By Deborah Davis, MS, MBA
Nextto your own intact skin, the gloves you wear are the first line of defenseagainst potentially infectious agents for you and your patients. Studies haveshown that at least one-third of all hospital infections are preventable. Recentreports of outbreaks and endemic infections caused by enterococci,including vancomycin-resistant enterococci (VRE), have indicated thatpatient-to-patient transmission of the microorganisms can occur either throughdirect or indirect contact via the hands of healthcare workers or throughcontaminated patient-care equipment or environmental surfaces.
Promotion of hand hygiene and the appropriate use of gloves are majorchallenges for infection control professionals (ICPs). Hand hygiene is thesimplest, most effective measure for preventing nosocomial infection, yet, for avariety of reasons, it is often difficult to achieve compliance.
The Role of Gloves
Robert A. Weinstein, MD, director of infectious disease services for the CookCounty Bureau of Health Services and co-chair of the Healthcare InfectionControl Practices Advisory Committee (HICPAC), discussed the roles of hospitalhygiene and antibiotic use in the control of antimicrobial resistance at arecent international conference on nosocomial infection. He noted that therelative contribution of epidemiological factors to the occurrence of endemicantimicrobial resistance suggests that 30% to 40% of resistant infections resultfrom cross-infection via hands of hospital personnel.
Weinstein cited studies of antimicrobial-resistant, gram-negative rods of Clostridiumdifficile diarrhea and VRE hand carriage, which showed that a strategy ofuniversal gloving resulted in effective control of resistant bacteria, as wellas C. difficile diarrhea.
The Bad Actors
Since their discovery in 1928, antibiotics have been hailed as miracle drugsand have been used for a multitude of illnesses. Antibiotics have savedcountless lives, but they are becoming less effective. Their overuse and misusehave caused once-rare, antibiotic-resistant mutant bacteria to flourish andproduce a large percentage of bacterial infections.
Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterium thathas plagued hospitals for years. The only effective treatment is the antibioticvancomycin. In 1988, however, another "super bug," VRE, appeared inhospitals. VRE are extremely communicable and have a 40% mortality rate. Invitro studies have shown that VRE can transfer the vancomycin resistance gene toother gram-positive bacteria, such as Staphylococcus aureus. Staphylococcusaureus infections are common in surgical wounds and in patients withartificial implants. This is a major concern to infectious disease experts sincea vancomycin-resistant strain of MRSA (or VRSA) would be virtually untreatable.
Today, nosocomial infections affect more than 2 million patients annually inthe US at a cost of more than $4.5 billion. Patients infected with a strain ofmethicillin-resistant S. aureus are hospitalized for an average of 12days longer than otherwise necessary at an average additional cost of $27,082.In addition, infections caused by S. aureus that are not resistant tomethicillin still lengthen hospitalization by an average of four days and add$9,661 to hospital costs. In 1981, about 5% of hospital S. aureusorganisms were resistant to methicillin; by 1991, methicillin resistance hadgrown to 38% and may have reached 50% in many hospitals today, according toMurray Abramson, MD, an infectious disease specialist at Duke University.
A Frontline of Defense
Keeping the skin of the hands intact and healthy is key to infection control.The skin is our largest organ, having a total area of almost two square meters.The epidermis provides the major barrier. The outermost layer is the stratumcorneum, which is composed of flattened, dead cells that are attached to eachother to form a tough layer of keratin mixed with various lipids. This layerhelps maintain the hydration, pliability, and barrier effectiveness of the skin.The stratum corneum consists of approximately 15 layers of cells, with a newlayer formed daily as old cells are shed. From healthy skin, approximately 10particles are disseminated into the air each day, and 10% of these containviable bacteria. Water content, humidity, pH levels, intracellular lipids, andrates of shedding help retain the protective barrier properties of the skin.
Two Kinds of Flora
The purpose of hand washing is to remove soil and transient microorganisms.Two major groups of microorganisms are found on the skin: resident flora(organisms that normally reside on the skin) and transient flora (contaminants).The pathogenic potential of the resident flora is typically low. Transientflora, which are easily removed by handwashing, cause most hospital infectionsresulting from cross-transmission, i.e., touch contamination. After gloveremoval, hand washing rids the hands of powder and other debris.
