Fluorescent Lotion Research Articles

Hand Hygiene Education Components Among First-Year Nursing Students

Few studies have directly and objectively measured the individual and combined effects of multifaceted hand hygiene education programs. To evaluate the individual and combined immediate effects of an instructional video and hand scan images on handwashing quality, decontamination, and knowledge improvement. This cluster randomized clinical trial was conducted in June to July 2023 among first-year nursing students at a university in Hong Kong. The study used an intention-to-treat analysis. Hand hygiene education sessions featuring an instructional video, hand scan images, or both. The primary outcome was the change in residue from fluorescent lotion remaining on participants' hands after handwashing before and after the intervention. The secondary outcomes included handwashing quality and knowledge of hand hygiene. A total of 270 of 280 students (mean [SD] age, 19 [1] years; 182 [67.4%] female) participated in the trial (96.4% participation rate). Participants were randomized to a control group (66 participants), hand scan image group (68 participants), instructional video group (67 participants), and hand scan image with instructional video group (69 participants). All intervention groups had greater reductions in residue after the intervention compared with the control group, although none reached statistical significance (hand scan image group: 3.9 [95% CI, 2.0-5.8] percentage points; instructional video group: 4.8 [95% CI, 2.9-6.7] percentage points; hand scan image with instructional video: 3.5 [95% CI, 1.6-5.4] percentage points; control group: 3.2 [95% CI, 1.3-5.2] percentage points). The instructional video group showed a significant improvement in their handwashing performance, with a higher percentage of participants correctly performing all 7 steps compared with the control group (22.4% [95% CI, 13.1% to 31.6%] vs 1.5% [-7.9% to 10.9%]; P < .001). Hand scan images revealed that wrists, fingertips, and finger webs were the most commonly ignored areas in handwashing. In this cluster randomized clinical trial of an education program for hand hygiene, a handwashing instructional video and hand scan images did not enhance the level of decontamination. The intervention group had improved handwashing techniques compared with the control group, a secondary outcome. ClinicalTrials.gov Identifier: NCT05872581.

Impact of medical waste bin on contamination of patient’s environment: An experimental study

Medical waste bins are a potential source of microbial contamination in the hospital environment, while there is no clear guidance for the management of them. We aimed to assess the impact of medical waste bins on patient's environment. This experimental study simulated microbial contamination by performing medical procedures on a patient model with fluorescent lotion. The waste bin was set as initially empty or two-thirds filled with waste, open or with a lid. The percentage of fluorescent-contaminated area in designated patient's environments was analyzed by 2 independent observers. Among a total of 120 experiments, the sides of the bins were more contaminated in open-occupied bins compared to open-empty bins and in open-occupied bins compared to lid-occupied bins (median 1.9175% vs 0.0916% [P=.001] and 1.9175% vs 0.0899% [P=.003], respectively). The top of the bedside equipment trolley for preparing medical procedures was more contaminated in lid-occupied bins than open-occupied bins (median 0.0080% vs 0.0040%, P=.013). In addition to reducing contamination of the bin itself, the manually operated lid had a potential risk of contributing to microbial transmission by contaminating the equipment trolley. Medical waste bins should be kept no more than two-thirds full, and caution should be taken when using the manually operated lid, to avoid cross-contamination.

A simulation study to evaluate contamination during reuse of N95 respirators and effectiveness of interventions to reduce contamination

