Tolerance and acceptability of 14 surgical and hygienic alcohol-based hand rubs

Tests were performed under working practice conditions to measure the tolerance and acceptability of commercially available hand rubs with proven efficacy. The products were compared with those in current use at the Hospices Civils de Lyon for surgical hand disinfection (Sterillium) and hygienic hand disinfection (Purell) to obtain information for public sector purchases. The 12 test products were Alcogel H, Assanis Pro, Clinogel, Dermalcool, Manugel Plus, Manugel Plus NPC, Manurub Liquid, Manurub Gel, Purell 85, Spitacid, Spitagel and Sterillium Gel. They were tested from mid-November to mid-April over four periods of three weeks, separated by two-week intervals during which the customary product was re-introduced. Participation of hospital wards and theatres was voluntary. Skin dryness and irritation were scored before and after each test period. Acceptability and ease of use were assessed by means of a questionnaire. Among the eight surgical hand rubs, only Manurub Liquid, Manurub Gel and Manugel Plus NPC did not cause significantly more dryness and irritation than Sterillium. For the 10 hygienic hand rubs, differences were noted depending upon the test period. Overall, Assanis Pro, Clinogel, Purell 85 and Sterillium Gel did not cause significantly more dryness and irritation than Purell. However, over the (colder) first three test periods, Assanis Pro and Sterillium Gel caused more irritation and Purell 85 caused more dryness than Purell. Responses to the questionnaires on acceptability indicated that users preferred their customary hand rubs (Sterillium and Purell). As these field tests involving many participants did not identify any superior products, previous purchase orders were renewed.

Microbial flora on operating room telephones

Approximately 500,000 surgical site infections (SSIs) occur each year in the United States. The purpose of this study was to determine if the bacteria most frequently involved in SSIs could be found on telephones in the OR. Twenty-six cultures were taken from telephones in 14 ORs and two substerile rooms at a large teaching medical center. Using standard laboratory procedures, the researchers identified coagulase-negative staphylococci in the cultures. The study found that telephones in the OR can serve as reservoirs for SSI-causing bacteria.

Occupational Therapists' Knowledge and Practice of Infection Control Procedures: A Preliminary Study

Occupational therapists often meet clients with infections in the course of their work, but research into such therapists' knowledge and practice of infection control procedures is limited. This small postal survey explored the deficit, gathering data from 63/93 (68%) occupational therapists working in 12 randomly selected English health care trusts. The results showed evidence of a discrepancy between respondents' knowledge and practice of infection control procedures. The respondents acknowledged the importance of infection control but did not always take the necessary precautions, reporting some difficulty in judging the latter. The reasons for the study findings and their potential implications for occupational therapy practice, research and education are considered.

Multicentre study on hand hygiene facilities and practice in the Mediterranean area: results from the NosoMed Network

Hand hygiene literature is scarce in the southern Mediterranean area. In order to establish a baseline position, a study was performed in four Mediterranean countries. Seventy-seven hospital wards in 22 hospitals were enrolled and information on hand hygiene practice and facilities were collected. The overall compliance rate was very low (27.6%), and was significantly higher where the perceived risk was considered to be high. Intensive care units showed the highest level of compliance. Analysis by country indicated higher compliance in Egypt (52.8%) and Tunisia (32.3%) compared with Algeria (18.6%) and Morocco (16.9%). Facilities for hand hygiene, particularly consumables, were shown to be deficient. Multi-approach programmes combining the production of official local recommendations, education and regular evaluation of hand hygiene practice are much needed to improve the present situation.

Can a handwashing intervention make a difference? Results from a randomized controlled trial in Jerusalem preschools

BACKGROUND

Preschools are often focal points for the spread of illness among young children. The objective of this preschool intervention trial was to determine whether a hygiene program can promote handwashing and thereby reduce illness absenteeism.

METHODS

This cluster randomized trial included 40 Jerusalem preschools with 1029 children for 6 baseline days and 66 study days, yielding 73,779 child days. The main outcomes were rates of handwashing and illness absenteeism. The intervention included an educational program and environmental changes. A simultaneous subtrial was run to test a home component.

RESULTS

This multi-site intervention program produced sustained behavioral and environmental changes over a 6-month period. An approximately threefold increase in handwashing with soap was observed among preschool children exposed to the intervention. Neither the preschool nor the home intervention program reduced illness absenteeism or overall absenteeism.

