Infection Control

Today’s wound care clinics have a myriad of clinical practice and regulatory considerations.
Infection control is one area that affects everyday clinical practice, but is also a regulatory consideration of growing significance. The prevalence of drug resistant microorganisms, such as Methicillin Resistant Staphylococcus Aureus (MRSA), has heightened the concern related to chronic wound infections and infection control practices in the outpatient wound clinic.
One of the Joint Commission’s National Patient Safety Goals require clinicians to reduce the risk of healthcare associated infections through compliance with current World Health Organization (WHO) or Centers for Disease Control (CDC) hand hygiene guidelines to reduce the transmission of infectious agents from clinicians to patients, as well as implement best practices for preventing surgical site infections. Since the primary mode of bacteria transmission is through contaminated hands of the healthcare worker, it only makes sense that proper hand hygiene be a part of standard practice.
Compliance of the healthcare worker in proper hand hygiene practices is another issue that has to be considered. To improve compliance, consider low irritancy potential products and solicit staff for input on the products used within the facility. Alternative products should be available for those with allergies or adverse reactions to the standard product in use. Hand lotions compatible with the facility’s soap and alcohol-based hand rub will also assist with hand hygiene compliance.

MRSA
MRSA, and other drug resistant microorganisms, are of growing concern in the outpatient wound clinic. This, coupled with the fact that the classic clinical signs of infection may be subtle or absent in the chronic wound, has led to the arbitrary use of systemic and topical antibiotics, which further contributes to the emergence of resistant microorganisms. Even though the classic clinical signs of an infection may be absent from the patient suffering with the infected chronic wound, a delay in healing or worsening of the wound will most likely be present. If an infection is suspected, a proper wound culture with sensitivity should be considered prior to treatment.
The emergence of Community Associated MRSA (CA-MRSA) is part of the growing MRSA alarm in outpatient wound clinics. Traditionally, MRSA infections have been associated with hospitalization or other healthcare-associated risk factors such as recent hospitalization, surgery, residence in a long-term care facility, receipt of dialysis, or presence of invasive medical devices1. In recent years healthcare providers have observed MRSA infections in an increasing number of people who lack traditional healthcare-associated risk factors, which is why the outpatient wound clinic is an opportune location for the presentation of CA-MRSA.

Infection Control
Proper hand hygiene is imperative in an effective infection control program; however, other precautions should also be factored in. As a clinic routinely working with body fluids, today’s wound clinics should integrate standard precautions as a part of everyday practice. Standard precautions combine universal precautions with body substance isolation. These precautions include proper hand hygiene, use of gloves, gown, mask, eye protection or face shield, and safe injection practices. The application of these standards is determined, by the healthcare worker based on the anticipated level of exposure to blood, body fluid, or pathogen exposure2.
Handling of contaminated medical equipment and maintaining a clean environment is also an essential part of an effective infection control program. Exam room surfaces should be cleaned with EPA-registered hospital detergent/disinfectant, in accordance with label instructions1. Proper personal protection equipment should be used whenever working with chemical cleansers.

Utilizing the internal resources, the hospital infection control department, will make development of effective infection control policies and practices for the wound clinic much easier. The infection control nurse should be encouraged to make rounds through the wound clinic during hours of operation to assist in the identification of infection control issues. This provides management of the clinic guidance on performance improvement opportunities as it relates to staff adherence to the infection control policies.

The infection control department can also assist with the development of a surveillance program if needed. Challenges for infection control surveillance in outpatient care settings include determining what infections to conduct surveillance, what definitions to use, who will conduct the surveillance, to whom the data will be reported, and who will be responsible for implementing the changes3. As electronic medical records become more mainstream in the outpatient clinical setting, surveillance will become easier to conduct allowing for data collection related to infections and other adverse events so that rates and trends can be monitored.

Patient Participation
A shift of medical care delivery from the inpatient care setting to the outpatient care setting has created a need for patient and caregiver involvement within infection control practices. These patients are in the community with open draining wounds, which increases the chance for cross contamination among family and other close contacts—particularly within their living quarters. Patient and caregiver education should include far more than just wound hygiene and dressing application. All should be informed of the diagnosis of infection and if dealing with an MRSA infection, they should be counseled to inform other healthcare providers that he/she has a history of MRSA infection. Standard precautions necessary to prevent the spread of MRSA to other household members and contacts should also be a routine part of the education process for the patient infected with MRSA. Such precautions include1:
l Keep wounds that are draining covered with clean bandages that remain dry on the outside.

l Clean hands regularly with soap and water or alcohol-based hand gel (even if hands are not visibly soiled). Always clean hands immediately after touching infected skin or any item that has come in direct contact with a draining wound.
l Maintain good general hygiene with regular bathing.
l Do not share items that may become contaminated with wound drainage, such as towels, clothing, bedding, bar soap, razors, and athletic equipment that touches the skin.
l Launder clothing that has come in contact with wound drainage after each use and dry thoroughly.
l If unable to keep your wound covered with a clean, dry bandage at all times, do not participate in activities where you have skin-to-skin contact with other persons (such as athletic activities) until your wound is healed.
l Clean equipment and other environmental surfaces with which multiple individuals have bare skin contact with an over the counter detergent/disinfectant that specifies Staphylococcus aureus on the product label and is suitable for the type of surface being cleaned.1 If unable to keep wound covered or manage drainage, don’t participate in skin-to-skin activities
l Clean equipment and environmental surfaces with which multiple individuals have bare skin contact with an over the counter detergent/disinfectant that specifies Staphylococcus aureus on the product label land is suitable for the type of surface being cleaned.

The wound clinic is a high-risk department for infection cross contamination. Precautions to prevent the spread of infection must be part of the standard practices within the wound clinic and should include education to the patient for infection control in the home. Performance improvement measures should be in place to regularly evaluate and improve staff adherence to infection control practices. The infection control nurse should also be involved to assist with the development of surveillance programs, policies, and the evaluation of infection control practices within the clinic.

Trisha Carlson MSN, MBA-HCM, RN, CWCN is the Director of Clinical Quality and Education for National Healing Corporation. She is available for questions at tcarlson@nationalhealing.com.