The Role of PPE in Contact Transfer
Part one in a series.
By Wava Truscott, PhD
THINK FOR A MOMENT ABOUT THIS ROUTINE SCENARIO. A healthcare worker (HCW) enters the room of a patient who has an antibiotic-resistant infection such as methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE). She dons a pair of ordinary disposable gloves and proceeds to examine the patient, listening to the heart and lungs and taking vital signs. She records the results on the patients chart. She chats with the patient for a few minutes, discards the exam gloves, washes her hands and moves on to the next room. There, she dons a new pair of gloves, puts her stethoscope in her ears, and begins the next examination.
Has the caregiver done anything to compromise her patients outcomes? She did wear and properly dispose of her gloves, after all. But glove usage is not enough to prevent the spread of infection. Without knowing it, the HCW has just transferred millions of harmful, antibiotic-resistant microorganisms to her second patient, just by touching the stethoscope with her contaminated gloves and then moving on to the next patient.
When portable equipment is carried by HCWs, such as stethoscopes, blood pressure cuffs, otoscopes, pens, and pagers,1 microorganisms can be carried directly to another patient or transferred to furniture or equipment. Thus unwittingly, microorganisms are transferred between patients. Many surfaces in the room can be affected, including bed rails, bed tables, linens, wheelchairs, thermometers, pulse oximeters, patient gowns, privacy curtains, patient charts, and doorknobs. Nurses gloves become contaminated 42 percent of the time after touching these contaminated surfaces.2
Despite the best efforts of healthcare facilities to maintain a clean and safe environment, contact transfer of harmful microorganisms appears to be inevitable. Studies have shown that, in rooms of patients who were colonized or infected, 70 percent of environmental surfaces were contaminated with potentially harmful microorganisms,3 and 65 percent of HCWs gowns were contaminated with MRSA after routine morning care for patients with MRSA in a wound or patients urine.4
The impact of healthcare-acquired infections (HAIs) is staggering:
- Annually, more than 2.9 million patients (5 percent to 10 percent) develop HAIs5
- Approximately 30 percent of patients in ICUs develop HAIs6
- Patients with HAIs spend an average of 12 additional days in the hospital7
- Treatment costs can range from $2,300 to $80,000 per patient8
- HAIs represents an annual impact of $6.7 billion to healthcare facilities9
- Approximately 90,000 deaths occur annually due to HAIs10
Setting the Standards
In recognition of HAIs profound impact on patient outcomes and healthcare costs, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) released strengthened infection control guidelines. In addition to raising awareness that infections can be acquired in any healthcare setting, including hospitals, ambulatory care, home care, and long-term care organizations, the new guidelines also address emerging antimicrobial resistance. The Centers for Disease Control and Prevention (CDC) highlighted the importance of utilizing contact precautions for mitigating the transmission of MRSA and VRE, underscoring the critical importance of a total protocol that includes proper handwashing, gloving, masking (for MRSA), gowning, and appropriate practices for handling devices and laundry, and for daily surface disinfection. The Society for Healthcare Epidemiology of America (SHEA) issued additional guidelines to address the increased prevalence of MRSA including active surveillance cultures, maximum barrier isolation precautions, strict hand hygiene and antimicrobial stewardship.
The Role of PPE
While these recommendations provide strong behavioral guidelines for preventing transmission, personal protective equipment (PPE) itself can become a potential source of cross-contamination from other surfaces within a facility. An increasing number of studies are focusing on the role of PPE contamination, paving the way for manufacturers to investigate methods to inhibit the growth of a broad spectrum of harmful microorganisms on the surface of these products. By gaining a better understanding of the modes of contact transfer, these innovations would lead to the development of permanent solutions that can break the chain of cross-contamination, not just another patient-centric, receptor site-specific antibiotic to which microorganisms can develop immunity. There are a few promising glove innovations on the horizon, but finding a solution for apparel is not an easy task.
Manufacturers are looking at ways to combine barrier characteristics with an active anti-microbial ingredient that would entrap or kill the microorganism, preventing transfer at the source, and ultimately reducing HAIs. One of the biggest challenges is finding specific solutions that remain effective after being added to latex and nitrile, SMS fabrics, linen and cotton. They must not create their own version of resistant organisms or super-bugs. Additionally, the antimicrobial agent needs to work quickly, remain effective when in contact with blood and other body fluids, and not irritate the wearers or patients skin.
