1) Diagnostic equipment is not always cleaned
in-between patients:
-
Unless the blood pressure cuff is attached to the wall or a cardiac
monitor in the room, chances are that the nurse rolled it into your room after
using it on another patient – and likely didn’t disinfect it in-between
patients.
-
Ditto for the thing they placed on your finger to “check your oxygen”
(commonly called an “O2 sat probe”), the thermometer, or the glucometer (to
check your blood sugar).
-
Even though the thermometer may have disposable probe cover on it, the
thermometer itself is placed on other patients’ beds, tables, etc. – and it
therefore contaminated (along
with the open package of probe covers attached to the back)….which means the nurse’s hands are now also contaminated. (The coiled cords connecting the probe to the
digital thermometers are difficult to clean – and are almost never properly
cleaned.)
- Now what about the equipment at
the “Triage Desk” in the Emergency Department?
2) Other equipment is not always cleaned
adequately:
-
Wheelchairs are rarely (if ever) disinfected.
-
Now think of that patient with his hind-end hanging out the back of his
hospital gown sitting on that wheelchair before you…
-
The seat, seat back, arm rest, handles for pushing, brakes, and hand
rails on the wheels all need to be disinfected between patients.
-
Workspaces need to be disinfected at least twice a day.
-
That includes desks, counters, phones, touch screens, computer keyboards
and mouse, chairs, etc.
-
If a patient uses a phone at the desk, it needs to be wiped off after
the patient is finished.
-
Telephones, furniture, and counters need to be cleaned in waiting rooms
and common areas at regular intervals.
(i.e. at least twice per day)
-
In reality, the floor is cleaned once a day, and everything else is
spot-cleaned.
3) Rectal thermometers are not usually
thoroughly and completely disinfected as soon it is taken out of the patient’s
room – and before being set down outside
of the patient’s room.
-
If the rectal thermometer is set down inside a patient’s room, that area
needs to be disinfected as soon as the rectal thermometer is removed.
-
Rectal thermometers should be clearly identified as such.
-
Rectal thermometers should have a dedicated storage space away from
other equipment, supplies, or workspaces (i.e. a clearly designated holder on
the wall).
-
They should never be stored (are transported) with other vital signs
equipment – especially oral thermometers.
-
They should never be placed anywhere other than that dedicated holder
when not in use.
4) Stretchers in the Emergency Department are
sometimes not cleaned properly in-between patients. In a rush to get the next patient into the
room on a busy day, a nurse or support staff may just take off the dirty
linen; give the mattress a quick wipe (or not clean it at all if it not visibly
soiled); and then put new linen on (or a new strip of paper that is peculiarly
too narrow for the mattress or exam table).
Good luck having the railings, stretcher controls, bedside table, drawer
handles, call bell, chairs, and other “high-touch” points cleaned if Housekeeping
staff are not immediately available (or not even staffed – on “off shifts”).
-
Emergency Departments need to ensure that Housekeeping staff are
adequately staffed on all shifts.
-
If Housekeeping staff are not immediately available, nurses and support staff need to thoroughly clean the stretcher/exam table, railings,
bedside table, stretcher controls, drawer handles, call bell, chairs, and other
“high-touch” points if cleaning the room themselves – regardless of whether it
is visibly soiled.
-
As discussed in the previous blog post, the mattress or exam table needs
to be allowed to completely air-dry prior
to new linen being applied. All other
surfaces and equipment need to air-dry
prior to use as well.
-
Unless I am breathing my last breath or a limb is falling off, I will
wait an extra few minutes to have my room properly cleaned.
-
The rolls of paper that are peculiarly too narrow for any stretcher or
exam table (often used in “fast-track” areas of the Emergency Department) need
to go – or insist on purchasing rolls that are sufficiently wide enough to
cover the surface of the mattress or exam table.
5) Items such as “IV/Phlebotomy baskets” are
brought into your room to start an intravenous (IV) and/or collect blood
specimens. The nurse likely places it on
your bed or table. He or she likely does
not wipe the handle, sides, and bottom of the basket after leaving your room.
- The tourniquet is also likely
re-used on other patients. (Arguably not
as much of an issue in out-patient labs in the community.)
6) Unless your commode chair (portable toilet on
wheels with a bedpan underneath) is dedicated to only your use during your
stay in hospital, chances are a nurse or other healthcare worker just gave the seat and handles a quick
wipe in-between patients (and sometimes only if it is visibly soiled).
-
Also, when commode chairs are cleaned (even if done completely and
properly), some hospitals and departments store them in their “soiled utility
rooms” – posing a significant risk of recontamination and cross-contamination. (U.S., Canadian and Ontario best practice
guidelines all state that clean equipment or supplies should not be stored in the area where they are
reprocessed or where soiled equipment, supplies, or waste are stored.)