CONCLUSIONS

This trial illuminates the potential of the preschool as a promising venue for health promotion activities leading to sustained behavioral change, yet suggests the need for enhanced approaches for reducing illness absenteeism.

Plan-do-study-act cycles as an instrument for improvement of compliance with infection control measures in care of patients after cardiothoracic surgery

The aim of this study was to determine whether compliance with infection control measures for the care of patients during and after cardiothoracic surgery could be improved by using 'plan-do-study-act' (PDSA) improvement cycles in a 715-bed university hospital. The endpoints of these cycles were indices of correct procedure based on infection control standards. The intervention consisted of instruction and training of nursing and medical staff on the use of PDSA cycles, feedback of the baseline measurements, and the use of posters in the proximity of the operating room (OR). At follow-up, overall compliance only improved in the room used by the perfusionists and the OR. After the follow-up period, monitoring revealed a drop in compliance in the OR, but improved compliance during vascular catheter care of patients with prolonged stay in the intensive care unit (ICU), and during wound care of patients on the nursing ward. The last series of monitoring showed that compliance with general infection control measures in the OR had improved again, and that compliance had remained satisfactory on the ward and in the ICU, with the exception of patients recently transferred to the ICU from the OR. The results show that by using PDSA cycles, compliance with infection control measures can improve significantly. However, repeated monitoring is necessary to ensure continued compliance.

Infection control in neonatal intensive care units

Healthcare-associated infection is a major problem in acute hospital settings. Hand decontamination is considered to be the most effective means of preventing healthcare-associated infection, but is poorly performed. Few studies have examined technique, which may be important in neonatal intensive care units (NICUs) where clinical procedures are intricate and could result in contamination of many areas of the hand, resulting in cross-infection. This study examined technique in six NICUs. Eighty-eight nurses were observed. A scoring system was developed so that technique could be quantified and subjected to statistical testing. The mean score was 6.29 out of 11 when hands were washed and 3.87 out of 7 when alcohol hand rub was used, indicating that performance was not optimal. Scores for technique were not significantly different in each NICU. Senior nurses achieved higher scores for handwashing (P<0.01), as did nurses holding positive feelings about the atmosphere in their NICU (P=0.04). Junior nurses scored less well on a knowledge questionnaire than senior nurses (P<0.01). Nurses who had been employed in the neonatal unit for less than one year also scored less well (P<0.01). Differences in technique were noted when comparing the beginning and end of long shifts. These differences were not noted at the beginning and end of standard shifts.

Could hospital patients' hands constitute a missing link?

The relationship between contamination of patients' hands and transmission of healthcare-associated infection has received only limited attention, but may represent a previously overlooked but potentially significant link in the chain of infection. This paper aims critically to review the literature to determine whether this possible epidemiological relationship is worthy of further consideration. Studies that have investigated the microbiology or hand hygiene behaviours of patients and other groups are examined to establish their limitations and implications for future practice and research. Examples of healthcare-associated infections where improving patient hand hygiene may have a favourable impact on transmission, and how this might be achieved within the context of current UK health service initiatives, are discussed. It is recommended that systematic studies of the role of patients' hands in the chain of hospital infection should be undertaken.

Barrier precautions, isolation protocols, and personal hygiene in veterinary hospitals

Because nosocomial and zoonotic diseases are inherent and ever-present risks in veterinary hospitals, proactive policies should be in place to reduce the risk of sporadic cases and outbreaks. Policies should ideally be put in place before disease issues arise, and policies should be effectively conveyed to all relevant personnel. Written policies are required for practical and liability reasons and should be reviewed regularly. Although no infection control program can eliminate disease concerns, proper implementation of barrier precautions and isolation can reduce the exposure of hospitalized animals and hospital personnel to infectious agents. Appropriate personal hygiene, particularly hand hygiene, can assist in the prevention of disease transmission when pathogens bypass barriers and are able to contact personnel. Veterinary hospitals have moral, professional, and legal requirements to provide a safe workplace and to reduce the risks to hospitalized patients. Based on experience in the human medical field and on the continual emergence of new infectious diseases, infection control challenges can only be expected to increase in the future. Regular reassessment of protocols based on ongoing research and clinical experiences is required.

