Gloves and gowns are not enough...

Back at Maryland, we had a surgeon who always asked for evidence that hand hygiene was necessary if he wears gloves. We gave him some evidence, but like many clinicians, he wanted data from his own institution. I guess everyone is the exception. Like good soldiers, we proceeded to collect that data. We gathered a great team over the years - Graham Snyder, Stephen Liang, Catherine Smith, Hannah Day and others to approach healthcare workers (HCW) before they entered patient rooms and collect cultures on their hands before entry and gowns/gloves after exiting the room.

The initial study from this work was published by Graham Snyder et al in ICHE 2008. He reported that MRSA was detectable on 19% of gowns/gloves of HCW after exiting an MRSA+ patients room, while that result for VRE was 9%.

The latest report from this group published in this month's ICHE by Dan Morgan et al, provides somewhat more humbling data. HCW had MDR-acinetobacter on their gloves 36% of the time after entering a colonized/infected patient's room. Wow. But the truly humbling finding was that after removing their gloves, 4.5% of the HCW still had it on their hands. Thus, while gloves reduce contamination of hands by around 85% per contact, to achieve true infection prevention, HCW must wash their hands after they remove there gloves.

I have posted Table 2 from the paper, which shows the likelihood of HCW contamination that would occur at various levels of compliance with contact precautions and hand hygiene. Even with 90% compliance with both wearing gloves and hand hygiene, almost 1% (0.8%) of contacts would be expected to contaminate the HCW hand and place them at risk for contaminating other patients and the environment. Multiply that 1% (or higher if lower compliance exists) by the number of HCW that enter the patients room in a day and you have an estimate of the daily transmission of MDR-AB. This sort of data highlights the Achilles heal of active detection and isolation strategies. No matter how much effort and money go into rapid detection of MDR organisms, without 100% compliance to gowns and hand hygiene, the effort is wasted. We have shared this data with our favorite surgeon. The description of how that went must wait for another study, or at least another day.

Graham Snyder 2008 ICHE paper (here)
Dan Morgan July 2010 ICHE paper (here)