New Guidance Targets Infection Hazards in Fingernails, Sinks, Excessive Hand-Washing

New infection prevention guidelines, recently issued by several organizations, tackle fingernails, sinks, and cracked hands.

Among the recommendations, published in Infection Control & Hospital Epidemiology, from the Society for Healthcare Epidemiology, the Infectious Diseases Society of America, the Association for Professionals in Infection Control and Epidemiology, the American Hospital Association, and the Joint Commission are:

• Healthcare workers should cut their fingernails so they don't extend beyond the fingertips, and should keep them natural.
• Patient-facing healthcare workers should avoid washing their hands so much that they become dry and cracked, which can lead to cuts or bruising and infection, putting the patient and the provider at risk. Instead, alcohol-based hand sanitizers should be used.
• Hospitals should install hand sanitizer dispensers not just on the inside or outside of each patient room, but in both places.
• Certain basins should be dedicated to hand-washing alone, with no other fluids being dumped into them, to avoid infectious organisms splashing onto the counter or becoming aerosolized. Instead, use a toilet or a dedicated receptacle for other fluid disposal purposes.
• Instead of cleaning sink drains with a splash of bleach -- now common practice -- use products newly approved by the U.S. Environmental Protection Agency specifically capable of removing biofilm.

The advisories are based on new evidence showing previously unappreciated ways that various pathogens can spread in healthcare settings. They are most appropriate for hospitals, but are applicable to long-term and ambulatory care settings, including dialysis facilities, said lead author Janet B. Glowicz, PhD, RN, of the CDC, in an interview with MedPage Today during which a CDC public relations representative was present.

The CDC participated in the guidelines' development, the latest in a 40-year series since 2014.

One of the most important recommendations has to do with new recognition of how pathogens can spread through "premise plumbing," i.e., the hospital's sinks.

"Nurses in particular don't realize that all the stuff they're putting down those sinks can create biofilms and can also create resistant bacteria, and that can be aerosolized and contaminate the patient environment," Glowicz said.

Hand Hygiene

More recent surveys of various healthcare settings since 2014 found enormous variation in hand hygiene compliance, ranging from 7% in a trauma resuscitation center (although the sample was small), to 83.5% among nurses and 45.2% among physicians in a Canadian intensive care unit.

"I don't think that healthcare personnel recognize the damage that can be done to their hands by hand-washing, and when hand-washing is their preferred method of cleaning their hands, they are probably removing the lipids from their hands," Glowicz said. "That's a very different message than what you see in a community setting, where it's hand-wash, hand-wash, hand-wash. We know that alcohol-based hand sanitizer kills more bugs than hand-washing removes."

"We are stating it explicitly, because we know that the skin on the hands of healthcare workers, when they over-wash their hands, they can damage that skin, and then their skin will carry more bacteria," she added.

Furthermore, fingernail polish and gel shellac are okay at the discretion of the organization's infection prevention program, except for healthcare professionals who scrub for surgical procedures. For them, nail polish and gel shellac "should be prohibited," according to the guidelines.

Monitoring Adherence

One section in the guidelines that may be controversial encourages healthcare organizations to monitor their workers' hand-washing practices through a combination of methods. There are drawbacks to the direct overt method, because when a monitor's presence in the room is known, workers tend to alter their behavior when they know they're being watched.

Other approaches include direct covert monitoring, like a "secret shopper" approach, although this strategy can also fail when workers alter their behavior after realizing the observer's presence.

Remote video observation, in which healthcare workers and patients are aware that cameras are recording hand hygiene behaviors but do not know who is observing them or when, can reduce this "Hawthorne effect," but views are limited to camera angles. Among the most important aspects of hand-washing adherence surveillance is that the frontline worker gets feedback, Glowicz and co-authors noted.

Glowicz said she wished there was concurrence on the best approach, "but there just isn't yet. It depends on the facility's needs and resources. Each method has strengths and weaknesses. Facilities need to do some combination of the methods."

Other take-aways in the guidelines include:

• Individual pocket-sized alcohol-based hand sanitizers should not be a substitute for wall-mounted dispensers.
• Soap, moisturizer, and alcohol-based sanitizer dispensers intended for single use should not be refilled.
• Except in response to certain "high-consequence pathogens," or in situations in which compounding pharmacists are preparing sterile medications, double gloving is not recommended, in part because of the risk of contamination from the outer glove.
• Healthcare workers should receive training in proper glove doffing and should wash their hands after removing their gloves, based on a study that showed inappropriate glove use among certified nursing assistants in a long-term care facility, among others.

According to Glowicz, the guidelines are supposed to be updated every 5 years, but the COVID-19 pandemic disrupted the schedule. The new report is not intended to replace recommendations from the CDC's Healthcare Infection Control Practices Advisory Committee, she said.

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