Washing

Our Hands of Healthcare-Acquired Infections

By: Bruce E. Ruben MD, Medical Director of Encompass HealthCare and Wound
Medicine
www.encompasshealthcare.com


According to the American Hospital Association, over 36 million patients are
admitted to hospitals every year. Presumably, these patients go to hospitals to get
well, but one in 20 end up getting something else: an infection. Worse, one in nine of
those infections result in death.

The statistics vary among reporting agencies including the Centers for Disease
Control and Prevention (CDC), the Department of Health and Human Services and
the Centers for Medicare & Medicaid services. But, the situation is bleak no matter
whose report youre reading.

The numbers are startling just by themselves. But when you consider how these
infections are acquired, they become tragic. For example, a patient goes into the
hospital for a routine appendectomy and ends up dying from Clostridium difficile
(C-diff) related colitis, an antibiotic-resistant bacteria that originated in some other
patients colon.

How Multidrug-Resistant Bacteria Colonize and Travel

How did the bacteria travel inside the hospital to infect the appendectomy patient?
Its simple. Bacteria can travel by any hospital care worker making direct patient
contact or making contact with the myriad of devices inserted in patients, including,
most often, venous catheters and urinary catheters.

Maybe it was the nurse who wasnt diligent enough with her hand washing. Perhaps
it was the physician who touched a contaminated surface right before rounding.
Somehow, though, feces went from point a to point b without adequate
intervention.

Almost 100,000 patients a year acquire an infection from something as ubiquitous
and seemingly innocuous as a urinary catheter. How? It could be the catheter was
left in too long, thus keeping the entire urinary tract vulnerable to infection from
inside the body and outside. Maybe the catheter was installed under less than ideal
aseptic conditions.

Here, two points need to be made. First, there are many avenues within the hospital
setting where multidrug-resistant and deadly bacteria can travel, colonize and
invade. Of course, hospitalized patients are the most vulnerable due to their

underlying medical problem in the first place. Thats the nature of the hospital beast
and really, it applies to any inpatient healthcare setting.

Most importantly, hospital strains of bacteria are exposed to the broadest and most
expansive spectrum antibiotics that have easily mutated to resist those drugs. With
the exception of Methacillin Resistant Staph Aureus (MRSA), most of the remaining
multidrug-resistant bacteria remain within hospitals and other inpatient facilities.
Still, some patients have already experienced the end of the antibiotic rope.

4 Ways to Prevent the Spread of Healthcare-Acquired Infections
Thats why we all need to evaluate the social causations of this problem. That is the
social conditioning that considers hospitals as the first choice, safe haven model to
deliver healthcare to the unhealthy, and strongly reject the 2% death rate associated
with hospitalization. Strong consideration must be given to ambulatory healthcare
delivery models that can achieve the same positive outcomes as inpatient facilities,
but without the added risks.

To that end, here are some basic recommendations that will undoubtedly help lower
the numbers.

1. HAND WASHING
Hand washing is the single most important measure healthcare providers can do to
reduce the risks of transmitting skin microorganisms from one person to another, or
from one site to another on the same patient.

That means washing hands as promptly as possible between patient contacts and
after contact with blood, body fluids, secretions, excretions, and equipment or
articles contaminated by them. Its also important to use the proper time and
technique when hand washing. Below are two instructional posters courtesy of the
World Health Organization.

Note that the guidelines suggest washing hands when theyre visibly soiled and then
to use an alcohol-based hand rub to supplement (see below). According to the CDC,
many studies have found that sanitizers with an alcohol concentration between 60-
95% are more effective at killing germs than those with a lower alcohol
concentration or non-alcohol-based sanitizers. Non-alcohol-based hand sanitizers
may not work well for all germs, they can cause germs to develop resistance to the
sanitizing agent and may only reduce the growth of germs rather than kill them
outright. Also, they may be more likely to irritate the skin than alcohol-based hand
sanitizers.

Here, its important to note that alcohol-based sanitizers can quickly reduce the
number of microbes on hands in some situations, but sanitizers do not eliminate all
types of germs. Thats because although alcohol-based hand sanitizers can inactivate
many types of microbes when used correctly, people may not use a large enough

volume of the sanitizers or may wipe it off before it has dried, rendering them less
effective.

Additionally, soap and water are more effective than hand sanitizers at removing or
inactivating certain kinds of germs including Cryptosporidium, norovirus and
Clostridium difficile.

