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A Controlled Trial of Universal Gloving vs. Contact Precautions for Preventing the Transmission of Multidrug-Resistant Pathogens. VCU Infectious Diseases Research Conference February 27, 2006. G. Bearman MD,MPH A. Marra, MD C. Sessler, MD W.R. Smith, MD R.P. Wenzel MD, MSc

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A Controlled Trial of Universal Gloving vs. Contact Precautions for Preventing the Transmission of Multidrug-Resistant Pathogens

VCU Infectious Diseases Research Conference

February 27, 2006

G. Bearman MD,MPH

A. Marra, MD

C. Sessler, MD

W.R. Smith, MD

R.P. Wenzel MD, MSc

M.B. Edmond MD,MPH,MPA

slide2
30%-40% of all Nosocomial Infections are Attributed to Cross Transmission: The Importance of Hand Hygiene
hand hygiene
Hand Hygiene
  • Single most important method to limit cross transmission of nosocomial pathogens
  • Multiple opportunities exist for HCW hand contamination
    • Direct patient care
    • Inanimate environment
  • Alcohol based hand sanitizers are ubiquitous
    • USE THEM BEFORE AND AFTER PATIENT CARE ACTIVITIES
hand hygiene4
Hand Hygiene
  • HCW’s perceive that their hand hygiene practice is excellent
    • Observational data does not support this claim
  • New technologies such alcohol based hand sanitizers make the practice of hand hygiene simpler than ever
    • There is simply no excuse for poor hand hygiene compliance
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Contact Precautions for drug resistant pathogens.

Gowns and gloves must be worn upon entry into the patient’s room

hypothesis
Hypothesis
  • The effectiveness of universal gloving (use of gloves for all patient care activity) in preventing the transmission of multidrug-resistant pathogens will be greater than the effectiveness of contact precautions for the following reasons:
    • Compliance with universal gloving will likely be greater than compliance with contact precautions.

Bearman et al.

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CDC/NNIS NI definitions applied; surveillance performed by VCUMC IC Department

  • Hand hygiene observations performed by trained observers
  • Active surveillance nasal and rectal cultures were obtained on all patients within the unit

Bearman et al.

methods
Methods
  • Microbiologic Data
    • One rectal swab culture performed for VRE and 1 nasal swab culture for MRSA performed on admission and every 4 days.
      • Once a patient was culture positive; then no further cultures were obtained for that organism.
        • Pulse field gel electrophoresis (PFGE) for genetic typing and antibiotic susceptibility testing were performed on all MRSA and VRE isolated after study was completed.

Bearman et al.

methods13
Methods
  • Healthcare Questionnaire
    • Administered at the end of the study protocol
      • Target: MRICU Nurses and Attending Physicians
        • Focus:
          • self reported compliance with infection control practice
          • acceptability of universal gloving vs. standard of care.

Bearman et al.

results
Results:

Bearman et al.

results hand hygiene compliance
Results: Hand Hygiene Compliance

A statistically significant reduction in hand-hygiene was observed in phase II

Bearman et al.

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Results:Compliance with Contact Precautions vs. Universal Gloving

Greater adherence during universal gloving was observed

Bearman et al.

results vre screening
Results: VRE screening

No difference was observed in the rate of VRE acquisition

Bearman et al.

results mrsa screening
Results: MRSA Screening

No difference was observed in the rate of MRSA acquisition

Bearman et al.

results mrsa pfge
Results: MRSA PFGE

ALL MRSA conversions were with clonal isolates

Bearman et al.

results vre pfge
Results: VRE PFGE

Most VRE conversions were with clonal isolates

results nosocomial infections rates
Results:Nosocomial Infections Rates

A statistically significant increase in NIs was observed

Bearman et al.

results nosocomial infections with vre or mrsa
Results: Nosocomial Infections with VRE or MRSA

4 VRE and MRSA infections were identified in Phase II

mricu demographics
MRICU Demographics

Utilization ratio=device days/patient days

results antibiotic usage defined daily dose ddd 1000 patients day
Results: Antibiotic UsageDefined daily dose (DDD/1000 patients-day)

The DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults

Example:DDD of levofloxacin is 0.5grams, if 200 grams were dispensed in a period with 4,500 patient days:(200g/0.5g)/4,500 pt days X 1000= 89 DDD/1000 PD

results questionnaire about ic compliance during universal gloving study
Results:Questionnaire about IC compliance During Universal Gloving Study
  • 34 respondents
    • 30 MRICU Nurses (45 eligible)
    • 4 Attending Physicians (7 eligible)
  • Overall survey compliance 65%
results questionnaire about ic compliance during universal gloving study30
Results:Questionnaire about IC compliance During Universal Gloving Study

Overall better care is delivered when:

Majority of respondents felt that better care was delivered during the Universal Gloving Phase of the study

universal gloving conclusions
Universal Gloving Conclusions
  • Observed compliance with universal gloving was significantly greater than compliance with contact precautions (gowns and gloves).
  • However, greater compliance with hand hygiene was observed in the standard of care phase.
  • No differences were detected between the two study phases for:
    • LOS, nurse:patient ratio,MRICU occupancy rate, invasive device utilization, and antibiotic usage
universal gloving conclusions32
Universal Gloving Conclusions
  • No differences in VRE and MRSA colonization was observed between the two study phases.
    • In both phases, the majority of VRE and MRSA conversions were of a clonal isolate
  • However, an increase in nosocomial infection rates was observed during the universal gloving phase of the study
    • 4 VRE and MRSA nosocomial infections were observed during the universal gloving phase
universal gloving conclusions33
Universal Gloving Conclusions
  • HCWs found gloving acceptable and believed that the use of universal gloving is associated with decreased risk of cross-transmission of nosocomial organisms
  • HCWs believed that better care was delivered under the universal gloving phase
  • Although universal gloving was highly accepted by the staff, its implementation should proceed with caution given the observed increase in nosocomial infection rates
    • The use of universal gloving may have lead to a misperception of decreased cross transmission risk
    • This may have lead to decreased hand hygiene compliance and a consequent increase in the rates of nosocomial infections