Advertisement

Assessment of the invisible blood contamination on nurses’ gloved hands during vascular access procedures in a hemodialysis unit

Open AccessPublished:December 25, 2021DOI:https://doi.org/10.1016/j.ajic.2021.12.009

      Highlights

      • The occult blood detection method provides a useful way of assessing blood contamination.
      • The nurses’ hands can be contaminated during vascular access procedures.
      • The results highlighted the important of hand hygiene and glove use during vascular access procedures.
      A prospective study was conducted to assess potential invisible blood contamination on nurses' gloved hands during vascular access procedures using the occult blood detection method in a hemodialysis unit. 60.13% (273/454) of samples tested positive for hemoglobin. These results highlighted the importance of hand hygiene and glove change during hemodialysis access care.

      Key Words

      Hemodialysis settings are considered high-risk environments for contamination by blood-borne pathogens, including hepatitis C virus (HCV).
      • Nguyen DB
      • Bixler D
      • Patel PR.
      Transmission of hepatitis C virus in the dialysis setting and strategies for its prevention.
      Many outbreaks of HCV among hemodialysis patients have been reported all over the world, with an estimated 20,000 new cases annually.
      • Jadoul M
      • Bieber BA
      • Martin P
      • et al.
      Prevalence, incidence, and risk factors for hepatitis C virus infection in hemodialysis patients.
      The low adherence to infection control practices by healthcare workers remains a major cause of the nosocomial transmission of HCV within hemodialysis settings.
      • Fabrizi F
      • Cerutti R
      • Messa P.
      Updated evidence on the epidemiology of hepatitis C virus in hemodialysis.
      Nursing staff plays a key role in providing vascular access care and are responsible for maintaining dialysis equipment, and reducing access-related complications. The importance of hand hygiene and glove use during vascular access procedures is well known, however, there is a lack of real-world evidence to support the necessity of implementing these standard precautions. The aim of this study was to use the occult blood detection method to assess blood contamination on the gloved hands of nurses performing hemodialysis access care.

      METHODS

      This prospective survey was conducted in an 80-bed hemodialysis unit from September 2020 to January 2021. There are 390 registered patients and 38 nurse practitioners who work double shifts from 7:30 to 11:50 am, and 12:20 to 5:00 pm. At the end of the vascular access connection and disconnection process, the nurses’ gloved hands were sampled using a convenience sampling method. Trained investigators worn gloves during the sampling process and changed the gloves after each sampling to avoid cross-contamination. This research project was approved by the ethical review board of the Affiliated Hospital of Inner Mongolia Medical University (No. KY2020027).
      To identity invisible blood contamination on the nurses’ gloved hands, we used filter paper or cotton swabs in occult blood detection kits (BWETM, Shanghai, China). Its detection principle is based on the characteristic that the iron porphyrin in hemoglobin has catalase-like activity. It uses the catalase substrate in hydrogen peroxide, and in the presence of hemoglobin, a discoloration reaction occurs. As the concentration of hemoglobin increases, the bluish-purple will be darker (Fig 1). The test reaches the highest level of discoloration within 5 minute, and maintains for 24 hour without fading. The method can identify hemoglobin in concentrations as low as 5 µg Hb/g. At the beginning of daily sampling survey, investigators conducted positive control and blank control tests to evaluate the quality of reagents.
      Fig 1
      Fig 1The color standard for hemoglobin-positive concentration (A) hemoglobin-positive concentration ≥ 5μg; (B) hemoglobin-positive concentration ≥ 10 μg; (C) hemoglobin-positive concentration ≥ 50 μg; (D) hemoglobin-positive concentration ≥ 100 μg.
      Analyses were performed using SPSS version 26 (IBM, Armonk, NY). All qualitative variables were presented as percentages. Chi-square test and Wilcoxon test were used as appropriate. All statistical tests were two-sided, and a P-value<.05 was considered statistically significant.

      RESULTS

      Over the study period, a total of 454 samples were collected from the gloved hands of nursing staff. 60.13% (273/454) of samples tested positive for hemoglobin, with 68.37% (134/196) hemoglobin-positive samples after the connection of vascular access and 53.88% (139/258) hemoglobin-positive samples after the disconnection of vascular access. There was a significant difference in the positive rate of blood contamination on gloved hands between the connection and disconnection groups (χ2 = 9•757, P = .002) (Table 1).
      Table 1The test results of blood contamination on nurses’ gloved hands
      ConcentrationConnection operating person-time (%)Disconnection operating person-time (%)P-value
      Negative62 (31.63)119 (46.12)0.002
      Chi-square test for the positive rate between the two groups.
      ≥5μg54 (27.55)102 (39.54)<0.001
      Wilcoxon test for the concentrations of hemoglobin-positive between the two groups.
      ≥10μg30 (15.31)23 (8.92)
      ≥50μg33 (16.84)11 (4.26)
      ≥100μg17 (8.67)3 (1.16)
      Total196 (100.00)258 (100.00)
      low asterisk Chi-square test for the positive rate between the two groups.
      Wilcoxon test for the concentrations of hemoglobin-positive between the two groups.
      In terms of the distribution of hemoglobin-positive concentrations from samples, the highest positive rate was shown for a concentration of hemoglobin ≥5 μg (34.4%), followed by ≥10 μg (11.7%), ≥50 μg (9.7%), and ≥100 μg (4.4%). There was a significant difference in the concentrations of hemoglobin detected from samples between the connection and disconnection groups (Z = -5.978, P < .001).

