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Journal of Nursing

Pathogen Transmission from Blood Pressure Cuffs 

by Sandra Taber RN, BSN Clinical Nurse Specialist Murray State University Department of Nursing [email protected]


Introduction


Decades of research has been conducted regarding the transmission of pathogens in hospitals from patient to patient, patient to staff, and staff into the community. Infectious diseases constitute the leading cause of death worldwide, and the third leading cause of death in the United States (Muto et al, 2003). As early as 1969 an Australian study identified the blood pressure cuff as a reservoir for bacteria, and that no other piece of hospital equipment was used more often without adequate disinfection (Beard, McIntyre, & Roundtree, 1969). Infection control programs were implemented three decades ago to help control the healthcare issue of antibiotic-resistance acquired infections and the spread of these infections. The Society for Healthcare Epidemiology of America appointed a taskforce to define evidence- based guideline for preventing pathogen transmission with a focus on Methicillin Resistant Staphlococcus Aureus (MRSA) and Vancomycin Resistant Enterococcus (VRE) (Muto et al, 2003). 




The Centers for Disease Control (CDC) have estimated that more than 2 million people per year acquire a hospital (nosocomial) related infection every year. CDC statistics state that the cost of treating these infections is $4.5 billion annually with mortality rates between 60,000 to 80,000 patients (CDC Recommendations and Report# 5005a1, 2001). Higher risk patients include the neonate or the patient in the Intensive Care Unit, Coronary Care Unit, surgery, or renal dialysis patients (de Gialluly, et.al, 2006, Myers 1978, Base-Smith, 1996, Baruah et al, 2008).


Content


Blood pressure cuffs have been found to be a major source of cross contamination between patients. A study by Webb (2002) using cultures taken from blood pressure cuffs found MRSA on 9% of the cuffs. A blood pressure cuff sleeve was then applied on these same cuffs and cultures were repeated at the end of the day. No MRSA was found on the cuffs after a barrier was used. Thirteen years ago Manian, Meyer, & Jenne (1996) reported a study that revealed contamination of blood pressure cuffs with Clostridium difficile (C diff) at levels that were the same as bedside commodes (10%). More recently Gupta, Walker, and Cheesbrough (2006) assessed the level of contamination of blood pressure cuffs used in hospital wards. Twenty four cuffs had viable organisms, eleven of these cuffs grew a single organism and three grew a mixture of organisms. All together there were 18 organisms isolated from the 24 cuffs: Methicillin Sensitive Staphlococcus Aeurus (MSSA) from 8 cuffs, MRSA from 2 cuffs, and C-Diff was found on 8 cuffs. Ellis (2008) identified blood pressure cuffs as a major environmental source for cross contamination.


According to the critical care Clinical Nurse Specialist at a rural southeast hospital there is acute awareness of this problem. The CNS at this local facility obtained cultures from blood pressure cuffs in the ICU, CCU, and overflow units. In all three units a number of the cuff cultures grew a gram negative rod which is an organism normally found in the gut. In this facility, a blood pressure sleeve was trialed for several weeks and repeat cultures were obtained. All repeat cultures were negative for organisms.


Increasing rates of drug resistant diseases such as MRSA and VRE make it imperative that the spread of pathogens from patient to patient be contained. The study by Walker, Gupta, and Cheesbrough (2006) reinforce these facts when they found multiple pathogens on the same cuffs. The results of the study prompted recommendation that a barrier between cuff and skin would be a viable option to help prevent this spread of pathogens.


The ongoing research on blood pressure cuff contamination only reinforces these results and the need for more vigilance with the use of equipment. Literature review of the evidence shows the same theme-blood pressure cuffs are vectors for the spread of pathogens.


Analysis


There are several options available to help reduce the spread of pathogens by blood pressure cuffs. The CDC (2007) recommends the use of disposables blood pressures cuffs in the guidelines for control of pathogen transmission. These cuffs would cost more and also disposal would be a consideration. The economics associated with the cost of disposable cuffs may not make this a realistic situation for many facilities. Units with high risk patients such as those in ICU, CCU, surgery, and renal dialysis may be able to obtain these disposable cuffs. The cost of using a disposable cuff needs to be considered in relation to treating the cost of a noscomial infection, especially with the new Medicaid/Medicare mandates of not paying for certain hospital acquired infections.


The use of a barrier such as a blood pressure sleeve is well supported in the review of literature by (Webb, 2002, Hwang et al, 1998, Marion et al, 1996). The blood pressure sleeve is an alternative that would be more cost effective, with prices between sixty-nine cents to ninety six cents per unit. (Bowen Medical, 2009). Staff education is vital for implementing changes such as the use of a blood pressure cuff sleeve. In the rural southeast hospital survey there were several staff complaints including: too much time to change the sleeves, cuffs not always available, and the correct size was not always available. Managers would need to address these concerns and assure that the product was available and the sizes of cuffs needed were supplied. Disinfecting and cleaning cuffs is by far the most common method used, but even after cleaning, organisms are still cultured from blood pressure cuffs, especially in areas such as the ICU (de Gialluly et al, 2006).


