Handwashing and glove use in a long-term-care facility

The Use of Copper as an Antimicrobial Agent in Health Care, Including Obstetrics and Gynecology

Health care-associated infections (HAIs) are a global problem associated with significant morbidity and mortality. Controlling the spread of antimicrobial-resistant bacteria is a major public health challenge, and antimicrobial resistance has become one of the most important global problems in current times. The antimicrobial effect of copper has been known for centuries, and ongoing research is being conducted on the use of copper-coated hard and soft surfaces for reduction of microbial contamination and, subsequently, reduction of HAIs. This review provides an overview of the historical and current evidence of the antimicrobial and wound-healing properties of copper and explores its possible utility in obstetrics and gynecology.

Deconstructing the relative benefits of a universal glove and gown intervention on MRSA acquisition

BACKGROUND

The 20-site Benefits of Universal Glove and Gown (BUGG) study found that wearing gloves and gowns for all patient contacts in the intensive care unit (ICU) reduced acquisition rates of meticillin-resistant Staphylococcus aureus (MRSA). The relative importance of gloves and gowns as a barrier, improved hand hygiene, and reduced healthcare worker (HCW)-patient contact rates is unknown.

AIM

To determine what proportion of the reduction in acquisition rates observed in the BUGG study was due to improved hand hygiene, reduced contact rates, and universal glove and gown use using agent-based simulation modelling.

METHODS

An existing agent-based model to simulate MRSA transmission dynamics in an ICU was modified, and the model was calibrated using site-specific data. Model validation was completed using data collected in the BUGG study. A full 2^k factorial design was conducted to quantify the relative benefits of improving each of the aforementioned factors with respect to MRSA acquisition rates.

FINDINGS

Across 40 simulated replications for each factorial design point and intervention site, approximately 44% of the decrease in MRSA acquisition rates was due to universal glove and gown use, 38.1% of the decrease was due to improvement in hand hygiene compliance on exiting patient rooms, and 14.5% of the decrease was due to the reduction in HCW-patient contact rates.

CONCLUSION

Using mathematical modelling, the decrease in MRSA acquisition in the BUGG study was found to be due primarily to the barrier effects of gowns and gloves, followed by improved hand hygiene and lower HCW-patient contact rates.

Implementation of the WHO multimodal Hand Hygiene Improvement Strategy in a University Hospital in Central Ethiopia

Background

The burden of health-care associated infections in low-income countries is high. Adequate hand hygiene is considered the most effective measure to reduce the transmission of nosocomial pathogens. We aimed to assess compliance with hand hygiene and perception and knowledge about hand hygiene before and after the implementation of a multimodal hand hygiene campaign designed by the World Health Organization.

Methods

The study was carried out at Asella Teaching Hospital, a university hospital and referral centre for a population of about 3.5 million in Arsi Zone, Central Ethiopia. Compliance with hand hygiene during routine patient care was measured by direct observation before and starting from six weeks after the intervention, which consisted of a four day workshop accompanied by training sessions and the provision of locally produced alcohol-based handrub and posters emphasizing the importance of hand hygiene. A second follow up was conducted three months after handing over project responsibility to the Ethiopian partners. Health-care workers’ perception and knowledge about hand hygiene were assessed before and after the intervention.

Results

At baseline, first, and second follow up we observed a total of 2888, 2865, and 2244 hand hygiene opportunities, respectively. Compliance with hand hygiene was 1.4% at baseline and increased to 11.7% and 13.1% in the first and second follow up, respectively (p < 0.001). The increase in compliance with hand hygiene was consistent across professional categories and all participating wards and was independently associated with the intervention (adjusted odds ratio, 9.18; 95% confidence interval 6.61-12.76; p < 0.001). After the training, locally produced alcohol-based handrub was used in 98.4% of all hand hygiene actions. The median hand hygiene knowledge score overall was 13 (interquartile range 11–15) at baseline and increased to 17 (15–18) after training (p < 0.001). Health-care workers’ perception surveys revealed high appreciation of the different strategy components.

Conclusion

Promotion of hand hygiene is feasible and sustainable in a resource-constrained setting using a multimodal improvement strategy. However, absolute compliance remained low. Strong and long-term commitment by hospital management and health-care workers may be needed for further improvement.

Electronic supplementary material

The online version of this article (doi:10.1186/s13756-016-0165-9) contains supplementary material, which is available to authorized users.

Impact of WHO Hand Hygiene Improvement Program Implementation: A Quasi-Experimental Trial

Objectives. As affirmed by the World Health Organization (WHO), hand hygiene is the most powerful preventive measure against healthcare-associated infections (HCAIs) and, thus, it has become one of the five key elements of patient safety program. The aim is to assess the effect of implementation of the WHO's Multimodal Hand Hygiene Improvement Strategy among healthcare workers of a tertiary teaching hospital in a developing country. Methods. Hand hygiene compliance was assessed among healthcare workers, according to five defined moments for hand hygiene of the WHO, before and after implementation of the WHO's Multimodal Hand Hygiene Improvement Strategy in fourteen wards of a tertiary teaching hospital in Shiraz, Iran. We used direct observation method and documented the results in WHO hand hygiene observation forms. Results. There was a significant change in compliance before and after implementation of WHO's Multimodal HH Improvement Strategy (29.8% and 70.98%, resp.). Conclusions. Implementing WHO hand hygiene program can significantly improve hand hygiene compliance among nurses.