To assess the potential for contamination of personnel, patients, and the environment during use of contaminated N95 respirators and to compare the effectiveness of interventions to reduce contamination. Simulation study of patient care interactions using N95 respirators contaminated with a higher and lower inocula of the benign virus bacteriophage MS2. In total, 12 healthcare personnel performed 3 standardized examinations of mannequins including (1) control with suboptimal respirator handling technique, (2) improved technique with glove change after each N95 contact, and (3) control with 1-minute ultraviolet-C light (UV-C) treatment prior to donning. The order of the examinations was randomized within each subject. The frequencies of contamination were compared among groups. Observations and simulations with fluorescent lotion were used to assess routes of transfer leading to contamination. With suboptimal respirator handling technique, bacteriophage MS2 was frequently transferred to the participants, mannequin, and environmental surfaces and fomites. Improved technique resulted in significantly reduced transfer of MS2 in the higher inoculum simulations (P < .01), whereas UV-C treatment reduced transfer in both the higher- and lower-inoculum simulations (P < .01). Observations and simulations with fluorescent lotion demonstrated multiple potential routes of transfer to participants, mannequin, and surfaces, including both direct contact with the contaminated respirator and indirect contact via contaminated gloves. Reuse of contaminated N95 respirators can result in contamination of personnel and the environment even when correct technique is used. Decontamination technologies, such as UV-C, could reduce the risk for transmission.

Hygiene in ENT examination: Fluorescence study with overview of current recommendations

Increasing normative demands on patient safety and quality assurance measures, but also the problem of multi-resistant germs and pathogens with a high potential for infection, increase the need for hygienically correct work.In this study, hygienically relevant potential sources of contamination in ENT examinations were to be identified and possible improvement strategies examined.A complete ENT examination was performed by 5 examiners with different professional experience, whose gloves were wetted with fluorescent lotion prior to the examination. Contaminations especially on the examination unit and on the instruments were identified. The potential risk of transmission of pathogens to subsequent patients was assessed using a specially developed score. Various strategies to reduce identified contamination possibilities were developed and thought through.The score of the investigators was very high with an average of 87.4 points (±3.6). The implementation of individual hygiene measures during the examination process would lead to a significant reduction of the score and thus to an improvement in hygiene: No shaking of hands (81.8), additional disinfection of patient's chair (79.8), disinfection of important surfaces (69.8), provision of standard instruments (60.2) or all instruments (32.2), disinfection of all relevant surfaces and provision of all instruments (7.4).The results show very clearly that an ENT examination is a complex procedure from the point of view of hygiene. For reliable protection against possible transmission events, a structured bundling of hygiene measures is therefore necessary.

Ambiguity in environmental cleaning: Identifying neglected potential reservoirs on inpatient units

Background: Environmental cleaning is critical to prevent transmission of pathogens in the hospital, particularly for organisms that persist on inanimate surfaces such as C. difficile. Cleaning responsibilities for items within the patient room are well defined in most environmental services and nursing protocols. However, shared medical equipment or frequently touched surfaces outside the patient room may not be cleaned as routinely; cleaning roles and schedules for these items are often less well-defined. Methods and materials: This study was performed at a tertiary care medical center on 5 units with high burden of C. difficile infection: bone marrow transplant, medical ICU, oncology, surgical ICU, and cardiology. We selected key equipment and surfaces and applied a tag of fluorescent lotion on to assess cleaning. We returned to evaluate for tag removal using a black light at the following intervals: 6 hours, 24 hours, 48 hours, 72 hours, 2 weeks, 5 weeks. Results were compared by unit and item type using chi-square tests with SAS version 9.4 (Cary, NC). Results: The time that elapsed before cleaning ranged from <6 hours to >5 weeks. Shared equipment with potential for direct patient contact such as scales, vitals machines, and glucometers were cleaned more readily than other equipment that theoretically should not be touching patients directly: ECG machines, procedure carts, and ultrasounds. High touch non-patient items such as keyboards and phones were cleaned infrequently. The bone marrow unit overall had superior cleaning. Five items could not be located on follow up (1 each from medical and surgical ICUs and oncology, 2 from cardiac unit), and thus were excluded from analysis. Conclusion: Healthcare providers should be aware that many of the frequently touched surfaces on inpatient units are not routinely cleaned. Regular hand hygiene is imperative in this context. Cleaning schedules for common areas should be drafted to include phones, keyboards, and table surfaces. Items that do enter patient rooms such as scales, lifts, ECGs, line carts and ultrasound should be cleaned after each use and may require reminders. We are currently drafting guidance materials for dissemination to frontline providers and cleaners.

