May 5 is World Hand Hygiene Day with the World Health Organization (WHO) choosing  “It’s in your hands – prevent sepsis in health care” as this year’s theme.

Dr Sally Roberts, the clinical lead of the Health Quality & Safety Commission, says the number of children being admitted to New Zealand paediatric intensive care units with severe infections, including sepsis, has increased over the last 10 years. About four per cent of these children die. She said the international evidence was clear that improved hand hygiene practices help to reduce healthcare-associated infections.

“Hand hygiene is the simplest, most effective way to prevent the spread of healthcare-associated infections, so it’s important that everyone working in the health sector practises good hand hygiene. Clean hands save lives,” said Roberts.

In 2011 the Commission started working in partnership with Auckland District Health Board to improve hand hygiene amongst healthcare workers via the Hand Hygiene New Zealand (HHNZ) quality improvement programme.

As part of the HHNZ programme, regular spot audits are carried out across the 20 DHBs to monitor how many healthcare workers at each DHB are complying with the Five Moments of Hand Hygiene (see below) that include cleaning your hands (either with soap and water or hand-rub gel) before touching a patient and after touching a patient.

The latest hand hygiene compliance report – released in the lead-up to World Hand Hygiene Day –shows that in the audit round to March 31 2018 that 14 DHBs met the 80 per cent  compliance target and national compliance now sits at 85.3 per cent.

Other positive trends included improvements in hand hygiene in areas where patients are at high risk of infection – including emergency departments.

Glove and Five Moments compliance

The report says it was good to see ‘continued, ongoing improvement” in better glove use and hand hygiene when gloves were put on. But inappropriate use of non-sterile gloves “remains a barrier to excellent hand hygiene practice”.

Back in 2014 hand cleaning moments were missed 33.3 per cent of the time when gloves were put on and this reduced to 22.6 per cent in 2015 and 13.2 per cent in the latest audit. But the latest audit shows there remains a large gap between good hand hygiene when gloves are put on and when gloves are taken off.

The latest glove statistics are:

• when gloves are taken OFF, the proportion of hand hygiene opportunities missed was 5.7 per cent compared with 5.5 per cent in the October 2017 audit
• when gloves are put ON, the proportion of hand hygiene opportunities missed was 13.2 per cent compared with 14.2 per cent in the October 2017 audit
• of all moments where glove use is recorded, healthcare workers failed to complete hand hygiene 12.1 per cent of the time, compared with 12.5 per cent in the October 2017 audit
• when gloves were worn continuously, hand hygiene opportunities were missed on every occasion.

Across the board all health professional groups have improved their hand hygiene compliance when working with patients – phlebotomists lead the rankings with 90 per cent compliance, followed by nurses and midwives at 88 per cent. Most health professionals’ and students’ compliance levels are now 80 per cent or above, but currently medical practitioners lag behind with 77.5% compliance and student doctors fell back from 80 per cent in October 2017 to 67.2 per cent in March 2018.

Sepsis trends

Roberts says the biggest increased in children admitted to paediatric ICU were babies aged less than 28 days because they were too young to be vaccinated against vaccine-preventable diseases.

“One reason for the increase in severe infections in older children is an increase in the number of invasive skin and soft tissue infections.”

She said advances in paediatric cancers and haematological malignancies were also leading to more severe immunosuppression and therefore increased infection risk, and there are also more children with co-morbidities.’

Dr Roberts said about 10 percent of adults admitted to intensive care units have severe sepsis.

“For the majority, sepsis developed before they were admitted to hospital. While the rate of death from severe sepsis or septic shock in adults has decreased over the last couple of decades, it’s still around 4.6 percent.”

Dr Roberts said with sepsis it was not uncommon for someone to seem completely well one day, and be very sick with sepsis, or even septic shock, 48 hours later. “The risk of death is significant if sepsis leads to septic shock, with approximately 40 percent of septic shock patients dying, even with treatment.”

One Waikato study found 10 percent of patients admitted to hospital because of infection had sepsis. Around 17 percent of these patients were admitted to intensive care units and nearly 34 percent of them died.

See more at: www.handhygiene.org.nz

The WHO Five Moments of Hand Hygiene

• Before touching a patient.
• Before a procedure.
• After a procedure or body fluid exposure risk.
• After touching a patient.
• After touching a patient’s surroundings.

The latest outbreak follows outbreaks that caused ward closures in September at Whangarei and Whakatane Hospitals.

Strict infection control have been put in place  in place in some Hawke’s Bay Hospital wards to prevent the spread of norovirus, the highly contagious vomiting and diarrhoea bug.

Chief Medical and Dental Officer John Gommans said norovirus was circulating in the community and infected patients had been admitted to hospital, affecting some hospital staff.

Dr Gommans said hospital visitors were reminded that they should stay away from visiting family or friends in hospital if they are sick.

“If you are unwell with vomiting and diarrhoea or have been around people who have been unwell, please do not visit the hospital for at least 48 hours.”

Visitors would also find that some wards were closed to new admissions, and visiting would be restricted and only allowed in exceptional circumstances to some areas of the hospital.

“The infection control measure we have put in place should contain any spread through the hospital, but as it is highly contagious we are being very vigilant, and will isolate other areas of the hospital to visitors if we have to,” Dr Gommans said.

