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Rituals in Infection Control: What Works in the Newborn Nursery?
principles and practice Rituals in Infection Control: What Works in the Newborn Nursery? ELAINE LARSON, RN, PHD, FAAN Two infection control practices common in the newborn nursery; handwashing and gowning, are compared with regards to historic origins, effectiveness, and extent of practice. The practice of handwashing is the direct result of efforts to prevent puerperal sepsis and has been shown to be effective in reducing neonatal risk of infection. Gowning has evolved from operating room practices and has been shown to be generally ineffective in reducing risk of infant infection. Nevertheless, gowning is practiced extensively and handwashing is often omitted. Such rituals need occasional reexamination so that those practices associated with maximum effectiveness receive appropriate attention.
A ritual is an established form or a formal and customarily repeated act. Rituals serve several important functions in the practice of nursing by increasing efficiency and saving time, because each individual nurse is not required to make a decision about each activity performed. Many tasks can be performed by habit. Rituals make communication easier by providing a common set of descriptors or meaning for words and acts. Rituals also make education easier by systematizing and categorizing certain procedures. On the other hand, rituals can interfere with critical appraisal of practice. Indeed, some rituals have been shown to be dysfunctional to quality patient care.' As a result, intermittent reappraisal of rituals is warranted.
Accepted: April 1987
November/December 1987 JOCNN
Infection control practices are particularly fraught with ritual, probably because of the high risks associated with failures in technique that have resulted in transmission of infectious agents. Two such rituals, handwashing and personnel gowning, are used for the purpose of infection control in the newborn nursery. A review of the origins, effectiveness, and extent of compliance with these two ritual practices yields important information to nurses who staff newborn nurseries (Table 1). ORIGINS OF THE RITUAL
The importance of air transmission of infectious agents was recognized by nurses as early as the 1860s. At that time, Florence Nightingale instituted a concept in a school of nursing in London called fever nursing which was the
precursor for current isolation procedures.* T h i p concept was adopted by mosf American nursing schools. By the turn of the century, emphasis in nursing began to reflect touch rather than air transmission as the primary method of spreading disease. A s early a s 1915, use of a card system to identify infectious patients as well as the use of long-sleeved gowns to protect the clothing of nursing personnel from contamination existed.' From 1916 to 1935 more attention in the nursing literature was directed toward the inanimate environment as a 'source of infectious agents. Heavy emphasis was placed on the practice of surgical asepsis-gowns, masks, gloves, etc. General patient care practices were greatly influenced by practices from the operating room. For example, gowns were recom-
411
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~
~~
Table 1. Rituals in the Newborn Nursery
Origins
Gowning
Handwashing
Transfer of practices of surgical asepsis in surgery to the nursery setting
Evidence that handwashing reduces deaths from puerperal sepsis and nosocomial infection rates
Evidence of efficacy
None to very little
Overwhelming
Nursery policy regarding the practice
Common'6
UniversaP
Compliance of staff with the practice
Excellent (>go%)''
Poor (40%)-
mended for every entry into the room of an infected patient, whether or not anything was t~uched.~ Several authors have suggested that practices such as gowning in the newborn nursery were based on the transfer of techniques from surgery and aimed at the prevention of life-threatening diseases such as puerperal sepsis, which are rare t ~ d a y . ~ In. ~1958, the American Hospital Association recommended that aseptic practices in nurseries be evaluated. These recommendations resulted from a national increase in staphylococcal infections in newborn nurseries, which seemed to be influenced very little, if at all, by contemporary infection control regimens! The practice of handwashing evolved directly from obstetric practice during the nineteenth century, the devastating effects of puerperal sepsis (which is now recognized a s group A streptococci infection), and the recognition by physicians such as Holmes in the United States and Semmelweis in Vienna of the contagiousness of puerperal s e p ~ i s .Sem~*~ melweis demonstrated that puerperal sepsis, or childbed fever, was transmitted on the hands of physicians who examined laboring mothers after their hands had
412
become contaminated by body tissues of women who had died of infection. Nevertheless, the practice of handwashing was slow to catch on in Europe and in America, and many health-care practitioners continued to attribute infections to bad air or miasmas rather than to direct transmission from person-to-person. Even Florence Nightingale, despite her feuer nursing plan, tenaciously clung to her supposition that the concept of contagion did not fit into the moral and social order of the universe. Although Nightingale viewed a filthy or otherwise unhealthy environment as the cause of disease, she refused to consider the germ theory, in which a specific disease was caused by the acquisition of a specific microorganism. This attitude was consistent with that held by many of her medical colleagues. The atmosphere, according to Nightingale, was the primary factor predisposing an individual to infection. Hence, Nightingale emphasized the importance of general hygienic measures while deemphasizing the importance of specific practices such as handwashing? Surgical teams did not begin to wear gloves until the early 1900s. The current recognition of handwashing as the cornerstone of in-
fection control has been attributed in large part to the classic, natural experiments of Semmelweis. EFFECTIVENESS OF THE RITUALS
Published studies evaluating the effectiveness of gowning for reducing infections and colonization among newborns date back to the 1950s. Forfar and McCabe randomly assigned two similar newborn nurseries to one of two regimens: one in which all personnel practiced strict gowning and masking and the other in which staff did not use masks or gowns routinely." Forfar and McCabe found similar rates of infection in both units (27% for the gowned unit and 30% for the nongowned unit)." Additionally, colonization rates of neonates by Staphylococcus aureus did not differ significantly (54% and 49% for gowned and nongowned units, respectively) .I1 Williams and Oliver sequentially reduced the numbers,pf rituals used in a newborn Rhrsery (including routine use of caps, masks, hairnets, and gowns) and found no changes in the staphylococcal colonization rates of neonates over a period of 21 months in the 1960s.'' A follow-up study at the same institution during the 1970s concluded that fluctuations in staphylococcal colonization rates were more influenced by infant bathing practices than by the protective garments worn by staff.13 Also in the 19709, Evans et al. reported results from a study conducted in a premature center in which gowning and modified gowning protocols were rotated every two-to-three months.I4 During the gowning periods all staff changed clothes and gowned before entering the unit. During modified gowning periods, staff
