Hiding in Plain Sight: How You Can Fight Bacterial Contamination in Your Clinic
By David Levine, PT, DPT, PhD, FAPTA, June Hanks, PT, DPT, PhD, and Henry Spratt, PhD
As health care providers, we see multiple patients each day up close and personal. It's not uncommon to catch a cold from a patient's cough. But did you know your clinical surfaces could be spreading germs as well? Our research team, the Clinical Infectious Disease Control (CIDC) research unit at The University of Tennessee at Chattanooga has been investigating bacterial contamination in physical therapy equipment.
Here are the results of 3 studies, some takeaways, and some common-sense tips to limit potential infections for you and your patients.
Topical lotions can be a source of bacterial contamination. In one study, we sampled 81 containers of common lotions used for soft tissue mobilization, such as Deep Prep®, Palmer’s Cocoa Butter®, and Free Up®, from 22 outpatient rehabilitation centers. Sixteen of the containers sampled—20%—contained bacteria including Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), and enteric bacteria such as E. coli. The majority of the bacteria found were present on the threads on the tips of the containers.
Ultrasound equipment can harbor germs—a lot of them. In another study, we cultured 31 ultrasound heads and 55 ultrasound gel bottles in 9 rehabilitation centers. Tips of gel bottles had the highest contamination, with 52.7% positive for nonspecific bacterial contamination and 3.6% positive for MRSA. While no MRSA was detected on ultrasound heads, 35.5% had nonspecific bacterial contamination. Disinfecting the ultrasound heads removed over 90% of the bacteria.
In a third study, we found that Staphylococcus aureus placed on ultrasound heads can survive, if not cleaned, for extended periods of time. Nearly 80% of Staphylococcus aureus placed on ultrasound heads in gel survived for 1 hour, with survival of 3 days possible in other types of organic matter, such as skin cells, or even the gel itself.
The takeaway: We need better and standardized cleaning and storage protocols for lotions, gels, and ultrasound heads, as well as general infection prevention protocols.
What Practice Managers Can Do to Prevent the Spread of Infection
Surveillance data collection is more challenging in outpatient settings than in inpatient settings due to short and sporadic patient encounters and the potential use of multiple medical facilities by infectious patients, but practice managers can promote best practices for infection prevention through official policies and protocols. Practitioners working in outpatient settings should follow recommended Centers for Disease Control and Prevention (CDC) health care-associated infection prevention practices, which include:
- Adherence to standard precautions such as cleaning equipment between uses
- Use of appropriate personal protective equipment including masks, gloves, and gowns
- Routine cleaning and disinfection of environmental surfaces most likely to become contaminated
- Strict adherence to hand hygiene practices (more on that later)
To reduce microbe contamination, environmental surfaces should be routinely cleaned and disinfected with appropriate solutions and following manufacturer recommendations. The CDC recommendations for cleaning and disinfecting environmental surfaces are based on the potential of the surface to transmit microbes if contaminated before use. Environmental surfaces are considered to be those that do not routinely come in direct contact with the patient during patient care, such as walls, floors, and knobs or handles on medical devices.
Even if you are a staff PT or PTA who isn't in a position to make decisions about a facility-wide protocol, there are some easy actions you can take right away:
- Routinely clean ultrasound heads with appropriate disinfectants.
- Use a tongue depressor to remove lotions from the container.
- Don't leave gel or lotion jars open.
- Don't reuse disposable bottles of ultrasound gels.
- Practice appropriate hand hygiene.
For patients who have open wounds or are immunosuppressed or immunocompromised, providers should take extra precautions, such as using sterile packets of lotions or gels for soft tissue mobilization or ultrasound, ensuring that any equipment that comes into contact with the patient (such as a goniometer) has been disinfected, and wearing personal protective equipment as needed.
Some Notes on Hand Hygiene
Hand hygiene should occur before and after each patient encounter.
Proper hand hygiene using alcohol-based hand sanitizers (ABHS) or soap and water significantly impacts microbe transmission and should be incorporated into routine patient care.
ABHS are the most efficacious method to reduce bacteria on hands. ABHS should be used according to manufacturer recommendations, which generally include putting the product on the hands and rubbing all surfaces of the hands together for at least 20 seconds until dry.
Handwashing with soap and water is recommended after treating patients with known or suspected norovirus or Clostridium difficile, since ABHS are not effective against these pathogens. To wash hands with soap and water, place the hands under running water, apply the soap, and vigorously rub all surfaces of the hand together for 15-20 seconds, rinse the hands, use a disposable towel to dry, and use the towel to turn off the water faucet.
Fingernails should be kept less than ¼ inch long, and excessive jewelry should be avoided. Frequent use of hand lotions that do not interfere with hand sanitizing products may help reduce hand dryness from frequent cleansing.
Everyone Has a Role to Play
All personnel play a role in the prevention of health care-associated infections. Administrators should ensure that policies and procedures regarding infection control are developed and implemented by health care personnel. Supplies necessary for adhering to standard precautions (eg, gloves, masks) should be readily available for use, and providers must be trained in infection-control measures.
David Levine is professor in the department of physical therapy at The University of Tennessee at Chattanooga (UTC) and a board-certified clinical specialist in orthopaedic physical therapy. June Hanks is associate professor in the department of physical therapy at UTC. Henry Spratt is professor in the UTC department of biology, geology, and environmental science.