Essentially, what works best to reduce the spread of germs in healthcare settings in
terms of hand hygiene is a combination of thorough, soap and water hand washing
and using an alcohol-based hand rub.

This principle not only applies to healthcare workers, but to patients and visitors as
well. Patients and visitors, after all, have bacteria colonizing on them just like
everyone else, and they touch surfaces within healthcare settings. So it makes sense
to teach and encourage them to use good hand hygieneto be active participants in
the reduction and elimination of healthcare-acquired infections.

2. GLOVES
Gloves are important in reducing the risks of transmission of microorganisms.
Theyre worn for three critical reasons in healthcare settings. First, they provide a
protective barrier when touching blood, other body fluids, mucus membranes and
non-intact skin.

Second, gloves also reduce the possibility that microorganisms from one patient or
healthcare-related items (such as catheters, IV drip tubes and stethoscopes) could
be transmitted to other patients during patient-care procedures.

Lastly, gloves reduce the likelihood that the hands of personnel contaminated with
microorganisms from a patient can be transmitted to another patient. Here, its
important to reiterate that gloves must be changed between patient contacts, and
hands should be washed after gloves are removed.

Its also important to note that wearing gloves does not replace the need for hand
washing because gloves may have small defects or they may be torn during use.
Plus, hands can become contaminated during glove removal. Obviously, failing to
change gloves between patient contacts is an infection control hazard.

b._ruben_proper_glove_removal.jpg
Proper glove removal so germs are not transmitted to the hands.

3. SANITIZING TOUCH SURFACES
Some germs can live for long periods of time on surfaces within healthcare settings,
particularly those surfaces that are frequently touched by healthcare personnel.
Sanitizing these surfaces on a regular basis is critical to reducing the number of
hospital-acquired infections.

Touch surfaces commonly found in hospital rooms, such as bed rails, call buttons,
touch plates, chairs, door handles, light switches, grab rails, intravenous poles,
dispensers (alcohol gel, paper towel, soap), dressing trolleys, and counter and table
tops are known to be contaminated with staphylococcus, MRSA and vancomycin-
resistant enterococcus (VRE).

Objects in closest proximity to patients have the highest levels of MRSA and VRE.
This is why touch surfaces in hospital rooms can serve as sources, or reservoirs, for
the spread of bacteria from the hands of healthcare workers and visitors to patients.

b._ruben_infection_sources.jpg

Common sites in a hospital setting where germs can be acquired through touch.

4. SPEAK UP!
Its up to healthcare workers to do all they can to stem the onslaught of healthcare-
acquired infections including hand washing, gloving up and making sure surfaces
are disinfected. Conversely, its up to patients and their advocates to speak up when
they see these guidelines not being followed.

Patients have to speak up.

If a healthcare worker is about to touch you and you havent seen him/her either
wash their hands or rub them properly with an antibacterial hand sanitizer, you
must speak up. It may sound dramatic, but considering the facts and figures stated
above, this could be a matter of life and death. Patients simply cannot accept the risk
of being silent in these situations.

Patients have to ask questions even though its often the most difficult thing for a
patient to do. How long will this catheter stay in? How often will the catheter be
changed? What can I do to make sure I dont get a surgical site infection?

The Importance of Reporting Adverse Healthcare Incidents
Reducing the number of healthcare-acquired infections is a primary concern for
hospitals, outpatient centers and long-term care facilities alike. And while some
recent reports suggest the numbers may have declined slightly, there is also a big
problem with getting hospital workers to recognize adverse healthcare incidents,
including infections, when they happen, and then to follow through with reporting
those incidents to management.

In fact, according to the January, 2012 report by the Department of Health and
Human Services Office of Inspector General, hospital staff did not report up to 86%
of adverse events (including infections) to incident reporting systems, partly
because of staff misperceptions about what constitutes an adverse event.

Clearly, much work needs to be done in order to improve patient safety and reduce
the number of healthcare-acquired infections. And it all begins with the most basic
action any healthcare worker can do: wash their hands.

About the Author
Dr. Bruce Ruben is the Founder and Medical Director of Encompass HealthCare,
located in West Bloomfield, Michigan. Encompass Healthcare is an outpatient facility
featuring advanced wound care, IV antibiotic therapies, hyperbaric oxygen treatment,
nutritional assessment, and other treatment modalities. Dr. Ruben is board certified in
Internal Medicine, Infectious Disease, and in Undersea and Hyperbaric Medicine. He is
a member of the Medical and Scientific Advisory