when alcohol hand rub gets in your eyes
TRANSCRIPT
Failure of endoscope decontamination
Madam,
The largest documented exposure of patients toprocedures with non-sterile instruments must surelybe that recorded in ‘The scandal of Cidex’,1 whichI reviewed for the Journal of Hospital Infection in2002.2 Some 34 870 patients in Belgium were ex-posed to instruments that had been decontami-nated using Batch 0001/2000 of Cidex, which hadbeen made with 2.2% water instead of glutaralde-hyde. This occurred because the operator did notrealize that to avoid a ‘millennium bug’, the glu-taraldehyde tank had been emptied and refilledwith water to prevent corrosion.
The Official Belgian report on the outcome (www.iph.fgov.be/epidemio/epifr/cidex_fr.pdf)3 makesinteresting reading, albeit in French. Of the pa-tients known to be involved, 24 832 were invitedto have blood tests, 18 315 agreed to a hepatitisB virus (HBV) test and 19 526 were tested for hep-atitis C virus (HCV). Questionnaires also requesteddetails of bacteraemias and tuberculosis that couldhave been associated with the incident.
The incidence of HBV and HCV seemed nodifferent to that in the general population. How-ever, for HCV in particular, the incomplete follow-up of those with initially positive results meantthat it was not possible to arrive at a definiteconclusion for all patients who had positive tests.Eight bacteraemias were reported; these werethought to be unlikely to be associated with theincident, although again there was not enough datafor a definite conclusion. No cases of tuberculosiswere reported, although the authors recommenda longer follow-up for patients with a positiveMantoux test, especially those bronchoscopedfollowing bronchoscopy of a known case oftuberculosis.
The report is dated November 2001, at whichtime, surprisingly, the results bear out the conclu-sions of Morris et al.4 that transmission of HBV orHCV during endoscopy with an inadequately dis-infected endoscope is low.
References
1. Hendrickx M. Le Scandale du Cidex�. La sante et l’etatBelges contamikne par un disinfectant. Brussels: Luc Pire;2001.
2. Newsom SWB. Le Scandale du Cidex. J Hosp Infect 2002;50:164.
3. Debacker N, Carsauw H. Suivi Epidemiologique de L’incidentCidex Lot No 0001. Brussels: Institut Scientifique de la santepublique. IPH/EPI Reports No 2001e010, 2001.
4. Morris J, Duckworth GJ, Ridgway GL. Gastro-intestinal en-doscopy decontamination failure and the risk of blood borneviruses: a review. J Hosp Infect 2006;63:1e13.
S.W.B. Newsom*11 The Footpath, Coton,Cambridge CB3 7PX, UK
E-mail address: [email protected]
Available online 7 August 2006
* Address: 11 The Footpath, Coton, Cambridge CB3 7PX, UK.Tel.: þ44 1954210228.
ª 2006 The Hospital Infection Society. Published by ElsevierLtd. All rights reserved.
doi:10.1016/j.jhin.2006.05.023
Letters to the Editor 199
When alcohol hand rub gets in your eyes
Madam,
Our trust, in accordance with a nationwide di-rective, has introduced alcohol-based hand geldispensers into many clinical and patient areas ofthe hospital, including waiting rooms and cor-ridors.1,2 This is one of a number of measuresintended to reduce hospital-acquired infection byencouraging good hand hygiene amongst ‘patients,relatives, carers and visitors’.3
Whilst we fully appreciate the need for handhygiene, most literature concerning alcohol-basedhand gel concerns its efficacy and the promotion ofits use, with little published concerning safety orrisk assessment.4 The identified hazards of alcohol-based hand gel are fire, abuse by ingestion anddetrimental effect on hands.4,5
In a recent incident in a waiting room at ourhospital, alcohol-based hand gel accidentally fellinto the eye of a four-year-old girl who wasstanding below the dispenser as it was adminis-tered. This immediately caused pain and redness,and she required irrigation of her eye and medicalassessment.
This incident illustrates a previously unreportedhazard of alcohol-based hand gel; accidental eyecontact. Fortunately, there were no long-termsequelae in this case, but such an accident couldeasily happen again with more severe conse-quences. Alcohol can easily debride corneal
200 Letters to the Editor
epithelium; a property that is utilized in somerefractive surgery procedures.6
Hospital staff should be made aware of this risk,and it should be considered as part of riskassessments before placing alcohol-based handgel dispensers. One simple solution to this partic-ular problem would be to ensure that wall-mounted dispensers have a drip tray.
The wider lesson to be learnt from the aboveincident reminds us that even when well-intentionedpolicies and ideas are introduced that have clearbenefit, theremay still beunexpected consequencesand outcomes.
References
1. Hospital Policy. Infection control link sessions: increasedusage and change of alcohol hand rub within City HospitalsSunderland. Sunderland: City Hospitals Sunderland; 2004.
2. Patient safety alert e clean hands help to save lives.National Patient Safety Agency; 2004.
3. Wording from hospital wide poster displayed next to hand geldispensers. Sunderland: Sunderland NHS Trust; 2004e2005.
4. Cooke RPD, Hughes J, O’Connor C. Hazards of alcohol-basedhand rubs. J Hosp Infect 2005;61:84.
5. Boyce JM, Pittet D. Guidelines for hand hygiene in healthcaresettings: recommendations of the Healthcare Infection Con-trol Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Taskforce. Infect Control HospEpidemiol 2002;23:S3eS40.
6. Yanoff M, Duker J. Excimer laser photorefractive keratec-tomy, Ophthalmology. 2nd edn. Mosby; 1999.
O. Baylis*S. Fraser
Department of Ophthalmology, Sunderland EyeInfirmary, Sunderland, UK
E-mail address: [email protected]
Available online 7 August 2006
* Corresponding author. Address: Department of Ophthalmol-ogy, Sunderland Eye Infirmary, Queen Alexandra Road, Sunder-land SR2 9HP, UK. Tel.: þ44 191 5656256; fax: þ44 191 5699060.
ª 2006 The Hospital Infection Society. Published by ElsevierLtd. All rights reserved.
doi:10.1016/j.jhin.2006.05.016