Raynaldo Diaz
May 7, 2008

Sonography:
Transmitting Sound, Not Infection

            “Each year, more than 2 million people in the United States acquire an infection during a hospital stay, and an estimated 90,000 people die from them -- more than from AIDS, breast cancer and auto accidents combined” (ABC News Internet Ventures, 2006). 

When the need arises and you or someone you know has to enter a hospital facility, either as a patient or to visit someone, catching a virus or infection from within the hospital should be the furthest thing on your mind.  After all, no matter where you go, a hospital is supposed to be a place for healing and recovery.  For those entering the hospital as a patient, it is imperative that their immune system is protected by remaining isolated from other patients that have infectious diseases and by donning the infectious patients with the appropriate contact precautions barriers. Failing to do so will compromise the patient’s immune system, causing them to acquire a nosocomial infection, which is an infection that was contracted after being hospitalized.  And for those coming to the hospital as a visitor, the same rules apply, except that they must also don the protective barriers to protect themselves and the patient they’re visiting if the patient is under contact precautions.

            Because thousands of Americans die in hospitals from nosocomial infections, the manner in which their infections control policy is enforced must be scrutinized.  When the infections control policy is not followed, health care workers (HCW’s), specifically diagnostic medical sonographers, are placed at a higher risk of acquiring and/or transmitting an infectious disease.

All hospitals in the United States are expected to implement effective infection control practices by following the guidelines for isolation precautions, such as those put forth by the Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC).  The purpose of the guideline is to demonstrate prevention methods that they recommend when handling infection control issues, such as how to isolate and prepare patients that are susceptible or capable of easily transmitting disease or infection.  Proper adoption of these guidelines reduces the risk of nosocomial infections and serves to protect not only the patient, but the HCW’s as well. 

            Having completed various clinical rotations as a diagnostic medical sonography student, the lack of HCW’s to follow the infections control policy consistently was seen on numerous occasions.  Unless current information regarding the patients’ contact precautions is adequately documented, communicated and observed in the medical facility that offers ultrasound exams, the job of a diagnostic medical sonographer can become very dangerous due to the spread of diseases and infections that can occur to both the patient and the sonographer. 

Diseases are becoming more resistant to antibiotics, and as such, the infections control policy cannot be ignored or taken lightly.  Due to the contact involved between the patient and the sonographer during an ultrasound exam, the sonographer is at a higher risk of acquiring a disease than other imaging modalities. The resident doctors and nursing staff in the hospital that are responsible for ordering an ultrasound examination for their patients must be committed to enforcing these precautions at all times and not be careless regarding documentation of patient charts or sharing the information to other HCWs, especially when they’re requesting an immediate ultrasound exam and the initial request is done by phone.  In addition, the infections control policy should not be enforced only during the time that the healthcare facility has applied for accreditation or is up for accreditation renewal, only to be relaxed once the accreditation review is complete.

What Is A Diagnostic Medical Sonographer?

A diagnostic medical sonographer performs an examination on a patient via a small handheld device called a transducer that uses high frequency sound waves that are inaudible to human hearing, called ultrasound.  The name of the resulting exam is called a sonogram, preceded by the type of exam performed, such as an abdominal, fetal, or pelvic sonogram just to name a few.  “Sonographers are known as the “image makers” with the ability to create images of soft tissue structures and organs inside the body…  In addition, sonographers are able to record hemodynamic information with velocity measurements through the use of Doppler spectral analysis to determine if a vessel or cardiac valve is patent or restricted” (Hagen-Ansert, 2006, p. 7). 

Due to the widespread use of ultrasound in obstetrics all over the world, most people identify having a sonogram with the thought of a pregnant woman that goes to the doctor for prenatal screening and has her fetus displayed on a monitor screen.  So unless someone in the family has had a sonogram for another reason, most people either have never heard of it or know that it is used to view a fetus or relate it to another imaging modality such as an x-ray.  As a matter of fact, when I happened to mention the field of ultrasound to fellow student and classmate Mark S. Laporte, his first question to me was “Is that something like an x-ray?”  “Medical sonography (ultrasonography) is an ultrasound-based diagnostic imaging technique used to visualize muscles and internal organs, their size, structures and possible pathologies or lesions. Obstetric sonography is commonly used during pregnancy and is widely recognized by the public. There are a plethora of diagnostic and therapeutic applications practiced in medicine” (Wikipedia, 2008) . 

