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Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Hand-touch contact assessment of high-touch and mutual-touch surfaces among healthcare workers, patients, and visitors V.C.C. Cheng a, b, P.H. Chau c, W.M. Lee b, S.K.Y. Ho b, D.W.Y. Lee b, S.Y.C. So a, S.C.Y. Wong a, J.W.M. Tai b, K.Y. Yuen a, * a
Department of Microbiology, Queen Mary Hospital, Hong Kong SAR, China Infection Control Team, Queen Mary Hospital, Hong Kong SAR, China c School of Nursing, University of Hong Kong, Hong Kong SAR, China b
A R T I C L E
I N F O
Article history: Received 12 August 2014 Accepted 23 December 2014 Available online xxx Keywords: Disinfection Environment High-touch Hand hygiene Mutual-touch
S U M M A R Y
Background: Unlike direct contact with patients’ body, hand hygiene practice is often neglected by healthcare workers (HCWs) and visitors after contact with patients’ environment. Contact with hospital environmental items may increase risk of pathogen transmission. Aim: To enumerate the number of hand-touch contacts by patients, HCWs and visitors with any hospital environmental items. Methods: All contact-episodes between person and item were recorded by direct observation in a six-bed cubicle of acute wards for 33 working days. High-touch and mutualtouch items with high contact frequencies by HCWs, patients, and visitors were analysed. Findings: In total, 1107 person-episodes with 6144 contact-episodes were observed in 66 observation hours (average: 16.8 person-episodes and 93.1 contact-episodes per hour). Eight of the top 10 high-touch items, including bedside rails, bedside tables, patients’ bodies, patients’ files, linen, bed curtains, bed frames, and lockers were mutually touched by HCWs, patients, and visitors. Bedside rails topped the list with 13.6 contact-episodes per hour (mean), followed by bedside tables (12.3 contact-episodes per hour). Using patients’ body contacts as a reference, it was found that medical staff and nursing staff contacted bedside tables [rate ratio (RR): 1.741, 1.427, respectively] and patients’ files (RR: 1.358, 1.324, respectively) more than patients’ bodies, and nursing staff also contacted bedside rails (RR: 1.490) more than patients’ bodies. Conclusion: Patients’ surroundings may be links in the transmission of nosocomial infections because many are frequently touched and mutually contacted by HCWs, patients, and visitors. Therefore, the focus of hand hygiene education, environmental disinfection, and other system changes should be enhanced with respect to high-touch and mutualtouch items. ª 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Address: Carol Yu Centre for Infection, Department of Microbiology, Queen Mary Hospital, Hong Kong SAR, China. Tel.: þ852 22553206; fax: þ852 28724555. E-mail address: [email protected] (K.Y. Yuen). http://dx.doi.org/10.1016/j.jhin.2014.12.024 0195-6701/ª 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: Cheng VCC, et al., Hand-touch contact assessment of high-touch and mutual-touch surfaces among healthcare workers, patients, and visitors, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2014.12.024
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V.C.C. Cheng et al. / Journal of Hospital Infection xxx (2015) 1e6
Introduction Multiple drug-resistant organisms (MDROs) such as vancomycin-resistant enterococci (VRE), carbapenemresistant Acinetobacter baumannii (CRAB), carbapenemresistant Enterobacteriaceae (CRE) and meticillin-resistant Staphylococcus aureus (MRSA) can survive in the hospital environment for a prolonged period and are major players in causing hospital outbreaks, thus requiring infection control attention.1e7 Therefore, besides the implementation of active surveillance culture, practice of contact precautions, and of promotion of hand hygiene with alcohol-based hand rub, environmental hygiene is another critical control point in infection control.8,9 Unlike practising hand hygiene after direct contact with patients’ bodies, hand hygiene after contact with patients’ surroundings is often forgotten and missed by healthcare workers (HCWs) and visitors.10,11 Therefore, appropriate environmental cleaning and disinfection may improve the control of hospital-acquired infections.12 A quantitative approach in defining high-touch surfaces in hospitals, by observation of 50 interactions between HCWs and patients during patient care practices, has recently been described.13 However, the types of high-touch surfaces touched by patients and visitors have not been addressed. More importantly, the types of surfaces which are mutually touched by both patients and HCWs, thus posing a higher risk for nosocomial transmission, have not been resolved. In this study, we investigated the spectrum of hospital items including patients’ bodies touched by HCWs, patients, and visitors by observing 1107 person-episodes of interactions in 6144 contact-episodes in acute medical, surgical, and neurosurgical wards. The aim was to identify high-risk environmental items in the hospital for cleaning and disinfection, and to identify where improvements in hand hygiene education after environmental contact were required.
Methods This observational study was performed in Queen Mary Hospital, Hong Kong; a university-affiliated hospital of 1600 beds with acute medical, surgical, and neurosurgical services. As part of the infection control measure for hand hygiene monitoring, activities of HCWs (medical staff, nursing staff, supporting staff, and allied health staff), patients, and visitors in three 30-bed wards (one acute medical, acute surgical, and acute neurosurgical ward) were unobtrusively observed by two designated infection control nurses for a period of 33 working days (between 13th January 2014 and 7th March 2014). Each infection control nurse performed a 1 h observation session per working day in a fully occupied six-bedded cubicle to assess the items of contact and frequency of contacts with each observed item. A contact-episode was defined as one interaction between one person and one item involving any amount of person’s hand-touching the item. If one person contacted one item intermittently during the observation, more than one contactepisode was counted. A person-episode was defined as persontime involved in performing one task. If two persons performed one task together, two person-episodes were counted. In each person-episode, there could be more than one contact-
episode. High-touch items were defined as the 10 most frequently touched items in this study. Mutually touched surfaces or items in relation to the activities of HCWs, patients, and visitors were analysed.
