Table of Evidence

Table of Evidence

Katira Marshall, Sharun Manu, and Toyin Ajayi

Department of Nursing, West Chester University

NSG 313: Applied Nursing Research

Megan A. Infanti Mraz RN, PhD


Theme Study #1 Study #2 Study #3

Purpose To determine the effectiveness of various hand washing methods in order to eliminate Escherichia coli and feline calicivirus (FCV) from fingernails, which is natural as well as artificial and are of different lengths (Lin et al., 2003). To compare the effectiveness of an antimicrobial soap and an alcohol-based hand cleansing gel on the colonization of fingernails, i.e., natural as well as artificial; determining the microflora differences in the healthcare worker’s nails (McNeil et al., 2001). To highlight the strategies for preventing healthcare- associated infections through the hand hygiene (Ellingson et al., 2014).

Design Bacterial inoculum preparation in which E. coli strain was added to the fresh grounded beef and was mixed with gloved hands; followed by the storage on ice before inoculating and immediately used after inoculating.

Tissue culturing and viral inoculum processing was done, collected and stored at -80◦ C, until the usage of viruses.

Accounting of virus populations and preparing viral inoculum.

Selection of human volunteers.

Inoculation of the fingernails using microbial sample.

Determining the microbial counts.

Evaluation of six hand washing methods. 21 volunteers were selected amongst the healthcare workers including inpatient and out patient care areas at University of Michigan and the Veterans Affairs Medical centers.

Cultured samples were obtained from the volunteers at different times during regular activities. Although cleaning of hands was not allowed just before the sampling, but they have cleansed their hands as usual.

Surfaces of the nails and subungual areas of all the five fingers of the most dominant hand were performed for culturing.

Different colonies were phenotypically quantified and identified S. aureus, enterococci, gram negative bacilli and yeasts. Hence, identification of all the organisms were done by the standard methods. Associating the hand hygiene improvisation as well as healthcare associated infection reduction (HAI).

Setting Laboratories. Medical Centers. Variety of settings (Healthcare settings or Hospitals; Medical centers; Laboratories).


Characteristics and Size Nonpathogenic E. coli JM 109 of 50 ml was used as bacterial indicators and feline calicivirus (FCV) strain F9 were used as viral indicators. Surfaces of the nails and subungual areas of healthcare workers.

Size- N/A. Pathogen specific- Clostridium difficile and norovirus.

Size- N/A.

Data Collection Data was collected from one of the involved volunteers for one hand washing method, which was considered as an experiment unit. 21 healthcare workers were wearing artificial nails and 20 healthcare workers was considered as control; i.e., before and after the usage of antimicrobial soap and alcohol-based gel. Direct observation.

Indirect volume.

Event count measurement.

Automated adherence monitoring by using advance technologies.

Data Measurement and Analysis Data analysis was done by performing statistical analysis, showing significant difference of P= 0.05 in E. coli or FCV counts amongst both the type of nails, which was determined by t test. Duncan’s test was then performed for multiple comparison for determining significant differences P= 0.05 of reduced microbial counts between hand was methods within same fingernail types and t test was done to determining significant differences P= 0.05 in microbial count reduction amongst natural and artificial nails with same hand wash method. Statistical analysis was overall done by the Statistical Analysis System program (SAS). Isolation frequency and organisms’ quantity were compared between the healthcare workers wearing artificial nails and the healthcare workers with native nails as the control.

Isolation frequency was done by X2 test and quantified differences of different organisms by Student’s t test.

Comparison of both the types of nails were done by the paired t test.

Statistical significance analyzed was as P≤ 0.05. Measured hand hygiene associated with the single measurement approach.

Direct observation helped in in-person monitoring of the behavior of hand hygiene.

Results (significant findings) Irrespective of the types of nails, long fingernails show to harbor more microbes when compared to the shorter nails.

When comparing natural and artificial nails in the same wash method, no significant reduction of E. coli JM 109 counts was found, except when soap and nailbrush both were used.

Average decrease of the FCV units, which is infectious, were found to be collected on the natural fingernails hand’s than the artificial nails. Hence, no statistically significant difference, P> 0.05. Significantly more cultures from the healthcare workers were found wearing artificial nails before cleaning of hands with soap or a gel; when compared to the healthcare workers as control had S. aureus, gram negative bacilli a well as yeasts isolated.

No healthcare workers with the native nails had gram negative bacilli, which was isolated after cleaning hands with the alcohol gel.

Therefore, alcohol-based gel was found to be more effective for elimination of pathogens when compared to antimicrobial soap. Performance measures are based on the internal reporting, which includes quality improvement, feedback, longitudinal assessment, improvisation through measurement and intervention strategies in individual facilities as well as different group of facilities in the same healthcare system.

Based on external reporting, hand hygiene metrics suffers from the non-trusted data, implies of misaligned incentives.

Limitations N/A Time constraints.

Cleaning of hands of the healthcare workers.

Improper usage of gloves. Lack of combined approach to explore further studies of feasibility and acceptability in order to refine the methods.


Ellingson, K., Haas, J., Aiello, A., Kusek, L., Maragakis, L., Olmsted, R. & Yokoe, D. (2014). Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene. Infection Control & Hospital Epidemiology, 35(S2), S155-S178. doi:10.1017/S0899823X00193900

Lin, C. M., Wu, F. M., Kim, H. K., Doyle, M. P., Michaels, B. S., & Williams, L. K. (2003). A comparison of hand washing techniques to remove Escherichia coli and caliciviruses under natural or artificial fingernails. Journal of Food Protection, 66(12), 2296-2301., S. A., Foster, C. L., Hedderwick, S. A., & Kauffman, C. A. (2001). Effect of hand cleansing with antimicrobial soap or alcohol-based gel on microbial colonization of artificial fingernails worn by health care workers. Clinical Infectious Diseases, 32(3), 367-372.

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