Health care professionals on the front line of infection control stress hand hygiene as the first, best way to control the spread of opportunistic infections from patient to patient. But, while they're vigilant about hand sanitation, they are keeping their eyes on other paths traveling microbes can follow - right down to the scrubs many wear on the job.
In 2011, working on a hunch, Israeli researchers collected samples from the uniforms of 75 RNs and 60 MDs, tested at Shaare Zedek Medical Center in Jerusalem, Israel, pressing standard blood agar plates on the torso, pockets, and at the bottoms of sleeves. The researchers were looking for both the presence of pathogenic bacteria as well as their bacterial load.
Not surprisingly, the study found bacteria, including MRSA, on 85 of the participants - more than 60 percent. Of the 135 practitioners tested, 79 said they wore a clean uniform every day while 104 claimed the hygiene level of their uniform was fair to excellent. More than 3 times as many nurses (21) than doctors (six) were positive for antibiotic-resistant bacteria, likely because nurses spend more time at patient bedsides than doctors do.
The Association for Professionals in Infection Control and Epidemiology (APIC) printed the study in the American Journal of Infection Control. APIC also issued a release noting the study was important because it showed the prevalence of antibiotic-resistant strains in close proximity to hospitalized patients.
And while researchers did not draw conclusions about the transmission of pathogenic bacteria from practitioner uniform to patient, or whether they could cause clinically relevant infections, many infection preventionists consider it a somewhat moot point.
"While the study is interesting, it's not really surprising," said Sue Barnes, BSN, RN, CIC, director of Northern California Regional Infection Control for Kaiser Permanente in Oakland. "We know there are organisms that can be cultured on just about any surface, including clothes and fabric in the healthcare environment."
Wash & Wear
The scrubs question has been in play before. Healthcare practitioners of all disciplines are seen regularly out in public in hospital scrubs, getting coffee, grocery shopping, picking up the kids from school. With the public clamoring for better safety measures, a number of healthcare organizations have taken a closer look at the issue.
In 2011, the Association of periOperative Registered Nurses issued a position statement saying operating room practitioners should only wear hospital-laundered scrubs to prevent the possible transmission of pathogens to patients in the OR, as well as to protect the general public should OR personnel wear their scrubs outside.
Barnes noted their concern, as well as that of APIC, refers fairly strictly to the sterile OR environment. "That's where the risk really is relative to scrubs," Barnes said. "In non-OR settings, in general clinics or nursing units, scrubs are just another type of uniform, so the risk is no greater than it would be for any other kind of garment worn by healthcare workers in non-OR environments.
"Anyone wearing any kind of attire can become contaminated with microorganisms," Barnes continued. "That's why the focus of infection prevention is still proper hand hygiene."
Barnes said the core task or prevention effort in non-OR environments is hand hygiene and environmental cleaning and disinfection. "What we know from science with 100 percent certainty is that the bad bugs like MRSA and acinetobacter [baumannii] are transmitted on hands of healthcare workers and sometimes on instruments or equipment, but the mechanics of that is it's the hands that are involved and the contaminated environment," she said. "The study raises more questions than it answers and provides areas for further research."
"The water temperature at home is not as hot as a professional or hospital laundry can get, but you can use hot water at home," Gullickson said. "But it isn't just the uniforms; it's a whole prevention and awareness package that (clinicians) have to understand."
Clinicians practicing in the OR, interventional radiology, and the bone marrow transplant unit at HealthONE health system in Denver all wear hospital-laundered scrubs. The health system has always provided hospital-laundered scrubs for its OR practitioners, and added in the other units over the past several years. But Carol Gullickson, RN, CIC, system infection preventionist, has not seen a decrease in the transmission of hospital-acquired infections (HAIs) as a result.
And that starts with awareness. "(Clinicians) must use the appropriate isolation precautions for patients with isolation protocols in place, and use appropriate hygiene procedures before entering and exiting patient rooms. Most infections are spread on the hands of healthcare workers. That's where it starts."
Barnes agreed. "General hygiene for healthcare workers, including attire, is important and is governed by attire policies," she said. "But when we're talking about infection transmission risk, the greater risk is with hands and hard-surface contamination.
"The real question and most important point is what contaminated surfaces are involved in transmitting infection?" Barnes mused.
It could be "hands and hard surfaces in the near-patient environment, [e.g.], a stethoscope, blood pressure cuff, or thermometer," that could be the contaminated surface, she said, "but most likely its solid surfaces where the nurse or patient put their hands, such as bed trays and bed rails.
"If you think about how hard surfaces are touched, it's a lot easier to contaminate solid, flat, hard surfaces, and for those bugs to remain on those surfaces, than it is to contaminate then transfer from a contaminated surface to another surface if they're not flat and hard."
Back to Basics
While environmental contamination is certainly on the radar for both Barnes and Gullickson, both said the one sure way to decrease potential HAIs continues to be proper hand hygiene. That means frequent, thorough handwashing.
"The hands are the culprit," Barnes said. "That's the focus of all infection prevention programs and that's why we don't want this study to divert attention that's really important away from hand hygiene."
Candy Goulette is a frequent contributor to ADVANCE.