Statistical analysis The mean frequency of contacts per hour in a cubicle was calculated by dividing the number of contact-episodes by the total number of observation hours. The mean frequency for different categories of persons (medical staff, nursing staff, supporting staff, allied health staff, patients, and visitors) was similarly calculated. The proportion of contact-episodes of the top 10 items of each category of persons was calculated by dividing the number of contact-episodes of that item by the total number of contacts made by the corresponding category of persons. For each category of persons, Poisson regression model was used to test whether the frequency of contacts with high-touch items in the hospital environment was different from the frequency of direct contact with patients’ bodies. Rate ratio (RR), the ratio of the frequency of contact with an item to the frequency of contact with patients’ bodies, was estimated from the Poisson regression model. Ninety-five percent confidence intervals (CIs) were also constructed. Estimated RR > 1 indicates higher contact frequency than with patients’ body (the reference item); RR < 1 indicates lower contact frequency. RR ¼ 1 indicates no difference. SPSS version 20 was used to perform the statistical analyses. P < 0.05 was considered significant.
Results During the study period, 1107 person-episodes were observed in 66 observation hours, with an average of 16.8 (1107 person-episodes per 66 h) person-episodes observed per hour in a cubicle. There was an average of 93.1 (6144 contact-episodes per 66 h) contact-episodes per hour in a cubicle, with 41.2 contact-episodes contributed by nursing staff, 26.6 by supporting staff, 10.6 by medical staff, 5.7 by allied health staff, 7.1 by patients, and 1.9 by visitors (Table I). Bedside rails topped the list of all contacted items with 899 contacts (14.6% of 6144 contacts) during the study period, equivalent to a mean frequency of 13.6 contact-episodes per hour in a cubicle; followed by bedside tables (812 contacts, 13.2%), equivalent to a mean frequency of 12.3 contactepisodes per hour in a cubicle. The top 10 items (including patient’s bodies) covered 4143 (67.4%) contacts of all observed contacts (Table II). The patient management-related activities were analysed as 957 person-episodes of HCWs with 3180 min of patient contacts. The median time per patient contact was 2 min (range: 0.5e38). In all, 5548 contact-episodes were observed. The median number of items touched was 5 per patient contact (range: 1e24). The RR of frequency of contact with high-touch hospital items by HCWs, patients, and visitors using patients’ body contacts as a reference showed that medical staff and nursing staff contacted bedside tables and patients’ files more than patients’ bodies, and nursing staff also contacted bedside rails more than patients’ bodies. However, patients and visitors
Please cite this article in press as: Cheng VCC, et al., Hand-touch contact assessment of high-touch and mutual-touch surfaces among healthcare workers, patients, and visitors, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2014.12.024
more frequently contacted bedside rails, bedside tables, linen, and lockers (Table III). With respect to the mutual-touched surfaces or items, 15 surfaces or items were mutually touched by HCWs, patients, and visitors (Figure 1). Among these 15 surfaces or items, eight (bedside rails, bedside tables, patients’ bodies, patients’ files, linen, curtains, bed frames, and lockers) were also in the list of the top 10 high-touch items.
Discussion In this study, ward-based nursing staff and supporting staff had the highest frequency of contact with hospital items, contributing to almost 73% of the observed contact-episodes. Patients and visitors constituted 10% of the observed contactepisodes during the study period, which was higher than allied health staff. Patients’ and visitors’ hands may constitute a missing link in infection control measures.14 Therefore, the focus of hand hygiene campaigns should include patients and visitors in addition to HCWs, with an emphasis on directly observed hand hygiene before intake of medications and meals at bedside.4,15 Bed rails and bedside tables were high-touch items, constituting almost 30% of all touched items, and were mutually touched by all ranks of HCWs, patients and visitors in patient care activities. Our findings were similar to those of previous studies indicating that bed rails and bed frames are the most, and second most, frequently touched items among near-patient surfaces, respectively.13,16 These near-patient surfaces have been found to be more frequently contaminated with MRSA that was genotypically indistinguishable from patients’ isolates.17 Therefore, environmental disinfection should be focused on these areas, as enhanced cleaning of near-patient surfaces has been shown to be associated with a significant reduction in new MRSA infections.17 Cleaning and disinfection of bed rails and bedside tables could be easily performed; this is more problematic in the case of patients’ files. This study found that files contributed to 10%
Table II Analysis of the top 10 high-touch itemsa including patient’s bodies by different categories of persons
Supporting staff includes healthcare assistants and phlebotomists, whereas allied health staff includes physiotherapists, occupational therapists, speech therapists, dieticians, and radiographers.
29 (23.0%) 18 (14.3%) 15 (11.9%) 2 (1.6%) 23 (18.3%) 6 (4.8%) 5 (4.0%) 13 (10.3%) 0 0 15 (11.9%)
3 BP, blood pressure. In total, 6144 contact-episodes of items, including direct contact with patient’s bodies, by 1107 person-episodes were observed for 33 working days (19th November 2013 to 18th March 2014). In total, 4143/6144 (67.4%) episodes of contacts were observed in the top 10 items. a Rank based on the contacts of all persons. b In total, 222 categories of hospital items were included.
