Plain, good old hand-washing key

Sixteen people with or on account of being infected with C. Difficile have died while in Ridge Meadows Hospital since 2009.

Dr. Marco Terwiel.

Dr. Marco Terwiel.

I do not like to think of the 25 patients who contracted Clostridium Difficile at Ridge Meadows Hospital last year as cases.

They were living breathing people, not cases, who were admitted to a place where you are supposed to get better, or at least are looked after with great care and attention when no cure is possible.

Instead, they were made worse, and 16 with or on account of being infected with C. Difficile have died while in our local hospital since 2009.

There are a lot of things one can do to prevent this complication and the protocols how to do them are clearly spelled out. Instead of actually vigorously implementing the well-researched and proven recommendations, the leadership of Fraser Health failed to protect the people who trusted their caregivers.

Instead of at least improving the situation, things were allowed to get worse, rising well above the accepted maximum infection rate of C. Difficile.

This year alone we already have 42 patients (not cases) suffering from the consequences of a hospital-acquired C. Difficile infection. It is small comfort that this is well below the rate of many other Fraser Health Authority hospitals, but still is hardly something to be proud of.

C. Difficile infections are as the name suggests, difficult, but not impossible to manage. Yes, things are even more difficult in an environment where there are many sick and debilitated people. And yes, the increasing overcrowding in our emergency and hospital wards adds to the challenge.

But when a recent hand hygiene audit of the health care personnel in RMH found that only 42 per cent sanitized their hands before and/or after attending to a patient, it is therefore little wonder why we have an increasing infection rate.

Moreover, we provide false sense of safety using alcohol-based hand rubs. They are not effective for eliminating C. Difficile. They may help for other infectious agents, but not for C. Difficile. Plain, good old hand washing with water and soap, however, is very effective, and cheap, too.

A Canadian Medical Association Journal article (August 31, 2004 vol. 171) described how a new strain of C. Difficile  was increasingly rampant in a region of Quebec and approximately 1,400 hospitalized people were infected with a death count as high as 89. All  were within less than a year.

The same bacteria spread to Toronto and elsewhere all over the world. For instance C. Difficile was mentioned on 6,480 death certificates in 2006 in the U.K.

The incidence among hospitalized people 65 and older increased eightfold in a span of 12 years. After all this was recognized, the protocols to control the problem were developed years ago, but not fully complied with in Fraser Health.

Where does C. Difficile come from?

A small percentage of people carry the bacteria in their gut, but it is kept in check by all the other good bacteria, and under normal circumstances, there’s no harm.

The root cause of this C. Difficile problem is the increased use of potent antibiotics, destroying the normal and protective bacteria in the large bowel and giving the C. Difficile a chance to flourish after most of the good bacteria are killed.

Since the C. Difficile is highly resistant to most antibiotics, it gets free range, multiplies vigorously and attacks the patient. One gets profuse diarrhoea, severe abdominal pain, fever, an inflamed large bowel (colitis) and dehydration. When already in a debilitated state, there is a real chance that one dies despite a few moderately effective remedies.

While one can eliminate the live C. Difficile bacteria with water and soap, one also needs to take into consideration that C. Difficile bacteria produce spores and only bleach will destroy them. Any other cleaning agent will fail.

Once the spores are in a hospital, it is extremely difficult to get rid of them, especially since they can easily become airborne in contrast to the live bacteria.

C. Difficile bacteria have no wings, nor do they jump after they are excreted in the stool.

It is when the C. Difficile  bacteria leave the body in astounding numbers, suspended in the diarrhea, that is when they contaminate a hand or both hands when using toilet paper, especially when there is profuse diarrhea – it is next to impossible not to contaminate the hands.

This pertains to the hands of the patients themselves and the hands of health care personnel assisting with the clean-up. Patients do not usually wear disposable gloves when visiting the bathroom, unlike the health care personnel.

The patients will then contaminate anything they touch: the bars to help them get up; the tap where they wash their hands (if they do); the door handle; the walker; the bed rails.

The health care personnel will also contaminate anything they touch while still wearing the contaminated gloves. Even with clean gloves before bringing in a food tray, just opening the door, lowering the contaminated bedside rail will give the lurking C. Difficile bacteria a wonderful chance to get onto the food tray and utensils.

Especially in two- and four-bed wards, it only takes one C. Difficile infected patient to readily contaminate the other previously clean roommates who have to use the same bathroom before it is decontaminated.

Not a wonderful experience when entering the hospital basically healthy for a surgical procedure and ending up with an often protracted miserable painful abdomen and very frequent trips to the bathroom.

This particular consideration of the pathway of infection has been sorely neglected in most if not all the official protocols.

Solutions:

• Treat all C. Difficile patients in private rooms,

• Decontaminate anything touched by the patient and health care personnel immediately after usage of the bathroom and not some time later in the day or even next day, and use bleach.

• Learn how to wash one’s hands effectively before touching one’s face or food. Use water and soap, not an alcohol rub.

• Follow all the other recommended measures.

Sadly, human nature, being what it is, I suspect the chances of all that happening are rather slim.

 

Dr. Marco Terwiel is a retired family physician who lives in Maple Ridge.