Understanding Infection Control

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 occur.

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.

1. 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.
2. 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 eating utensil.
3. 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.
4. 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.
5. 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 wrists. 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 hands “dirty.”
• 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.

1. 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)
2. Centers for Disease Control and Prevention, Hand Hygiene Fact Sheet

Tim Hogan, RRT, PhD, is an associate with The Corridor Group, Inc. He may be contacted by phone at 913/362-0600 or through [email protected].

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 visit.
• 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