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Herd Immunity: Study Shows ICU Gown, Glove Use Can Cut MRSA Rates by 40%

Herd Immunity: Study Shows ICU Gown, Glove Use Can Cut MRSA Rates by 40%

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Image courtesy of NIAID

Wearing gloves and gowns in health care settings lower infection rates, a new study shows.

But, wait. Wearing gloves and gowns doesn’t lower infection rates. That’s from the same study.

And hence the confusion in the media over the past week over whether doctors and nurses should even bother covering their hands and bodies or just show up in t-shirts, shorts, and flip flops every day. If you’re going to pass along a potentially fatal, highly infectious disease to your patient, why not do it in comfort?

These were some of the headlines:

Gowns And Gloves For Hospital Workers Could Cut MRSA Rates

Universal Glove, Gown Use Doesn't Cut MRSA, VRE in ICU

Wearing Gowns and Gloves Helps Prevent MRSA

No overall benefit with universal gown, glove use

Now, what did the study, published online on October 4 in the Journal of the American Medical Association, actually say?

First, it’s worth noting that this was a fairly extensive effort on the part of researchers from the University of Maryland School of Medicine and the Yale New Haven Health System Center for Healthcare Solutions. They didn’t just go to their respective intensive care units and look at a few patient files. They enrolled 20 ICUs from 15 states to participate in a ten-month study last year year. They analyzed more than 92,000 bacterial cultures from 26,180 patients.

One group of health care workers wore gloves and gowns any time they were in a patient’s room. Let’s call them the Gowns. The other group wore them only when dealing with patients already infected with antibiotic-resistant bacteria, which is in accord with the Centers for Disease Control and Prevention’s “standard isolation protocol.” Let’s call them the Skins.

The researchers measured infection rates prior to the start of the Gowns vs. Skins competition so they could see whether the change made an improvement, made no difference at all, or made things worse. They looked for the acquisition of MRSA (methicillin-resistant staphylococcus aureus) or VRE (vancomycin-resistant enterococci). And they calculated these acquisitions as a rate per patient day. One patient in the ICU for one day is a patient day. When the same patient stays another day, that’s two patient days, and when a new patient comes to the ICU for a day, that’s a third patient day.

Bear with me a bit while I explain what they found.

For the Gowns, acquisitions of MRSA or VRE fell to  from 21.35 acquisitions per 1000 patient-days (95% CI, 17.57 to 25.94) in the baseline period to 16.91 acquisitions per 1000 patient-days (95% CI, 14.09 to 20.28) in the study period. That seems pretty good. But look at what happened with the Skins. They saw a drop from 19.02 acquisitions in the baseline period to 16.29 acquisitions per 1000 patient-days. The end result? No statistically significant difference. And hence some of the headlines saying that gowns and gloves didn’t matter.

When you break it down by the bacteria, though, you see that gloves and gowns do appear to work against MRSA. For the Gowns, ICUs saw a decrease from 10.03 acquisitions per 1,000 patient days in the baseline period to 6 acquisitions in the study period. That’s a 40% decrease. What about the Skins? They went from 6.98 acquisitions to 5.94 acquisitions per 1,000 patient-days. That’s a 14% decrease. And this time the differences were determined to be statistically significant.

Why does all of this matter?

"Healthcare workers are the most important vector in the spread of antibiotic-resistant bacteria," study co-author Dr. Anthony Harris from the University of Maryland said, according to Michael Smith at MedPage Today.

Smith also wrote:

The universal use of gloves and gowns cut the number of the times healthcare workers entered patient rooms -- 4.28 entries per hour compared with 5.24 in the control units.

The intervention units also saw better hand hygiene when workers left patient rooms, he reported, and the intervention had no significant effect on the rate of adverse events.

The findings show some promise for preventing transmission of multidrug-resistant pathogens, commented Mary Hayden, MD, of Rush University Medical Center in Chicago.

But, she said, there are some possible drawbacks. "The cost would be a downside," she told MedPage Today, "as well as the trash that you would generate, because (the gowns and gloves) are all disposable."