Prophylactic Dressings for Maintaining Skin Integrity of Healthcare Workers When Using N95 Respirators While Preventing Contamination Due to the Novel Coronavirus: A Quality Improvement Project.

PURPOSE:Extended use of N95 respirator masks is far more prevalent during the coronavirus disease 2019 (COVID-19) pandemic. As WOC nurses, we were tasked with formulating procedures for protecting the facial skin integrity of healthcare workers (HCWs) using personal protective devices when caring for patients with suspected or active COVID-19, while avoiding contamination when the masks are donned or doffed. This quality improvement project describes how we approached this project within the limited time frame available as we cared for patients with established and suspected COVID-19.PARTICIPANTS AND SETTING:This project focused on HCW use of N95 respirator masks and dressings currently available in our facility. The 4 WOC nurses acted as quality improvement project directors and as participants. The setting for our project was our facility's simulation laboratory.APPROACH:We evaluated 6 topical products (an alcohol-free liquid acrylate, thin film dressing, thin hydrocolloid dressing, hydrocolloid blister care cushion, thin foam transfer dressing, and thick foam dressing) applied to skin in contact with 3 N95 respirators; all are available on our facility's formulary and all are in widespread clinical use. After the product was applied to the face and nose, the N95 respirator was donned and evaluated for fit. Participants then wore the devices for 10 hours and doffed the mask using established facility procedures. In order to evaluate for potential contamination including possible aerosolization, we applied a commercially available fluorescent lotion to simulate the presence of infectious particles. Contamination was assessed using an ultraviolet light for all dressings except for the alcohol-free liquid acrylate. We also evaluated cutaneous responses (skin integrity, irritation, comfort) during this period.OUTCOMES:We found that contamination of the simulated pathogen did not occur with removal of any of the protective products. No skin irritation was noted with any of the tested products after a 10-hour wear time underneath the N95 respirator masks, but mild discomfort was experienced with 3 of the dressings (thin film dressing and both hydrocolloid dressings).CONCLUSION:Based on these experiences, we recommend application of an alcohol-free liquid acrylate film to prevent facial skin injury associated with friction from the extended use of an N95 respirator mask. We further recommend performing a fit test and user-performed seal check with the use of any topical dressing and especially those that add cushion. For the duration of the COVID-19 pandemic, we recommend use of protective dressings to maintain skin integrity and protection from coronavirus infection as HCWs continue to provide care to all of patients under their care.

Evaluating the efficacy of handwashing demonstration on hand hygiene among school students - An interventional study.

BACKGROUND:Washing of hands and maintenance of appropriate hand hygiene plays a significant role in preventing the spread of many communicable diseases. However, literature demonstrating the efficacy of the World Health Organization (WHO) recommended handwashing procedure among schoolchildren in India is scanty.AIM:The aim of this study was to assess hand hygiene efficacy through graphical assessment technique utilizing ultraviolet (UV)-sensitive fluorescent lotion before and after handwashing demonstration among students aged 12–18 years.MATERIALS AND METHODS:This was an interventional study carried out over a period of 5 days among 21 schoolchildren aged 12–18 years in their respective school premises. Participants were requested to rub their hands with an UV-sensitive fluorescent lotion and then wash them. Hands were air-dried and examined under UV rays for blue light emission in a dark room. Emission of blue light highlighted parts of hand where lotion is still present and area not washed properly. Such areas were painted with nontoxic skin-friendly paints. Painted hands were imprinted over graph papers. Hand hygiene demonstration was provided to the participants as per the WHO guidelines by qualified public health dentists using audiovisual aids. Postintervention, the procedure followed at baseline was adopted to obtain imprints of uncovered (not covered during hand hygiene process) parts of hands. The mean percentage of uncovered parts of hand was assessed and compared between baseline and postintervention.RESULTS:The overall mean percentage score of uncovered hand area significantly reduced from 73.90 ± 19.81 mm2 at baseline to 20.05 ± 17.0 mm2 after demonstration of proper hand hygiene guidelines (P < 0.001).CONCLUSION:Hand hygiene demonstration by qualified public health dentists using audio-visual aids has significantly contributed to improving their hand hygiene practice.

