Hygiene in practice – what one does not waste much thought on in “normal” times, becomes a topic of increasing importance in times of the pandemic. For physicians, consistent compliance with hygiene measures is important in order to protect themselves, employees and, of course, patients, and ultimately to be able to maintain practice operations.
Hygiene – according to the official definition – is the science of keeping people healthy by keeping the body and clothing clean and the working environment clean. These include, in particular, measures that prevent the unwanted proliferation of microorganisms (bacteria, viruses, fungi, parasites) and thus the spread of disease. In this context, practice hygiene refers to a comprehensive package of measures that regulates the processes in the practice from the point of view of the transmission of infections and which must be complied with by all members of the practice team without exception.
Personal hygiene
Hospital and practice hygiene aims to interrupt transmission pathways. The four classic transmission routes are:
- Droplet infection (e.g. influenza, SARS-CoV-2, resp. viruses, norovirus)
- Contact infection or indirect contact infection (Clostridium difficile, MRSA, multidrug-resistant gram-neg. bacteria)
- Aerogenic infections (tuberculosis, measles, varicella, SARS-CoV-2)
- Transmission via blood/tissue/organs (HIV, hepatitis B/C, malaria)
When it comes to interrupting them, we’re talking primarily about personal hygiene. Its initial purpose is to maintain staff health and prevent pathogen transmission. The most important components – the so-called standard hygiene measures that are always used when dealing with patients – are hygienic hand disinfection, no private clothing and jewelry in direct patient contact, personal protective measures (gloves, surgical mask/protective goggles, over-apron) and the well-known coughing rule (on the part of both staff and patients).
These standard hygiene measures are always applied, regardless of who the patient is and what is known about them. The measures are based on the fundamental assumption that every patient is initially infectious. Accordingly, the goals are to prevent bloodborne diseases, protect against exposure to body fluids, and minimize/prevent the spread of (unknown or multidrug-resistant) germs such as MRGN, MRSA, VRE, Candida auris, or respiratory viruses. “If you consistently use and adhere to the standard measures, you have almost reached isolation in terms of quality,” explained Nina Durisch, MD, Head of Internal Medicine and Infectious Diseases at Uster Hospital [1].
The most important tool remains hand hygiene. The World Health Organization (WHO) recommends 5 moments of hand hygiene:
- BEFORE patient contact
- BEFORE aseptic activities
- AFTER contact with potentially infectious material
- AFTER patient contact
- AFTER contact with the direct patient environment
A prerequisite for good hand hygiene is always that the hands should also be disinfectable, i.e. they must not be brittle or cracked, which makes disinfection difficult. For the same reason, rings or watches, etc. should not be worn.
Gloves, goggles and apron as “tools”.
The hygienic appearance of the doctor also includes taking off private clothes and putting on work clothes when starting work. Private clothes are kept separate from work clothes and in case of contamination, work clothes are to be changed directly. Washing should be done at least 60 °C.
Gloves are primarily intended to protect medical personnel, not patients, Dr. Durisch reminded. Accordingly, gloves are indicated for (possible) exposure to blood or body fluids and when handling potentially skin-damaging substances (e.g. surface disinfectants). Otherwise, gloves are not mandatory and have therefore been excluded from the rules on contact insulation in Switzerland for some time. When using them, it is important to disinfect hands before and also after.
Mouth/nose protection has its place in the standard measures whenever something with a splash hazard is done, e.g. rinsing wounds. In addition, there is an indication if the patient is coughing or has a cold. In addition, there are the invasive measures, such as lumbar puncture, to prevent staff from transferring anything to the wound. Currently, of course, mouth-nose protection is standard pandemic equipment as part of droplet isolation.
Safety goggles also have their place among the standard measures, although they are used rather rarely. “We see that in our hospital, too, that acceptance is not very high,” the expert stated. She suspects the goggles are often seen as annoying and tarnish, but they are also important for potential exposure of blood/body fluids to the eyes, splash hazards when handling potentially mucous membrane-damaging substances, and as part of droplet isolation and SARS-CoV-2. “I think the goggles are useful if only because you’re automatically much less likely to grab your eyes and face when you’re wearing them.”
An overapron is indicated when major contamination is imminent, such as when stool is involved or a soiled bed needs to be freshly made, also when rinsing wounds. It is also part of the protective measures for contact isolation (for patient contact) and in the context of the SARS-CoV-2 pandemic. “Psychologically very important, one has the feeling, but purely from the transmission mechanism yet rather of secondary importance.” Hands and MNS play a much more important role here, according to Dr. Durisch. The FFP2 mask is not one of the standard measures. It protects against both droplets and aerosols. The right fit is important, as is correct donning and doffing. For aerosol-generating procedures (e.g., intubation, non-invasive ventilation, bronchoscopy, tracheostomy), the mask is certainly useful or necessary.
Last but not least, the prevention of blood-borne diseases is also a standard measure. The staff should be protected by vaccinations, according to the specialist, it is somewhat up to the hospitals and practice owners how strict they are in this regard. is and how to check it. Vaccinations include hepatitis B, influenza (annually), pertussis, measles, mumps, rubella, varicella. In the future, COVID vaccinations will certainly become a priority.
Environmental Hygiene
In environmental hygiene, on the one hand, we are talking about cleaning, i.e. the mechanical removal of microorganisms, which does not require killing. Then from disinfection, which reduces the number of pathogenic germs so that the treated item no longer poses a risk of infection. A distinction must be made between chemical disinfection (i.e. insertion or wipe disinfection) and thermal disinfection using a pot washer or instrument washer. Finally, sterilization: the killing of all microorganisms and the inactivation of all viruses including. Spores.
The question of the appropriate disinfectant is not always easy to answer. The manufacturer’s information must always be observed (overview 1). The general advice of the expert: Less is more! So you should try not to have too many different agents in practice.
Regarding surface cleaning and disinfection, medical staff should always ask themselves a few questions. Why: The aim is to reduce sources of infection emanating from surfaces. How: What material is needed and how is disinfection carried out? Is protective equipment necessary and must it be ventilated, for example? What: floors, surfaces, med. equipment, sanitary facilities? When and with what: Which agents should be used and at what intervals?
With regard to the use of spray disinfection, Dr. Durisch concluded with a clear message: Where wiping is possible, spraying should not be used! She referred to the relevant Recommendations of the Robert Koch Institute: Spray disinfection endangers the person carrying out the work and achieves only an unreliable effect. It should therefore be restricted exclusively to those areas that cannot be reached by wipe disinfection.
Take-Home Messages
- Develop smart hygiene concept (interdisciplinary) for practice
- Involve personnel
- Regularly check and train
- Tighten/review products
- Adhere to, respect and exemplify hygiene guidelines for patient and staff safety.
Source:
- Workshop “Hygiene Issues in Family Practice”; 60th Davos Medical Congress – Online Event, February 11, 2021.
InFo PNEUMOLOGY & ALLERGOLOGY 2021; 3(2): 34-35.