November/December 1987 JOCNN
wore gowns only when infants were out of the incubators. These investigators reported small increases in both infections and staphylococcal colonization rates during modified gowning periods. However, handwashing practices also differed during the two phases. Only during the gowning phase did all staff scrub with hexachlorophene for three full minutes at the beginning of every shift. A scrub procedure was not required during t h e modified gowning phase. In 1981, Murphy et al. studied the effects of two regimens on staff acquisition of respiratory infections when caring for infected inf a n t ~ Volunteer .~~ personnel members were randomly assigned to handwashing alone or handwashing, gowning, and masking groups. Significant differences between the two groups in the numbers who demonstrated respiratory symptoms or in t h e severity of symptoms once presented were not identified. The authors postulated that viral transmission may not have been prevented by masks and gowns.15 The latest study of the effects of gowning on infections among neonates also assessed the impact of gowning on the frequency of staff handwashing, testing the hypothesis that the gown may serve as a reminder t o staff to wash their hands. The investigator reported that gowning was ineffective in influencing infection rates (13% and 9% rates during periods of gowning and nongowning, respectively) and had no effect on handwashing frequency (31% and 30% of staff reported handwashing during gowning and nongowning periods, respectively). The study concluded that gowning was an expensive and ineffective method of decreasing colonization or infection rates among neonates.16 Additionally, Nystrom reported
November/December 1987 JOGNN
no significant differences between contamination levels in an intensive care unit in which gowns were worn for 6 or for 24 hours or in a regular unit in which gowns were worn for longer periods of time.17 Nystrom concluded that, in terms of bacterial contamination, changing a gown more frequently than every 24 hours was not necessary.17The same low level of contamination could have been accomplished if the nurse wore a clean uniform for each working day. Using data from the literature, and a method developed by Jackson to calculate the risk of acquiring infection from nondisposable dishes," the joint probability of the risk of transmission of an infectious agent from one infant to another in the nursery through the uniform or gown of a health-care attendant has been calculated. This calculation assumed no attempts on the part of the staff to prevent contamination of the uniform. It is likely that nursing efforts to prevent contamination of the clothing and a good level of hygiene would decrease the risk of transmission even further. The risk of transmitting infection through nurses' clothing was calculated to be less than 2 per 10,000 when handling an infant who is colonized with an infectious agent. Additionally, Donowitz" has calculated that the cost of gowns for one, four-bed newborn unit over a period of six months was approximately $17,000-a large expense for a ritual of questionable efficacy. From 1846 to 1848, Semmelweis demonstrated a 90% reduction in maternal deaths due to infection from a rate of 13.7% to a rate of 1.3% by the introduction of a rigid handwashing regimen.lg MakiZ0 has pointed out that since the time of Semmelweis, very few clinical trials of the efficacy of handwash-
ing have been performed for ethical and practical reasons. First, withholding handwashing in a control group is considered unethical, since this practice has been demonstrated to reduce the risk of infection. Second, planning a clinical trial of the effects of handwashing is difficult because extremely large sample sizes would be required and many extraneous variables would interfere. For these reasons, more common reports have included retrospective studies in which the practice of handwashing is absent rather than prospective clinical trials. Invariably, reports of infection outbreaks in newborn nurseries attribute the problem, at least in part, to inadequate handwashing by personnel and attribute the termination of t h e outbreak to control measures such as increased handwa~hing?l-~~ Many studies conducted throughout t h e past century have concluded that contamination of the hands plays a primary role in the transmission of infectious agents between Contamination through hm"d contact has been identified as the route of transmission not only for bacteria but for viruses such as rotavirusm and the rhinovirus that causes the common A recent study demonstrated a significant reduction in the number of patients infected with Klebsiella following the introduction of routine antiseptic handwashing by staff in an intensive care ~ n i t . 2b ~i t t l e et al. reported a significant reduction in infections in critically ill patients following the introduction of a handwashing agent effective against an epidemic strain of gram-negative In another study, a termination of a nursery outbreak of infection was determined to follow t h e identification of a staff member who carried the epidemic strain on her hands.23
413
Two classic investigations of the importance of hands in the transmission of staphylococci in the newborn nursery were conducted in the 1960s. Wolinsky et al. studied the acquisition of strains of staphylococci by infants in a nursery and demonstrated a very low infant-to-infant spread.32However, 54% of infants handled by the unwashed hands of a nurse who was colonized with staphylococci acquired the organism after only one contact. The investigators concluded that actual handling of the infant was required for personnelto-infant transmission. Even more impressive were the results of a study by Mortimer et al.,33 in which an infant who was colonized with S. aureus was placed in one room with six other infants. Half of the noncolonized infants were handled by nurses who washed their hands between contacts; the rest of the infants were handled by nurses who did not wash their hands between infant contacts. The vast majority of the infants (92%) handled with unwashed hands acquired the index strain of S. aureus, as compared with 53% of neonates handled with washed hands, In addition, infants handled with washed hands required four times as long as infants handled with unwashed hands to become colonized with the staphylococci. Many unanswered questions about handwashing still exist. For example, whether or not use of an antiseptic-containing soap offers superior advantage over nonmedicated soap is not known. Reports by Hargiss and Larson from 1970 to 1976 and by Maki in 1986 demonstrate the positive effect of antiseptic soap but additional data are needed before the issue is completely r e ~ o l v e d . 'In ~ ~addition, ~~ the role of the quantity of soap used on the effectiveness of handwashing has only recently been
414
described.w Nevertheless, studies such as the ones cited above provide unequivocal evidence of the effectiveness of handwashing in reducing the risk of nosocomial infection to neonates.
