G. Bearman, MD, MPH T.M. Duane, MD Adriana E. Rosato, PhD Cheryl V. Haner, RN, BSN Kara Elam, MPH

1. A Controlled Trial of Universal Gloving with Emollient Impregnated Gloves to Promote Skin Health, Improve Hand Hygiene, and Prevent the Transmission of MDROs in a Surgical ICU G. Bearman, MD, MPH T.M. Duane, MD Adriana E. Rosato, PhD Cheryl V. Haner, RN, BSN Kara Elam, MPH Valentina Kazlova, MS M.B. Edmond, MD, MPH, MPA R.P. Wenzel MD, MSc

2. Disclosure Funding: An investigator initiated grant by Cardinal Health The sponsor played no role in the design, conduct, interpretation, or summary of this investigation

3. Objective To study the effectiveness of universal gloving with an emollient impregnated glove in promoting skin health and preventing the transmission of multi-drug resistant organisms in an intensive care unit setting

4. Concurrent surveillance for hospital acquired infections VRE, MRSA surveillance cultures on admission & every 4 days Hand hygiene compliance, HCW hand cultures & skin assessment Contact precautions for VRE, MRSA colonized/infected pts Universal gloving; no contact precautions Methods: Study Design Phase I Phase II

5. Methods:Surveillance • 16 bed surgical ICU of an 820-bed, tertiary care, academic medical center • Closed-ICU staffing model with 5 attending intensivists • Concurrent surveillance performed by experienced ICPs • CDC/NHSN HAI definitions employed • Hand hygiene observations performed by trained observers

6. Methods:Microbiologic Studies • One rectal swab culture for VRE and one nasal swab culture for MRSA performed on admission and every 4 days • Once culture positive, no further cultures were obtained for that organism • Pulse field gel electrophoresis (PFGE) for genotyping of patient and HCW MRSA and VRE isolates

7. Methods:HCW Hand Skin Measurements • Assessment tools for hand skin condition* • Visual scoring of skin by trained observer • Erythema grading of skin by trained observer • Subjective hand skin questionnaire by HCW • Microbiologic assessment of skin • Bag broth technique was employed to study the resident and transient skin flora on the hands of HCWs • Each HCW had 3-6 attempted hand cultures + skin condition assessments per study phase at 4 week minimum interval

8. Methods:Healthcare Worker Questionnaire • 11 item survey was administered at the end of the study protocol • Target: SICU nurses and attending physicians • Focus: • Self reported compliance with infection control practice • Acceptability of universal gloving vs. standard of care

9. Total patient days Length of stay Monthly unit occupancy Device utilization ratios Nurse to patient ratios Methods:Additional Data Elements

10. Results

11. Results: Hand Hygiene Compliance Number of HH observers: 10 - Inter-rater reliability Kappa 0.897

12. Results:Compliance with Infection Control Strategy % compliance P = .01 Phase 1 Contact Precautions Phase 2 Universal Gloving

13. Results:MRSA & VRE Screening

14. Results:Molecular Typing of Patient Strains n=16

15. Results:HCW Hand Cultures N =38 HCWs % positive P = .17 P = .23 P = .16

16. ResultsPFGE of HCW Hands

17. Results:HCW Hand Skin Assessment Significantly better skin health in Phase 2 N=52 HCWs

18. Results:HAI Rates

19. Results:HAIs with VRE or MRSA

20. Results:SICU Additional Data Utilization ratio=device days/patient days

21. Results:HCW Questionnaire N=39 (56% compliance)

22. Study Strengths • Prospective design • Trained ICPs for HAI surveillance • All data collected by study personnel with standardized data collection forms • Study measured confounders such as device days, N:P ratio and LOS

23. Study Limitations • Quasi-experimental • Single institution and single unit observation • Results may not be generalizable • Fewer patient days in P2 due to architectural redesign of unit • Hand hygiene compliance may have been influenced by the Hawthorne Effect • Skin condition assessment was performed by one member of the study team who was unblinded to study phase/ glove type

24. Conclusions • Compliance with universal gloving was greater than compliance with contact precautions • Greater compliance with hand hygiene was observed during universal gloving • HCW hand skin condition improved during universal gloving • The improvement may have been due to the glove or to seasonal variation • There were fewer HCWs with MRSA and VRE positive hand cultures during universal gloving

25. Conclusions • There was no significant change in MRSA and VRE patient conversions between the two phases • There were fewer MRSA and VRE HAIs during universal gloving • During universal gloving, HAIs decreased, but not statistically significant • Universal gloving with emollient impregnated gloves was well accepted by the study subjects • In an intensive care unit, universal gloving may be an alternative to contact precautions for the control of multi-drug resistant organisms