Hospital hygiene and nosocomial infections. Problems and solutions.

The major challenge faced by a hospital is healthcare-associated infections. Hygiene plays a vital role in preventing them, and for effective control, protocols for washing and disinfecting hands, surfaces, instruments, and medical devices, the hospital's functional circuits, the proper handling of waste resulting from medical activities, the correct use of personal protective equipment, and immunization programs must be followed.

Healthcare-associated infections

Preventing and minimizing HAIs (Healthcare-Associated Infections, so-called nosocomial infections) has always been a major objective of medicine, serving as the best indicator of the safety and quality of medical care.

Nosocomial infections affect patients, medical staff, and medical institutions alike. Infected patients can develop serious complications, thereby extending their hospital stay, affecting their quality of life, and increasing the risk of death. Medical staff can also become infected, with the probability of transmitting the infection further to other patients and increasing their workload. Medical units can thus become overcrowded, care costs rise (treatments, diagnostic tests, various surgical procedures (Benenson, et al., 2020)), and the level of patient trust in the quality of medical care may be affected. (Al Shamsi, Almutairi, & Al Mashrafi, 2020)

HAIs can be exogenous infections resulting from contact with visitors or other patients, contaminated surfaces, instruments, and equipment, and endogenous infections, when the body's normal microflora becomes pathogenic under conditions of reduced immunity. Another route of infection is through broken skin.

At the national level, there is a "Single Report Form for Communicable Disease Cases," provided for in Government Decision no. 657/2022, for the surveillance, identification, and reporting of communicable diseases with nosocomial potential for medical personnel. This allows for timely control measures to be taken to prevent and/or limit a potential epidemic. (GD 657/2022)

The main causes involved in the production of HAIs (Cepoi & Azoicăi, 2012):

• Inadequate hygiene inside the hospital (wards, hallways, food block, operating and dressing rooms)
• Non-compliance with disinfection and medical waste disposal procedures
• Non-use of personal protective equipment by medical personnel
• Inappropriate functional circuits
• Visitor access to intensive care units and operating rooms
• Overcrowding of wards
• Prolonged hospitalization, which may lead to contact with other patients who may be carriers of pathogenic germs
• Poor patient hygiene
• Failure to detect carriers of pathogenic germs in time
• Increased number of immunocompromised patients (premature infants, the elderly, chronic patients, those with viral diseases, and those undergoing immunosuppressive treatments)
• Therapeutic interventions (prophylactic antibiotic therapy before certain surgical procedures, self-medication, etc.) and diagnostic procedures (endoscopies, colonoscopies, urethral catheterizations, tracheal intubations, intravenous infusions, etc.)
• Poor professional training of medical staff

To prevent infection and the transmission of pathogens, medical personnel must observe certain universal precautions (MS Order no. 1101/2016):

• Correct use of personal protective equipment (gown, gloves, mask, goggles/face shield), especially when exposed to blood or body fluids/secretions
• Hand hygiene is essential before and after contact with each patient, as well as after removing gloves
• Changing gloves after each patient
• Specific procedures for preventing the transmission of infectious diseases following the preparation and administration of parenteral medications must be followed
• Safe handling of medical equipment
• Correct management of medical waste (infectious, sharp, anatomical-pathological and anatomical parts, chemical and pharmaceutical, radioactive)
• In the case of a potentially contaminated area, it must be properly cleaned and disinfected
• Respiratory hygiene and cough etiquette (cough and sneeze technique using a disposable handkerchief, maintaining a distance of at least 1 meter from other people, followed by hand hygiene)

Hand hygiene through hygienic or surgical disinfection

Hands are the main route of pathogen transmission, which is why their hygiene is the foundation of the HAI prevention process. The effectiveness of disinfection depends primarily on performing it correctly, but also on the quality of the water, soap, and disinfectants used.

To prevent potential contamination, it is necessary to keep nails cut as short as possible, clean, and without polish; rings, bracelets, and watches must be removed; and appropriate protective equipment must be worn.