Hand hygiene practices in a neonatal intensive care unit: a multimodal intervention and impact on nosocomial infection

OBJECTIVE

Health care-associated infections persist as a major problem in most neonatal intensive care units. Hand hygiene has been singled out as the most important measure in preventing hospital-acquired infection. However, hand hygiene compliance among health care workers (HCWs) remains low. The objective of this study was to assess the frequency and nature of patient contacts in neonatal intensive care units and observe the compliance and technique of hand hygiene among HCWs before and after the implementation of a multimodal intervention program.

METHODS

The nature and frequency of patient contacts, the hand hygiene compliance, and hand-washing techniques of HCWs were observed unobtrusively to reflect the baseline compliance and to investigate factors for noncompliance. The intervention consisted of problem-based and task-orientated hand hygiene education, enhancement of minimal handling protocol and clustering of nursing care, liberal provision of alcohol-based hand antiseptic, improvement in hand hygiene facilities, ongoing regular hand hygiene audit, and implementation of health care-associated infection surveillance. The observational study was repeated 6 months after the completion of the intervention program, which extended over 1-year period.

RESULTS

Overall hand hygiene compliance increased from 40% to 53% before patient contact and 39% to 59% after patient contact. More marked improvement was observed for high-risk procedures (35%-60%). The average number of patient contacts also decreased from 2.8 to 1.8 per patient per hour. There was improvement in most aspects of hand-washing technique in the postintervention stage. The health care-associated infection rate decreased from 11.3 to 6.2 per 1000 patient-days.

CONCLUSION

A problem-based and task-orientated education program can improve hand hygiene compliance. Enhancement of minimal handling and clustering of nursing procedures reduced the total patient contact episodes, which could help to overcome the major barrier of time constraints. A concurrent decrease in health care-associated infection rate and increase in hand hygiene compliance was observed in this study. The observational study could form part of an ongoing audit to provide regular feedback to HCWs to sustain the compliance.

Hand washing and hand disinfection: more than your mother taught you

Hand washing is considered the single most important intervention for prevention of nosocomial infections in patients and health care workers. Unfortunately, compliance with standard protocols for hand hygiene in the health care environment, and especially within intensive care areas such as operating rooms and post-anesthesia care units, has been generally poor. In this article, we consider the current standards for hand hygiene as they pertain to the practice of anesthesiology. We discuss the consequences of poor compliance with hand washing practices for patient and health care provider safety. And we describe modern innovations in hand washing procedures and products that improve the opportunities for anesthesiologists to employ safe hand hygiene.

Comparative in vitro and in vivo study of nine alcohol-based handrubs

BACKGROUND

Hygienic hand disinfection using alcohol-based handrubs (AHRs) is an alternative method to conventional handwashing in hospital wards. Because a documented choice of such products would consider data from in-care evaluation, we designed a comparative study of 9 AHRs both in vitro and in vivo in actual care conditions.

METHODS

The bactericidal activity of AHRs was first measured in vitro against 4 hospital strains exhibiting multiple antibiotic resistance: Acinetobacter baumannii, Staphylococcus aureus, Pseudomonas aeruginosa, and Enterobacter aerogenes. In a second time, AHRs were tested in an intensive care unit for antibacterial activity against the cutaneous flora of personnel hands and for acceptance by the care personnel.

RESULTS

The 9 AHRs could be classified in 3 groups on the basis of their in vitro activity: products of the first group showed a bactericidal activity higher than 4 log(10) against the 4 strains. Only 1 of these products presented simultaneously an effective antibacterial activity against the cutaneous flora of care personnel hands and a good acceptance by the care personnel.

CONCLUSION

The in vitro study allowed the differentiation of the AHRs tested on the basis of bactericidal activity, but evaluation in an in-care situation allowed further discrimination through both antibacterial activity and acceptance. Thus, the combination of in vitro and in vivo evaluations should provide helpful arguments in the choice of AHRs.

