Infection control measures

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In February 2008, it was announced that Canada’s federal government was launching a national effort to reduce the number of hospital-acquired, or nosocomial, infections in the country’s hospitals. As part of this effort, the Public Health Agency of Canada (PHAC) said it was making patient safety in the hospitals its number one hospital priority.

PHAC has established the program in response to what is considered staggering numbers of infections contracted by patients and hospital staff. Initially, the program was to focus on three superbugs: MRSA, vancomycin-resistant enterococci and clostridium difficile or C. diificile. However, ultimately this list was narrowed down to include only MRSA because, among other reasons, its occurrence can be reduced significantly and rather simply by implementing proper hand hygiene measures.

It is estimated that as many as 220,000 Canadians develop nosocomial illnesses, including MRSA, each year. About 8,000 people die annually of these infections. In comparison, although it generated considerably more press and concern, the SARS outbreak of 2003 resulted in the deaths of only 44 people.

Before the launch of PHAC’s program, most Canadian hospitals were on their own in attempts to reduce the number of nosocomial infections occurring each year in their facilities. The result: inconsistent policies and outcomes, with some medical facilities doing much better than others. The new program should help put all hospitals on the “same page,” incorporating proven practices and procedures that can help protect the health of hospital patients and staff.

One directive of the program is to pre-screen patients for MRSA and other potentially life-threatening illnesses upon admission. If one is detected, these patients will be isolated from the rest of the hospital patients. Additionally, more thorough cleaning procedures will be implemented for this area of the hospital, and doctors, hospital staff, and visitors will be required to wear gloves, gowns, and masks when visiting these patients.

MRSA’s evolutionary story

Although scientists identified the bacterium Staphylococcus as far back as the 19th century, many medical experts say the first cases of MRSA, which is caused by a particular strain of Staphylococcus, or something resembling MRSA were discovered in the early 1950s. Most of these cases were reported in British medical facilities. However, there was little concern at the time because the infection was easily treated with penicillin, then still considered the wonder drug of the century.

But, within a few years, the bacterium causing the disease had adapted to penicillin, and doctors began to recognize that this strain of Staphylococcus had an uncanny ability to rapidly change itself so that it became resistant to drug treatment. Hope was rekindled in 1959 when the new antibiotic methicillin was developed. But once again, the bacterium adapted and this drug became ineffective as well. After this happened, doctors began calling the disease methicillin-resistant Staphylococcus aureus.

“We can always expect antibiotic resistance to follow antibiotic use, as surely as night follows day,” says Dr. John Jernigan, a medical epidemiologist with the federal Centers for Disease Control and Prevention (CDC). And because MRSA is particularly adaptive, treating it with antibiotic drugs has been proving to be an ever-growing challenge.

Among the first American cases of MRSA were reported in Boston in 1968. Although the number of incidents was small, MRSA continued to occur throughout the 1970s and into the 1990s. However, it gathered little attention during this time because of the relatively few cases and because, if caught early, it could be effectively treated with newly developed powerful antibiotics.

However, things have changed rather dramatically in the past 10 years. The bacterium causing MRSA has become ever more drug tolerant. Newer and even more potent antibiotics, such as vancomycin, along with combinations of other antibiotics have been used to treat patients but often prove effective only if the disease is caught it its earliest stages.

This means that, at least currently, the key to reducing the number of cases of MRSA—and many nosocomial infections—is prevention. And one of the most effective and proven preventive methods, as PHAC has already determined, is thorough hand washing and proper hand hygiene. Unfortunately, although studies may vary, it is estimated that only about 40 percent of Canadian health-care workers properly wash their hands.

Hand hygiene awareness

Before the mid-1800s, there was little knowledge or awareness of the importance of proper hand hygiene. At about that time, Vienna doctor Ignaz Semmelweis started instructing his medical students to wash their hands after anatomy class and before working with patients. He suspected that pathogenic bacteria from the cadavers were regularly transmitted to the hands of the students and physicians and then on to patients.

To his astonishment, there was a 500 per cent drop in the number of deaths at his medical facility. What might be even more astonishing is that even after his findings were reported, it still took a good 50 years before many other hospitals adopted similar hand washing practices.

Soon, restaurants, food service and processing facilities, schools, pharmaceutical manufacturers, and others recognized the value and importance of hand washing. Proper hand washing is now considered a landmark achievement in protecting public health. Despite this, however, a lack of proper hand hygiene continues to be a problem in all types of facilities, even though the CDC says that “hand hygiene is the single most critical measure for reducing the transmission of [potentially harmful] pathogens and organisms.”

Today, washing up between patients is recognized as crucial and should be standard practice. However, as referenced earlier, less than half of Canadian health-care workers wash up as often as necessary. And the situation is not much better in the United States, where studies indicate compliance among health-care providers is, on average, also below 50 per cent.

Hand hygiene

roadblocks

“There are really two key hand hygiene roadblocks in most medical facilities,” says Jim Glenn, CEO of Resurgent Health and Medical, which manufactures automated handwashing and compliance monitoring systems, “and those are time and convenience. Either health-care staff does not take the time to wash their hands as often as they should or, if they do, to wash their hands properly, or sinks and soap are not readily available.”

To properly wash hands, Glenn says that medical workers should:

• Wash hands frequently, especially after meeting with a patient as well as after removing gloves.

• Wash with soap and water for at least 20 seconds and with warm water at least 100 degrees Fahrenheit.

• Scrub, but scrub gently. Scrubbing can cause cracks and small cuts, giving pathogens a place to grow.

• Dry hands thoroughly. Wet hands are more likely to spread germs.

• Use hand lotions. These help keep skin intact so that cuts and cracks do not develop.

To help improve hand hygiene practices, some medical facilities are turning to automation. Automatic hand washing systems were actually developed more than 20 years ago, but are most frequently found in the food processing industry, where proper hand hygiene is also a must.

“The system takes about 12 seconds to thoroughly wash hands and effectively remove 99.9 per cent of transient microorganisms found on hands,” says Glenn. “To do this, hands are safely inserted into a rotating cylinder, which provides a high-pressure, low-volume spray of water to effectively clean hands.”

These machines use specially formulated cleaning solutions that also include a moisturizer to help prevent chapping and dry skin. The short wash cycle and the effectiveness of the machine appear to overcome the first roadblock of taking the time to properly wash hands. Typically, the systems can be installed wherever water/drainage connections are available, helping to eliminate the other major roadblock: convenience.

Raising awareness

One of PHAC’s goals is to focus on awareness: re-educating health-care providers about the importance of hand hygiene and how to wash hands frequently and properly. And awareness programs can be successful in reducing infections and illness. In one U.S. school district, sinks, hand soap, and towels were installed throughout the school, not just in restrooms and food service areas. Posters were installed promoting the need for proper hand washing and instructing students and teachers on how to wash their hands properly. The district achieved a 43 per cent drop in student absenteeism due to illness with the program in place.

Similar awareness programs are necessary in Canadian health-care facilities. “Along with this, installing automatic hand washing machines so that hand washing is easy, convenient, and quick can significantly improve compliance,” adds Glenn, “and doing so can help eradicate MRSA and other infections from medical facilities.”