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

Professor Didier Pittet (infectious disease physician) and his team developed the "The Five Moments for Hand Hygiene" concept, training medical staff on the critical moments and the reasons why hand hygiene must be performed: (WHO, 2009)

1. Before touching a patient: to protect the patient from potential contamination with germs from the hands
2. Before aseptic procedure: to protect the patient from potential contamination with germs, as a result of medical procedures that can be "portals of entry"
3. After body fluid exposure risk: for personal protection
4. After touching a patient: for personal protection, protection of subsequent patients, and all people with whom one will come into contact
5. After touching patient surroundings: for personal protection, and protection of the hospital environment, other patients, and colleagues.

Vaccination of medical personnel

This is one of the important measures for protection against nosocomial infections. Health units must encourage awareness of vaccination and facilitate worker access to immunization programs.

Disinfection of surfaces, instruments, devices, and medical equipment

Globally, the morbidity and mortality caused by nosocomial infections are steadily increasing and are associated with resistance to disinfectants. A report published by the World Health Organization (WHO) in 2022 stated that over 24% of patients are affected by healthcare-associated sepsis, and 52.3% of those treated in the ICU die each year. Another WHO report showed that in health units where good infection prevention and control practices are followed, 70% of these infections can be prevented. (***, 2022)

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

Disinfectants are one of the most widely used protections against infections, aside from biosecurity, but the abusive and inadequate use of these constitutes a factor in the increase of antibiotic-resistant and disinfectant-resistant genes. Those diluted and released into the environment could increase bacterial tolerance through phenotypic adaptation, gene mutation, and horizontal gene transfer. (Rozman, Pušnik, Kmetec, Duh, & Turk, 2021)

Although it is possible that the ideal disinfectant does not yet exist, a careful selection process and correct use of biocides are necessary to reduce negative effects on the safety and health of patients and staff in health units.

An ideal disinfectant should have the following properties:

• Broad antimicrobial spectrum
• Rapid action
• Not affected by environmental factors
• Have a residual effect
• The disinfected surface must remain wet for a sufficient duration
• Have a low level of toxicity if it cannot be non-toxic to the user, visitors, and patients
• Not be flammable
• Easy to use, with clear instructions on the label
• Compatible with a wide range of surfaces
• Odorless or with a pleasant odor
• Present stability
• Be water-soluble
• Have good cleaning properties
• Economical
• Ecological

However, in reality, it is impossible for a product to meet all these conditions; therefore, the most important aspects to consider before purchasing a disinfectant are: stability in use, toxicity in relation to the indication for use, at least medium-level efficacy, and efficiency under dirty conditions (even if the biocide is used in a clean environment, because this ensures an additional safety margin). Periodic training of medical personnel regarding the correct and safe use of biocides and their proper storage is necessary. It is also necessary to periodically evaluate the sensitivity/resistance of microorganisms to disinfectants frequently used in health units to monitor effectiveness and continue making the best decisions for nosocomial infection prevention.

Design and layout of hospital units

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

Compliance with the hospital's functional circuits

These facilitate the correct and safe conduct of activities in the hospital, avoiding cross-contamination. The Healthcare-Associated Infection Prevention Service/Department (S/CPIAAM) is responsible for the organization, supervision, and control of compliance with functional circuits within the health unit (MS – Order no. 1101/2016, 2016).

The functional circuit comprises the septic circuit (infected environment) and the aseptic circuit (uninfected environment). To prevent HAIs, septic circuits must be separated from aseptic ones.

This is achieved by delineating spaces by profile and schedule, taking organizational measures, and following hygiene rules.

The main functional circuits in a hospital are (Cluj-Napoca Municipal Clinical Hospital, 2016):

• entry and exit circuit for medical personnel, volunteers, residents, students, and trainees
• patient circuit
• visitor circuit
• linen circuit
• food and dishware circuit
• instrument and material circuit
• operating room circuit
• medication circuit
• waste circuit

Correct and safe management of medical waste

This involves their collection, packaging, temporary storage, transport, and disposal. The responsibilities of the waste producer (the medical unit) are to separate them according to their origin, reduce their quantity, and recycle those suitable for such processes.

MS Order no. 1226/2012 is the specific technical regulation for medical waste that addresses all stages of its management, from categorization to final disposal, with the aim of protecting the population and the environment. (Curea, Bratu, Constantin, & Teodorescu, 2021) The legislation in force includes the training of medical personnel for the collection, storage, handling, transport, and neutralization of hazardous medical materials.

