dgkh000044 Original Contribution Stellenwert der Desinfektion als Infektionsprophylaxe im Wandel der Zeit – Anaesthesie, Intensiv- und Notfallmedizin, Schmerztherapie Lingnau Lingnau Werner W Univ. Prof. Dr.

Klinik für Anaesthesie und Allg. Intensivmedizin, Medizinische Universität Innsbruck, Anichstrasse 35, A-6020 InnsbruckUniversity Clinic for Anaesthetics and Intensive Care at the Leopold Franzens University Innsbruck, Austria

werner.lingnau@uibk.ac.at author German Medical Science

Düsseldorf, Köln

610 20070913 engl 1863-5245 2 1 GMS Krankenhaushygiene Interdisziplinär GMS Krankenhaushyg Interdiszip 40 years of infection control - Did we improve? 11 Es ist alarmierend, wenn Anästhesisten ähnlich wie in früheren Jahren als Spezialisten mit der geringsten Befolgung einfacher, eigentlich allgemein gültiger Hygieneregeln erkannt werden. Infektionsprophylaxe ist dem Arzt leider immer nur dann ein besonderes Anliegen, wenn er Infektionen bei „seinem“ Patienten als Konsequenz seiner hygienischen Unachtsamkeit diagnostizieren und behandeln muss. Hygienemaßnahmen am Bett sind nicht eingehalten worden, bieten Ansatz für Aufklärung und Fortbildung der Mitarbeiter, sind Basis für deren Betroffenheit. In der Notfallmedizin kann dieser Mechanismus weit weniger genutzt werden. Der Arzt sieht selten, was aus dem Patienten wird. Fehler in der Infektionsprophylaxe bleiben ohne erkennbare Folgen. „Die vitale Bedrohung lässt mir dazu keine Zeit“, sagt der Notarzt. „Während der Einleitphase zur Vollnarkose oder bei chirurgischen Blutungen stehe ich unter Stress, da habe ich für Hygiene keine Zeit“, gibt der Anästhesist im OP zu. Um dies zu verbessern, muss an den Ursachen der Ignoranz und Gedankenlosigkeit zur Hygiene angeknüpft werden. Neben allgemeiner Aus- und Fortbildung zu richtiger Durchführung hygienischer Maßnahmen und den Folgen der Nichteinhaltung der Leitlinien muss heute der individuelle Aspekt der Motivation angesprochen werden. Jeder Behandler macht mit seinem individuellen hygienischen Verhalten einen Unterschied für den Patienten. Jeder Ober- und Chefarzt macht in seiner Vorbildwirkung einen Unterschied im Verhalten künftiger Anästhesisten. Und im System des Krankenhauses muss der Faktor Personalüberlastung und Zeitdruck als Ursache mangelnden Hygienverhaltens klar sein. Heute bedeutet Hygiene nicht nur einfach „sauberes Arbeiten“ und reduzierte Morbidität der Patienten. Heute bedeuten reduzierte Infektionsraten Kosteneinsparung im Gesundheitswesen und damit Reserve für künftige Versorgung der Bevölkerung. Heute weiß man, dass hygienisches Verhalten am Patienten nicht lästiges Übel ist, sondern sich rechnet. Wir müssen es „nur“ umsetzen. It is alarming that anesthetists, just as in earlier years, have been shown to be the specialists with the poorest rate of compliance with simple, basis everyday rules of hygiene. Unfortunately, infection prophylaxis is something to which the physician ascribes importance only when he sees the consequences of his actions, that is to say when he has to diagnose and treat infections in “his” patient as a result of his “failure” to adhere to infection control regulations. That infection control measures have not been taken at the bedside highlights the need for enlightenment and education of staff and serves as the basis for their involvement. Such measures can be taken much less easily in emergency medicine. The emergency physician / anesthetist is rarely confronted with the patient’s outcome. Any errors in infection prophylaxis have no perceptible consequences. “The threat posed to vital functions does not allow any time,” said the emergency doctor. ”During the time elapsing from first administering the anesthetic until full narcosis is reached or in the case of intrasurgical bleeding, I’m feeling stressed and then have no time for hygiene” admits the anesthetist in the OR. To improve this situation, the root cause of ignorance and thoughtlessness as regards hygiene must be addressed. Apart from general training and continuing education for correct conductance of hygienic measures and regarding the consequences of failure to observe the guidelines, today the individual aspect of motivation must be addressed. Each professional administering treatment makes a difference for the patient through his individual approach to hygiene. Each head physician and medical director makes a difference to the behavior of future anesthetists by acting as a role