Transmission of Methicillin-Resistant Staphylococcus aureus (MRSA) to Healthcare Worker Gowns and Gloves During Care of Nursing Home Residents

OBJECTIVE

To estimate the frequency of methicillin-resistant Staphylococcus aureus (MRSA) transmission to gowns and gloves worn by healthcare workers (HCWs) interacting with nursing home residents to better inform infection prevention policies in this setting

DESIGN

Observational study

SETTING

Participants were recruited from 13 community-based nursing homes in Maryland and Michigan

PARTICIPANTS

Residents and HCWs from these nursing homes

METHODS

Residents were cultured for MRSA at the anterior nares and perianal or perineal skin. HCWs wore gowns and gloves during usual care activities. At the end of each activity, a research coordinator swabbed the HCW's gown and gloves.

RESULTS

A total of 403 residents were enrolled; 113 were MRSA colonized. Glove contamination was higher than gown contamination (24% vs 14% of 954 interactions; P1.0; P<.05). We also identified low-risk care activities: giving medications and performing glucose monitoring (OR<1.0; P<.05). Residents with chronic skin breakdown had significantly higher rates of gown and glove contamination.

CONCLUSIONS

MRSA transmission from MRSA-positive residents to HCW gown and gloves is substantial; high-contact activities of daily living confer the highest risk. These activities do not involve overt contact with body fluids, skin breakdown, or mucous membranes, which suggests the need to modify current standards of care involving the use of gowns and gloves in the nursing home setting.

The misuse and overuse of non-sterile gloves: application of an audit tool to define the problem

BACKGROUND

The use of non-sterile gloves (NSG) has become routine in the delivery of health care, often for procedures for which they are not required; their use may increase the risk of cross contamination and is generally not integrated into hand hygiene audit. This paper describes a small-scale application and validation of an observational audit tool devised to identify inappropriate use of NSG and potential for cross contamination.

METHODS

Two observers simultaneously observed the use of NSG during episodes of care in an acute hospital setting. The inter-rater reliability (IRR) of the audit tool was measured corrected for chance agreement using Kappa.

RESULTS

A total of 22 episodes of care using NSG were observed. In 68.6% (24/35) of procedures there was no contact with blood/body fluid; in 54.3% (19/35) NSG-use was inappropriate. The IRR was 100% for eight of 12 components of the tool. For hand hygiene before and after NSG removal it was 82% (Kappa = 0.72) and 95% (Kappa = 0.87).

CONCLUSIONS

In this small-scale application of a glove-use audit tool we demonstrated over-use and misuse of NSG and potential for cross transmission on gloved hands. The audit tool provides an effective mechanism for integrating glove use into the audit of hand hygiene behaviour.

Acceptability and tolerability of liquid versus gel and standard versus virucidal alcohol-based hand rub formulations among dental students

BACKGROUND

Hand hygiene is effective to prevent the transmission of microorganisms in health care settings, but compliance remains low, even when easy access to hand cleaning agents is provided.

OBJECTIVE

Formulation of alcohol-based hand rub (ABHRs) may influence staff compliance to hand hygiene. The aim of this prospective longitudinal study (1 week) was to investigate possible differences of 4 different gel or liquid ABHR formulations, with or without virucidal claim among dental students.

METHODS

Participants were randomly assigned to dental treatment cubicles, equipped with either a gel or a liquid based ABHRs, with our without a virucidal claim. Participants assessed the subjective acceptability and the tolerability of test formulations on their hands over a period of 1 week using the 14 item, 7-point Lickert scale World Health Organization questionnaire.

RESULTS

All tested ABHRs passed the subjective acceptability criteria of ≥50% above 4 for the items "color and fragrance" and for all other items of >75% above 4 and may be regarded as "good." Significant differences were observed between the 2 gels but not between the 2 liquid ABHRs. For subjective skin tolerability, no significant difference was observed between the liquid formulations after 1 consecutive week of application. However, the difference between the 2 gels was highly significant.

CONCLUSION

Virucidal ABHR formulations may be better accepted and tolerated over prolonged periods by dental students than anticipated. The user acceptability of ABHRs depend more on the specific product's formula than its general category.

Impact of health campaign on hand hygiene with alcohol-based hand rubs in a non-clinical setting

BACKGROUND

Hand hygiene has been acknowledged as the single most important measure to prevent nosocomial infections. Likewise, for non-clinical settings, hand hygiene is recognized as a key element to prevent the spread of infectious diseases, nevertheless poor compliance has been documented. The feasibility of hand hygiene interventions in open-community settings with adults is mostly unclear.

AIM

To investigate the acceptability and feasibility of a health campaign to promote hand hygiene with alcohol-based hand disinfectants at workplaces in a non-clinical setting.

METHODS

The surveys were conducted as part of a prospective, controlled intervention study with volunteers from the administration of the Ernst-Moritz-Arndt-University Greifswald, the municipality of Greifswald and the state of Mecklenburg-West Pomerania. Participants in the intervention group were provided with alcohol-based hand disinfection; the control group was unchanged. Eleven volunteers filled out an initial survey at the beginning of the intervention regarding demographic and health-related questions as well as questions about the type of work, and a survey after completion of the intervention to evaluate the study's impact on the participants' attitudes toward hand hygiene. Participants in the experimental group filled out a monthly questionnaire regarding their compliance with hand hygiene measures, feasibility of hand disinfection and possible side-effects.

FINDINGS

From 850 employees asked to participate, 134 were included in the study, and surveys from 129 participants (intervention: 64 vs control: 65) were accepted for analysis. Overall, datasets of 1230 person-months (79.46% of total possible follow-up surveys) were collected. Return rate and compliance remained high during the study period. Hand disinfection did not lead to skin problems in the majority of person-months. After the intervention, a majority of participants would favour a further use of hand disinfectants.

CONCLUSION

Campaigns that enforce the use of alcohol-based hand disinfectants can have a sustainable effect on the compliance with hand hygiene measures in non-clinical settings. Campaigns have been shown to be feasible and effective in the prevention of transmissible diseases, therefore employers should consider whether hand hygiene campaigns to introduce waterless hand rubs could be included in companies' health programmes.