Medical Officer of Health Nick Jones said it was likely the bug was circulating in the community.

“To help prevent the spread of the virus, it is very important for anyone with nausea, vomiting, diarrhoea and stomach cramps to stay away from work for 48 hours after symptoms disappear.”

He said sick children should also be kept away from school for the same period of time, he said.

It was advised if symptoms didn’t get better, or if people were becoming dehydrated, that they seek medical attention and phone ahead to your general practice clinic for advice if you become concerned.

Dr Jones said anyone attending the Hawke’s Bay show this week, should also be mindful that norovirus was circulating and wash their hands thoroughly before eating food and after using public toilets.

Good hand cleaning involves washing hands often with soap and warm water for at least 20 seconds before drying thoroughly.

This learning activity is relevant to the Nursing Council competencies 1.1, 1.4, 2.1, 2.8, 2.9, 4.1, 4.2 and 4.3.

Learning outcomes

Reading and reflecting on this article will enable you to:

• define catheter-associated urinary tract infection (CAUTI)
• describe the pathogenesis of CAUTI
• identify risk-factors associated with CAUTI
• identify CAUTI prevention strategies that nurses can implement to promote patient safety.

Introduction

Catheter-associated urinary tract infection (CAUTI) is the most common healthcare-associated infection (HAI) worldwide¹. Urinary tract infections (UTI) comprise 40 per cent of HAIs and 80 per cent of these UTIs are attributed to indwelling catheters². Catheter-associated urinary tract infection complications include genito-urinary tract infections and life-threatening bloodstream infections that develop secondary to a UTI⁴.

The primary risk factor for CAUTI is the prolonged use of urinary catheters⁵. With the catheter in place, the daily risk for bacterial growth in the urine or bacteriuria is about 3 to 7 per cent^6,7. Ten per cent of patients with bacteriuria will develop CAUTI, while three per cent will go on to develop bloodstream infections. Bloodstream infections result in discomfort, prolonged hospital stays, increased costs and, sometimes, deaths^3,4,8.

CAUTI events are costly for both the patient and the entire healthcare system^7,9. The clinical consequences and economic burden of CAUTI makes CAUTI prevention fundamental to patient safety. (See Box 1 below for definition of CAUTI)

CAUTI pathogenesis

Indwelling urinary catheters are used therapeutically to drain urine from the bladder; however, when used inappropriately, catheters can pose both mechanical and physiological risks to patients¹.

Catheters cause mechanical erosion of the bladder mucosa and ischemic damage when swelling occurs due to blockage. Catheters also provide a route for microbial entry from the colonised perineum to the sterile bladder through a catheter’s internal and external surfaces¹. Microorganisms that colonise the perineum and intestinal tract cause about two-thirds of CAUTI, while a third are caused by urine collection systems contaminated by healthcare workers’ hands¹¹.

Urinary catheters interrupt the normal bladder defence mechanism^1,11. When bacteria are present in the urinary system, the bacteria bind to the sterile mucosa, which starts an inflammatory response characterised by the inflow of neutrophils and shedding of epithelial cells¹². When the catheter is in place, the bacteria bind to catheter surfaces and form a biofilm, which bypasses the normal bladder defence mechanism¹¹.

Biofilm

Biofilm formation is central in the development of CAUTI¹². Biofilms are slimy structures made up of communities of microorganisms. Biofilm forms when a conditioning film of host components attaches itself to the inner and outer surface of a urinary catheter after insertion. Biofilm traps free-swimming microorganisms that then multiply, attract more microorganisms, and further secrete extracellular matrix that makes the biofilm grow in size. Biofilm microorganisms function as a community and communicate closely with one another^1,13. Some microorganisms also detach from the biofilm and seed the urine¹.

Biofilms help microorganisms survive through: resistance to being swept away by shear forces; resistance to being engulfed by other cells, and resistance to antimicrobial agents^1,13. Studies have shown that antimicrobial agents penetrate biofilms; however, the slow growth of microorganisms in a biofilm confers antimicrobial resistance¹¹. The affinity of microorganisms with each other in a biofilm also permits the exchange of antimicrobial resistance genes, thereby increasing the risk for other CAUTI complications¹².

Risk factors for CAUTI

Prolonged catheterisation is the major risk factor for CAUTI^3,5. Other risk factors include: non-adherence to aseptic technique during catheter insertion11; poor hand hygiene compliance8; catheter insertion after the sixth day of hospitalisation; poor hand hygiene; catheter insertion outside the operating room⁹, and a break in the closed drainage system^8,14.

Strategies to prevent CAUTI

Multiple strategies have been shown to prevent CAUTI. Prevention strategies were published by the US CDC in 1981 and subsequently updated in 2009⁸ and 2014³. These strategies and recommendations were summarised by the USA-based Institute for Healthcare Improvement (IHI)⁷ into four components of urinary catheter care. Australia and New Zealand’s 2013 catheterisation guidelines break down the principles for reducing CAUTI into similar sections or components, but with the addition of a section on selecting the appropriate catheter type and drainage system¹⁸. The following discussion expands on those components of care to include other evidence-based recommendations.

