Hospital hygiene and nosocomial infections. Problems and solutions.

The major challenge facing a hospital is healthcare-associated infections. Hygiene plays a vital role in their prevention and good control requires adherence to protocols for washing and disinfection of hands, surfaces, instruments and medical devices, hospital operating circuits, proper handling of waste resulting from medical activities, proper use of personal protective equipment and immunization programmes.

Healthcare associated infections

The prevention and minimization of HAIs (Healthcare Associated Infections, so-called nosocomial infections) has always been a major objective of medicine, being the best indicator of safety and quality of care.

Healthcare-associated infections affect patients and healthcare workers as well as healthcare institutions. Infected patients can develop serious complications, thus prolonging their stay in the hospital, quality of life is affected and the risk of death increases. Healthcare staff can also become infected, with the likelihood of spreading the infection further to other patients and thus increasing workload. Medical facilities may thus become overcrowded, the costs of care increase (treatments, diagnostic tests, and various surgical procedures (Benenson, et al., 2020)) and patients’ confidence in the quality of care may be affected. (Al Shamsi, Almutairi, & Al Mashrafi, 2020)

HAIs can be exogenous infections due to contact with visitors or other patients, contaminated surfaces, instruments and equipment and endogenous infections, when the body’s normal microflora becomes pathogenic as the body’s immunity decreases. Another route of infection is through injured skin.

At the national level there is the “Single communicable disease case report sheet”, provided for in Government Decision No. 657/2022, for the surveillance, identification and reporting of communicable diseases with nosocomial potential for healthcare workers. This allows timely control measures to be taken to prevent and/or limit a possible epidemic. (HG 657/2022)

Main causes involved in the occurrence of HAIs (Cepoi & Azoicăi, 2012):

• Poor hygiene inside the hospital (wards, hallways, food block, operating and dressing rooms)
• Failure to follow disinfection and medical waste disposal procedures
• Non-use of protective equipment by medical staff
• Inadequate functional circuits
• Visitor access to resuscitation rooms and operating theatres
• Overcrowding of wards
• Prolonged hospitalization which may result in contact with other patients who may be carriers of pathogens
• Poor patient hygiene
• Failure to detect pathogen carriers in time
• Increased number of immunosuppressed patients (premature, elderly, chronically ill, those with viral diseases and those on immunosuppressive treatments)
• Therapeutic (protective antibiotic therapy before certain surgical procedures, self-medication, etc.) and diagnostic interventions (endoscopies, colonoscopies, urethral probing, tracheal intubation, intravenous infusions, etc.)
• Poor training of medical staff

In order to prevent infection and transmission of pathogens, healthcare personnel must observe certain universal precautions (MS Order No 1101/2016;):

• Correct use of personal protective equipment (gown, gloves, mask, goggles/visor) and especially when exposed to blood or body fluids/secretions
• Hand hygiene is essential before and after contact with each patient, but also after removing gloves
• Change gloves after each patient
• Specific procedures to prevent the transmission of infectious diseases following the preparation and administration of parenteral medicinal products shall be followed
• Safe handling of medical equipment
• Proper management of medical waste (infectious, sharps, pathologic and anatomical parts, chemical and pharmaceutical, radioactive).
• In the case of a possibly contaminated area, it should be properly cleaned and disinfected
• Respiratory hygiene and cough etiquette (coughing and sneezing technique with the use of a disposable nose tissue, with positioning at least 1 meter away from the rest of the persons, followed by hand hygiene)

Hand hygiene by hygienic or surgical hand disinfection

Hands are the main route of transmission of pathogens, so hand hygiene is the cornerstone of HAI prevention. The effectiveness of disinfection depends primarily on its correct performance, but also on the quality of the water, soap and disinfectants used.

To prevent possible contamination, nails should be trimmed as short as possible, nails should be clean, without varnish, rings, bracelets and watches should be removed and appropriate protective equipment should be worn.

Hand hygiene saves between 5 and 8 million lives every year.

