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Thursday, May 17, 2012

Physics of Flying Feces – not for faint folk!

Some of you may have heard my Webber Teleclass with the above title, or my follow up presentation "Portal of Entry: the Missing Link". Both presentations look at how we handle fecal waste in our healthcare facilities and the organisms that are harboured in the patient's feces: I focussed primarily on Vancomycin Resistant Enterococci (VRE), Clostridium difficile (CD), but this list could be expanded to include the Extended Spectrum Beta lactamase (ESBL) organisms and the Carbapenem Resistant Enterobacteriaceae (CRE). All found frequently in fresh (or foul) feces (no more alliteration, I promise!).

In putting these presentations together, I recognized the importance of effective environmental hygiene and the importance of hand hygiene, not just of healthcare providers, but also of patient and families or visitors. Through previous Virox blogs and other journal articles I realize it does not matter what chemical is on a cloth wiping a surface if the surface is not wiped at all, or if the solution does not have the contact time required to kill the possible pathogens. There is no such thing as instantaneous kill; and surfaces with coatings or metals that kill bacteria still require a period of time to be effective. This leaves us with hand hygiene as our last line of defense, so if we pick up a "not quite dead" organism, we can either wash it off or kill it with alcohol based hand rub (ABHR).

Our environmental arsenal now includes sporicidal agents to be used when we have a CD infected patient. I have heard of some facilities that are now using the sporicidal agents on all discharge cleans of patient washrooms, in case the patient was an asymptomatic carrier of CD. This makes sense from a Routine Practices perspective: we don't really know who has what, and what they may share with whom. Don’t worry about the acronyms (MRSA, VRE, CD, ESBL, CRE)…worry about what is happening to the environment (yes, I have a presentation called Acronym Madness). In that presentation I summarize routine practices in 20 words:  "If they are leaking or soiling the environment, limit their movement and protect yourself. If it is dirty, clean it!" These 20 words will encompass Routine Practices and Additional Precautions such as Contact and Droplet. I think the only sign we really need is one for airborne transmitted organisms if we follow these words with dedication and readily available personal protective equipment. If you used a piece of equipment or your hands, they are dirty, clean them!

I have spent over 20 years trying to make hand hygiene so integral to all healthcare providers that it would be performed without thought, but with effectiveness. Demonstrations using finger paint on gloved hands to indicate where someone might miss while lathering their hands has opened many an eye, and even evoked the comment from a first year resident: "Why is it at this point in my career that someone finally showed me I do a lousy job at washing my hands"! We also have the hand wash demonstration where oil is put on staff hands, they wash and we show them where they missed while lathering. I have always hoped for a product whose fluorescence is inactivated by alcohol, so the same demonstration can be used with application of ABHR.

I was thrilled to see the April 2012 American Journal of Infection Control with a paper on patient hand hygiene. We do a great job in our healthcare settings to make it very hard for patients to perform hand hygiene, either keeping the sink against a wall for our mobility impaired patients already in their bed when a meal arrives, or not providing readily assessable ABHR near the patient. Even with ABHR available, if the patient does not have the strength or mobility to depress the plunger, they can't clean their hands. Let's assess our patient's ability to perform hand hygiene and warn staff that this patient may require assistance with hand hygiene. Let's allow a patient who is being moved from wheelchair to bed via a ceiling lift, in preparation for supper, to wash their hands at the room sink before their meal. They will have just moved their wheelchair through our healthcare facility and their hands will have acquired the same bacterial stew as the floors in our hospital's hallways. I don't know about you, but that is something I would not want to feed to myself along with my sandwich.

Control of feces is paramount to many of the acronyms. We have in our arsenal systems that wash and sanitize our bedpans after each use, we have liners which limit the spread of feces during disposal, and we have disposable bedpans that guarantee a single use. We also have older facilities (and newer ones) with none of this and an environment that gets soiled. Each new case of VRE or CD can be traced back to feces being where it should not be, or a surface or hand that was not cleaned effectively. With ESBL and CRE, when it shows up in an infected site, it might just be opportunistic and came from that patient, but it could also have been present where it should not be, in our environment.

The portal of entry for most of my acronyms is the mouth. Careful and effective handling of feces, scrupulous environmental hygiene, and fastidious hand hygiene helps break this link in the Chain of Transmission.

Jim Gauthier, MLT, CIC

Infection Control Professional
Providence Care, Kingston ON
President, CHICA-Canada

Jim Gauthier has been working in the field of Infection Prevention and Control for over 20 years.  He is a Medical Laboratory Technologist by training and loves his bugs so much so that he has written, arranged and performed several catchy tunes such as “I’m so much cleaner” and “Goodbye MRSA”.  Jim is currently an Infection Prevention and Control Practitioner at Providence Care in Kingston ON. He is also the President of CHICA-Canada.

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