Workplace Safety 2004: Long Fingernail Ban Helps Hospitals Prevent Infections

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By Kristin Rothwell, associate editor

While long fingernails or nails enhanced with sculptured artificial nails, intricate jewelry or nail art have gained in popularity, they pose various risks when worn by health care professionals or those who work directly or indirectly with hospitalized patients, according to the Centers for Disease Control and Prevention (CDC).

The CDC recommended in its hand hygiene guidelines published in Oct. 2002, that “health care personnel should avoid wearing artificial nails and keep natural nails no longer than one quarter of an inch long if caring for patients at high-risk of acquiring infections.”

p>Many hospitals have implemented the recommendations into their patient care policies.

Children’s Hospital in Columbus, Ohio, made a system-wide decision to be in complete compliance to prohibit its staff from wearing long or artificial nails in May 2001—prior to the CDC recommendations being made.

Jodi Vinsell, RN, BSN, CIC, an infection control nurse at Children’s Hospital, explained that staff working in operating rooms, bone marrow transplant and NICU, were never permitted to wear long and/or artificial nails due to the large immunosuppressed patient population they serve, but the organization believed the same rules should apply to the entire system.

“We decided we wanted to do the best thing for our patients,” Vinsell said.

Children’s Hospital banned artificial nails, which were defined as substances or devices applied to natural nails to augment, enhance or extend the nails, which include but are not limited to bonding, tips, wraps, tapes and inlays.

The hospital also defined that natural nails should be kept less than a quarter inch past the finger and recommended that natural nails be left unpolished. However, staff members choosing to paint their nails were recommended to use clear polish and if polish was worn, it could not be chipped, cracked or peeling.

The staff at Children’s Hospital including all direct caregivers and those who prepare products for patients such as pharmacy and food service, were educated about the new fingernail policies at meetings and through the infection control liaison group.

The infection control liaison group, led by the infection control department and made up of members from various departments in the hospital, met to discuss infection control issues and to get answers to questions brought up by departmental personnel.

“We didn’t just go and say, ‘Do this,’ ” Vinsell said. “By the time it happened, all the questions had been answered, the staff knew that administration was behind it…[and] some people that never take care of patients or didn’t fall into the groups [not allowed to wear artificial or long nails] went ahead and had their artificial nails taken off.”

She added, “Without that type of support, this organization would have had great difficulty.”

Research regarding hand hygiene and fingernails has not been taken lightly by hospitals.

In 1998, two nurses at St. Luke’s Episcopal Hospital in Houston, Texas, studied the cultured nails of 89 operating room staff members before and after a five-minute surgical scrub. They found that colonization by Gram-negative rods or bacteria was more common among staff with artificial nails than those with natural nails, both before (44 percent to 16 percent) and after (37 percent and 6 percent) the surgical scrub. The researchers concluded that artificial nails contain more bacteria than natural nails, putting patients at greater risk for infection.

In 2000, a research article published in the American Journal of Nursing reported that when 92 health care workers were assessed for fingernail length and presence of artificial nails, those with short- or medium-length nails had a low risk of Pseudomonas aeruginosa colonization (one in 80), a Gram-negative bacterium, while those with long natural or artificial nails had a significantly higher risk (two in 12).

Pseudomonas aeruginosa, is noted for its environmental versatility, which can cause disease in particular susceptible individuals, can be resistant to antibiotics and can produce a number of toxic proteins. The toxic proteins can cause extensive tissue damage and interfere with the human immune system's defense mechanisms, according to the report.

The CDC estimates that each year nearly 2 million patients in the United States get an infection in hospitals and that about 90,000 of these patients die as a result of their infection. But one-third to one-half of hospital-acquired infections could be prevented by simply ensuring that hospital workers properly disinfect their hands, the CDC asserted on its Web site.

In addition to the CDC’s findings and guidelines, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently went a step further to include the CDC guidelines in its 2004 National Patient Safety Goals, which became effective Jan. 1.

Organizations seeking JCAHO accreditation are now required to implement the safety goals as they pertain to the facility or face failure to demonstrate full compliance, which can result in a facility’s change in status to provisional accreditation.

Barbara Russell, RN, MPH, CIC, director of infection control services at Baptist Hospital of Miami in Florida, said that JCAHO’s inclusion of the CDC hand hygiene guidelines in the patient safety goals helped indirectly make the CDC guidelines an industry standard.

“In infection control this is good because many times the things we’re trying to put in place [are] difficult because maybe no one else is doing it or because there really isn’t any strong science until organizations like JCAHO, as an authority, come along and support it.”

Russell said that while her facility discussed discouraging the wearing of long or artificial nails by hospital staff over the past 10 years, it wasn’t until the CDC hand hygiene guidelines were published that Baptist Hospital implemented system-wide rules prohibiting employees from wearing them.

While not all organisms can be transmitted from hands, Russell said that Staphylococcus aureus is the most common bacteria because the population will have it on them 40 to 60 percent of the time. Though the staph carrier may not be sick or become sick, it can cause an infection at some time or leave their body and be transmitted to another person, place or thing.

Russell said, “There’s no question that the attention to hands, which means no nails, clean nails or short nails and handwashing are important in keeping [infections] from spreading around.”

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