A Study on the Process of Donning and Doffing Personal Protective Equipment of Health Care Workers (HCWs) in China

Introduction:Personal protective equipment (PPE) is a necessary item in the period of unknown and high risk emerging infectious disease. It is not only the necessary requirement of strict isolation but also the last line of defense to protect medical staff.Aim:To determine the frequency and sites of contamination of personnel during the process of using Chinese PPE.Methods:Recruit 56 health care workers (HCWs) who worked in front-line clinical to test PPE issued by the Chinese Center for Disease Control for preventing Ebola virus. Eight batches of HCWs were divided to conduct simulations of contaminated PPE removal using fluorescent lotion. Then the frequency and sites of contamination of personnel were recorded after removal of contaminated PPE. The method of visual observation was used to determine contamination.Results:The frequency of easily contaminated parts included: left hand and wrist (7 times), left calf (7 times), front chest center, left and right chest (6 times each), and left abdomen (5 times). Mistakes in the process of wearing PPE included: clothing touching the ground (20.00%), N95 air mask tightness not checked (13.33%), glove air-tightness not checked (4.44%), protective clothing zipper not checked (4.44%). Mistakes in doffing PPE included: clothes touching the ground or the inner surface is polluted (20.00%), the wrong method of removing N95 mask (14.44%), touching the pollution goggles mirror with hands (12.22%), incomplete washing steps, insufficient time and frequency of hand hygiene (11.11%).Discussion:It is necessary to carry out training on PPE donning and doffing for Chinese medical workers.

A Comparison of Two Types of Personal Protective Equipment (PPE) Doffing Process: Frequency and Sites of Contamination

Introduction:Personal protective equipment (PPE) is a necessary item in the period of unknown and high-risk emerging infectious disease. It is not only the necessary requirement of strict isolation, but also the last line of defense to protect medical staff.Aim:Compare the differences between contaminated frequency and sites under two types of PPE doffing.Methods:Recruited 56 health care workers (HCWs) who worked in clinical to follow the different PPE removal guidelines issued by the Chinese Center for Disease Control (CDC) and the World Health Organization (WHO) final resolution for preventing Ebola virus. Eight batches of HCWs were divided to conduct simulations of contaminated PPE removal using fluorescent lotion (Glitter Bug Potion, On Solution Pty Lt). Then we recorded the frequency and sites of contamination of personnel after removal of contaminated PPE by the method of visual observation.Results:According to China’s CDC process, the parts that are easily contaminated during PPE removal are: left hand and wrist (7 times), left calf (7 times), front chest center and left and right chest (6 times each) and left abdomen (5 times). Contaminated parts of the PPE process in accordance with the WHO process from high to low were: right hand and wrist (13 times), left hand and wrist (12 times), middle of the abdomen (10 times), left chest (9 times), and left abdomen (6 Times). There was no statistical difference between the two kinds of PPE piercing and removal (Z=1.177, P &gt; 0. 05).Discussion:Under the guidance of the two processes recommended by China CDC and WHO, there was no significant difference in the frequency of pollution after removing PPE. It is speculated that the PPE recommendation processes issued by WHO and China CDC are effective for personal protection against fulminating infectious diseases.

