Wednesday, May 1, 2013

Recommendations regarding hand hygiene for Primary Health Care

Clean Hands

Recommendations regarding hand hygiene for Primary Health Care Personnel  and Health Care Centers in Spain
Jesús Palacioa, Mª Dolores Martínb, Carlos Aibarc, Rosa Marecac and the SEMFYC Patient Safety Working Group*
1.- Introduction
The WHO’s Clean Care is Safer Care campaign gives special attention to hand hygiene. These recommendations are guidelines for Primary Health Care doctors and nursing personnel, as regards when and how we should wash our hands and put on gloves, in order to prevent transmission of diseases to our patients. 
It is up to health care services to provide the resources so that professionals in this field, as well as in others, may offer quality service.

2. Hand hygiene - procedures
-          With liquid soap and water. Useful for eliminating visible dirt. The reduction in the amount of microorganisms depends on the time spent in washing and the soap’s antiseptic content. Antiseptic soaps are more harmful to the skin than regular soaps, and more time is needed to adequately wash when using them. Regular soap eliminates transient or contaminating flora without affecting resident flora. Washing with soap and water can be finished in 40 seconds.
-          With alcohol-based formulations. Handrubbing with alcohol-based formulations is faster, less irritating since these formulations contain an emollient, and has an antiseptic capacity similar to that of washing with antimicrobial soaps. Washing for twenty seconds is sufficient time for adequate antisepsis, equivalent to the time allowed for alcohol volatility.
3. When should we wash our hands and put on gloves?
The recommendations of the Guidelines for Hand Hygiene published in 2002 by the Centers for Disease Control (CDC) serve as the basis for the majority of the guidelines prepared since then. There are no current studies carried out in PHC that show consistent and applicable evidence at this level. With reference to application of the abovementioned recommendations at the Primary Health care level, hand washing is recommended at the following times and under the following circumstances:
3.1 Hand washing:
-          At the start of and after the appointment. It is recommended that hands be washed with soap and water or with an alcohol-based formulation, in case hands are already visibly clean.
-          Before and after carrying out certain exams that involve direct and continual contact with the patient’s skin and mucus:  Respiratory and genital exams

-          Before and after putting on sterile gloves in order to perform interventions that require them, such as minor surgery, treatment of injuries, urinary catheter insertion. The method of choice of PHC is handrubbing with alcohol-based formulations.
-          When there exists risk of exposure to body liquids, such as contact with bodily fluids, secretions or excretions, mucous membranes, broken skin or other objects that show visible evidence of contamination by such liquids.  Also after having been exposed to these risks while wearing gloves, after having taken them off.
-          Between patient consultations, depending on the kind of direct contact that has been occurred between the health professional and the patient, as well as on the patient’s pathology. For instance, it is beneficial to wash hands after auscultating a patient, if there is a chance of contamination. Under these circumstances, the importance of this measure will be related to the risk assessment, in other words, to the type of pathology. The health care professional must adapt this recommendation according to his circumstances, since the risk of hand contamination greatly varies, for instance, if an administrative procedure is performed, such as a patient report or discharge confirmation, or if a patient has been visited that is suffering from a serious disease that is easily transmitted by hand contact.
Some common primary health care exams present low risks, such as checking the pulse, blood pressure, and temperature, performing an ECG or auscultating patients that do not present a contagious pathology. Therefore it is not strictly necessary to take either pre- or post-exam preventive measures either before or after these exams, except in special cases, such as suspected contamination by drops or by contact with microorganisms transmitted by hand contact.
3.2 Use of gloves:
Gloves are a common protective measure for health care personnel and patients. However, by no means does the use of gloves eliminate the necessity of hand washing.
Their use should be limited to the time of their application, being taken off immediately afterwards and specifically not being utilized while attending to different patients, using the telephone, or computer, or writing by hand.
Use of sterile gloves is required for:
-          Handling of skin areas with solution of continuity
-          Treatments and minor surgery
-          Any type of catheterization
The use of clean non-sterile gloves is restricted to:
-          Emergency attention
-          Pelvic and rectal exams
-          Oropharyngeal exam
-          Handling of bodily fluids and contaminated material
-          Blood sample extraction