Extent of Compliance With the Ritual
Studies describing the level of compliance of nursery staff with gowning protocols have not been reported. An informal, telephone survey conducted by the author in 1987 of 10 mid-atlantic hospital nurseries revealed that many nurseries have policies which restrict admission to the unit or the handling of newborns to those individuals wearing gowns. Staff questioned during this survey reported that compliance with gowning requirements was high and that gown requirements were easily monitored and enforced because a gown is immediately visible. Compliance with handwashing regimens, on the other hand, has been well studied and demonstrated to be very low. Iffy noted that handwashing in the perinatal unit was infreq~ent.3~ Observation studies of the frequency of handwashing have been conducted in which rates of handwashing between patient contacts ranged from 29 to 44%.3639Donowitz reported that even when staff were involved in a study and were under surveillance, only 30% of contacts with newborns were followed by a handwash.16Additionally, intervention studies to increase the level of handwashing by health-care personnel generally meet with only minimal sucC ~ S S . ~ O - ~ ~
SUMMARY The most important single measure in the prevention of neonatal infection is handwashing between each infant handling. The use of
masks and gowns, on the other hand, has been shown to make little or no difference in nursery infection Why is gowning, which has little or no effect on infections among neonates, widely practiced whereas handwashing, which can significantly reduce the risk to neonates of nosocomial infections, so often omitted by nursery personnel? One reason for this discrepancy is probably that gowning, a visible practice, is much easier to monitor than handwashing. A second reason may be that frequent washing can cause drying of the skin and subsequent discomfort. Indeed, this has been identified by nurses and physicians as a deterrent to some h a n d w a ~ h i n g . However, ~~.~ investigators have demonstrated that frequent handwashing does not necessarily cause skin damage and that, contrary to popular opinion, washing with an antiseptic soap is not more drying to the skin than washing with plain s0ap.4~ Another explanation for the low levels of handwashing. could be that staff do not recognize or believe that this practice makes a difference in the infection risks to neonates. Because infection rates in the newborn nursery are low and because newborns are discharged after very short hospital stays, staff rarely see the results of handwashing. The same problem that confronted Semmelweis more than a century ago is still present today: handwashing is an infection control measure of demonstrated efficacy, but staff perform handwashing at less than optimal levels. Measures which may promote adequate handwashing practices include the provision of accessible handwashing facilities which are acceptable to the staff as well as the inclusion by unit managers and/or head nurses of an evalua-
November/December 1987 JOGNN
tion of handwashing behavior as part of staff performance evaluation. As providers of quality health care, nurses should actively encourage the practice of handwashing, which is clearly efficacious and cost-effective and should reexamine the purpose and value of the practices of gowning in the newborn nursery. ~
~~
REFERENCES 1. Walker, V.H. 1967.Nursing and ritualistic practice. New York: MacmilIan. 2. Richardson, D.L. 1915. Aseptic fever nursing. Am. J. Nurs. 151082-93. 3. Mattson, E.F. 1933. Medical asepsis. Am. J. Nurs. 33:335-39. 4. Jackson, M.M., and P. Lynch. 1985. Isolation practices: A historical perspective. Am. J. Infect. Control 13:21-31. 5. Weinstein, R.A., K.M. Boyer, and E.S. Linn. 1983. lsolation guidelines for obstetric patients and newborn infants. Am. J. Obstet. Cynecol. 146:353-60. 6. Thompson, L.R. 1958. Staphylococcus aureus. Am. J. Nurs. 5 81098-100. 7. Holmes, O.W. The contagiousness of puerperal fever. 1842. N. Engl. Q.J. Med. Surg. 1:503-30. 8. Semmelweis, I.P. 1941. The Etiology,the concept, and the prophylaxis of childbed fever. Translated by F.P. Murphy. Baltimore: Williams and Wilkins. 9. Rosenberg, C.E. 1979. Florence Nightingale on contagion: T h e hospital as moral universe. In Healing and history. C.E. Rosenberg, ed. New York Science History Publications. 10. Symonds, H.P. 1904. The principles of modern surgery. Br. Med. J. 2793. 11. Forfar, J.O., and A.F. MacCabe. 1958. Masking and gowning in nurseries for the newborn infant. Br. Med. J. 1:76-9. 12. Williams, C.P.S., and T.K. Oliver. 1969.Nursery mutines and staphylococcal colonization of the newborn. Pediatrics 44:640-46. 13. Hargiss, C., and E. Larson. 1978. The epidemiology of Staphylococcus aureus in a newborn nursery from 1970 through 1976. Pediatrics 61 :348-353.