Component One: Reduce inappropriate use of urinary catheters

Urinary catheter presence in the bladder is the primary risk for CAUTI; thus, reducing inappropriate use is the best way to prevent it^11,15.

Catheters should only be inserted when clinically indicated.

Some indications for using short-term catheterisation are:

• acute and chronic urinary retention
• urinary obstruction
• close monitoring of fluid intake and output of critically ill patients
• risk of worsening sacral decubitus ulcer due to urinary incontinence or end-of life care^5,8,16,17
• selected surgical procedures that last more than three hours
• management of acute urologic conditions when straight catheterisation is not possible^8,16,17
• patients undergoing urologic surgery or surgery on other genitourinary tract structures
• patients anticipated to receive large-volume infusions or diuretics during surgery, and the need for intraoperative monitoring of urinary output.
• urinary catheterisation may also be indicated for patients requiring prolonged immobilisation⁸.

Inappropriate indications for using indwelling catheters include:

• as a substitute for nursing care of incontinent patients
• as a means of obtaining urine for culture when the patient can voluntarily void⁸
• for prolonged postoperative duration without appropriate indications⁸.

Nurses are also encouraged to: use a bladder scanner in assessing urine volume to reduce unnecessary catheter insertions, and consider other bladder management methods such as intermittent catheterisation^3,8.

Component Two: Perform proper techniques for indwelling catheter insertion

Indwelling catheter insertion is an invasive procedure that requires care and proper technique to avoid pain, trauma and infection. For more guidance you can view the best-practice urinary catheterisation guidelines [see recommended resources] developed by the Australia and New Zealand Urological Nurses Society (ANZUNS)¹⁸.

Selection of catheter

• Select appropriate length and type of catheter for patient.
• Use smallest gauge catheter possible, while ensuring good drainage to minimise bladder neck and urethral trauma^3,8.

Hand hygiene

Hand hygiene before and after catheter insertion prevents the introduction of microorganisms into the catheter, thereby minimising CAUTI risk^3,8.

Aseptic technique and the use of sterile equipment

Aseptic technique minimises the risk of microbial entry into the sterile urinary system. Aseptic technique during catheter insertion, the use of sterile equipment, and even the setting of catheter insertion all play a significant role in reducing the incidence of bacteriuria¹⁹. The use of sterile gloves, drape, sponges, an appropriate antiseptic or sterile solution for periurethral cleaning, and a single-use packet of lubricant jelly for insertion is recommended⁸.

Secure indwelling catheters after insertion to prevent movement and urethral traction

Indwelling catheters should be kept secure to minimise movement that may cause urethral trauma or erosion of the bladder mucosa^7,8,20. Trauma to the bladder mucosa releases organic molecules, which, when combined with glycoprotein from the urine, facilitate bacterial colonisation, thereby increasing CAUTI risk¹².

Component Three: Implement proper urinary catheter maintenance procedures

Proper maintenance of urinary catheters focuses on maintaining a closed system and maintaining an unobstructed urine flow⁸. Ongoing good hand and general hygiene is also very important^3,8.

Maintain a closed drainage system

Urinary drainage systems should remain closed because disconnections at the catheter-collecting tube junctions have been shown to significantly increase bacteriuria risk due to bacterial spread along the internal surface of the catheter.

The relative risk of acquiring CAUTI the day after catheter disconnection has been shown to double²¹. If there are breaks in aseptic technique, disconnection or leakage, nurses should replace the catheter and collection bag using aseptic technique and sterile equipment⁸.

Microbial spread along the internal catheter surface can also happen if urine in the collection bag is contaminated through improper emptying. In this way microorganisms can gain access to the drainage system and ascend to the bladder, particularly if standard precautions are not observed²². When draining the bag, nurses are also encouraged to avoid splashing urine, to use a separate clean collecting container for each patient, and to prevent contact of the drainage spigot with the non-sterile collecting container^3,8,20.

The CDC further recommends that the collection of urine samples should be performed aseptically through the needleless sampling port or the drainage bag using a sterile syringe/cannula after the port is cleansed with a disinfectant⁸.

Maintain an unobstructed urine flow

Unobstructed urine flow can be achieved through the following measures: keeping the catheter and collection bag free from coils or kinks and off the floor at all times, and emptying the collection bag regularly^3,8,20,23.

A study conducted among intensive care patients showed that drainage tubing kinking or coiling was significantly associated with fever and bacteria in the urine²³. The presence of kinks and coils is thought to compromise bladder emptying and possibly increase bladder hydrostatic pressure, thereby causing transient bacteriuria, thus the fevers.

The recommendation that the collection tubing and bag should always remain below the patient’s bladder to allow proper urine drainage is supported by a large prospective study in the US showing that improper positioning of the collection tubing and bag is associated with a significantly increased risk in CAUTI because of the backflow of potentially contaminated urine from the drainage bag²⁴.

The authors of a European microbiology study explain that when the drainage bag is placed above the level of the bladder, microorganisms from the urine bag can gain access to the drainage system along the internal catheter surface and ascend to the bladder²².