Why Are Sonographers At A Higher Risk?

Because ultrasound has become one of the imaging modalities of choice for many types of exams, such as abdominal, cardiology, obstetrics, gynecology, urology, and neonatal brains, sonographers are exposed to patients having a wider variety of symptoms, infections and diseases than almost any other imaging modality, which increases their chance of becoming infected when the proper contact precautions have not been applied.

Imaging modalities such as x-ray, CT, or MRI require minimal contact between the patient and the imaging technician.  In these exams, the patient is simply placed on a table, positioned and then the images are taken by a machine that hovers above or surrounds the patient, although for some exams such as a chest x-ray or mammograms, the patient must stand or is allowed to sit down for their exam.  After positioning the patient and giving them instructions such as how to breathe, not to move and so forth, the technician has no other contact with the patient as the exam takes place and the machine takes the images.  In fact, the technician controls the imaging equipment either from behind a glass partition in a separate area of the examination room or from another room altogether which has a window to observe the patient.  The patients for these exams are usually completely or partially covered either with lead protection sheets in an x-ray exam or at the very least with hospital gowns and the contact isolation barriers required.  Contact between the patient and the technician is usually limited to the time it takes the technician to position the patient properly before images are taken.

In contrast to these other medical imaging exams, an ultrasound exam requires physical contact with the patient’s skin, with the exception of a transvaginal or transrectal exam, which are internal exams.   An ultrasound exam consists of the placement of the handheld transducer directly over the area to be imaged on the patient’s skin by the sonographer, along with some coupling gel to allow the ultrasound waves to penetrate through the skin.  The gel also has the added benefit of allowing the transducer to slide easily from place to place and while undesirably accumulates on the sleeve of the sonographer’s lab coat.  Because the ultrasound examination is operator dependent, placement of the transducer directly on the patient means that the sonographer will spend the entire length of the exam in very close proximity to the patient.  At no time can the ultrasound images be taken without the sonographer manually scanning the patient.

Patients that are having an ultrasound examination done must expose the area of the body from which the images will be taken.  Outpatients are sometimes given the option to change into a hospital gown due to clothing that restricts access, such as a long dress, or when a hospital gown will simply facilitate getting the exam done more quickly.  When in-patients cannot be scanned in their room with the ultrasound machine or because the patient is well enough to be moved, they are brought over to the ultrasound department for their exam.  Usually, the patient arrives in their wheelchair or stretcher, along with their medical chart, by dedicated workers from the “transport” department whose main job is to transport patients to and from their destination all day long. Inpatients that cannot move or that have difficulty lifting their hospital gown will usually have it raised or unbuttoned by the sonographer, who will then assist the patient in getting into the proper position to obtain the best quality images.  For example, a patient that presents with right upper quadrant pain will usually have their gallbladder examined closely to check for the presence of gallstones, which can vary in size from as small as grains to as big as marbles.  The patient will be examined in a supine position or lying flat on their back, and if seen, to prove to the radiologist that they are in fact gallstones, the sonographer must turn the patient to a left lateral decubitis position or right side up.  This is done in an attempt to shift the stones to another location within the gallbladder and prove that the stones are mobile and confirm they’re not something else, such as polyps, which are growths from the lining of the gallbladder and are not mobile. The extended amount of contact between the patient and the sonographer increases the sonographer’s risk of contamination.

What Are Contact Precautions?

Infectious agents transmitted during healthcare derive primarily from human sources but inanimate environmental sources also are implicated in transmission. Human reservoirs include patients, healthcare personnel, and household members and other visitors. Such source individuals may have active infections, may be in the asymptomatic and/or incubation period of an infectious disease, or may be transiently or chronically colonized with pathogenic microorganisms, particularly in the respiratory and gastrointestinal tracts (Siegel, Rhinehart, Jackson, Chiarello & Healthcare Infection Control Practices Advisory Committee, 2007).

Remaining healthy while treating sick patients in a hospital is of great concern.  In order to prevent transmission of infectious diseases, the Centers for Disease Control (CDC) introduced the very first edition of their guidelines in 1970, in which they listed the type and duration of precautions that they recommended for certain types of infections and conditions.  These guidelines are aimed towards those in charge of infection control programs and also towards the healthcare administrators in any healthcare setting such as: hospitals, ambulatory care, long-term healthcare facilities, hospice and home care.  It can also be used by anyone who is simply seeking information regarding infection control measures to prevent transmission of infectious agents. 

