TY - JOUR
AU - FCCM, Elizabeth A. Mann-Salinas, PhD, RN,
AB - Abstract The purpose of this study was to identify the presence or absence of pathogenic bacteria on burn intensive care unit employees' common access cards (CACs) and identity badges (IDs) and to identify possible variables that may increase risk for the presence of those bacteria. A prospective, cross-sectional study was conducted in our regional Burn Center in which bacterial swab specimens were collected from both the CAC and ID of 10 burn intensive care unit employees in each of five cohorts (nurses, respiratory therapists, physical therapists, physicians, and ancillary staff). Ten additional paired samples, collected from direct care staff in the outpatient burn clinic, served as control. Additional information described how the cards were worn and if/how they had been cleaned in the previous week. Fifty-eight CACs and 60 IDs were swabbed from participants. The overall contamination rate was 75%, with no trends identified based on how cards were worn. Bacteria were recovered from 86% (50/58) of CACs and 65% (39/60) of IDs, with CACs being significantly more contaminated overall than IDs (P < .01). In terms of potentially pathogenic bacteria, the overall rate was 3%, with 100% of those isolates coming from the outpatient clinic staff cohort (P < .001). When cleaned in the last week (n = 16), the contamination rate dropped to 50% overall (P = .003), indicating that even periodic cleaning appears to have a positive effect on bacterial contamination rates. The simple practice of routine identity card decontamination may reduce potential threats to patient safety as a result of nosocomial bacterial transmission. Regardless how well a surface is cleaned or how thoroughly clinicians wash their hands, touched objects will harbor bacteria. Although some bacteria are harmless or even beneficial, others have a great potential for causing disease. Pseudomonas aeruginosa, Acinetobacter spp., and Klebsiella spp. are three examples of pathogenic bacteria commonly associated with clinical infections known to cause septic shock in burn intensive care patients. These bacteria are also capable of remaining viable on dry surfaces for several months.1 A 12-year review of patients who died at University of Washington Regional Burn Center found that 28% of the 237 deceased patients died from sepsis or multiorgan failure. Of the deceased with late-onset decline, 71% were attributable to sepsis or multiorgan failure; these finding indicate that infection is a major contributor to death in the burn population.2 Burn intensive care unit (BICU) patients are at such increased risk for infection that our unit has specific infection control requirements unique to this facility.3 Hand hygiene is given top priority followed by additional barrier protection methods. Each patient room has an anteroom that contains supplies, a bedside computer, and a sink. All BICU patients are immediately placed on contact precautions; before entering the main patient room, visitors and staff must clean their hands and don gloves and a clean moisture-resistant gown. In addition, to reduce incidence of microorganism transmission from home, the hospital contracts with a private company to provide all Burn Center clinicians with clean scrubs. These additional measures are taken because the burden of an infection far exceeds the additional supply cost,4 and conforms to the guiding ethical principle of primum non nocere (first do no harm). On hire, all new Burn Center employees are issued two identity cards: an identification badge (ID) and a common access card (CAC). Both are small credit card size plastic cards, which display an employee's photo, name, and employment status. The ID is designed to be displayed on an employee's upper body and is used to access controlled areas of the hospital by means of wall-mounted proximity readers. The CAC is used to access secure electronic data via computer terminals within the facility. This card can be carried in various types of display holders (Figure 1); it may serve as a secondary form of identification, or simply placed in the owner's wallet or pocket until needed. Figure 1. View largeDownload slide Image of two common access card (CAC) holders that can be attached to a clip or lanyard. Identification badges and other items are typically carried behind these clips, secured by the clear plastic strap and metal snap. Figure 1. View largeDownload slide Image of two common access card (CAC) holders that can be attached to a clip or lanyard. Identification badges and other items are typically carried behind these clips, secured by the clear plastic strap and metal snap. In 2012, new institutional cyber-security safeguards were implemented requiring all computer terminals be accessible only by CAC authentication. As a result, clinicians now must insert their cards into the computer's card reader every time they review a record or enter information into the patient record, including hourly vital signs or medication administration. Because multiple clinicians use the bedside computers, staff must remove their CACs to allow access to other users, and whenever they step away from the computer. This results in bedside nurses and other staff inserting and removing their CACs dozens of times each day, sometimes urgently. Despite their constant use within close proximity to the patient, there is currently no policy in effect for cleaning or disinfecting IDs and CACs. According to infection control audit reports, hand washing compliance averaged 92% in the BICU from April 2012 to April 2013 (Chafin, unpublished data, 