Determinants of hand hygiene noncompliance in intensive care units

BACKGROUND

Hand hygiene (HH) is single most effective preventive measure for health care-associated infection, but compliance rates remain low. This study estimated HH compliance among health care workers (HCWs) and examined factors associated with noncompliance.

METHODS

An observational study design was carried out in 5 intensive care units (ICUs) at the University Hospital in Riyadh, Saudi Arabia. Among 242 HCWs, a total of 3,940 HH opportunities were observed by 6 trained medical interns and students. The World Health Organization's "Five Moments for Hand Hygiene" procedure was used as a basis for the observations.

RESULTS

The overall observed noncompliance rate was 58%. The factors associated with noncompliance were HCW job title (physicians, odds ratio [OR], 2.8; 95% confidence interval [CI], 1.8-4.2; allied health professionals, OR, 2.9, 95% CI, 1.9-4.6); working the a.m. shift (OR, 1.5; 95% CI, 1.3-1.8), working in a pediatric ICU (OR, 1.8; 95% CI, 1.5-2.2), and performance of HH before patient contact (OR, 4.5; 95% CI, 2.6-7.8).

CONCLUSIONS

Overall HH noncompliance was high in ICUs of this hospital. The demanding ICU work setting was an important factor associated with noncompliance. HH compliance was highest among therapists and technicians because of fewer patient interactions and thus fewer HH noncompliance opportunities per person. Further studies on the relationship between work environment demands and HH compliance rates are needed.

Effectiveness of a comprehensive hand hygiene program for reduction of infection rates in a long-term care facility

BACKGROUND

Alcohol-based hand rubs play a key role in reducing the transmission of pathogens in acute care settings, especially as part of a comprehensive hand hygiene program. However, their use in long-term care facilities (LTCFs) has been virtually unstudied.

METHODS

Infection data, including those meeting McGeer et al and the Pennsylvania Patient Safety Authority's surveillance definitions, for lower respiratory tract infections (LRTIs) and skin and soft-tissue infections (SSTIs), as well as hospitalization data were collected in a 174-bed LTCF for 22 months (May 2009 to February 2011). In March 2010, a comprehensive hand hygiene program including increased product availability, education for health care personnel (HCP) and residents, and an observation tool to monitor compliance, was implemented.

RESULTS

Infection rates for LRTIs were reduced from 0.97 to 0.53 infections per 1,000 resident-days (P = .01) following the intervention, a statistically significant decline. Infection rates for SSTIs were reduced from 0.30 to 0.25 infections per 1,000 resident-days (P = .65). A 54% compliance rate was observed among HCP.

CONCLUSION

This study demonstrates that the use of alcohol-based hand rubs, as part of a comprehensive hand hygiene program for HCP and residents, can decrease infection rates in LTCFs.

The effect of glove material upon the transfer of methicillin-resistant Staphylococcus aureus to and from a gloved hand

BACKGROUND

Although disposable gloves can protect the hands of a health care worker from acquiring bacteria, during patient care the glove surface itself can become heavily contaminated making cross transmission via contaminated gloved hands likely. The aim of this study was to determine whether the type of glove worn by health care workers could influence the spread of methicillin-resistant Staphylococcus aureus (MRSA).

METHODS

Laboratory studies were conducted to assess the ease with which MRSA was transferred between different types of glove and surfaces likely to be found within the ward environment.

RESULTS

In the absence of simulated body fluid, mean bacterial transfer to and from the different gloves ranged from 0.1% to 16% and from 0.01% to 19.5%, respectively. Glove material and glove hydrophobicity were identified as the 2 most important factors influencing bacterial transfer. Nitrile gloves were associated with the lowest transfer rates. The highest numbers of bacteria were transferred to and from the most hydrophilic and most hydrophobic glove, respectively. The adsorption of simulated body fluids altered the physiochemical properties of the gloves. Bacterial transfer significantly increased and was similar to and from all glove types.

CONCLUSION

Disposable glove type can affect cross-contamination rates among patient, health care worker, and environment. Nonetheless, choice of glove should be considered less important than the correct use of gloves and proper hand hygiene.

Temporal effects of infection control practices and the use of antibiotics on the incidence of MRSA

BACKGROUND

Meticillin-resistant Staphylococcus aureus (MRSA) has spread throughout the world and has become highly endemic worldwide. The need for implementing MRSA control strategies is no longer a matter of debate.

AIM

To determine the temporal association between various infection control practices, the use of antibiotics and the incidence of MRSA in a 1200-bed French university hospital.

METHODS

A multi-variate time-series analysis, based on monthly data from a nine-year period (January 2000-December 2008), was performed in a 1200-bed French university hospital to determine the temporal association between different variables and the incidence of MRSA. MRSA colonization pressure, infection control practices and use of antibiotics were considered in the analysis.

FINDINGS

Time-series analysis showed a positive significant relationship between the incidence of hospital-acquired MRSA (HA-MRSA) and MRSA colonization pressure, the use of antibiotics (fluoroquinolones, macrolides and aminoglycosides) and the use of gloves. Conversely, a global negative correlation was observed between the incidence of HA-MRSA and the use of alcohol-based hand rub. Overall, the model explained 40.5% of the variance in the monthly incidence of MRSA.

CONCLUSION

This study showed that admission of patients with MRSA, the use of antibiotics and infection control practices contributed to the incidence of HA-MRSA. This suggests that efforts should be focused on high compliance with hand disinfection. These results also raise concerns about the use of gloves when caring for patients with MRSA.