2717 (44.2%) 1757 (28.6%) 699 (11.4%) 375 (6.1%) 470 (7.6%) 126 (2.1%) 6144 (100%)
111 (23.6%) 77 (16.4%) 2 (0.4%) 15 (3.2%) 31 (6.6%) 22 (4.7%) 24 (5.1%) 27 (5.7%) 1 (0.2%) 1 (0.2%) 159 (33.8%)
470 (42.5%) 278 (25.1%) 145 (13.1%) 64 (5.8%) 122 (11.0%) 28 (2.5%) 1107 (100%)
235 (13.4%) 170 (9.7%) 221 (12.6%) 107 (6.1%) 123 (7.0%) 113 (6.4%) 62 (3.5%) 25 (1.4%) 48 (2.7%) 0 653 (37.2%)
6144 (100%)
64 (17.1%) 45 (12.0%) 51 (13.6%) 48 (12.8%) 34 (9.1%) 9 (2.4%) 20 (5.3%) 4 (1.1%) 1 (0.3%) 1 (0.3%) 98 (26.1%)
1107 (100%)
377 (13.9%) 361 (13.3%) 253 (9.3%) 335 (12.3%) 135 (5.0%) 114 (4.2%) 104 (3.8%) 22 (0.8%) 38 (1.4%) 69 (2.5%) 909 (33.5%)
2260 (36.8%) 2402 (39.1%) 1482 (24.1%)
83 (11.9%) 141 (20.2%) 81 (11.6%) 110 (15.7%) 56 (8.0%) 23 (3.3%) 23 (3.3%) 3 (0.4%) 1 (0.1%) 11 (1.6%) 167 (23.9%)
515 (46.5%) 332 (33.0%) 260 (23.5%)
Bedside rail Bedside table Patient body Patient file Linen Curtain Bed frame Locker BP cuff Syringe Other itemsb
Contact-episodes
1 2 3 4 5 6 7 8 9 10 11
Ward setting Acute medical ward Acute surgical ward Acute neurosurgical ward Total Category of person Nursing staff Supporting staff Medical staff Allied health staff Patients Visitors Total
Person-episodes
Items
Location/person
Rank
Table I Description of 1107 person-episodes involving in 6144 contactepisodes with the hospital environment
Medical staff Nursing staff Allied health staff Supporting staff Patients Visitors (699 contact-episodes) (2717 contact-episodes) (375 contact-episodes) (1757 contact-episodes) (470 contact-episodes) (126 contact-episodes)
V.C.C. Cheng et al. / Journal of Hospital Infection xxx (2015) 1e6
Please cite this article in press as: Cheng VCC, et al., Hand-touch contact assessment of high-touch and mutual-touch surfaces among healthcare workers, patients, and visitors, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2014.12.024
RR, rate ratio; CI, confidence interval; BP, blood pressure; NA, not applicable. a Items that are mutually touched by healthcare workers, patients, and visitors. b RR and 95% CI across 1 denoted that the frequency of contacts of the hospital item was indifferent to touching patients’ body by the studied staff group. c RR and 95% CI > 1 denoted that the frequency of contacts of the hospital item was more frequent than direct contact with patients’ body by the studied staff group (P 0.002). d RR and 95% CI < 1 denoted that the frequency of contacts of the hospital item was less frequent than direct contact with patients’ body by the studied staff group (P < 0.006). e RR and 95% CI < 1 denoted that the frequency of contacts of the hospital item was less frequent than direct contact with patients’ body by the studied staff group (P ¼ 0.033).
8.235 (5.192e13.062)c 5.588 (3.461e9.021)c 1.000 (0.531e1.883)b 3.176 (1.895e5.325)c 1.647 (0.934e2.904)b 1.706 (0.972e2.994)b 0.059 (0.008e0.436)d 0.059 (0.008e0.436)d 0.059 (0.008e0.436)d 2.353 (1.386e3.996)c 1 (as reference) 1.063 (0.936e1.208)b 0.769 (0.660e0.896)d 0.484 (0.403e0.582)d 0.557 (0.472e0.657)d 0.511 (0.416e0.628)d 0.281 (0.221e0.357)d 0.217 (0.166e0.284)d NA 0.204 (0.154e0.269)d 0.113 (0.077e0.166)d 1 (as reference) 1.255 (0.946e1.665)b 0.882 (0.651e1.196)b 0.941 (0.727e1.218)b 0.667 (0.459e0.968)e 0.176 (0.087e0.357)d 0.392 (0.250e0.616)d 0.020 (0.003e0.138)d 0.020 (0.003e0.138)d 0.020 (0.003e0.138)d 0.078 (0.024e0.258)d 1 (as reference) 1.490 (1.319e1.683)c 1.427 (1.256e1.621)c 1.324 (1.181e1.485)c 0.534 (0.441e0.645)d 0.451 (0.363e0.559)e 0.411 (0.337e0.502)d 0.150 (0.109e0.206)d 0.273 (0.215e0.347)d 0.130 (0.093e0.183)d 0.087 (0.055e0.137)d 1 (as reference) 1.025 (0.790e1.329)b 1.741 (1.414e2.144)c 1.358 (1.118e1.650)c 0.691 (0.509e0.939)d 0.284 (0.186e0.434)d 0.284 (0.183e0.441)d 0.012 (0.002e0.099)d 0.136 (0.070e0.264)d 0.012 (0.002e0.088)d 0.037 (0.012e0.115)d 1 (as reference) Bedside raila Bedside tablea Patient filea Linena Curtaina Bed framea BP cuff Syringe BP machine Lockera Patient bodya
Allied health staff (375 contact-episodes) RR (95% CI) Medical staff (699 contact-episodes) RR (95% CI)
Nursing staff (2717 contact-episodes) RR (95% CI)
Supporting staff (1757 contact-episodes) RR (95% CI)
Patients and visitors (596 contact-episodes) RR (95% CI)
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Surface
Table III Contact rate ratio with high-touch and mutual-toucha hospital items by different categories of persons using rate of contact with patients’ body as reference
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Patients (7 items only touched by patients in 9 contactepisodes)
Healthcare Workers
(a) (b)
(181 items only touched by healthcare workers in 1022 contact-episodes)
(c)
(d)
Visitors (3 items only touched by visitors in 3 contactepisodes)