Soaps and detergents have been described as the most damaging of allsubstances applied to the skin. Each time the skin is washed, it undergoeschange, most of which is temporary. However, in occupations that requirefrequent hand washing, such as in healthcare, changes in the skin can result inchronic damage, irritant contact dermatitis, eczema, and changes in normal skinflora. Damaged skin may harbor increased numbers of pathogens and often shedshigher numbers of organisms. Additionally, washing damaged skin is lesseffective at reducing numbers of bacteria than washing normal skin.
Factors in Noncompliance
One hospitalwide survey showed that in 2,834 observed opportunities for handhygiene, average compliance was 48%. The lowest compliance rate (36%) was foundin ICUs where indications for hand washing were typically more frequent.
Healthcare workers (HCWs) report a number of reasons for not adhering to handhygiene recommendations. These include: skin irritations, interference withpatient care, forgetfulness, lack of scientific evidence of impact, disagreementwith guidelines, insufficient time, high workload and understaffing, and thebelief that wearing gloves obviates the need for proper hand washing.
Wearing gloves may actually represent a barrier for compliance with handhygiene due to the belief by some clinicians that wearing gloves makes handwashing unnecessary. Hand washing is recommended after glove removal because ofthe potential for contamination of the hands to occur during glove removal orvia glove leaks.
The Centers for Disease Control and Prevention's Hospital Infection ControlPractices Advisory Committee (CDC-HICPAC) recommends the use of gloves, gowns,and hand washing to prevent person-to-person transmission of VRE. Failure toremove gloves after patient contact or between dirty and clean body site carefor the same patient is considered to be noncompliant with hand hygienerecommendations.
Washing and reusing gloves between patient contact is ineffective. In fact,OSHA's Bloodborne Pathogens Standard specifically prohibits washing ordecontaminating disposable (single-use) gloves for reuse.
Strategies for Improving Compliance
Patient populations that are becoming increasingly vulnerable, such as older,more immunocompromised individuals, require even greater vigilance in handhygiene compliance from HCWs. Strategies for improving compliance need to beboth individual- and system-based. Individual--based strategies effectbehavioral changes, i.e., education and motivation. System-basedstrategies include physical plant considerations as well as policies andprocedures, such as the accessibility of sinks or other facilities, the supportand role modeling of management, and the promotion and facilitation of skin carefor HCWs.
By establishing a protocol and undertaking a consistent, effective hand careregime, HCWs will maintain the integrity of their skin against bloodbornepathogens and other infectious material. A hand care protocol should address thefollowing: hand washing, use of lotions/moisturizers, and appropriate gloveusage.
Frequent hand washing has been shown to be damaging to skin, and a mildemulsion cleaning rather than hand washing with liquid soap was associated withsignificant improvement in the skin of nurses' hands. Additionally, formulationsthat were developed more recently may be superior to antiseptic detergents forrapid microbial killing on skin and are probably milder due to the addition ofemollients.
Moisturizing improves skin health and reduces microbial shedding from theskin. Skin moisturizing products should be carefully assessed for compatibilitywith natural rubber latex gloves, for any topical antimicrobial products beingused, and for physiological effects on the skin.
The level of acceptance of products by personnel can also increase compliancewith recommended hand hygiene practices. Continuing education and motivationalefforts may be necessary for wide acceptance and frequent use of disinfectantsand other hand hygiene products.
Some individuals may be sensitive to either the chemicals used in themanufacturing of gloves or the protein allergens in natural rubber latex. Thesesensitivities may be manifested as irritations, contact dermatitis, or allergicreactions defined as Type IV or Type I hypersensitivity. Most skin reactions areirritations that can be managed by improved hand care and appropriate glovingpractices.
The accessibility of sinks or antiseptic products may be another mportantfactor in compliance to hand hygiene. Additionally, making a rapidly effective,waterless antiseptic agent accessible at each patient's bedside should make iteasier to comply with recommended hand hygiene practices.
The Best Hygiene Strategy, Hands Down
HCWs are aware of the reasons hand washing should be done. There are manybehavioral and logistical reasons why compliance is a continual challenge. Anumber of studies suggest that sustained data (daily memos with feedback onhandwashing practices or information about patient infections) can positivelyinfluence performance. Additionally, the use of role models or mentors caninfluence behavior and demonstrate management support for a culture of HCWs andpatient safety.
Compliance to hand hygiene recommendations is a complex issue, so there is nosimple solution. Effective strategies must recognize that individual andinstitutional factors are interdependent and incorporate a mix of individualbehavioral and system change approaches.
Deborah Davis, MS, MBA, is technical director for Allegiance HealthcareCorporation's gloves business.
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