One Ring to Rule Them All, One Ring to Find Them…*

Abstract & Commentary

Synopsis: Ring wearing by health care workers increases the frequency of hand contamination with nosocomial pathogens and decreases the efficacy of all types of hand hygiene studied, included alcohol-based hand rub.

Source: Trick WE, et al. Impact of ring wearing on hand contamination and comparison of hand hygiene agents in a hospital. Clin Infect Dis. 2003;36:1383-1390.

Trick and colleagues evaluated the risk factors for hand contamination with nosocomial pathogens, as well as the efficacy of 3 hand hygiene agents in critical care unit nurses. Using the "glove juice" technique, Trick et al cultured 1 hand before, and the other hand after, performance of hand hygiene. Hygiene was randomly allocated to 1 of 3 agents, including soap and water, 0.1% benzalkonium chloride hand wipes, and alcohol-based hand rub. Sampling was conducted during the nurses’ workday.

Trick et al collected a total of 282 pairs of before and after hand hygiene samples. They performed 2 separate analyses, 1 to evaluate risk factors for hand hygiene contamination, and another to evaluate hand hygiene efficacy. Before performance of hand hygiene, hands were contaminated by Gram-negative bacilli (10%), Staphylococcus aureus (13%), Candida spp. (12%), and vancomycin-resistant enterococci (2%). Thirty-two percent of hands carried at least 1 of these pathogens. The presence of 1 or more rings was an independent risk factor for the presence of each pathogen and for the presence of any pathogen (OR 3.0, 95% CI 1.8-4.9). The risk of hand contamination increased with the number of rings worn. Wearing a ring at home but not at work was not a risk factor for carriage of a pathogen. Use of an alcohol hand rub significantly decreased the risk of pathogen carriage (OR 0.3; 95% CI 0.2-0.6); use of the other hand hygiene products did not. Hands with rings were more than 2-fold more likely to be contaminated after use of alcohol-based hand rub than hands without rings.

Comment by Robert Muder, MD

This study clearly demonstrates that wearing a ring while working in an intensive care unit increases the likelihood of hand contamination by potential nosocomial pathogens. Further, the presence of a ring decreases the effectiveness of hand hygiene. The study has a number of strengths that include studying nurses during the course of work, using each nurse as his or her own control, a large number of observations, and an appropriate statistical analysis. Thus, the conclusions appear valid and are likely to be broadly applicable.

The presence of a ring may exert its deleterious effect on hand contamination and hygiene by providing a warm, moist, and relatively protected site for pathogens to persist. Local dermatitis is unlikely to be a factor since wearing a ring at home but not at work did not increase the risk of hand contamination.

As the hands of health care personnel are the means of spread of most nosocomial pathogens, it would appear prudent to discourage the wearing of rings by personnel with direct patient contact in high-risk areas such as critical care units.

(*from J.R.R. Tolkien’s The Lord of the Rings.)

Dr. Muder is Hospital Epidemiologist Pittsburgh VA Medical Center Pittsburgh Section Editor, Hospital Epidemiology