Over the years, it has been revised for the following reasons:

1. In keeping up to date with strains of viruses that have become more resistant to antibiotics, like the "flesh-eating" methicillin-resistant Staphylococcus aureus bacteria, also known as MRSA.
2. New pathogens that have emerged, such as SARS-CoV associated with the severe acute respiratory syndrome (SARS) and AIDS.
3. The increasing concern for attacks of war with the use of bioweapons.

Their latest edition, in conjunction with the Healthcare Infection Control Practices Advisory Committee (HICPAC), is called “Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007.”  It is because of these guidelines that the transmission of infections occurring in hospitals was significantly reduced, but only when used as recommended.  But when patients acquire a nosocomial infection, it is most likely due to HCW’s that have become contaminated and are spreading the germs because somewhere along the line the proper precautions were not used.  Table 1 provides a history of the guidelines from their inception:
Table 1. HISTORY OF GUIDELINES FOR ISOLATION PRECAUTIONS IN HOSPITALS

(Siegel, Rhinehart, Jackson, Chiarello & Healthcare Infection Control Practices Advisory Committee, 2007)

            To help prevent the spread of disease between patients, HCWs and visitors of the patient, two levels of precautions have been established, which are Standard Precautions and Infection-Based Precautions.  The type of infectious disease that the patient has determines which precaution to follow:

1. Standard Precautions
1. Evolved mostly from the Universal Precautions that was created to safeguard health care workers and now includes safeguards for the patient.
2. Is based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents.
3. Includes a group of infection prevention practices, such as hand hygiene, the use of gloves, a gown, mask, eye protection or a face shield by the HCW and applies to all patients regardless of whether the infection is suspected or confirmed.
4. Contamination of equipment in the patient environment must be properly cleaned and disinfected or sterilized before using on another patient.
2. Transmission-Based Precautions
1. They are separated into three sections:
1. Contact Precautions
1. Used to prevent the transmission of infectious agents that can be spread by direct or indirect contact with the patient or the patient’s environment.
2. Can be used for patients that have excessive wound drainage, fecal incontinence, or other discharges from the body that suggest an increased risk of transmission.
3. Single patient rooms are recommended.
4. HCWs should wear a gown and gloves for all contact with the patient or with areas in the patient’s environment that may be contaminated.
2. Droplet Precautions
1. Used to prevent transmission of pathogens that spread through close respiratory or mucous membrane contact with respiratory secretions
2. Includes pathogens such as B. pertussis, influenza virus, adenovirus, rhinovirus,  N. meningitides, and group A streptococcus .
3. Single patient rooms are recommended.
4. HCWs should wear a mask when having close contact with the patient.
5. Patients on Droplet Precautions should wear a mask.
3. Airborne Precautions
1. Used to prevent transmission of pathogens that remain infectious over long distances when they are suspended in the air.
2. Includes pathogens such as the rubeola virus (measles), varicella virus (chickenpox), M. tuberculosis and SARS.
3. A single patient, airborne infection isolation room (AIIR) should be used.
4. HCW’s should wear a mask or respirator.

(Siegel, Rhinehart, Jackson, Chiarello & Healthcare Infection Control Practices Advisory Committee, 2007)

What is the point of having these guidelines and procedures in place in the hospital if the medical residents that have been assigned to their patients either forget or just don’t bother to follow the correct procedures?   The medical resident may have done their job partly by isolating the patient from other patients in a single patient room, but when a sonographer is sent to a patient’s bedside to perform a portable ultrasound exam, there is no way of knowing that the patient has been placed under any type of contact precaution unless the information was originally input into the patient’s chart, the administrator of the ultrasound department was given this information to be written on the patient’s exam request, or most importantly, unless the proper colored-coded contact precautions sign has been posted on the door of the patient’s room to alert both visitors and other HCWs.  This becomes extremely important when fulfilling portable ultrasound requests because the sonographer is required to scrub down all surfaces they touch on the ultrasound machine after examining a patient with an infectious disease.  By knowing which patient has contact precautions beforehand, those patients would be scanned last in order to prevent the possibility of cross contamination with other patients and allows the sonographer to clean the ultrasound machine in another location after all of the requests have been completed. 

