Research Article: Contamination of Medical Charts: An Important Source of Potential Infection in Hospitals

Date Published: February 18, 2014

Publisher: Public Library of Science

Author(s): Kuo-Hu Chen, Li-Ru Chen, Ying-Kuan Wang, Eric S. Halsey.


This prospective study aims to identify and compare the incidence of bacterial contamination of hospital charts and the distribution of species responsible for chart contamination in different units of a tertiary hospital.

All beds in medical, surgical, pediatric, and obstetric-gynecologic general wards (556) and those in corresponding special units (125) including medical, surgical, pediatric intensive care units (ICUs), the obstetric tocolytic unit and delivery room were surveyed for possible chart contamination. The outer surfaces of included charts were sampled by one experienced investigator with sterile cotton swabs rinsed with normal saline.

For general wards and special units, the overall sampling rates were 81.8% (455/556) and 85.6% (107/125) (p = 0.316); the incidence of chart contamination was 63.5% and 83.2%, respectively (p<0.001). Except for obstetric-gynecologic charts, the incidence was significantly higher in each and in all ICUs than in corresponding wards. Coagulase-negative staphylococci was the most common contaminant in general wards (40.0%) and special units (34.6%) (p>0.05). Special units had a significantly higher incidence of bacterial contamination due to Staphylococcus aureus (17.8%), Methicillin-resistant Staphylococcus aureus (9.3%), Streptococcus viridans (9.4%), Escherichia coli (11.2%), Klebsiella pneumoniae (7.5%), and Acinetobacter baumannii (7.5%). Logistic regression analysis revealed the incidence of chart contamination was 2- to 4-fold higher in special units than in general wards [odds ratios: 1.97–4.00].

Noting that most hospital charts are contaminated, our study confirms that a hospital chart is not only a medical record but also an important source of potential infection. The plastic cover of the medical chart can harbor potential pathogens, thus acting as a vector of bacteria. Additionally, chart contamination is more common in ICUs. These findings highlight the importance of effective hand-washing before and after handling medical charts. However, managers and clinical staff should pay more attention to the issue and may consider some interventions.

Partial Text

Reducing healthcare-associated infection (HAI) remains a critical issue for clinicians and managers in hospitals and healthcare institutions all over the world. Correct hand washing has been proved the most effective way to prevent HAIs [1]–[4]. Based on the WHO guidelines, good hand hygiene can lower the risk of hand transmission of microorganisms [1], [5]. However, it is difficult to examine whether clinical staff conform to the guidelines in daily practice. Worrisomely, previous studies have showed that the compliance with hand hygiene guidelines is low and unsatisfactory among healthcare workers [6]–[9]. Most healthcare personnel do not wash their hands between handling medical charts and touching patients [9]. Despite many attempts to promote or measure the compliance of hand hygiene [5], [8], [10]–[13], adherence remains questionable. In addition, detecting possible vectors of pathologic microorganisms in healthcare institutions is another important step in blocking the transmission or eradicating these pathogens. Although a number of methods, including hand washing, have been used to minimize the occurrence of related infections, there has not been much focus on the source of potential infection in the environment, particularly, the role of hospital medical charts as a possible vector of pathogens.

Table 1 summarizes the characteristics and results of the medical charts retrieved for sampling in the study. In this study, we evaluated a total of 681 charts comprising 556 charts of patients in the general wards and 125 charts of patients in the special units,.The 681 beds included 313 medical, 179 surgical, 30 pediatric, and 34 Obs-Gyn beds in the general wards, as well as 62 medical, 30 surgical, 22 pediatric ICU beds, and 11 Obs-Gyn delivery or tocolytic beds. After excluding the beds that did not meet the inclusion criteria, we enrolled 455 beds in the general wards and 107 beds in the special units for chart sampling. In the general wards and special units, the sampling rates of medical charts were 81.8% (455/556) and 85.6% (107/125) for total beds (p = 0.316), 81.8% and 82.3% for medical beds (p = 0.930), 81.0% and 86.7% for surgical beds (p = 0.611), 70.0% and 90.9% for pediatric beds (p = 0.092), and 97.1% and 90.9% for Obs-Gyn beds (p = 0.433), respectively. Of the medical, surgical, pediatric, and Obs-Gyn beds investigated, we found no significant differences in the sampling rates of medical charts between each or between total general wards and special units.

The results of this study revealed that most medical charts were contaminated by bacteria (63.5% in general wards and 83.2% in special units). In addition, medical charts in medical, surgical, and pediatric ICUs were more likely to be contaminated than those in each corresponding general ward (p<0.05), with the exception of Obs-Gyn units. Our data suggest that the medical chart is indeed a possible vector of bacteria and also a potential source of infection. This is particularly true of medical charts in the ICUs. The plastic covers of medical charts can harbor potential pathogens. In addition to CoNS, other causative and opportunistic pathogens were found on the surfaces of medical charts and the risk of chart contamination by these pathogens was 2- to 4-fold [OR: 1.97–4.00] higher in special units than in general wards. The incidence of chart contamination by MRSA was also significantly higher in special units (9.3%) when compared with that in general wards (4.0%). Logistic regression analysis showed that the odds ratio of bacterial contamination by MRSA was 2.50 [95% CI: 1.12–5.59] in special units when compared with general wards. In this study, the incidence of MRSA colonization in special units (9.3%) was even higher than that (6.8%) reported previously [20]. Increased chart contamination by MRSA, one of the most common nosocomial pathogens, is a serious problem in ICUs. Chart contamination by other pathogens is also more common, and probably increases the risk of nosocomial infection.   Source: