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Hospitals face hand-washing crackdown


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Apr 23, 2007
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Years ago my mother almost died from a hospital-acquired infection. Back then most people thought it an extremely rare event. Now 220,000 people develop such infections each year - and a surprising portion is due to people not knowing basic hygiene, like hand washing.

Hospitals face hand-washing crackdown

Amid growing concern over spread of infection, watchdog demands hygiene audits and compliance plans from acute-care facilities

From Tuesday's Globe and Mail
May 20, 2008 at 2:00 AM EDT

Canadian hospitals seeking accreditation will soon be required to audit whether their doctors and nurses are washing their hands – and are expected to do something about it if they are not.

Beginning next January, Accreditation Canada will compel virtually all acute-care hospitals – in addition to those nursing homes and other facilities seeking stamps of approval – to not only do hand-hygiene audits but to have a plan to maintain or improve hand-washing compliance.

Not even hospital volunteers will be exempt: They and hospital staff will be trained on how to properly wash their hands and to know when it is required.

“Clearly, hand hygiene is a very important step in the prevention and/or control of spread of infection,†said Wendy Nicklin, president and chief executive officer of Accreditation Canada, formerly known as the Canadian Council on Health Services Accreditation, a non-profit, independent organization. “ …We're at the point where we can't afford not to do it.â€

No wonder: With only 40 per cent of health-care providers in Canada properly washing their hands, experts say, infection prevention has become a hot-button issue.

An estimated 220,000 people develop hospital-acquired infections in Canada each year; at least 8,000 patients are killed by them, roughly the same number as those who die from car accidents and breast cancer combined. And yet, half of all infections could be prevented through proper hand hygiene, experts say.

Although accreditation is a voluntary process, 99 per cent of Canada's acute-care hospitals participate in it, as do many nursing homes, some community health centres, home-care organizations and other health-care facilities. Accreditation Canada accredits 3,515 sites of 995 organizations.

By compelling hospitals and other health-care facilities to do hand-hygiene audits, the organization is following the lead of other countries. In the United States, hospitals not only face similar audits, but health-care providers are required to cleanse their hands 90 per cent of the time when it is warranted, such as before and after seeing a patient.

“It's high,†said Louise Kuhny, senior associate director of the standards interpretation group of the Joint Commission, a non-profit organization that accredits and certifies U.S. health-care organizations, of the 90-per-cent hand-hygiene compliance rate. “And it's a big requirement but we feel that it's important because clearly infections are directly related to this.â€

Michael Gardam, director of infection prevention and control for Toronto's University Health Network, said most hospitals do not have the resources to do the labour-intensive auditing – something that will likely change with the new requirement.

Typically, auditing involves dispatching a roaming posse of hand-hygiene workers with clipboards to discreetly observe whether health-care providers are washing up.

“By making it mandatory, they will need the resources to be able to do the audits, which in my mind is really important,†said Dr. Gardam, who heads MRSA intervention for Safer Healthcare Now!, a national group that helps implement safer health-care practices in hospitals.

The problem of poor hand hygiene has confounded some of the best scientific minds in search of a solution. There have been poster campaigns and buttons. Hospitals have even doled out Tim Hortons coupons as a reward to health-care workers who scrub up. Some of the problem has been attributed to a perception deficit: Many health-care workers think they are already doing a good job of washing their hands.

In an effort to prevent infections, some hospitals have even instituted bans. At Sunnybrook Health Sciences Centre in Toronto, artificial fingernails, long natural nails and rings with stones are forbidden; no staff member providing direct patient care can wear them.

Bracelets that dangle past the wrist near the hand are another no-no, save for religious reasons. Even in those cases, the bracelets must be pushed up on the arms and kept in place. Plain wedding bands are discouraged but not banned.

Mary Vearncombe, Sunnybrook's medical director of infection prevention and control, said the bans are based on scientific evidence. Artificial nails, for example, trap moisture and can harbour yeast and gram-negative bacteria such as Pseudomonas aeruginosa.

“There have been some patients who have died, babies who have died [in North America], traced back to artificial nails,†said Dr. Vearncombe, who is also chairwoman of the provincial infectious diseases advisory committee's subcommittee on infection prevention and control in Ontario.

If the last audit, done in March, is any indication, Sunnybrook's hand-hygiene efforts are paying off. It showed health-care workers washed their hands 60 per cent of the time when required, which is higher than the nationally cited figure of 40 per cent.

