Elsevier

Journal of Hospital Infection

Effect of an infection control programme on bacterial contamination of enteral feed in nursing homes

Summary

Background

Inadequate infection control knowledge about enteral feeding (EF) practices among nursing home staff may lead to contamination of EF systems.

Aim

To investigate the effectiveness of an infection control programme (ICP) on knowledge and practice of EF of nursing home staff, and to explore the correlation between the ICP and bacterial contamination of the hands of staff and feeding equipment.

Methods

Using a quasi-experimental pre–post-test control design, each intervention and control group consisted of 15 residents and 10 staff. EF knowledge and practice were assessed by questionnaire and observation. The intervention group received an ICP. Samples were collected from the hands of staff, enteral feed, flow regulators, feeding tube hubs, and the nasopharynx and gastric fluid of residents, and analysed for total bacterial counts and presence of meticillin-resistant Staphylococcus aureus (MRSA) before and after the ICP.

Findings

The intervention group showed a significant improvement in knowledge and practice after the ICP (P < 0.05). Pretest samples from the hands of staff, tube hubs, and the nasopharynx and gastric fluid of residents were contaminated with >104 colony-forming units/mL. Contamination was significantly lower in the post-test samples of the intervention group (P < 0.05), and remained unchanged in the control group. The mean (± standard deviation) number of MRSA-positive samples decreased from 2.1 ± 1.6 to 0.4 ± 0.7 (P < 0.05) in the intervention group. MRSA hand contamination was highly correlated with contamination of regulators, gastric fluid, tube hubs and enteral feed (P < 0.05), illustrating the close relationship between contaminated feed and poor hand hygiene.

Conclusion

An effective ICP can significantly reduce the contamination of enteral feed. The provision of ICPs is strongly recommended in nursing homes.

Introduction

Nasogastric tubes can serve as reservoirs for transmission of organisms such as meticillin-resistant Staphylococcus aureus (MRSA), the presence of which is associated with 2–2.5-fold increases in mortality rates.1 Approximately 3.5% of patients in Hong Kong residential care facilities use feeding tubes for long-term enteral nutrition.2 Contamination of enteral feed can lead to abdominal distension, septicaemia, bacteraemia, diarrhoea, salmonellosis, pneumonia and death.3 Extranasal colonization with MRSA is common among nursing home residents, particularly those with nasogastric tubes.4 Several studies5, 6, 7 have demonstrated that contamination of the external surface of enteral feed tubing was significantly associated with the species of organisms present in the hub of the nasogastric tube. The highest correlation was between the hub and the patients' sites.8 Inadequate knowledge about enteral feeding (EF) among healthcare workers (HCWs) may lead to bacterial contamination of EF systems as a result of incorrect handling procedures.9 Studies have shown that the major source of transmission of pathogens between patients is from contaminated hands of HCWs to clean environmental or skin sites,10, 11, 12, 13 and that areas such as flow regulators are contaminated by HCWs' hands.8 Other sources of enteral feed contamination include inadequately cleaned equipment and poor kitchen/nursing home environment.14 The aim of this study was to determine knowledge of nursing home staff about appropriate infection control measures in EF and rates of enteral feed contamination, and to investigate any correlation between these parameters and colonization of residents and contamination of the hands of staff and equipment. The effectiveness of an infection control programme (ICP) was determined by investigating improvement in the contamination of enteral feed in terms of decreasing overall bacterial counts and MRSA contamination of EF systems.

Section snippets

Methods

A quasi-experimental pre–post-test control design was used in this study. Thirty residents aged 65 years or more receiving EF and 20 staff were recruited from three nursing homes in Hong Kong. They were divided into intervention and control groups with 15 residents and 10 staff in each group. Two nursing homes were designated as the intervention group and one nursing home was designated as the control group; this was done at random. All nursing homes were government-subsidized institutions

Knowledge and practical assessment scores of staff

Following the ICP, significant differences were found in both knowledge and practical assessment scores between pretest and post-test in the intervention group (P < 0.05), but no significant difference was found in the control group. The knowledge scores (mean ± standard deviation) for the intervention group increased from 13.7 ± 1.4 to 17.7 ± 1.6, and the practical assessment scores increased from 52.9 ± 13.3 to 91.2 ± 7.9 (Table II).

Before EF

Total bacterial counts showed a significant reduction

Discussion

This study has highlighted the importance of the role of the environment and staff hands in the spread of MRSA. The most commonly contaminated sites in this study were the hands of staff, with two left hands and five right hands of the intervention group yielding MRSA in the pretest study. Failure to wash hands correctly leads to contamination of the EF tube equipment and the enteral feed. Although such cross-transmission was not studied, it is likely that the spread of bacteria from the

Acknowledgements

The authors wish to thank Senior Medical Officer Dr. Mike Kwan and Advanced Practice Nurses Miss Sylvia Lai and Miss Peggy Or for their helpful comments and support on the content validity index scoring.

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    A comprehensive protocol based on the World Health Organization (WHO) multimodal HH improvements strategy, including the use of alcohol-based handrub placed at point of care on dedicated racks; the use of pull reels; HH posters and reminders; an educational program; and performance feedback, which resulted in both compliance improvement and reduction in respiratory outbreaks and MRSA infection requiring hospital admission15 A multimodal protocol targeted at HCWs that reduced hand colonization and resolved longstanding issues of enteral feed contamination16 Transitional care is defined as "a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care in the same location".17

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