November/December 1987 JOCNN
14. Evans, H.E., S.O. Akpata, and A. Baki. 1971. Bacteriologic and clinical evaluation of gowning in a premature nursery. J. Pediatr. 78:883-86. 15. Murphy, D., J.K. Todd, and R.K. Chao. 1981.The use of gowns and masks to control respiratory illness in pediatric hospital personnel. J. Pediatr. 99:746-50. 16. Donowitz, L.G. 1986.Failure of the overgown to prevent nosocomial infection in a pediattk intensive care unit. Pediatrics 77:35-38. 17. Nystrom, B. 1980.The contamination of gowns in an intensive care unit. J. Hosp. Infect. 2167-70. 18. Jackson, M.M. 1984.From ritual to reason with a rational approach for the future: An epidemiologic prospective. Am. J. Infect. Control 12213-20. 19. Rotter, M.L. 1984. Hygienic hand disinfection. Infect. Control 5:18-22. 20. Maki, D.G. 1986. Skin a s a source of nosocomial infection: Directions for future research. Infect. Control 7:113-17. 21. Gaynes, R.P., D. Simpson, S.A. Reeves, et al. 1984.A nursery outbreak of multiple-aminoglycosideresistent Escherichia coli. Infect. Control 5:519-24. 22. Kominos, S.D., C.E. Copeland, and G. Grosiak. 1972. Mode of transmission of Pseudomonas aerugiRosa in a burn unit and an intensive care unit in a general hospital. Appl. Microbial, 23:309-12. 23. Parry, M.F., J.H. Hutchinson, N.A. Brown, et al. 1980.Gram-negative sepsis in neonates: A nursery outbreak due to hand carriage of Citrobacter diversus. Pediatrics 65:1105-09. 24. Brunn, J., and C. Solberg. 1973. Hand carriage of gram-negative bacilli and Staphylococcus aureus. Br. Med. J. 2:580-82. 25. Casewell, M.,and I. Phillips. 1977. Hands as route of transmission for Klebsiella species. Br. Med. J. 2:1315-17. 26. Knittle, M.A., D.V. Eitzman, and H. Baer. 1975. Role of hand contamination of personnel in the epidemiology of gram-negative nosocomial infection. J. Pediatr. 86:43337. 27. Murray, J., and R. Calman. 1955. Control of cross-infection by means of an antiseptic hand cream. Br. Med. J. 1931-83. 28. OjajarVi, J. 1980. Effectiveness of
handwashing and disinfection methods in removing transient bacteria after patient nursing. J. Hyg. 85:193-99. 29. Salzman, T.C., J.J. Clark, and L. Klemm. 1968.Hand contamination of personnel a s a mechanism of cross-infection in nosomial infections with antibiotic-resistant Escherichia coli and KlebsiellaAerobacter. Antimicrob. Agents Chemother. 97-100. 30. Samadi, A.R., M.1. Hug, and Q.S. Ahmed. 1983. Detection of rotavirus in handwashes of attendants of children with diarrhea. Br. Med. J. 1:188-91. 31. Gwaltney, J.M., P.B. Moskalski, and J.O. Hendley. 1978. Hand-tohand transmission of rhinovirus colds. Ann. Intern. Med. 88463-67. 32. Wolinsky, E., P.J. Lipsitz, E.A. Mortimer, et al. 1960.Acquisition of staphylococci by newborns. Lancet 2620-22. 33. Mortimer, E.A., P.J. Lipsitz, E. Wolinsky, e t al. Transmission of staphylococci between newborns. Am. J. Dis. Child 104:289-95. 34. Larson, E.L., P.I. Eke, and B.E. Laughon. 1987.Effects of quantity of handwashing soap on antimicrobic efficacy. Infect. Control (In press). 35. Iffy, L., H.A. Kaminetzky, J.E. Maidman, et al. 1979. Control of perinatal infectian by traditional preventive medures. Obstet. Cynecol. 54:403-07. 36. Albert, R.K., and F. Condie. 1981. Handwashing patterns in medical intensive care units. N. Engl. J. Med. 304:1465-66. 37. Larson, E., and M. Killien. 1982. Factors influencing handwashing behavior of patient care personnel. Am. J. Infect. Control 10:93-99. 38. Larson, E., K. McGinley, G. Grove, et al. 1986.Physiologic, microbiologic, and seasonal effects of handwashing on the skin of health care personnel. Am. J. lnfect. Control 51-59. 39. Preston, G.A., E.L. Larson, and W.E. Stamm. 1981. The effect of private isolatl8n rooms on patient care practices, colonization, and infection in an intensive care unit. Am. J. Med. 70:641-45. 40. Bryan, C.S. 1986. Of s o a p and Semmelweis. Infect. Control 7:44547. 41. Larson, E., and E. Larson. 1983,Influence of a role model on hand-
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washing behavior (Abstr.). Am. J.
hygiene in hospital. J. Hyg.
tnfect. Control 11:146.
86:275-83.
42. Mayer, J.A., P.M. Dubbert, M. Miller, et al. 1986. Increasing
45. Larson, E., K. McCinley, G. Grove, et al. 1986. Physiologic, microbio-
handwashing in an intensive care unit. tnfect. Control 7:259-62. 43. McSwiggan, D.A. 1979. Neonatal and perinatal infection: Routes of transmission and prevention. J. Antimicrob. Chemother. 5(Suppl. A): 1-12. 44. Ojajarvi, J. 1981. The importance of soap selection for routine hand
logic, and seasonal effects of handwashing on the skin of healthcare personnel. Am. J. infect. Control 14:51-59.
Address for correspondence: Elaine Larson, RN, PhD, FAAN, The Johns Hopkins University School of Nursing,
600 North Wolfe Street, Baltimore, MD 21205.
Elaine Larson is currently the Nutting chair in clinical nursing at the Johns Hopkins University School of Nursing, Baltimore, Maryland. Dr. Larson is a Fellow of the American Academy of Nursing, the Institute of Medidne of the National Academy of Sciences, and is actively involved in the Association for Practitioners in Infection Control.
What skills should a licensed nurse be able to demonstrate before using an electronic fetal monitor independently during the intrapartum and anteparturn periods? What kind of training is needed to prepare a licensed nurse to use electronic fetal monitoring during those periods? Get your answers from the experts. Order NAACOG's newest document, Electronic Fetal Monitoring: Nursing Practice Competencies and Educational Guidelines, today . NAACOG's electronic fetal monitoring guidelines were prepared by a special task force convened by NAACOG and including three nurses and one physician skilled in the use of electronic fetal monitoring. Additional comments used in preparing the document were provided by members and corresponding members of NAACOG's Committee on Education and Committee on Practice. Production of the document was funded in part by the March of Dimes Birth Defects Foundation. Copies of the electronic fetal monitoring guidelines are available for $5.50, which includes postage and handling. To order, send a check to the Publications Department, NAACOG, 600 Maryland Ave., SW, Suite 200E, Washington, DC 20024; (202)638-0026. Please mention that you read about the guidelines in JOGNN.