“We need to sustain and improve on that,†Dr. Vearncombe said. “We all want to be 100 per cent. If we could get at 90 per cent, I'd be thrilled.â€

The low-tech solution – hand washing to prevent infections – is a hot-ticket item in hospitals. So far, 150 of 158 hospital corporations have attended or are registered for one of the 15 training sessions of Ontario's Just Clean Your Hands program, according to its project manager, Liz McCreight. Eligible facilities include acute-care hospitals, mental-health facilities and rehab hospitals.

As part of that program, designated trainers in hospitals are shown how to teach hand hygiene to their staff. The results of compliance are to be shared among individual hospital units.

“This thing is really about making a system change to make sure that they have what they need when they need it to perform hand hygiene,†said Ms. McCreight, adding that making alcohol-based hand gel easily accessible is also part of the solution.

Phil Hassen, chief executive officer of the Canadian Patient Safety Institute, said while mandatory hand-hygiene audits are important, “we do need some monitoring of infection rates, because in the end you need to know whether you are actually making a difference or not.â€

Pamela Fralick, president and chief executive officer of the Canadian Healthcare Association, predicted most health-care facilities would embrace the new requirement, as the benefits far outweigh costs.

“This is an era of accountability and patient safety,†she said in a telephone interview from Ottawa. “The two go hand in hand.â€

Hand hygiene

When performed correctly, hand hygiene is the single most effective way to prevent the spread of communicable diseases and infections.

In health care, hand hygiene is required:

- Before and after contact with patients, their body substances or items contaminated by them.

- Between different procedures on the same patient.

- Before and after performing invasive procedures.

- Before preparing, handling, serving or eating food or feeding a patient.

- After assisting patients with personal care.

- Before putting on and after taking off gloves.

- After performing personal functions such as using the toilet and blowing the nose.

- After hands have come into contact with secretions, blood and other body fluids. Source: The Community and Hospital Infection Control Association of Canada

Prometheus The Supremo

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Apr 23, 2007
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a strange reality, bizarro toronto
i've encountered some nasty conditions in the hospital circuit. some nurses feel that gloves are solely for their protection and not yours. putting on gloves, touching faucet knobs, garbage cans, hospital room curtains, etc. and then doing a procedure on a patient with those contaminated gloves is a real no no in my books.

also, bringing a cripple a "toiletchair" with someone else's crap splattered all over it is an extreme no no.

and also, if you should be laying in your ward bed and you smell the putrid stench of rotten fish for a few days, lean over and look on the floor beside your bed because there just might be a bag of someone else's shit laying there.


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Apr 22, 2007
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I think part of the problem is that health care professionals get tired of washing their hands.

Some countries have made the elimination of hospital-acquired infections a priority. In the Netherlands, giving doctors and nurses belt-mounted hand sanitizer dispensers and better quarantine rules for infected individuals and materials have almost eliminated these kinds of infections.

The CBC did a story on it... apparently one hospital left a bed in a hallway that had had someone with C. dificile on it, only with a piece of paper saying "CD" on it to warn people. So dozens of people may have touched it, not knowing the surface was contaminated.

In other words, a lot of it is a result of incredibly sloppy hospital operations.

Prometheus The Supremo

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Apr 23, 2007
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a strange reality, bizarro toronto
Hospitals reusing single-use devices without validated cleaning: survey

2 hours, 53 minutes ago

By Helen Branswell, The Canadian Press

TORONTO - A significant number of Canadian hospitals are still reusing single-use medical devices and the vast majority of those that do sterilize or "reprocess" the devices in-house - a practice fraught with risk, infection control experts say.

But while there appears to be consensus that a national policy is needed and that the practice of in-house reprocessing ought to be banned, a regulatory void means that in many parts of the country hospitals can do as they wish when it comes to reuse of single-use medical devices.

Among the devices being reused are biopsy forceps used in stomach and bowel surgery, membrane scrapers used in eye surgery, breast pump kits and blades, burrs and drill bits used to bore through bone.

"I'm absolutely appalled," says Dr. Mark Miller, head of infection prevention and control with Montreal's Jewish General Hospital, and the author of a 2001 report on reuse of single-use devices that for a time put the issue on the political front burner.

Miller was commenting on the findings of the latest survey into single-use device reuse by Canadian hospitals, the results of which are published in the May issue of the journal Infection Control and Hospital Epidemiology.