Figure 1. Mutual-touch surface or items in relation to the activities of hospital healthcare workers, patients, and visitors. (a) The 33 surfaces or items included blood pressure cuff (89 contactepisodes), syringe (82 contact-episodes), blood pressure machine (81 contact-episodes), intravenous pole (78 contactepisodes), monkey pull (58 contact-episodes), and other items with 20% of patients’ files in an intensive care unit (ICU) and surgical ward, respectively, were contaminated with various Gram-positive and Gram-negative organisms such as MRSA, Pseudomonas aeruginosa, Acinetobacter baumannii, Klebsiella pneumoniae, and Serratia marcescens.18 Another study showed that the contamination rate of patients’ charts in a surgical ICU and surgical ward with pathogenic or potential pathogenic bacteria were >90% and >70%.19 Electronic filing and frequent disinfection of keyboards may be the ultimate solution. Linens and curtains were the fifth and sixth most common high-touch items, being mutually touched by HCWs, patients, and visitors (5e6% of all observed contact-episodes). Whereas linens were replaced after patients’ discharge or when there was visible dirt, hospital curtains were only changed once every four weeks unless they were obviously contaminated by blood or patients’ secretion. Hospital curtains may also be a source of bacteria; in one study >90% of hospital curtains showed contamination within one week, with positive isolation of MRSA and VRE; another study found curtains to be a potential source for dissemination of Clostridium difficile.20,21 The use of curtains incorporating a complex element compound
Please cite this article in press as: Cheng VCC, et al., Hand-touch contact assessment of high-touch and mutual-touch surfaces among healthcare workers, patients, and visitors, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2014.12.024
V.C.C. Cheng et al. / Journal of Hospital Infection xxx (2015) 1e6 with antimicrobial properties may increase the median time of first contamination, although the evidence is not definitive.22 Blood pressure cuffs and blood pressure machines were mutually touched by HCWs and patients; previous studies have generated conflicting findings about the frequency of touch of blood pressure monitoring equipment.13,16 This might be related to differences in clinical practice in different types of ward setting. As a difficult-to-clean item, the blood pressure cuff had been shown to be frequently contaminated with MDROs, which may serve as a vector for transmission.23,24 Disposable blood pressure cuffs are available but are not widely used in the clinical setting.25 In addition to the 10 high-touch items, some often-forgotten items such as drinking cups and reusable water bottles were mutually touched by HCWs, patients, and visitors. Drinking cups were patients’ personal items, whereas reusable water bottles were provided by the hospital. If reusable water bottles were contaminated by a patient colonized with MDROs, crosscontamination may occur when supporting staff collect the bottles for refill. With this observation, we have implemented a system change by providing two sets of reusable water bottles per patient, so that the used one can be collected for disinfection. There were several limitations in our study. First, there may have been inter-observer variation between the two designated nurses. Moreover, activities can only be observed in one cubicle during each session, and only events on a single patient can be observed at any given time, even if there were simultaneous ongoing activities in the same cubicle on other patients. Furthermore, activities were not observed when privacy curtains were drawn. Second, we did not record hand hygiene compliance or the use of gloves. Third, our findings may have underestimated the activities of visitors, which only constituted 2.1% of the observed person-episodes. The study was conducted during the winter influenza peak season when visiting time was restricted to 2 h per day as an additional infection control measure. Finally, our observations were focused on acute care service, thus may not be generalized to non-acute care service. Despite these limitations, our study revealed the types of high-touch items in acute wards by HCWs, visitors, and patients. Such items are potential routes of transmission of pathogens, including MDROs. Infection control policy development should incorporate these observations, with enhanced hand hygiene education, environment cleaning, and other system changes targeted at reducing MDRO transmissions via these items. Conflict of interest statement None declared. Funding source This study was supported by the Health and Medical Research Fund (HMRF), Food and Health Bureau, Hong Kong SAR Government (Ref. No. HKM-15-M12).
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21. Trillis 3rd F, Eckstein EC, Budavich R, Pultz MJ, Donskey CJ. Contamination of hospital curtains with healthcare-associated pathogens. Infect Control Hosp Epidemiol 2008;29:1074e1076. 22. Schweizer M, Graham M, Ohl M, Heilmann K, Boyken L, Diekema D. Novel hospital curtains with antimicrobial properties: a randomized, controlled trial. Infect Control Hosp Epidemiol 2012;33:1081e1085. 23. Grewal H, Varshney K, Thomas LC, Kok J, Shetty A. Blood pressure cuffs as a vector for transmission of multi-resistant organisms:
colonisation rates and effects of disinfection. Emerg Med Australas 2013;25:222e226. 24. Matsuo M, Oie S, Furukawa H. Contamination of blood pressure cuffs by methicillin-resistant Staphylococcus aureus and preventive measures. Ir J Med Sci 2013;182:707e709. 25. Alpert BS, Cohen ML. The PAPERCUFF, a new disposable blood pressure cuff. Am J Cardiol 1996;77:531e532.