Prof. Didier Pittet (infectious diseases physician) and his team developed the concept of “The Five Moments for Hand Hygiene” by educating health care workers about the critical moments and reasons why hand hygiene should be performed: (WHO, 2009)

1. Before patient contact: to protect the patient from possible germ contamination on the hands
2. Before the aseptic procedure: to protect the patient from possible germ contamination as a result of medical procedures that may be ‘ports of entry’
3. After exposure to the patient’s biological fluids: for your own protection
4. After contact with the patient: for your own protection, the protection of subsequent patients and all persons with whom you will come into contact
5. After contact with the patient’s environment: for one’s own protection, the in-hospital environment, other patients, colleagues.

Immunization of healthcare personnel

It is one of the important preventive measures against nosocomial infections. Health facilities should encourage vaccination awareness and facilitate workers’ access to immunization programs.

Disinfection of surfaces, instruments, devices and medical equipment

Worldwide, morbidity and mortality from nosocomial infections are increasing and are associated with disinfectant resistance. A report published by the World Health Organization (WHO) in 2022 stated that more than 24% of patients are affected by healthcare-associated sepsis, and 52.3% treated in the ICU die each year. Another WHO report showed that in health facilities where good infection prevention and control practices are followed, 70% of infections are preventable (***, 2022) (***, 2022).

Hygiene of the hospital environment is an important pillar of nosocomial infection prevention and control. Surfaces can be contaminated by patients and healthcare staff with potentially harmful and multi-drug resistant pathogens. Therefore, routine daily cleaning and disinfection of frequently touched surfaces in wards and hospital is a standard procedure performed to prevent the transmission of pathogens to other patients.

Disinfectants are one of the most widely used safeguards against infection, apart from biosecurity, but their misuse and inappropriate use is a factor in the increase in antibiotic- and disinfectant-resistant genes. Those diluted and released into the environment might increase bacterial tolerance through phenotypic adaptation, gene mutation and horizontal gene transfer (Rozman, Pušnik, Kmetec, Duh, & Turk, 2021).

Although the ideal disinfectant may not yet exist, a careful selection process and proper use of biocides is necessary to minimize negative effects on the safety and health of patients and staff in healthcare facilities.

An ideal disinfectant should have the following properties:

• Broad antimicrobial spectrum
• Fast acting
• Unaffected by environmental factors
• Have a residual effect
• The disinfected surface remains moist long enough
• Low toxicity if it cannot be non-toxic to the user, visitors and patients
• Not flammable
• Easy to use with clear instructions on the label
• Compatible with a wide range of surfaces
• Odorless or pleasant smelling
• Stable
• Water soluble
• Good cleaning properties
• Economical
• Environmentally friendly

However, in reality, a product can’t fulfill all these conditions, therefore the most important aspects to consider before purchasing a disinfectant are: stability in use, toxicity about the indication for use, at least medium level efficacy, effectiveness in dirty conditions (even if the biocide is used in a clean environment, as this ensures an additional reserve of efficacy). There is a need for regular training of health care staff on the correct and safe use of biocides and their proper storage. Periodic evaluation of the sensitivity/resistance of microorganisms to commonly used disinfectants in healthcare facilities is also necessary to monitor efficacy and to continue to make the best decisions for the prevention of nosocomial infections.

Design and layout of hospital facilities

Well-designed spaces allow for the smooth flow of staff, patients and equipment, reducing the risk of cross-contamination. The use of easy-to-clean, smooth and germ-resistant materials helps to maintain a hygienic environment. (Salonen, et al., 2013)

Compliance with hospital functional circuits

These facilitate the proper and safe conduct of hospital activities, avoiding cross-contamination. The Service/Department for the Prevention of Healthcare Associated Infections (S/CPIAAM) is in charge of organizing, supervising and controlling the compliance with the functional circuits within the health facility (MS – Order No. 1101/2016, 2016).

The functional circuit includes septic circuit (infected environment) and aseptic circuit (uninfected environment). To prevent HAI the septic circuits must be separated from the aseptic circuits.

It is achieved by delimiting the spaces by profile and time schedule, taking organizational measures and observing hygiene rules.