Component Four: Review catheter necessity daily and remove promptly

The length of time a urinary catheter is in place is the strongest predictor of CAUTI development⁸. Recommendations indicate that indwelling urinary catheters should be removed as soon as possible post-operatively, preferably within 24 hours unless there are indications for continued use⁸. It has been found that patients develop bacteriuria at a rate of three to seven per cent per day⁷. This risk increases to 25 per cent when the catheter remains in place for one week and increases to nearly 100 per cent when the catheter remains in place for up to a month⁷.

Effective catheter care involves collaborative effort⁸; however, nurses remain largely responsible for indwelling catheter care. Daily assessment of catheter need and the possibility of removal is recommended³, with electronic alerts or other daily reminder systems important in acute care. Nurses are also advised to use standard precautions during catheter removal to prevent cross-transmission of microorganisms, thereby preventing CAUTI⁸.

Conclusion

In summary, the components of care to prevent CAUTI include: reduction of inappropriate use of urinary catheters; performance of proper indwelling catheter insertion techniques; selection of correct catheter and drainage system; implementation of proper catheter maintenance procedures, and removal of catheters in a timely manner.

These catheter management components are all inter-related and can help to prevent this most common of the healthcare-associated infections – CAUTI.

In addition, education on CAUTI prevention should not only focus on one aspect of care, but should also be spread across all components
of care.

Box 1: CAUTI definition

The definition of CAUTI varies worldwide, as does the criteria for identifying CAUTI. One of the more commonly used definitions in acute care settings is that of the National Healthcare Safety Network (NHSN) of the United States Government’s Centers for Disease Control and Prevention (CDC). The NHSN define CAUTI as a urinary tract infection in a person with an indwelling urinary catheter for more than two days and at least one of the following criteria:

• With catheter still in place, the person develops at least one of the following – fever (> 38C), suprapubic tenderness, costovertebral angle pain, and a positive urine culture of > 105 colony-forming units (CFU)/ml with no more than two species of microorganisms.
• With catheter removed the day prior to, or on the day, the person manifests at least one of the following – fever (> 38C), urgency, frequency, dysuria, suprapubic tenderness, costovertebral angle pain, and a positive urine culture of > 105 CFU/ml with no more than two species of microorganisms (reference 10).

View the PDF of this article (and related learning activity) here >>

REFERENCES

1. SIDDIQ D & DAROUICHE R (2012). New strategies to prevent catheter-urinary tract infections. Nature Reviews Urology, 9, 305-314.
2. WEBER D, SICKBERT-BENNETT E, GOULD C ET AL. (2011). Incidence of catheter-associated and non-catheter-associated urinary tract infections in a healthcare system. Infection Control & Hospital Epidemiology, 32(8), 822-823.
   http://dx.doi.org/10.1086/661107
3. LO E, NICOLLE L, COFFIN S ET AL. (2014). Strategies to prevent catheter- associated urinary tract infections in acute care hospitals: 2014 update. Infection Control and Hospital Epidemiology, 35(5), 464-479. doi:10.1086/675718
4. CENTERS FOR DISEASE CONTROL (2013). April 2013 CDC/NHSN protocol corrections,clarification, and additions. Retrieved from
   https://www.cdc.gov/nhsn/pdfs/pscmanual/7psccauticurrent.pdf
5. MOHAJER M & DAROUICHE R (2013). Prevention and treatment of urinary catheter-associated infections. Current Infectious Disease Reports, 15(2), 116-123.
6. REBMANN T & GREENE L (2010). Preventing catheter-associated urinary tract infections: An executive summary of the Association for Professionals in Infection Control and Epidemiology, Inc, elimination guide. American Journal of Infection Control, 38(8), 644-646.
7. INSTITUTE FOR HEALTHCARE IMPROVEMENT (2011). How to guide: Prevent catheter-associated urinary tract infection. Retrieved from http://www.ihi.org/Topics/CAUTI/Pages/default.aspx
8. GOULD C., UMSCHEID C, AGARWAL R, ET AL. (2009). Guideline for prevention of catheter-associated urinary tract infections. Retrieved from
   www.cdc.gov/hicpac/pdf/cauti/cautiguideline2009final.pdf
9. BURTON D, EDWARDS J, SRINIVASAN A ET AL. (2011). Trends in catheter-associated urinary tract infections in adult intensive care units – United States, 1990–2007. Infection Control and Hospital Epidemiology, 32(8), 748-756
10. CENTERS FOR DISEASE CONTROL (2015). Urinary tract infection (catheter-associated urinary tract infection and non-catheter-associated urinary tract infection and other urinary system infection events. Retrieved from
    www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf
11. CHENOWETH C & SAINT S (2013). Preventing catheter-associated urinary tract infections in the intensive care unit. Critical Care Clinics, 29(1), 19-32 doi:10.1016/j.ccc.2012.10.005
12. TRAUTNER B & DAROUICHE R (2004). Role of biofilm in catheter-associated urinary tract infection. American Journal of Infection Control, 32, 177-183.
13. NIKOLAEV Y, & PLAKUNOV A (2007). Biofilm -“City of microbes” or an analogue of multicellular organisms? Microbiology, 76(2), 125-138.
14. KING C, GARCIA ALVAREZ L, HOLMES A ET AL. (2012). Risk factors for healthcare-associated urinary tract infection and their applications in surveillance using hospital administrative data: a systematic review. Journal of Hospital Infection, 82, 219-226.
15. BERNARD M, HUNTER K & MOORE K (2012). A review of strategies to decrease the duration of indwelling urethral catheters and potentially reduce the incidence of catheter-associated urinary tract infections. Urologic Nursing, 32(1), 29-37.
16. TITSWORTH W, HESTER J, CORREIA T ET AL. (2012). Reduction of catheter-associated urinary tract infections among patients in a neurological intensive care unit: A single institution’s success. Journal of Neurosurgery, 116(4), 911-920.
    http://dx.doi.org/10.3171/2011.11.JNS11974
17. MURPHY C, FADER M & PRIETO J (2013). Interventions to minimise the initial use of indwelling urinary catheters in acute care: a systematic review. International Journal of Nursing Studies, 1-10.
18. AUSTRALIA AND NEW ZEALAND UROLOGICAL NURSES SOCIETY CATHETERISATION GUIDELINE WORKING PARTY (2013). Catheterisation Clinical Guidelines. ANZUNS, Victoria.
    www.anzuns.org/wp-content/uploads/2015/03/ANZUNS-Guidelines_Catheterisation-Clinical-Guidelines.pdf
19. BARBADORO P, LABRICCIOSA F, RECANATINI C, ET AL. (2015). Catheter-associated urinary tract infection: Role of the setting of catheter insertion. American Journal of Infection Control, 43(7), 707-710.
20. HOOTON T, BRADLEY S, CARDENAS D ET AL. (2010). Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guidelines from the Infectious Diseases Society of America. Clinical Infectious Diseases, 50(5),625-663. doi:10.1086/650482
21. PLATT R, MURDOCK B, FRANK POLK B, & ROSNER B (1983). Reduction of mortality associated with nosocomial urinary tract infection. The Lancet, 321(8330), 893-897. doi:10.1016/S0140-6736(83)91327-2
22. WENZLER-RÖTTELE, DETTENKOFER, SCHMIDT-EISENLOHR ET AL. (2006). Comparison in a laboratory model between the performance of a urinary closed system bag with double non-return valve and that of a single valve system. Infection, 34(4), 214-218.
23. KUBILAY Z, LAYON A, KUBILAY Z ET AL. (2013). What we don’t know may hurt us: Urinary drainage system tubing coils and CAUTIs – A prospective quality study. American Journal of Infection Control, 41(12),1278-1280. doi:10.1016/j.ajic.2013.06.009
24. MAKI D, & TAMBYAH P (2001). Engineering out the risk for infection with urinary catheters. Emerging Infectious Diseases, 7(2), 342.

