INFECTION PREVENTION AND CONTROL


Several researchers have noted that gloves may give healthcare workers a false sense of confidence in protecting patients and themselves.29 It is worth noting that healthcare workers may significantly misjudge their hand- hygiene compliance. In a study of eight Hong Kong hospital NICUs, 80% of healthcare workers reported, via questionnaire, that they had followed hand hygiene guidelines both before and after high-risk situations. But covert observers found just 34% compliance before high risk situations and 27% compliance afterward.30 When staff know they are being


pairs.28


observed, several studies show, hand- hygiene compliance typically improves. For example, in a study of five ICUs at two Berlin hospitals, compliance was 29% when healthcare workers did not know they were being watched and 45% when they were told.31 Yet hand hygiene habits can become so ingrained that even full knowledge of surveillance may not help. In an American study, healthcare workers who already had demonstrated excellent compliance performed even better when told they would be observed, but among their peers with poor track records, the knowledge did not significantly improve compliance.32 Hand hygiene compliance is difficult to measure - so difficult that the Joint Commission issued a 204 page monograph detailing the obstacles related to study design, observer training, data collection, and more.33


All of this makes a recent Swiss study of intensive care units particularly compelling. Researchers outfitted nurses and doctors with head-mounted cameras during morning rounds, a study design that allowed for more rigorous monitoring than in-person observation. “We could show for the first time in a fast-paced, real clinical setting how frequently healthcare workers’ hands touch surfaces,” the authors wrote, “corroborating the fast spread of microorganisms in healthcare settings.”34 Partly this is because healthcare workers are human, and like all human beings, they engage in automatic, unconscious behaviours. “People often are unaware of what exactly their hands do while they are focused on the main task goal,” the Swiss researchers noted.


Swiss research


findings Hands deposit - and likely transmit - potentially harmful microorganisms every four seconds onto patients and surfaces. The doctors and nurses sustained hand rubbing for a median of 11 seconds, far short of the recommended 20 to 30 seconds.35 Overall, hand hygiene compliance ranged from 1% to 5%.


The fact that lethal microbes are invisible does not help. “Because we can’t see them,” one microbiologist observed, “it is easy to forget that they are there.”36


But hospitals face another large obstacle to improving compliance: healthcare workers are strapped for time. “In our era of budget cuts and reduced healthcare staffing,” Prof Assadian noted, “it is difficult for healthcare workers to master the art of aseptic and contamination-free patient care. “Maintaining perfect compliance, especially during invasive patient-care activities, may not be feasible in this changed healthcare environment.” It is important to note that even 100% hand hygiene compliance would not solve the problem of pathogen contamination via healthcare workers’ hands. In the Ohio glove-and-gown-removal study, skin and clothing were contaminated 30% of the time when proper techniques were followed. Hospitals must continue to promote hand hygiene, but they must also know of its significant shortcomings.


The failures of su rface cleaning: Superbugs win


Given the limitations of hospital hand hygiene and the proliferation of superbugs, meticulous surface cleaning is all the more critical. As Prof Assadian noted: “The more contaminated the surface, the more likely healthcare workers and patients will pick up bacteria on their hands.” Virulent microbes have remarkable staying power in the hospital environment. Clostridium difficile can last five months on hospital floors and has been found on the shoes of healthcare workers.37


resistant enterococci (VRE) can survive for up to 58 days on countertops38


and noroviruses,


tolerant to a broad range of commonly used hospital disinfectants, can survive on carpets for up to 12 days.39


It is no wonder patients


have a 40% elevated risk of contracting an infection when they stay in rooms previously occupied by infected patients.40 American research conducted on 23 hospitals shows that following terminal disinfection of a room, more than 50% of surfaces are missed completely during manual cleaning. And whereas the study found sinks, toilet seats, and tray tables were relatively well cleaned, with an average rate over 75%, cleaning rates fell below 30% for toilet handles, bedpan cleaners, light switches, and door knobs.41 In a different study, the same lead author determined that 40% of high-touch surfaces sampled were inadequately disinfected.42 Microbes accumulate 24 hours a day, as visitors, staff, and medical devices come and go. Humidifiers, stethoscopes, supply carts, wheelchairs, stretchers, glucometers, IV poles, portable computers – all can serve as vectors for transmission when even minor flaws in surface cleaning occur. “The danger extends far beyond the handful of patients who stay in that room, spreading from room to room to potentially affect the entire facility,” Cornell University researchers warned.43


Medical devices considered at low risk for transferring infection, such as blood pressure cuffs and oximetry sensors, may actually pose a greater risk than invasive instruments because they are used on so many patients. “The laryngoscope blade is likely less of a problem than the handle,” cautioned Janet Haas, DNSc, director of Infection Prevention and Control at New York Medical College.44 To fight surface hazards in the superbug era, many hospitals have raised cleaning standards. They use microfiber mopping systems, remove isolation-room curtains for cleaning, and disinfect toilet handles, bathroom doors, call buttons, tray tables, light switches, and other bacteria-laden surfaces. Despite these efforts, hospital surface cleaning remains inadequate.


One culprit: the global phenomenon of outsourced cleaning


Vancomycin-


In response to financial crises, “hospitals have gutted cleaning staff,” wrote University of Toronto sociologist Dan Zuberi, PhD, author of “Cleaning up: How hospital outsourcing is hurting workers and endangering patients.” Zuberi spent three years tracking hospital cleaners in British Columbia, where legislation prompted all hospital cleaning to be outsourced. Zuberi called the change a “disaster,” both for cleaners and patients.45


Often,


Smaller, lighter particles can waft in the air for hours and travel long distances via currents, while larger particles settle on surfaces


42 I WWW.CLINICALSERVICESJOURNAL.COM


outsourced staff aren’t given sufficient time to do their jobs. “Basically, you do the big stuff, and then you start cutting corners,” one hospital cleaner told Zuberi. “You just cannot get it all done. When I say ‘cutting corners,’


SEPTEMBER 2018


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