Where do hands go? An audit of sequential hand-touch events on a hospital ward

Reservoirs of pathogens could establish themselves at forgotten sites on a ward, posing a continued risk for transmission to patients via unwashed hands. To track potential spread of organisms between surfaces and patients, and to gaina greater understanding into transmission pathways of pathogens during patient care. Hand-touch activities were audited covertly for 40 30 min sessions during summer and winter, and included hand hygiene on entry; contact with near-patient sites; patient contact; contact with clinical equipment; hand hygiene on exit; and contact with sites outside the room. There were 104 entries overall: 77 clinical staff (59 nurses; 18 doctors), 21 domestic staff, one pharmacist and five relatives. Hand-hygiene compliance among clinical staff before and after entry was 25% (38/154), with higher compliance during 20 summer periods [47%; 95% confidence interval (CI): 35.6e58.8] than during 20 winter periods (7%; 95% CI: 3.2e14.4; P < 0.0001). More than half of the staff (58%; 45/77) touched the patient. Staff were more likely to clean their hands prior to contact with a patient [odds ratio (OR): 3.44; 95% CI: 0.94e16.0); P ¼ 0.059] and sites beside the patient (OR: 6.76; 95% CI: 1.40e65.77; P ¼ 0.0067). Nearly half (48%; 37/77) handled patient notes and 25% touched the bed. Most frequently handled equipment inside the room were intravenous drip (30%) and blood pressure stand (13%), and computer (26%), notes trolley (23%) and telephone (21%) outside the room. Hand-hygiene compliance remains poor during covert observation; understanding the most frequent interactions between hands and surfaces could target sites for cleaning

Monitoring environmental cleanliness on two surgical wards

Ten hand-touch sites were screened weekly on two surgical wards over two consecutive six-month periods. The results were analysed using hygiene standards, which specify 1) an aerobic colony count (ACC) >2.5cfu/cm2, and 2) presence of coagulase-positive staphylococci, as hygiene failures. Sites most often failing the standards were beds and hoist (64%: 33 of 52 weeks), bedside lockers (62%: 32 of 52) and overbed tables (44%: 23 of 52). Methicillin-susceptible/resistant Staphylococcus aureus (MSSA/MRSA) were more often recovered from lockers, overbed tables and beds. Recovery of MSSA/MRSA at any site was significantly associated with an ACC>2.5cfu/cm2 from that site (p=0.001; OR: 3.35 (95% CI 1.79, 6.28)). In addition, total ACC's>2.5cfu/cm2 each week were significantly associated with weekly bed occupancies >95% (p=0.0004; OR: 2.94 (95% CI 1.44, 6.02)). Higher microbial growth levels from hand-touch sites reflect weekly bed occupancies and indicate a risk for both resistant and susceptible S.aureus. These organisms are more likely to be recovered from near-patient sites on the ward

Revising Nightingale's legacy

The recent editorial from this Journal does well to highlight the benefits of hand hygiene once again [ 1 ]. It is entirely appropriate to support the need for clean hands, especially during an ongoing pandemic. But there is another message that seems to have got lost. This message is about cleaning the surfaces that hands touch, since hands only require attention because of their capacity for contact with a host of contaminated sites [ 2 ]. Why is there this perpetual disconnect between hands and hand-touch sites? Does it not make sense to tackle the cleaning aspects of both

Approaching zero : temporal effects of a restrictive antibiotic policy on hospital-acquired Clostridium difficile, extended-spectrum β-lactamase-producing coliforms and meticillin-resistant Staphylococcus aureus

