-based nurses. As part of the study, nurses were asked to describe episodes of wound care and to discuss the factors which could affect the quality of such care. One of the most interesting themes to emerge from the data was the apparent ambivalence of the nurses' attitudes towards infection control in wound care. Nurses discussed the concept of 'aseptic technique' in fatalistic terms and seemed uncertain about what could be achieved in terms of infection control. Although their policy guidelines referred to 'aseptic technique', their educational experience appeared to have made them feel uncertain about the implementation of the measures involved. With the proviso that this was a small scale qualitative study, the author concludes by suggesting that there is a need for greater clarity, both in what is taught and in what is included in practice policy with regard to infection control in wound care.

Improving hand hygiene in community healthcare settings: the impact of research and clinical collaboration

Observation of nursing activities and bacteriological studies undertaken with a sample of nurses employed in a community NHS trust indicated that considerable scope for cross infection existed during domiciliary visits. Poor conditions in patients' homes compromised nurses' ability to perform hand hygiene effectively, increasing risks. A clinical trial indicated that carriage of medically significant bacteria likely to contribute to cross infection could be reduced by applying an antiseptic cream which exhibited residual effectiveness. An audit of hand hygiene throughout the inner city trust indicated the need to pay greater attention to hand hygiene, especially during home nursing visits. The situation was less acute in a rural trust where a second audit was performed for comparative purposes. The motivation of clinical staff to improve hand hygiene precautions was high.

Preliminary analysis of the transmission dynamics of nosocomial infections: stochastic and management effects

A simple mathematical model is developed for the spread of hand-borne nosocomial pathogens such as Staphylococcus aureus within a general medical-surgical ward. In contrast to previous models a stochastic approach is used. Computer simulations are used to explore the properties of the model, and the results are presented in terms of the pathogen's successful introduction rate, ward-level prevalence, and colonized patient-days, emphasizing the general effects of changes in management of patients and carers. Small changes in the transmissibility of the organism resulted in large changes in all three measures. Even small increases in the frequency of effective handwashes were enough to bring endemic organisms under control. Reducing the number of colonized patients admitted to the ward was also an effective control measure across a wide range of different situations. Increasing surveillance activities had little effect on the successful introduction rate but gave an almost linear reduction in colonized patient-days and ward-level prevalence. Shorter lengths of patient stay were accompanied by higher successful introduction rates, but had little effect on the other measures unless the mean time before detection of a colonized individual was large compared to the mean length of stay. We conclude that chance effects are likely to be amongst the most important factors in determining the course of an outbreak. Mathematical models can provide valuable insights into the non-linear interactions between a small number of processes, but for the very small populations found in hospital wards, a stochastic approach is essential.

Three major issues in infection control

In considering the three major issues in infection control the author decided upon education and empowerment, community practices, and research availability and application as they span a range of infection control practices and healthcare settings. Education and empowerment of staff is needed to ensure safe practice. This requires collaboration between education providers and infection control personnel and should be available to all disciplines of staff. Infection control needs to be seamless across the primary and secondary care interface and must include infection prevention advice to the population in general. Evidence relating to infection control is either lacking or not achievable. When it is available, it is not always implemented because of lack of resources.

Multiresistant bacteria as a hospital epidemic problem

Since the introduction of antibiotics into clinical use, bacteria have protected themselves by developing antibiotic resistance mechanisms. Currently, there are increasing problems worldwide with multiresistant bacteria. These problems are especially evident within hospitals, where they frequently present as nosocomial epidemics. Currently, the most important nosocomial resistance problems on a global scale are caused by methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci and Enterobacteriaceae with plasmid-encoded extended-spectrum beta-lactamases. In this review we describe the characteristics of nosocomial epidemics of these three groups of multiresistant nosocomial pathogens. Despite the differences in bacterial species, the differences in mechanisms of resistance, the different ecological niches and the different infections caused by these pathogens, there are striking similarities in the variables determining nosocomial spread. The existence of each of these multiresistant micro-organisms and their concurrent spread seem to result from extensive antibiotic use and lapses in compliance with infection control measures. Problems with these bacteria became evident as monoclonal outbreaks, soon followed by establishment of endemicity especially in intensive care units. Finally, endemicity seems to be established on general hospital wards and in chronic care facilities and nursing homes, creating a continuous influx of colonized patients into special care wards. High compliance with infection control measures and a prudent and more restrictive use of antibiotics are the key measures to prevent these epidemics.

Eyecare for the sedated patient undergoing mechanical ventilation: the use of evidence-based care

There is a need to evaluate different nursing procedures to determine whether in today's cost-conscious climate of health care they genuinely benefit the patient. If such procedures are indeed found to be of value, ways must be explored of ensuring that the manner in which they are performed conforms to acceptable standards. In the study reported here eyecare for the ventilated, sedated patient was examined because variations in clinical practice had been observed and a preliminary examination of the literature indicated that this patient group was at particular risks of developing serious ocular complications. The study was conducted in two phases. Phase 1 took the form of a literature review which demonstrated that although many questions remained unanswered, sufficient information relating to eyecare existed to help develop protocols to guide care. Phase 2 consisted of non-participant observation with 15 nurses employed in an intensive care unit to examine the standard of eyecare actually delivered. The standard of eyecare fell short of the ideal and as in other studies designed to observe nursing procedures accurately and in detail, there was no demonstrable relationship between clinical practice, knowledge or clinical experience. From the study overall it was possible to conclude that patients would benefit from the implementation and audit of guidelines of eyecare but that before these innovations are undertaken barriers to good practice should be explored in intensive care units.