In any case, hand washing or handrubbing with alcohol-based solutions is indicated, before and after putting on sterile gloves, avoiding the wearing of excessively long nails.
The infectious capacity and the seriousness of potentially transmissible diseases will be kept in mind in order to decide on the required level of hygiene and precautions in particular cases, as with all cases.
4. Recommendations for public health centers
It is the responsibility of the health care management officials, and of the primary health care centers, to supply the necessary resources in order to perform adequate hand hygiene.
Every consulting room should be supplied with:
-          A sink and running water
-          Regular liquid soap with dispenser
-          Disposable towels
-          Alcohol-based formulation with wall dispenser
-          Alcohol-based formulation in small containers of 100 cc, for home visits
-          Moisturizing cream with dispenser
-          Sterile gloves
-          Non-sterile gloves
aFamily practitioner, Centro de Salud Muñoz Fernández-Ruiseñores, Zaragoza, Spain
bSpecialist in Family and Community Medicine, Quality Control Department, Fundación Pública Urxencias Sanitarias de Galicia-061
cSpecialist in Preventive Medicine and Public Health, Patient Safety Department, Servicio Aragonés de Salud (SALUD)
*SEMFYC Patient Safety Improvement Group: Fernando Palacio (coordinator), Carlos Aibar, María Pilar Astier, Rafael Bravo, Maria José Gómez, Marian López, José Ángel Maderuelo, Mª Pilar Marco, Mª Dolores Martín, Sergio Minué, Guadalupe Olivera, Jesús Palacio, Marisa Torijano.
Correspondence: Jesús Palacio, Centro de Salud Muñoz Fernández-Ruiseñores, Pº de Sagasta, 52, 5006, Zaragoza, Spain Email:

Spanish Society of Family and Community Medicine

See also: 

SEMFYC adapts the WHO recommendations on hand hygiene for Primary Care. Aten Primaria 2010; 42(8): 401-402 (Spanish) 

Thursday, October 7, 2010

What to do if things go wrong: a guide for junior doctors

This National Patient Safety Agency's booklet is a guide for junior doctors to manage a patient safety incident.

It is organized in 6 sections.

First, a description of a personal experience of having a medical incident. Second, to document the incident in the patient’s medical records and to inform consultant and/or supervisor. Third, to communicate the incident to the patient, family and caregivers and apologise to all. Fourth, to report the incident in a local reporting system. Fifth, the guide enhance that junior doctors, on the frontline of care, are vital in the identification of learning from reporting. Finally, an algorithm is presented to deal with the complaints process in England.

Every section is introduced by an incident description from a relevant medical doctor in England.

It is easy to read and a good example to adapt in every country as a guide to promote good answers to incidents in practice for junior doctors.

Medical error. What to do if things go wrong: a guide for junior doctors

Posted by Pilar Astier
English version by Pilar Astier

Monday, October 4, 2010

Infections, oral anticoagulant therapy, cotrimoxazole and ciprofloxacin

The newsletter on Patient Safety of the Ministry’s Quality Agency has published a new edition with articles of great interest. Among them, one published in Archives of Internal Medicine that associate the increased occurrence of upper gastrointestinal (UGI) tract hemorrhage in patients undergoing oral anticoagulant therapy with warfarin, if they are prescribed cotrimoxazole or ciprofloxacin, for a lower urinary tract infection (UTI), for example.