7) Nursing and other staff often throw dirty
(aka contaminated) linen and diapers on the floor in the patient’s room when
changing the patient and/or the bed.
This linen and diaper is often also contaminated with urine or feces if
the patient is incontinent (unable to control their bladder or bowel
movements). This leaves the floor even
more contaminated, as well as everything placed on it - including your shoes
–which will carry the contamination out into the hall and into other patient
areas.
- This occurs throughout the
hospital, but ironically this breach in practice occurs even more frequently in
Critical Care areas (i.e. ICU, CCU, etc.) where patients are at a higher risk
for infection – and are most often incontinent due to the severity of their
condition, sedation, etc.
8) We are not supposed to use or bring anything
into the patient’s room that has been in another patient’s room without
disinfecting it in-between patients, nor would we pick something up off the
floor and place it on a patient’s bed.
- Now think about the “Pet Therapy” dogs that go
from room to room, patient to patient.
Small dogs are often placed on the patient’s bed or lap.
- These dogs were also likely petted by everyone
from the front entrance to the elevator and every hallway throughout the
hospital.
- We cannot disinfect the dogs or their paws
in-between patients.
- We look the other way on this one because it
is “good for patients’.
- Good for their morale, perhaps. But is something that places patients at
increased risk of a healthcare-associated infection really good for them?
-
In cases where a patient acquires a healthcare-associated infection
(especially in outbreak situations), are hospitals and Infection Control
Departments even looking to see if these patients were visited by Pet Therapy
dogs to assess whether this is a possible link?
-
Something to think about……
[This Pet Therapy issue will
generate a lot of discussion and controversy – as it is dear to many people’s
hearts.]
9) As noted in the Joint Commission’s document “Preventing Central Line-Associated
Bloodstream Infections”, open infusion systems/containers
such as glass bottles or semi-rigid plastic bottles or burettes that need to be
vented externally to allow air to enter and fluid to egress are associated with
a higher risk of contamination during initial set-up and administration than
closed systems (i.e. IV bags) that do not need to be vented. The use of closed systems has been shown to
significantly reduce the incidence of Central Line-Associated Bloodstream
Infections (CLABSIs).
- Hospitals and pharmaceutical
manufacturers need to consider alternative containers for the few remaining
medications that are administered via glass bottles.
-
Hospitals that still use burettes for pediatric or adult patients need
to phase them out.
[Sidebar #1 (for the naysayers): Many years ago, it was thought that burettes
(aka buretrols) still needed to be used with infusion (IV) pumps for safety
reasons.
-
This was primarily because:
1) Some infusion pumps at the time allowed the
free-flow of fluid if a system failure occurred.
2) Many infusion pumps were not accurate at low
hourly flow rates.
- This is no longer an issue because:
1) Current infusion pumps lock out and allow NO
flow if a system failure occurs.
2) Current infusions pumps accurately infuse and
are routinely used to infuse fluids at rates of 0.5ml or 1ml per hour – with regular
IV infusion pumps tubing.
- Phasing out burettes is also
cost effective – as burettes are significantly more expensive than regular IV
tubing, secondary (aka “piggy-back”) tubing for medications, or syringe pumps
tubing.
- For neonates and infants, medications can be
administered via a syringe pump (that is either an add-on module for your
current infusion pump system – or as a stand alone syringe pump).
- All of the same safety features and drug
libraries in regular infusion pumps are available in syringe pumps.
- Administering a medication via a syringe pump
is cost effective, as it only requires the syringe the medication was drawn up
in, “micro-bore” tubing, and a “flush” syringe.
The tubing can then be clamped off and saved until the next medication
is due.]
[Sidebar #2: Burette chambers are never completely rinsed
of medication – despite our best efforts.
(This has been well demonstrated in a coroner’s report in Toronto a few
years ago – as well as other literature.)
This means: a) Not all of the
medication is reaching the patient – which can be significant when small
volumes are administered to pediatric patients, and b)
subsequent medication may interact with residue from previous medications and
produce crystals/precipitate (even if not visible) that may place the patient
at risk.]
[Sidebar #3: When I was working in the United States, younger
nurses had never even heard of or seen a burette. One of the older nurses joked that you could
tell how old someone was by whether or not they knew what a burette was.
- They are superfluous and out-dated technology.
- They are confusing for nurses.
- They are not part of evidence-based practice or best practice guidelines.
- They are not part of evidence-based practice or best practice guidelines.
- They need to go!]
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