Sunday, February 12, 2006

Sterile environments anything but routine

"There is no such thing as a sterile operating room environment," said Dale Bratzler, MD, of the Oklahoma Foundation for Medical Quality, who helped write national guidelines for reducing infection after surgery. "We make things as clean as possible, but most hospital surfaces still contain bacteria."
This chilling quote comes from a November Boston Globe article about a series of infections at a New England hospital. One of the infections may have been responsible for a patient's death. And this hospital, it should be noted, has a national reputation for an aggressive approach to infection control, according to the article.
In the situation cited in the Globe, the surgeon unknowingly had a staphylococcal infection, which went into his nose. The bacteria then went through his surgical mask and into the patient's lower back through the incision.

According to the Centers for Disease Control and Prevention, 20% of operating room workers have a staph infection, but show no symptoms. It's worth remembering that most institutions don't even test for it because it is so common, and unless a patient's immune system is severely weakened, staph is usually not a threat.
Of course, many hospitals and surgeons don't stop there in terms of infection control. Statistics cited in the Globe article claim that almost 70% of surgeons said they give patients antibiotic treatment before an operation, which is up 15% from 2001. And while 70% isn't bad (although I do wonder about the accuracy of the figure), the flip side is that 30% of surgeons don't feel this particular precaution is necessary.
And of course, along with the ubiquitous "wash your hands" signs, all personnel are instructed to wear gloves and masks and the patient's incision site is often shaved and cleaned before the procedure.
And yet, despite all that, patients get sick and some die from iatrogenic infections.
And, while it's not an apples to apples comparison, if you replace "operating room" with any of a choice of terms for examination room-any place, in fact, where practitioners are treating patients with wounds-the importance of proper care against infection is clear.
And yet, how do you impress on every practitioner, every staff member, every patient, even, the importance of this level of precaution?
After a while, those "wash your hands" signs become like anything you see over and over again. The importance stops registering and it becomes routine. But practicing that routine at the level necessary every single time falls to the rush to get to the next patient, the next procedure, the next location.
And the same logic applies with the prophylactic antibiotics. There are probably some situations where they aren't strictly necessary. Pharmaceuticals can be expensive, especially for small facilities. And sometimes the problem is not even the facility or medical staff. Patients might be given the drugs and then forget to take them before an outpatient procedure, for example. I know when I had my wisdom teeth out a few months back, the oral surgeon's office called me the day before the procedure to remind (I won't say nag) me about taking the antibiotics. But that takes staff time and leadership.
And maybe a real awareness, also, of the fiscal liability inherent in infection control. A patient gets sick while you are treating him, and even after he recovers, do you think he's coming back to your practice? How likely is he to consider some sort of action to recover damages? I don't know. But the threat of this kind of legal action should scare everyone to the sink for another round of scrubbing. Reference:Anthony R Edwards ( Biomechanics Journal) February 2006.

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