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While much of the focus has been on the new emphasis on alcohol-based antiseptic agents, draft hand hygiene guidelines by the Centers for Disease Control and Prevention (CDC) also ban artificial nails and surgical scrub brushes. Although the guidelines have not been finalized, ICPs may expect staff resistance to the changes if they remain in the final version. The guidelines dismiss the longstanding practice of using surgical scrub brushes as an outdated ritual that actually increases bacterial load.
"Surgical staff are very used to the ritual of scrubbing, so that is going to be a major change," says Elaine Larson, RN, PhD, professor of pharmaceutical and therapeutic research at Columbia University School of Nursing in New York City. "But it is not effective. . . . Most of the research shows if you do a scrub, you actually increase shedding of bacteria. It made theoretical sense; it’s just that now that we’ve looked at it, it doesn’t [any more]," Larson explains.
In explaining the recommendation, the CDC draft guidelines state: "For many years, preoperative hand-washing protocols required personnel to scrub with a brush. However, this practice may damage the skin of personnel and can result in increased shedding of bacteria from the hands."1
In addition, several studies suggest that neither a brush nor a sponge is necessary to reduce bacterial counts on the hands of surgical personnel to acceptable levels, especially if alcohol products are used.2-6 Regarding fingernails, the CDC notes that numerous studies have documented that subungual areas of the hand harbor high concentrations of bacteria, most frequently coagulase-negative staphylococci, gram-negative rods (including Pseudomonas species), corynebacteria, and yeasts.7,8 Freshly applied nail polish does not increase the number of bacteria recovered from periungual skin, but chipped nail polish may support the growth of larger numbers of organisms on fingernails, the guidelines state.9
Even after careful hand washing or surgical scrubs, personnel often harbor substantial numbers of potential pathogens in the subungual spaces, according to the guidelines. In addition, a growing body of evidence suggests that wearing artificial nails may contribute to transmission of health care-acquired pathogens.10-12 (See Journal Reviews in this issue.) Health care workers who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips than are those who have natural nails, both before and after hand washing, the CDC notes.
Though the guidelines are yet to be finalized, an ICP who has been following the literature on fingernails has already implemented a policy at her facility. "Over the past several years, we have been sharing information with nursing leadership and the union heads about the literature that was coming out on acrylic nails," says Mary Standridge, RN, MSN, CIC, infection control nurse at the Veteran’s Affairs Medical Center in Memphis, TN. "It wasn’t like it was just out of the blue that we wanted to change this policy," she adds.
The policy adopted at the facility states, "All employees doing direct patient care will not have acrylic nails, chipped nail polish, excessively long fingernails, or multiple rings per hand."
While aspects of the policy are open to interpretation, Standridge says she is comfortable with that because she has had such strong support from the chief nurse and staff union representatives. "The key to our success was the buy-in, especially the chief nurse’s tremendous support of it and willingness to enforce it," she says. "Enforcement is the problem. You have to have people who are willing to enforce it," Standridge points out.
With the union brought in from the onset, the hospital effectively removed a primary avenue for workers to protest the policy, Standridge notes. Though some resistance was expected, the argument for patient safety has been compelling. "We really haven’t had a problem. I’m surprised; we are all very surprised."
(The Centers for Disease Control and Prevention has removed its draft guidelines on hand hygiene from its web site pending finalization. However, the executive summary of the draft document and the CDC recommendations are posted on your free subscriber web site at www.HIConline.com. Click on guidelines and regulations.)
1. Centers for Disease Control and Prevention, the CDC Healthcare Infection Control Practices Advisory Committee, Boyce JM, Pittet D, the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Draft Guidelines for Hand Hygiene in Healthcare Settings. Atlanta; 2001.
2. Meers PD, Yeo GA. Shedding of bacteria and skin squames after handwashing. J Hyg (CAMB) 1978; 81:91-105.
3. Kikuchi-Numagami K, Saishu T, Fukaya M. Irritancy of scrubbing up for surgery with or without a brush. Acta Derm Venereol 1999; 79:230-232.
4. Dineen P. The use of a polyurethane sponge in surgical scrubbing. Surg Gynecol Obstet 1966; 123:595-598.
5. Bornside GH, Crowder VH Jr., Cohn I Jr. A bacteriological evaluation of surgical scrubbing with disposable iodophor-soap impregnated polyurethane scrub sponges. Surgery 1968; 64:743-751.
6. McBride ME, Duncan WC, Knox JM. An evaluation of surgical scrub brushes. Surg Gynecol Obstet 1973; 137:934-936.
7. McGinley KJ, Larson EL, Leyden JJ. Composition and density of microflora in the subungual space of the hand. J Clin Microbiol 1988; 26:950-953.
8. Hedderwick SA, McNeil SA, Kauffman CA. Pathogenic organisms associated with artificial fingernails worn by healthcare workers Infect Control Hosp Epidemiol 2000; 21:505-509.
9. Baumgardner CA, Maragos CS, Larson EL. Effects of nail polish on microbial growth of fingernails. AORN J 1993; 58:84-88.
10. Wynd CA, Samstag DE, Lapp AM, et al. Bacterial carriage on the fingernails of OR nurses. AORN J 1994; 60:796-805.
11. McNeil SA, Foster CL, Hedderwick SA. Effect of hand cleansings with antimicrobial or alcohol-based gel on microbial colonization of artificial fingernails worn by health care workers. Clin Infect Dis 2001; 32:367-372.
12. Moolenaar RL, Crutcher M, San Joaquin VH, et al. A prolonged outbreak of Pseudomonas aeruginosa in a neonatal intensive care unit: Did staff fingernails play a role in disease transmission? Infect Control Hosp Epidemiol 2000; 21:80-85.