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Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Hand-touch contact assessment of high-touch and mutual-touch surfaces among healthcare workers, patients, and visitors V.C.C. Cheng a, b, P.H. Chau c, W.M. Lee b, S.K.Y. Ho b, D.W.Y. Lee b, S.Y.C. So a, S.C.Y. Wong a, J.W.M. Tai b, K.Y. Yuen a, * a
Department of Microbiology, Queen Mary Hospital, Hong Kong SAR, China Infection Control Team, Queen Mary Hospital, Hong Kong SAR, China c School of Nursing, University of Hong Kong, Hong Kong SAR, China b
A R T I C L E
I N F O
Article history: Received 12 August 2014 Accepted 23 December 2014 Available online xxx Keywords: Disinfection Environment High-touch Hand hygiene Mutual-touch
S U M M A R Y
Background: Unlike direct contact with patients’ body, hand hygiene practice is often neglected by healthcare workers (HCWs) and visitors after contact with patients’ environment. Contact with hospital environmental items may increase risk of pathogen transmission. Aim: To enumerate the number of hand-touch contacts by patients, HCWs and visitors with any hospital environmental items. Methods: All contact-episodes between person and item were recorded by direct observation in a six-bed cubicle of acute wards for 33 working days. High-touch and mutualtouch items with high contact frequencies by HCWs, patients, and visitors were analysed. Findings: In total, 1107 person-episodes with 6144 contact-episodes were observed in 66 observation hours (average: 16.8 person-episodes and 93.1 contact-episodes per hour). Eight of the top 10 high-touch items, including bedside rails, bedside tables, patients’ bodies, patients’ files, linen, bed curtains, bed frames, and lockers were mutually touched by HCWs, patients, and visitors. Bedside rails topped the list with 13.6 contact-episodes per hour (mean), followed by bedside tables (12.3 contact-episodes per hour). Using patients’ body contacts as a reference, it was found that medical staff and nursing staff contacted bedside tables [rate ratio (RR): 1.741, 1.427, respectively] and patients’ files (RR: 1.358, 1.324, respectively) more than patients’ bodies, and nursing staff also contacted bedside rails (RR: 1.490) more than patients’ bodies. Conclusion: Patients’ surroundings may be links in the transmission of nosocomial infections because many are frequently touched and mutually contacted by HCWs, patients, and visitors. Therefore, the focus of hand hygiene education, environmental disinfection, and other system changes should be enhanced with respect to high-touch and mutualtouch items. ª 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Address: Carol Yu Centre for Infection, Department of Microbiology, Queen Mary Hospital, Hong Kong SAR, China. Tel.: þ852 22553206; fax: þ852 28724555. E-mail address: [email protected] (K.Y. Yuen). http://dx.doi.org/10.1016/j.jhin.2014.12.024 0195-6701/ª 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: Cheng VCC, et al., Hand-touch contact assessment of high-touch and mutual-touch surfaces among healthcare workers, patients, and visitors, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2014.12.024
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V.C.C. Cheng et al. / Journal of Hospital Infection xxx (2015) 1e6
Introduction Multiple drug-resistant organisms (MDROs) such as vancomycin-resistant enterococci (VRE), carbapenemresistant Acinetobacter baumannii (CRAB), carbapenemresistant Enterobacteriaceae (CRE) and meticillin-resistant Staphylococcus aureus (MRSA) can survive in the hospital environment for a prolonged period and are major players in causing hospital outbreaks, thus requiring infection control attention.1e7 Therefore, besides the implementation of active surveillance culture, practice of contact precautions, and of promotion of hand hygiene with alcohol-based hand rub, environmental hygiene is another critical control point in infection control.8,9 Unlike practising hand hygiene after direct contact with patients’ bodies, hand hygiene after contact with patients’ surroundings is often forgotten and missed by healthcare workers (HCWs) and visitors.10,11 Therefore, appropriate environmental cleaning and disinfection may improve the control of hospital-acquired infections.12 A quantitative approach in defining high-touch surfaces in hospitals, by observation of 50 interactions between HCWs and patients during patient care practices, has recently been described.13 However, the types of high-touch surfaces touched by patients and visitors have not been addressed. More importantly, the types of surfaces which are mutually touched by both patients and HCWs, thus posing a higher risk for nosocomial transmission, have not been resolved. In this study, we investigated the spectrum of hospital items including patients’ bodies touched by HCWs, patients, and visitors by observing 1107 person-episodes of interactions in 6144 contact-episodes in acute medical, surgical, and neurosurgical wards. The aim was to identify high-risk environmental items in the hospital for cleaning and disinfection, and to identify where improvements in hand hygiene education after environmental contact were required.