model. And within the hospital system the factors “overburdened personnel and time pressure” as the cause of inappropriate infection control must be clarified. Today hygiene does not merely denote “clean working practices” and reduced patient morbidity. Today reduced infection rates mean reduced costs in the healthcare sector and hence reserves for the future care of the population. Today we know that hygienic practices when attending to the patient are not an onerous burden but that they pay off. We must “only” get around to implementing them. Text The vast field of anesthesia with its manifold tasks means that inevitably a range of diverse approaches are taken to infection prophylaxis. Set against a background where the prime focus is on the preservation of vital functions, infection control measures are assigned a minor role. It is alarming when anesthetists in a recent survey , just as in earlier years, were seen to be the specialists with the poorest rate of compliance with simple, really everyday rules of hygiene. This study had assessed activities carried out by doctors on patients and the associated infection control measures based on published guidelines in the light of conductance of obligatory measures such as hygienic hand disinfection or the wearing of gloves. With an average rate of 57% for hand disinfection in mandatory situations, also in the presence of known resistant bacteria, anesthetists scored only 23%. Why is that so? The earlier guidelines governing infection control behavioral mechanisms advocated “hand washing” as a necessary measure. It is above all the anesthetist in the operating theater who cannot turn away from the patient following contamination in order to go to a washbasin situated outside the OR and spend the time there it takes to wash his hands. However, alcoholic products for hygienic hand disinfection are today standard practice and can be used in situ without a washbasin. The argument about the lack of facilities is generally no longer valid today. Likewise, the problem of skin irritation and drying is generally not a problem either since the incorporation of remoisturizing agents. And especially in the case of soap and also of alcohol, the mean exposure times at between 6 and 15 seconds, as borne out by studies, are relatively short for assured efficacy. So if it is not the lack of facilities that is stopping anesthetists from taking hygienic measures, what is it then? Unfortunately, infection prophylaxis is something to which the physician ascribes importance only when he sees the consequences of his actions, that is to say when he has to diagnose and treat infections in “his” patient as a result of his “failure” to adhere to infection control regulations. In intensive care medicine the implications of such experiences have been known for a long time now. The anesthetist in the intensive care unit, for example, admits a young, healthy but polytraumatized patient to his unit. Just a few days later he must concede that this patient who “only” suffered from tissue contusion and blood loss that warranted treatment, is now suddenly suffering from pneumonia that is posing a threat to this lung function. He treats the patient with antimicrobial chemotherapy. But soon the patient is exhibiting the entire clinical manifestations of sepsis. And it is not at all uncommon that colonization or infections with the same bacterium, which today will prove in most cases to be resistant to antibiotics, is seen in the immediate vicinity of this index case. Consistent infection control measures have not been taken at the bedside; this highlights the need for enlightenment and education of staff and serves as the basis for their involvement. In the past this was used, and even today is still used, as a motivation for hand disinfection. Such measures can be taken much less easily in emergency medicine outside the hospital setting and in anesthesia in the operating theatre. The team treats the patient only for a very short period of time, ranging from minutes to a few hours, and then loses sight of the patient again. Rarely does the physician see how things turn out for the patient. Errors in infection prophylaxis relating to disinfection, in handling infusion solutions, dealing with arterial and central venous catheters do not have any perceptible consequences. “The threat posed to vital functions does not allow any time” said the emergency doctor. Often, there