Environmental surface cleanliness and the potential for contamination during handwashing

Effective handwashing (including drying) is important in infection control. The ability of the various stages of handwashing to decrease skin-surface microbial counts has been documented. However, an important element, environmental surface cleanliness, and the potential for contamination of hands during the process has not been well studied or quantified. An examination of the adenosine triphosphate (a measure of residual organic soil), bacterial, and staphylococcal load on ward handwash station surfaces, which could be touched during handwashing, is reported. Hand contact surfaces tested consisted of approximately 620 each of: faucet handles, soap dispenser activator mechanisms, and folded paper-towel dispenser exits. Failure rates in excess of benchmark clean values were higher with adenosine triphosphate assays than microbial counts. This could indicate the presence of a higher level of general organic debris (eg, skin cells) as opposed to microbial contamination or could reflect greater assay sensitivity. Faucet handles were more likely to be contaminated and be in excess of benchmark values than paper-towel dispenser exits. However, the latter are likely to be the final surface touched during the handwashing process and overall nearly 20% were above microbiologic benchmark values. Many of the organisms isolated were staphylococci and the results are discussed within the context of microbial cross-contamination and potential pathogen spread.

Technique to determine contamination exposure routes and the economic efficiency of folded paper-towel dispensing

Handwashing and hand drying are key elements of infection control. Paper towels are generally accepted as the most hygienic means of drying hands and are often distributed from generic dispensers. Effective dispensing of towels is of importance economically and may influence infection control objectives if hands become contaminated during hand drying. In this study, a method to identify potential exposure routes for hand contamination and evaluate the efficiency of paper-towel dispensing is described and applied to 5 different folded paper towels using a generic wall-mounted dispenser. A total of 18 male and female participants of varying heights participated in pull testing of 400 paper towels each, in controlled hand-drying simulations. All events having the potential for hand contamination, including towel jamming, towels falling onto the floor, and incidental contact of paper exits, were monitored and documented. There was considerable variation in dispensing efficiency between different towel brands. One towel (Z) had significantly (P <.05) superior dispensing properties from the generic dispenser. Participants of a shorter height obtained a lower incidence of dispensing malfunctions using all towel products and type. The results indicated likely contamination exposure routes and wastage levels for each towel type. Environmental service managers and infection control practitioners should carefully consider, for economic and infection control reasons, the siting and design of towel dispensers and the types of towel purchased.

Handwashing among female college students

Handwashing has been recognized as a critical factor in infection control policies. Whereas handwashing compliance among health care workers and school-aged students has been previously documented, practices among college students remain relatively unknown. The objective of this study was to determine handwashing compliance of female college students after using the bathroom. A researcher situated in a toilet stall unobtrusively observed handwashing compliance among 100 female students. Most students (63%) washed their hands, 38% used soap, 32% washed with soap for 5 or more seconds, but only 2% washed their hands with soap for 10 or more seconds. Fewer students left without handwashing when someone else was present in the sink area (9%) than when they were alone (45%) (P =.002). Substantial bacterial colony counts were found on a female bathroom sink faucet and toilet seat confirming the need for programs to increase handwashing compliance. Potential strategies to optimize infection control include harnessing the influence of peer pressure on handwashing and the installation of motion-activated faucets, disposable seat covers, and exit doors that can be pushed open. These results should be confirmed in a larger study that includes both male and female college students.

The importance of evaluating product dispensers when selecting alcohol-based handrubs

BACKGROUND

To promote improved hand hygiene among personnel, a hospital installed dispensers for an alcohol-based hand rinse throughout the facility. Soon after installation, dispensers began to malfunction and continued to do so despite efforts to rectify the problem.

METHODS

Sixteen months after installation, dispensers in all patient rooms were examined, and surveyors recorded the condition of dispensers, the number of times the dispenser lever was pressed to obtain product, how the product was delivered onto the hand, and a qualitative estimate of the volume delivered.

RESULTS

Of 166 dispensers, 2% were broken, 7% had no product container, 5% had an empty product container, 9% contained product but were totally obstructed, and 77% were functional. Of the 128 functional dispensers, 65% delivered product after a single stroke of the lever, 13% after 2 strokes, 9% after 3 strokes, and 13% after 4 or more strokes. Seventeen percent delivered a small volume onto the hand, and 16% squirted the product onto the wall or floor.

CONCLUSION

Evaluation of alcohol-based handrubs should consider not only product characteristics, user acceptability, skin tolerance, and cost but also the design and function of the dispensers that will ultimately be installed.