416
November/December 1987 JOG"
A ritual is an established form or a formal and customarily repeated act. Rituals serve several important functions in the practice of nursing by increasing efficiency and saving time, because each individual nurse is not required to make a decision about each activity performed. Many tasks can be performed by habit. Rituals make communication easier by providing a common set of descriptors or meaning for words and acts. Rituals also make education easier by systematizing and categorizing certain procedures. On the other hand, rituals can interfere with critical appraisal of practice. Indeed, some rituals have been shown to be dysfunctional to quality patient care.' As a result, intermittent reappraisal of rituals is warranted.
Accepted: April 1987
November/December 1987 JOCNN
Infection control practices are particularly fraught with ritual, probably because of the high risks associated with failures in technique that have resulted in transmission of infectious agents. Two such rituals, handwashing and personnel gowning, are used for the purpose of infection control in the newborn nursery. A review of the origins, effectiveness, and extent of compliance with these two ritual practices yields important information to nurses who staff newborn nurseries (Table 1). ORIGINS OF THE RITUAL
The importance of air transmission of infectious agents was recognized by nurses as early as the 1860s. At that time, Florence Nightingale instituted a concept in a school of nursing in London called fever nursing which was the
precursor for current isolation procedures.* T h i p concept was adopted by mosf American nursing schools. By the turn of the century, emphasis in nursing began to reflect touch rather than air transmission as the primary method of spreading disease. A s early a s 1915, use of a card system to identify infectious patients as well as the use of long-sleeved gowns to protect the clothing of nursing personnel from contamination existed.' From 1916 to 1935 more attention in the nursing literature was directed toward the inanimate environment as a 'source of infectious agents. Heavy emphasis was placed on the practice of surgical asepsis-gowns, masks, gloves, etc. General patient care practices were greatly influenced by practices from the operating room. For example, gowns were recom-
411
~
~
~~
Table 1. Rituals in the Newborn Nursery
Origins
Gowning
Handwashing
Transfer of practices of surgical asepsis in surgery to the nursery setting
Evidence that handwashing reduces deaths from puerperal sepsis and nosocomial infection rates
Evidence of efficacy
None to very little
Overwhelming
Nursery policy regarding the practice
Common'6
UniversaP
Compliance of staff with the practice
Excellent (>go%)''
Poor (40%)-
mended for every entry into the room of an infected patient, whether or not anything was t~uched.~ Several authors have suggested that practices such as gowning in the newborn nursery were based on the transfer of techniques from surgery and aimed at the prevention of life-threatening diseases such as puerperal sepsis, which are rare t ~ d a y . ~ In. ~1958, the American Hospital Association recommended that aseptic practices in nurseries be evaluated. These recommendations resulted from a national increase in staphylococcal infections in newborn nurseries, which seemed to be influenced very little, if at all, by contemporary infection control regimens! The practice of handwashing evolved directly from obstetric practice during the nineteenth century, the devastating effects of puerperal sepsis (which is now recognized a s group A streptococci infection), and the recognition by physicians such as Holmes in the United States and Semmelweis in Vienna of the contagiousness of puerperal s e p ~ i s .Sem~*~ melweis demonstrated that puerperal sepsis, or childbed fever, was transmitted on the hands of physicians who examined laboring mothers after their hands had
412
become contaminated by body tissues of women who had died of infection. Nevertheless, the practice of handwashing was slow to catch on in Europe and in America, and many health-care practitioners continued to attribute infections to bad air or miasmas rather than to direct transmission from person-to-person. Even Florence Nightingale, despite her feuer nursing plan, tenaciously clung to her supposition that the concept of contagion did not fit into the moral and social order of the universe. Although Nightingale viewed a filthy or otherwise unhealthy environment as the cause of disease, she refused to consider the germ theory, in which a specific disease was caused by the acquisition of a specific microorganism. This attitude was consistent with that held by many of her medical colleagues. The atmosphere, according to Nightingale, was the primary factor predisposing an individual to infection. Hence, Nightingale emphasized the importance of general hygienic measures while deemphasizing the importance of specific practices such as handwashing? Surgical teams did not begin to wear gloves until the early 1900s. The current recognition of handwashing as the cornerstone of in-
fection control has been attributed in large part to the classic, natural experiments of Semmelweis. EFFECTIVENESS OF THE RITUALS
Published studies evaluating the effectiveness of gowning for reducing infections and colonization among newborns date back to the 1950s. Forfar and McCabe randomly assigned two similar newborn nurseries to one of two regimens: one in which all personnel practiced strict gowning and masking and the other in which staff did not use masks or gowns routinely." Forfar and McCabe found similar rates of infection in both units (27% for the gowned unit and 30% for the nongowned unit)." Additionally, colonization rates of neonates by Staphylococcus aureus did not differ significantly (54% and 49% for gowned and nongowned units, respectively) .I1 Williams and Oliver sequentially reduced the numbers,pf rituals used in a newborn Rhrsery (including routine use of caps, masks, hairnets, and gowns) and found no changes in the staphylococcal colonization rates of neonates over a period of 21 months in the 1960s.'' A follow-up study at the same institution during the 1970s concluded that fluctuations in staphylococcal colonization rates were more influenced by infant bathing practices than by the protective garments worn by staff.13 Also in the 19709, Evans et al. reported results from a study conducted in a premature center in which gowning and modified gowning protocols were rotated every two-to-three months.I4 During the gowning periods all staff changed clothes and gowned before entering the unit. During modified gowning periods, staff
November/December 1987 JOCNN
