Physiologic, microbiologic, and seasonal effects of handwashing on the skin of health care personnel

The handwashing practices of 22 personnel on an oncology unit in an urban medical center were studied for 2 months. During 891 person-hours of observation, 986 handwashes were observed. Subjects washed a mean of 1.1 times an hour for a mean of 13.2 seconds. Reported and observed handwashing behavior was only moderately correlated (p = 0.05 for frequency, 0.30 for duration of handwashing). Physicians washed significantly less often (p less than 0.001), but more thoroughly (p less than 0.001), than did nurses. Nurses washed more often after minimal or no patient contact than did physicians (p less than 0.001). Individuals were very consistent in their handwashing technique. A total of 558 isolates were recovered from 158 hand cultures. The mean log count was 4.88, with no significant difference between physicians and nurses. Coagulase-negative staphylococci isolated from hands of physicians and nurses were significantly more resistant to antimicrobial agents than those of personnel with minimal patient contact (p less than 0.01). Subjects had more skin damage in winter than in summer, as indicated by increased shedding of skin squames (p less than 0.05). We conclude that handwashing practices vary significantly by profession and that reporting of handwashing practices by personnel is inaccurate.

Certification: philosophy, goals, and methods, with application to the discipline of infection control practice

The philosophy, goals, and methods of certification are complex and need to be understood in general before they can be applied to a specific practice discipline. This article is intended to provide background information about certification, summarize the history of credentialing for health occupations, and briefly describe methods for test design and construction. Philosophy, goals, methods, and preparation for certification are then applied to the discipline of infection control practice, with specific reference to the Infection Control Certification Examination, offered for the first time in November 1983 and in each subsequent year.

Physiologic and microbiologic changes in skin related to frequent handwashing

Handwashing practices may be adversely influenced by the detrimental effects of handwashing on skin. A protocol was developed to assess the physiologic and microbiologic effects of frequent handwashing. Fifty-two female volunteers washed their hands 24 times per day for 5 days. Five agents were tested: water alone, non-medicated bar soap, a chlorhexidine-containing antiseptic, and two agents containing povidone-iodine (one currently available on the market and one being tested for possible marketing). Some damage to the outer membrane of skin, the stratum corneum, occurred in all groups. There were significant changes in the amount of evaporation water loss (p = .001) and in self assessments of skin condition (p = .005) from pre-to-post test for the entire group. Skin damage was also assessed by visualizing desquamating stratum corneum cells, which are shed in large aggregates when detergents injure skin. Significantly less such shedding occurred in subjects using water alone, bar soap, and the chlorhexidine formulation (p = .02). Greater antimicrobial activity of an agent was not correlated with increased skin trauma. We have quantitated, using objective physiologic parameter, the skin damage that occurs during even a short period of frequent handwashing. We recommend that further studies using the methods described be conducted to quantitate skin damage over longer periods of time, more closely resembling handwashing practices of health care personnel.

Phenytoin and acute mountain sickness on Mount Everest

Twenty-one climbers who were members of the American Ultima Thule Everest Expedition participated in a double-blind, randomized clinical trial of phenytoin prophylaxis for acute mountain sickness during the approach to the northeast ridge of Mount Everest. The study was carried out between Beijing and base camp at 16,800 feet. Time spent ascending from Beijing to base camp averaged 13 days. High-altitude symptom questionnaires were filled out beginning in Lhasa at 11,800 feet and in Xigatse at 12,000 feet, in Xegar at 14,000 feet, and at base camp. Computer analysis of the questionnaire answers performed by an impartial analyst revealed that climbers who took phenytoin were less likely to have headaches at base camp. No other statistically significant differences were observed, but the power of the sample size was low.

Chlamydial infections

Chlamydiae are small bacteria that have a unique life cycle. There are two species, Chlamydia psittaci and C. trachomatis, which cause a wide spectrum of clinical disease, including neonatal conjunctivitis and pneumonia, sexually transmitted disease, psittacosis, and trachoma. The importance of chlamydial disease in public health is being increasingly recognized, and the incidence in developed countries seems to be increasing. An understanding of chlamydial disease, its prevention and treatment, is essential for the infection control practitioner, who can play a significant role in patient education.

Evaluating handwashing technique

Though standards for handwashing have been defined, little effort has been made to assess the quality of handwashing in clinical settings. This paper describes tests of reliability and validity of tools to evaluate two aspects of handwashing--appropriateness and technique. Based on these tests, methods to evaluate handwashing are recommended.

Quality assurance. Evaluate thyself

Quality assurance (qa) programs must be documented carefully, systematically, and completely to be of continued value. A literature review revealed that no tools had been developed to evaluate the effectiveness of qa programs. A tool was designed and tested to assess the reports of qa studies, as an initial step in establishing the benefits of qa. The tool was found to yield reproducible results and its use is recommended to others.

Infection control issues in critical care: an update

NIs continue to be a frequent and serious complication in the critically ill patient. Although not all NIs can be prevented, two essential components of health care practice that are aimed at protecting both patients and staff have been discussed--isolation techniques and handwashing. We have also discussed the infectious complications of intravascular therapy, one of the most essential and common treatments for the critically ill patient. An effective infection control program for critical care must have certain elements: established standards of infection control practice, continual surveillance and feedback regarding infection rates, adequate physical facilities including personnel to maintain a clean environment, orientation and continuing education for personnel, but most important, a staff with a high level of awareness about the need to prevent NI. This awareness is developed by a leader who communicates his/her concern about the issue of infection control.