A restrictive antibiotic policy banning routine use of ceftriaxone and ciprofloxacin was implemented in a 450-bed district general hospital following an educational campaign. Monthly consumption of nine antibiotics was monitored in defined daily doses (DDDs) per 1000 patient-occupied bed-days (1000 pt-bds) 9 months before until 16 months after policy introduction. Hospital-acquired Clostridium difficile, meticillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum -lactamase (ESBL)- producing coliform cases per month/1000 pt-bds were identified and reviewed throughout the hospital. Between the first and final 6 months of the study, average monthly consumption of ceftriaxone reduced by 95% (from 46.213 to 2.129 DDDs/1000 pt-bds) and that for ciprofloxacin by 72.5% (109.804 to 30.205 DDDs/1000 pt-bds). Over the same periods, hospital-acquisition rates for C. difficile reduced by 77% (2.398 to 0.549 cases/1000 pt-bds), for MRSA by 25% (1.187 to 0.894 cases/1000 pt-bds) and for ESBL-producing coliforms by 17% (1.480 to 1.224 cases/1000 pt-bds). Time-lag modelling confirmed significant associations between ceftriaxone and C. difficile cases at 1 month (correlation 0.83; P < 0.005), and between ciprofloxacin and ESBL-producing coliform cases at 2 months (correlation 0.649; P = 0.002). An audit performed 3 years after the policy showed sustained reduction in C. difficile rates (0.259 cases/1000 pt-bds), with additional decreases for MRSA (0.409 cases/1000 pt-bds) and ESBL-producing coliforms (0.809 cases/1000 pt-bds). In conclusion, banning two antibiotics resulted in an immediate and profound reduction in hospital-acquired C. difficile, with possible longer-term effects on MRSA and ESBL-producing coliform rates. Antibiotic stewardship is fundamental in the control of major hospital pathogens

Novel Technology for Door Handle Design

We note the recent article on ‘The potential of alcohol release doorplates to reduce surface contamination during hand contact’ in the Journal of Hospital Infection [1]. We agree that reducing microbial contamination of frequently touched door surfaces and bacterial transfer via hands could feasibly reduce the risk of healthcare-associated infections (HCAIs) [1–3]. We recently examined a novel prototype door handle with precisely the same intention. This door handle is steel-framed and vertically aligned with the hand-grip portion encased by a specially prepared surface material (Figure 1)

Measuring environmental contamination in critical care using dilute hydrogen peroxide (DHP) technology: An observational cross-over study

BackgroundThe environment has an important role in the transmission of healthcare associated infections. This has encouraged interest in novel methods to improve hygiene in hospitals. One such technology is the use of hydrogen peroxide to decontaminate rooms and equipment; there are, however, few studies that have investigated the effect of continuous dilute hydrogen peroxide (DHP) in the clinical environment. The aim of this study was to examine the use of dilute hydrogen peroxide (DHP) in a critical care unit and measure the microbiological impact on surface contamination.MethodsWe conducted a prospective observational cross-over study in a ten-bed critical care unit in one rural Australian hospital. Selected high-touch sites were screened using dipslides across three study phases: baseline; continuous DHP; and no DHP (control). Quantitative aerobic colony counts (ACC) were assessed against a benchmark standard of ACC >2.5 cfu/cm 2 to indicate hygiene failure.ResultsThere were low levels of microbial contamination in the unit for baseline; DHP; and no DHP phases: 2.2% (95% CI 0.7–5.4%) vs 7.7% (95% CI 4.3–13.0%) vs 6% (95% CI 3.2–10.4%) hygiene failures, respectively. Significant reduction in ACCs did not occur when the DHP was operating compared with baseline and control phases.ConclusionFurther work is needed to determine whether continuous DHP technology has a role in decontamination for healthcare settings

COS-Speech: Protocol to develop a core outcome set for dysarthria after stroke for use in clinical practice and research

