The role of barrier precautions in infection control

Knowledge of infection control practices among intensive care nurses in a tertiary care hospital

BACKGROUND

The threat of hospital-acquired infections persists despite advances in the health care system. A lack of knowledge regarding infection control practices among health care workers decreases compliance with these practices. We conducted a study to assess the knowledge of infection control practices among nursing professionals at our hospital.

METHODS

In total, 100 nurses in the intensive care units at our hospital were given a questionnaire with 40 multiple choice questions, including 10 questions each regarding hand hygiene, standard and transmission-based precautions, care bundles and general infection control practices. The responses were scored as percentages.

RESULTS

The overall knowledge and awareness regarding different infection control practices were excellent (>90% positive responses) in 5% of the nursing professionals, good (80-90% positive responses) in 37%, average (70-80% positive responses) in 40% and below average (<70% positive responses) in 18%.

CONCLUSION

The infection control knowledge among the nurses was fairly good; however, there is still a wide scope of improvement with regular educational programs and in-house training.

Health care-associated infections and visiting policy in an intensive care unit

A frequent objection to the unrestricted visiting policy in intensive care units (ICUs) is the risk of acquired infections. In a mixed 8-bed ICU, an adopted shift from a restricted to a partially unrestricted visiting policy did not result in an increase in ICU-acquired infections.

[Attitudes and needs of pediatric intensivists in relation to the death of their patients]

INTRODUCTION

Most deaths in infants and children occur in hospitals and especially in pediatric and neonatal intensive care units.

OBJECTIVES

To determine 1) how often pediatric intensivists have to manage dying patients, 2) their approach to these patients, and 3) their knowledge of this field and their needs.

MATERIAL AND METHOD

A 28-item questionnaire was sent by surface mail to each physician, as well as another questionnaire with general questions on the work of the pediatric intensive care unit (PICU) in 2000.

RESULTS

Responses were obtained from 20 PICUs (54 %) from different parts of Spain. There where 373 deaths. More of the half of the deaths (62 %) were due to acute events or occurred during the neonatal period. Ninety-four physicians completed the questionnaire. Each physician attended four deaths (SD = 3.1; range 0-20). Sixty-eight percent of the physicians believed that families were helped by knowing the possibility that the child might die. Intensivists believed that pediatric patients should not be informed that they were dying. In 64 % of deaths, the physicians were with their patients at the moment of death. More than half of the patients died without physical contact with their parents. Forty-six percent of the physicians interpreted death among their patients as a personal or professional failure and most (92 %) wanted training. Only three PICUs allowed parents to stay all day with their children.

CONCLUSIONS

Almost half the physicians experienced death as a personal or professional failure and most wanted training to help them deal with death in their professional work. Most PICUs restrict the time parents are allowed to stay with their children.

Using an integrated infection control strategy during outbreak control to minimize nosocomial infection of severe acute respiratory syndrome among healthcare workers

Healthcare workers (HCWs) are at risk of acquiring severe acute respiratory syndrome (SARS) while caring for SARS patients. Personal protective equipment and negative pressure isolation rooms (NPIRs) have not been completely successful in protecting HCWs. We introduced an innovative, integrated infection control strategy involving triaging patients using barriers, zones of risk, and extensive installation of alcohol dispensers for glove-on hand rubbing. This integrated infection control approach was implemented at a SARS designated hospital ('study hospital') where NPIRs were not available. The number of HCWs who contracted SARS in the study hospital was compared with the number of HCWs who contracted SARS in 86 Taiwan hospitals that did not use the integrated infection control strategy. Two HCWs contracted SARS in the study hospital (0.03 cases/bed) compared with 93 HCWs in the other hospitals (0.13 cases/bed) during the same three-week period. Our strategy appeared to be effective in reducing the incidence of HCWs contracting SARS. The advantages included rapid implementation without NPIRs, flexibility to transfer patients, and re-inforcement for HCWs to comply with infection control procedures, especially handwashing. The efficacy and low cost are major advantages, especially in countries with large populations at risk and fewer economic resources.

Misuse of gloves: the foundation for poor compliance with hand hygiene and potential for microbial transmission?

