You expect a surgeon to wash his hands before an operation, but did you know he should wash it for all of two to three minutes, and preferably in hypochlorite solution? Or that he should not breathe on instruments? Or that he should disinfect his bronchoscope with ortho-phthalaldehyde?
Given the thousands of operations that are stitched up in the city every day, these dos and don’ts seem a bit excessive. But nosocomial infections, or infections acquired in hospitals, are a notorious breed of pests that attack more virulently in a healthcare institution and are too common and dangerous to be ignored.
Some of these disturbing and revealing facts came through in a three-day conference of the Hospital Infection Society of India (HISI), held recently at Tata Memorial Hospital. Data culled from diverse experts exemplifies that no amount of pre-operation and post-operation vigil is too much either for the patient or his caregivers such as the doctor, nurses or even his family.
For instance, hand washing, for all its value, may transfer flora from users on to the soap. A study at Nair hospital showed even so-called antibacterial soaps harboured bacteria such as non-fermenters and enterobacteriaceae. Even stethoscopes, that first point of contact between doctor and patient, can house an army of pathogens and non-pathogenic organisms. In a study by Gurjeet Singh and others from a Navi Mumbai hospital, 90 per cent stethoscopes showed bacterial contamination. The remedy? An alcohol rub.
Similarly, operation theatres are a bug nest where every bit of air and piece of object could be conspiring to assail you. As Dr RA Bhalerao, director, research and planning, Hinduja Hospital. observed, single filament sutures should be generally preferred over polyfilament ones which have greater potential for transmitting an infection. The big daddy of infections in a hospital setting are contagious diseases like tuberculosis, swine flu, the difficult-to-treat MRSA and chicken pox. Tuberculosis, especially the multi-drug resistant (MDR) variety could be fatal or debilitating.
The WHO Global TB report of 2012 said that by the end of 2011, India and the Russian Federation combined with China had contributed a massive 60 per cent of the global MDR-TB burden. Last year, Hinduja hospital had reported some totally drug-resistant cases of TB, which is its severest form, though the nomenclature was diluted after central government’s intervention.
Both contact and airborne precautions assume a vital importance in the context of such an infection. So, simple etiquette such as using a piece of cloth while coughing assumes gigantic proportions in a hospital. Dr Shaheen Mehtar, extraordinary professor at Stellenbosch University, Tygerberg, South Africa, used TB as the rallying point for all infections acquired in a hospital environment. She said administrative controls, environment controls and personal protective equipment go a long way in curtailing infections in a hospital environment.
In administrative controls, rapid triage (prioritising patients according to urgency), training of healthcare workers and staff, and assessing risk and developing written protocols make a sweeping difference, she observed on the basis of a study done in her hospital. She said that the reduction in transmission in her hospital following the execution of these measures was nothing short of dramatic. Environmental controls such as negative room pressure (to allow ventilation into but not out of the patient’s room) and bronchoscopy rooms are easier to control and do more than a bit to control infection transmission. The last category demands personal attention.
Protective equipment such as masks have to be necessarily used intelligently, with the predominant criterion being that they fit the nose. An ill-fitting mask will harm rather than protect. Emphasising on the importance of using different masks for different nose types, Dr Mehtar criticised the use of N95 surgical masks for patients. These masks are to be used only for healthcare workers as they trap the bacilli behind them.
As Dr Rajeev Soman, infectious diseases specialist, pointed out chillingly, “Theoretically, even one microorganism introduced into the operating field can set up an infection.” In the absence of any meaningful data about healthcare worker infections in India, Dr Murali Chakravarthy, of Fortis Hospital, estimated about 1 crore to 1.15 crore such injuries in the country.
If healthcare workers are at high risk, patients are perhaps worse off because of their lowered immunity. A Centers for Disease Control (US) estimate indicates approximately five per cent of all persons admitted to a hospital develop an infection during their stay. Worse, as Dr Lalit Kapoor, medico-legal expert, observed, it is not too easy for a patient to get clinching evidence against a hospital to prove a nosocomial infection.
The best option, in the circumstances, appears to be to stay healthy and out of hospital.
The writer is a senior journalist based in Mumbai