Basic hygiene principles in wound care
Chronic wounds are never sterile wounds. In almost all situations, we, accordingly, do not have to perform a sterile procedure. However, we have to work cleanly and avoid introducing new bacteria into the wound. This involves using non-sterile single-use gloves, a facemask, and clean instruments. If your instruments ( i.e., scalpel, scissors, forceps) are not single-use, they have to be sterilized between every patient to avoid the transmission of pathogenic microbes like Hepatitis virus and HIV. Note that the recommendations below are for normal chronic wounds. More strict procedures will apply if the patient has multi-resistant bacterial strains like MRSA or VRE. We have written a separate chapter for these situations.
1. Good hand hygiene is one of the essential aspects. Always disinfect your hands between each patient and before every procedure. You have to disinfect your hands even when using gloves because there may be tiny holes in the gloves, or the glove may unintentionally tear during the procedure. Usually, an alcohol-based hand disinfectant is sufficient for this. If you, without thinking about it, have removed an old dressing with your bare hands ( without gloves), you should wash your hands with soap and water first, followed by alcohol-based hand disinfection. This is because old dressings contain very high concentrations of pathogenic bacteria. We have written a separate chapter about hand hygiene- please also refer to this.
2. It is a lot easier to work hygienically if you work with a colleague. Then you can remain in the field close to the wound while your colleague assists you or vice-versa. If you are working on your own, plan ahead! Take off the old dressing to inspect the wound, and then plan all the equipment you will need. If you don't plan ahead, you will take on and off your gloves many times. This is an inefficient manner of working; it means wasting time and many gloves. It also looks unprofessional to the patient if you have to remove your gloves several times during the procedure and get up to fetch some more equipment.
3. Some simple wounds can be easy to treat in a hygienic manner alone. Other patients can be so demanding that you impossibly can work cleanly without having an extra pair of helping hands. As an example -a patient with contractures of the hips and an ulcer in the groin area where you will unlikely be able to reach the wound without assistance.
4. Watches, jewelry like rings, or bracelets are not acceptable to wear when you are involved in wound care as these harbor high concentrations of bacteria. It is simply unprofessional, no matter how fancy a watch you have.
5. Do not use clothing with long sleeves. A traditional doctor's coat has no place in a wound care clinic. The ends of the sleeves get quickly contaminated with bacteria. When possible, wear short-sleeved clothing. A short-sleeved lab coat that can be buttoned down is ideal for working in wound care
6. Protect your work attire. If you are dealing with extensive wounds and much exudate, you may have to use a protective gown with long sleeves. This can be a single-use or a multiple-use gown, but they always have to be changed between patients. For most wounds, a single-use plastic apron is recommended. Many hospitals in Africa have aprons of thicker material that are not single-use, and these have to be disinfected between each patient.
7. If you know that your clothing touched areas of contamination, you will have to change your clothes before you treat another patient. In many African hospitals and other medical institutions, the staff must buy their own work clothing. Not all staff have several sets of clothing available. In this case, it is even more critical that you protect your clothing from possible contamination.
8. Always use gloves when working in close vicinity of the wound. Remember that you also always have to wear gloves when removing the old dressing as this usually harbors very high concentrations of pathogenic bacteria. In typical cases, the procedure will be as follows: you put on a pair of non-sterile gloves to remove the old dressing. After this, you throw away that pair of gloves. You disinfect your hands and find all the equipment you need. You disinfect your hands again and don a new pair of non-sterile gloves to debride the wound/ put on the new dressing. As a minimum, you will need two pairs of non-sterile gloves to change even a simple dressing.
9. Normal glove dispensers for single-use, non-sterile gloves are not ideal when working in an environment with many situations with high concentrations of bacteria, as in a wound care clinic. When we remove a new glove from the box, it is easy to contaminate several other gloves inside the box. We have all experienced that not always do the gloves come out one by one. Sometimes we pull out more gloves than needed and stuff the other gloves back into the box. Or a glove is stuck, and we have to fumble around in the opening to be able to pull out the glove. When we only have such dispensers available, we must keep a strict hygiene routine to avoid these pitfalls. Always disinfect your hands before removing gloves from such a dispenser. Teach your colleagues and staff about this as well.
If you have the resources available, you should invest in a modern glove dispenser that hangs upside down and make it easy to remove only one glove at a time. The gloves are folded in a special way inside the box so that you always remove them with the cuff first. Studies have shown that this dispenser system reduces non-sterile gloves' cross-infection by up to 96% compared to standard dispensing systems.
However, the drawback is that they are more expensive than regular single-use glove dispensers. Popular brands are SafeDon and Dermagrip, and we have found out that both these brands actually are the same product- only with different packaging. Note that you have to purchase special wall brackets for these boxes. Remember that you will have to provide three standard sizes of gloves - small, regular, and large.
10. When rinsing a wound try to hold some cotton gauze or equivalent as a shield to avoid droplets contaminating the working area.
11. We always place a single-use absorbent pad under the patient when we treat a wound to prevent our working bench from being contaminated by rinsing fluid or exudate. If you do not have the resources for single-use pads, you should have a stock of cotton material for this purpose. You will have to change this between patients and boil the material between use.
12. As we already mentioned earlier - take a look at the wound and then make a plan for what equipment you will need. Avoid running back and forth from your patient and to your storage. Do not take more equipment than you need into your working area - you will likely contaminate the material you didn't use!