2013). This means up to 8% of staff may be contaminating their patients, their identity cards, or both during routine clinical activities. The purpose of this study was 2-fold: to identify the presence or absence of pathogenic bacteria on BICU employees' CACs and IDs and to identify possible variables that may affect risk for the presence of those bacteria. METHODS This prospective, cross-sectional study was conducted under an institutionally approved laboratory protocol. Our regional, American Burn Association verified center treats adult patients with thermal, electrical, and chemical injuries or exfoliating dermatologic diseases. The 16-bed BICU is staffed with a multidisciplinary team that includes registered and licensed vocational nurses, physical and occupational therapists, nutritionists, intensivists, surgeons, case managers, and ancillary staff. As a whole, the Burn Center employs approximately 300 medical professionals. During a 6-week period in 2013, without advance notice to employees, the principal investigator (PI) individually approached 10 clinicians/staff from each of 5 BICU cohorts listed in Table 1. All study information was recorded to mask the identity of the participants. Bacterial swab specimens were collected from both the CAC and ID of each clinician. For purposes of control compared with the BICU environment, 10 additional paired samples were collected from direct care staff working in the outpatient burn center. Specimen collection was performed by the PI using convenience sampling of available individuals within each cohort at various times during day and evening shifts. Table 1. Breakdown of bacterial samples collected and the cohorts from which they came View Large Table 1. Breakdown of bacterial samples collected and the cohorts from which they came View Large Sampling Technique Using clean exam gloves, the PI removed a sterile culture swab (BBL™ CultureSwab™, Beckton, Dickinson, and Company, Sparks, MD) from its packaging and inserted the swab into the sponge media at the bottom of the transport tube. This facilitated wetting of the swab for improved microorganism adherence. While holding the card by the top and bottom edges, the swab was removed from the tube and wiped across the entire front of each employee's identification badge, using a scrubbing motion. Lastly, the side edges of the badge were swabbed before returning the swab to the transport tube. Using the same technique, a second swab specimen was obtained from the same employee's CAC. However, because the card is touched on all sides when inserted into a computer card reader, in this instance both front and back of the CAC were swabbed. If the CAC was displayed in an open-face holder (Figure 1), the inside corners of this holder were wiped with the same swab as the CAC. Tubes were labeled with a unique study identification number that connected the sample with the badge type and cohort. A data collection sheet was completed for each pair of identity cards. The goal was to identify possible variables that could potentially increase the risk for pathogenic bacteria. In addition to clinical role of the card owner, questions on the data sheet included the following: How are ID cards worn? (clip on clothing, lanyard, stored in a pocket, etc.) Were cards cleaned in the last week? If yes, how were they cleaned? Is CAC carried in black, open-face holder? Are additional items carried with the identification cards? What type and how many? Within 24 hours after collection, the swabs were transported to the onsite microbiology research laboratory. Specimens were cultured on Trypticase™ Soy Agar with 5% sheep blood (Beckton, Dickinson, and Company), MacConkey II agar, and fluid thioglycollate medium using conventional microbiological techniques. All cultures were incubated at 35 to 37°C for up to 48 hours. All organisms seen were identified using standard microbiological methods. Analysis The relative pathogenicity of recovered organisms was considered based on the potential for causing disease in the burn patient. The expected bacterial sources for this population would have included P. aeruginosa, Acinetobacter spp., Klebsiella pneumoniae, and Staphylococcus aureus. The study was powered using a minimum threshold of 10% contamination; a minimum sample of 68 identification cards would ensure with 95% confidence detection of pathogenic bacteria. With a focus on specific pathogens, which may have been less common, the sample size was increased to 120 (60 pairs). Descriptive statistics were used for basic demographics, collected data, and organisms cultured from the identification cards. Chi-squared and Fisher's exact tests were performed to compare groups. Significance was accepted at a P < .05 level. RESULTS Fifty-eight CACs and 60 IDs were swabbed (N = 60 participants) during the study period; 2 BICU ancillary staff members were not carrying a CAC at the time of collection. The overall contamination rate was 75% (89/118). Table 2 describes the isolated bacteria for each cohort. Bacteria were recovered from 86% (50/58) of CACs and 65% (39/60) of IDs, with CACs being significantly more contaminated overall than IDs (P < 0.01). The overall rate of pathogenic bacteria was 3%, with 100% from the outpatient clinic cohort of 10 pairs; of the four isolates detected, three originated from IDs and one from a CAC. Table 2. Recovered isolates and overall contamination rates by cohort View Large Table 2. Recovered isolates and overall contamination rates by cohort View Large The vast majority of identity cards (90/118; 76%) were worn on a clothing-clip device with a retractable