Even though hand hygiene is the most important factor in preventing hospital acquired infection, staff remains reluctant to comply with any guidelines. Even on an intensive care unit appropriate hand hygiene techniques are rarely practiced by medical and nursing staff. Insufficient washbasins or supplies of liquid soap and paper towels do not help matters. Worse still are the grubby bars of soap that still turn up occasionally (Barker, Keith F, 1997).

During my clinical rotation in one particular hospital, I encountered various instances where proper infection control procedures were not followed.  At each instance, the contact isolation information was not communicated properly.  Either the ultrasound department wasn’t told that the in-patient arriving for their exam was under contact precautions, the information was not supplied when a portable ultrasound exam was ordered, or the sign that is supposed to be placed outside the patient’s room was not placed in an appropriate location, such as the day I accompanied the sonographer on a portable request and found the contact precautions sign behind the door of the patients room rather than on the outside of the door.  The frustration and fear that occurs at the thought of handling a contact isolation patient without the proper protection is beyond compare.  An experienced sonographer may be able to recognize the patient whose diagnosis for the exam raises a flag which indicates that the patient is a candidate for contact isolation barriers, but new and inexperienced sonographers rely on having that information provided before the start of the exam. 

“For Awa Gee it had become increasingly clear that the people were up against the giants.  But the giants had been ruthless for too long; the giants had become deluded about their power” (Leslie Marmon Silko, p. 683).  Despite being scolded numerous times by the supervisor of the ultrasound department, the residents simply shrug their shoulders and promise not to do it again.  Some will actually apologize.  But by the look on their face, it is easy to see that they dismiss what they’re being told because they want to give the orders, not take them. 

What Is Accreditation?

In an effort to comply with federal regulations regarding how well they are maintaining the standards of health care delivery, hospitals seek accreditation from The Joint Commission as a means of proving their compliance.

The Joint Commission evaluates the quality and safety of care for more than 15,000 health care organizations.  To maintain and earn accreditation, organizations must have an extensive on-site review by a team of Joint Commission health care professionals, at least once every three years. The purpose of the review is to evaluate the organization's performance in areas that affect your care.  Accreditation may then be awarded based on how well the organizations met Joint Commission standards (The Joint Commission, 2008). 

The problem that occurs when the hospital is under review by The Joint Commission is that all HCWs are reminded that they are around and are directed to ensure that all of their actions meet the commission’s standards.  HCWs will usually receive verbal warnings, reminders via email or in print form via little booklets with instructions of what should and should not be done to ensure that the hospital passes the accreditation.  For instance, in every hospital I’ve done a clinical rotation in, the rooms that are used for the ultrasound exam are done for the most part with the door of the room open, except for invasive ultrasound exams.  Sometimes, the room will contain a curtain which can still maintain the patient’s privacy during the exam, others do not.  But when The Joint Commission is around, the doors to the patient rooms are kept closed as they’re supposed to be.  But once the accreditation review is over, it’s back to the same routine of leaving the doors open.  And so the same principle seems to apply as far as residents and nursing staff that ensure they inform the ultrasound department of patient contact precautions only when The Joint Commission is around.

Overall, anyone seeking treatment at any hospital would be wise to inquire about their accreditation status.  While there are no guarantees, this will ensure that they have a better chance of receiving quality care as compared to those that are not accredited.  In fact, more and more health insurance companies are specifically demanding that certain tests be administered from accredited labs or face rejection of the claim. 

How Should Patients Be Prepped?

Upon patient arrival, the chart is given to either the person handling the administrative process of “arriving” the patient or it is given directly to the sonographer.  However, before the patient can be taken from their room, any special precautions for that patient must be noted on their chart, and the patient must also be prepared before coming out of their room.

The type of precaution that the patient has been put on governs the kind of protection or barrier that will be placed on the patient.  The patient may be donned with a contact isolation gown, which is usually bright yellow in color and somewhat translucent, they may have a mask placed over their nose and mouth if on Droplet or Airborne Precautions, areas of their body that have infectious skin lesions should be covered by sheets, and they may also wear latex or non-latex gloves on their hands. The transport person handling the patient may sometimes be seen wearing contact isolation gowns and masks, which can be helpful in alerting the sonographer of that patient’s status even before taking a look at their chart. 