Of 398 hospitals that responded, 28 per cent admitted to reusing single-use devices. While some of the reprocessing is farmed out to U.S. companies certified by the U.S. Food and Drug Administration, 85 per cent of the hospitals that admitted to reprocessing said they did the work in-house.

The senior author of the study, Dr. Michael Gardam, says the numbers are probably even higher. "I doubt that we're underestimating the problem."

Forty per cent of the hospitals that reprocess single-use devices reported that they had no written policy on the practice. "They just do it," Miller says, sounding incredulous.

In fact, the percentage of hospitals that currently reuse single-use medical devices is only slightly lower than the 31 per cent that reported reuse of single-use devices in a survey taken in 1986.

In the 20-plus years since that earlier survey, tragedies like the tainted blood scandal and cases of variant Creutzfeldt-Jacob disease - the human form of mad cow disease - linked to reuse of tools used in brain surgery have deepened the understanding of infection risks and raised the bar for infection control in hospitals.

And in recent years, a number of hospitals have had to ask former patients to be tested for HIV and hepatitis after discovering they had not been properly cleaning devices they reused. In 2004, nearly 1,500 Quebecer who had undergone hip surgery had to be tested after it was learned hospitals weren't completely cleaning a reamer, a type of surgical drill part.

Most in the field believe some single-use devices can be reused safely, if they are put through a thorough reprocessing procedure. They say medical device manufacturers almost routinely designate devices "single-use," for economic not safety reasons.

"If they can make it disposable, they can sell a hell of a lot more devices and it's actually a lot easier to bring it to market," explains Gardam, head of infection control for Toronto's University Health Network.

"Because if you want to make it reusable, you have to ... prove you can reprocess them. So obviously the manufacturer would far rather churn out single-use devices, because they only have to prove that it's sterile in the package when you get it."

The multitude of single-use devices drives up health-care costs and generates extraordinary amounts of waste.

In the United States, the FDA regulates an industry that has cropped up to reprocess single-use devices. Companies in the business must provide proof that the devices they reprocess can be thoroughly sterilized without compromising the integrity of the material from which the device is made.

A number of Canadian hospitals - Gardam's and Miller's among them - take advantage of that industry, trucking things like $3,000 single-use cardiac catheters to Minnesota to be reprocessed for about $1,000 a trip.

Accredited companies log each device, using bar codes and similar technology to ensure each one goes back to the sending hospital and that devices are only reprocessed the number of times that testing suggests is safe. That means if it's been determined the cardiac catheter can be safely reprocessed 10 times, it will be discarded if it makes an 11th trip to Minnesota.

Health Canada does not regulate this field. And while infection control experts have called for the department to take on this task, it says it does not have the legal authority to do so.

"The Food and Drugs Act, from which the Medical Devices Regulations derive their authority, is not intended to apply to the use of a device after its sale," the department explains in an e-mail from spokesman Paul Duchesne.

"Reprocessing of a device by a hospital for reuse in that hospital does not constitute sale. Therefore, Health Canada does not have the authority to regulate reuse or reprocessing."

Furthermore, it doesn't plan to seek those powers.

"The practice of reprocessing by hospitals of medical devices relates to health-care system management in provincial and territorial jurisdiction and therefore is not within the federal role. Therefore, creating new authorities is not being considered."

Instead, it says it is exploring with provincial and territorial partners the possibility of creating a "pan-Canadian framework."

Currently some jurisdictions have rules, while others are silent on the issue.

Manitoba bans reuse of devices that come in contact with blood or are used inside the body. Since the start of this year, British Columbia has ordered that these so-called critical contact devices can only be reused if they are reprocessed by regulated companies.

In Ontario, guidelines Gardam helped to write for the Ontario Hospital Association say reuse of single-use devices is only permissible if hospitals prove it is safe to reuse them.

The only way to do that, he says, is to use licensed third-party reprocessors. "They take them through far more hoops than a hospital would to reprocess a multi-use device. So they're very, very stringent in terms of what they do."

But Gardam believes a large percentage of hospitals that are reusing single-use devices haven't taken the steps to prove what they are doing is safe. And Miller says hospitals that reprocess in-house simply don't have the wherewithal to do the work the way it needs to be done.

"We don't have the resources, the people and the money to be able to do it properly. And I know that the hospitals that are reprocessing - unless they're different than every other hospital that's been reprocessing across North America - that they're not doing it according to all the norms," he says.

"And therefore if they're not doing it according to all the norms, then they're exposing patients and the workers who are working with these instruments to potential dangers. And that's just the way it is."