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Supportive Care for Prevention of Infections For Caregivers and Patients
Ernest H. Rosenbaum, MD
It has been found that routine, daily prevention techniques can help prevent infections. This is very important for those caring for patients, both medical staff, as well as family and friends. The bottom line involves hand washing, which is vital, and unfortunately is only used by a third to half of caregivers consistently.
Abstracted from "On Washing Hands" by Atul Gawande, M.D., M.Ph. from The New England Journal under the Massachusetts Medical Society, 2004.
In 1847, at the age of 28, Semmelweis deduced that by not washing the hands consistently or well enough, doctors were to blame for puerperal fever leading to maternal deaths in hospitals. He developed rules for scrubbing hands and nail brushing with chlorine, and the puerperal fever rate dropped from 20% to 1%, giving proof to his theory as fact. Unfortunately, his colleagues appeared to be offended by these claims and results and could not accede to the knowledge that they were killing their patients, and Semmelweis was dismissed by his hospital staff. At that time, he did not publish his theory and logic, and he was viciously attacked by his colleagues when he insulted them with statements that they were causing a massacre and were murderers. He has been described as having both genius and lunacy in the way he approached this problem. He subsequently moved to Pest in Hungary, where he continued to promote his theory, knowing infectious contamination (bacteria) was all over the body, especially on the hands as well as the hair, axillae, and groin. Skin crevasses in the hands trap 10-20% more bacteria, making scrubbing and sterilization very difficult, but the worse place is under the fingernails.
It has subsequently been found that plain soaps do a reasonable job, as their detergents remove loose dirt and grime, but there's only a modest reduction after fifteen seconds of washing with ordinary soap. Thus, Semmelweis used a chlorine solution that was more effective. Of note is that in today's medical world, soaps contain chemicals, such as chlorhexidine, which disrupt microbial membranes and proteins.
It has also been noted that to do a thorough job, you must remove rings, watches, and jewelry, and after wetting hands, soap has to be lathered on all surfaces, including the lower third of the arms, for a full duration of at least fifteen to thirty seconds with a thirty-second rinse. The hands must be dried with a clean, disposable towel, which is then used to turn off the water. This technique is obviously difficult to promote and achieve, although frequent hand washing is essential. Skin irritation and dermatitis can be a secondary problem, and less irritating soaps, gels, and alcohol rinses that have been popular in Europe are now becoming more available. Alcohol concentrations of 50-95% are more effective in killing organisms, although pure alcohol is less effective.
The gels in dispensers at the bedside or in the hallway have become more available and are used with a better compliance of 40-70%. At the same time, vancomycin-resistant Enterococcus (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) infections are still prevalent and appear to be increasing.
Thus, following Semmelweis' obsession of hand washing is the gold standard, and anything less is considered inadequate.
At the same time, one must be careful that in the patient's surroundings spills, unclean toilets, drippy faucets, empty gel dispensers, or overflowing needles boxes can be the cause for promoting an infectious problem. Care also needs to be taken if the patient has a central intravenous line for lifetime parenteral nutrition or a dialysis line, which needs to be protected.
One of the main problems is just forgetting to wash one's hands after one leaves the patient, or has seen other patients prior to a visit, or in caring for another patient. To help reduce infection rates, some hospitals have bought automated sinks or expensive precaution cards ($5,000). One also needs to take extra precautions after visiting or shaking hands with patients with flu, colds, sniffling, or changing patient's dressings; and even the stethoscope needs to be cleaned by the medical staff between patient visits.
- In a brief presentation in March of 2006, Elspeth Connatty, R.N., and representing associates, Laurel Gibbs, M.T., Anthony Kiskakis, D.P.M., and Amy Nichols, R.N., from the hospital Epidemiology and Infectious Control of UCSF Medical Center presented standards and precautions that if used correctly at all times will successfully stop infectious disease transmission. They presented what they call standard precautions:
- 1. Hand hygiene
2. Surface disinfection
3. Personal protective equipment
- They discussed the use of gloves before and after patient contact, pre-invasive procedure prevention techniques, wound contact and bodily substance prevention information, equipment handling, supplies and disposal of contaminated linen with body substances, techniques in handling sterile supplies, precautions to be taken after use of the restroom, and prevention techniques after touching or blowing the nose.
Standard Precautions of Hand Hygiene
- 1. Soap and water wash using water to wet the hands, vigorous washing for 15-20 seconds, rubbing back of hands, nail beds, between fingers, up to wrists, and a thorough rinse. Use of paper towels for drying, which are also used to turn off the water faucet.
2. Additional precautions include alcohol-based hand rub, having available dispensers in the room or hallway, vigorous rubbing of back of hands, between fingers, into nail beds, and wrists, allowing air drying, and not wiping or washing off the alcohol gel.
3. Thirdly, having hand awareness and knowing where your hands have been and the potential danger of transmitting an infection.
- Standard Precautions of Surface Disinfection
- These include disinfecting and cleansing all items and surfaces used in multiple patient contacts, such as stethoscopes, medical instruments, etc. In addition, any visible soiling of linens in the bed must be removed, and the use of approved disinfectant, which is allowed to air dry prior to the next patient contact, in a hospital or nursing home environment.
- Personal and Protective Equipment
- There are standard precaution and prevention techniques known as personal protective equipment (PPE). This includes how to put on a gown, use of oxygen masks or a respirator, which needs a flexible band to bridge the nose, or changing the tubing periodically for nasal oxygen, the use of goggles or face shields for prevention of skin and eye infections, and glove techniques. When removing gloves, turn one inside out over one hand, and the second glove is peeled off and removed over the first glove. In addition, always clean hands before leaving the room after removal of personal protective equipment.
For the transmission-based precautions used in practice when a person has symptoms of a communicable disease, there needs to be tests to verify that there is a truly infectious agent after initiating precautions. Sometimes, isolation is important.
One of the major problems secondary to the use of single or multiple antibiotics is that of diarrhea caused by Clostridium Difficile. It is important to use hand hygiene with soap and water, not alcohol gel, following contact with patients with diarrhea and C-Difficile, and this is discontinued when the diarrhea resolves. More virulent, resistant strains of C-Difficile are emerging, and the spore-forming organisms are often difficult to eliminate from environmental contamination.
- Hopefully, what we have learned from the time of Semmelweis one hundred thirty years ago and our current up-to-date knowledge about the handling of infectious disease and precautions necessary to prevent transmission by some of the simple techniques described above - mainly hand washing - will help prevent patients from acquiring dangerous and possibly lethal transmitted infections.
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