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Common sense and Semmelweiss
By Jessica Hilburn
Recently, I was a speaker at the South Central Cystic Fibrosis
Consortium. The presenter before me, Dr. Jane Siegel from
Children’s Medical Center Dallas, told attendees that routine infection control
measures will prevent transmission of highly resistant Pseudomonas aeruginosa and MRSA between
cystic fibrosis patients in the hospital
and clinic. I sat in the audience thinking about this statement.
When it was my turn at the podium, I said, “Dr. Siegel is right in
that routine infection control procedures will prevent transmission
of pathogens from one patient to another patient. And I also know
she will agree with my next statement: Routine infection control
measures are all but routine in hospitals.”
A hand hygiene study done at Texas Children’s Hospital demonstrated
that average compliance among physicians in our hospital is 56
percent. Another study at Texas Children’s evaluated compliance with
isolation practices. Compliance ranged from 20 percent to 100
percent depending on the inpatient unit. In one inpatient unit,
physician noncompliance was a whopping 93 percent.
What have I seen in hospitals? I have seen a physician sneeze on his
hand and walk into a patient’s room and shake the patient’s hand. I
have repeatedly seen doctors, nurses, therapists, and volunteers
ignore the posted isolation signs on the door. (These instructions
are designed to prevent transmission of infectious diseases from one
patient to another patient and to the health care worker.) I have
heard a toilet flush, and while it was still flushing the doctor
opened the door obviously forgetting to wash his hands. I have seen
a nurse eating her lunch outside of a VRE isolation room. If I see
these things, patients and their parents see them, too. What must
they think?
I don't think anyone intends to harm a patient, but noncompliance
with hand hygiene or isolation practices is not acceptable.
Why dos this happen? Don’t we see the isolation signs? Are we
too busy to read the sign? Do we think germs cannot infect us? Don’t
we realize we can spread microorganisms to ourselves and other
patients through dirty hands, clothes and stethoscopes? Don’t we
know that 90,000 patients a year die of nosocomial infections in the
United States? It is not possible to prevent all nosocomial
infections, but we all must be diligent to prevent those that we can
prevent. So, how can we do this? Hand hygiene and isolation are a
great start.
Hand hygiene
In 1852, Ignatz Semmelwiess discovered that disinfecting hands with
lime prevented childbed fever in women delivering babies, and
infection prevention was born. Today, we have products that are
kinder to the skin than lime and kill microorganisms effectively.
Are you using them?
Alcohol products such as gels and foams have almost replaced soap
and water and are now the preferred method to disinfect the hands.
When should one sanitize the hands with alcohol?
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BEFORE AND AFTER you touch a patient whether or not gloves are worn
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BEFORE AND AFTER handling patient care devices such as respiratory
equipment, urinary Foleys, or catheters, or doing wound care
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Before and after eating or drinking
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Before handling clean or sterile supplies
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After touching potentially contaminated items such as objects in a
patient’s room (bed, bedside table, charts, etc.)
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After removing gloves
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After touching the eyes, nose, face, hair, or after sneezing,
blowing nose
When should one wash the hands with soap and water? Wash hands with
soap and water if visibly dirty or contaminated with body fluids and
after using the restroom.
Standard precautions
Standard precautions means that you assume each patient is carrying
pathogenic microorganisms. Use gloves when touching non-intact skin,
mucous membranes or wounds. Use a mask and eye protection and a gown
with any patient who has respiratory secretions of any kind if you
are within 3 feet of the patient or when doing a procedure where you
may be sprayed or splashed with bodily fluids. Use a gown if you
anticipate substantial personal contact with the patient to protect
your clothing. These are the actions that protect the patient from
harm in the health care setting. These actions also help protect you
from unnecessary exposures to infectious diseases.
Isolation precautions
For all isolation precautions, all equipment used on a patient
(stethoscopes, scales, BP machines, etc.) must be kept in the room
or cleaned before leaving the room. Take off all personal protective
equipment (PPE) in the patient’s room and discard in the patient’s
room. Wash or sanitize the hands before putting on gloves and after
taking off gloves. Remember, a sign on the door does not protect the
patient–we protect the patient.
Contact precautions
A few examples of when to use contact precautions are for RSV,
bronchiolitis, croup, pneumonia, and patients with respiratory
secretions, diarrhea, shingles, scabies, lice or MRSA colonization
or infection. The pink contact isolation signs placed on the
patient’s door contain all the information one needs to know to
protect yourself and the patient. Wear gloves when entering the
room.
Droplet precautions
Droplet precautions are most often used for influenza, respiratory
adenovirus, suspected bacterial meningitis, or suspected pertussis.
Use a mask and eye protection within 3 feet of the patient. Use
gowns and gloves as you would for standard precautions. Read the
green sign on the door for a reminder.
Special contact precautions
We use special contact for VRE and C.difficile patients. Both of
these bacteria will survive for a long time in the environment.
C.difficile spores can survive in the environment up to six months!
Use gowns and gloves when entering the room. Use masks and eye
protection as you would in standard precautions. Read the dark
purple signs on the door for more detail.
Airborne precautions
Airborne precautions are most commonly for r/o tuberculosis
patients. When ruling out tuberculosis, call Infection Control to
facilitate the ordering of chest X-rays for family members of
patients, as most children with tuberculosis contracted tuberculosis
from a close family member. Use airborne and contact precautions for
Varicella patients and patients with measles.
In airborne precautions for tuberculosis, a N-95 respirator is used
instead of a surgical mask. The respirator needs to be individually
fitted and tested for each physician caregiver by Baylor Employee
Health.
In summary, infection prevention is literally in your hands. I
direct the Infection Control program at Texas Children’s
Hospital, but neither the Infection Control Department nor I can
prevent a single infection in a single patient. Why? We seldom touch
or care for any patient in the hospital. This is why each physician
must lead by example, using good hand hygiene and standard
precautions with all patients and appropriate isolation precautions.
Your patients and parents of patients expect and deserve nothing
less.
Jessica Hilburn is manager of Texas Children’s Hospital Infection
Control. |