The role of the home environment in the transmission of infectious diseases

The purpose of this paper is to examine current health care literature (1980-2000) regarding the microbiology of the home environment, to summarize evidence of transmission within the home, and to assess effectiveness of cleaning practices and products. The home environment, particularly the kitchen and bathroom, serves as a reservoir of large numbers of microorganisms, particularly Enterobacteriacae, and infectious disease transmission has been demonstrated to occur in 6-60% of households in which one member is ill. Current food preparation and cleaning practices provide multiple opportunities for intra-household member spread. Routine cleaning is often sufficient, but in cases of household infection, may not adequately reduce environmental contamination. The effectiveness of disinfectants varies considerably and depends on how they are used as well as their intrinsic efficacy. The behavioral aspects of infection prevention in the home (e.g., foodhandling and cleaning practices) warrant increased public attention and education.

Nosocomial infections in pediatric intensive care units

Nosocomial infections are a significant problem in pediatric intensive care units. While Indian estimates are not available, western PICUs report incidence of 6-8%. The common nosocomial infections in PICU are bloodstream infections (20-30% of all infections), lower respiratory tract infections (20-35%), and urinary tract infections (15-20%); there may be some differences in their incidence in different PICUs. The risk of nosocomial infections depends on the host characteristics, the number of interventions, invasive procedures, asepsis of techniques, the duration of stay in the PICU and inappropriate use of antimicrobials. Most often the child had endogenous flora, which may be altered because of hospitalization, are responsible for the infections. The common pathogens involved are Staphylococcus aureus, coagulase negative staphylococci, E. coli Pseudomonas aeruginosa, Klebsiella, enterococci, and candida. Nosocomial pneumonias predominantly occur in mechanically ventilated children. There is no consensus on the optimal approach for their diagnosis. Bloodstream infections are usually attributable to the use of central venous lines; use of TPN and use of femoral site for insertion increase the risk. Urinary tract infections occur mostly after catheterization and can lead to secondary bacteremia. The diagnostic criteria have been discussed in the review. With proper preventive strategies, the nosocomial infection rates can be reduced by up to 50%; handwashing, judicious use of interventions, and proper asepsis during procedures remain the most important practices.

An organizational climate intervention associated with increased handwashing and decreased nosocomial infections

Handwashing practices are persistently suboptimal among healthcare professionals and are also stubbornly resistant to change. The purpose of this quasi-experimental intervention trial was to assess the impact of an intervention to change organizational culture on frequency of staff handwashing (as measured by counting devices inserted into soap dispensers on four critical care units) and nosocomial infections associated with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). All staff in one of two hospitals in the mid-Atlantic region received an intervention with multiple components designed to change organizational culture; the second hospital served as a comparison. Over a period of 8 months, 860,567 soap dispensings were recorded, with significant improvements in the study hospital after 6 months of follow-up. Rates of MRSA were not significantly different between the two hospitals, but rates of VRE were significantly reduced in the intervention hospital during implementation.

Effect of hand cleansing with antimicrobial soap or alcohol-based gel on microbial colonization of artificial fingernails worn by health care workers

This study was undertaken to determine differences in microflora on the nails of health care workers (HCWs) wearing artificial nails compared with control HCWs with native nails and to assess the effect on these microflora of hand cleansing with antimicrobial soap or alcohol-based gel. Cultures were obtained from 21 HCWs wearing artificial nails and 20 control HCWs before and after using antimicrobial soap or alcohol-based gel. Before cleansing with soap, 86% of HCWs with artificial nails had a pathogen (gram-negative bacilli, Staphylococcus aureus, or yeasts) isolated, compared with 35% of controls (P=.003); a similar difference was noted before hand cleansing with gel (68% vs. 28%; P=.03). Significantly more HCWs with artificial nails than controls had pathogens remaining after hand cleansing with soap or gel. Of HCWs with artificial nails, only 11% cleared pathogens with soap compared with 38% with gel. Of control HCWs, only 14% cleared with soap compared with 80% with gel. Artificial acrylic fingernails could contribute to the transmission of pathogens, and their use by HCWs should be discouraged.