Gloves were once a rare sight on a hospital ward.

Now gloves are constantly being donned, doffed and discarded during a nurse’s working day.

But does regularly pulling on gloves reduce the risk of infection? Do patients feel more comfortable or ‘untouchable’ if a nurse dons gloves as they approach them? And just who is protecting who when some common nursing procedures are increasingly done with a layer of latex between the nurses’ hands and the patient?

These are questions that infection control nurse specialist Dr Jennie Wilson has been researching in recent years. Wilson, now an associate professor and researcher in healthcare epidemiology at the University of West London, recently spoke to the Infection Prevention and Control Nurses College NZNO conference in Napier on her findings in a presentation called ‘To glove or not to glove?’.

Wilson, who has worked in the field of infection prevention and control for more than 30 years, says concern about the overuse of clinical gloves began to appear in the research literature about a decade ago.

It wasn’t until the HIV epidemic in the late 1980s that healthcare workers were encouraged to use disposable gloves during direct contact with patients’ blood and body fluids, because blood-borne viruses were seen to pose a risk to staff.

Wilson says this didn’t instantly trigger widespread use of gloves and in the mid-1990s there was still a concern that nurses weren’t using gloves as often as they should. But gradually the glove habit became increasingly embedded until, during the 2000s, a new concern started to surface; healthcare workers being too ready to pull on gloves and not quite so quick to pull them off or change them.

Glove cross-contamination risk

The Five Moments for Hand Hygiene guidelines were introduced by the World Health Organisation in 2009 to focus healthcare workers’ attention on good hand hygiene as a simple but effective means of infection prevention and control.

The aim is to promote the routine use of hand hygiene at each ‘moment’ to reduce the risk of cross-contamination of infection-causing bacteria or viruses from one patient (or patient environment) to another.

Wilson says if you assume cross-contamination can occur whether you touch the patient or patient environment with bare hands or gloves then not to change gloves (or use adequate hand hygiene after removing gloves) at the ‘Five moments’ would also risk cross-contamination (see box).

She was part of a research team that set out to observe when healthcare workers (HCW) at a UK hospital used gloves, why they were using them, and whether how they were using them posed a risk of cross-contamination.

They published findings in 2013 that showed nearly 40 per cent of the time that gloves were used in patient care there was a risk of cross-contamination (see box 2 for examples), including gloves used for toileting a patient not being removed before touching other surfaces or patients. The majority of the healthcare episodes using gloves involved nurses, and nurses were slightly more likely to cause cross-contamination risks than other HCW, such as doctors or healthcare assistants.