Methods This observational study was performed in Queen Mary Hospital, Hong Kong; a university-affiliated hospital of 1600 beds with acute medical, surgical, and neurosurgical services. As part of the infection control measure for hand hygiene monitoring, activities of HCWs (medical staff, nursing staff, supporting staff, and allied health staff), patients, and visitors in three 30-bed wards (one acute medical, acute surgical, and acute neurosurgical ward) were unobtrusively observed by two designated infection control nurses for a period of 33 working days (between 13th January 2014 and 7th March 2014). Each infection control nurse performed a 1 h observation session per working day in a fully occupied six-bedded cubicle to assess the items of contact and frequency of contacts with each observed item. A contact-episode was defined as one interaction between one person and one item involving any amount of person’s hand-touching the item. If one person contacted one item intermittently during the observation, more than one contactepisode was counted. A person-episode was defined as persontime involved in performing one task. If two persons performed one task together, two person-episodes were counted. In each person-episode, there could be more than one contact-
episode. High-touch items were defined as the 10 most frequently touched items in this study. Mutually touched surfaces or items in relation to the activities of HCWs, patients, and visitors were analysed.
Statistical analysis The mean frequency of contacts per hour in a cubicle was calculated by dividing the number of contact-episodes by the total number of observation hours. The mean frequency for different categories of persons (medical staff, nursing staff, supporting staff, allied health staff, patients, and visitors) was similarly calculated. The proportion of contact-episodes of the top 10 items of each category of persons was calculated by dividing the number of contact-episodes of that item by the total number of contacts made by the corresponding category of persons. For each category of persons, Poisson regression model was used to test whether the frequency of contacts with high-touch items in the hospital environment was different from the frequency of direct contact with patients’ bodies. Rate ratio (RR), the ratio of the frequency of contact with an item to the frequency of contact with patients’ bodies, was estimated from the Poisson regression model. Ninety-five percent confidence intervals (CIs) were also constructed. Estimated RR > 1 indicates higher contact frequency than with patients’ body (the reference item); RR < 1 indicates lower contact frequency. RR ¼ 1 indicates no difference. SPSS version 20 was used to perform the statistical analyses. P < 0.05 was considered significant.
Results During the study period, 1107 person-episodes were observed in 66 observation hours, with an average of 16.8 (1107 person-episodes per 66 h) person-episodes observed per hour in a cubicle. There was an average of 93.1 (6144 contact-episodes per 66 h) contact-episodes per hour in a cubicle, with 41.2 contact-episodes contributed by nursing staff, 26.6 by supporting staff, 10.6 by medical staff, 5.7 by allied health staff, 7.1 by patients, and 1.9 by visitors (Table I). Bedside rails topped the list of all contacted items with 899 contacts (14.6% of 6144 contacts) during the study period, equivalent to a mean frequency of 13.6 contact-episodes per hour in a cubicle; followed by bedside tables (812 contacts, 13.2%), equivalent to a mean frequency of 12.3 contactepisodes per hour in a cubicle. The top 10 items (including patient’s bodies) covered 4143 (67.4%) contacts of all observed contacts (Table II). The patient management-related activities were analysed as 957 person-episodes of HCWs with 3180 min of patient contacts. The median time per patient contact was 2 min (range: 0.5e38). In all, 5548 contact-episodes were observed. The median number of items touched was 5 per patient contact (range: 1e24). The RR of frequency of contact with high-touch hospital items by HCWs, patients, and visitors using patients’ body contacts as a reference showed that medical staff and nursing staff contacted bedside tables and patients’ files more than patients’ bodies, and nursing staff also contacted bedside rails more than patients’ bodies. However, patients and visitors
Please cite this article in press as: Cheng VCC, et al., Hand-touch contact assessment of high-touch and mutual-touch surfaces among healthcare workers, patients, and visitors, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2014.12.024
more frequently contacted bedside rails, bedside tables, linen, and lockers (Table III). With respect to the mutual-touched surfaces or items, 15 surfaces or items were mutually touched by HCWs, patients, and visitors (Figure 1). Among these 15 surfaces or items, eight (bedside rails, bedside tables, patients’ bodies, patients’ files, linen, curtains, bed frames, and lockers) were also in the list of the top 10 high-touch items.
Discussion In this study, ward-based nursing staff and supporting staff had the highest frequency of contact with hospital items, contributing to almost 73% of the observed contact-episodes. Patients and visitors constituted 10% of the observed contactepisodes during the study period, which was higher than allied health staff. Patients’ and visitors’ hands may constitute a missing link in infection control measures.14 Therefore, the focus of hand hygiene campaigns should include patients and visitors in addition to HCWs, with an emphasis on directly observed hand hygiene before intake of medications and meals at bedside.4,15 Bed rails and bedside tables were high-touch items, constituting almost 30% of all touched items, and were mutually touched by all ranks of HCWs, patients and visitors in patient care activities. Our findings were similar to those of previous studies indicating that bed rails and bed frames are the most, and second most, frequently touched items among near-patient surfaces, respectively.13,16 These near-patient surfaces have been found to be more frequently contaminated with MRSA that was genotypically indistinguishable from patients’ isolates.17 Therefore, environmental disinfection should be focused on these areas, as enhanced cleaning of near-patient surfaces has been shown to be associated with a significant reduction in new MRSA infections.17 Cleaning and disinfection of bed rails and bedside tables could be easily performed; this is more problematic in the case of patients’ files. This study found that files contributed to 10%
Table II Analysis of the top 10 high-touch itemsa including patient’s bodies by different categories of persons
Supporting staff includes healthcare assistants and phlebotomists, whereas allied health staff includes physiotherapists, occupational therapists, speech therapists, dieticians, and radiographers.
