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Hospital infections lay bare systemic flaws

Hospital infections lay bare systemic flaws

The novel coronavirus has spread its tentacles to the precincts of our premier medical institutions, infecting a large number of frontline healthcare workers (HCWs) — doctors, nurses, paramedics. This also brings into sharp focus the aspects of hospital-acquired infections (HAIs), threatening the lives of patients and their attendants as well as HCWs. While HAI is one of the major causes of mortality and morbidity of patients, it assumes greater importance during a pandemic, since it strikes the medics as well. This puts highly skilled people out of circulation and renders them super-spreaders. The decision of the administration to close all hospitals for non-Covid patients and receive only Covid suspects in the OPDs was flawed de novo. A Covid hospital could have been set up on an emergency basis with the help of the army in a place like a cricket stadium.

The issue of patient safety in the wake of hospitals being a perennial source of infections has been catching the attention of the world community from time to time.

However, the matter of saving the HCWs from contracting deadly infections from the patients has arisen only now that Covid-19 has taken the lives of many HCWs. It is on record that all hospitalised patients are susceptible to contracting HAIs. Covid-19 has changed the paradigm; all HCWs are also at risk. The elderly and persons with compromised immune systems are more likely to get infected. Other risk factors are long hospital stays, the use of catheters or tube in windpipe, failure of HCWs to wash their hands, and abuse of antibiotics. As per American estimates, HAIs account for 1.7 million infections and 99,000 deaths each year. In India, where accountability and awareness is less, the numbers may be astronomical.

How do healthcare workers minimise HAIs in hospitals across the globe?

  • HCWs clean their hands with soap and water frequently
  • Catheters, Ryle’s tubes used only when absolutely necessary
  • Thoroughly cleaning the skin over the surgical site
  • HCWs wear appropriate hair covers, masks, gowns, boots and gloves and also contain the source of infection from patient/visitors

Reports of doctors and other HCWs getting infected with coronavirus are pouring in from all over the country. A rough estimate puts the figure at over 500 HCWs. According to the data, most HCWs affected in Chandigarh and other cities like Delhi, Hyderabad, Chennai, Mumbai and Srinagar were involved in non-Covid-19 operations and were not provided with good-quality N-95 masks and personal protective equipment (PPE) at all times. In Chandigarh, most of those infected were working in ‘emergency’ areas dealing with non-Covid-19 patients and they often complained of lack of PPE and training to work in the ICU.

This lack of preparedness has exposed HCWs and their families to various hazards, including pathogen exposure, psychological distress, fatigue, occupational burnout, stigma, physical and psychological violence, depression and suicide.

According to a recent article published in The Lancet, HCWs deployed at Covid-19 facilities suffered from exhaustion, the torment of difficult triage decisions, and the pain of losing patients and colleagues, in addition to the infection risk.

It is vital that governments and society at large treats HCWs not simply as pawns to be deployed without adequate training and protection, but as human beings whose safety must be ensured. HCWs, unlike ventilators or equipments and materials, cannot be urgently manufactured or run at 100 per cent occupancy for long periods. As more and more doctors and other HCWs are getting infected, soon the situation might get out of control and lead to a paralysis of the healthcare services.

There is a need to have a dedicated Covid-19 hospital for HCWs, where they can be provided the best possible medical care in order to ensure their speedy recovery.

As a preventive measure against asymptomatic and pre-symptomatic transmission, implement source control for everyone entering the hospital. Cloth masks are not considered PPE because their capability to protect HCWs is not adequate. There is a need to screen everyone for fever and symptoms of Covid-19 before they enter the designated area. Emphasise hand hygiene, install barriers to limit contact with patients at triage, cohort Covid patients, limit the number of staff providing care, and prioritise respirators for aerosol-generating procedures. HCWs in such situation should wear an N-95 or higher level respirator, such as disposable filtering face-piece respirators (PAPRs) and elastomeric respirators, eye protection shields, gloves, and gowns. It has been found that PPE kits meant for examining HIV patients are not efficient to resist permeation by coronavirus.

Droplet-size body fluids containing microorganisms can be generated during coughing, sneezing, talking, suctioning, and bronchoscopy. They are propelled a short distance before settling quickly on to a surface, which becomes infectious. They can also get deposited directly onto a susceptible person’s mucosal surface (eg conjunctivae, mouth, or nose) or on to nearby environmental surfaces, which can then be touched by a susceptible person who auto-inoculates their own mucosal surface.

Due to the highly contagious nature of the virus, many staffers have been demanding mass testing of hospital contacts, PPE kits and hazmat suits for all HCWs, but their demands were not heeded, citing the constraints of supply and optimisation of the scarce protective resource. It is now, after a score of HCWs are infected and isolated, that the authorities have relaxed the Indian Council of Medical Research guidelines to provide N-95 masks and superior PPE kits to every HCW in the emergency department. Similarly, HCWs should get suitable protective gear in the OPDs also.

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