Effect of an expanded physical facility on nosocomial infections in a neonatal intensive care unit

Fifty-two months' data were reviewed to assess the effect of a threefold increase in space per infant in a neonatal intensive care unit on rates of nosocomial infections (NIs) and colonization with Staphylococcus aureus (39 months in a crowded 18-bed unit and 13 months in a spacious 32-bed unit). Mean length of stay, survival rates, mean birth weights, and other parameters indicated that infant populations in the old and new units were similar. NI rates were not significantly different in the old and new units (11.7% and 9.6%, respectively; p = 0.17) nor were rates of colonization of anterior nares with S. aureus (11.7% and 10.7%; p = 0.5). NI rates, but not S. aureus colonization rates, were significantly higher during months of high patient turnover (p less than 0.01). Sites of infection were similar in the old and new units. There was, however, a significant change in bacterial species causing NI. Klebsiella pneumoniae and Pseudomonas aeruginosa caused 20.4% of NIs in the old unit, but only 2.1% in the new unit (p less than 0.001) and NIs caused by S. epidermidis increased from 4.7% to 14.9% (p = 0.02) in the new unit. There was also a marked decrease in the numbers of clusters of NI occurring in the new unit, indicating that cross-infections between infants were probably minimized.

Handwashing and skin. Physiologic and bacteriologic aspects

Handwashing practices are often based on tradition and belief. To develop sound rationale for handwashing practices, the physiologic and bacteriologic effects of handwashing must be examined. The purposes of this article are to review the three major microenvironments of the skin with their bacterial flora, to discuss physiologic and bacteriologic characteristics of the skin with particular reference to handwashing, and to describe current handwashing recommendations and practices.

Bringing the new isolation guideline into focus

In 1983 the Centers for Disease Control published a new Guideline for Isolation Precautions in Hospitals. This article briefly reviews some general principles of barrier techniques, compares the old and revised isolation guidelines, and discusses the difficulty in obtaining compliance with isolation practices.

Health policy and NIH: implications for nursing research

Since their beginnings in the 1930s, categorical institutes funded for medical research have been controversial. Some individuals in administrative positions, such as the surgeon general, director of National Institutes of Health (NIH), and members of the Department of Health and Human Services, argue that separate institutes add administrative costs and are unnecessary because research can be done better in a less fragmented fashion. Some scientists express concern about intellectual freedom when research directions are legislatively dictated. Proponents of institutes, usually lay people, legislators, or scientists with specific research interests, contend that the problem warrants a national research effort since it is not handled within current structures. Two major foci of nursing research are on disease prevention and on improvement of the quality of care for the acutely and chronically ill, whereas the traditional priorities of NIH for basic research have been disease diagnosis and cure. Therefore, NIH support for nursing research has been negligible. To bring nursing into "the mainstream of scientific investigation," as recommended by a 1983 study conducted by the Institute of Medicine, an Institute of Nursing or an acceptable alternative within NIH seems advisable.

A decentralized approach to maintenance of intravenous therapy

A prospective experiment was conducted in a university-affiliated hospital to evaluate the effectiveness of a core of specially trained staff nurses in the maintenance of IV therapy. Five staff nurses for each of two experimental units were trained for 1 month by an IV nurse educator and were expected to perform venipuncture and monitor peripheral IV care on their units. On three control units, IV therapy continued to be a shared function of all medical house staff and nurses. During this study, 876 IV infusions on 707 patients were studied. There was a decrease in the phlebitis rate on experimental units from baseline to study periods of from 33.5% to 20.9% (relative risk, controlled for duration of the use of an IV device, 0.53, p = 0.05), whereas the rate on control units increased slightly (23.8% to 26.7%, p = greater than 0.5). Regardless of duration of use, steel needles were associated with lower phlebitis rates than were plastic catheters. The mean duration that each infusion device was in place was significantly shorter on experimental units than on control units (2.4 vs. 3.3 days, p = less than 0.001). However, bacterial colonization of IV devices occurred more often on experimental units than on control units both at baseline (12.7% vs. 7.1%; p = 0.25) and during the study phase (19.4% vs. 5.9%; p = less than 0.01). This increased colonization occurred with IV infusions started by both physicians and nurses. There were no septic complications of IV therapy in the patients studied. Patient comfort, measured by number of sticks for each venipuncture and patient interview, was significantly improved (p = less than 0.001) on experimental units during the study phase. Costs to start such a decentralized IV program on 10 clinical units was calculated to be about +10,000. This study provides information useful to those making administrative decisions regarding the value of IV teams or other methods for IV therapy maintenance. We concluded that a decentralized program can be successful with commitment of time and money resources and with a system of monitoring to ensure compliance with written IV guidelines.

Storage of human breast milk

The bacteriologic content of expressed breast milk was studied in 30 mothers at the time of expression and after 24 and 48 hours of refrigeration. There were no significant differences in colony counts between the three time intervals. All samples contained Staphylococcus epidermidis. In addition, eight other species were found, including four which were gram-negative. All samples contained less than 10(6) colonies/ml, and there were no significant differences in mean colony counts between samples expressed at home and at the hospital. We conclude that it is bacteriologically safe to refrigerate expressed breast milk for up to 48 hours.