Should finger rings be removed prior to scrubbing for theatre?

Effectiveness of healthcare worker screening in hospital outbreaks with gram-negative pathogens: a systematic review

Background

Identifying the source of an outbreak is the most crucial aspect of any outbreak investigation. In this review, we address the frequently discussed question of whether (rectal) screening of health care workers (HCWs) should be carried out when dealing with outbreaks caused by gram negative bacteria (GNB).

A systematic search of the medical literature was performed, including the Worldwide Outbreak Database and PubMed. Outbreaks got included if a HCW was the source of the outbreak and the causative pathogen was an Escherichia coli, Klebsiella spp., Enterobacter spp., Serratia spp., Pseudomonas aeruginosa, or Acinetobacter baumannii.

This was true for 25 articles in which there were 1196 (2.1%) outbreaks due to GNB, thereof 14 HCWs who were permanently colonized by the outbreak strain. Rectal screening of HCWs was helpful in only 2 of the 1196 (0.2%) outbreaks. Instead, the hands of HCWs served as a reservoir for the outbreak strain in at least 7 articles – especially when they suffered from onychomycosis or used artificial fingernails or rings.

Conclusion

Due to very weak evidence, we do not recommend rectal screening of HCWs in an outbreak situation with GNB. However, besides a critical review of hand hygiene habits, it might be useful to examine the hands of staff carefully. This measure is cheap, quick to perform, and seems to be quite effective.

Electronic supplementary material

The online version of this article (10.1186/s13756-018-0330-4) contains supplementary material, which is available to authorized users.

The Case for Using Evidence-Based Guidelines in Setting Hospital and Public Health Policy

Objective

Hospital systems and regulating agencies enforce strict guidelines barring personal items from entering the operating room (OR) – touting surgical site infections (SSIs) and patient safety as the rationale. We sought to determine whether or not evidence supporting this recommendation exists by reviewing available literature.

Background data

Rules and guidelines that are not evidence based may lead to increased hospital expenses and limitations on healthcare provider autonomy.

Methods

PubMed, Embase, Scopus, Cochrane Library, Web of Science, and CINAHL were searched in order to find articles that correlated personal items in the OR to documented SSIs. Articles that satisfied the following criteria were included: (1) studies looking at personal items in the OR, such as handbags, purses, badges, pagers, backpacks, jewelry phones, and eyeglasses, but not just OR equipment; and (2) the primary outcome measure was infection at the surgical site.

Results

Seventeen articles met inclusion criteria and were evaluated. Of the 17, the majority did not determine if personal items increased risk for SSIs. Only one article examined the correlation between a personal item near the operative site and SSI, concluding that wedding rings worn in the OR had no impact on SSIs. Most studies examined colonization rates on personal items as potential infection risk; however, no personal items were causally linked to SSI in any of these studies.

Conclusion

There is no objective evidence to suggest that personal items in the OR increase risk for SSIs.

Impact of Finger Rings on Transmission of Bacteria During Hand Contact

Objective.

To investigate the impact of finger rings on the transmission of bacteria from the hands of healthcare workers and the impact on the microflora on the hands of healthcare workers in clinical practice.

Design.

Our study had a nonequivalent control group posttest-only design (pre-experimental). Healthcare workers who wore finger ring(s) on 1 hand and no ring on the other hand (n = 100) and a control group of healthcare workers who did not wear any rings (n = 100) exchanged standardized hand shakes with an investigator wearing sterile gloves. Samples from the gloved hands of the investigators and the bare hands of the healthcare workers were thereafter obtained by the glove juice technique.

Setting.

Two Norwegian acute care hospitals.

Participants.

Healthcare workers (n = 200) during ordinary clinical work.

Results.