Impact of a team and leaders-directed strategy to improve nurses' adherence to hand hygiene guidelines: a cluster randomised trial

BACKGROUND

Improving hand hygiene compliance is still a major challenge for most hospitals. Innovative approaches are needed.

OBJECTIVE

We tested whether an innovative, theory based, team and leaders-directed strategy would be more effective in increasing hand hygiene compliance rates in nurses than a literature based state-of-the-art strategy.

DESIGN AND SETTING

A cluster randomised controlled trial called HELPING HANDS was conducted in 67 nursing wards of three hospitals in the Netherlands.

PARTICIPANTS

All affiliated nurses of the nursing wards. Wards were randomly assigned to either the team and leaders-directed strategy (30 wards) or the state-of-the-art strategy (37 wards).

METHODS

The control arm received a state-of-the-art strategy including education, reminders, feedback and targeting adequate products and facilities. The experimental group received all elements of the state-of-the-art strategy supplemented with interventions based on social influence and leadership, comprising specific team and leaders-directed activities. Strategies were delivered during a period of six months. We monitored nurses' HH compliance during routine patient care before and directly after strategy delivery, as well as six months later. Secondary outcomes were compliance with each type of hand hygiene opportunity, the presence of jewellery and whether the nurses wore long-sleeved clothes. The effects were evaluated on an intention-to-treat basis by comparing the post-strategy hand hygiene compliance rates with the baseline rates. Multilevel analysis was applied to compensate for the clustered nature of the data using mixed linear modelling techniques.

RESULTS

During the study, we observed 10,785 opportunities for appropriate hand hygiene in 2733 nurses. The compliance in the state-of-the-art group increased from 23% to 42% in the short term and to 46% in the long run. The hand hygiene compliance in the team and leaders-directed group improved from 20% to 53% in the short term and remained 53% in the long run. The difference between both strategies showed an Odds Ratio of 1.64 (95% CI 1.33-2.02) in favour of the team and leaders-directed strategy.

CONCLUSIONS

Our results support the added value of social influence and enhanced leadership in hand hygiene improvement strategies. The methodology of the latter also seems promising for improving team performance with other patient safety issues.

TRIAL REGISTRATION

ClinicalTrials.gov [NCT00548015].

Comparison of hand contamination rates and environmental contamination levels between two different glove removal methods and distances

BACKGROUND

Gloves are a necessary contact precaution to prevent transmission of infectious pathogens that spread by direct or indirect contact with an infected person or a contaminated environment. This article reports a study investigating hand and environmental contamination levels when health care workers (HCWs) followed two different methods of removing gloves at two distances from the rubbish bin.

METHODS

Fifty HCWs performed a personal or causal glove removal method (pretest) and a Centers for Disease Control (CDC)-recommended glove removal method (posttest) at distances of 2 feet and 3 feet from the rubbish bin after the application of fluorescent solution (the simulated contaminant) onto their gloved hands.

RESULTS

The incidence of the small patch of fluorescent stain (<1 cm(2)) on the front of the doffed gloves was significantly lower in the posttest than in the pretest. The incidence of small and large patches (>1 cm(2)) on the front of the doffed gloves and on the cover of the rubbish bin was significantly lower at 3 feet than at 2 feet. Health care assistants had significantly higher levels of contamination than other HCWs in the pretest but not in the posttest. There was no significant difference in hand contamination rate between pretest and posttest based on distance from the rubbish bin and type of HCW.

CONCLUSION

The impact of the glove removal procedure and the distance to the bin in which used gloves are discarded should be taken into consideration on a daily basis, along with the supervision of infection control measures by minor staff.

Diurnal variation in hand hygiene compliance in a tertiary level multidisciplinary intensive care unit

BACKGROUND

Hand hygiene compliance among health care providers is considered to be the single most effective factor to reduce hospital acquired infections. Despite continuous education and awareness, compliance with hand hygiene guidelines has remained low, particularly during evening shifts.

OBJECTIVE

Our objective was to determine the compliance with hand hygiene guidelines among doctors, nurses, and paramedical staff during day and night duties in a multidisciplinary intensive care unit (ICU).

METHODS

We used a prospective, observational, 6-month study conducted in a 34-bed ICU within a tertiary care teaching hospital. All doctors, nurses, and paramedical staff in the ICU were included. An investigator, placed within the ICU setting, observed the hand hygiene practices during day and night. Day and night shift change times were 08:00 and 20:00 hours, respectively.

RESULTS

Of the 5639 opportunities for hand hygiene, 3383 (59.9%) were properly performed. Overall rates of compliance were 66.1% for doctors, 60.7% for nurses, and 38.6% for paramedical staff. Hand hygiene compliance dropped during the night for doctors (81% vs 46%, respectively, P < .001), for nurses (64% vs 55%, respectively, P = .02), and for paramedical staff (44% vs 31%, respectively, P = .01). Characterization of noncompliance is as follows: "No handwashing after procedure" in 41%, "improper duration of handwashing" in 32%, and "no handwashing done at all" in 27% of the events. "No handwashing done at all" occurred in 55% of the time at night with doctors having the highest rate of noncompliance, making 163 (34%) contacts without handwashing.

CONCLUSION

Whereas compliance with hand hygiene guidelines was lower at night compared with day, irrespective of discipline in all 3 groups of health care providers, both periods of compliance would benefit from additional training focusing on the importance of hand hygiene around the clock.

