Quantitative Characterization of High-Touch Surfaces in Emergency Departments and Hemodialysis Facilities

Abstract

An observational study was conducted to characterize high-touch surfaces in emergency departments and hemodialysis facilities. Certain surfaces were touched with much greater frequency than others. A small number of surfaces accounted for the majority of touch episodes. Prioritizing disinfection of these surfaces may reduce pathogen transmission within healthcare environments.

Introduction:

The healthcare environment can serve as a reservoir for many microorganisms and, in the absence of appropriate cleaning and disinfection, contribute to pathogen transmission.[1] Prior studies have identified high-touch surfaces (HTS) in hospital patient rooms and operating rooms, such as patient beds, medication and supply carts, and shared portable equipment, that represent the greatest transmission risk in an effort to prioritize cleaning and disinfection activities in these settings.[2–5] The Centers for Disease Control and Prevention’s (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities recommend cleaning and disinfecting HTS more frequently than minimal touch surfaces.[6] However, these guidelines and toolkits include only HTS found in typical hospital rooms.[7] HTS in other healthcare settings, including high-volume and high-acuity settings such as emergency departments (EDs) and hemodialysis facilities (HDFs), have not been well-studied or defined.

Methods:

An observational study was conducted in two EDs and three HDFs within the same multicampus institution in New York City during routine operations. ED observations were performed at an 862-bed academic medical center and a 180-bed community hospital. HDFs included one inpatient and two outpatient hemodialysis units. The study was deemed not to be human subjects research by the Institutional Review Board of Weill Cornell Medicine.

Data were collected using a structured observation tool. A list of surfaces was identified by preliminary observations in study EDs and HDFs and used to create a data collection tool. Surfaces were classified as being allocated to individual patients (i.e., stretchers) or shared across multiple patients (i.e., portable vital sign machines) during the observation period. Hand touch episodes were defined as hand-to-surface contact regardless of hand hygiene and/or glove use. Non-hand contact episodes were defined as any other body-to-surface contact, such as leaning, sitting, or stepping on surfaces. Non-hand contact episodes were only recorded for designated surfaces (i.e., stretcher rails) that were noted to be subject to frequent non-hand contact during prelimary observations. Recorded hand touch and non-hand contact episodes included those made by healthcare personnel (HCP), patients, and visitors.

Observations were conducted during times of high-volume activity. ED observations were performed in one-hour blocks and HDF observations were performed in two-hour blocks. Single treatment areas were observed (i.e., one ED room or curtained cubicle or one HDF treatment station). HCP working in areas under observation were informed of the study purpose prior to each observation period. A total of 28 hours of observation (14 hours each in EDs and HDFs) was conducted between October and November 2019. To ensure inter-rater reliability, initial observations were conducted simultaneously and independently by two researchers. One observer performed all subsequent observations. After completion of observations, the number of hand touch episodes and non-hand contact episodes were tallied. The number of hand touch and non-hand contact episodes per hour were calculated for each surface.

Results:

Overall, 1,805 hand touch episodes were observed on 58 surfaces and 320 non-hand contact episodes were observed on 6 surfaces. On average, more hand touch episodes were observed per hour in HDFs than in EDs (86 versus 43 episodes, respectively), while more non-hand contact episodes were observed per hour in EDs compared to HDFs (16 versus 7 episodes per hour, respectively).

Emergency Departments

A total of 815 contact episodes occurred in EDs. Among these, 597 (73%) were hand touches and 218 (27%) were non-hand contact episodes. Of the 25 distinct surfaces touched, six (24%) were shared among multiple patients. Among hand touch episodes, 581 (97%) involved individual patient surfaces and 16 (3%) involved shared surfaces. The most frequently hand-touched surfaces included stretcher rails, privacy curtains, visitor chair armrests and backs, and patient bedside tables, which together accounted for 80% of hand touch episodes (Figure 1). Non-hand contact episodes were recorded for stretcher rails, visitor chair seats, and stretcher cushions (4.14, 3.45, and 2.30 touches per hour, respectively).

Figure 1.

Frequency of hand touch episodes among surfaces and equipment in emergency departments.

Hemodialysis Facilities

A total of 1,310 contact episodes occurred in HDFs. Of those, 1,208 (92%) were hand touches and 102 (8%) were non-hand contact episodes. Shared surfaces accounted for 11 (30%) of the 37 observed surfaces. Individual patient surfaces and shared surfaces were involved in 855 (71%) and 353 (29%) hand touch episodes, respectively. The most frequently hand-touched surfaces were supply cart drawers, dialysis machine control panels and keyboards, handwashing faucet handles, bedside worktables, and bed rail or dialysis chair armrests, which comprised 71% of all hand touch episodes (Figure 2). Non-hand contact episodes were recorded for bed rails or dialysis chair armrests, dialysis bed or chair cushions, and visitor chair seats (4.43, 2.50, and 1.25 touches per hour, respectively).

Figure 2.

Frequency of hand touch episodes among surfaces and equipment in hemodialysis facilities.

Discussion:

To our knowledge, this is the first quantitative study to identify HTS in EDs and HDFs. Previous studies have focused primarily on HTS in hospital inpatient rooms.[2, 5, 8] While some of the HTS identified in our study overlap those seen in these studies, the distinct work flows, type of care provided, and environmental services resources in EDs and HDFs may present unique opportunities and challenges for infection prevention.

Our observations reveal that certain surfaces within EDs and HDFs are subject to a substantially greater frequency of hand contact than others and that a relatively small number of surfaces account for a majority of hand touch episodes. Notably, while the majority of hand touch episodes in EDs occurred with individual-patient surfaces, hand touch episodes in HDFs more frequently involved surfaces that were shared during provision of care to multiple patients. These shared surfaces may represent an even greater risk of patient-to-patient pathogen transmission than individual-patient surfaces.[3] In addition, some surfaces were also subject to frequent non-hand contact. HCP apparel has been previously implicated in the transmission of pathogens and these findings support the potential for transmission to or contamination by the non-hand body surfaces of HCP, patients, or visitors.[9]

This study has important implications for the development of effective environmental cleaning interventions. Studies show that admission to hospital rooms previously occupied by a patient infected or colonized with a pathogen is a risk factor for subsequent acquisition and suggest that current cleaning practices are not adequate.[10] Identification of HTS which may represent high-risk of pathogen transmission could inform effective and efficient cleaning strategies tailored to EDs and HDFs.

Our study has several limitations. First, our study is subject to the Hawthorne effect due to its observational nature. Although HCP in participating EDs and HDFs were informed of study goals prior to the observation period and ensured of the absence of protocol adherence monitoring, HCP may still have altered their behavior in response to being observed. Second, sampling of surfaces was not performed as part of this study and we were unable to correlate frequency of touch with microbial bioburden. Future research involving an assessment of the microbial bioburden of the HTS identified in this study could provide further insight into pathogen transmission risks in these environments. Lastly, all observations were made in facilities within the same healthcare system, thereby potentially limiting generalizability of findings to other EDs and HDFs.

Appropriate environmental infection control strategies may reduce the risk of pathogen transmission and HAIs. The identification of HTS in EDs and HDFs contributes to a better understanding of the risk of environment-related pathogen transmission and may allow prioritization and optimization of cleaning and disinfection resources and protocols within these healthcare settings.