Containers must be stored temporarily for a maximum of 48 hours in specially designated areas, unless they are temporarily stored in a place equipped with a cooling system that ensures a constant temperature of less than 4°C. In this case, the storage duration can be up to 7 days. The conditions for temporary storage of medical waste must comply with current hygiene standards. Subsequently, they are collected and transported for neutralization within a maximum of 72 hours. This prevents the fermentation of organic products and the multiplication of pathogens. Transport is carried out through specially designed corridors, using authorized transport means, at predetermined days and times. (Curea, Bratu, Constantin, & Teodorescu, 2021)

To reduce the risk of contamination for employees in the health unit who handle medical waste, several measures must be taken (Curea, Bratu, Constantin, & Teodorescu, 2021):

• Personal protective equipment must be worn, consisting of gloves, masks, goggles/face shields, apron, gown, or coveralls
• Hygiene standards must be followed by washing hands and using disinfectants
• Cleaning and disinfection procedures must be followed
• Food or beverages must not be consumed, and smoking is prohibited in areas with a risk of contamination
• Any incident must be reported (for example, needle-stick or cut injuries with sharp waste)
• In the case of infections caused by defective waste handling, it is necessary to apply primary prophylaxis methods

Non-compliance with procedures, combined with incorrect waste handling, can endanger caregivers, employees who manage it, patients and their families, as well as the population around the facilities. Improper treatment or disposal of waste can even lead to environmental contamination or pollution.

Following defective handling 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 potentially contaminated hospital linen

Hospital linen represents all textile items used in a hospital: sheets, tablecloths, towels, medical staff uniforms, pajamas, patient clothing items, etc.

The collection and packaging of hospital linen at the source must be done in compliance with precautionary standards. Soiled linen is collected and packaged at the place of production so that it is handled as little as possible, in order to prevent the contamination of the air, staff, and patients.

Staff who collect and package the linen must check that no sharp or pointed objects remain in the linen. They will wear appropriate protective equipment, including gloves. After removing it, staff will wash their hands.

Correct handling of catheters and probes

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

Correct handling and maintenance of medical devices

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

Storing and preparing food under hygienic conditions

The food service area is a potential generator of HAIs, given that food for hospitalized patients is handled and prepared at this level. Improper conditions can cause illnesses, some even life-threatening.

The food flow and food hygiene must be respected. Procurement and food preparation must be carried out at temperatures that prevent the risk of bacterial growth. Cross-contamination can be caused by dirty hands, work surfaces, utensils, cooking pots, and improperly disinfected dishware.

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

Periodically, the health status of food service staff will be monitored in accordance with GD no. 355/2007.

Good air and water quality in medical institutions

By using a ventilation system with appropriate filters to remove particles, bacteria, and viruses from the air, the risk of inhaling pathogens can be reduced. At the same time, increasing the amount of fresh air entering the building by opening windows helps to dilute and eliminate contaminants in the air. This is vital for patients susceptible to infections and those with respiratory diseases. Ventilation systems must be correctly designed and periodically maintained to prevent the appearance and multiplication of mold and other pathogens.

An effective water management system must include proper disinfection and control of the Legionella sp. bacterium. The death rate among patients is approximately 5-10%. (ECDC, 2016)

Collaboration between healthcare professionals

Prevention and control of HAIs are possible through close cooperation between microbiologists, epidemiologists, doctors, and clinical pharmacists.

They must all collaborate to create and implement effective prevention measures, researching and discussing best practices, regularly reviewing hygiene strategies and compliance, while also developing training programs. (Dik, et al., 2016)

Healthcare-associated infections represent a significant public health issue with harmful effects on patients and medical staff, as well as on healthcare institutions. The role of hygiene in preventing infections cannot be underestimated.

The important issues currently facing hospitals regarding HAI control have been highlighted in this article, along with effective ways to address them. The existence and monitoring of the correct implementation of clear protocols, sufficient and periodic training of medical and auxiliary staff, and modern technology are essential. However, without increased awareness for the efficient implementation of these solutions on the part of decision-makers and facility management, change is not possible.

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