In previous posts (here and here) we have already reviewed bacterial and fungal nosocomial pathogens that are found in the hospital environment. We have also reviewed the variety of surfaces that can be colonized (here).

These bacterial and fungal pathogens, which originate mainly from infected or colonized patients, can contaminate the hospital environment by direct transmission from the patients themselves or by others, such as via contaminated hands of healthcare workers or visitors.

In the current post we would like to review in more detail what are the most commonly touched surfaces in a patient room.

A traditional method to determine the most touched surfaces is observation of healthcare workers and scoring of surfaces touched during their duties. There are questions regarding behavioral changes during observation (the Hawthorne effect) but this is still the most successful method for these studies as normally there is covert observation.

An excellent example of an observational study is Huslage et al.,(1)  who quantitatively assessed the frequency of healthcare worker contact with different surfaces in a patient’s immediate environment. The study was conducted in 5 intensive care units (ICUs) and on 7 general medical-surgical floors during 18-months. A total of 1,490 surface contacts were recorded, of which 74.4% were in the ICUs.

Huslage et al
Summary of Huslage et al Frequency of Touched Surfaces in an ICU and Medical Surgery Floor Patient Rooms

Bed rails had the highest frequency of contact in both types of healthcare settings, accounting for 7.76 contacts per interaction (95% CI, 3.30–15.44 contacts per interaction) in the ICUs and 3.12 contacts per interaction (95% CI, 0.67–8.95 contacts per interaction) on the medical-surgical floors.

Three surfaces, the bed rail, the bed surface, and the supply cart accounted for 40.2% of the contacts recorded in the ICUs. These 3 surfaces, which sustained more than 3 contacts per interaction [95% CI, 2.17–13 contacts per interaction], were defined as “high touched surfaces” .

In the medical-surgical floors the bed rail, the over-bed table, the intravenous pump, and the bed surface accounted for 48.6% of the contacts recorded and were defined as the “high touched surfaces” [95% CI, 0.2–6.99 contacts per interaction]). Other surfaces were touched too, but to a significant lower degree.

Smith et al (2) covertly audited similar healthcare worker interactions and noted that 58% of clinical staff touched the patient, and 48% handled patient notes. In addition 25% of clinical staff touched the bed.

Another key study is that of Cheng et al (3), who followed on from the Huslage study and confirmed that eight of the top 10 high-touch items, including bedside rails, bedside tables, patients’ bodies, patients’ files, linen, bed curtains, bed frames, and lockers were mutually touched by HCWs, patients, and visitors.

Cohen et al (4) measured a slightly different outcome which was who entered the room, how often people entered the room, and duration. In addition this study also looked at what was touched in broad categories. This study established that there were 0 to 28 visits per patient (median, 5.5), and patients received visits from 0 to 18 different persons per hour (median, 3.5). Nurses made the most visits (45%), followed by personal visitors (23%). Visits lasted 1 to 124 minutes (median, 3 minutes for all groups). Persons entering patients’ rooms touched nothing inside the room, only the environment, the patient’s intact skin, or the patient’s blood/body fluids 22%, 33%, 27%, and 18% of the time, respectively. Medical staff estimated visiting an average of 2.8 different patients per hour (range, 0.5–7.0), and nursing staff estimated visiting an average of 4.5 different patients per hour (range, 0.5–18.0).

 

Overall these studies are all valuable as paint an interesting picture of touch points in the patient room. These studies demonstrate that there are multiple entries into a patient room per hour, and these visits are by a wide range of visitors from family and loved ones to clinical staff.  For the clinical staff multiple patients are then visited within an hour. Inside the room the environment is touched in 33% of visits, and those touches routinely include the bed and surrounding area. The bed linens, bed surface, bed rails, bedside tables, and privacy curtains are confirmed as high touch point surfaces in these visits. This all adds up to the environment making visitors and clinical staff vectors for pathogens.

 

References cited in this article’

  1. Huslage K, Rutala WA, Sickbert-Bennett E, Weber DJ. A quantitative approach to defining “high-touch” surfaces in hospitals. Infect Control Hosp Epidemiol 2010;31:850-853.
  2. Smith SJ, Young V, Robertson C, Dancer SJ. Where do hands go? An audit of sequential hand-touch events on a hospital ward. J Hosp Infect. 2012Mar;80(3):206-11
  3. Cheng VC, Chau PH, Lee WM, Ho SK, Lee DW, So SY, Wong SC, Tai JW, Yuen KY. Hand-touch contact assessment of high-touch and mutual-touch surfaces among healthcare workers, patients, and visitors. J Hosp Infect. 2015 Jul;90(3):220-5
  4. Cohen B, Hyman S, Rosenberg L, Larson E. Frequency of Patient Contact with Health Care Personnel and Visitors: Implications for Infection Prevention. Joint Commission journal on quality and patient safety / Joint Commission Resources. 2012;38(12):560-565.