The Time is Now
Bacteria with adaptive mechanisms such as MRSA and VRE are survivors; they multiply and give their adaptation to their progeny. By doing so, they alter their own genetic evolution to favor resistant strains as the predominate population. Incredibly, bacteria can also transfer the genetic information to construct these defensive weapons into other bacteria and even other bacterial species. Clearly, the problem of antibiotic resistance isnt going away. So the objective is to lessen the need to use them by getting HAIs under control. And like almost everything else in healthcare, it will take a comprehensive protocol of behavioral changes and product evolutions across the care continuum to resolve the issue. And we need to step it up now.
Wava Truscott, PhD, is director of scientific affairs and clinical education for Kimberly-Clark Health Care.
1. Muto C., Jernigan, J., Ostrowsky B., Richet H., Jarvis W., Boyce J., and Farr B. SHEA Guideline for Preventing Nosocomial Transmission of Multidrug-Resistant Strains of Staphylococcus aureus and Enterococcus. Infect Control Hosp Epidemiol. 2003, 367.
2. Boyce J.M. Infect Control Hosp Epidemiol. 1997; 18:622-627.
3. Boyce J.M. Infect Control Hosp Epidemiol. 1997;18:622.
4. Muto C., Jernigan J., Ostrowsky B., Richet H., Jarvis W., Boyce J., and Farr B. SHEA Guideline for Preventing Nosocomial Transmission of Multidrug-Resistant Strains of Staphylococcus aureus and Enterococcus. Infect Control Hosp Epidemiol. 2003, 367.
5. CDC. 1992; 41: 783-7.
6. CDC. 1992; 41: 783-7.
7. Kopp B., Nix D., and Armstrong E. Ann Pharmacother.2004;9:1377-82; Carbon C.J Antimicrobial Chemotherapy. 1999;44:31-36.
8. Salgado C. and Farr B. Infect Control Hosp Epidemiol. 2003;24:690-698; Managing Infection Control. 2003;3:14-16.
9. CDC Guideline 1999 Surgical Site Infections.
10. Weinstein R.A. Emerging Infectious Diseases. 1998.
11. Proceedings of the Fourth Decennial International Conference on Nosocomial Infections And Healthcare-Associated Infections; 2000 March 5-9; Atlanta, Ga.
12. Boyce J.M. Infect Control Hosp Epidemiol. 1997;18:622.
13. Muto C., Jernigan J., Ostrowsky B., Richet H., Jarvis W., Boyce J., and Farr B. SHEA Guideline for Preventing Nosocomial Transmission of Multidrug-Resistant Strains of Staphylococcus aureus and Enterococcus. Infect Control Hosp Epidemiol. 2003, 367.
14. Muto C., Jernigan J., Ostrowsky B., Richet H., Jarvis W., Boyce J., and Farr B. SHEA Guideline for Preventing Nosocomial Transmission of Multidrug-Resistant Strains of Staphylococcus aureus and Enterococcus
Contact Transfer by the Numbers
- Thirty percent to 40 percent of resistant infections result from contact transfer via the hands of HCWs11
- Seventy percent of rooms had environmental contamination when the patient was colonized or infected12
- Bed rails, wheelchairs, thermometers, pulse oximeters, doorknobs, bed tables, linen, patient gowns, charts, etc.13
- Sixty-four percent of environmental surfaces in burn units were contaminated14
- VRE can persist on dry environmental surfaces anywhere from seven days to four months15
- MRSA can survive on sterile packages for more than 38 weeks16
- Forty-two percent of nurses gloves were contaminated with MRSA after touching environmental surfaces even if they never touched the MRSA infected patient17
- Forty percent of HCWs gowns were contaminated with VRE after care of a colonized or infected patient18
- Sixty-five percent of HCWs gowns were contaminated with MRSA after routine morning care for patients with MRSA in a wound or in their urine19
- Of 144 employees, none carried MRSA in the nose if wearing a mask when caring for MRSA patients during the first eight months of a NICU breakout20
- Four out of five studies reported lower rates of patients becoming VRE positive when HCWs used gowns and gloves as compared to gloves alone21
- A significantly lower rate of colonization was found among HCWs caring for MRSA patients when wearing gloves, a gown, and a mask instead of just a glove and gown22