Risk of self-contamination during doffing of personal protective equipment

The aim of this study was to describe the risk of self-contamination associated with doffing of personal protective equipment (PPE) and to compare self-contamination with various PPE protocols. We tested 10 different PPE donning and doffing protocols, recommended by various health organizations for Ebola. Ten participants were recruited for this study and randomly assigned to use 3 different PPE protocols. After donning of PPE, fluorescent lotion and spray were applied on the external surface of the PPE to simulate contamination, and ultraviolet light was used to count fluorescent patches on the skin. After testing 30 PPE sequences, large fluorescent patches were recorded after using "WHO coverall and 95" and "North Carolina coverall and N95" sequences, and small patches were recorded after using "CDC coverall and N95" and "Health Canada gown and N95" sequences. Commonly reported problems with PPE use were breathing difficulty, suffocation, heat stress, and fogging-up glasses. Most participants rated PPE high (18/30) or medium (11/30) for ease of donning/doffing and comfort. PPE sequences with powered air-purifying respirators (PAPRs) and assisted doffing were generally associated with fewer problems and were rated the highest. This study confirmed the risk of self-contamination associated with the doffing of PPE. PAPR-containing protocols and assisted doffing should be preferred whenever possible during the outbreak of highly infectious pathogens.

Modified gloves: A chance for the prevention of nosocomial infections

Non-sterile gloves primarily serve as a barrier protection for health care workers (HCWs). However, pathogens may often contaminate the skin of HCWs during glove removal; therefore, pathogens may be further transmitted and cause nosocomial infections. A field study was conducted comparing contamination rates when using standard gloves or a new modified product equipped with an additional flap (doffing aid) for easier removal. Gloves were removed after bathing gloved hands in an artificial fluorescent lotion. The number of contamination spots was then visually examined using ultraviolet light. There were 317 individuals who participated in this study: 146 participants (104 nurses and 42 physicians) used standard gloves, whereas 171 participants (118 nurses and 53 physicians) used the modified product. Use of the modified gloves instead of the standard product (15.8% vs 73.3%, respectively; P < .001) and being a physician rather than a nurse (29.5% vs 47.7%, respectively; P = .003) were the only independent risk factors for reduction of contamination. This study shows that the modified product could, at least in vitro, significantly reduce the rate of hand and wrist contamination during removal compared with standard gloves. By this, it may significantly improve the overall quality of patient care when used on the wards directly at the patient's site.

Cleansing technique using high-velocity steam–air micromist jet spray

Application of a high-velocity steam–air micromist jet spray (HVS-AMJS; micromist average diameter: 2.4 μm) for cleansing the skin is proposed. Low-pressure steam is mixed with compressed air (pH 6.5) in a nozzle, and then sprayed at a pressure of ≦0.25 MPa and a velocity of ≧0.34 m/s on the skin or surface of material located approximately 5–10 cm from the nozzle. The temperature on the sprayed surface and water flow rate could be controlled between 42 °C and 46 °C and at approximately 50 mL/min, respectively. Compared with ultrasonic cleansing with tap water and rubbing with only tap water, the HVS-AMJS successfully removed fluorescent lotion covering pieces of wood and significantly reduced both the number of coliforms and the total viable counts on pieces of wood and gauze. Furthermore, the HVS-AMJS effectively removed oily ink from the skin of hairless rats, and temporarily elevated the skin temperature and blood flow, indicating massage effects. The striking characteristics of this cleansing technique using HVS-AMJS are not only its ability to remove microbes and residue without using any chemicals or detergents but also its massage effects.

Do medical students receive training in correct use of personal protective equipment?

ABSTRACTBackground: Healthcare personnel often use incorrect technique for donning and doffing of personal protective equipment (PPE).Objective: We tested the hypothesis that medical students receive insufficient training on correct methods for donning and doffing PPE.Methods: We conducted a cross-sectional survey of medical students on clinical rotations at two teaching hospitals to determine the type of training they received in PPE technique. The students performed simulations of contaminated PPE removal with fluorescent lotion on gloves and were assessed for correct PPE technique and skin and/or clothing contamination. To obtain additional information on PPE training during medical education, residents, fellows, and attending physicians completed written questionnaires on PPE training received during medical school and on knowledge of PPE protocols recommended by the Centers for Disease Control and Prevention.Results: Of 27 medical students surveyed, only 11 (41%) reported receiving PPE training, and none had received training requiring demonstration of proficiency. During simulations, 25 of 27 (92.5%) students had one or more lapses in technique and 12 (44%) contaminated their skin with fluorescent lotion. For 100 residents, fellows and attending physicians representing 67 different medical schools, only 53% reported receiving training in use of PPE and only 39% selected correct donning and doffing sequence.Conclusions: Our findings suggest that there is a need for development of effective strategies to train medical students in correct use of PPE.Abbreviations: PPE: Personal protective equipment; MRSA: Methicillin-resistant Staphylococcus aureus; SARS: Severe acute respiratory syndrome; MERS: Middle East respiratory syndrome; WHO: World Health Organization; CDC: Centers for Disease Control and Prevention; OSCE: Objective structured clinical examination