Wilson says the risk of cross-contamination from gloves had already been demonstrated by a French research team, Girou et al, recovering pathogens from 86 per cent of gloves used by HCW, even after the use of an alcohol hand rub. In 2007 another research team, led by Gonzalo Bearman, found a significant increase in healthcare-associated infections when gloves were used for all patient contact, compared with just using gloves for standard precautions (i.e. involving blood and body fluids). And a University of Otago research team reported in 2013 that it was likely poor HCW hand hygiene that led to faecal and other bacteria being found on unused gloves in glove boxes on a busy hospital ward.

Gloves not always needed

So is it a case that – rather than protecting patients from infection – wearing gloves is potentially putting patients at greater risk?

The short answer is, quite possibly. Wilson’s initial research found that not only were glove wearers failing to meet the ‘Five moments of hand hygiene’ around 40 per cent of the time, but they were also using gloves unnecessarily.

In fact, 42 per cent of the time, HCW were observed using gloves when they didn’t need to, including using gloves for low-risk procedures.

“The overall message from that was that gloves are being put on too early and taken off too late,” says Wilson. Gloves were being put on “way before” people had direct contact with the patient and then weren’t taken off immediately after doing the procedure. Or the gloves weren’t being changed, and hand hygiene used, between carrying out a ‘dirty’ and ‘clean’ procedure, for example between cleaning up a patient’s incontinence and then handling their IV device or catheter.

The research team has since extended its observations to cover two more hospitals and found exactly the same pattern repeated.

This swing in the practices of healthcare workers – who just two decades before had to be persuaded to use gloves to protect themselves but were now quick to pull on gloves even when not needed – prompted the first study to interview 25 staff at the initial hospital about what influenced their wearing of gloves.

Disgust, fear and protection

The research team found that one primary motivation for wearing gloves was an emotional response. “There was a fear and anxiety about touching things that are perceived to be unclean or dirty. And a sense of disgust – that some things were too ‘yucky’,” says Wilson.

Another major theme was that glove wearing was now part of the organisation’s culture, with gloves widely available on the ward and a perception that HCW wear gloves because it was ‘safer’.

“The overarching message that staff picked up is that they are not only protecting themselves but also protecting their patients by wearing gloves,” says Wilson. “They don’t seem to recognise that gloves don’t act as a sterile covering for the hands or that gloves aren’t immune from bacteria… gloves will pick up bacteria in exactly the same way that hands do.”

The healthcare workers interviewed were not without empathy and some expressed strong concerns that their glove-wearing might make patients feel uncomfortable or ‘dirty’. But others also had the perception that patients preferred them to wear gloves as it appeared cleaner and more clinical.

The follow-up research (yet to be published) includes interviews with patients about their views on glove use. Wilson says early indications are that the public’s perception about when gloves should be worn are quite a close match to infection control guidelines, like, for instance, expecting gloves to be worn when taking blood or clearing up after incontinence.

“You could maybe argue that the public have a clearer understanding of when gloves should be worn than perhaps the staff who are delivering the care.”

Both patients and staff talked about gloves providing a form of ‘protection’ when receiving and giving intimate cares, however. “It’s not seen to be quite as intimate if you touch somebody wearing gloves than if you touch somebody with a bare hand,” says Wilson. “When patients are having their private parts washed then perhaps they like the ‘psychological barrier’ of having a gloved rather than a bare hand.

“So there may be situations when it makes the patient feel more comfortable for staff to wear gloves but they aren’t necessarily infection control reasons.”

Wilson stresses it is really important to be clear why gloves are necessary. “Because if you are not clear when gloves are required (for infection control reasons) then you start to get into the situation that they are used as a personal preference and the reason may be obscure.”

For example, she says there is no infection control reason why nurses or other healthcare workers should wear gloves to feed a patient. “It’s quite demeaning to the patient … feeding is the kind of task that needs to be done with compassion and wearing gloves conveys the wrong message when we are helping someone with a basic human need.”

Likewise, when showering and dressing a person, unless there is incontinence, there is no reason to wear gloves, says Wilson. “It indicates some unrealistic need to protect yourself and conveys to the patient a sense that they are dirty or unclean in some way.”

Glove overuse costly and risky

But, most simply, reducing unnecessary glove use just makes good infection control sense.

Wilson reiterates that nurses and healthcare workers should think twice before using gloves as her research, and others, indicate the more often HCW wear gloves the more likely they are to risk cross-contamination. “Because they put them on too soon and take them off too late.”

The unnecessary use of gloves not only increases the risk of healthcare acquired infections, which is costly in itself to patients and hospitals, but also the risk of costly wastage of the healthcare dollar.

“We are saying that at least half the glove use, in the UK settings we observed, was unnecessary so that means half the budget we are spending on gloves in these hospitals is being wasted.” Most of those wasted gloves are also going into a clinical waste stream so there is a further cost to dispose of them.

So ‘to glove or not to glove?’ is a question that Wilson believes nurses should always ask themselves before they reach their – of course, freshly clean – hands into the closest gloves box.

But the reality is that hand hygiene in our hospitals doesn’t scrub up that well, and keeping your hands clean is easier said than done.