Availability of an alcohol solution can improve hand disinfection compliance in an intensive care unit

We investigated whether rubbing with an alcohol solution increases compliance with hand disinfection in a medical intensive care unit (MICU). During a first period (P1), hand disinfection was achieved only through conventional washing, whereas during a second period (P2), hand disinfection could be achieved either through conventional washing or rubbing with an alcohol solution. There were 621 opportunities for hand disinfection during P1 and 905 opportunities during P2. General compliance during P1 was 42.4%, and reached 60.9% during P2 (p < 0.001). This improvement was observed among nurses (45.3% versus 66.9%, p < 0.001), senior physicians (37. 2% versus 55.5%, p < 0.001), and residents (46.9% versus 59.1%, p = 0.03). Acceptability and tolerance were evaluated through the answers to an anonymous questionnaire distributed to all 53 health care workers in the MICU. Rubbing with alcohol solution was an easy procedure (100% of responses) and induced mild side effects in less than 10% of respondents. In a complementary study conducted 3 mo after the first one, compliance remained better than during P1 (51. 3% versus 42.4%, p = 0.007). These findings suggest that rubbing with alcohol solution increases compliance with hand disinfection, and that it could be proposed as an alternative to conventional handwashing in the MICU.

Skin hygiene and infection prevention: more of the same or different approaches?

The purpose of this article is to review research indicating a link between hand hygiene and nosocomial infections and the effects of hand care practices on skin integrity and to make recommendations for potential changes in clinical practice and for further research regarding hand hygiene practices. Despite some methodological flaws and data gaps, evidence for a causal relationship between hand hygiene and reduced transmission of infections is convincing, but frequent handwashing causes skin damage, with resultant changes in microbial flora, increased skin shedding, and risk of transmission of microorganisms, suggesting that some traditional hand hygiene practices warrant reexamination. Some recommended changes in practice include use of waterless alcohol-based products rather than detergent-based antiseptics, modifications in lengthy surgical scrub protocols, and incorporation of moisturizers into skin care regimens of health care professionals.

A close look at alcohol gel as an antimicrobial sanitizing agent

BACKGROUND

Hand transmission of microbes by health care workers is a primary cause of nosocomial infections in both long-term and acute care facilities. Compliance with effective handwashing and hand sanitization regimens can break this cycle.

METHODS

We investigated the antimicrobial efficacy and irritation potential of 5 handwash product regimens: a nonantimicrobial lotion soap, an antimicrobial lotion soap, an alcohol gel sanitizer, a nonantimicrobial lotion soap with an alcohol gel sanitizer, and an antimicrobial lotion soap with an alcohol gel sanitizer. The regimens were evaluated by using a Healthcare Personnel Handwash procedure, and irritation was assessed by using expert hand evaluation after 25 consecutive washes.

RESULTS

The Healthcare Personnel Handwash data showed that the mean log reductions from baseline were greatest for the lotion soaps with alcohol gel sanitizer, less for the alcohol and the antimicrobial soap alone, and least for the bland soap. All of the product regimens showed a low potential for skin irritation.

CONCLUSION

In terms of both microorganism reduction and skin irritation, the most effective product regimens were the use of alcohol gel sanitizer in combination with either an antimicrobial or a plain lotion soap.

Effect of several interventions on the frequency of handwashing among elementary public school children

BACKGROUND

The purpose of this educational project was to assess the effect of several interventions on the frequency of handwashing among elementary public school children.

METHODS

Participants in this project were first-graders and fourth-graders from jurisdictions within a mid-Atlantic metropolitan area. Phase I included a baseline assessment of bathroom cleanliness as well as adequacy of supplies for handwashing in each school. During phase 2, the frequency of handwashing before lunch or after bathroom use was monitored and recorded during a 2-month period. The schools were separated into four groups: a peer education group, a hand wipes and instructional poster group, a combination of the education and hand wipes/poster groups, and a (control) comparison school.

RESULTS

Overall, a significant increase occurred in the proportion of handwashing frequency from preintervention to postintervention for each intervention group (wipes: 0.50 vs 0.66, p = 0.03; education only: 0.64 vs 0.72, p = 0.02; and education and wipes: 0.45 vs 0.67, p = 0.03) but not in the control group (0.42 vs 0.46, p = 0.26). When the first 3 weeks and the last 3 weeks after intervention were compared, handwashing frequency remained unchanged in the wipes only group (0.66 vs 0.66, p = 0.96), decreased in the education group (0.77 vs 0.65, p = 0.006), and increased in the education and wipes group (0.58 vs 0.75, p = 0.003), as well as in the control group (0.37 vs 0.52, p = 0.01).

CONCLUSION

Education combined with accessible convenient hand hygiene may result in a sustainable increase in the frequency of handwashing among elementary school children.