A significantly higher bacterial load (odds ratio, 2.63 [95% confidence interval, 1.28-5.43]; P = .009) and a significantly higher number of bacteria transmitted (odds ratio, 2.43 [95% confidence interval, 1.44-4.13]; P = .001) were associated with ringed hands, compared with control hands. However, a multiple analysis of covariance revealed no statistically significant effect of rings alone. The prevalence of nonfermentative gram-negative bacteria (42% vs 26%) and Enterobacteriaceae (26% vs 13%) was also significantly higher among persons who wore rings than among persons who did not wear rings. However, no statistically significant differences in the incidence of transmission of these pathogens were detected after hand contact. The prevalence of Staphylococcus aureus and incidence of transmission of S. aureus were the same in both groups.

Conclusions.

Wearing finger rings increases the carriage rate of nonfermentative gram-negative bacteria and Enterobacteriaceae on the hands of healthcare workers. However, no statistically significant differences in the incidence of transmission of nonfermentative gram-negative bacteria or Enterobacteriaceae were detected between the healthcare workers who wore rings and those who did not.

Prevention of infection in orthopaedic joint replacement

Infection of a prosthetic joint is a significant adverse event, affecting the patient, the surgical team, and consuming hospital resources. The patient faces multiple operations, a prolonged hospital stay and a more challenging period of rehabilitation. The surgeon must perform longer and more technically demanding revision operations in order to remove the infected prosthesis, increasing the burden on hospital resources. It has been estimated that that the cost of managing an infected total hip replacement (THR) is four times greater than for a primary procedure (Dreghorn & Hamblen 1989). The personal cost to the patient must also be emphasised.

Adherence to recommendations designed to decrease intra-operative wound contamination

INTRODUCTION

The incidence of wound infection following total hip and knee arthroplasty has fallen with the introduction of laminar vertical laminar airflow, occlusive clothing and prophylactic antibiotics. However, infection still occurs after prosthetic joint replacement and can have devastating consequences. Intra-operative wound contamination is the major source of infection. Measures proven to decrease intra-operative wound contamination include chlorhexidine lavage, removal of jewellery, covering old jewellery, ears, nose, mouth and hair and wearing theatre clothing in an occlusive manner.

PATIENTS AND METHODS

Posters explaining this practice were placed at eye level in the scrub area of orthopaedic theatres and adoption of these techniques was observed covertly before and after.

RESULTS

Eighty-two personnel were audited before the poster was erected and 90 afterwards. Only 2 of 12 observed standards were adhered to 100% of the time.

CONCLUSIONS

Education by posters did not significantly improve adherence to protocols. Compliance with protocols was worse amongst non-scrubbed theatre personnel.

Wedding rings are not a significant source of bacterial contamination following surgical scrubbing

INTRODUCTION

Despite some evidence that the wearing of rings may increase the microbial load, there is currently nothing to suggest that viable bacteria remain following a standard surgical scrub. The aim of the study was to examine the distribution and type of microbial flora seen on the hands of doctors following a standard surgical scrub.

MATERIALS AND METHODS

Ten surgeons and 10 anaesthetists, all of whom wore wedding rings on the fourth finger of their left hand, participated in the study. Each individual was asked to 'scrub-up' as for their normal first scrub of the day. Following completion of washing, the wedding ring was removed, its internal circumference swabbed and the swab placed in a culture medium. Volunteers placed each hand palm-down on separate agar plates. The plates were incubated and the number of colonies counted and classified.

RESULTS

The culture plates of one of the anaesthetists were damaged in transit leaving a total of 19 subjects for analysis. In all the palm imprint plates, coagulase-negative staphylococci were grown. One surgeon grew coagulase-negative staphylococci from the ring swab. A Candida spp. from the right hand of one surgeon was grown. There was no statistically significant difference between the number of colony-forming units (CFUs) cultured from the right and left (ring-wearing) hands of the surgeons (P = 0.260) and anaesthetists ( P = 0.345). There was no statistical difference in CFUs when surgeons were compared with anaesthetists (P = 0.383 for right hand and P = 0.234 for left).

CONCLUSIONS

This preliminary study would suggest that a traditional band wedding ring is not a source of a bacterial load following a standard surgical scrub procedure and, as such, there is no requirement for their removal pre-operatively.