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Behavioral health challenges much like pathogens: Unique, unpredictable, everchanging


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Editor’s note: This is the third installment of a special series focusing on IC issues specific to hospital departments and specialties.

It’s difficult enough for facilities to prevent healthcare-associated infections (HAI) among patients who follow proper hand hygiene and other self-protective measures. Those challenges magnify for behavioral health patients who have the potential to increase environmental contamination and infection risks if they can’t—or won’t—comply with basic IC measures. Behavioral health patients, including substance abusers or individuals with mental health problems, may pose unique IC problems. For example, these patients may act out violently and bite or scratch other patients or staff members, says Philip Smith, MD, chief of infectious diseases at the University of Nebraska in Omaha. Because this group tends to have higher rates of HIV, hepatitis B (HBV) and C (HCV), and tuberculosis (TB), this behavior poses a safety threat to others within the facility, he says. Patients may also come into the facility carrying insects, such as fleas, scabies, and lice, that present IC problems of their own, says Allison McGeer, MD, director of IC at Mount Sinai Hospital in Toronto, Ontario.

And typical IC strategies, such as locating alcohol-based hand sanitizers in patient rooms, may present risks with this population—people with a history of substance abuse, for example, should not have access to products containing alcohol, says McGeer.

For these and other reasons, behavioral health patients present unique challenges for ICPs, say McGeer and Smith.

Injury could lead to infection

Your goal in implementing an IC program in behavioral health is to protect patients and staff members not only from microbiological threats but from physical threats. You must keep staff members safe, says Smith.

Your facility should provide staff members with apparel that would reduce their risk of exposure to bites and scratches. Because of the potential to break skin, workers interacting with potentially violent patients are at an increased risk of exposure to bloodborne pathogens. Thus, it is critical that you have strategies in place to address this type of exposure, and to do it rapidly.

According to the U.S. Public Health Service guidelines, healthcare workers are at risk of HIV, HBV, and HCV infection if they suffer a needlestick or cut with a sharp object. They are also at risk if blood, tissue, or other potentially infectious body fluids come into contact with mucous membranes or nonintact skin, such as blood, semen, and vaginal secretions. Although these have not been implicated in occupational transmissions, they should be considered potentially infectious, according to the guideline.

Establish protocols

“Feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomitus are not considered potentially infectious unless they contain blood. The risk for transmission of HBV, HCV, and HIV infection from these fluids and materials is extremely low,” states the guideline.

If an exposure occurs, it is crucial that your facility has in place protocols that are available and easily accessible. Often, the success of a treatment hinges upon treating the patient quickly, says Smith (see the sidebar on p. 10).

Smith and McGeer say that another important way to protect staff members from infection risks is to ensure that they are vaccinated against HBV and that your facility provides regular TB testing. Solid employee health programs are critical for staff members who will be in contact with behavioral health patients.

By taking these measures, you will be able to reduce some of the risks staff members face and ensure that if an injury does occur, you are prepared to respond in a timely fashion.

Spotlight: Infection control and Alzheimer’s

Patients with Alzheimer’s and other forms of dementia typically don’t pose as great a bloodborne pathogens threat as patients who bite and scratch. However, they do present other types of IC challenges, says Allison McGeer, MD, director of IC at Mount Sinai Hospital in Toronto, Ontario. ICPs should take note of the following special issues, says Phillip Smith, MD, chief of infectious diseases at the University of Nebraska in Omaha.

Wandering. Alzheimer’s patients are prone to wandering, a habit that could be especially dangerous if the person has an infectious disease such as active MRSA with a large wound. ICPs should work with nursing staff members to make sure that these patients are properly supervised, says Smith.

Pressure ulcers. Alzheimer’s patients may have decreased sensation of their bodies and, as a result, are at greater risk for pressure ulcers.

Aspiration pneumonia. As dementia progresses, so may physical deterioration, such as difficulty in swallowing and breathing. Such difficulties place patients at high risk for aspiration pneumonia, says Smith. ICPs should follow best practices to help prevent this problem in Alzheimer’s patients, including feeding the patient in the upright position, keeping the patient upright for 30–60 minutes after feeding, and avoiding oversedation.

Swallowing problems also mean that advanced care for such patients may require the use of tubes—urinary catheters or oxygen and feeding tubes—which represent “a major risk factor for healthcare-associated infections,” says Smith. ICPs need to establish protocols to ensure proper care of these devices, a critical step toward preventing infection.

C. diff considerations. Alzheimer’s patients are at increased risk of contracting C. diff because they may be incontinent. “C. diff, on top of incontinence, provides opportunities for vast environmental contamination,” says Smith. “The problem is magnified by the fact that the patients require nursing intervention.” In this situation, there are many opportunities for the contamination to spread, he says, so it is best to focus on proper environmental cleaning, hand hygiene, and use of contact precautions.

Vaccination programs. Proper vaccinations are critical for this group of patients. “Alzheimer’s patients are a very vulnerable host in terms of infection,” says Smith. This makes it critical for the hospital to ensure that these individuals have vaccinations such as flu shots and tetanus.

It’s important when working with populations such as Alzheimer’s patients to take into account their special needs and the unique risks they face to ensure that your IC program can accommodate them.

Education. Because Alzheimer’s patients have an impaired short-term memory, they often can’t follow instructions. Reinforce the need for such patients to perform hand hygiene, stay out of isolation rooms, and cover their mouths when they cough, says McGeer.