Infection Control and the Long-Term Care Facility

Approximately 70% of health care associated pathogens are resistant to one or more antibiotics. Experts maintain that most antimicrobial-resistant pathogens develop from antibiotic overuse and inappropriate antibiotic selection or treatment duration. Up to 70% of long-term care residents receive at least one course of an antimicrobial agent during a one-year period. Four types of infections occur most often among long-term care residents: urinary tract, respiratory tract, skin and soft tissue, and gastrointestinal tract, and outbreaks are common. Diagnostic uncertainty, failure to recognize fever's clinical manifestation in the elderly, treatment of asymptomatic bacteriuria, and bacterial colonization contribute to antibiotic overuse. Recent infection control guidelines recommend more targeted antibiotic utilization review. Recommendations are presented for implementing antibiotic utilization programs. Hand washing and other measures, such as droplet precautions, are discussed. Economic disincentives surrounding antimicrobial research are highlighted.

Adherence to hand hygiene in an Italian long-term care facility

In an Italian long-term-care facility (LTCF), we observed a 17.5% adherence to hand hygiene (HH), as well as 47.5% rate of glove use. Performing a procedure at high risk for cross-transmission of germs was the factor most strongly associated with noncompliance (odds ratio = 13.3; 95% confidence interval = 6.2 to 28.8; P < .0001). No significant differences in compliance related to health care worker category were found. Adherence to HH in the LTCF was similar to that found in a rehabilitation medicine unit of an acute care hospital (15.8%) but significantly lower than that reported in an infectious disease unit (53.7%; P < .0001). Our findings indicate that compliance with HH is a similar problem in LTCFs as in acute care facilities.

Hand hygiene practices of health care workers in long-term care facilities

Little is known about hand hygiene practice in the long-term care setting. In this study, we observed 459 hand hygiene opportunities in 2 long-term care facilities in Hamilton, Ontario. Overall hand hygiene adherence was 14.7%, with a mean handwashing time of 15.9 seconds. Adherence varied by activity performed and the presence or absence of a sink.

Pseudooutbreak of Stenotrophomonas maltophilia bacteremia in a general ward

BACKGROUND

Stenotrophomonas maltophilia is a significant nosocomial pathogen and is commonly isolated in the hospital environment. We investigated the risk factors for a bloodstream pseudooutbreak of S maltophilia in a general ward.

METHODS

On November 24 and 25, 2005, 7 patients without evidence of sepsis were reported as positive for blood culture with S maltophilia from blood samples collected on November 21 and 22, 2005. We conducted an epidemiologic investigation and a case-control study of this pseudooutbreak.

RESULTS

All 7 S maltophilia showed the same antibiogram and an indistinguishable pattern on pulsed-field gel electrophoresis. The observational study revealed multiple lapses in infection control, including multiple use of a single bottle of saline for dilution of antibiotics. A case-control study showed that one health care worker, who collected blood samples from 6 of 7 patients, was a significant risk factor for the pseudooutbreak of S maltophilia (P < .05).

CONCLUSION

We suggest that the combination of multiple lapses in infection control and the blood-collecting behavior of a health care worker might be the cause of the pseudooutbreak of S maltophilia.

Indwelling device use and antibiotic resistance in nursing homes: identifying a high-risk group

OBJECTIVES

To quantify the relationship between indwelling devices (urinary catheters, feeding tubes, and peripherally inserted central catheters) and carriage of antimicrobial-resistant pathogens in nursing home residents.

DESIGN

Cross-sectional.

SETTING

Community nursing home in Southeast Michigan.

PARTICIPANTS

Residents with indwelling devices (n=100) and randomly selected control residents (n=100) in 14 nursing homes.

MEASUREMENTS

Data on age, functional status, and Charlson comorbidity score were collected. Samples were obtained from nares, oropharynx, groin, wounds, perianal area, and enteral feeding tube site. Standard microbiological methods were used to identify methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and ceftazidime-resistant (CTZ-R) gram-negative bacteria (GNB).

RESULTS

Use of indwelling devices was associated with colonization with MRSA at any site (odds ratio (OR)=2.0, P=.04), groin (OR=4.8, P=.006), and perianal area (OR=3.6, P=.01) and CTZ-R GNB at any site (OR=5.6, P=.003). Use of enteral feeding tubes was associated with MRSA colonization in the oropharynx (OR=3.3, P=.02).

CONCLUSION

Use of indwelling devices is associated with greater colonization with antimicrobial-resistant pathogens. This study serves as an initial step in defining a high-risk group that merits intensive infection control efforts.

Evaluation of hand hygiene adherence in a tertiary hospital

BACKGROUND

Although hand hygiene is the most important measure in the prevention of nosocomial infection, adherence to recommendations among health care workers (HCW) is low. Evaluation of compliance with hand hygiene was carried out in a Spanish teaching hospital.

METHODS

In 2005, adherence to hand hygiene was evaluated hospital wide through direct observation, collecting data on hand hygiene carried out whenever indicated (opportunity for hand hygiene). Compliance was defined as handwashing/disinfection in an opportunity for hand hygiene according to hospital protocols. The results were analyzed using mixed effects models, with the HCW observed as the random effect.

RESULTS

A total of 1254 opportunities for hand hygiene were observed in 247 HCWs. Mean compliance was 20%. Although few differences were observed among types of HCW, compliance varied according to hospital area (69% in the intensive care unit [ICU]) and timing with respect to patient contact (compliance after contact was twice that before contact). Multivariate analyses revealed a protective odds ratio (OR) for nonadherence in ICUs (OR, 0.04; 95% confidence interval (95% CI): 0.01-0.10) and after patient contact (OR, 0.25; 95% CI: 0.17-0.38).

CONCLUSION

Low adherence observed suggests that new interventions should focus in modification of HCWs' habits and attitudes, working at several levels: individual and institutional.

