1. What is the UCSF Medical Center's Policy on fingernails?
2. Who is responsible for giving TB skin tests to patients?
3. How do I get fit tested for an N95 respirator?
4. Where do I get more Isolation Signs?
5. Where do I order the "Wash your hands with soap and water on EXIT" sign?
6. What items can be stored under the sinks at UCSF?
7. What isolation precautions are needed for patients with methicillin-resistant Staphylococcus aureus (MRSA)?
1. What is the UCSF Medical Center’s policy on fingernails? Back to Questions
Q: When was this policy implemented?
A. On February 1, 2003.
Q: What healthcare workers are affected by the restrictions?
A: Personnel affected include, but are not limited to nurses, physicians, respiratory therapists, phlebotomists, PCAs, PSAs, and anyone who has direct patient contact or staff who handle patient care products.
Q: Why are nail enhancements such as artificial nails, wraps, tips, acrylics, gels, etc. no longer permitted for these staff?
A: Employees have a responsibility for maintaining hand hygiene by adhering to specific infection control practices. Artificial fingernail enhancements contribute to nail changes that can increase the risk of colonization and transmission of pathogens to patients. Outbreaks of infections have been traced to the artificial fingernails of health care workers. For those reasons they are prohibited for anyone having patient contact. See RESEARCH-BASED RATIONALE FOR ELIMINATION OF ARTIFICIAL FINGERNAILS below.
Q. How short should I keep my nails?
A: Nails are to be kept clean and short. They should not extend past the fingertips.
Q: I already use good hand hygiene techniques. Won't that prevent contamination or colonization?
A: Studies have shown that hospital personnel with nail enhancements can have more bacteria both before and after hand washing than personnel with natural nails. Long natural nails can also harbor bacteria. See #1 and #3 under Other Resources below.
Q: If I wear gloves doesn’t that protect the patient?
A: Gloves are not a substitute for hand washing and artificial nails may harbor organisms and prevent effective hand washing. Long nails, artificial or natural, may cause gloves to tear more readily. See EVIDENCE-BASED AND CURRENT STANDARDS below.
Q: Who enforces this policy?
A: Each employee has a responsibility for maintaining hand hygiene, which now includes the removal of artificial nails and trimming long, natural nails, as defined by the policy. Managers will ensure that these standards are maintained. Additionally, the UCSF Medical Center will, in 2007, roll out a comprehensive hand hygiene campaign that will include education and monitoring to ensure that all staff are complying with existing hand hygiene policies, including the length and condition of nails.
EVIDENCE-BASED AND CURRENT STANDARDS Back to Questions
1. Association of Operating Room Nurses (AORN) Standards, Recommended Practices, and Guidelines. Denver, CO: AORN, Inc, 1997, pp 197-202.
• "Fingernails must be kept short, clean, and healthy."
Rationale: "The subungual region harbors the majority of microorganisms found on the hand. Removing debris from fingernails requires vigorous brushing and running water; additional effort is necessary for longer nails. The risk of tearing gloves increases if fingernails extend past the fingertips. Long fingernails may scratch or gouge patients during the moving or positioning processes."
• "Artificial nails should not be worn."
Rationale: "Artificial or acrylic nails on healthy hands have not been proven to increase the risk of surgical infection. However, artificial nails may harbor organisms and prevent effective handwashing. Higher number of gram negative microorganisms have been cultured from the fingertips of personnel wearing artificial nails than from personnel with natural nails, both before and after handwashing. Numerous state boards of cosmetology report that fungal growth occurs frequently under artificial nails as a result of moisture becoming trapped between the natural and artificial nails".
2. Guidelines for Perinatal Care. American Academy of Pediatrics and The American College of Obstetricians and Gynecologists. Hauth, JC, et al. 1997; pg. 256.
• "Fingernails should be trimmed short, and no false fingernails or nail polish should be permitted."
3. Growing numbers of hospitals and health care centers do not allow artificial fingernails for health care workers. These include all Kaiser facilities in California, New York Presbyterian Hospital, Boston Childrens' Hospital, and many more.
PROPOSED STANDARDS Back to Questions
1. CDC Guidelines 2002 Draft Revision of the Guideline for Hand Hygiene in Health Care Settings, Centers for Disease Control, 1992, pg. 46.
• "Do not wear artificial nails or extenders when providing patient care", recommendation type 1A.
2. Draft guidelines from the Hospital Infection Control Practices Advisory Committee for hand hygiene grade the elimination of artificial nails from the hands of HCWs in the highest category of importance.