13. Never use contaminated gloves to get some more equipment. It is incredible how many of our colleagues ignore this crucial yet straightforward principle. Once your gloves have touched the patient, they are to be counted as contaminated, and you cannot use these gloves to touch anything else, be it a drawer or a box of cotton gauze. If you need something more, you have to take off the gloves, disinfect your hands, get the equipment, and don new gloves. That is why it is so important to plan ahead. As we mentioned earlier, it is easier to work cleanly if you have an assistant.
14. Another common mistake is touching a rinsing fluid bottle with contaminated gloves. We see this a lot.
15. If you are lucky enough to own a handheld Doppler to measure the ABI, be aware that this very easily gets contaminated. It is most often the inflatable cuff that gets contaminated but also the apparatus itself can easily get contaminated. Always use plastic cling wrap around the patient's skin before applying the cuff. Always use a fresh pair of non-sterile gloves when doing this procedure. Avoid touching the patient's skin with gloves during the procedure. Always disinfect the cuff, wires, and apparatus after using an appropriate disinfectant. Note that not all electrical machines tolerate all types of disinfectants. Some disinfectants will make the material of the cuff, doppler head, wires, and tubing brittle.
16. Especially with more minor wounds, it is common to cut a piece of a bigger dressing and use the rest another time. Always wear a fresh pair of non-sterile gloves when you do this. The scissors you use for this should be disinfected.
17. Even at specialized wound care clinics, there is paradoxically often a lack of clean scissors. We know this from our workplace. Like socks in a washing machine, scissors have a habit of disappearing. We see this as serious because a lack of clean scissors is a risk factor for hygiene. When we do not have clean scissors, we start to improvise. We may end up wiping off a previously used scissor with alcohol, which is unacceptable! Make sure that you have a good stock of scissors. You should never run out of clean scissors at the end of a workday! The scissors you use within the wound or for removing a dressing has to be sterilized in an autoclave between use. You should have a separate stock of scissors to cut up dressings and bandages. These can be disinfected at regular intervals using, for example, alcohol-based solutions.
18. The patient bench must be thoroughly disinfected ( surface disinfection) between each patient. You should use a protective paper sheet between the patient and the bench if available. Usually, this type of paper is available as large rolls. As we mentioned earlier, we also recommend using an absorbent pad between the patient and the bench to minimize contamination.
When the patient has left, you have to do surface disinfection of the bench using an appropriate disinfectant. The type of surface disinfectant available to you will vary depending on where you work. Note that not all materials tolerate all types of disinfectants. Some materials will rapidly become brittle if treated with an inappropriate cleaning agent! Always use gloves when handling surface disinfectants as they are harsh on the skin. Never use the same gloves you wore when treating the wound when cleaning up after the patient has left!
19. Make yourself familiar with the routines for handling contaminated instruments at your workplace. Do not let biological material like blood and tissue residues dry on the instruments as they will be harder to clean. There are special foams available ( see image below) which you can cover the instruments with and aid in removing biological residues. Some people place the instruments in a container with clean water and a liquid detergent - be aware that the instruments shouldn't lie in water too long as this can cause rust formation - even in stainless steel instruments. At the end of the workday, the instruments should be manually cleaned with a small brush ( for example, a toothbrush), placed in a disinfectant, and be prepared for sterilization. Again, there is much variation in what routines different workplaces have for this, and it also depends on the type of cleaning agents available.
20. Some detergent instrument cleaners contain anti-rusting agents and will keep your instruments clean and shiny. We have very good experiences with Haemarinz detergent instrument cleaner. It comes in small bags. One bag can be diluted into several liters of water. After each patient, we simply place the used instruments into the container with this solution, and we can let them lie there to soak for a whole day without worrying about rust formation. There are other similar products available.
21. In your work area - be it a workbench, a table, or a trolley - mark the clean and contaminated zones clearly. This must be so well marked that it is clear to everybody working there what is the clean area and what area is, for example, reserved for used instruments.
22. Be aware that creams and lotions also can become contaminated with pathogenic microbes. Never touch tubes and bottles with contaminated gloves. Again, this all comes down to good planning. Note that it can be more practical to have smaller-sized tubes with products as they reduce the chance of cross-infection when possible. If you have a large bottle or tube which lasts for months, the chances of contaminating the product are much greater.
23. All the staff who use the wound treatment area ( also nursing- and medical students) must receive a basic introduction to hygiene principles in this working area. Ideally, you should have written instructions readily available for this purpose. Or- let them read this chapter on the WoundsAfrica website.
24. Staff who work at the wound clinic should ideally change their attire when going to other parts of the clinic or hospital. It is, for example, unacceptable to sit in the break room or cantine with other staff if you haven't changed your clothes.
25. If your patient is in a situation where multi-resistant bacteria (i.e., MRSA or VRE) cannot be ruled out or where the patient already is a documented bearer of these bacteria, extra hygienic precautions must be made. We have written a separate chapter about this.
26. Many institutions have a person appointed responsible for hygiene there. You may even have a hygiene committee. Engage these people to help you develop the best routines for preventing cross-infections. A wound clinic is a place rife with many types of pathogenic microbes. By using only a few basic principles, we can ensure that all of our patients are safe. Sound hygienic principles are something that requires regular training. Set aside half a day each year to arrange some training for you and your staff to go through the principles discussed in this chapter.