A pilot study to assess use of fluorescent lotion in patient care simulations to illustrate pathogen dissemination and train personnel in correct use of personal protective equipment.

BackgroundSimulations using fluorescent tracers can be useful in understanding the spread of pathogens and in devising effective infection control strategies.MethodsDuring simulated patient care interactions in which providers wore gloves and gowns, we evaluated environmental and personnel dissemination of fluorescent lotion and bacteriophage MS2 from a contaminated mannequin. The frequency of skin and clothing contamination after removal of personal protective equipment (PPE) was compared before versus after an intervention that included education and practice in PPE donning and doffing.ResultsTen healthcare personnel participated in 30 pre-intervention and 30 post-intervention patient care simulations. Fluorescent lotion and bacteriophage MS2 were rapidly disseminated to touched surfaces throughout the room; there was no difference in the frequency of contamination before versus after the PPE training intervention. After the intervention, there was a decrease in skin and/or clothing contamination with fluorescent lotion (9/30, 30 % versus 1/30, 3 %; P = 0.01) and bacteriophage MS2 (8/30, 27 % versus 2/30, 7 %; P = 0.08) and there was a significant reduction in the concentration of bacteriophage MS2 recovered from hands (0.31 versus 0.07 log10plaque-forming units; P < 0.01).ConclusionsOur findings suggest that simulations with fluorescent lotion can be a useful teaching tool to illustrate the spread of pathogens and provide further evidence that simple PPE training interventions can be effective in reducing contamination of personnel.

Impact of soap type—foaming vs. gel-based—on handwashing time

Handwashing (HW) is used daily in the food service industries to prevent disease transmission. Limited published research into the efficacy of foaming handsoap exists when compared to gel-based handsoap. Understanding how foaming soap may affect HW behavior as represented by time is critical to maximize HW effectiveness and minimize transmission of foodborne pathogens. Here, 12 participants completed a baseline HW, and then applied a known amount of Glo Germ (GG) fluorescent lotion and washed their hands with the assigned handsoap. Hands were then swabbed to quantify the amount of GG remaining on hands. Hand wash and hand rinse times were also recorded. No significant difference in efficacy between soap types was observed 1) in terms of GG remaining (p = 0.35) nor 2) in hand wash and rinse times (p = 0.77 and p = 0.48, respectively). However, consistently longer time (4.5 s on average) in both wash time and rinse time for gel-based handsoap did occur when compared to foaming handsoap. This may indicate a possible benefit to using gel-based handsoap as opposed to foaming types for better protection of public health; however, more research is needed to elucidate these differences.

Contamination of Health Care Personnel During Removal of Personal Protective Equipment.