The Hand Hygiene New Zealand (HHNZ) campaign seeks to educate health care workers about not only when, but also why, to use hand hygiene. The Health Quality & Safety Commission-funded campaign includes a national auditing programme to see how many hand hygiene opportunities are taken, or missed, and what impact this has on common health-care associated infections.

Finding out just how often they’ve skipped cleaning their hands comes as a shock to many nurses, says infection control nurse Christine Sieczkowski. She is Infection Prevention & Control Coordinator for Auckland District Health Board – the DHB contracted to deliver the national hand hygiene programme since its first beginnings back in 2008.

Sieczkowski says hand hygiene has always been core business for infection control nurses, but up until now, programmes were ad hoc up and down the country and often took a back seat as already stretched teams coped with infection outbreaks and other competing clinical issues.

And hand hygiene is a topic many people dismiss as old hat.

“Yeah, hand hygiene … what else can you tell us about hand hygiene? How hard can it be?” is not an uncommon response, says Sieczkowski.

Shock at initial results

When a baseline audit revealed Auckland DHB health care workers were cleaning their hands only about a third of the time they should be, it came as a shock to many.

But not to Sieczkowski and her auditor team, who knew from the international literature that initial compliance rates were likely to be low.

The baseline audit was just that – finding out the level of hand hygiene compliance, prior to educating staff why and when they should be carrying out the World Health Organisation’s Five Moment for Hand Hygiene (see box).

That audit was also prior to ensuring alcohol-based hand gel dispensers were attached to each and every patient bed – so health care workers don’t have to waste time hunting for the closest gel dispenser.

Sieczkowski says with 56 wards to equip, this was no simple task, with the first lengthy obstacle being tendering for a quadrupling of hand gel dispensers and gel. The second was keeping gel bottles firmly attached to the patient’s bed, so they didn’t mysteriously disappear when orderlies wheeled a patient to surgery or radiology.

“We kept joking that there must be a black hole somewhere swallowing up all these missing bottles.”

The effort to educate and make easier compliance to the ‘five moments’ has made its mark.

An evaluation three years down the track of Auckland’s pilot HHNZ programme (as published in a recent New Zealand Medical Journal article) showed hand hygiene compliance had risen to 60 per cent, and at the same time, the reduction in Staphylococcus aureus bloodstream infections was statistically significant.

The HHNZ programme has since been rolling out around the country, with the 20 boards now at various level of implementation – some still struggling to get gel at every bed and others with more established programmes and experienced auditing teams.

Seventeen out of 20 DHBs took part in the last quarterly hand hygiene audit, with national compliance results averaging 62.3 per cent (compared to 75.7 per cent in Australia, which has a more longstanding campaign and is the origin of our auditing system).

Joshua Freeman, an Auckland DHB microbiologist and clinical lead for HHNZ, says there is a growing body of evidence that actually following the WHO ‘five moments’ makes a real difference to patient outcomes.

“But it requires a culture change, as people not only need to know what to do, but they also need to know why it’s important and believe in it.”

So how dirty are our hands?

Getting that culture change takes different strokes for different folks.

Sieczkowski says nurses – ever practical – want visual, physical proof of exactly how dirty their hands are.

“So we plate up the agar plates, get them to put their fingers on their plates and see what grows in the lab.”

This is pretty effective in convincing them their hands aren’t squeaky clean.

Also effective is getting nurses to use a ‘glow’ hand cream, wash their hands like normal, and then put their hands into an ultra violet light box. Any cream left on will let off a tell-tale glow, revealing weaknesses in their hand hygiene technique.

It literally highlights the areas most likely to get neglected like around the thumbs, wrists, under fingernails, and between fingers. Sieczkowski says it also brings home the message about why jewellery wearing is discouraged.

Doctors are more sceptical. They want research-based evidence on why they need to clean their hands so frequently. They also regularly score well below nurses in their hand hygiene compliance (see sidebar).

Freeman says there is a misconception amongst some in the medical profession that the call for hand hygiene is nurse-led hype and isn’t based in hard science.

“A lot of my work is to try and explain that there’s a very compelling scientific rationale to performing hand hygiene,” says Freeman.

It’s also very important to get senior medical staff on board to champion hand hygiene.

“Positive role models can have a hugely positive, but negative role modelling, and a publicly dismissive kind of statement, can also have a very negative effect on the hand hygiene practices of more junior colleagues looking up to their seniors.”

Flash mobs and league tables

The trick is not just to improve hand hygiene compliance but also to keep improving and not slip back into complacency.

This is where Louise Dawson comes in, a registered nurse turned baby product entrepreneur, who in January brought her marketing expertise to a new role as Auckland DHB’s first dedicated hand hygiene coordinator.

Dawson is ready to use emotive appeal, league tables, inter-ward rivalry, peer pressure, and afternoon tea bribes – as well as science and statistics – to improve hand hygiene compliance.

This year, she even injected some fun into International Hand Hygiene Day by launching a flash mob on an unsuspecting lunchtime crowd at Auckland Hospital. About 50 volunteers had several lessons with a local dance studio before “throwing their hands up in the air” to 2010 smash hit Dynamite.

“It created quite a buzz around the hospital,” says Dawson.