      DISCUSSION

      This study is the first to use the occult blood detection kits to assess the blood contamination of nurses’ gloved hands during vascular access procedures. Our results highlight the fact that the low adherence to hand hygiene and glove change by nursing staff may be at risk of transmitting blood-borne pathogens.
      From 2008 to 2019, a total of 22 outbreaks of occurred in hemodialysis settings, with 104 outbreak-associated cases of HCV in the United States.

      Centers for Disease Control and Prevention. Health care-Associated Hepatitis B and C Outbreaks (≥ 2 cases) Reported to the CDC 2008-2019. Available at: https://www.cdc.gov/hepatitis/outbreaks/healthcarehepoutbreaktable.htm. Accessed Noverber 10, 2021.

      A common finding from the outbreak investigations was that newly infected patients were often found to have been treated in close proximity to a previously HCV patient. Epidemiologic studies reported that blood contamination has been detected in the hemodialysis environment.
      • Nguyen DB
      • Gutowski J
      • Ghiselli M
      • et al.
      A large outbreak of hepatitis C virus infections in a hemodialysis clinic.
      ,
      • Girou E
      • Chevaliez S
      • Challine D
      • et al.
      Determinant roles of environmental contamination and noncompliance with standard precautions in the risk of hepatitis C virus transmission in a hemodialysis unit.
      In our study, 60.1% of samples tested positive for hemoglobin, indicating a potential risk of blood contamination on nurses’ hands during vascular access care. As the catheters are disposable, the potential blood contamination on the nurses’ gloved hand during vascular access connection may mainly come from the patient, while the contamination during vascular access disconnection may come from the patient or the catheter. Considering high patient-to-staff ratio and increased baseline HCV prevalence,
      • Shimokura G
      • Chai F
      • Weber DJ
      • et al.
      Patient-care practices associated with an increased prevalence of hepatitis C virus infection among chronic hemodialysis patients.
      adherence to hand hygiene and glove use by nursing staff are critical to prevent transmission of HCV in hemodialysis settings.
      Our study had some limitations. This prospective survey was conducted in a single center, and the positive rate of blood contamination can only reflect the actual situation of the hemodialysis unit that was sampled. Thus, further studies with more centers are necessary. Second, the positive rate of nurses’ gloved hands in connection group was higher than that in disconnection group in our study, whether this phenomenon was caused by sampling error or other influencing factors remains to be further studied.

      CONCLUSION

      The described method provides a useful way of assessing invisible blood contamination on nurses’ hands in hemodialysis settings. This study provides evidence of the importance of hand hygiene and glove change during vascular access procedures.

      References

        • Nguyen DB
        • Bixler D
        • Patel PR.
        Transmission of hepatitis C virus in the dialysis setting and strategies for its prevention.
        Semin Dial. 2019; 32: 127-134
        • Jadoul M
        • Bieber BA
        • Martin P
        • et al.
        Prevalence, incidence, and risk factors for hepatitis C virus infection in hemodialysis patients.
        Kidney Int. 2019; 95: 939-947
        • Fabrizi F
        • Cerutti R
        • Messa P.
        Updated evidence on the epidemiology of hepatitis C virus in hemodialysis.
        Pathogens. 2021; 10: 1149
      1. Centers for Disease Control and Prevention. Health care-Associated Hepatitis B and C Outbreaks (≥ 2 cases) Reported to the CDC 2008-2019. Available at: https://www.cdc.gov/hepatitis/outbreaks/healthcarehepoutbreaktable.htm. Accessed Noverber 10, 2021.

        • Nguyen DB
        • Gutowski J
        • Ghiselli M
        • et al.
        A large outbreak of hepatitis C virus infections in a hemodialysis clinic.
        Infect Control Hosp Epidemiol. 2016; 37: 125-133
        • Girou E
        • Chevaliez S
        • Challine D
        • et al.
        Determinant roles of environmental contamination and noncompliance with standard precautions in the risk of hepatitis C virus transmission in a hemodialysis unit.
        Clin Infect Dis. 2008; 47: 627-633
        • Shimokura G
        • Chai F
        • Weber DJ
        • et al.
        Patient-care practices associated with an increased prevalence of hepatitis C virus infection among chronic hemodialysis patients.
        Infect Control Hosp Epidemiol. 2011; 32: 415-424