Fewer than one-fifth of nurses who work in medical practices affiliated with the largest health care system in the region say they follow all nine steps that are highly recommended to prevent infection with the hepatitis C virus.

The steps are formally known as standard precautions for infection prevention, measures that are widely accepted throughout health care. But a team of doctoral-level nurses at Northwell Health, assisted by experts at Case Western Reserve University in Cleveland, found that some nurses skip steps, leaving themselves and patients vulnerable.

The team examined infection control methods in ambulatory care — at medical practices large and small — associated with the local health care giant.

Public health officials at the Centers for Disease Control and Prevention have found that the majority of people in the United States treated for medical conditions seek care in the ambulatory setting, accounting for 1.2 billion visits annually to physicians’ practices, outpatient centers and emergency rooms in hospitals.

But the new local research reveals that most nurses follow some infection-control steps; few adhere to all nine. Worse, some have poor knowledge about hepatitis C, an infectious agent that is on the rise.

“We questioned nurses in Suffolk, Nassau and Queens,” said Donna Armellino, vice president for infection prevention at Northwell’s division in Lake Success and a researcher on the study.

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Armellino worked closely with her Northwell colleague Donna Powers, who began the research as a doctoral thesis, which morphed into an exposé of problems afoot in medical practices. The analysis is published in the current issue of the American Journal of Infection Control.

Powers and Armellino gave the nurses paper questionnaires and required that they be filled out in ink. They said sending the questions via email ran the risk of nurses deleting the questionnaires.

Nurses surveyed in the study were assessed based on precautionary measures known through evidence-based medicine to prevent infections in health care settings. While the precautions are strongly recommended by the CDC, they are not enforced by law.

All nine measures can help prevent transmission of hepatitis C — the focus of the analysis — as well as other serious viral infections, such as hepatitis B, HIV and deadly drug-resistant bacteria.

This is what Powers and Armellino asked nurses:

  • I provide nursing care considering all patients as potentially contagious
  • I wash my hands after the removal of gloves
  • I avoid placing foreign objects on my hands
  • I wear gloves when exposure of my hands to body fluids is anticipated
  • I avoid needle recapping
  • I avoid the disassembling of a used needle from a syringe
  • I use a face mask when exposure to air-transmitted pathogens is anticipated
  • I wash my hands after the provision of care
  • I discard used sharp materials into sharps containers

The team found that the highest rate of compliance involved gloving because 92 percent of nurses reported wearing them. Face mask usage was second at 70 percent. But compliance fell off in one of the most critical areas of health care — only 63 percent of participants reported washing their hands after glove removal.

In addition to the lapses in hygienic practices, the team also found that nurses lacked knowledge about hepatitis C, a virus that attacks the liver and can remain undetected for decades.

An estimated 26 percent of the nurses erroneously thought the pathogen is most commonly spread through sexual contact. Sexual transmission is low compared with needle sharing among drug users, or body piercing and tattooing in unhygienic settings.

Armellino said the analysis is important because it uncloaks problems about infection control and lapses in knowledge about a serious pathogen.

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“There is a lot of research that focuses on hospitals,” with respect to infection control, Armellino said. “We wanted to add to the knowledge in the literature about the ambulatory setting.”