Nurses' bags play key role in infection control

Steps taken to ensure no pathogens

Wash hands, wear gloves, and clean equipment. All home health nurses know that these are the basic steps to take to protect patients from infection. What about the nurses' bag? How clean is it and does it pose an infection threat?

These are questions asked and answered by a study conducted by Irena L. Kenneley, PhD, APRN-BC, CIC, infection control consultant and assistant professor at Case Western University School of Nursing in Cleveland. "We recruited four home health agencies to participate in the study and cultured the inside and outside of their nurses' bags along with the patient equipment in the bags," she explains.

Nurses were told to bring their bags to the next staff meeting but were not told why, says Kenneley. "When the meeting started, we explained the research project and asked them to sign an informed consent before we tested their bags," she explains. "Not many nurses opted out of the study, because most were eager to find out if their bags were contaminated and how they could better prevent transmission of infections," she adds.

More than 450 cultures were collected from 127 bags. "Overall, 66.7% of cultures collected from the outside of the bags, 48.4% of cultures collected inside the bags, and 22.3% of cultures collected from the patient care equipment tested positive for infectious agents," she adds. Pathogens include gram-negative bacilli, E. coli, and multidrug-resistant organisms (MDRO) such as methicillin resistant Staphylococcus aureus and vancomycin-resistantEnterococcus.

In the first agency tested, the number of cultures that tested positive for pathogens was in the upper 80% range, says Kenneley. "After the bags were thoroughly cleaned and used for two weeks, we re-cultured them," she says. The level of pathogens present on the bags dropped by 31% in the retest, she says. "This raised the question of cleaning protocols and how they affect the number and type of pathogens on the bags," she explains.

To address this question, researchers asked nurses at the next three agencies to complete a survey about cleaning practices and care of the bag, says Kenneley. "The survey answers were linked to the results of the cultures to identify different practices and types of bags and how they impact the presence of pathogens," she says.

The survey showed a wide range of cleaning practices, admits Kenneley. "One nurse had owned her bag over 10 years and never cleaned it," she says. Others cleaned their bag when they appeared soiled or at irregular intervals. "The best practice is to clean the bag weekly," suggests Kenneley.

The cleaning products used for the bags were not always effective, points out Kenneley. "Many nurses used Formula 409, Windex, or Lysol to clean their bags because they were cleaning them at home and had those products available," she says. The study shows that the most effective cleaning solutions are institutional-grade cleaners that contain bleach, she adds.

Leather better than cloth

The type of material used for the bag also affected the likelihood that pathogens were present, says Kenneley. Multidrug-resistant organisms and pathogens were most likely to be present on cloth bags and least likely to be present on leather bags. "This is in line with the Centers for Disease Control and Prevention Guidelines that recommend that porous materials not be used for surface materials in healthcare settings, she points out. Nonporous materials are less likely to absorb and retain pathogens that can be spread to areas in the patient's home and to patient care equipment in the bag, she adds.

Another correlation found in the study is that the presence of MDROs and pathogens on the outside of the bag significantly increases the likelihood that MDROs and pathogens will be found inside the bag and on patient care equipment within the bag, says Kenneley. "Even though nurses' bags are considered noncritical equipment, when considering infection control practices, this study does point out that the condition of the bag affects the equipment inside," she adds.

Several issues were identified as necessary to reduce the risk of contamination by the bags, says Kenneley. The need to standardize or set parameters for the type of bag carried by nurses is important, she says. "Home health care nurses work autonomously as part of their everyday job, so it is not common for agencies to tell them what type of bag to carry," she admits. However, the data from the study is so convincing that some of the participating agencies are setting parameters for the type of bag that nurses must use, she says.

One agency took standardization a step further and provides the bag for the nurse, points out Kenneley. The same agency ensures a thorough cleaning of the bag by requiring the nurse to bring it to the agency once a month for cleaning by a staff member who is trained in the proper protocol to clean the inside and outside of the bag. "Standardizing cleaning protocols and providing the proper cleaning solutions is important for nurses' weekly cleaning of their bags, but the required once a month cleaning is an added measure of safety," she says.

Even after setting parameters for the type of bag used and establishing clear guidelines for cleaning procedures, ongoing education is the key to making sure that the nurses' bags don't harbor pathogens, says Kenneley. "People are enthusiastic at the beginning of any new program, but they get lax," she admits. "Ongoing education will keep the awareness high and help the agency avoid managing a potential crisis such as an MDRO outbreak."


  • Irena Kenneley, PhD, APRN-BC, CIC, Infection Control Consultant and Assistant Professor, Case Western University School of Nursing, 10900 Euclid Avenue, Cleveland, Ohio 44106-4904. Telephone: (216) 368-4841. E-mail: