Within hospitals, nosocomial infections continue to be recognized as a potential source of increased morbidity and mortality. 1 In August of 1987, the Center for Disease Control issued an advisory recommending the routine use of universal precautions, which emphasized barrier control methods to minimize the risk of exposure to body fluids. 2 Over time, both the benefits of universal precautions and their considerable expense have been recognized. In one 5-yr hospital review, isolation material costs increased by 92%, of which 64% was due to the cost of rubber gloves and 25% was related to the purchase of disposable gowns. 3
Despite continuing extraordinary efforts to isolate hospital personnel from potential sources of infection by the use of disposable paraphernalia, including gloves, gowns, masks, eyeglasses, and sharps containers, the potential for cross-infection in the hospital persists. The vector of transmission may be as innocent as a ballpoint pen, 4 white coat, 5 gloves, 6 stethoscope, 7 digital thermometer, 8 beepers, 9 or the medical chart, 1 as it is conveyed from the nursing station to the bedside and back again. Physicians, nurses, and clerks are all routinely exposed to nosocomial infections as they leaf through the clinical chart, particularly if they engage in the additional risk behavior of repetitively licking their fingers (RLF) before turning the pages.
Noting that this pertinacious habit was far more common than heretofore recognized, a survey of health professionals was initiated on the rehabilitation unit and, thereafter, throughout the hospital for self-acknowledged or observed RLF behavior among fellow health professionals. A random selection of clinical charts, including two with methicillin-resistant Staphylococci aureus (MRSA), were cultured and evaluated as to their antibiotic sensitivity.
We interviewed 50 healthcare professionals on the rehabilitation unit, including physicians, registered nurses, physical therapists, occupational therapists, recreational therapists, social workers, and unit secretaries. Three questions were asked: 1) Do you lick your fingers while reviewing the clinical chart? 2) Have you witnessed others licking their fingers while paging through the chart? 3) Do you always wash your hands after handling the chart?
Culture and Sensitivity of the Charts.
A total of 14 charts were randomly selected from the chart racks on the rehabilitation unit. One chart was from a patient with MRSA and another from a patient with vancomycin-resistant enterococcus. Each chart was cultured on Rhodac plates with brain-heart infusion agar. These samples were incubated at 37°C for 48 hr, with the subsequent growth identified microscopically. Antibiotic sensitivities were evaluated with Microscan using National Clinical Laboratory standards.
Of the 50 healthcare professionals questioned, five (10%) admitted to RLF while paging through a chart, and 45 (90%) denied this habit. However, with regard to the second question (witnessing others with an RLF habit), 30 (60%) answered in the affirmative. As to always washing their hands after a chart review, 47 (94%) responded negatively (Figs. 1–3).
Cultures from all 14 charts grew environmental flora, with nine demonstrating the additional presence of S. aureus. On sensitivity testing, three cultures grew MRSA, and the remainder grew methicillin-susceptible S. aureus. Paradoxically, the cultures in which MRSA was found were not on the charts of the MRSA-infected patients. None of these cultures demonstrated the presence of vancomycin-resistant enterococcus.
As in a previous report, 1 this survey once again demonstrates that hospital medical charts are frequently contaminated with bacteria. Importantly, this study revealed a very high ratio of charts positive for S. aureus, a potentially significant source of nosocomial infection in susceptible healthcare workers and their patients (i.e., 9 of 14 clinical chart cultures [64%] grew S. aureus). This organism is commonly found throughout hospitals, often colonizing the skin of hospital personnel.
The patient’s chart is exposed daily to the vicissitudes of bed-side clinical practice. In one instance, it may be casually placed on a bed stand recently dampened with body fluids and, in another instance, on or in the bed clothes of an infectious patient. With respect to these two scenarios, the wonder is that there is not far greater numbers of MRSA-related outbreaks. An unconscious RLF habit while reviewing hospital charts is an ongoing endemic hazard, with the potential for a significant hospital-wide epidemic.
Of the nine charts whose cultures grew S. aureus, three (30%) were identified as contaminated with MRSA. In these cases, the risk of cross-contamination is significantly enhanced by habitual RLF. Although only 5 of 50 healthcare professionals surveyed (10%) admitted to an RLF habit, 30 (60%) had witnessed others engaged in this activity. These observations would suggest that RLF is far more widespread than has been commonly acknowledged (i.e., everyone else guilty of this habit other than the individual interviewed). In several instances, before and shortly after questioning an individual who had just denied an RLF habit, the individual was observed unwittingly licking his or her fingers before paging through the chart.
As in this example, RLF is often an unconscious habit that even when called to the attention of the healthcare worker, may stubbornly persist or, even if temporarily interrupted, later reoccur. A mindful education program that repetitively calls attention to RLF and to its consequences may succeed in reducing or abolishing this habit. However, in refractive cases, hypnotic techniques that can elevate unconscious actions to a level of consciousness may forestall its reoccurrence.
Although multiple methods of sterilizing the charts have been considered (i.e., disposable covers, periodic wiping with antiseptic solutions, and autoclaving and irradiation), frequent handwashing before and after a chart review remains the cost-effective method of choice. With handwashing, the healthcare professional is protected from patient cross-contamination, and conversely, the patient and coworkers are sheltered from the health worker with an RLF habit. As an immediate consequence of this study, dispensers (Fig. 4) containing antimicrobial hand wash with 70% ethyl alcohol solution were initially installed in the hallways of the rehabilitation unit. Later, they were placed conveniently throughout the hospital corridors. Their overwhelming acceptance has now generated a welcomed new problem—how to keep them filled to meet the daily demand.
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