A descriptive study of the handwashing environment in a long-term care facility

The authors present a clinical research project accomplished by a nurse during her first year of practice after graduating from a B.S.N. program. In her caregiving at a long-term care facility subacute unit, she was unable to do proper handwashing. The poorly placed pump-style paper towel dispensers were inadequate for the task. She knew that handwashing before and after resident contact is the single most effective infection control measure to prevent nosocomial infections. In consultation with her university professor, she designed and implemented a descriptive study of the facility's handwashing environment. She mapped and measured handwashing areas, explained constrictions the environment placed on handwashing technique, collected random cultures from the sinks and dispenser levers, and illustrated for administrative and auxiliary personnel the basic principles of microbiology. Implications for infection prevention and control in long-term care facilities are discussed in light of increased "high-end skilled nursing" being offered in subacute units.

Distribution of bacteria on hands and the effectiveness of brief and thorough decontamination procedures using non-medicated soap

Our perception of the role of hand washing in the clinical situation is based on experimental studies in which test-bacteria are usually inoculated onto the skin surface and removed using hand washing preparations containing antiseptics. In this study, we have investigated the distribution of bacteria on the hands of volunteers and the effectiveness of long (3 minute) and brief (10 second) washes in removing both naturally-occurring and artificially-inoculated bacteria (Micrococcus sp.), using only soap and water. There was a tenfold reduction in median counts of artificially inoculated bacteria following both long and brief washes. However, less than 50% of naturally-occurring bacteria were removed and, for hands previously disinfected by immersion in 70% ethanol, the washing procedure increased bacterial counts. In both unwashed hands, and hands washed following a strict protocol, the mean variation in counts of naturally-occurring bacteria at different sites (wrists, dorsal surface, palmar surface, fingertips and interdigital spaces) was only two-fold. The efficiency of recovery of naturally-occurring organisms was estimated by repeated swabbing, to be more than 60%. The data question the value of typical hand wash procedures recommended by many authorities for use in clinical situations and of the perfunctory hand washes frequently adopted by nursing staff in busy wards. Experimental evidence is required to justify procedures and to identify the precise circumstances in which they are of value.

The use of a ward-based educational teaching package to enhance nurses' compliance with infection control procedures

Obtaining study leave is becoming difficult for clinical nurses in the current economic climate, but the need to develop new clinical skills and to maintain existing good practice remains of prime importance to patient care and will become mandatory with the advent of post-registration education and practice (PREP) in the UK. The ward is widely acknowledged as the best venue for learning clinical skills by nurse educationalists and for many nurses is the preferred learning environment. The feasibility of using a ward-based teaching package to enhance nurses' compliance with key infection control precautions (hand decontamination, the use of gloves and the safe handling and disposal of sharp instruments) was tested in a quasi-experimental research study conducted on matched surgical wards in a teaching hospital, controlling for variables likely to influence performance (knowledge, availability of resources to perform infection control, previous opportunity to develop infection control expertise and nursing workload). Nurses on two wards received the intervention (experimental group). The remaining wards, which received no intervention, operated as controls. The ward-based sessions consisted of a carefully planned sequence of theory and practical demonstration delivered to qualified nurses in the clinical environment at convenient times selected by the ward managers. Performance of infection control precautions was audited before the intervention and 3 months afterwards. The sessions were well evaluated and the clinical environment was considered suitable for teaching by the nurses, but heavy and unpredictable workload prevented the teaching programme from being implemented as planned. The analysis of covariance failed to detect any changes in performance between nurses in the control and experimental groups. The implications of the study findings are discussed to help develop creative new ways of strengthening ward-based educational programmes.

Using vignettes to collect data for nursing research studies: how valid are the findings?

Vignettes are simulations of real events which can be used in research studies to elicit subject's knowledge, attitudes or opinions according to how they state they would behave in the hypothetical situation depicted. Advantages associated with the use of vignettes as research tools include: the ability to collect information simultaneously from large numbers of subjects, to manipulate a number of variables at once in a manner that would not be possible in observation studies, absence of observer effect and avoidance of the ethical dilemmas commonly encountered during observation. Difficulties include problems establishing reliability and validity, especially external validity. This paper considers the advantages and disadvantages associated with the use of vignettes as data collection tools, concluding with a check-list to help critique vignettes studies.

Creative infection control

In spite of the widespread use of educational programmes, there still remains a low staff knowledge and non-compliance of infection control policies. In order to overcome these problems we have attempted to increase interest and raise awareness of infection control by introducing a motivational programme termed Creative Infection Control. Some of the activities are illustrated and are loosely structured, and rely largely on humour and intergroup competition. These methods are based on sound psychological principles with an emphasis on adult-learning theory. Objective measures indicate that such programmes can significantly influence infection control outcomes.