Hand washing has always been the tried and true practice to reduce transmission of pathogens between patients and patient to staff /others and is still needed with using blood pressures cuffs between patients.  Hand sanitizers are becoming more popular, but staff needs to keep in mind that not all pathogens are killed by hand sanitizers. The current practice of using hand sanitizers appears to have become more attractive as the products become more user-friendly and not as rough on skin integrity. Deshpande and Rothchild (2006) suggest that infectious control providers need to incorporate behavior change interventions that will appeal to the healthcare worker. The benefits of using hand sanitizers are such that “even busy healthcare workers will find hand rubs fast, convenient, and effective at killing the superbugs on their hands” (2006). Medical providers can help with the growing numbers of drug resistant pathogens by carefully prescribing antibiotics, ordering and monitoring cultures, and prescribing medications according to culture results (Muto et al, 2003). Patient education in the hospital and in the community is another area where physicians and other providers can help with prevention.


Conclusion


Prevention is the key to reduce the transmission of pathogens through equipment use, such as the blood pressure cuff.  Results from this paper suggest that nurses will need to be more cognitive of how we interact with patients and what is being done to maintain their health and prevent the spread of pathogens. Following good hand washing practices, following facility practices and standards of care, and the use of blood pressure cuff barriers are all options to decrease the transmission of pathogens. Evidence Based Practice provides the best standards of care that will give nurses the data to support changes such as the use of disposable cuffs or sleeves for blood pressure cuffs. Knowing what antibiotics the patients are taking, if cultures are done, and if the antibiotics are appropriate for treatment of positive cultures are also resources for the nurse to use. Keeping updated on data of transmittable infectious diseases will enhance outcomes for the patients. Improved patient outcomes, more time for patient care and organizational benefits such as the reduction of recidivism, reduced healthcare costs, and resource allocation are all benefits of controlling pathogen transmission. 
 
 
References


Baruah, J., Kumar, S., Gratix, A., Dibb, W. & Madeo, M. (2008). Blood pressure cuffs as a potential form of transmission of pathogenic micro-organisms: A prospective study in a university teaching hospital. British Journal of Infectious Control, 9 (4): 19-21. Retrieved November 28, 2008 from: www.bji.sagepub.com.


Beard, M., McIntyre, A., & Roundtree, P. (1969). Sphygmomanometers as a reservoir of  Pathogen bacteria. The Medical Journal of Australia, 2: 758-760. Retrieved December 5, 2008 from: www.gehealthcare.com. Bowen Medical. Retrieved March 5, 2009 from:www.bowenmed.com.


Centers for Disease Control (2001). CDC Recommendation and Report #5005a1.
Atlanta, Georgia. Retrieved March 3, 2009 from:
 www.cdc.gov.


Centers for Disease Control (2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007. Atlanta, Georgia. Retrieved March 12, 2009 from: www.cdc.gov. de Gialluly, M., Morange, V., de Gialluly, E., Loulergue, J., van der Meer, N., & Quentin, R. (2006).


Blood pressure cuff as a potential vector of pathogenic microorganisms: A prospective study in a teaching hospital, Infectious Control Hospital Epidemiology, 27: 940-943. Retrieved November 28, 2008 from: www.journals.uchicago.edu.


Deshpande, S., Rothchild, M. (2006). Social marketing: A behavior change technology for infection control. American Journal of Infection Control, 34 (7), 452-457. Ellis, S. (2008). Fomites and infection transmission. Infectious Diseases Today. Retrieved November 8th, 2008 from: www.infectiouscontroltoday.com.


Hwang, Y., Brinton, B., Leonard, P., Wood, M., &Carroll, K. (1998). Investigation of an outbreak of Vancomycin resistant Enterococcus in a low prevalence university hospital. Journal of Investigative Medicine, 46 (9): 435-443. Retrieved December 7, 2008 from:www.ncbi.nlm.nih.gov.


Manian, F., Meyer., L., & Jenne, J. (1996). Contamination of blood pressure cuffs at a rate similar to bedside commodes. Infectious Control Hospital Epidemiology, 17 (3), 180-182. Retrieved November 28, 2008 from: www.hpa.org.


Muto, C., Jernigan, J., Ostrowsky, B., Richet, H., Jarvis, W., Boyce, J., & Farr, B. (2003) SHEA guideline for preventing nosocomial transmission of multidrug-resistant strains of staphylococcus aureus and enterococcus. Infection Control Hospital Epidemiology, 24: 362-386. Retrieved March 1st, 2009 from: www.ncbi.nlm.nih.gov.


Walker, N., Gupta, R., & Cheesbrough, J. (2006). Blood pressure cuffs: friends or foe? Journal of Hospital Infections, 64(2): 167-169.


Webb, S. (2002). Single-use blood pressure cuff barrier reduces microbial concentrations. Richmond: Virginia Commonwealth University, Department of Microbiology.





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