Have your own thoughts on the value of gowns and gloves? Write me at askantidote [at] gmail.com or on Twitter @wheisel.

Comments

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I was expecting to see was evidence of misinterpretation, but what i saw was more like no interpretation. Just cut and paste, probably by several staff on the same mag who don't talk to each other. The articles contradict themselves, in one sentence saying there was no benefit for preventing MRSA, and the next line saying there was. Several sources simply reposted the HealthDay story, so they just wrote a headline. Even huffington post, which did it's own rewrite, contradicted themselves from one line to the next. News reporting of all types is increasingly becoming a kind of afterhours hobby, so the chances of getting a skilled journalist are dropping every minute. That means that the press release writers really need to spoon feed and anticipate the most likely misinterpretation and be REALLY obvious about it. Like a car ad. It also means there will be no opinions from outside sources to round out stories. just press release journalism.

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"When you break it down by the bacteria, though, you see that gloves and gowns do appear to work against MRSA. For the Gowns, ICUs saw a decrease from 10.03 acquisitions per 1,000 patient days in the baseline period to 6 acquisitions in the study period. That’s a 40% decrease. What about the Skins? They went from 6.98 acquisitions to 5.94 acquisitions per 1,000 patient-days. That’s a 14% decrease. And this time the differences were determined to be statistically significant." If I'm reading this correctly, the Gown group already started with a higher MRSA rate than the Skins. What were the Skins doing better at baseline to start with a lower MRSA rate?

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I was trained as a nurses aide about 40 years ago. Back then, we did not know about MRSA or VRE. I worked in many different departments in the hospital in this capacity. I have not researched this study, but both as a patient, an employee that worked not only as a nurses aide, but also as unit secretary, and pharmacy tech, I have strong feelings on this issue. I also have a B.S. in Health Education.
First of all, there are usually different floors in a major hospital. There is usually a pediatric unit, a unit for newborns (nursery), a medical floor, a surgical floor, intensive care, coronary care. Sometimes there is a neonatal unit (premies). And there can be special heart units, special burn units, and cancer floors.
There are studies that show that a physician's coat is contaminated at the end of the day. This is a reason for a physician to have multiple coats, and to wash or have them cleaned frequently ( after each day). As a former hospital employee, I never would have considered not taking off my uniform the minute that I got home from work, and I also showered immediately. Even then, we knew that we could be carrying things home on our clothing.
Some hospital floors require doctors and nursing staff to change out of their clothes from home, and to put on hospital scrubs. This is the case for units like the operating room, neonatal intensive care (NICU), and other units where a patient's immune system is vulnerable. And when you are in those scrubs, we used to have to put on a gown if we left our unit to go to the cafeteria, etc. In this case, I was working in a NICU, and it was extremely important to use care in not bringing anything contagious back into the nursery. There were certain rules - the time and method in which personnel in that unit scrubbed from elbow to fingers and for how long.
There are reasons to wear gowns over a uniform - whether you put a uniform on at home, or whether it is a hospital provided one. If you have disposable gowns and gloves outside the patient's room, it is either because they are in reverse isolation ( they are at risk from germs being brought in), or they are in isolation ( as is usually the case with a patient with an antibiotic resistant disease or another contagious disease).
I think this issue has many factors. First of all, hospitals that I have visited recently even have the elevator doors covered with signs related to hand washing. Alcohol based gels are in bathrooms around hospitals, in patient rooms, etc. Therefore, I think that there are many issues at play related to transmission of hospital borne infections. That includes the behavior of not only the nursing personnel, the physicians, but also the housekeeping staff.
When I was hospitalized a few years back, I was quick to observe the practices of the nurses and housekeeping, the use of gloves, hand washing, or the use of the antibacterial gels.
Just as you see a physician on TV scrub and put on masks, etc, prior to surgery, it is important to me to see the physicians in a hospital environment at least have on their lab coat even if it is over street clothes. Then, if there is an accident, which is easy to do when near fluids, wounds, etc, the physician can change their lab coats or put on new scrubs. I am not convinced that the hospitals in this case were only controlling for gowns and gloves. I think that there were probably other warning systems in place - other barriers in place related to the prevention of carrying infectious diseases to other patients. I am interested in this study, and it adds to questions I have related to hospital borne infections. Thanks for posting this.