Contamination of the skin and clothing of health care personnel during removal of personal protective equipment (PPE) contributes to dissemination of pathogens and places personnel at risk for infection. To determine the frequency and sites of contamination on the skin and clothing of personnel during PPE removal and to evaluate the effect of an intervention on the frequency of contamination. We conducted a point-prevalence study and quasi-experimental intervention from October 28, 2014, through March 31, 2015. Data analysis began November 17, 2014, and ended April 21, 2015. Participants included a convenience sample of health care personnel from 4 Northeast Ohio hospitals who conducted simulations of contaminated PPE removal using fluorescent lotion and a cohort of health care personnel from 7 study units in 1 medical center that participated in a quasi-experimental intervention that included education and practice in removal of contaminated PPE with immediate visual feedback based on fluorescent lotion contamination of skin and clothing. The primary outcomes were the frequency and sites of contamination on skin and clothing of personnel after removal of contaminated gloves or gowns at baseline vs after the intervention. A secondary end point focused on the correlation between contamination of skin with fluorescent lotion and bacteriophage MS2, a nonpathogenic, nonenveloped virus. Of 435 glove and gown removal simulations, contamination of skin or clothing with fluorescent lotion occurred in 200 (46.0%), with a similar frequency of contamination among the 4 hospitals (range, 42.5%-50.3%). Contamination occurred more frequently during removal of contaminated gloves than gowns (52.9% vs 37.8%, P = .002) and when lapses in technique were observed vs not observed (70.3% vs 30.0%, P < .001). The intervention resulted in a reduction in skin and clothing contamination during glove and gown removal (60.0% before the intervention vs 18.9% after, P < .001) that was sustained after 1 and 3 months (12.0% at both time points, P < .001 compared with before the intervention). During simulations of contaminated glove removal, the frequency of skin contamination was similar with fluorescent lotion and bacteriophage MS2 (58.0% vs 52.0%, P = .45). Contamination of the skin and clothing of health care personnel occurs frequently during removal of contaminated gloves or gowns. Educational interventions that include practice with immediate visual feedback on skin and clothing contamination can significantly reduce the risk of contamination during removal of PPE.

The Increasing Visibility of the Threat of Health Care Worker Self-contamination.

The vulnerability of health care workers to acquisition and propagation of infectious agents has received global attentionbecause of recent outbreaks of highly communicable and fataldiseases, includingEbola virusdiseaseandsevereacute respiratory syndrome. The emergenceof thesehigh-profilepathogenshaspromptedcalls for better personal protective equipment (PPE), specifically, masks, gowns, and gloves, to protect health care workers and patients. In this issue of JAMA Internal Medicine, Tomas and colleagues1 provide a timely addition to the existing literature on the limitations of our current PPE. In a series of related studies thatusepreviouslydescribedmethods2 tosimulatecontaminatedPPE, the investigatorsconvincinglydocumentahigh frequencyofhealthcareworkerself-contaminationwhenusing PPE. Thebulk of their data come from435 simulations of donning and/or doffing of gowns and gloves contaminatedwith a fluorescent lotion: 234were soiled glove simulations, and 201 were soiled gown simulations. Almost half (46.0%) of these simulations resulted in health care worker self-contamination of skin or clothing. Specific sites of contamination varied butmost commonly involved thehands during glove removal and the neck during gown removal. Furthermore, 39.5% of participantswereobserved tobeusing improper techniqueby 2 independent observers who compared participants’ techniques with the Centers for Disease Control and Prevention (CDC) procedure3 for donning and/or doffing PPE. The probabilityof self-contaminationwasmuchgreaterwhenusing improper technique (70.3%vs 30.0%). In a separate experiment, the investigators document that fluorescent lotion contamination is a reliablepredictor ofmicrobe contaminationbymixing bacteriophage MS2 to the solution and performing additional simulations; contamination with the lotion vs MS2 was not statistically different.1 Theseresultshaveclear implications for thesafetyofhealth careworkers and the spread of hospital-acquired infections. It has been documented that higher levels ofmicrobial contamination of hospital surfaces lead to higher rates of health care worker contamination with multidrug-resistant organisms.4 Because environmental bioburden is a concern for the crosstransmission of hospital-acquired pathogens, the microbial burden of health care worker hands and apparel represents another element in this equation. Collectively, this increased contamination of the animate and inanimate environment contributes to the risk of hospital-acquired infections. Tomas et al report a potential for improvement in the intervention portion of their study. A subset of participants were able to decrease self-contamination after a training session that includeda 10-minute instructional videowith structured practice using simulated contamination with fluorescent lotion. The authors found that this real-time assessment with “immediate visual feedback” was able to reduce health careworker self-contaminationby68%(from60.0%to18.9%). This reductionwassustainedat 1-and3-monthfollow-upswith no additional training.1 A standardized training procedure for health care workers on the recommended techniques for donning and/or doffing gowns and gloves is long overdue. The training should include educational context, proficiency monitoring, and feedback. The “immediate visual feedback”usedbyTomas et al1 appears to be particularly effective in altering staff behaviors.However, a standard,accepted,andvalidatedtrainingprogram has unfortunately not been developed, and debate remains as to what constitutes best practice for donning and doffing. The CDC’s recommendations are widely adopted. However, even theCDC’sprocedureshavebeen foundbysome to be insufficient.2 In fact, notwithstanding the significant benefit of the intervention reported in this issue, therewas still 30% residual contamination of intervention participants.1 Double gloving and cleaning of gloves before doffing have beensuggestedasadditions to thecurrentCDCpractices,1,2 but evidence of the effectiveness of these interventions for routine patient care interactions is lacking. Any standardized procedure and training program will need to take into account the individual health care worker’s comfort, scope of duty, previous training, and typical workload. Minute attention to details of donning and/or doffing is of vital importancetowardthegoalofprotectingpatientsandstaff, yet these efforts are undercut by poor adherence to the use of PPE.Healthcareworker fatiguewithcontactprecautions iswell documented,withdeficiencies increasinginproportiontoworkload and percentage of patients adhering to precautions in a givenunit.5,6 Inaddition,handhygienehasbeenreportedtodecreasewith increased glove use.7 Therefore, a prioritization of patients for contact precautions is needed to optimize adherencewithgloveandgownprecautions in the instanceswhen it will be most important. Patients should be targeted for isolation based on the presence of highly transmissible, nonendemicorganismsassociatedwithsignificantmorbidityandmortality.Aselectiveapproachto isolationmaximizesstaffattention to the transmission risk posedbypriority organisms and limits theadverseeffectsof contactprecautionsonpatientsandstaff. In the absence of such anorganism, efforts are best focusedon the fundamental horizontal infection control strategies that should be used for every patient care interaction. Last, the residual contamination of health care workers, even with optimal donning and/or doffing technique, highlights the ongoing importance of hand hygiene on completion of doffing activities. Of interest, Tomas et al applied their Related article page 1904 Health Care Personnel Contamination During Protective Equipment Removal Original Investigation Research

