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The Prepared Patient
We're all in infection control together

Center For Advancement of Health
Volume 1, Issue 6, March 2008

These days, antibiotic-resistant tuberculosis and staph are making headlines, while this year’s flu shot is uncertain protection against this year’s flu strain.

Germ phobia is in the air, and some patients are wondering if medical visits could actually make them sicker. Others are worried about what they’ll pick up in the waiting room or on the examining table.

“It’s OK for the patient to speak up.
We’re all in infection control together.”
--April Strider, SafeSmart CEO

Of course, people have been going to doctors’ offices for at least a century without worrying too much about germs. But if you’re still concerned you can reduce your family’s risk by taking a few simple precautions.

“The single most important thing a patient can do is ask everyone who is going to be treating you to clean their hands,” says Betsy McCaughey, founder of the Committee to Reduce Infection Deaths. “Ask that they do it in front of you. Don’t be misled by gloves; gloves are no assurance at all.”

Many moms and dads dread visiting a pediatric waiting room full of sneezing kids in the height of flu season and try to keep their toddlers away from much-handled community toys.

“Bring along a children’s book,” McCaughey suggests. “Bring an alcohol-based (waterless) hand cleanser, too. Don’t worry about looking obsessed — other parents will catch on.”

She advises parents to be especially careful if a child has a scraped knee or another gateway for infection. “If your kid has a wound — keep him or her on your lap and cover the wound; have them wear long pants.”

Chrissy Boylan is the Fairfax, Va., mother of a five-year-old, a three-year-old and an infant. She visits the pediatrician frequently, and while she believes she doesn’t worry more than the average parent, “you do figure out that you only want to bring them in when they’re really sick.”

Her pediatrician’s office has “sick” and “well” waiting rooms, but Boylan says “I wonder if they’re using different examining rooms, too. I feel like the [dual waiting rooms] are more to make parents feel better.”

Dual waiting rooms don’t work, says Dr. Steven Hirsch, a pediatrician in solo practice in Rockville, Md.

“It’s an imperfect system; ideally, though you would want to separate out children with contagious infections such as a common cold or stomach virus from those who are not contagious, it’s too difficult to figure out,” Hirsch says. “A lot of children there for well visits actually have contagious viruses — or their siblings do.”

“Make sure people ‘scrub and glove’ and that
you see them do it.”
--Betsy McCaughey, head of Committee to Reduce Infection Deaths.

Sneezing and coughing aren’t the biggest problem, Hirsch says: “The flu virus is not spread by aerosolized particles floating in the air. Transmission usually occurs when you come in direct contact with a droplet.”

This can happen when a sick person touches his or her eyes, nose, or mouth then touches an inanimate object such as a doorknob or elevator button. That living germ gets transferred to the inanimate object. If you touch the same object soon afterward, then touch your child’s eyes, nose or mouth, that virus gets transmitted into her body, Hirsch says.

So instead of shared toys, Hirsch’s staff provides individual buckets of toys for each child to play with during their visit. At day’s end, staff members wipe down the toys and let them dry overnight, long enough for most germs to die.

Inside the exam room, Hirsch says that fresh, unwrinkled paper on the table is a tangible — but inadequate — proof of a sanitary space. “You rip the used paper off after each patient and people see the clean, crisp paper and are reassured that the office is clean,” he says.

But that’s not good enough, he adds. “After every patient, it only takes a short period of time with an antibacterial wipe for me, or a staff member, to clean the examining table, door knobs, chair railings and counter tops — anything that’s been touched.”

Marian Sonnenfeld, M.D., former chief of mammography at Brigham and Women’s Hospital in Boston, says a woman can ask the technologist if the equipment is wiped down in between each patient, for mammograms and other X-ray procedures as well.

Her own medical issues have forced Sonnenfeld to step back from her role as a clinician and increasingly view infection prevention from the patient’s perspective.

She recalls going to a physical therapy office where they “changed the sheet on the treatment table but not the pillowcase on the pillow. I did most definitely say something about that. They said something along the lines of changing the pillowcases every morning, which of course was totally insufficient.”

On the other end of the spectrum, she describes a gastroenterology practice, whose patients include transplant recipients, that supplies tissues, hand gel and masks in the waiting room, and posts signs urging people — whether vulnerable patients or visitors with contagious illnesses — to use them.

Chrissy Boylan doesn’t believe in being alarmist: “It’s hard enough dragging kids to the doctor’s office; I don’t want them to feel like they can’t touch anything.” And yes, she lets them read those shared books in the waiting room.

“My general take is that as a parent you should take precautions, but I believe in my children building up their immune systems,” by not being too fearful of germs. “I like parents that kind of chill out,” Boylan adds.

Be alert, speak up — but don’t let fear of contagion keep you away from needed office visits.

“The risk of developing infection after an outpatient clinic or office visit has been evaluated. In all instances, children who visited physicians’ offices had better outcomes than children who did not receive regular care,” according to the Web site of the American Academy of Pediatrics.

While it’s worth insisting on clean medical offices and uncontaminated caregivers, it can feel awkward.

“Absolutely, it is hard to assert yourself and to speak up,” acknowledges Bradford Jordan, director of development for McCaughey’s committee. “But as long as doctors, hospitals and administrators are not taking it on, it’s our only line of defense.” He says to avoid infection, prepared patients have to get comfortable with the idea of making their health care worker feel uncomfortable.

Sonnenfeld says it’s possible to be respectful of the practitioner while “making sure one’s own needs are addressed and met. A patient might say, ‘I know you’ve had a lot of sick patients here today and just for my own comfort, I’d like to confirm that you’ve washed your hands between the other patients and me.’”

If you find it hard to be assertive: “Bring a family member, bring a brochure with the steps for reducing infections,” McCaughey says.

What You Can Do:

- Speak up if doctor’s office germ precautions don’t meet your expectations

- Avoid community toys at the pediatrician’s office; bring your own from home

- Ask the doctor to clean his or her stethoscope; stethoscopes can be source of staph

- Undergoing outpatient surgery? If hair has to be removed, ask for a clipper shave instead of a razor. Razors can scrape and make nicks — welcome mats for bacteria

- Make sure you see health workers ‘scrub and glove’ before any outpatient procedure

- Make washing your own hands the first thing you do when you get home from anywhere, not just the doctor’s office.