By Peter Teska and Jim Gauthier / Special to Healthcare Facilities Today

It’s no surprise that patient environments of care need to be hygienic. Some studies have detected pathogens at epidemiologically relevant levels on commonly touched surfaces, and others have found an increased rate of infection for patients staying in a room where the previous patient had certain infections. Organizations such as the World Health Organization (WHO) have placed a heavy focus on the importance of hand hygiene to manage the transmission of pathogens. But do staff practice hand hygiene and surface disinfection as frequently as they should, especially given environmental surface contamination and patient room traffic? 

Hand-hygiene adherence

The WHO guideline on hand hygiene reviewed studies that measured hand hygiene adherence and found that overall adherence for healthcare workers was 38.7 percent. Healthcare worker hand hygiene was performed 5–42 times per shift or 1.7 to 15.2 times per hour with hand hygiene opportunities of up to 80 opportunities per patient hour of care. A recent review article by Boyce found that nurses performed hand hygiene an average of 7.75 times per hour, but that the range can extend to 15 times per hour. This data demonstrates that healthcare workers are expected to perform hand hygiene but consistently fail to perform hand hygiene at the levels necessary to properly protect patients. 

Environmental surface contamination

If environmental surfaces are contaminated and are subsequently touched by healthcare workers, their hands become contaminated. Thus, keeping environmental surfaces and patient care equipment free of pathogens is an important part of infection prevention and patient safety. However, cleaning compliance of surfaces is not optimal. Carling studied patient room discharge cleaning on 14 high-touch surfaces across 23 acute care hospitals. Cleaning compliance was 49 percent, with individual surfaces ranging from 20 to 82 percent compliance across the study. Daily cleaning of environmental surfaces and patient care equipment is not believed to be any more compliant than discharge cleaning. This emphasizes that improving cleaning compliance for both daily and discharge cleaning should be an important infection prevention goal. However, improving cleaning and disinfection by focusing solely on the cleaning performed by the environmental services (EVS) staff is unlikely to optimize the hygiene of environmental surface and patient care equipment because of the frequency with which these surfaces become contaminated.

Patient room traffic & surface touches

Cohen et. al. studied the number of people entering a patient room, finding that the average number of room entries was 5.5 per hour. Nursing staff were only 45 percent of those entering the room. Of the staff entering the room, there were 3.5 different people entering the patient room per hour, so some of the people entered the room more than once per hour. The average nurse entered 4.5 patient rooms per hour. This study was conducted across a 15 hour waking day for the patient, implying that 5.5 people per hour for 15 hours per day would equal 82.5 people entering a typical patient room in that timeframe.

The Cohen study also highlighted which surfaces were touched in the patient room. A third of room entrants touched the environment, but not the patient, while 27.1 percent touched the patient’s intact skin, 17.8 percent had contact with the patient’s blood or body fluids and 16 percent touched nothing. Surprisingly, visitors had a higher recorded contact with blood and body fluids (19.6 percent) than nurses did (15.6 percent).

Huslage, et. al. investigated what surfaces staff touch while in the patient room for both an ICU and a general medical-surgical room. In the general medical-surgical room, bedrails were the most commonly touched surface, averaging 3.1 touches per interaction. Over bed tables (1.6), IV pumps (1.4) and bed surfaces (1.3) were the next three most commonly touched surfaces. 

Huslage also reported that in a medical-surgical unit, the staff touched on average 15.2 surfaces per interaction, while in an ICU, staff touched 44 surfaces per interaction. Across a 12 hour shift, the average nurse would be expected to touch 821 surfaces (4.5 patient rooms per hour X 15.2 surface touches per interaction X 12 hours = 821 surfaces) with a hand hygiene adherence of less than 40 percent. Using the WHO’s five moments of hand hygiene model, staff would not be expected to perform hand hygiene after each surface contact, but would minimally be expected to perform it at regular intervals based on entry and leaving the patient zone.

Daily surface touch frequency

Combining the Cohen data with the Huslage data suggests that the typical patient bedrail is touched 256 times per day on average.