LOWER RESPIRATORY TRACT INFECTIONS IN ELDERLY PATIENTS WITH ASTHMA

Infection plays a significant role in the morbidity and mortality of the elderly. One population in which infection has not been adequately studied is the elderly asthmatic. This article examines the problems of lower respiratory tract infections in elderly asthmatics in the context of their host defenses, the severity of infection, and their risk of infection with specific organisms. The role of infection in the pathogenesis of asthma and consideration of prophylaxis and therapy are presented.

Nurses' infection-control practice: hand decontamination, the use of gloves and sharp instruments

Infection is an acknowledged hospital problem. Micro-organisms are disseminated mainly via hands but there is evidence that hand decontamination, the most important means of prevention, is performed too seldom, and not always after activities likely to result in heavy contamination. Nurses themselves are exposed to risks of infection, chiefly through contact with blood and body fluids, yet it has also been reported that gloves are not always worn during contact with patients' secretions and that the handling and disposal of sharp instruments may be performed unsafely. The study reported in this paper documents nursing behaviour in relation to hand decontamination, the use of gloves and sharps, taking into consideration a number of variables which could influence practice: availability of the expertise afforded by an infection-control nurse, clinical setting, nursing workload, knowledge and the resources available to control infection. Hands were decontaminated after 28.78% of patient contacts. Hands were decontaminated after 49.85% of activities likely to result in heavy contamination. Performance was related to nursing workload and the availability of hand decontaminating agents, especially when the nurses became busy. Use of gloves when they were available also proved good, with little evidence of wasteful use. The handling and disposal of sharps were commendable for most subjects but a few grossly unsafe incidents were nevertheless witnessed, apparently not associated with any of the variables examined.

The effects of 'in-use' surgical handwashing on the pre- and postoperative fingertip flora during cardiothoracic and orthopaedic surgery

Two operating teams (25 persons) were followed for two months with fingerprint samples taken preoperatively; before and after 'in-use' surgical handwashing; and immediately postoperatively, with and without surgical gloves. The mean time for handwashing for the cardiothoracic team (CT) was 2 min and for the orthopaedic team (OT) was 3.5 min. A closer observation of 10 persons revealed a great individual variation in washing techniques, in spite of standard guidelines. The CT team performed eight, and the OT team nine sterile operations with an average duration of 3 h and 20 min and 2 h and 40 min, respectively. Surgical handwashing resulted in fingertip sterility in 111/118 (94.1%) cases; in 61/66 (92.4%) samples from the surgeons and in 50/52 (96.2%) samples from the assistants. Postoperative fingerprinting with gloves on showed sterile conditions in 85/91 (93.4%) samples; 57/59 (96.6%) from the surgeons and 28/32 (87.5%) from the assistants. Immediately after removal of the gloves, 43/67 (64.2%) of fingerprint samples from the surgeons and 13/48 (27.1%) from the assistants were still sterile. Coagulase-negative staphylococci (CNS) and Bacillus species predominated in fingerprint samples. Of the 105 CNS strains tested, 11.4% were methicillin resistant. Only five strains of Staphylococcus aureus were isolated; in 4/5 cases from the OT. This study illustrates that in spite of standard guidelines, there is great individual variation in surgical handwashing. However, in most instances, the bacteria are eradicated from the fingertips. Even after surgery for 2-3 h, there may still be a residual effect of the hand disinfecting agent in half of the cases.

Reality of glove use and handwashing in a community hospital

BACKGROUND

Since the advent of universal precautions and body substance isolation, few studies have examined the relationship between glove use and handwashing.

METHODS

During a 5-month period in 1991, 477 structured observations were conducted on 19 patients care units at a community teaching hospital during each of three shifts. Patient care contacts were defined as either high level or low level according to potential for blood or body fluid contact.

RESULTS

Health care workers were potentially exposed to body fluids (high-level contact) on 152 occasions. Eighty-eight percent of all high-level contacts were limited to the hands; 47% of these contacts occurred during the night shift. Handwashing occurred after 32% of high-level contacts. Health-care workers wore gloves in 57% of high-level contacts. Rates of handwashing and glove use varied markedly among patient care units. Correct handwashing (> or = 9 seconds) occurred after 20% of contacts when health care workers wore gloves but after only 3% of high-level contacts when gloves were not used (p = 0.004).

CONCLUSIONS

Despite universal precautions or body substance isolation, educational efforts, and written policies, rates of handwashing and glove use are inadequate in cases of potential blood and body fluid contact. The perceived need for gloves may encourage handwashing.

