Scratch That
With research indicating that artificial and natural long nails can harbor bacteria, hospitals file a ban on the lengthy culprits to cut the spread of infection

By Phil Barber
June 11, 2003

Enid Eck, MPH, RN, had read the body of literature, weighed recommendations from various professional societies and consulted with other infection experts. Her scale was finally tipped the night she saw a Pseudomonas aeruginosa outbreak-and its likely vector-detailed on network television.

"I went to our medical directors and quality committees," recalled Eck, senior consultant on HIV and infectious disease with the California Division of Kaiser Permanente. "I said, 'OK, it's on "60 Minutes" now, folks.' This was our chance to be leaders."

Eck and other Kaiser officials began taking aim at what they perceived to be a major culprit in the spread of nosocomial infection: artificial fingernails and exceptionally long natural nails. By July, they were ready to act throughout the Southern California region.

"We gave our [health care workers] the Fourth of July holiday weekend," Eck said. "If they wanted red, white and blue nails, they could do that. But the Monday after, the nails had to be gone."

Kaiser, which later expanded the policy nationwide, has plenty of company. Seton Healthcare Network in Austin, Texas; Northwestern Memorial Hospital in Chicago; New York-Presbyterian Hospital and many more have said no to fake nails.

Plenty of research supports their decision. The University of Michigan Health System's Infection Control & Epidemiology department cites no less than 21 studies, most of them published in the last decade, that focus on fingernails and infection control. The majority echoes a single message-that health care workers who wear artificial nails are more likely to harbor pathogens than those who don't.

Public attention

Then there are those headline-generating outbreaks. It was Pseudomonas that killed 16 babies in a neonatal ICU in Oklahoma City in 1997 and 1998. That contagion eventually was traced to two nurses, one with artificial nails and another with long natural nails.

In a 1994 outbreak of Serratia marcescens among cardiovascular surgery patients at a California hospital, the trail led to a jar of exfoliant cream in the home of a scrub nurse who wore artificial nails.

In 1996, an operating room technician with artificial nails was implicated in the post-laminectomy deep wound infections (Candida albicans) of three patients in a Connecticut hospital.

Research offers several logical reasons to suspect artificial nails. First, most handborne microbes congregate in the subungual zone (the crook between the fingertip and the nail), and long nails of any material make it harder to clean this area.

Second, an artificial nail can separate from the natural nail base if bumped or snagged, leaving an opening that invites dirt and germs. Gram-negative bacteria or fungi then can spread to the natural nail.

Further, long nails are more likely to tear latex gloves, bringing nurses into contact with skin or fluids.

These are some of the factors that prodded doctors at the CDC to include artificial-nail commentary in its voluminous "Guideline for Hand Hygiene in Health-Care Settings," released in October. One of the recommendations was, "Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (e.g., those in intensive-care units or operating rooms)."

Kaiser went further, applying the standards to anyone providing hands-on care or handling instruments or equipment that would be used directly on patients. The group's nurse executives voluntarily removed their nails, too.

"We felt that the organisms under your nails don't know where they are," Eck said. "They might be in critical care or with a med/surg patient. There was clear evidence in a high-risk environment. But germ theory applies elsewhere, too."

NCH Healthcare System, a Florida company that consists of two hospitals and several walk-in clinics, took a similar approach when it banned artificial nails in November. NCH administrators applied the prohibition not only to direct-care health workers, but also to cleaning staff and food servers who could conceivably infect patients-or be infected themselves.

Everybody wins

Part of the message has been that dumping artificial nails protects not only patients, but also health care workers and their families.

Another common educational element has to do with nail care. There's no denying that nursing, with its constant handwashing, is tough on the fingernails. Kaiser, for its part, organized nail fairs, recommended manicurists and distributed hand care kits.

NCH had to deal with this issue as well. "One complaint we had was that when people took off their artificial nails, their natural nails were deformed, not in good repair," said Rebecca Malphus, RN, CIC, an infection control practitioner with NCH. "That showed us how damaging artificial nails were. In a way, it was a blessing in disguise. Eventually, their natural nails got healthier and grew out, and it was much better for everyone."

According to hospital spokespeople, the education campaigns were effective in garnering support for the policy. "We really didn't hear too much about it," said Carrie Skifton, RN, NCH's vice president for nursing. "People knew this was the right thing to do."

Eck said that only one worker, a respiratory therapist, left Kaiser in protest. And this is a group with more than 30,000 nurses. But that doesn't mean the prohibition didn't ruffle a few feathers. Terri Hitt, RN, works in labor and delivery at a hospital in Los Angeles County and takes per-diem shifts for Kaiser. She isn't buying Kaiser's arguments.

In Hitt's view, the no-nails policy unnecessarily impinges upon the personal choices of its female nurses, while offering no substantive advantages in safety. A former manicurist, she insisted that proper hygiene is the key to maintaining any nails, no matter the length or material. She also wondered whether the microbial research has any bearing on health care workers who are gloved for patient contact. Finally, she strongly disagreed with Eck's assessment of employee acceptance.

"They claim there was no protest from the union, and thus there was no protest from nurses," Hitt said. "Quite the contrary. What happened was that many of the nurses who had objections, although they did not leave Kaiser employment, merely transferred to nonpatient care areas. This move decreased the number of nurses available for patient care.

"In addition, Kaiser's policy has decreased the number of registry nurses who will service the institution. Kaiser's answer has been to train less-educated personnel for roles such as scrub tech. They have no microbiology background, and at times, their sterile technique is questionable."

Hitt's primary employer still allows artificial nails. As it stands, Hitt now works for Kaiser only when she has removed her acrylics, which she changes every six weeks. "They're getting less [of this] nurse," she said.

Kaiser's reaction is a polite "good riddance." Eck remains convinced that artificial nails directly increase the risk of nosocomial infection, and her hospital won't hire anyone who refuses to take them off. "She probably hasn't seen all the work done on this subject," Eck said of Hitt. "The evidence is simply there."

Has the policy change improved conditions? Kaiser has conducted some observational studies of handwashing since issuing its edict nearly a year ago. It has also attempted to track resistant organisms across medical centers. But it's nearly impossible to link this data specifically to artificial nails.

"There's not much to go on, other than outbreaks," which Kaiser hasn't had subsequent to the policy, Eck said. "And that's good."

Contact Phil Barber at barzell@napanet.net