From a safety and quality perspective, infection control is one
of the most important — and least understood — concerns
of the HME industry. It isn't even mentioned in CMS' supplier
quality standards, yet the industry's accreditation organizations
will rightfully push infection control practices to the forefront
for each HME organization.
Several steps must be taken to be accreditation-worthy. Step one
is better understanding how infections occur.
There are things about the science of infection control that are
important and universal. We know how most infections are spread. We
know that some people are more susceptible to infections than
others. Finally, we know how to reduce the risk, or, in some cases,
prevent infections from spreading.
High school biology taught us about the infection triangle. The
three things that need to be linked together to create an infection
are the infectious microorganism (germ), the susceptible host
(patient or HME personnel) and transmission (spread of the germ) to
a susceptible host.
All of these things must be present for an infection to
Routes of Transmission1
The transmission of the germ to the patient or HME employee can
occur through one of five basic ways: direct contact, indirect
contact, droplet, airborne or common vehicle transmission.
Direct Contact: Physical transfer of microorganisms
(germs) to a susceptible host by body surface-to-body surface
contact. Most often associated with blood-borne or sexual contact,
this can also occur during patient care activities like turning or
bathing. Acquiring or transmitting infections via this route would
be a rare occurrence, since HME personnel typically have only
brief, casual contact with patients and their environment.
Indirect Contact: Contact of a susceptible host with
contaminated hands or object. This probably represents the most
common transmission route for HME personnel. It can happen when
they do not wash their hands between patient visits, or when
contact is made with a contaminated personal item such as soiled
clothing or bedding.
It can also occur when they come in contact with a contaminated
common-use item such as a TV remote, writing pen, child's toy or
Droplet Contact: Nasal, oral, or conjunctival (membrane
that lines the eyelids) mucosa comes in contact with relatively
large droplets containing germs from an infected person that is
close by, usually within three feet.
Germs can spread through the air through an unprotected cough,
sneeze or talking — from a patient to HME personnel and vice
versa, or between HME personnel.
Airborne Transmission: Extremely small (droplet nuclei)
germs that are suspended in the air or dust enter the respiratory
tract. Unlike droplet contact, airborne transmissions are suspended
in the air for significant periods of time and spread by
environmental air currents.
Important examples include tuberculosis, measles and chickenpox,
which in the case of active symptoms or a confirmed diagnosis,
require that HME personnel use a protective mask.
Common Vehicle Transmission: Contact with contaminated
food, water, medications, devices or equipment. HME providers'
patients or employees can become infected by coming in contact with
contaminated equipment or supplies.
A variety of germs (bacteria, viruses or fungi) can be the root
of an infection. Certain germs serve useful purposes, but some
germs are just plain bad. Good germs can become bad germs when they
are introduced into warm, moist areas like the eye, ear or nose and
multiply into large quantities.
Germs can produce localized infections like staph infection, or
celluitis of the skin, or they can become systemic, getting into
the blood stream and invading the entire body.
Many things can affect an individual's susceptibility to
infections. Stress, nutrition, genetic makeup and pre-existing
disease can all play a part. Any person (patient or HME employee!)
can act as a susceptible host for infectious agents. Individuals
with low white blood cell counts, such as those with leukemia or
patients with debilitating COPD are, by the very nature of their
disease, more susceptible to infections than a healthy person.
Breaking the Link: Hand Hygiene
In an effort to reduce the number of nosocomial infections, the
Centers for Disease Control developed the following guidelines for
hand hygiene.2 The term “nosocomial”
classically means a hospital-acquired infection, but the basics of
hand hygiene for anyone caring for the sick also apply to HME.
Hand washing with soap and water continues to be the most
sensible strategy for hand hygiene in non-health care settings.
When health care personnel's hands are visibly soiled, they should
take the time to wash up.
Proper hand-washing technique includes washing with soap and
water using plenty of lather and friction for 15 seconds, or about
the time it takes to sing “Happy Birthday!” Cover all
surfaces of the hands, including palms, in between the fingers and
under fingernails, the backs of the hands and around the
If hands are not visibly soiled or if running water is not
available, then an alcohol hand sanitizer can be used.
Use of alcohol-based hand rubs can address some of the
obstacles that health care professionals, such as HME
technicians, face when taking care of patients.
These hand rubs can significantly reduce the number of
microorganisms on skin and are fast-acting. When using an
alcohol-based hand rub, apply the product to the palm of one hand
and rub both hands together, covering all surfaces of hands and
fingers, until they are dry.
Note that the volume of rub needed to reduce the number of
bacteria on hands varies by product.
Health care personnel should avoid wearing artificial nails
and keep natural nails less than one-quarter inch long if they
care for patients at high risk of acquiring infections.
The use of gloves does not eliminate the need for hand hygiene.
Likewise, the use of hand hygiene does not eliminate the need for
gloves. When used correctly, gloves can reduce hand
contamination by 70 to 80 percent, prevent cross-contamination and
protect patients and health care personnel from infection.
Note: HME personnel should use gloves when making contact with
blood or body fluids, non-intact skin, mucus membranes or visually
contaminated surfaces. During a typical work day for most HME
providers, these situations would be rare. For guidelines on
appropriate use of gloves for HME employees, read on.
Hand rubs should be used before and after contact with each
patient, just as gloves should be changed before and after each
patient visit when appropriate.
The Issue of Gloves
When should HME personnel use gloves?
The proper use of protective, clean, non-sterile gloves is
something else often misunderstood by some in HME. In many
situations, home care professionals — delivery techs and
therapists included — gain a false sense of security,
believing that by wearing gloves they will neither transmit nor be
susceptible to infections.
Some HME providers compound the misunderstanding of how
infections are transmitted by instructing personnel to put on
gloves before entering a patient's home. However, simply adding a
layer to the skin will not prevent the spread of infections.
Use clean, non-sterile gloves:
If you feel you might come in direct contact with blood or body
fluids. Examples include urine, feces, mucus and non-intact skin.
(Body sweat is not included in this group.)
When handling visually soiled or contaminated equipment.
As you feel the need for personal protection from getting your
When you see something you don't want to touch: dirt, grime and,
of course, blood and body fluids.
When you have cuts or sores on your hands that may introduce
germs that would set you up for a localized infection.
Gloves are not needed to do routine HME procedures, like opening
the door, shaking the patient's hand, handling the service
clipboard, delivering equipment and supplies or picking up
equipment that is not visually contaminated.
There is no sound infection control science for HME personnel to
wear gloves except as described.
Accreditation will require that reasonable infection control
practices be in place. Understanding the basics is the first step
to quality and safety. Using a professional approach to hand
hygiene and a common-sense use of gloves can help in establishing
an effective infection control program.
Centers for Disease Control and Prevention, “Guideline for
Infection Control in Health Care Personnel, 1998.” Published
simultaneously in AJIC: American Journal of Infection
Control (1998; 26:289-354) and Infection Control and
Hospital Epidemiology (1998; 19:407-3-630)
Centers for Disease Control and Prevention, Hand Hygiene Fact
Tim Hogan, RRT, PhD, is an associate with The Corridor
Group, Inc. He may be contacted by phone at 913/362-0600 or through
When should HME personnel disinfect their hands?
Before and after each patient contact. For delivery techs
and respiratory therapists, that typically means washing hands in
the patient's home before they leave, or using an alcohol rub when
they get back to their vehicle before driving on to the next home
After contact with environmental surfaces or medical
equipment used by or located near the patient
After removing latex gloves
After contact with body fluids, mucous membranes,
non-intact skin or wound dressings
After using the bathroom
Before and after eating
After sneezing or coughing
When hands are visibly contaminated