Ventilator associated pneumonia and infection control

Ventilator associated pneumonia (VAP) is the leading cause of morbidity and mortality in intensive care units. The incidence of VAP varies from 7% to 70% in different studies and the mortality rates are 20-75% according to the study population. Aspiration of colonized pathogenic microorganisms on the oropharynx and gastrointestinal tract is the main route for the development of VAP. On the other hand, the major risk factor for VAP is intubation and the duration of mechanical ventilation. Diagnosis remains difficult, and studies showed the importance of early initiation of appropriate antibiotic for prognosis. VAP causes extra length of stay in hospital and intensive care units and increases hospital cost. Consequently, infection control policies are more rational and will save money.

Methicillin-resistant Staphylococcus aureus in elderly care facilities

Among multidrug-resistant bacteria, methicillin-resistant Staphylococcus aureus (MRSA) is of immediate concern, given its potential for pathogenicity and widespread presence in geriatric hospitals. Epidemiological surveys indicate that rates of MRSA cross-transmission are increasing in elderly care facilities. MRSA carriage is far more frequent than MRSA-positive clinical specimens in this setting, and the consequences of these epidemics in terms of morbidity, remain limited within these facilities. However, given that patients are continually transferred between long-term and acute-care facilities, it is reasonable to consider these units together with all other care units and to measure the effect of MRSA on a regional healthcare network, rather than on the scale of a given ward or hospital. With regard to the worldwide increase in morbidity associated with MRSA, the emergence of a community-based disease linked to these strains and the emergence of glycopeptide-resistant strains, the application of a voluntary strategy including screening, isolation and eventually, topical decolonization in elderly care facilities, appears to be an urgent matter of priority, even if this strategy will be expensive.

Preventing infections in nursing homes: a survey of infection control practices in southeast Michigan

BACKGROUND

Studies on adherence to infection control policies in nursing homes (NHs) are limited. This pilot study explores the use of various infection control practices and the role of infection control practitioners in southeast Michigan NHs.

METHODS

A 43-item self-administered questionnaire and explanatory cover letter were mailed to 105 licensed NHs in southeast Michigan. A second mailing was sent to the nonresponders 4 weeks later.

RESULTS

Significant variability existed in adoption of various infection control measures with respect to time spent in infection control activities (50% of facilities having a full-time infection control practitioner), definitions used in monitoring infections, and immunization rates (influenza: range, 0%-100%; mean, 73.2%; pneumococcal: range, 0%-100%; mean, 38.5%).

CONCLUSION

Although strides have been made in infection control research in NHs, significant variations exist in implementation of infection control methods and guidelines. Future research should focus on identifying barriers to infection control in NHs.

Infection control policies and hospital-associated infections among surgical patients: variability and associations in a multicenter pediatric setting

BACKGROUND

Hospital-associated infections are an important cause of patient morbidity and death. Little is known about the variability of infection rates and infection control practices among pediatric hospitals.

METHODS

This cross-sectional study was performed with the Pediatric Health Information System database, which includes demographic and diagnostic data for 35 freestanding, noncompeting, children's hospitals, and with data from a survey of the hospitals, which yielded additional information on infection control policies and practices. Patients undergoing elective surgical procedures were included in this study.

RESULTS

Of the 35 eligible hospitals, 31 (89%) chose to participate in the survey component of this study. A total of 48278 patients met the inclusion criteria for the study; 2.3% of these patients had respiratory infections and 0.8% had gastrointestinal infections. The frequency of patients diagnosed with respiratory or gastrointestinal infections varied considerably among the hospitals and ranged from <1% to 6%. Certain infection control processes also varied among the hospitals during the study period. For instance, of the 31 hospitals, 12 monitored hand hygiene, 19 had administrative support of hand hygiene, and 16 had alcohol hand gel present for the entire study period. The presence of alcohol hand gel for the entire study was strongly and independently associated with lower odds of gastrointestinal infections (adjusted odds ratio: 0.64; 95% confidence interval: 0.49-0.85).

CONCLUSIONS

Hospitals should support the use of alcohol hand gel, with the aim of decreasing hospital-associated infection rates.

Handwashing in healthcare workers: accessibility of sink location does not improve compliance

In spite of its importance, handwashing frequency in healthcare workers is generally low. The rebuilding and relocation of an 800-bed tertiary referral hospital on the same campus allowed assessment of the impact of easy accessibility to sinks on handwashing compliance. The new hospital design ensured that no clinical activity could occur more than 5 m (usually much less) from a sink. In the old hospital, clinical staff were often up to 30 m from a sink. Covert observation of nursing staff was undertaken in intensive care, infectious diseases, internal medicine and urology wards, over a total of 24 h during three consecutive days, two months before and one and 10 months after relocation to the new hospital. In all areas, handwashing compliance was greater before than after-patient contact. Initial increases (9-24%) in after-patient contact handwashing frequency following patient contact were demonstrated in units of both high and low clinical care activity one month after relocation. However, no sustained clinically significant improvement could be demonstrated nine months later. Glove use was shown to diminish compliance with handwashing protocols by as much as 25%. Improved accessibility to sinks does not lead to an improvement in healthcare workers' handwashing compliance.

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.

Increase in methicillin-resistant Staphylococcus aureus acquisition rate and change in pathogen pattern associated with an outbreak of severe acute respiratory syndrome

Background. An outbreak of severe acute respiratory syndrome (SARS) occurred in our 22-bed intensive care unit (ICU; Prince of Wales Hospital, Hong Kong, HKSAR, China) from 12 March to 31 May 2003, when only patients with SARS were admitted. This period was characterized by the upgrading of infection control precautions, which included the wearing of gloves and gowns all the time, an extensive use of steroids, and a change in antibiotic prescribing practices. The pattern of endemic pathogenic organisms, the rates of acquisition of methicillin-resistant Staphylococcus aureus (MRSA), and the rates of ventilator-associated pneumonia (VAP) were compared with those of the pre-SARS and post-SARS periods.