RESEARCH-BASED RATIONALE FOR THE ELIMINATION OF ARTIFICIAL AND LONG, NATURAL FINGERNAILS Back to Questions
1. Candida osteomyelitis and Diskitis after Spinal Surgery: An Outbreak That Implicates Artificial Nail Use. Parry MF, Grant B, Yukna M, Adler-Klein D, McLeod GX, Taddonio R, Rosenstein C. Clin Infect Dis 2001 Feb 1;32(3):352-7 (ISSN: 1058-4838); The Stamford Hospital, Stamford, CT, and Columbia University College of Physicians and Surgeons, NY, USA.
• 3 laminectomy patients with post op Candida diskitis found epidemiologically linked to an OR tech who had artificial nails.
2. Long or Artificial Fingernails Implicated in ICU Outbreak of P. aeruginosa.Moolenaar RL, Crutcher JM, San Joaquin VH, Sewell LV, Hutwagner LC, Carson LA, Robison DA, Smithee LM, Jarvis WR. Infect Control Hosp Epidemiol 2000 Feb;21(2):80-5 (ISSN: 0899-823X) Acute Disease Division, Oklahoma State Department of Health, Oklahoma City, USA.
• 46 NICU patients acquired P. aeruginosa, 16 of them died; this outbreak was linked epidemiologically to 2 nurses, one with artificial nails and another with long, natural nails.
3. Endemic Pseudomonas aeruginosa infection in a neonatal intensive care unit. Foca M, Jakob K, Whittier S, Della Latta P, Factor S, Rubenstein D, Saiman L. N Engl J Med 2000 Sep 7; 343(10):695-700 (ISSN: 0028-4793). Department of Pediatrics, New York-Presbyterian Hospital and Columbia-Presbyterian Medical Center, New York, USA.
• 6 infants found colonized or infected with P. aeruginosa - risk factors identified were health care workers with artificial nails or nail wraps.
1. Impact of a 5-minute scrub on the microbial flora found on artificial, polished, or natural fingernails of operating room personnel. Edel E, Houston S, Kennedy V, LaRocco M. Nursing Research, 47(1), 54-59 (1998).
• The results of this study indicate that OR personnel with artificial fingernails more often harbored gram-negative rods both before and after a 5-minute scrub using microbial soap. Additionally, artificial nails had higher bacterial loads, as compared with natural or polished nails.
2. Pathogenic organisms associated with artificial fingernails worn by healthcare workers. Hedderwick S, McNeil S, Lyons M, Kauffman CA. Infection Control and Hospital Epidemiology, 21(8), 505-509 (2000).
• Artificial fingernails were more likely to harbor pathogens, especially gram-negative bacilli and yeasts, than native nails.
3. Effect of hand cleansing with antimicrobial soap or alcohol-based gel on microbial colonization of artificial fingernails worn by health care workers. McNeil SA, Foster CL, Hedderwick S, Kauffman CA. Clinical Infectious Disease, 32, 367-372 (2001).
• Significantly more HCWs with artificial nails than controls had pathogens remaining after hand cleansing with soap or gel. Of HCWs with artificial nails, only 11% cleared pathogens with soap compared with 38% with gel. Of control HCWs, only 14% cleared with soap compared with 80% with gel.
4. Banning artificial nails from health care settings. Saiman L, Lerner A, Saal MA, Todd E, Fracaro M, Schneider N, Connell JA, Castellanos A, Scully B, Drusin LM. American Journal of Infection Control, 30, 252-254 (2002).
• New York Presbyterian Hospital has instituted a policy wherein only well-groomed, natural nails of reasonable length are permissible for HCWs who have patient contact.
2. Who is responsible for giving TB skin tests to patients? Back to Questions
3. How do I get fit tested for an N95 Respirator? Back to Questions
A. You must first obtain a medical clearance, usually from Employee Health Services or other health care provider. Then call EHS at 476-1300 to make an appointment. Appointment times are available on Thursdays between 1:00 PM and 4:00 PM. Complete details can be found in “Respiratory Protection Program” found in the Aerosol Transmissible Disease Exposure Control Plan.
4. Where do I get more Isolation Signs? Back to Questions
These signs reflect the revised Standard and Transmission-based Precautions policy. If your department still has old versions of the isolation signs, please discard them and order the new ones. Please contact us if you have any problems ordering these signs.
Contact Isolation: Product Number: 500-0075
Enteric Contact Isolation: Product Number: 500-0520
5. Where do I order the "Wash your hands with soap and water on EXIT" Sign? Back to Questions
A. Material Services has a limited supply of "Wash your Hands with Soap and Water on Exit" sign if needed quickly. They can be ordered using the online ordering tool https://creator.zoho.com/alfiolevy/ms-requests# along with your other supplies. Please use PMM# 58963.
Wash your hands with soap and water on EXIT: Product Number: 500-0450
7. What isolation precautions are needed for patients with methicillin-resistant Staphylococcus aureus (MRSA)? Back to Questions
A. At this time, Standard are required for patients with methicillin-resistant Staphylococcus aureus (MRSA).