wore gowns only when infants were out of the incubators. These investigators reported small increases in both infections and staphylococcal colonization rates during modified gowning periods. However, handwashing practices also differed during the two phases. Only during the gowning phase did all staff scrub with hexachlorophene for three full minutes at the beginning of every shift. A scrub procedure was not required during t h e modified gowning phase. In 1981, Murphy et al. studied the effects of two regimens on staff acquisition of respiratory infections when caring for infected inf a n t ~ Volunteer .~~ personnel members were randomly assigned to handwashing alone or handwashing, gowning, and masking groups. Significant differences between the two groups in the numbers who demonstrated respiratory symptoms or in t h e severity of symptoms once presented were not identified. The authors postulated that viral transmission may not have been prevented by masks and gowns.15 The latest study of the effects of gowning on infections among neonates also assessed the impact of gowning on the frequency of staff handwashing, testing the hypothesis that the gown may serve as a reminder t o staff to wash their hands. The investigator reported that gowning was ineffective in influencing infection rates (13% and 9% rates during periods of gowning and nongowning, respectively) and had no effect on handwashing frequency (31% and 30% of staff reported handwashing during gowning and nongowning periods, respectively). The study concluded that gowning was an expensive and ineffective method of decreasing colonization or infection rates among neonates.16 Additionally, Nystrom reported
November/December 1987 JOGNN
no significant differences between contamination levels in an intensive care unit in which gowns were worn for 6 or for 24 hours or in a regular unit in which gowns were worn for longer periods of time.17 Nystrom concluded that, in terms of bacterial contamination, changing a gown more frequently than every 24 hours was not necessary.17The same low level of contamination could have been accomplished if the nurse wore a clean uniform for each working day. Using data from the literature, and a method developed by Jackson to calculate the risk of acquiring infection from nondisposable dishes," the joint probability of the risk of transmission of an infectious agent from one infant to another in the nursery through the uniform or gown of a health-care attendant has been calculated. This calculation assumed no attempts on the part of the staff to prevent contamination of the uniform. It is likely that nursing efforts to prevent contamination of the clothing and a good level of hygiene would decrease the risk of transmission even further. The risk of transmitting infection through nurses' clothing was calculated to be less than 2 per 10,000 when handling an infant who is colonized with an infectious agent. Additionally, Donowitz" has calculated that the cost of gowns for one, four-bed newborn unit over a period of six months was approximately $17,000-a large expense for a ritual of questionable efficacy. From 1846 to 1848, Semmelweis demonstrated a 90% reduction in maternal deaths due to infection from a rate of 13.7% to a rate of 1.3% by the introduction of a rigid handwashing regimen.lg MakiZ0 has pointed out that since the time of Semmelweis, very few clinical trials of the efficacy of handwash-
ing have been performed for ethical and practical reasons. First, withholding handwashing in a control group is considered unethical, since this practice has been demonstrated to reduce the risk of infection. Second, planning a clinical trial of the effects of handwashing is difficult because extremely large sample sizes would be required and many extraneous variables would interfere. For these reasons, more common reports have included retrospective studies in which the practice of handwashing is absent rather than prospective clinical trials. Invariably, reports of infection outbreaks in newborn nurseries attribute the problem, at least in part, to inadequate handwashing by personnel and attribute the termination of t h e outbreak to control measures such as increased handwa~hing?l-~~ Many studies conducted throughout t h e past century have concluded that contamination of the hands plays a primary role in the transmission of infectious agents between Contamination through hm"d contact has been identified as the route of transmission not only for bacteria but for viruses such as rotavirusm and the rhinovirus that causes the common A recent study demonstrated a significant reduction in the number of patients infected with Klebsiella following the introduction of routine antiseptic handwashing by staff in an intensive care ~ n i t . 2b ~i t t l e et al. reported a significant reduction in infections in critically ill patients following the introduction of a handwashing agent effective against an epidemic strain of gram-negative In another study, a termination of a nursery outbreak of infection was determined to follow t h e identification of a staff member who carried the epidemic strain on her hands.23
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Two classic investigations of the importance of hands in the transmission of staphylococci in the newborn nursery were conducted in the 1960s. Wolinsky et al. studied the acquisition of strains of staphylococci by infants in a nursery and demonstrated a very low infant-to-infant spread.32However, 54% of infants handled by the unwashed hands of a nurse who was colonized with staphylococci acquired the organism after only one contact. The investigators concluded that actual handling of the infant was required for personnelto-infant transmission. Even more impressive were the results of a study by Mortimer et al.,33 in which an infant who was colonized with S. aureus was placed in one room with six other infants. Half of the noncolonized infants were handled by nurses who washed their hands between contacts; the rest of the infants were handled by nurses who did not wash their hands between infant contacts. The vast majority of the infants (92%) handled with unwashed hands acquired the index strain of S. aureus, as compared with 53% of neonates handled with washed hands, In addition, infants handled with washed hands required four times as long as infants handled with unwashed hands to become colonized with the staphylococci. Many unanswered questions about handwashing still exist. For example, whether or not use of an antiseptic-containing soap offers superior advantage over nonmedicated soap is not known. Reports by Hargiss and Larson from 1970 to 1976 and by Maki in 1986 demonstrate the positive effect of antiseptic soap but additional data are needed before the issue is completely r e ~ o l v e d . 'In ~ ~addition, ~~ the role of the quantity of soap used on the effectiveness of handwashing has only recently been
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described.w Nevertheless, studies such as the ones cited above provide unequivocal evidence of the effectiveness of handwashing in reducing the risk of nosocomial infection to neonates.