Methods. Data on pathogenic isolates were obtained from the microbiology department (Prince of Wales Hospital). Data on MRSA acquisition and VAP rates were collected prospectively. MRSA screening was performed for all ICU patients. A case of MRSA carriage was defined as an instance in which MRSA was recovered from any site in a patient, and cases were classified as imported or ICU-acquired if the first MRSA isolate was recovered within 72 h of ICU admission or after 72 h in the ICU, respectively.

Results. During the SARS period in the ICU, there was an increase in the rate of isolation of MRSA and Stenotrophomonas and Candida species but a disappearance of Pseudomonas and Klebsiella species. The MRSA acquisition rate was also increased: it was 3.53% (3.53 cases per 100 admissions) during the pre-SARS period, 25.30% during the SARS period, and 2.21% during the post-SARS period (P < .001). The VAP rate was high, at 36.5 episodes per 1000 ventilator-days, and 47% of episodes were caused by MRSA.

Conclusions. A SARS outbreak in the ICU led to changes in the pathogen pattern and the MRSA acquisition rate. The data suggest that MRSA cross-transmission may be increased if gloves and gowns are worn all the time.

Hand hygiene: improved standards and practice for hospital care

PURPOSE OF REVIEW

To review the most recently published literature on hand hygiene practices in healthcare settings.

RECENT FINDINGS

Adherence with recommendations for hand hygiene remains low, but key factors of noncompliance have been identified and corrective actions proposed. Current guidelines recommend the use of alcohol-based handrub formulations as the new standard of care, thus requiring a system change in most hospitals. In addition, healthcare worker education and motivation are obviously important to modify hand hygiene behavior and must be part of multimodal strategies to enhance compliance in hospitals. Compliance improvement is associated with reduced infection rates and resistance spread. Handrub application according to recommended practices is an alternative to conventional surgical handscrubbing with antiseptic soap and water for surgical hand preparation.

SUMMARY

System change must be addressed in most hospitals where alcohol-based handrubbing has not become a standard of care. Strategies to improve hand hygiene compliance must be multimodal and include staff education and motivation, the use of performance indicators, and hospital management support. Successful campaigns will result in reduced infection rates, antimicrobial resistance spread, and enhance patient safety.

Rates of hand disinfection associated with glove use, patient isolation, and changes between exposure to various body sites

BACKGROUND

Handwashing is the most effective and economic intervention shown to reduce nosocomial infection rates. However, studies have consistently documented low hand disinfection compliance. Literature regarding the roles that concomitant glove use and isolation precautions play in health care worker compliance with hand disinfection is limited. It is unclear whether workers change gloves and disinfect hands adequately between exposures to different body sites/secretions while caring for a patient.

METHODS

This was an observational study in which hand disinfection compliance and glove use among workers was evaluated in 2 intensive care units at a tertiary care hospital.

RESULTS

Five hundred eighty-nine opportunities for hand disinfection were recorded in 40 hours of observation. Overall compliance was 22.1%. We found a statistically significant, positive association between glove use and subsequent hand disinfection (relative risk [RR], 3.9 [95% CI, 2.5-6.0]; P <.0001). Isolation precautions did not significantly increase disinfection compliance. Only 4.8% (3/63) of workers appropriately complied with disinfection when hands were exposed to multiple body sites/secretions while caring for a patient.

CONCLUSIONS

Glove use increases compliance with hand disinfection. Isolation precautions do not increase compliance. Workers do not appropriately comply with disinfection guidelines when attending to multiple body sites/secretions on the same patient. Compliance with hand disinfection remains low.

Staphylococcus aureus Carriage and Health Care-acquired Infection

Staphylococcus aureus is one of the most common nosocomial pathogens. Its propensity to establish prolonged carriage among hospitalized patients and increasing resistance to antibiotics makes control of this organism within the hospital difficult. High-level vancomycin resistance has now been reported in a single clinical isolate of S. aureus, emphasizing the need to increase efforts to control nosocomial spread. Knowledge of the epidemiology of S. aureus colonization among patients has shed new light on the potential difficulties in interrupting nosocomial transmission. Effective control of S. aureus within the hospital and community will require more aggressive measures that include earlier diagnosis of colonized patients, better handwashing and barrier precaution measures, and renewed efforts to eradicate the carriage state.

Compliance with hand disinfection and its impact on hospital-acquired infections

Hand hygiene prevents cross-infection in hospitals, but adherence to guidelines is poor among healthcare workers. Although some interventions to improve compliance have been successful, none had achieved lasting improvement until very recently. Reasons for non-compliance with recommendations occur at individual, group and institutional levels. The complexity of the process of behavioural change would suggest that the application of multimodal, multidisciplinary strategies are necessary. Both easy access to hand hygiene in a timely fashion and skin protection appear necessary prerequisites for satisfactory hand hygiene behaviour. Alcohol-based hand-rub may be superior to traditional handwashing as it requires less time, acts faster, irritates hands less often, and recently proved significantly to contribute to sustained improvement in compliance associated with decreased infection rates. This paper reviews barriers to appropriate hand hygiene and describes the results of the first successful experience of sustained hand hygiene promotion and its effectiveness on hospital-acquired infection.

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.

Improving adherence to hand hygiene practice: a multidisciplinary approach

Hand hygiene prevents cross-infection in hospitals, but health-care workers' adherence to guidelines is poor. Easy, timely access to both hand hygiene and skin protection is necessary for satisfactory hand hygiene behavior. Alcohol- based hand rubs may be better than traditional handwashing as they require less time, act faster, are less irritating, and contribute to sustained improvement in compliance associated with decreased infection rates. This article reviews barriers to appropriate hand hygiene and risk factors for noncompliance and proposes strategies for promoting hand hygiene.

