Return to Main Menu

Infection Control takes aim at artificial fingernails by Jodell Johnson, R.N. Infection Control Coordinator A threat to hospitalized patients lurks at the tips of health care workers' fingers, even if their hands are washed and gloved. The threat: pathogens harbored beneath artificial fingernails. When it comes to patient safety, physicians and other health care workers are always aware that their actions can cause or prevent harm. If all health care workers took definitive action in one area alone, that of hand hygiene, multiple infections could be prevented. But, do artificial fingernails contribute to  transmission of healthcare-acquired infections? This issue has been a matter of debate in infection control for several years.  As early as 1988 researchers became concerned about the growing use of artificial fingernails.   Several studies  showed increased numbers of microbes on artificial nails compared with natural nails. A growing body of evidence is now in existence to show that indeed they may contribute to transmission of certain pathogens (Gram negative bacilli and yeast).  A  recent study at the University of Michigan demonstrated that health care workers with artificial nails are more likely to harbor pathogens than those with native nails. The effect of hand cleansing on microbial colonization of artificial fingernails was also studied with similar results.  Personnel wearing artificial fingernails have been linked to an outbreak of postoperative wound infections caused by Serratia marcescens  and an outbreak of Candida osteomyelitis and diskitis following spinal surgery. The event that seems to have brought the issue home to infection control professionals occurred in a Neonatal Intensive Care Unit when an outbreak of Pseudomonas aeruginosa was partly attributed to a nurse who wore artificial fingernails.  Questions concerning the use of nail polish have arisen but there is conflicting evidence about its effect on hand hygiene. One study performed in an operating room setting showed significantly more colony forming units on nurses with chipped nail polish than those with fresh polish or natural nails. All other studies concerning nail polish have shown no significant difference between the colony counts on nurses with polished and natural nails.  There is no literature implicating nail polish in the actual transmission of infection. Guidelines  from the CDC and Other Organizations All of these studies have led the Centers for Disease Control and Prevention (CDC) to include a statement concerning artificial fingernails in the “Draft Guidelines for Hand Hygiene in Healthcare Settings,” published on Nov. 10, 2001,  <http://www.cdc.gov/ncidod/hip/hand/hhfedreg.htm>. “Do not wear artificial fingernails or extenders when providing patient care” is a Category 1A recommendation. Category 1A recommendations are “strongly recommended for implementation and strongly supported by well-designed experimental, clinical or epidemiologic studies.” While the draft guidelines make no recommendations concerning the use of nail polish, they do recommend that natural nails be kept less than 1/4-inch long. The Association for Professionals in Infection Control and Epidemiology (APIC) recommends that nails be kept short and that the hands, including the nails and surrounding tissue, be free of inflammation. The Association of Perioperative Registered Nurses recommends that surgical personnel not wear artificial nails. MUSC Medical Center Policy This past fall a statement was added to the Medical Center policy A-4, Personal Appearance and Dress Code.  The statement reads, “Artificial fingernails, tips, wraps, or fillers may not be worn by direct care employees.”  The policy took effect Nov. 1, 2001.   The Medical Center is under no illusion that this is a popular policy.  However, with the supporting research, and the CDC guidelines, we would be jeopardizing patient safety if we do not do this. CDC guidelines do not carry the legal authority of an OSHA Standard or a state licensing law, but many of the later are based upon them.  The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) will cite CDC guidelines in their accreditation inspections.  It is up to each health care worker,  to become a model of prevention. This includes not wearing artificial nails, keeping nails trimmed and neat, and washing hands when necessary. References citing research referred to in this article may be obtained in the Medical Center Infection Control office (room 286, main hospital).