Where's the fire?

I recently visited a large, newly built long term care facility. It was impressive, designed with the input of experts, had inspired architecture and was constructed to the latest standards. The staff were the best combination of the wisdom of “experienced hands” and the eagerness of the newly graduated. It was beautiful, inspiring and — had one critical failing which had no doubt already cost lives, and would cost more in the future.

That failing hit me just inside the front door. There was a large sign on the wall insisting that all visitors sanitize their hands due to an occurrence of flu-like symptoms. The symptoms were described, but did not say directly “Norwalk”, though staff later confirmed there was an outbreak of the Norwalk virus.

Visitors were required to use the squirt bottle of sanitizer on the table before entering the facility. It was a large bottle of a well known brand, foamy and smelling of alcohol, and entirely not up to the job of protecting the residents, staff, or the public. The problem is that Norwalk is a virus, and viruses are hard to kill; the sanitizer offered absolutely no efficacy against viruses (a closely related topic is that bacteria are becoming resistant and hence, harder to kill as well).

Another problem is that there is no unanimity here and in the United States on what type of hand hygiene is “good enough” in healthcare settings. One camp is in favor of hand washing with germicidal soap, which largely relies on the emulsification action of soap to carry the offending germs from the hands down the drain.

This has been the accepted practice for decades in everything from primary nursing to surgery prep. This practice has so permeated the mind of the public that huge numbers of homes have the obligatory squirt bottle of antibacterial soap on the edge of every sink in the house.

The other camp is firmly entrenched in the opinion that alcohol based hand sanitizers are the preferred method. Clinical testing demonstrates that this approach yields better results.

There is a third, much smaller camp, that advocates both; washing first and then using an alcohol based sanitizer.

One of the problems that Canada has to live with is our curse of geography; we’re bound, cheek by jowl, to the United States and this, to a large extent, restricts our horizons. The U.S. dominates us economically, militarily and especially medically. If we look a little farther over the horizon to Europe, we’d find a place which regards this hand washing dilemma akin to arguing about how many angels can dance on the head of a pin.

The European standard for efficacy in infection prophylaxis is decades ahead of anything commonly available here — and their standards, which have been in effect for 15 years, require efficacy against bacteria, viruses and even fungi in 30 seconds of use. Some of the products they use have been on the market for three decades and have the added benefit of not drying hands or being hard on the skin (this is of particular note for health care workers who wash their hands dozens of times a day).

Health Canada allows testing to the European standard and even the World Health Organization strongly supports the adoption of its EN 1500 standard. To date there is, to my knowledge, only one line of product available in Canada that meet these standards. The best primer I’ve found on the subject is at www.antiseptica.com.

Having the tools to control or stop an outbreak is frequently not enough; it requires the dedicated use of them by everyone entering or leaving a facility. It’s not enough for only some of the staff to observe good clinical hygiene — everyone, including visitors (who are frequently the agents of transmission), must be educated about the importance of good hygiene.

Through Herculean effort, we have practically eliminated measles, mumps and chicken pox. The dreaded scourge of polio was virtually eliminated in one generation. It is shameful and embarrassing how lax we have become to contagion that compromises quality of life and takes lives. Has our flame gone out?

The Norwalk virus has made the rounds again this winter — two or three times in some cases. A resistant strain of C. diff continues to spread in eastern Canada. Recently one of the largest prenatal wards in Canada was isolated due to Staph. The public notices and are affected by these things. Huge amounts of money are spent on treatment and education in healthcare facilities, so why is it a common joke among Canadians that “if you want to get sick, go to a hospital?”

The recent emergence of hospital acquired (especially surgically acquired) infections should cause everyone to re-examine the efficacy of current North American practices. The cost of treating patients for hospital acquired infection frequently exceeds the cost of the original treatment. This is especially important for the senior population as it covers everything from heart bypass and hip and knee replacement to toenail trimming. It’s time to steal a page from the environmental movement and start to “think globally, act locally.”

It all comes down to time; the time it takes to observe good hygiene in your healthcare setting, the time lost in employee absenteeism (a sick employee is an absent employee whether they are at work or not) and the time and expense of isolating a resident (bed changes, room and facility wipe downs). Most important is the cost to residents, both in reduced quality of life and an early demise due to a preventable sickness.

That’s what it’s all about — time and quality of life. The tools are available and the clock is ticking. Where’s the fire? Just look around you.