Health-care workers and latex allergy

Latex hypersensitivity can pose a threat to anyone, but health-care providers are among the high-risk groups for developing latex hypersensitivity. Latex hypersensitivity likely results from health-care workers' increased use of gloves following implementation of universal precautions. It is also believed that the antigenic load of latex gloves causes an increase in latex hypersensitivity resulting from massive production of gloves. Although there are many studies on the prevalence of latex hypersensitivity among health-care workers, there appear to be discrepancies, which may affect the different apparent prevalence. Testing for latex hypersensitivity raises another problem. Latex allergens cannot be identified specifically; therefore, there is no standard test or testing solution that can identify hypersensitive persons. Although latex glove hypersensitivity was first identified in the late 1970s, there remain many uncertainties associated with it; as a result, there is a growing concern among health-care providers. The authors offer several precautions to avoid the development of latex hypersensitivity.

Maximising handwashing rates in the critical care unit through yearly performance feedback

Handwashing following patient contact reduces the incidence of nosocomial infections. Despite this, handwashing rates by health care workers (HCWs) are often poor. Feedback on handwashing has been shown to significantly improve its rates. This study determined the optimum time to repeat performance feedback on handwashing rates of hospital staff in order to maximise its incidence. The baseline incidence of handwashing by staff following patient contact was determined by covert observation. This was followed by a period of feedback on handwashing performance by means of histograms displayed in the unit. Handwashing incidence was reassessed 6 and 12 months after the feedback ended. Performance feedback induced significant increases in handwashing incidence amongst nurses (p = 0.0433), resident medical officers (p = 0.0134), specialists (p = 0.0021) and radiographers (p = 0.0001). Non-significant increases were noted in handwashing rates amongst wardsmen/women and physiotherapists. Overall, handwashing incidence declined significantly (p = 0.0001) 12 months post feedback. This study demonstrated that feedback should be repeated within 12 months in order to maximise handwashing rates with the minimum intervention.

Residential care and the elderly: the burden of infection

Long term care facilities (LTCFs) include a variety of different types of healthcare settings, each with their own unique infectious disease problems. This report focuses on the epidemiological considerations, risk factors and types of infections that occur in elderly patients institutionalized in nursing home settings. In the US, the number of patients in nursing homes continues to grow as the population ages. Today, patients in nursing homes have more complicated medical conditions than they did five years ago as they become even more elderly and the trend continues towards shorter and shorter hospital stays in acute care facilities. The patient population in nursing homes is uniquely susceptible to infections because of the physiological changes that occur with ageing, the underlying chronic diseases of the patients and the institutional environment within which residents socialize and live. In addition, in nursing home settings, problems with infections may be more difficult to diagnose because of their subtle presentations, the presence of co-morbid illnesses which obscure the symptoms of infection and the lack of on site diagnostic facilities. Delays in diagnosing and treating infections allow transmission to occur within the facility. Both endemic and epidemic infections occur relatively commonly in nursing homes. The incidence of endemic infections, such as catheter-associated urinary tract infections, lower respiratory infections and skin infections, is influenced by the debility level of the patients. Calculations of infection rates are influenced by the intensity of surveillance methods at each institution. Many endemic infections are unpreventable. Epidemic infections account for 10-20% of nursing home infections. These include clusters of upper or lower respiratory infections, gastroenteritis, diarrhoea, and catheter-associated UTI's. Epidemic infections are potentially preventable with sound infection control practices. Special attention must be paid to promote universal precautions and give certain patients, such as those with known infection or colonization with Clostridium difficile, MRSA or VRE, special consideration. The potential for epidemic infections with antibiotic-resistant organisms is real. In the nursing home setting, attention must be given to develop and support strong infection control programmes that can monitor the occurrence of institutionally-acquired infections and initiate control strategies to prevent the spread of epidemic infections. Education in infection control issues and attention to employee health is essential to enable staff to care appropriately for today's nursing home population and to prepare them for the even more complicated patients who will be cared for in this type of setting in future.

Soil, seed and climate: developing a strategy for prevention and management of infections in UK nursing homes

Most studies of nursing home (NH) infections come from the USA and very few from the UK. USA studies lead us to anticipate a rate of 7 infections per 1000 patient days with a point prevalence as high as 16% in UK NH residents. Pneumonia, skin and urine infections would be the most frequent, followed by enteric infection and bacteraemia. Colonization with resistant organisms is increasing in UK NH residents (e.g., MRSA in 4-17%). Surveillance studies are needed in UK NHs to report incidence of infection, residents' characteristics, existence of and adherence to above standards and policies. Trials of effectiveness of different infection control programmes and of NH vs hospital management are required. Management of infection may be a useful marker of quality of care in NHs and therefore of interest to health and local authorities.

Infection prevention and control in the long-term-care facility. SHEA Long-Term-Care Committee and APIC Guidelines Committee

More than 1.5 million residents reside in US nursing homes. In recent years, the acuity of illness of nursing home residents has increased. Long-term-care facility residents have a risk of developing nosocomial infection that is similar to acute-care hospital patients. A great deal of information has been published concerning infections in the long-term-care facility, and infection control programs are nearly universal. This position paper reviews the literature on infections and infection control program in the long-term-care facility, covering such topics as tuberculosis, bloodborne pathogens, epidemics, isolation systems, immunization, and antibiotic-resistant bacteria. Recommendations are developed for long-term-care infection control programs based on interpretation of currently available evidence. The recommendations cover the structure and function of the infection control program, including surveillance, isolation, outbreak control, resident care, and employee health. Infection control resources also are presented.