The main functional circuits in the hospital are (Hospitalul Clinic Municipal Cluj-Napoca, 2016):

• the circuit of entry and exit of medical staff, volunteers, residents, students and practicing students
• patient circuit
• visitors circuit
• linen circuit
• food and dishes circuit
• instruments and materials circuit
• operating theatre circuit
• medicines circuit
• waste circuit

Managing medical waste correctly and safely

It involves their collection, packaging, temporary storage, transportation and disposal. The responsibilities of the producer of the waste (the health care facility) are to separate it according to its origin, reduce its quantity and recycle what is suitable for recycling.

MS Order No. 1226/2012 is the technical regulation specific to medical waste that deals with all stages of their management, from their framing to their final disposal, to protect the population and the environment. (Curea, Bratu, Constantin, & Teodorescu, 2021) The legislation in force regulates also the training of medical staff for the collection, storage, handling, transport and neutralization of hazardous sanitary materials.

Containers must be temporarily stored for a maximum of 48 hours in specially equipped warehouses unless they are temporarily stored in a place equipped with a cooling system that constantly ensures a temperature below 4°C. In this case, the storage period may be a maximum of 7 days. The conditions of temporary storage of medical waste must comply with the hygiene rules in force.

They are then collected and transported for neutralization within a maximum of 72 hours. This avoids fermentation of organic products and the multiplication of pathogens. The transportation is done through specially arranged corridors, with authorized means of transport, on predetermined days and hours (Curea, Bratu, Constantin, & Teodorescu, 2021).

Several measures should be taken to reduce the risk of contamination of health facility employees handling medical waste (Curea, Bratu, Constantin, & Teodorescu, 2021):

• Personal protective equipment should be worn, consisting of gloves, masks, goggles/visors, apron, gown or overalls
• Hygiene rules will be respected by washing hands and using disinfectants
• Cleaning and disinfection procedures will be followed
• No food, drink or smoking in areas at risk of contamination
• Any incident must be reported (e.g. by puncture or cutting with sharps waste)
• In the case of infections caused by mishandling of waste, primary prophylaxis should be applied

Failure to follow procedures, with incorrect handling of waste can endanger care staff, the employees who handle it, patients and their families, and the population surrounding the facilities. Improper treatment or disposal of waste can even lead to environmental contamination or pollution.

As a result of m mishandling of medical waste, 292 cases of Hepatitis B (48%), 202 cases of Hepatitis C (34%) and 110 cases of blood-borne viral infections (18%) have been reported (Badea, 2021).

Safe handling of possibly contaminated hospital linen

Hospital linen is all textiles used in the hospital: sheets, tablecloths, towels, towels, uniforms of medical staff, pyjamas, patient garments, etc.

Hospital linen shall be collected and packaged at source with due care. Soiled linen shall be collected and packaged at the place of production in such a way as to minimize handling in order to prevent contamination of air, staff and patients.

The staff collecting and packaging the linen shall check that no sharps remain in the linen. They will wear appropriate protective equipment including gloves. After removal, staff will wash their hands.

Correct handling of catheters and catheters

Incorrect handling and insertion techniques are the causes of many nosocomial infections. To reduce these risks, it is essential to use aseptic techniques, with strict adherence to hand hygiene measures, use of sterile equipment, and proper cleaning of insertion sites. (Koh, Gowardman, Rickard, Robertson, & Brown, 2008)

Proper handling and maintenance of medical devices

Strict cleaning, disinfection and sterilization protocols must be followed, along with proper storage to prevent cross-contamination. Ongoing staff training in the handling of medical devices is crucial for maintaining high standards of hygiene (Bahreini, Doshmangir, & Imani, 2019).

Hygienic food storage and preparation

The food block is a potential generator of HPAI because this is where food is handled and prepared for hospitalized patients. Unsanitary conditions can cause illness, some even life-threatening.

Food circuits and food hygiene must be respected. Food must be supplied and prepared at temperatures that prevent the risk of bacterial growth. Cross-contamination can be caused by dirty hands, dirty work surfaces, utensils, cookware and crockery.

The storage of raw materials and finished products requires controlled conditions of hygiene, temperature, ventilation, humidity and safety.