The role of the hospital environment in the transmission of infections

In light of recent research findings on hand hygiene compliance rates, cleaning has never been more important within healthcare settings.

There have been an interesting series of papers published recently focused on the transmission of infectious microbes via hands and hospital surfaces. There are new superbugs to consider, as well as some new evidence on old problems.

Firstly, the team led by Professor Mary Lou McLaws have been at it again with real and quantitative hand hygiene compliance data. This latest research demonstrated that – surprise – doctors don’t wash their hands very often. But the contentious aspect is that the official Australian Hand Hygiene Compliance data suggests everything is terrific.

This is incredibly important work. There is a real problem in the quality of hand hygiene compliance data which is biased by the audit approach of a person with a clipboard counting hand hygiene opportunities (under the ‘5 Moments of Hand Hygiene’) and then counting hand hygiene compliance events.

In Australia the mantra was set for 70 per cent compliance but more recently it was lifted to 80 per cent. Most Australian hospitals report compliance in excess of the guidelines, all based on the clipboard audit model.

The work by the UNSW team led by Professor McLaws used quantitative methods of counting hand hygiene compliance events and triangulated the data for comparisons. The real data suggests the official numbers are wrong by between 30 per cent and 50 per cent!

So, the last thing touched by a health care worker prior to patient contact becomes pretty important. If that surface or object was contaminated by biofilms or transient pathogens, then those hands are contaminated.

Those unwashed hands can transfer bugs straight from the contaminated surface or object, and then onto a patient! Hand hygiene and the hospital environment are inevitably linked because of the human behaviours of touching.

Despite the assurance of the official data on Hand Hygiene compliance, Professor McLaws’ research demonstrates the real position is hand hygiene compliance is woefully lacking where it is needed most.

Touching can be an act of friendship and warmth between two people. There are many healthcare tasks that require touching a patient in the normal course of patient care. However, if a well-meaning healthcare worker touches a patient with unwashed hands, they are potentially passing on infectious, pathogenic, and multi drug resistant microbes. The personal care of touching with contaminated hands is perhaps just “killing them softly” (a quote from Professor McLaws).

Work published internationally by the Dry Surface Biofilm team at Macquarie University and Western Sydney University has already found the dirtiest locations in any Intensive Care Unit (ICU) are where the cleaners are not allowed to work.

Objects such as movable chairs in the ICU and at the workstation and items located on the workstation desks are highly contaminated. More recent work has again reconfirmed mobile elements are also a cause of significant concern with organisms such as VRE.

A recent Australian study published in the Infection Control and Hospital Epidemiology journal looked at the transmission of VRE within the ICU of a major teaching hospital in Sydney.

The VRE bugs moved seamlessly from patients into the environment, onto other patients, and then back again. Mobile elements including resuable medical devices such as ultrasound machines (none of which are cleaned by cleaning staff) were regularly contaminated and bugs moved around the ICU on these mobile devices. Unwashed hands were again an implicated pathway for microbial transmission and cross infection.

Another recent paper by Professor Elaine Larsen, the very eminent editor of the American Journal of Infection Control, demonstrated via a ‘meta-analysis’ that the biggest single risk for catching an MRO is when a hospital bed was previously occupied by an infected patient.

The unclean bed acted as the vehicle of microbial transmission. Superbugs are located within the healthcare environment and if they are not cleaned away they try to find a new home, and any patient will do. The recipient of the next infection could be your mum or dad, your sister of brother, one of your children, another relative, or a close friend that gets an infection when they are already sick and in hospital. Effective cleaning is the answer.

But wait, there’s more. It’s the terrifying new yeast infection named Candida auris (C. auris). A paper at the recent Society of Healthcare Epidemiology of America conference in the US reviewed serious issues with this horrible little beast and the mortality rate for blood stream infections (Candidemia).

Not only is it resistant to two of the three classes of available antimicrobial treatments, it is also resistant to most disinfectants and is able to survive on surfaces for more than a few weeks. Fortunately, a multi drug resistant (MDR) C. auris has not been reported in Australia – yet.

Cleaning has never been more important within healthcare settings, and the cleaning staff are the significant heroes in this real life epic. Cleaning done well saves lives. All of which should remind you to wash your hands after every bathroom visit. So, keep clean and keep well.

This was first published in the August issue of INCLEAN NZ. 

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