Reduction of ICU Nosocomial Catheter-Associated Urinary Tract Infections

ISSUE: The Infection Control Department is responsible for an annual review and update of the surveillance plan. Surveillance is extremely important in the context of continuous quality improvement because it makes use of objective data to improve organizational performance. Catheter-associated urinary tract infection (CA-UTI) rates were compared to data from the National Nosocomial Infection Surveillance System (NNIS). It was noted that infection rates in the intensive care unit (ICU) from October 2001 to September 2002 were consistently greater than the 90th percentile when compared to NNIS. PROJECT: An action plan was devised through a root-cause analysis identifying issues in practice, patient demographics, and human characteristics. The action plan included lecture and demonstration in handwashing techniques with a program that included the use of fluorescent lotion to help the staff with visualization of residue left on the hands after hand hygiene, encouraging the use of a waterless hand sanitizer (already available in all the ICU rooms), anonymous culturing of the hands of the ICU staff (for educational purposes), environmental culturing, trialing a new catheter securement device, and reviewing the CDC recommendations for prevention and/or reduction of CA-UTIs. RESULTS: The action plan was implemented from July through September 2002. The data collected from September 2002 to the present shows a consistent decline in the incidence of CA-UTIs in the ICU, with a rate of 2.8 infections per 1000 urinary catheter days, which falls between the 25th and 50th percentile when compared to NNIS. Annual statistics show a total of 13 infections per 1000 urinary catheter days from October 2001 to August 2002, and a total of 4 infections per 1000 urinary catheter days from September 2002 to September 2003, a decrease of 70%. LESSONS LEARNED: It is extremely important to continue to monitor and give feedback to the staff on all of the actions taken. Several monitoring systems were also put into place, one for the usage of the alcohol hand sanitizer and one for the use of the new catheter securement device.