Unfortunately, because of the failure at times to alert the ultrasound department that a patient with contact precautions will be arriving, having sent the patient for the exam without wearing any of the barriers that they’re supposed to wear doesn’t raise a flag either. In addition, when the patient is brought to the ultrasound department, they are usually placed in the patient waiting area, along with other inpatients, which may result in patients with nosocomial infections.  “In the United States, about 5 million persons work in more than 7,000 hospitals. These personnel may become infected through exposure to infected patients if proper precautions are not used, or acquire infection outside the hospital. They may then transmit the infection to susceptible patients or other hospital personnel, members of their households, or other community contacts” (Williams, 1998). 

In one of my clinical rotations not too long ago, an in-patient was brought down with a diagnosis of abdominal pain.  I had briefly noticed that the female transport person was wearing a yellow contact isolation gown when she locked the wheels of the patient’s bed in the inpatient waiting area, but the patient was not wearing one.  At first I paid no mind to it because we – the sonographer and me the student – were still in the midst of scanning another patient, which at the time was left alone in the room so that she could change into a hospital gown for the second part of her pelvic exam.  By the time we had completed the pelvic exam, the patient I’d seen brought down was still in the same spot because all other sonographers were still examining their patients. 

When I received the request to bring the patient into a room for his exam, I had not thought about what I had seen earlier.  But as soon as the sonographer placed the ultrasound probe on the patient’s abdomen, I suddenly remembered the image of the transport person wearing the isolation gown.  I quickly informed the sonographer that this might be a contact isolation patient, and she immediately stopped the exam and grabbed the patient’s chart in frustration and looked it over, trying to see if she had somehow missed the section that indicated the precautions that should be observed.  When she didn’t find any annotations regarding contact precautions, she asked me if I was sure.  I told her that I was fairly sure of what I saw, but that I might be mistaken.  Despite the fact that the patient was groggy and in pain, I asked him if he remembered whether or not the transport person was wearing a yellow isolation gown and if the transport person was a male or female.  He immediately confirmed that it was a female transport person wearing the yellow isolation gown.  The sonographer then got off her chair and marched to the administrator that printed the patient’s exam order, and he said that he was not given any information regarding contact precautions.

            When the sonographer tried to pull up the patient’s records from the electronic patient database, the information was not coming up.  When she grew tired of waiting for the information to come up on the screen, she told me that we should just wear the isolation gown anyway to be on the safe side, and so we did.  When the exam was completed, as is routine with every patient, the exam was brought to the attention of the radiologist that is reading exams that day.  After he reviewed the ultrasound images, he decided he needed to take a look and scan the patient himself.  As he rushed over to the room to scan the patient, neither I nor the sonographer told the radiologist that the patient might have contact precautions.  Honestly, it hadn’t even occurred to me to tell him, perhaps because I thought that if it wasn’t on the patient’s chart, then it was not necessary. 

A few minutes after the radiologist started scanning the patient, with me, the sonographer, and a resident present, one of the other sonographers stopped by to deliver a message from the administrator, informing us that the patient was under contact precautions!  After a very brief pause, the radiologist answered back, “oh, that’s wonderful”, then spent just a minute more scanning the patient and then ended his exam.  As he left the room, he told the sonographer that the ultrasound images she had taken were fine, but that she got a demerit for not telling him about the contact precautions.  We both felt extremely horrible for the rest of the day, especially because this occurred in the morning, which left us with the entire day to face him with other exams as they were completed.

Why Follow The Rules?

When infections control protocols are followed as implemented by hospitals, the risk of contamination can be virtually eliminated.  Lack of cooperation or the reluctance of those persons that order exams for their patients to follow these protocols is detrimental to sonographers and the patient being examined. 

            “They spend much time in this aimless fashion, their natural faculties neither seeing, hearing, nor feeling the varied life that surrounds them.  There is about them no awareness, no acuteness, and it is this dullness that gives ugly mannerisms full play; it takes from them natural poise and stimulation” (Finch & Elder, 2002, p. 329).  As diseases become more resistant to antibiotics, more effort should be made to prevent contamination.  It is unfair when a sonographer does their best to prevent contamination by taking the time to pull up a patient’s medical record and check what the patient’s contact precautions are if the information is inaccurate or missing.  From my interview with the supervisor of the abdominal ultrasound lab at Bellevue hospital, it is the nursing staff or the residents who are at fault. And while it is understandable how tired these individuals can be due to the volume of patients they must care for and the pressure they’re under, exceptions do not exist when it comes to maintaining a clean and safe environment, as well as preventing the spread of disease. 

