Wed | Aug 23, 2017

Fixing Health: Breaking those bad habits

Published:Wednesday | January 13, 2016 | 1:00 AMDr Alfred Dawes
An alarmingly high portion of healthcare workers still do not adhere to proper hand washing protocols. Even more disturbing is that it is often not with the attitude of the workers but the availability of water and soap at the institutions.
Dr Alfred Dawes, immediate past president, Jamaica Medical Doctors Association.
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In 1847, Ignaz Semmelweis, a Hungarian physician working in Austria, made an outrageous declaration. New mothers were dying of fever, not because they were victims of sin, but rather they were getting infections from doctors performing autopsies and not washing their hands before delivering babies.

For this egregious accusation he was castigated and committed to an insane asylum were he eventually died in disgrace.

Ironically, it was an infection of the wounds he sustained during a beating that led to his demise.

Today, Dr Semmelweis is hailed as the father of modern sterile practice.

Later on, Joseph Lister proved that antisepsis during surgery led to less wound infections.

He fared better than Semmelweis, and sterility became the cornerstone of surgical and medical practice, significantly decreasing infections and mortality rates.

The story is told of Japanese elders who used mouldy bread as a poultice to dress wounds. The wounds would seldom get infected with these dressings and would heal much faster than untreated wounds.

The reason for the success of this concoction in decreasing infections made sense when Alexander Flemming discovered penicillin from a fungus (mould) in 1928. That discovery spawned the antibiotic era in modern medicine.

Close to defeating microbes

With antiseptic techniques and proper antibiotic use, we have, for the first time in history, come close to defeating microbes that have been the bane of our existence from the dawn of man.

Newer antibiotics from different classes, and with different modes of action, have been produced over the decades after the discovery of penicillin.

Newer sterilisation techniques have been employed and greater awareness of the importance of preventing infections have been accomplished.

So why then are we having such a serious problem in our intensive-care units and hospitals?

No easy solution

This is not an easy problem to solve.

The truth is that simple guidelines are not adhered to, and this has led to increased outbreaks and more antibiotic-resistant bacteria, not only in Jamaica, but the whole world.

In fact, bacteria are getting so used to neutralising drugs that we are at the brink of what some term an antibiotic apocalypse. In that scenario, superbugs are resistant to every antibiotic used. We would go back to the dark ages where once you got an infection, doctors would have nothing to offer as treatment and millions would die.

This doomsday scenario has stemmed from years of misuse of antibiotics, not only by health-care professionals, but also in farming. Livestock are often given antibiotics in their feed, and this results in reducing farmers' losses due to infections.

This, however, has the effect of exposing bacteria to the drugs. The bacterium develops resistance that can be genetically shared with other bacteria, leading to widespread resistance that moves from country to country fairly rapidly.

Doctors are sometimes guilty of overprescribing antibiotics, often at patients' requests. It is a common practice for patients with viral illnesses, or even allergies, to ask if a physician is not going to prescribe antibiotics, even though none are deemed necessary.

Even in hospitals, this abuse of antibiotics is rampant.

The inappropriate use of antibiotics is not only an expensive waste, but is downright dangerous. This has led to the formation of infectious-diseases committees that regulate the use of antibiotics to prevent the development of resistance.

Prevention

Of course, the best and cheapest way to address infections is prevention. This is where many local hospitals have been thrown into a bad light.

Cleaning a hospital is far different from cleaning other buildings. It requires an appreciation of the way infections are transmitted and the vulnerability of certain types of patients to bacteria that would normally have no impact on healthy individuals.

Adequate training for janitorial staff and the provision of proper tools to carry out this specialised cleaning is of paramount importance in preventing infectious-disease outbreaks.

'Invisible' places such as air-conditioning ducts that recirculate air have been identified as sources of outbreaks and should be periodically cleaned.

Health-care workers undergo training in sterile and aseptic techniques. In spite of this, an alarmingly high portion of healthcare workers still do not adhere to proper hand-washing protocols. This simplest of tasks, known for more than a hundred years to combat infections, is too often ignored to the detriment of patients.

Even more disturbing is the revelation that the root of this problem, oftentimes, is not with the attitude of the workers, but the availability of water and soap at the institutions.

Greater attention needs to be paid to the adherence of protocols by all health-care workers, patients, and visitors. Proper personal-protective equipment should be made available to visitors and workers alike. Oftentimes, it is not the wearer who is protected, but the patient on the other side of the gown.

Infectious-diseases committees should be active in all hospitals and periodic audits conducted.

One dreaded meeting during my residency was the morbidity and mortality conference. Here, residents had to present any adverse developments befalling their patients. Woe be unto the team that had a bad outcome because of a preventable cause. They would be raked across coals and, in the process, learn a valuable lesson that would save many lives later on in their career.

Many hospitals practise a kinder version of this internal audit of practices within that institution. Not only have internal audits been shown to result in better patient outcomes but they inculcate best practices in staff and trainees, who eventually go on to lift standards in other hospitals.

Maybe what we need to address the breaches in sterility noted in the recent health audits are conferences of this nature, involving not only the medical staff, but also every category of worker, including janitorial and administrative staff. Only then will persons who disregard or handicap sterility protocols see that their actions affect living, breathing human beings, and not just a faceless statistic.

Recommendations

- Continuing medical education on infection-control principles for all members of staff.

- Ensure proper training and outfitting of contracted janitorial teams.

- Morbidity and mortality conferences in hospitals.

- Active infectious-disease committees in hospitals.

- Random infectious-disease audits of hospitals and clinics.

- Ensure adequate personal-protective equipment is available.

- Dr Alfred Dawes is the immediate past president of the Jamaica Medical Doctors Association.

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