cord. Approximately half of staff (26/58; 45%) used black, open-faced CAC holders as opposed to clear, slide holders, pockets, wallets, or other storage devices. Contamination rates varied from 60% to 88% depending on how a badge was carried (Figure 2). Staff also tended to carry additional items with their cards (99/112; 88%), with 78% (83/112) routinely carrying three to six additional items. Typically, these included the emergency, safety, and policy reference cards provided by the institution. However, ATM cards, keys, markers, other identification documents, immunization records, and decorative items were also attached to the CAC and/or ID. Bacterial detection rates varied from 60% to 100% when badges were evaluated according to number of additional items (Figure 3). Figure 2. View largeDownload slide Number of identity cards according to how displayed or carried at time of bacterial swab collection. Each category is further broken down by bacterial culture result. Figure 2. View largeDownload slide Number of identity cards according to how displayed or carried at time of bacterial swab collection. Each category is further broken down by bacterial culture result. Figure 3. View largeDownload slide Number of identity cards graphed by number of additional items attached to it at time of bacterial swab collection. Each category is further broken down by bacterial culture result. Eight badges had unknown/unrecorded numbers of additional items because of being carried in wallets or similar means. Figure 3. View largeDownload slide Number of identity cards graphed by number of additional items attached to it at time of bacterial swab collection. Each category is further broken down by bacterial culture result. Eight badges had unknown/unrecorded numbers of additional items because of being carried in wallets or similar means. Most identity cards (86%; 102/118) had not been cleaned in the last week. Employees who did clean routinely reported using CaviWipes™ (Metrex® Research, Romulus, MI; 38%; 6/16), Clorox® Disinfecting Wipes (The Clorox Company, Oakland, CA; 25%; 4/16), water (13%; 2/16), alcohol-based wipes (13%; 2/16), alcohol-based hand gel (6%; 1/16), or Wex-Cide 128 (Wexford Labs, Kirkwood, MO) (6%; 1/16). As shown in Figure 4, the contamination rate dropped to 50% overall when cards were cleaned in the previous week (P = .003). However, when cleaned cards were broken down according to type, only 22% (2/9) of IDs grew bacteria as opposed to 86% (6/7) of CACs. At this time, the rate at which CACs and IDs become reinoculated after cleaning is unknown. Figure 4. View largeDownload slide Graphics illustrate differences in contamination rates according to whether or not the badge has been cleaned in the last week. Figure 4. View largeDownload slide Graphics illustrate differences in contamination rates according to whether or not the badge has been cleaned in the last week. DISCUSSION In this study, the commonly identified bacteria on IDs were nonpathogenic skin and respiratory flora. No significant trends in contamination rates were detected based on how badges were carried or the number of additional items with which they were carried. As a whole, BICU contamination rates did not differ from the outpatient cohort (P = .10). However, the BICU had a significantly lower rate of pathogenic bacteria than the outpatient clinic (P < .001). There were two additional significant findings in this study. First, CACs were more often contaminated with bacteria than IDs. This finding is not unexpected given that CACs are touched constantly on both sides of the card during routine computer use throughout the shift. In contrast, IDs are displayed for security purposes and need only be presented in the vicinity of an electronic security reader when entering access-controlled areas of the hospital. Second, there was a significant drop in contamination rates if a badge had been cleaned in the previous week. Although it is unlikely that patients would die from the majority of bacteria cultured in this study, the overall rates were high. Even innocuous bacteria have been known to cause infection and extend hospital stays for severely immunocompromised patients. This concern is based on relative proximity to the patient; clinicians usually touch CACs while inside patient anterooms, after they have already sanitized their hands once. Although the policy is for staff to sanitize a second time before entering the main room, it makes sense that this step may be forgotten if the clinician does not feel they have touched anything “dirty.” Outpatient burn clinic patients could be at equal risk; although they are generally much healthier, most continue to have open skin areas to be examined and treated. Because there is no anteroom in the outpatient clinic, computers are at the bedside, allowing clinicians to interact with the patient while documenting in the electronic health record. Furthermore, hand hygiene is not routinely tracked in the outpatient setting. Many investigators have evaluated various hospital fomites. Published studies include examinations of vectors of disease as the following: patient files,5 scrubs,6 lanyards,7 pens,8 and stethoscopes.9 Three studies specifically evaluated badges and security swipe cards where pathogenic bacteria rates varied from 13% to 25%.7,10,11 Our study found much lower rates overall (3%), but found rates within published ranges when specifically examining the outpatient clinic (20%) compared with the BICU (0%; P < 0.001). The reasons for this difference are not clear, but it may be a combination of the BICU staff adherence to rigorous hand hygiene