29 (23.0%) 18 (14.3%) 15 (11.9%) 2 (1.6%) 23 (18.3%) 6 (4.8%) 5 (4.0%) 13 (10.3%) 0 0 15 (11.9%)
3 BP, blood pressure. In total, 6144 contact-episodes of items, including direct contact with patient’s bodies, by 1107 person-episodes were observed for 33 working days (19th November 2013 to 18th March 2014). In total, 4143/6144 (67.4%) episodes of contacts were observed in the top 10 items. a Rank based on the contacts of all persons. b In total, 222 categories of hospital items were included.
2717 (44.2%) 1757 (28.6%) 699 (11.4%) 375 (6.1%) 470 (7.6%) 126 (2.1%) 6144 (100%)
111 (23.6%) 77 (16.4%) 2 (0.4%) 15 (3.2%) 31 (6.6%) 22 (4.7%) 24 (5.1%) 27 (5.7%) 1 (0.2%) 1 (0.2%) 159 (33.8%)
470 (42.5%) 278 (25.1%) 145 (13.1%) 64 (5.8%) 122 (11.0%) 28 (2.5%) 1107 (100%)
235 (13.4%) 170 (9.7%) 221 (12.6%) 107 (6.1%) 123 (7.0%) 113 (6.4%) 62 (3.5%) 25 (1.4%) 48 (2.7%) 0 653 (37.2%)
6144 (100%)
64 (17.1%) 45 (12.0%) 51 (13.6%) 48 (12.8%) 34 (9.1%) 9 (2.4%) 20 (5.3%) 4 (1.1%) 1 (0.3%) 1 (0.3%) 98 (26.1%)
1107 (100%)
377 (13.9%) 361 (13.3%) 253 (9.3%) 335 (12.3%) 135 (5.0%) 114 (4.2%) 104 (3.8%) 22 (0.8%) 38 (1.4%) 69 (2.5%) 909 (33.5%)
2260 (36.8%) 2402 (39.1%) 1482 (24.1%)
83 (11.9%) 141 (20.2%) 81 (11.6%) 110 (15.7%) 56 (8.0%) 23 (3.3%) 23 (3.3%) 3 (0.4%) 1 (0.1%) 11 (1.6%) 167 (23.9%)
515 (46.5%) 332 (33.0%) 260 (23.5%)
Bedside rail Bedside table Patient body Patient file Linen Curtain Bed frame Locker BP cuff Syringe Other itemsb
Contact-episodes
1 2 3 4 5 6 7 8 9 10 11
Ward setting Acute medical ward Acute surgical ward Acute neurosurgical ward Total Category of person Nursing staff Supporting staff Medical staff Allied health staff Patients Visitors Total
Person-episodes
Items
Location/person
Rank
Table I Description of 1107 person-episodes involving in 6144 contactepisodes with the hospital environment
Medical staff Nursing staff Allied health staff Supporting staff Patients Visitors (699 contact-episodes) (2717 contact-episodes) (375 contact-episodes) (1757 contact-episodes) (470 contact-episodes) (126 contact-episodes)
V.C.C. Cheng et al. / Journal of Hospital Infection xxx (2015) 1e6
Please cite this article in press as: Cheng VCC, et al., Hand-touch contact assessment of high-touch and mutual-touch surfaces among healthcare workers, patients, and visitors, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2014.12.024
RR, rate ratio; CI, confidence interval; BP, blood pressure; NA, not applicable. a Items that are mutually touched by healthcare workers, patients, and visitors. b RR and 95% CI across 1 denoted that the frequency of contacts of the hospital item was indifferent to touching patients’ body by the studied staff group. c RR and 95% CI > 1 denoted that the frequency of contacts of the hospital item was more frequent than direct contact with patients’ body by the studied staff group (P 0.002). d RR and 95% CI < 1 denoted that the frequency of contacts of the hospital item was less frequent than direct contact with patients’ body by the studied staff group (P < 0.006). e RR and 95% CI < 1 denoted that the frequency of contacts of the hospital item was less frequent than direct contact with patients’ body by the studied staff group (P ¼ 0.033).