The researchers conducted a population-based, nested case-control study. Cases were hospitalized with UGI tract hemorrhage. For each case, we selected up to 10 age- and sex-matched control subjects. We calculated adjusted odds ratios (aORs) for exposure to cotrimoxazole, amoxicillin trihydrate, ampicillin trihydrate, ciprofloxacin hydrochloride, nitrofurantoin, and norfloxacin within 14 days before the UGI tract hemorrhage.Cases were patients taking warfarin and who were hospitalized with UGI tract hemorrhage. 2151 cases and 21434 controls were identified (10 for each). Researchers investigated whether the patients had taken in the days before cotrimoxazole, amoxicillin or ampicillin, ciprofloxacin, nitrofurantoin and norfloxacin (antibiotic commonly used to treat UTIs). Cotrimoxazole was even associated with increased risk of UGI hemorrhage, with an OR of 3.84. It also occurred with ciprofloxacin, with an OR of 1.94. Amoxicillin, ampicillin, nitrofurantoin and norfloxacin were not associated with an increased risk.

Although cotrimoxazole is rarely used in Spain at present, ciprofloxacin is usually prescribed. This article provides guidelines for a safer –and more rational- treatment of the UTIs or other location.

Fischer HD, Juurlink DN, Mamdani MM, Kopp A, Laupacis A. Hemorrhage during warfarin therapy associated with cotrimoxazole and other urinary tract anti-infective agents: a population-based study. Arch Intern Med 2010; 170 (7):617-21. [PMID: 20386005].

Posted by Fernando Palacio
English version by Erika Céspedes

Saturday, October 2, 2010

Increased reporting of medication errors in a Healthcare Area

Virginia Greciano, of the Area 2 of Madrid, presented an interesting oral communication on medication error reporting, which is summarized below.

Given the necessity to extend definitively the culture of reporting medication errors (ME) and facing an increasing number of targets by the organization, the Functional Unit for Health Risks Management (FUHRM) proposed the Pharmacy Department to develop strategies to promote reporting.

Managers designed a training session on ME for healthcare centers in the Area 2. This session was directed at doctors, pediatricians and nursing, and other non-healthcare professionals. The main objective was to deepen the concept of ME and its differentiation from other adverse events. The content was also aimed at promoting reporting by simple steps, as well as illustrating the session with useful information and examples.

There were a few support messages based on 4 basic principles:

1. Curiosity: about any circumstance that cause surprise about a drug or pharmaceutical product at any time.

2. No doubt: "at the dilemma of whether it is an ME, an adverse reaction or other event, report it. An excess of notification does not hurt anybody and do so could get a risk to the patient ".

3. No blame: the ME is a part of the sanitary work. Reporting is anonymous, encourages a culture of risk and helps us grow as healthcare professionals.

4. Avoid bureaucracy: do not let papers paralyze you. To report a ME, just publicize it and ask for collaboration.

The results of the sessions were very interesting in terms of number of people attending and the number of notifications that have been received later. In less than six months reported a number of EM sufficient to achieve the goal of the year, reaching 42% report a higher than agreed. At the end of 2009, we were the third AP Management goal percentage and fourth in number of notifications.

Having identified the improvement areas and made the balance in the FUHRM, various measures have been proposed to maintain this line of work in the future.

To view the full presentation click here

Posted by Fernando Palacio
English version by Erika Céspedes

Wednesday, September 29, 2010

Patient Safety 2010 Eurobarometer

The supplement on Patient Safety, of the newsletter of the National Health System’s Quality Agency, announces the publication of the Patient Safety 2010 Eurobarometer.

It is a very complete report, with 107 pages, containing the results of 26,663 questionnaires in the 27 EU countries.

Nosocomial infections are the adverse effects perceived as most frequent, followed by misdiagnosis and problems with medication.

When people are asked about the risk of having an adverse effect in the hospital, Greeks express the greatest mistrust, measured at 83%. The EU average stands at 50% and in the case of Spain, by 35%.

When the question refers to the risk in Primary Care, Greeks repeats the worst result, 78%. The EU average is 46% and 32% in Spain.