practices and the infection control policies listed previously. A 2009 investigation by Sultan et al11 examined security swipe cards similar to the IDs used in our study. Participants were asked to complete a questionnaire about card decontamination; 82% of those surveyed reported never cleaning their swipe cards. This theme was echoed in our facility and would indicate that although hand hygiene practices are now strictly enforced, cleanliness of the items clinicians routinely touch has not been made a priority. Tellingly, of the four badges that returned pathogenic isolates in our study, none were reported as having been cleaned. Limitations The major limitation of this study is that there is no direct connection between the study data and relevant impact on the patient. Although many implications can be presumed regarding transfer of these bacteria to immunocompromised patients, the design was simply to determine what was growing on IDs and CACs, not how or if transfer was actually occurring. Second, this study was conducted over a 6-week period. During that time, it is possible that employees could have heard about the study and prophylactically cleaned their badges. However, in such a case, one would expect higher rates of cleaning. Employees were also asked directly whether or not badges had been cleaned. A few employees were reluctant to admit not cleaning them, and at least one person changed their answer after confirming that study data could not be connected with a particular individual. As a result, actual cleaning rates may have been lower than reported. Another limitation is this study was conducted in a single burn center with a particular workflow and use of CACs for computer access. Comparing these results with other units within the institution may reveal different findings in contamination rates and card cleaning compliance. Clinical Implications Although this study was designed around CACs, the scientific question is one that has implications for many medical institutions around the world. As electronic records continue to become increasingly sophisticated and accessible to diverse care teams, institutions are forced to remain vigilant in their protection of patient medical information and maintenance of patient physical security. Hospitals and other medical facilities are legally obligated to find ways of insuring only appropriate individuals are viewing patient records. Often this is done using electronic proximity readers or computer swipe cards, making this risk of bacterial contamination a commonplace problem should widespread adoption of this method of security occur. CONCLUSION CACs and employee IDs in our Burn Center were found to harbor bacteria. Although most cards carried normal flora, potentially pathogenic bacteria rates varied by department. Simple awareness of badge bacteria may be the first step in protecting patients, as it may improve compliance to the infection control policies already in place. In addition, routine weekly cleaning is associated with a reduction in contamination and is a simple practice that may reduce potential threats to patient safety. ACKNOWLEDGMENTS We thank the Burn Center clinical staff and our Infection Control Specialist Ms. Kristine Chafin. REFERENCES 1. A Kramer, I Schwebke, G Kampf How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infect Dis  2006; 6: 130. Google Scholar CrossRef Search ADS PubMed  2. JW Swanson, AM Otto, NS Gibran Trajectories to death in patients with burn injury. J Trauma Acute Care Surg  2013; 74: 282– 8. Google Scholar CrossRef Search ADS PubMed  3. EF Keen, BJ Robinson, DR Hospenthal Incidence and bacteriology of burn infections at a military burn center. Burns  2010; 36: 461– 8. Google Scholar CrossRef Search ADS PubMed  4. N Graves Economics of preventing hospital infection. Emerg Infect Dis  2004; 10: 561– 6. Google Scholar CrossRef Search ADS PubMed  5. BR Panhotra, AK Saxena, AS Al-Mulhim Contamination of patients' files in intensive care units: an indication of strict handwashing after entering case notes. Am J Infect Control  2005; 33: 398– 401. Google Scholar CrossRef Search ADS PubMed  6. CA Krueger, CK Murray, K Mende, CH Guymon, TL Gerlinger The bacterial contamination of surgical scrubs. Am J Orthop (Belle Mead NJ  2012; 41: E69– 73. Google Scholar PubMed  7. D Kotsanas, C Scott, EE Gillespie, TM Korman, RL Stuart What's hanging around your neck? Pathogenic bacteria on identity badges and lanyards. Med J Aust  2008; 188: 5– 8. Google Scholar PubMed  8. DF Wolfe, S Sinnett, JL Vossler, J Przepiora, BG Engbretson Bacterial colonization of respiratory therapists' pens in the intensive care unit. Respir Care  2009; 54: 500– 3. Google Scholar PubMed  9. JS Jones, D Hoerle, R Riekse Stethoscopes: a potential vector of infection? Ann Emerg Med  1995; 26: 296– 9. Google Scholar CrossRef Search ADS PubMed  10. K Ota, R Profiti, F Smaill, AG Matlow, M Smieja Identification badges: a potential fomite? Can J Infect Control  2007; 22: 162– 165. Google Scholar PubMed  11. MJ Sultan, A Alm, A Hindmarsh, RA Greatorex Security swipe cards and scanners are a potential reservoir for hospital-acquired infection. Ann R Coll Surg Engl  2009; 91: 155– 8. Google Scholar CrossRef Search ADS PubMed  Copyright © 2015 by the American Burn Association
TI - Bacterial Contamination of Burn Unit Employee Identity Cards
JF - Journal of Burn Care & Research
DO - 10.1097/BCR.0000000000000254
DA - 2016-09-01
UR - https://www.deepdyve.com/lp/oxford-university-press/bacterial-contamination-of-burn-unit-employee-identity-cards-mKP0r10gMG
SP - e470
EP - e475
VL - 37
IS - 5
DP - DeepDyve
ER -