Table 1 summarizes the information obtained during
the observational periods. The risk factors identified were (1) PACU personnel not sufficiently aware of cross-contamination, (2) a high level of fluctuation of patients, and (3) the ease in the PACU to transmit microorganisms from patient to patient. Cross-contamination in the PACU is most likely because of cross-transfer from a contaminated device, poor hand hygiene compliance because of acute overcrowding and high workload, and/or because of high frequency patient
contact.