Nurses' hand decontamination practice: results of a local study

Cross-infection in hospital occurs mainly via hands. Hand washing is the most effective means of prevention, yet it has been reported that hands are washed too seldom, often inappropriately and that technique is poor. However, these claims are often made without explaining precisely how data were collected. This study employed more rigorous criteria than earlier research to judge the appropriateness and technique of nurses' hand contamination. During the 2 h that they were observed nurses decontaminated hands after 28.7% patient contacts. The data were then reanalysed so that only those activities likely to result in heavy contamination were examined. This revealed that such 'essential' decontaminations were performed on 49.8% occasions. Differences were found between hospitals related to the availability of hand decontaminating agents, particularly when nursing workload became high. A scoring system to assess technique was developed for the study. Mean score was 8.6 out of 12. Technique was superior for nurses employed in intensive care units regardless of the hospital in which data were collected (P < 0.0001). Nurses' knowledge of infection control was poor, but those with more knowledge decontaminated hands more appropriately (P < 0.004), although they did not have a better technique. It is recommended that future research move beyond mere description, with its inevitable conclusion that clinical staff should improve performance, turning toward the identification of local barriers to effective practice. This could be followed by improvement in resources and educational intervention should these emerge as problematic.

A multicentre survey of hand hygiene practice in intensive care units

A detailed survey of hand hygiene in 16 intensive care units (ICUs) in Yorkshire was undertaken with the aim of following up the results of a national survey of infection control policies and practices which had been conducted in 1990 (Inglis et al., Br J Anaesthesia 1992; 68, 216-220). The main problems associated with infection control were identified as: the limited relevance of some infection control policies to the specialist nature of intensive care, poor compliance by nurses to local infection control policies, sub-optimal hand hygiene by all healthcare professionals and a need for more effective communication of research-based infection control recommendations in the ICU. Our results suggest that hand hygiene practice in the ICU is sub-optimal as a consequence of ineffective communication of infection control recommendations, insufficient promotion and enforcement of agreed research-based infection control practices, and a deficiency in infection control education. The current methods of communicating infection control recommendations have a limited effect on compliance rates in the ICU and are not evaluated adequately. Recommendations for further development in this field are to prioritise surveillance of infection rates in ICUs and to feedback infection rates to intensive care staff, to identify local priorities for infection control and to introduce continuous infection control education for all healthcare professionals. Further research is required to investigate and understand why educated health professionals are not complying with recommended research-based infection control practices.

An epidemiological study assessing the relative importance of airborne and direct contact transmission of microorganisms in a medical intensive care unit

A prospective epidemiological survey was carried out over a period of seven weeks in a medical intensive care unit. Bacteria from patients, staff and air were monitored and the transmission of isolated microorganisms was followed. Handwashing samples revealed pathogenic bacteria in 30.8% of physicians (average number of colony forming units: 71,300 per hand) and 16.6% of nurses (39,800 cfu per hand). Air cultures yielded pathogens in 15% of sampling periods and nine of 53 patients were found to be colonized with Gram-negative bacteria, Staphylococcus aureus or Candida spp. The spectrum of bacteria recovered from patients and air was generally different, whereas strains recovered from patients and their attendants' hands were indistinguishable on multiple occasions. The results of this study confirm that direct contact is the principal pathway of microbial transmission, whereas little evidence for a significant role of airborne transmission is shown. The call for more extensive air-filtering and ventilation systems in medical intensive care units is not supported by the results shown in this communication.

Frequency and duration of handwashing in an intensive care unit

The effects on hand decontamination of the introduction of an antiseptic handrub lotion in an intensive care unit was studied. To obtain baseline data, nursing, medical, physiotherapy, radiology, and orderly staff members were observed. Further observations were carried out after the introduction of the handrub lotion. Patient care activities were classified as high or low, according to the degree of contact with the patients or their equipment. A total of 884 patient contacts and 341 hand decontamination episodes was observed: 440 contacts and 140 handwashes in stage one (32%) and 444 contacts and 201 handwashes in stage two (45%). There was an increase of 13% in hand decontamination frequency after the introduction of the handrub lotion. The data indicate that the frequency of hand decontamination is below levels recommended by infection control authorities. Increasing the accessibility of hand decontamination facilities did result in a slight increase in handwashing compliance.