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MDROs Can be Guided by a Modeling of Hand Hygiene

Should you have to choose between hand hygiene (HH) compliance and environmental cleaning (EC) interventions in your efforts to eliminate multidrug-resistant organisms (MDROs)? A study published in Infection Control and Hospital Epidemiology (ICHE)1 attempted to discern if HH compliance outweighed EC in disrupting the MDRO chain of transmission. The researchers performed 100 replications each for 175 parameter-based scenarios involving the transmission of MDR A. baumannii, Methicillin-Resistant Staph aureus (MRSA,) and Vancomycin-Resistant Enterococcus (VRE) for one year in a 20-bed intensive care unit (ICU) then compared the effects of the two experimental factors, HH and terminal cleaning (TC) on acquisition rates.

The authors stated that “when healthcare facilities are investing limited resources in infection prevention strategies, it would be useful to know which strategy is likely to have the greater impact on preventing transmission.” The researchers found that for all three organisms, increases in HH compliance outperformed equal increases in thoroughness of terminal cleaning from baseline. A 20% improvement in TC was needed to match the reduction of MDRO acquisition when there was a 10% increase in HH compliance. The results also showed that MDRO acquisition rates would increase much more if HH compliance fell 10% or 20% than it would if cleaning thoroughness fell from its baseline level.  Another analysis of the trending results proposes that for organisms with low environmental impact (i.e., those in which the risk of getting an MDRO from the prior room occupant is lower), some effort to improve HH compliance should accompany tactics to improve terminal cleaning.  In the end, it was not clear if these findings give more importance to investing in HH compliance over improving EC. The authors suggest that for institutions with low levels of compliance for both HH and EC, the question may be which strategy is easiest to employ.

For discussion, let us look at some of the study limitations:

  • Parameters used were taken from the literature when available but unpublished data from a single center was also used
  • Admission prevalence of MDROs and compliance rates for HH and TC thoroughness are likely to vary from institution to institution
  • Model focused only on TC after patient discharge and not daily cleaning when the room was occupied
  • Staff parameters limited to physicians and nurses
  • Median length of stay was 2 days
  • C. difficile and Norovirus not included in the study

While this was an interesting study and presented a business case for utilizing resources, there are other considerations to take into account, such as patient contact with other personnel in addition to physicians and nurses who enter the room, whether the patient had a procedures (surgical, cardiac catheterization, interventional radiology, colonoscopy, etc.), or devices such as central lines, ventilators, Foleys, or IVs that the patient may have.

Drs. Weber and Rutala note in a special topic issue in ICHE that “substantial scientific evidence has accumulated indicating that contamination of environmental surfaces in hospital rooms plays an important role in the transmission of several key healthcare-associated pathogens, including methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, Clostridium difficile, Acinetobacter, and Norovirus.”2 It is probably agreeable that transient carriage of organisms on the hands of healthcare providers  (HCP) is a common cause of transfer of these organisms from HCP to patient. However, contaminated hospital surfaces and equipment can also be indicated in this chain of transmission, so the importance of EC should not be underestimated.

When Rhode Island Hospital (Providence), a tertiary care hospital undertook a multidisciplinary approach to reduce C. difficile infections, the hospital plan entailed six interventions, including enhanced environmental cleaning of patient rooms and equipment, as published in a Joint Commission newsletter3.

Healthcare institutions should not have to choose between allocating resources for increasing hand hygiene compliance or improving environmental cleaning. We are in a partnership to provide the best care for patients which must include a balance among parameters known to impact a patient’s acquisition of a healthcare-associated pathogen which can lead to a devastating infection.

Have you had to choose between increasing hand hygiene compliance or improving environmental cleaning? How do you prioritize?


  1. Sean L. Barnes, Daniel J. Morgan, Anthony D. Harris, Phillip C. Carling and Kerri A. Thom (2014). Preventing the Transmission of Multidrug-Resistant Organisms: Modeling the Relative Importance of Hand Hygiene and Environmental Cleaning Interventions. Infection Control & Hospital Epidemiology, 35(9), pp 1156-1162.

  1. Understanding and Preventing Transmission of Healthcare-Associated Pathogens Due to the Contaminated Hospital Environment?Author(s): David J. Weber, MD, MPH; William A. Rutala, PhD, MPH?Source: Infection Control and Hospital Epidemiology, Vol. 34(5), Special Topic Issue: The Role of the Environment in Infection Prevention (May 2013), pp. 449-452.

  1. The Joint Commission Journal on Quality and Patient Safety, Volume 39, Number 7, July 2013, pp. 298. Retrieved from the Internet August 13, 2013.;jsessionid=6i9itk6m9fib5.alexandra


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