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I believe that there is a lot of research going on at hospitals right now related to how to prevent these hospital borne infections.
This article discusses a prospective study in which it was determined that within 3 hours, the physician's coat had about 50 % of the level of contamination that it would have after 8 hours:
http://www.ncbi.nlm.nih.gov/pubmed/21312328
"CONCLUSIONS:
Bacterial contamination occurs within hours after donning newly laundered short-sleeved uniforms. After 8 hours of wear, no difference was observed in the degree of contamination of uniforms versus infrequently laundered white coats. Our data do not support discarding long-sleeved white coats for short-sleeved uniforms that are changed on a daily basis."
This is another study: http://www.ncbi.nlm.nih.gov/pubmed/20357558
"The potential for nosocomial infection transmission by white coats used by physicians in Nigeria: implications for improved patient-safety initiatives.
Uneke CJ, Ijeoma PA.
Source
Department of Medical Microbiology/Parasitology, Faculty of Clinical Medicine, Ebonyi State University Abakaliki, Nigeria. unekecj@yahoo.com
Abstract
Microbiological analysis of swabs taken from the cuffs and pocket mouths of physicians' white coats in an acute care hospital showed that 91.3% of the coats had bacterial contamination. Specifically diphtheroids, Staphylococcus aureus and Gram-negative bacilli were isolated. In contrast, comparatively lower rates of bacterial contamination were observed on the white coats (1) of visiting physicians, (2) of the medical unit compared with the rest of the hospital, (3) that were less 1 year old, and (4) that were laundered daily. Further, the white coats of physicians who wore them only when seeing patients had significantly lower bacterial contamination than white coats of physicians who wore theirs during clinical and nonclinical duties (chi(2) = 4.99, df = 1, p < .05). In particular, white-coat cuffs had a higher bacterial load than the mouths of the pockets. The bacterial isolates were resistant to nearly all of the antibiotics tested; the most effective, however, was ciproflox. Results suggest that physicians' white coats may increase nosocomial infection transmission. Proper handling of white coats by physicians and other healthcare workers could minimize cross-contamination and improve patient safety by potentially reducing nosocomial infections.
PMID: 20357558 [PubMed - indexed for MEDLINE]"
I believe that hospitals and physicians are being made aware of the problems related to hospital borne infections and the potential for them to be carried on these long sleeved physician's coats. I also believe that there are procedures in place that ask the patient questions - did you see the physician wash their hands before examining you, etc.
There are other stories and studies online related to this issue.
I do not believe that the conclusion should be that gloves and gowns are not necessary. I believe that the conclusion should be that gowns, physician's coats, scrubs, etc, are contaminated within hours of an employee working in a hospital or nursing home, urgent care, or office situation. It is, in my opinion, a "best practice" that an employee should go to work in a clean uniform each day if that is their required uniform. This second study implied to me that physicians should not be wearing their "coats" in public and in other situations where they will pick up potential contaminants outside, and bring them to into the hospital environment. I am sure there must be ongoing hospital and best management practice training for physicians and employees. There are tools that should be wiped frequently with disinfectants such as a stethoscope that would be used from one patient to the next. Hand washing should occur when an employee has entered a patient room - door handles are not clean. While the nurse or physician is in the room, if they come in contact with the patient or anything that is contaminated, they need to wash hands again before they continue to other activities. Nurses and nurse aides would understand these times when they would need to use these best practices. And finally, each nurse, nurses aide, or doctor should use the gels or wash their hands before leaving the patient's room.
For further information on best practices, I would contact hospitals to see what their current practices are for prevention of antibiotic resistant illnesses.

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