Hospital environments can be hazardous

By Bill Guerin

JAKARTA (JP): A hundred years ago, pioneers like Dr.Lister, a surgeon, and Florence Nightingale, a nurse, began to bring healing processes to hospitals, previously sites of death from septicemia. The speed and scale of our advances in knowledge since then is without equal, but we are facing newer and graver dangers today.

Those of us working in the healthcare field, manufacturers or doctors and nurses, mostly focus on the problems of hospital acquired infection, i.e. an infection a patient contracts during his stay in the hospital.

Nosocomial infection kills more people than car accidents, and is in the "Top Ten" causes of death with cancer and heart disease.

The CDC (Centre for Disease Control and Prevention) in the USA states that the single most important measure in reducing risk of nosocomial infection is good handwashing practice, with an effective antimicrobial product also formulated to protect the skin.

The CDC has stressed that gloving does not replace handwashing, and it is essential to wash one's hands after removing the gloves.

Gloves alone offer very limited protection from transmission of diseases -- it has been found that even new gloves leak about 2 percent of the time, and this leakage rate rises to 50 percent if gloves are stressed during use.

The problem in most countries is compliance, i.e. the tendency for healthcare staff not to wash their hands as often and as thoroughly as needed, when in fact a 15-second handwash can save a life.

This basic protective measure will become even more vital now that hospitals are faced with a potential doomsday scenario resulting from the widespread risk of VRE (Vancomycin resistant enterococci) infection.

Quite simply, these organisms are resistant to vancomycin (a very powerful antibiotic) and therefore most other drugs used to treat infection, can intermutate with common micro-organisms such as Staphylococcus aureus and thus cause them to be resistant. So the time can come when hospitals have outbreaks (epidemics) of common bacteria which can no longer be treated with the antibiotics available.

Continuing education programs, emphasis on proper handwashing, using microbiologically effective products, and a shared sense of responsibility are vital for hospitals, whatever size, and in whatever country.

However, what about the dangers to healthcare staff themselves, when working in a hospital? These risks and dangers are many and diverse, ranging from exposure to life-threatening viruses like HIV and Hepatitis, to poisoning with toxic chemicals used in hospital disinfection processes.

Most governments spend money educating the public about the transmission of HIV, the deadly virus causing AIDS, and it is largely a disease contracted by risky lifestyles. But in the USA alone, the latest figures show over 140 cases contracted by occupational exposure to the virus, i.e. contracted whilst working in a hospital environment. Imagine the feelings of those who have chosen a career to care for patients and save lives, when they themselves receive a death sentence.

This is very sad, and a totally unnecessary waste of human life, because the virus, (and the Hepatitis B virus), is categorized in the Lipid or medium-sized viruses, which are the least resistant to chemical germicides (tuberculosis and poliomyelitis, for example, are more resistant).

The protection comes from procedures, and in the USA, the system known as Universal Precautions was implemented, and enforced by law -- the OSHA (Occupational Safety Health Act) allows for large fines and other sanctions against hospitals not fully implementing the precautions.

This system assumes that all patients are considered potentially infected with HIV and/or other blood-borne pathogens, and describes precautions to be taken in various patient procedures and also the proper cleaning and decontaminating of blood spills or other body fluids.

The Hepatitis risk is even greater -- current figures, again from the USA, show over 7,000 hospital workers per year will contract Hepatitis B at work.

The same compliance problems may exist, and published studies indicate poor levels of compliance. For example, in a study of doctors and staff nurses in a trauma unit, 84 percent failed to consistently adhere to the units regulations. Can those people really care so little about their lives?

Factors shown to improve compliance rates were a belief in the value of the system, and education about HIV infection and transmission.

Hazardous chemicals pose a risk to hospital workers, mainly from chlorine compounds. In the USA, the EPA (Environmental Protection Agency) has proposed to Congress that chlorine products be drastically restricted, leading towards an eventual total ban. In Indonesia, the most commonly used chlorine active is sodium hypochlorite in the form of liquid bleach.

These products are first class for killing many bacteria and viruses, but because of their toxicity need to be handled with great care.

Bleach is highly corrosive, and gives off objectionable and irritating odors from chlorine gas (used in chemical warfare). It can badly burn the skin, and when mixed with certain body fluids (e.g. urine) can release highly toxic fumes.

The state of California, for example, which bans bleach as a disinfectant, reported at least 330 people in 1991 sick after using bleach.

Personnel handling these compounds need to wear protective clothing and be educated about the dangers.

Decontamination of instruments used in an operation can also be a risky business for healthcare workers. The system for many years used to include manual scrubbing of the instruments to remove blood, pus and other organic matter, before the instruments were sterilized. However, concern regarding workers' exposure to potential disease led to guidelines for protection when working in the decontamination area, such as wearing masks, eye glasses, waterproof aprons and gloves.

This is because scrubbing releases aerosols (bubbles) which may include life threatening viruses or other pathogenic organisms, and the very latest safety measure is to use an enzymatic detergent to decontaminate the instruments.

A simple soak in these products very quickly removes all organic contaminants, and the instruments can be rinsed and sterilized (cutting out the scrubbing step)

Those responsible for control and reduction of nosocomial infection and cross infection in hospitals have an awesome responsibility, and they have no real choice but to adopt the widely accepted standards in the USA and Europe, which can be summarized, for protection of patient, staff and the reputation of the hospital, as follows: Provision of approved and registered antimicrobial products with proven ability to kill micro- organisms, the formulation of widely used and accepted procedural practices, and continuing education for healthcare workers.

The writer works as a Consultant and Technical Adviser in Infection Control, in association with Huntington Laboratories USA.