Improvement in hand hygiene compliance is important for reducing cross-infection by micro-organisms. The objective of this prospective observational study was to measure how the improper use of gloves limits compliance to hand hygiene and exposes patient's to infection. The study was conducted in five wards (three intensive care units and two medical wards) in a French university hospital. Staff-patient and staff-environment contacts were observed in 120 healthcare workers caring for patients colonized or infected with pathogenic bacteria. Hand hygiene was not undertaken due to improper gloving in 64.4% (95%CI, 64.1% to 65.1%) of instances. Possible microbial transmission might have occurred in 18.3% (95%CI, 17.8% to 18.8%) of all contacts because used gloves were not removed before performing care activities that necessitated strict aseptic precautions. Failure to change or remove contaminated gloves was a major component in the poor compliance with hand hygiene and carried a high-risk of microbial transmission. Improving hand hygiene compliance will require changing healthcare workers behaviour towards glove use.

A review of single-use and reusable gowns and drapes in health care

Gowns and drapes are used widely in healthcare facilities. Gowns have been used to minimize the risk of disease acquisition by healthcare providers, to reduce the risk of patient-to-patient transmission, and during invasive procedures to aid in maintaining a sterile field. Drapes have been used during invasive procedures to maintain the sterility of environmental surfaces, equipment, and patients. This article reviews the use of gowns and drapes in healthcare facilities, including the characteristics, costs, benefits, and barrier effectiveness of single-use and reusable products. Currently, gowns protect healthcare personnel performing invasive procedures from contact with bloodborne pathogens. Although gowns have been recommended to prevent patient-to-patient transmission in certain settings (eg, neonatal intensive care unit) and for certain patients (eg, those infected with vancomycin-resistant enterococci), scientific studies have produced mixed results of their efficacy. While appropriate use of drapes during invasive procedures is recommended widely as an aid in minimizing contamination of the operative field, the efficacy of this practice in reducing surgical-site infections has not been assessed by scientific studies. Based on an evaluation of the functional requirements, environmental impact, and economics of gowns and drapes, clear superiority of either reusable or single-use gowns and drapes cannot be demonstrated. The selection of particular gowns and drapes by individual healthcare facilities requires an assessment of the facility's requirements, available products, and costs and should be based on the desired characteristics of an ideal gown or drape as defined in this paper.

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.

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.

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.

Is hand washing really needed in an intensive care unit?

OBJECTIVES

To determine whether a rigorous antiseptic hand washing of bare hands with 4% chlorhexidine and alcohol reduced fingertip microbial colonization as compared with the use of boxed, clean, nonsterile latex gloves. In addition, to investigate if aseptic donning technique and/or a prior hand washing would reduce the level of glove contamination.

DESIGN

Prospective, randomized, crossover design, with each subject serving as his/her own control.

SETTING

University intensive care unit.

SUBJECTS

Forty-three intensive care nurses.

INTERVENTIONS

The fingertips of 20 nurses were cultured before and after a strict antiseptic hand washing and before and after the routine and aseptic donning of sterile gloves. Subsequently, the fingertips of 43 nurses were cultured before and after the casual donning of nonsterile gloves over unwashed hands and before and after a strict antiseptic hand washing. Fingertip cultures were plated directly on agar, incubated for 24 hrs, and counted and recorded as the number of colony-forming units (cfu) for each hand. Different colony types were then subcultured.

MEASUREMENTS AND MAIN RESULTS

Hand washing with antiseptic reduced colonization from 84 to 2 cfu (p < .001). The proportion of cases with > or = 200 cfu/hand was reduced from 30% to 9%. Aseptic or casual donning of sterile gloves, with or without prior antiseptic hand washing, resulted in consistently low glove counts between 0 and 1.25 cfu. Nonsterile gloves casually donned over washed or unwashed bare hands diminished the bioburden to 2.17 and 1.34 cfu, respectively. No qualitative difference was found in the microorganisms recovered from gloved or bare hands.

CONCLUSIONS

Antiseptic hand washing and the use of nonsterile gloves over unwashed hands confer similar reductions in the number of microorganisms. There is no additional benefit with the use of aseptic donning technique, prior antiseptic hand washing, or the use of individually packaged sterile gloves.