Prevention of Hospital Acquired Infections
Healthcare acquired infections remain a major cause of morbidity and mortality among patients today, often leading to an increased length of stay, increased costs, dissatisfied patients, and most importantly, patient harm.
This article will address three issues in the prevention of HAI’s:
- The importance of hand hygiene and proper technique
- The avoidance of Clostridia difficile diarrhea
- The role visitors may play in the acquisition and transmission of these infections
The importance of hand hygiene
It goes without saying that standard precautions including hand hygiene before and after contact with any patient, even when using gloves, is a must. Considerations include:
- Putting gloves, gowns, and eye protection between you and the patient to prevent exposure to bodily fluids
- Use of respiratory hygiene, including the application of barrier tissues when coughing
- Masks in both patient rooms and waiting areas
- Safe injection practices and disposal of sharp tools
Hand hygiene is THE single most important factor in reducing the transmission of all microorganisms from HCW to patients, from patients to patients, and from visitors to patients. The challenge is to perform this procedure correctly, and thus effectively. This simple act is rarely done right, and monitoring cannot effectively measure the technique.
Hand hygiene should be performed before touching a patient, after touching a patient, before cleaning or sterilizing procedures, after body fluid exposure, and after touching anything in the patient’s environment.
The introduction of alcohol based hand disinfection, AHD, has greatly increased compliance with hand hygiene and has been shown to be superior to soap and water in most situations, excluding spore forming organisms like Clostridia difficile and Norovirus infections. In those cases, it is not really the soap and water, but the friction of the scrubbing that does the job.
Proper hand washing procedure
If you have observed hand cleansing in the healthcare setting (or for that matter, in any airport bathroom), you have probably seen what I call the “swish and promise” method: a two-second swish with hand sanitizer gel, palms only, or a quick water rinse and pump of the soap dispenser followed by the two-second scrub. Psychologically satisfying, yes, but not effective at all. This type of effort assuredly comes with a promise that there are still germs on the hands.
The safest proven technique is as follows:
- When decontaminating hands with an alcohol-based hand rub, apply the product to the palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry.
- When washing hands with soap and water, wet hands first with water, apply the soap product to the hands and rub hands together vigorously for 20 seconds. All surfaces of hands should be covered. Rinse hands with water and dry with a disposable towel which should then be used to turn off the faucet (hopefully all areas will have touch free faucets in the future).
- Liquid, leaflet, or powdered forms of plain soap are acceptable when washing with soap and water. Remember, it is the scrubbing, not the soap.
- Multiple use towels or roller towels are not acceptable.
Additional note about finger nails: they should be short enough that when you hold up your hand with the palm towards you, you cannot see your nails. Artificial or gel nails should not be permitted as they increase periungual colonization, which has been linked to outbreaks of infection in intensive care units, neonatal units and patients undergoing surgery.
Preventing Clostridia difficile diarrhea
Now let’s talk about a problem which is difficult to contain and plagues every healthcare facility: Clostridia difficile diarrhea. Nobody likes diarrhea, not the patient who experiences it, nor the nurse who cleans it up, nor the doctor as it compromises the patient’s other conditions and has limited treatment. Not to mention the administrators who know its direct and indirect costs of doing business.
Clostridium difficile is a spore forming organism that can cause a spectrum of diseases including diarrhea, antibiotic associated colitis, and toxic megacolon. It can also contribute to death via sepsis from a non-intact bowel wall, a colonic rupture, or severe dehydration and malnutrition.
Two events are usually required for its development:
- Disruption of normal bowel floral, usually caused by exposure to antibiotics that kill off competing flora, which allows for overgrowth of Clostridium difficile
- Ingestion of spores via the fecal oral route because of contamination of the environment, hands and fomites with the organism, and inadequate hand hygiene or cleaning
An initial episode can be prevented by minimizing antibiotic use and poor indications through an antibiotic stewardship program, avoiding gastric acid suppression unless essential for care, and judicious use of probiotics.
Unfortunately, the disease is recurrent for many patients. Prevention of recurrence requires meticulous hand hygiene and contact precautions, fecal transplantation to restore the normal bowel flora and, for those with two or more episodes, vancomycin prophylaxis when another course of antibiotics cannot be avoided.
Prevention strategies include early isolation of any patient with diarrhea until C diff is ruled out, strict contact precautions for patients and visitors, rigorous scrubbing of hands with soap and water, and environmental cleaning. When possible, disposable medical equipment should be used. The impact of UV light on the incidence of this disease is also being studied, and while there are conflicting opinions, I believe that those who are early adopters of this technology will show a decreased rate of infection over time.
Remember, these spores can live on dry surfaces for several months. Because of this, I believe visitors should follow the same rules as HCW to prevent this organism from spreading to families and others in the community.
Most antibiotics have been implicated in this problem, but there is some consensus that fluoroquinolones, clindamycin, broad spectrum cephalosporins, and penicillin are most frequently associated. These are occasionally followed by macrolides and trimethoprim sulfa. Rarely, they are accompanied by amino glycosides, tetracycline, metronidazole, and vancomycin. The role of a vigorous and interactive antibiotic stewardship program cannot be overemphasized.
Visitors’ role in infection prevention
Finally, when it comes to infection control, there is much controversy pertaining to visitors. Clearly, most infection control guidelines were established for the protection of patients and followed by HCW who go from room to room. The role of visitors as vectors for these HAIs, the benefits to patients, and the consequences of physically isolating patients from their families and visitors, are important areas for research.
Expert guidance has recently been issued to help hospital epidemiologists with this issue. (Munoz-Price LS, Banach DB, Bearman G, et al. Isolation Precautions for Visitors. Infection Control Hosp Epidemiology 2015;36(7):747-58.)
Several tenets apply:
- Hand hygiene stations should be readily available to visitors and they should be educated on their correct use
- Visitors who are clinically ill or have respiratory pathogens should avoid visiting patients
- Visitors should avoid contact with multiple patients, and if they must, like clergy or caseworkers from outside institutions, should follow the same procedures as HCW
A case can be made for any visitor to follow strict isolation guidelines when seeing a patient with known multi-drug resistant organisms. I would include C diff as an organism requiring visitors to follow contact isolation.
There also must be a sensitivity to the patient’s psychological well-being and chances of social isolation. I believe this can be done with appropriate education and thoughtfulness. The alternative is more harm from these infections.
Infection control has become more of a science rather than an art as validated research continues to be done to determine and prove what works and what doesn’t. But the public has been told that no infection is acceptable, and regardless of the difficulty that perception imposes, it behooves us all to work towards that goal.
Bottom line, there is absolutely no excuse for not washing your hands. To ignore this simple act, in my mind, should not be tolerated.