8.235 (5.192e13.062)c 5.588 (3.461e9.021)c 1.000 (0.531e1.883)b 3.176 (1.895e5.325)c 1.647 (0.934e2.904)b 1.706 (0.972e2.994)b 0.059 (0.008e0.436)d 0.059 (0.008e0.436)d 0.059 (0.008e0.436)d 2.353 (1.386e3.996)c 1 (as reference) 1.063 (0.936e1.208)b 0.769 (0.660e0.896)d 0.484 (0.403e0.582)d 0.557 (0.472e0.657)d 0.511 (0.416e0.628)d 0.281 (0.221e0.357)d 0.217 (0.166e0.284)d NA 0.204 (0.154e0.269)d 0.113 (0.077e0.166)d 1 (as reference) 1.255 (0.946e1.665)b 0.882 (0.651e1.196)b 0.941 (0.727e1.218)b 0.667 (0.459e0.968)e 0.176 (0.087e0.357)d 0.392 (0.250e0.616)d 0.020 (0.003e0.138)d 0.020 (0.003e0.138)d 0.020 (0.003e0.138)d 0.078 (0.024e0.258)d 1 (as reference) 1.490 (1.319e1.683)c 1.427 (1.256e1.621)c 1.324 (1.181e1.485)c 0.534 (0.441e0.645)d 0.451 (0.363e0.559)e 0.411 (0.337e0.502)d 0.150 (0.109e0.206)d 0.273 (0.215e0.347)d 0.130 (0.093e0.183)d 0.087 (0.055e0.137)d 1 (as reference) 1.025 (0.790e1.329)b 1.741 (1.414e2.144)c 1.358 (1.118e1.650)c 0.691 (0.509e0.939)d 0.284 (0.186e0.434)d 0.284 (0.183e0.441)d 0.012 (0.002e0.099)d 0.136 (0.070e0.264)d 0.012 (0.002e0.088)d 0.037 (0.012e0.115)d 1 (as reference) Bedside raila Bedside tablea Patient filea Linena Curtaina Bed framea BP cuff Syringe BP machine Lockera Patient bodya
Allied health staff (375 contact-episodes) RR (95% CI) Medical staff (699 contact-episodes) RR (95% CI)
Nursing staff (2717 contact-episodes) RR (95% CI)
Supporting staff (1757 contact-episodes) RR (95% CI)
Patients and visitors (596 contact-episodes) RR (95% CI)
V.C.C. Cheng et al. / Journal of Hospital Infection xxx (2015) 1e6
Surface
Table III Contact rate ratio with high-touch and mutual-toucha hospital items by different categories of persons using rate of contact with patients’ body as reference
4
Patients (7 items only touched by patients in 9 contactepisodes)
Healthcare Workers
(a) (b)
(181 items only touched by healthcare workers in 1022 contact-episodes)
(c)
(d)
Visitors (3 items only touched by visitors in 3 contactepisodes)
Figure 1. Mutual-touch surface or items in relation to the activities of hospital healthcare workers, patients, and visitors. (a) The 33 surfaces or items included blood pressure cuff (89 contactepisodes), syringe (82 contact-episodes), blood pressure machine (81 contact-episodes), intravenous pole (78 contactepisodes), monkey pull (58 contact-episodes), and other items with 20% of patients’ files in an intensive care unit (ICU) and surgical ward, respectively, were contaminated with various Gram-positive and Gram-negative organisms such as MRSA, Pseudomonas aeruginosa, Acinetobacter baumannii, Klebsiella pneumoniae, and Serratia marcescens.18 Another study showed that the contamination rate of patients’ charts in a surgical ICU and surgical ward with pathogenic or potential pathogenic bacteria were >90% and >70%.19 Electronic filing and frequent disinfection of keyboards may be the ultimate solution. Linens and curtains were the fifth and sixth most common high-touch items, being mutually touched by HCWs, patients, and visitors (5e6% of all observed contact-episodes). Whereas linens were replaced after patients’ discharge or when there was visible dirt, hospital curtains were only changed once every four weeks unless they were obviously contaminated by blood or patients’ secretion. Hospital curtains may also be a source of bacteria; in one study >90% of hospital curtains showed contamination within one week, with positive isolation of MRSA and VRE; another study found curtains to be a potential source for dissemination of Clostridium difficile.20,21 The use of curtains incorporating a complex element compound
Please cite this article in press as: Cheng VCC, et al., Hand-touch contact assessment of high-touch and mutual-touch surfaces among healthcare workers, patients, and visitors, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2014.12.024
V.C.C. Cheng et al. / Journal of Hospital Infection xxx (2015) 1e6 with antimicrobial properties may increase the median time of first contamination, although the evidence is not definitive.22 Blood pressure cuffs and blood pressure machines were mutually touched by HCWs and patients; previous studies have generated conflicting findings about the frequency of touch of blood pressure monitoring equipment.13,16 This might be related to differences in clinical practice in different types of ward setting. As a difficult-to-clean item, the blood pressure cuff had been shown to be frequently contaminated with MDROs, which may serve as a vector for transmission.23,24 Disposable blood pressure cuffs are available but are not widely used in the clinical setting.25 In addition to the 10 high-touch items, some often-forgotten items such as drinking cups and reusable water bottles were mutually touched by HCWs, patients, and visitors. Drinking cups were patients’ personal items, whereas reusable water bottles were provided by the hospital. If reusable water bottles were contaminated by a patient colonized with MDROs, crosscontamination may occur when supporting staff collect the bottles for refill. With this observation, we have implemented a system change by providing two sets of reusable water bottles per patient, so that the used one can be collected for disinfection. There were several limitations in our study. First, there may have been inter-observer variation between the two designated nurses. Moreover, activities can only be observed in one cubicle during each session, and only events on a single patient can be observed at any given time, even if there were simultaneous ongoing activities in the same cubicle on other patients. Furthermore, activities were not observed when privacy curtains were drawn. Second, we did not record hand hygiene compliance or the use of gloves. Third, our findings may have underestimated the activities of visitors, which only constituted 2.1% of the observed person-episodes. The study was conducted during the winter influenza peak season when visiting time was restricted to 2 h per day as an additional infection control measure. Finally, our observations were focused on acute care service, thus may not be generalized to non-acute care service. Despite these limitations, our study revealed the types of high-touch items in acute wards by HCWs, visitors, and patients. Such items are potential routes of transmission of pathogens, including MDROs. Infection control policy development should incorporate these observations, with enhanced hand hygiene education, environment cleaning, and other system changes targeted at reducing MDRO transmissions via these items. Conflict of interest statement None declared. Funding source This study was supported by the Health and Medical Research Fund (HMRF), Food and Health Bureau, Hong Kong SAR Government (Ref. No. HKM-15-M12).
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