• 5.5 people entering the room per hour X 3.1 bedrail touches per interaction = 17.1 touches per hour

• 17.1 bedrail touches per hour X 15 hours per day = 256 bedrail touches per day

Adams et. al. published an article providing similar data and attempting to connect frequency of hand contact with the level of aerobic bacteria and MRSA. The right and left bedrails were touched 20 and 16 times per hour respectively, which agrees with the Cohen data. They also found that higher touch frequency correlated with the number of bacteria on the surface for several surfaces, including the bedrail.

The primary cleaning intervention for patient room surfaces is to have the EVS worker clean and disinfect the bedrail and other surfaces once per day. This likely occurs with less than a 50 percent frequency. While the clinical staff may have pre-wetted disinfectant wipes available to disinfect high-touch surfaces in the patient environment of care, there is little data available to demonstrate the frequency with which this occurs, and it is likely to occur rarely. 

Since daily disinfection is unlikely to address all risks, and clinical staff perform hand hygiene less than 40 percent of the time, the probability of staff hands being contaminated at any given time is high. The WHO hand hygiene guidelines for healthcare workers states that these employees “typically touch a continuous sequence of surfaces and substances including inanimate objects, patients’ intact or non-intact skin, mucous membranes, food, waste, body fluids, and the worker’s own body. With each hand-to-surface exposure, a bidirectional exchange of microorganisms between hands and the touched object occurs and the transient hand-carried flora is thus continually changing. In this manner, microorganisms can spread throughout a healthcare environment and between patients within a few hours.”

This highlights that the risk is bidirectional. Pathogens in the near-patient environment may represent little risk to the patient if they are part of the patient’s microbiome, but that’s only one part of the risk to the patient. As the WHO position makes clear, there is also a risk that healthcare workers are transferring organisms throughout the healthcare facility, increasing the risk of infection for patients. 

Improving environmental hygiene & patient hand hygiene

There are daily care procedures that may require surfaces in the near-patient environment to be disinfected in case the healthcare worker’s technique was not perfect. While no studies have demonstrated the frequency with which surface disinfection needs to occur to protect the patient, once per day with a 50 percent frequency is arguably too little. At the very least, surface disinfection should occur around these moments:

• Before placing a food tray

• After any procedure involving feces within the patient bed space

• After dressing/changing wounds

• After assistance with productive coughing or vomiting

• After bed baths and personal hygiene sessions 

• When surfaces are visibly soiled

Further investigation is needed to determine the impact on bacterial counts on high-touch surfaces in the near-patient environment and on healthcare associated infection rates. The CDC states “the methods, thoroughness, and frequency of cleaning and the products used are determined by health-care policy”, and recognizes that high-touch housekeeping surfaces (doorknobs, bedrails, etc.) should be cleaned and disinfected more frequently.

In addition to improved environmental hygiene, a good patient hand hygiene program is also critical. The patient generally has the ‘portal of entry’ from the chain of infection, and in many cases the patient is the ‘mode of transmission’ (touching their mouth or other mucous membranes). Landers describes moments for patient hand hygiene, but every patient should be assessed on admission for their capability to understand when to perform hand hygiene, and if they are physically and mentally able to do their own hand hygiene. Patients who require assistance with hand hygiene, either due to physical or cognitive issues, should be well identified for all staff, to allow the healthcare and support team to assist the patient with regular hand hygiene, using product that is readily available.

Creating safer environments of care

Surface disinfection must be considered alongside hand hygiene to adequately address the risk of infection for patients. While currently little data exists to support the frequency with which this must occur, current practices result in the patient bedrail being touched upwards of 256 times per day, while surface disinfection is done once per day with a 50 percent frequency. All healthcare facilities need to address the other 255 contacts with a consistent, well described program for Environmental Hygiene.

Peter Teska is a Global Infection Prevention Application Expert with Sealed Air's Diversey Care division and can be reached at peter.teska@sealediar.com. Jim Gauthier is a Senior Clinical Advisor with Diversey Care and can be reached at james.gauthier@sealedair.com. For more information, visit www.sealedair.com.

1. World Health Organization, “WHO guidelines on hand hygiene in health care”, WHO Press, 2009; Geneva, Switzerland.

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8. Recommendations from CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Chicago IL; American Society for Healthcare Engineering/American Hospital Association; 2004.

9. Landers T, Abusalam S, Coty MB, Bingham J. Patient-centered hand hygiene: the next step in infection prevention. Am J Infect Control 2012; 40: S11-S17.