A major focus of her job is motivating the ten high risk wards for infections, which are audited quarterly for the HHNZ national compliance audit, to improve their compliance rates, including training one or two hand hygiene observers (or champions) per ward.

Dawson’s resource toolbox includes a video (of an ex-patient sharing their real life story of having a hospital-acquired bloodstream infection) that pulls an emotional punch and cold hard statistics on what such infections cost the hospital.

Another powerful motivator is competitive rivalry, and she used the last quarterly audit results to rank and compare the combined scores of nurses, doctors, and other health care workers across the ten wards.

“That’s a first for ADHB. We’ve never really done league tables,” says Dawson “But it’s been a real driver for change.”

The ward doctors at the bottom of the league table were very sceptical of the auditing process, opening up an opportunity for further education.

“But those doctors, nurses, and health care workers at wards that got the best results weren’t sceptical at all.”

Her overall approach is working, with the six wards she has worked with to date having a 25 per cent increase in compliance in the latest audit. This, in turn, brings up the whole board’s compliance rates.

With the board having gone through a particularly tough May and June – leading to nurses managing a lot more patients and a lot more being asked of them – she is also aware hand hygiene can sometimes slip because of barriers like multiple pressures on nursing time.

Stretched resources and auditing demands

Another passionate believer in the HHNZ project is Jo Stodart, charge nurse manager for infection prevention control at the Southern District Health Board.

Like Sieczkowski, she has been trained to platinum auditor level by Hand Hygiene Australia – just one of six in New Zealand – to ensure that all auditors trained across the country use the same consistent standards.

And like Dawson, she knows each organisation can come across barriers or challenges – temporary or more complex – to improving and maintaining their hand hygiene compliance, including competing priorities for quality initiatives.

She says for her small infection control team, the hand hygiene culture change campaign has to be part of business as usual, including labour intensive audits each quarter of the national reporting wards.

Auditors have to pop in and out of wards at different times of the day, keeping a watchful eye out for each hand hygiene “opportunity” (missed or taken) to get their quota of moments. In the last national audit, 21,660 moments were observed across the 17 boards.

“They say it takes a minute a moment,” says Stodart.

She thinks this is probably a conservative estimate and those 20,000 plus moments represents many, many hours of auditors’ – mainly infection control nurses’ – time.

It is also represents a lot of hand cleansing by busy health care workers – a level logistically impossible before the advent of convenient and effective alcohol-based hand gel. Dawson says a rough rule of thumb is roughly 70 per cent hand cleaning with alcohol rub to 30 per cent old-fashioned soap and water.

Sieczkowski says having moisturiser in the hand gels also means they are well tolerated.

“I could count the people on one hand who have gone to occupational health with problems.”

Stodart is not so sure and believes it may be an under-reported issue.

The passionate hand hygiene advocates are all united in backing a culture change, which is simple in concept if more complex in reality, that can make such a difference to patient safety.

“We’re always keeping in sight the patient in bed who hopefully won’t get a hospital-acquired infection,” says Stodart.

“It needs to be just as automatic as putting your seat belt on.”

So why clean hands so often?

The rise and rise of antibiotic resistant super bugs is a major driver behind hand hygiene campaigns internationally.

Evidence that a successful hand hygiene “culture-change” campaign in Victoria significantly reduced blood stream infections from methicillin-resistant Staphylococcus aureus (MRSA) was behind the launch of the national Hand Hygiene Australia campaign that the New Zealand campaign is built on.

Another motivator is the crude dollar cost to the health care system of preventable health care associated infections (HCAIs) from all bugs, including everyday Staphylococcus aureus.

Joshua Freeman says decade old data conservatively estimates the cost of HCAIs in order of $140 million. Then there is the personal cost to the patients’ themselves.

“If you want to look at it purely in financial terms, the arguments there, but if you want to look at in humanitarian terms, I think it’s the right thing to do ethically. We are under obligation to do this for our patients,” says Freeman.

“There’s still a mentality out there that HCAIs are the inevitable consequences of modern health care and they can’t be prevented as ‘oh well, the person was very old’ or ‘the person was very sick’ or ‘they had to have a line in’ and their infection was unavoidable.”

However, evidence shows that simple interventions like hand hygiene can put a huge dent in infection rates.

Both the Australian and New Zealand campaigns are built on Five Moments for Hand Hygiene. These aim to not only prevent bacteria spreading from one patient to another but also to stop transmitting a patient’s own bacteria from one site to another like, for example, from a contaminated catheter to an infection-vulnerable site like an IV cannula. This has led to the ‘moments’, stressing the need for hand hygiene before and after procedures, including contact with any indwelling device.

The fifth ‘moment’ highlights the fact that a patient’s immediate surroundings become contaminated with the patient’s bacteria, so if their chart is picked up, their locker shifted, or their bed remade, nurses are being exposed to bacteria and need to clean their hands.

The risk of contamination is always heightened by the chance the bacteria is antibiotic resistant. Freeman says some of these bugs are becoming virtually untreatable, and there is little commercial incentive for drug companies to develop new antibiotics to counter them if a resistant variant quickly emerges.

“It makes sense that we change our focus from treatment to prevention (of infections) and we increase our efforts and raise the bar to prevent them as the stakes have become higher,” says Freeman.