It is surprising that, despite the different kind of care, there is little difference between the estimation by the citizens of suffering harm in the hospital (35%) or primary care (32%).

Those are good results for Spain in terms of public confidence in the NHS, which compels us to continue working to not disappoint it.

Posted by Fernando Palacio
English version by Erika Céspedes

Monday, September 27, 2010

Detection of potential interactions by the electronic medical record: A new approach to improve patient safety

The European Journal of General Practice has published the article: Prevalence and typology of potential drug interactions occurring in primary care patients. Authors: López-Picazo JJ, Ruiz JC, Sanchez JF, Ariza A, Aguilera B, Lazarus D, Sanz GR.

The objective of this article is to determine the prevalence and type of potential drug interactions in primary care patients.

It is very interesting because its content is directly related to medical errors and their consequences, adverse effects and drug interactions in primary care. This field has a huge impact on the global patient safety due to the high number of visits, the level of prescription and other factors such as pluripathology.

The authors start from the difficulty of identifying and confirming the actual prevalence of drug interactions, to propose a preventive approach. It is acting on potential drug interactions identified by the electronic medical records (and confirmed by prescription -recipes used-), according to the evidence available, and using software that identifies patients likely to suffer these potential interactions. All this would be completed by a warning system, related to the medical record, that, in real time, allows the family physician identify the potential interaction, and with the automatic proposal of safe therapeutic alternatives. Every active ingredient that each patient can be taking simultaneously is analyzed.

The study confirms the existence of a serious safety problem for patients, because 1 in 20 Spanish citizens is subject to the risk of drug interaction. And, more important, with a high rate of serious or high risk interactions.

At the time of analysis 29.4% of the population took medication. Of these patients, 73.9% took more than one drug and, therefore, was at risk of interactions; more than a half of the potential interactions could be clinically important. However, the percentage of interactions observed is usual in the literature.

There are more interactions among people with chronic conditions, the elderly, females and polymedicated patients. The active ingredients most frequently involved were hydrochlorothiazide, ibuprofen and acenocumarol. Respect to interactions that should be avoided, the most common are combinations with omeprazole, acenocumarol and diazepam.

This approach and the results of this study provide us valuable information and, most of all, a new simple and practical approach, which should not be wasted by the professionals or the institutions involved, for the benefit of our patients.

Edited by José Saura Llamas
English version by Erika Céspedes

Saturday, September 25, 2010

Europe removes drugs containing rosiglitazone (Avandia®, Avandamet® and Avaglim®)

Finally, rosiglitazone (Avandia®) is no longer available in Europe.

In a previous post we discussed an article of The New York Times, which might help to explain why the FDA refuses its full withdrawal, although rosiglitazone is not better than pioglitazone, but causes more cardiovascular problems.

Yesterday, El País reported extensively on the ban, until Glaxo can "identify the group of patients in which the drug benefit exceeds the risks".

Avandia® sold 920 million Euros last year, and had arrived in 2006 to more than 2000 million. The question is: If the alert was given, and there are equally effective alternative medications, and safer, why was it still prescribed?

+ Info: - Spanish Agency for Drugs and Health Care Products (AEMPS):

Patient information note on the suspension of marketing of drugs containing rosiglitazone (Avandia ®, Avandamet ®, Avaglim ®)

Communication for professionals

- European Medicines Agency (EMA):

Press release: European Medicines Agency recommends suspension of Avandia, Avandamet and Avaglim

Questions and answers on the suspension of rosiglitazone-containing medicines (Avandia, Avandamet and Avaglim)

- In this blog:

GSK hid the rosiglitazone (Avandia) is associated with cardiovascular risk

GSK recibe una reprimenda de la FDA por ocultar datos sobre su antidiabético rosiglitazona (Avandia) (GSK receives a rebuke from the FDA for hiding data on its antidiabetic rosiglitazone Avandia)

Posted by Fernando Palacio
English version by Erika Céspedes