BACKGROUND: Dysarthria after stroke is when speech intelligibility is impaired, and this occurs in half of all stroke survivors. Dysarthria often leads to social isolation, poor psychological well-being and can prevent return to work and social lives. Currently, a variety of outcome measures are used in clinical research and practice when monitoring recovery for people who have dysarthria. When research studies use different measures, it is impossible to compare results from trials and delays our understanding of effective clinical treatments. The aim of this study is to develop a core outcome set (COS) to agree what aspects of speech recovery should be measured for dysarthria after stroke (COS-Speech) in research and clinical practice. METHODS: The COS-Speech study will include five steps: (1) development of a long list of possible outcome domains of speech that should be measured to guide the survey; (2) recruitment to the COS-Speech study of three key stakeholder groups in the UK and Australia: stroke survivors, communication researchers and speech and language therapists/pathologists; (3) two rounds of the Delphi survey process; (4) a consensus meeting to agree the speech outcomes to be measured and a follow-up consensus meeting to match existing instruments/measures (from parallel systematic review) to the agreed COS-Speech; (5) dissemination of COS-Speech. DISCUSSION: There is currently no COS for dysarthria after stroke for research trials or clinical practice. The findings from this research study will be a minimum COS, for use in all dysarthria research studies and clinical practice looking at post-stroke recovery of speech. These findings will be widely disseminated using professional and patient networks, research and clinical forums as well as using a variety of academic papers, videos, accessible writing such as blogs and links on social media. TRIAL REGISTRATION: COS-Speech is registered with the Core Outcome Measures in Effectiveness Trials (COMET) database, October 2021 https://www.comet-initiative.org/Studies/Details/1959. In addition, “A systematic review of the psychometric properties and clinical utility of instruments measuring dysarthria after stroke” will inform the consensus meeting to match measures to COS-Speech. The protocol for the systematic reviews registered with the International Prospective Register of Systematic Reviews. PROSPERO registration number: CRD42022302998. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s13063-022-06958-7

Is there an association between airborne and surface microbes in the critical care environment?

BackgroundThere are few data and no accepted standards for air quality in the intensive care unit (ICU). Any relationship between airborne pathogens and hospital-acquired infection (HAI) risk in the ICU remains unknown.AimFirst, to correlate environmental contamination of air and surfaces in the ICU; second, to examine any association between environmental contamination and ICU-acquired staphylococcal infection.MethodsPatients, air, and surfaces were screened on 10 sampling days in a mechanically ventilated 10-bed ICU for a 10-month period. Near-patient hand-touch sites (N = 500) and air (N = 80) were screened for total colony count and Staphylococcus aureus. Air counts were compared with surface counts according to proposed standards for air and surface bioburden. Patients were monitored for ICU-acquired staphylococcal infection throughout.FindingsOverall, 235 of 500 (47%) surfaces failed the standard for aerobic counts (≤2.5 cfu/cm2). Half of passive air samples (20/40: 50%) failed the ‘index of microbial air’ contamination (2 cfu/9 cm plate/h), and 15/40 (37.5%) active air samples failed the clean air standard

COVID-19 and use of non-traditional masks: how do various materials compare in reducing the risk of infection for mask wearers?

Abstract not available

Beware Biofilm! Dry biofilms containing bacterial pathogens on multiple healthcare surfaces; a multicentre study

BackgroundWet biofilms associated with medical devices have been widely studied and their link with healthcare-associated infections (HCAIs) is well recognized. Little attention has been paid to the presence of dry biofilms on environmental surfaces in healthcare settings.AimTo investigate the occurrence, prevalence, and diversity of dry biofilms on hospital surfaces.MethodsSixty-one terminally cleaned items were received from three different UK hospitals. The presence of dry biofilm was investigated using culture-based methods and scanning electron microscopy (SEM). Bacterial diversity within biofilms was investigated using ribosomal RNA intergenic spacer analysis (RISA)–polymerase chain reaction and next-generation sequencing.FindingsMulti-species dry biofilms were recovered from 95% of 61 samples. Abundance and complexity of dry biofilms were confirmed by SEM. All biofilms harboured Gram-positive bacteria including pathogens associated with HCAI; 58% of samples grew meticillin-resistant Staphylococcus aureus. Dry biofilms had similar physical composition regardless of the type of items sampled or the ward from which the samples originated. There were differences observed in the dominance of particular species: dry biofilms from two hospitals contained mostly staphylococcal DNA, whereas more Bacillus spp. DNA was found on surfaces from the third hospital.ConclusionThe presence of dry biofilms harbouring bacterial pathogens is virtually universal on commonly used items in healthcare settings. The role of dry biofilms in spreading HCAIs may be underestimated. The risk may be further exacerbated by inefficient cleaning and disinfection practices for hospital surface