I know that pathogens on hospital floors are a potential risk for infection. How easily can these pathogens be transmitted to other surfaces, and what can nurses do to protect patients?-S.R., N.C.

Ervin A. Alcantara Espana, and Bridget Parsh, EdD, RN, CNS, reply: Since the 1960s, hospital floors have been identified as reservoirs for pathogens.1 In one recent study, vancomycin-resistant Enterococcus (VRE) was found in 69% of samples taken from floors, and methicillin-resistant Staphylococcus aureus (MRSA) was detected in 17% of samples.2 Patient and clinician footwear such as nonslip socks and surgical shoe covers can be vectors for the transmission of pathogens from the floor to other surfaces as well as to people.

The evidence shows that transmission of pathogens from the floor to footwear occurs readily. Walking for 5 minutes throughout the unit, including bathrooms, patient rooms, and corridors, can contaminate shoe covers tenfold.3 Pathogens on the floor can also contaminate patients' socks and disseminate throughout the patient's room and even to the nurses' station.4

Pathogens hitch a ride on socks

In one study, 54 pairs of socks and 35 environmental floor samples were obtained from seven hospital units. VRE was found on 85% of nonslip socks and MRSA was found on 9% of socks. Environmental sampling cultured VRE from 69% of floor samples and MRSA from 17% of floor samples.2

Research has also shown how pathogens can be transferred from the floor to bed linens.3 A recent study investigated whether nonskid socks that had been in contact with the hospital floor and were then worn into bed would contaminate bed linens.5 Swab samples were collected from hospital floors, nonskid sock bottoms, and bed linens in two hospitals. Bacterial isolates were identified and tested for antibiotic resistance. Isolates obtained from the samples were identified on all three surfaces at both hospitals. Antibiotic sensitivity testing revealed that a significant number of isolates collected were resistant to at least two antibiotics.5 This study demonstrated the transfer of potentially dangerous bacteria from the hospital floor to the socks and finally the bed linens.

In a study of viral contamination, researchers inoculated the floors in patient rooms with a nonpathogenic virus (MS2) to test how pathogens could potentially disseminate from the floor to other surfaces. On the first day of the study, MS2 was detected on multiple surfaces inside all the rooms.4 The researchers suspected that after virus from the floor contaminated patients' footwear, patients transferred the virus to their hands when touching their footwear. Once the virus was on a patient's hands, it could easily be transferred to other surfaces in the room via patient touch. The researchers also found MS2 in other rooms in the unit, in the nursing station, and on portable equipment such as vital signs equipment and wheelchairs, suggesting that both patients and nurses may have disseminated the virus.4

Nursing considerations

Nurses who understand the risks can play a major role in the prevention of healthcare-acquired infections by leading and participating in infection prevention efforts.6 To prevent the transfer of pathogens from footwear, nurses should ask patients not to wear socks in bed and consider wearing gloves to remove their footwear before they return to bed. Nurses who do not wear gloves should perform hand hygiene immediately after removing footwear.

If a patient wants to wear socks in bed, consider keeping two pairs of socks at the bedside, one to ambulate in and the other to wear in bed.

Finally, it is best to not send patients home with used hospital socks. If patients insist on taking socks home, either give them a fresh pair or place the used socks in a separate bag and advise them to launder the socks immediately upon their return home.

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