Extent of Compliance With the Ritual
Studies describing the level of compliance of nursery staff with gowning protocols have not been reported. An informal, telephone survey conducted by the author in 1987 of 10 mid-atlantic hospital nurseries revealed that many nurseries have policies which restrict admission to the unit or the handling of newborns to those individuals wearing gowns. Staff questioned during this survey reported that compliance with gowning requirements was high and that gown requirements were easily monitored and enforced because a gown is immediately visible. Compliance with handwashing regimens, on the other hand, has been well studied and demonstrated to be very low. Iffy noted that handwashing in the perinatal unit was infreq~ent.3~ Observation studies of the frequency of handwashing have been conducted in which rates of handwashing between patient contacts ranged from 29 to 44%.3639Donowitz reported that even when staff were involved in a study and were under surveillance, only 30% of contacts with newborns were followed by a handwash.16Additionally, intervention studies to increase the level of handwashing by health-care personnel generally meet with only minimal sucC ~ S S . ~ O - ~ ~
SUMMARY The most important single measure in the prevention of neonatal infection is handwashing between each infant handling. The use of
masks and gowns, on the other hand, has been shown to make little or no difference in nursery infection Why is gowning, which has little or no effect on infections among neonates, widely practiced whereas handwashing, which can significantly reduce the risk to neonates of nosocomial infections, so often omitted by nursery personnel? One reason for this discrepancy is probably that gowning, a visible practice, is much easier to monitor than handwashing. A second reason may be that frequent washing can cause drying of the skin and subsequent discomfort. Indeed, this has been identified by nurses and physicians as a deterrent to some h a n d w a ~ h i n g . However, ~~.~ investigators have demonstrated that frequent handwashing does not necessarily cause skin damage and that, contrary to popular opinion, washing with an antiseptic soap is not more drying to the skin than washing with plain s0ap.4~ Another explanation for the low levels of handwashing. could be that staff do not recognize or believe that this practice makes a difference in the infection risks to neonates. Because infection rates in the newborn nursery are low and because newborns are discharged after very short hospital stays, staff rarely see the results of handwashing. The same problem that confronted Semmelweis more than a century ago is still present today: handwashing is an infection control measure of demonstrated efficacy, but staff perform handwashing at less than optimal levels. Measures which may promote adequate handwashing practices include the provision of accessible handwashing facilities which are acceptable to the staff as well as the inclusion by unit managers and/or head nurses of an evalua-
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tion of handwashing behavior as part of staff performance evaluation. As providers of quality health care, nurses should actively encourage the practice of handwashing, which is clearly efficacious and cost-effective and should reexamine the purpose and value of the practices of gowning in the newborn nursery. ~
~~
REFERENCES 1. Walker, V.H. 1967.Nursing and ritualistic practice. New York: MacmilIan. 2. Richardson, D.L. 1915. Aseptic fever nursing. Am. J. Nurs. 151082-93. 3. Mattson, E.F. 1933. Medical asepsis. Am. J. Nurs. 33:335-39. 4. Jackson, M.M., and P. Lynch. 1985. Isolation practices: A historical perspective. Am. J. Infect. Control 13:21-31. 5. Weinstein, R.A., K.M. Boyer, and E.S. Linn. 1983. lsolation guidelines for obstetric patients and newborn infants. Am. J. Obstet. Cynecol. 146:353-60. 6. Thompson, L.R. 1958. Staphylococcus aureus. Am. J. Nurs. 5 81098-100. 7. Holmes, O.W. The contagiousness of puerperal fever. 1842. N. Engl. Q.J. Med. Surg. 1:503-30. 8. Semmelweis, I.P. 1941. The Etiology,the concept, and the prophylaxis of childbed fever. Translated by F.P. Murphy. Baltimore: Williams and Wilkins. 9. Rosenberg, C.E. 1979. Florence Nightingale on contagion: T h e hospital as moral universe. In Healing and history. C.E. Rosenberg, ed. New York Science History Publications. 10. Symonds, H.P. 1904. The principles of modern surgery. Br. Med. J. 2793. 11. Forfar, J.O., and A.F. MacCabe. 1958. Masking and gowning in nurseries for the newborn infant. Br. Med. J. 1:76-9. 12. Williams, C.P.S., and T.K. Oliver. 1969.Nursery mutines and staphylococcal colonization of the newborn. Pediatrics 44:640-46. 13. Hargiss, C., and E. Larson. 1978. The epidemiology of Staphylococcus aureus in a newborn nursery from 1970 through 1976. Pediatrics 61 :348-353.
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14. Evans, H.E., S.O. Akpata, and A. Baki. 1971. Bacteriologic and clinical evaluation of gowning in a premature nursery. J. Pediatr. 78:883-86. 15. Murphy, D., J.K. Todd, and R.K. Chao. 1981.The use of gowns and masks to control respiratory illness in pediatric hospital personnel. J. Pediatr. 99:746-50. 16. Donowitz, L.G. 1986.Failure of the overgown to prevent nosocomial infection in a pediattk intensive care unit. Pediatrics 77:35-38. 17. Nystrom, B. 1980.The contamination of gowns in an intensive care unit. J. Hosp. Infect. 2167-70. 18. Jackson, M.M. 1984.From ritual to reason with a rational approach for the future: An epidemiologic prospective. Am. J. Infect. Control 12213-20. 19. Rotter, M.L. 1984. Hygienic hand disinfection. Infect. Control 5:18-22. 20. Maki, D.G. 1986. Skin a s a source of nosocomial infection: Directions for future research. Infect. Control 7:113-17. 21. Gaynes, R.P., D. Simpson, S.A. Reeves, et al. 1984.A nursery outbreak of multiple-aminoglycosideresistent Escherichia coli. Infect. Control 5:519-24. 22. Kominos, S.D., C.E. Copeland, and G. Grosiak. 1972. Mode of transmission of Pseudomonas aerugiRosa in a burn unit and an intensive care unit in a general hospital. Appl. Microbial, 23:309-12. 23. Parry, M.F., J.H. Hutchinson, N.A. Brown, et al. 1980.Gram-negative sepsis in neonates: A nursery outbreak due to hand carriage of Citrobacter diversus. Pediatrics 65:1105-09. 24. Brunn, J., and C. Solberg. 1973. Hand carriage of gram-negative bacilli and Staphylococcus aureus. Br. Med. J. 2:580-82. 25. Casewell, M.,and I. Phillips. 1977. Hands as route of transmission for Klebsiella species. Br. Med. J. 2:1315-17. 26. Knittle, M.A., D.V. Eitzman, and H. Baer. 1975. Role of hand contamination of personnel in the epidemiology of gram-negative nosocomial infection. J. Pediatr. 86:43337. 27. Murray, J., and R. Calman. 1955. Control of cross-infection by means of an antiseptic hand cream. Br. Med. J. 1931-83. 28. OjajarVi, J. 1980. Effectiveness of
handwashing and disinfection methods in removing transient bacteria after patient nursing. J. Hyg. 85:193-99. 29. Salzman, T.C., J.J. Clark, and L. Klemm. 1968.Hand contamination of personnel a s a mechanism of cross-infection in nosomial infections with antibiotic-resistant Escherichia coli and KlebsiellaAerobacter. Antimicrob. Agents Chemother. 97-100. 30. Samadi, A.R., M.1. Hug, and Q.S. Ahmed. 1983. Detection of rotavirus in handwashes of attendants of children with diarrhea. Br. Med. J. 1:188-91. 31. Gwaltney, J.M., P.B. Moskalski, and J.O. Hendley. 1978. Hand-tohand transmission of rhinovirus colds. Ann. Intern. Med. 88463-67. 32. Wolinsky, E., P.J. Lipsitz, E.A. Mortimer, et al. 1960.Acquisition of staphylococci by newborns. Lancet 2620-22. 33. Mortimer, E.A., P.J. Lipsitz, E. Wolinsky, e t al. Transmission of staphylococci between newborns. Am. J. Dis. Child 104:289-95. 34. Larson, E.L., P.I. Eke, and B.E. Laughon. 1987.Effects of quantity of handwashing soap on antimicrobic efficacy. Infect. Control (In press). 35. Iffy, L., H.A. Kaminetzky, J.E. Maidman, et al. 1979. Control of perinatal infectian by traditional preventive medures. Obstet. Cynecol. 54:403-07. 36. Albert, R.K., and F. Condie. 1981. Handwashing patterns in medical intensive care units. N. Engl. J. Med. 304:1465-66. 37. Larson, E., and M. Killien. 1982. Factors influencing handwashing behavior of patient care personnel. Am. J. Infect. Control 10:93-99. 38. Larson, E., K. McGinley, G. Grove, et al. 1986.Physiologic, microbiologic, and seasonal effects of handwashing on the skin of health care personnel. Am. J. lnfect. Control 51-59. 39. Preston, G.A., E.L. Larson, and W.E. Stamm. 1981. The effect of private isolatl8n rooms on patient care practices, colonization, and infection in an intensive care unit. Am. J. Med. 70:641-45. 40. Bryan, C.S. 1986. Of s o a p and Semmelweis. Infect. Control 7:44547. 41. Larson, E., and E. Larson. 1983,Influence of a role model on hand-
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hygiene in hospital. J. Hyg.
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42. Mayer, J.A., P.M. Dubbert, M. Miller, et al. 1986. Increasing
45. Larson, E., K. McCinley, G. Grove, et al. 1986. Physiologic, microbio-
handwashing in an intensive care unit. tnfect. Control 7:259-62. 43. McSwiggan, D.A. 1979. Neonatal and perinatal infection: Routes of transmission and prevention. J. Antimicrob. Chemother. 5(Suppl. A): 1-12. 44. Ojajarvi, J. 1981. The importance of soap selection for routine hand
logic, and seasonal effects of handwashing on the skin of healthcare personnel. Am. J. infect. Control 14:51-59.
Address for correspondence: Elaine Larson, RN, PhD, FAAN, The Johns Hopkins University School of Nursing,
600 North Wolfe Street, Baltimore, MD 21205.
Elaine Larson is currently the Nutting chair in clinical nursing at the Johns Hopkins University School of Nursing, Baltimore, Maryland. Dr. Larson is a Fellow of the American Academy of Nursing, the Institute of Medidne of the National Academy of Sciences, and is actively involved in the Association for Practitioners in Infection Control.
What skills should a licensed nurse be able to demonstrate before using an electronic fetal monitor independently during the intrapartum and anteparturn periods? What kind of training is needed to prepare a licensed nurse to use electronic fetal monitoring during those periods? Get your answers from the experts. Order NAACOG's newest document, Electronic Fetal Monitoring: Nursing Practice Competencies and Educational Guidelines, today . NAACOG's electronic fetal monitoring guidelines were prepared by a special task force convened by NAACOG and including three nurses and one physician skilled in the use of electronic fetal monitoring. Additional comments used in preparing the document were provided by members and corresponding members of NAACOG's Committee on Education and Committee on Practice. Production of the document was funded in part by the March of Dimes Birth Defects Foundation. Copies of the electronic fetal monitoring guidelines are available for $5.50, which includes postage and handling. To order, send a check to the Publications Department, NAACOG, 600 Maryland Ave., SW, Suite 200E, Washington, DC 20024; (202)638-0026. Please mention that you read about the guidelines in JOGNN.
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