is a lack of facilities here, too. While there are gloves available, they are worn then to perform clean and unclean tasks on the patient without being changed, and thus ineffective. However, somewhere in the emergency chest there is a small bottle of alcoholic hand disinfectant. But in the concrete situation it cannot be reached. ”During the time elapsing from first administering the anesthetic until full narcosis is reached or in the case of intrasurgical bleeding, I’m feeling stressed and then have no time for hygiene” admits the anesthetist in the OR. Any danger posed to the patient, whose immune system has now been compromised by the operation, is viewed as a distant, theoretic and unimportant threat. To improve this situation, the root cause of ignorance and thoughtlessness as regards hygiene must be addressed at present and in the future. Apart from general training and continuing education for correct conductance of hygienic measures and regarding the consequences of failure to observe the guidelines, the individual aspect of motivation must be addressed. Each individual professional administering treatment makes a difference for the patient. Each head physician and medical director makes a difference to the behavior of future anesthetists by acting as a role model. And within the hospital system the factors “overburdened personnel and time pressure” as the cause of inappropriate infection control must be clear. Today hygiene does not merely denote “clean working practices” and reduced patient morbidity. Today reduced infection rates mean reduced costs in the healthcare section and hence reserves for the future care of the population Today we know that hygienic practices when attending to the patient are not an onerous burden but that they pay off. We must only get around to implementing them. Curriculum Vitae Prof. Dr. med. univ. Werner Lingnau Figure 1 Specialist for Anaesthetics and General Intensive Care Medicine, sports physician, emergency doctor. Werner Lingnau was reading medicine at the Leopold Franzens University in Innsbruck in Austria. 1983 her received his doctorate and started his education at the University Clinic for Anaesthetics and Intensive Care to become a specialist. For several months he moved to the „Onze Lieve Frowe Gasthuis” Clinic in Amsterdam to work with CP Stoutenbeek and then to the University of Texas (Medical Branch). During his anaesthetical work Professor Lingnau became member of the Antibiotics Committee and the Drug Committee for all of the University clinics, furthermore Commissioner for Hygiene of the University Clinic for Anaesthetics and General Intensive Care Medicine in 1991. In this role he gets his hygiene education at the Royal College of Surgeons and at the King’s College Hospital in London. 1998 he habilitates in the special subject of Anaesthetics and General Intensive Care Medicine and receives the Venia legendi. A lot of publications, articles for books, abstracts and 138 national and international „invited lectures” on the subjects of trauma, sepsis, multi-organ-collapse and infection prevention give proof of this wide range of competence. Pittet D Hand Hygiene among Physicians: Performance, Beliefs, and Perceptions 2004 Ann Intern Med 1-8 Pittet D et al. Hand Hygiene among Physicians: Performance, Beliefs, and Perceptions. Ann Intern Med. 2004;141:1-8 Hospital Infection Control Practices Advisory Committee (HICPAC) Recommendations for preventing the spread of vancomycin resistance 1995 Infect Control Hosp Epidemiol 105-13 Hospital Infection Control Practices Advisory Committee (HICPAC). Recommendations for preventing the spread of vancomycin resistance. Infect Control Hosp Epidemiol. 1995;16:105-13. Garner JS Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals 1996 Infect Control Hosp Epidemiol 53-80 Garner JS. Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol. 1996;17:53-80. Pittet D Mourouga P Perneger TV Members of the Infection Control Program. Compliance with handwashing in a teaching hospital 1999 Ann Intern Med 126-30 Pittet D, Mourouga P, Perneger TV. Members of the Infection Control Program. Compliance with handwashing in a teaching hospital. Ann Intern Med. 1999;130:126-30. Boyce JM It is time for action: improving hand hygiene in hospitals 1999 Ann Intern Med 153-5 Boyce JM. It is time for action: improving hand hygiene in hospitals. Ann Intern Med. 1999;130:153-5. 0

1 1 Figure 1: Werner Lingnau

1 0 0