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Handwashing and Glove Use in a Long-Term-Care Facility -- Maryland, 1992

Residents of long-term-care facilities (LTCFs) are at risk for acquiring facility-associated infections and consequent mortality (1,2). Despite this risk, no national guidelines exist for infection-control practices in LTCFs, and information regarding the nature of infection-control practices in LTCFs is limited. To evaluate glove use and handwashing practices in an LTCF, and to determine factors associated with compliance with infection-control policies and the frequency of microbial transmission, Maryland Department of Health and Mental Hygiene (DHMH) and CDC staff observed glove use and handwashing practices on a chronic-care ward of an LTCF in Maryland for a 1-month period during 1992. This report summarizes the findings of this study.

The 56-bed ward was located in a 255-bed, university-based LTCF. Most ward residents were elderly and had been admitted to the ward because of severe decubitus ulcers. Staff-resident interactions were selected systematically, and all were observed by the same DHMH staff person. Staff-resident interactions were observed if they involved one of the following activities: oral feeding, bathing, transferring, excretory care, respiratory care, dispensation of oral medication, wound care, soiled linen change, or gastrostomy care. Existing policies in this facility were used as a basis for determining when glove use, glove change, and handwashing had been required. These policies required glove use when contact with mucous membranes, nonintact skin, or any moist body substance was anticipated. Handwashing was required before and after any direct resident contact and immediately after touching mucous membranes, nonintact skin, moist body substances, or contaminated environmental surfaces and before touching a different care site on the same resident, a different resident, or a clean environmental surface; handwashing was required regardless of glove use.

During the 1-month study period, 231 interactions performed by at least 44 different staff members were observed. Gloves were required for 192 (83%) of the interactions and were used for 161 (84%) of these episodes. Changing of soiled gloves was required during 152 (94%) of the 161 interactions and occurred during 24 (15%). The proportion of staff members who used gloves when required varied by activity and was lowest during gastrostomy care (23 {68%} of 34) and highest during wound care (33 {100%} of 33). The rate of glove use when required was 74% (37/50) for registered nurses (RNs) and 87% for both licensed practical nurses (LPNs) (41/47) and nursing assistants (NAs) (80/92).

Handwashing was required during 213 of the 231 interactions. The proportion of staff members who washed hands when required varied by stage of interaction: 32% (25/79) of the time, hands were washed when required before an interaction; less than 1% (1/182) of the time, during an interaction; and 64% (114/179) of the time, after an interaction. The rate of handwashing when required after an interaction varied by activity performed and ranged from 50% (16/32) after soiled linen changes to 100% (25/25) after wound care. LPNs complied with handwashing guidelines more frequently than RNs or NAs, regardless of stage of interaction.

During 158 (68%) of the 231 interactions, a staff member's soiled (i.e., contact with mucous membranes, nonintact skin, or any moist body substance) hands or gloves touched other areas of the resident being cared for, a different resident, themselves, or an environmental surface, potentially resulting in microbial transmission. The proportion of interactions varied by type of activity performed and ranged from 50% (16/32) during wound care to 97% (37/38) during soiled linen changes.

Based on the findings of this investigation, DHMH and CDC personnel re commended measures to improve infection-control practices in this facility. Recommendations focused on the need to better educate and motivate staff members to adhere to infection-control policies. Reported by: S Denman, MD, Johns Hopkins Univ School of Medicine, Baltimore; DM Dwyer, MD, Center for Clinical Epidemiology, E Israel, MD, State Epidemiologist, Maryland State Dept of Health and Mental Hygiene. P Vacek, MS, Biometry Facility, Univ of Vermont, Burlington. Childhood and Respiratory Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases; Div of Field Epidemiology, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: Since the early 1980s, guidelines have been developed for and studies have been conducted on the surveillance, prevention, and control of facility-associated infections, especially in acute-care settings (3-5). Although studies of staff practices (e.g., handwashing) that may be associated with facility-associated infections have been conducted in acute-care hospitals (6,7), little is known about infection-control practices in LTCFs (8). In addition, although general routes of disease transmission are known, it is unknown how, and under what circumstances, facility-associated infections are acquired.

The findings in this report characterize staff practices that may be related to LTCF-associated infections. However, these findings are subject to at least two limitations. First, because staff members could not be uniquely identified, observations may not have been independent. Second, the presence of an observer may have altered glove use and handwashing practices among LTCF staff. In addition, the findings in this LTCF may not be representative of other LTCFs in terms of residents or infection-control practices.

Because of the aging of the U.S. population and the increasing number of persons residing in LTCFs, the economic and health impact of LTCF-associated infections is likely to increase. The prevalence of facility-associated infections among LTCF residents is approximately 15% (2,9), and each resident is likely to acquire an average of two infections per year (1). Although factors such as decreased immune function, immobility, and frequent transfers to acute-care hospitals contribute to an increased risk for infection among LTCF residents, other risk factors, including breaches in handwashing and glove use, can be rectified by adherence to infection-control measures.

Effective infection-control practices are important in preventing infection in LTCF residents and reducing associated morbidity and mortality. The findings in this report indicate that lapses in infection control occur in LTCFs. Other factors likely to contribute to these lapses include high employee turnover, lack of an on-site infection-control practitioner, and reliance on staff with limited health-care training. In addition, LTCFs may not have written infection-control policies (10). Because no national guidelines exist for infection-control policies in LTCFs, many of these facilities have adopted guidelines developed for acute-care hospitals; however, further study is needed to determine whether these guidelines are practical or cost-effective.


  1. Jackson MM, Fierer J, Barrett-Connor E, et al. Intensive surveillance for infections in a three-year study of nursing home patients. Am J Epidemiol 1992;135:685-96.

  2. Garibaldi RA, Brodine S, Matsumiya S. Infections among patients in nursing homes. N Engl J Med 1981;305:731-5.

  3. Haley RW, Culver DH, White JW, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol 1985;121:182-205.

  4. Lynch P, Jackson MM, Cummings MJ, Stamm WE. Rethinking the role of isolation practices in the prevention of nosocomial infections. Ann Intern Med 1987;107:243-6.

  5. Garner JS, Simmons BP. Guideline for isolation precautions in hospitals. Infect Control 1983;4:245-325.

  6. Simmons B, Bryant J, Neiman K, Spencer L, Arheaut K. The role of handwashing in prevention of endemic intensive care unit infections. Infect Control Hosp Epidemiol 1990;11:589-94.

  7. Kaplan LM, McGuckin M. Increasing handwashing compliance with more accessible sinks. Infect Control 1986;7:408-10.

  8. Smith PW, Daly PB, Roccaforte JS. Current status of nosocomial infection control in extended care facilities. Am J Med 1991;91(suppl):281S-5S.

  9. Scheckler WE, Peterson PJ. Infections and infection control among residents of eight rural Wisconsin nursing homes. Arch Intern Med 1986;146:1981-4.

  10. Khabbaz RF, Tenney JH. Infection control in Maryland nursing homes. Infect Control Hosp Epidemiol 1988;9:159-62.

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