            “If a society forgets or no longer cares where it lives, then anyone with the political power and the will to do so can manipulate the landscape to conform to certain social ideals or nostalgic visions.  People may hardly notice that anything has happened, or assume that whatever happens – a mountain stripped of timber and eroding into its creeks – is for the common good” (Finch & Elder, 2002, p. 919).  When entering a hospital, people use common sense and stay away from patients they’re not there to visit.  In fact, the worse they look, the farther away they stay.  The possibility of acquiring an infection or disease from someone in the hospital is always there and can affect everyone.  Some hospitals appear extremely clean, while others leave you mumbling to yourself, “Wow, what a dump”.  But when you consider the neighborhood these hospitals are in, it is somehow easy to correlate the conditions in that hospital with the surrounding area.  And because of that, it becomes easier to tolerate those conditions and dismiss what is seen, without realizing the greater potential that exists for the spread of infection. 

            Time and time again, the stories we hear about deaths occurring due to nosocomial infections are all the same.  Such is the story of Mark Bennett who went to the hospital simply to treat a cough.  He was 88 years old and regarded as energetic.  But within a time span of only four months, he died after he experienced swelling and discoloration of his leg.  “It turns out that hospital personnel had passed on at least six different bacterial infections, inducing drug-resistant strains, to Bennett, according to his son, Michael Bennett” (ABC News Internet Ventures, 2006).  Another story is that of Dorothy Etheridge, who contracted an infection after having early lung cancer removed and was given a positive prognosis regarding her recovery. “She had contracted a nasty antibiotic-resistant germ known as methicillin-resistant Staphylococcus aureus—MRSA—and she spiraled into respiratory failure. Through eight months of rehabilitation, bedsores and recurring infections, Etheridge fought back” (Greider, 2007).  Unfortunately, she died of a brain hemorrhage only one week after going home.

            Residents and the nursing staff must realize that the care they provide does not begin and end solely with their patient and that the condition of the hospital, no matter how poor, is no reason to provide a lower standard of care.  They have to take into consideration all other HCW’s that may provide additional care for their patients, such as sonographers, as well as visitors coming to see the patient.  It is a big responsibility that cannot be taken lightly.  “Our rootlessness – our refusal to accept the discipline of living as responsive and responsible members of neighborhoods, communities, landscapes, and ecosystems – is perhaps our most serious and widespread disease” (Finch & Elder, 2002, p. 984).

One time while accompanying the sonographer on portable exam requests, there was an instance where no one was available at the nurse’s desk located in front of the patients’ rooms.  And when I say no one was available, I don’t mean that they were so busy that they could not attend to anyone; I meant that the area was devoid of anyone.  So if a sonographer arrives to fulfill a request to scan a patient whom did not have the precautions sign posted or the sign was obscured, although the nurse or resident caring for the patient will know to wear the appropriate contact barrier for themselves, it will not help the sonographer, which might have already started the exam by the time they return.  It is easy to imagine that the same thing can happen if a visitor came to see a patient and didn’t wear precautions barriers both because they didn’t see the sign or it was missing and because no one was available to enforce the policy. 

            If it isn’t a case of being overworked and extremely tired, could it be then that the nurse or resident that didn’t follow the infections control protocol is just plain careless or negligent? The demeanor of some of the residents that I’ve come across throughout my clinical rotations thus far is one of arrogance.  There have been instances where the resident assumes they can boss a sonographer around and submit verbal requests for them to scan other patients under their care, simply because they wanted to confirm a diagnosis and because they felt the exam was needed at that moment, despite the fact that they had not gone through the proper steps and put in an order for it.  While this behavior does not necessarily mean that these specific residents are the ones responsible for not following the infections control protocol, it might however shed some light as to those that have the inclination to make their own rules and ignore standard operating procedures.  ”We live in a different world now.  Liars and feeble-minded are everywhere, getting elected to public office or appointed federal judge.  Spoken words can no longer be trusted.  Put it in writing” (Leslie Marmon Silko, 1992, p. 217).

            We never intend to catch someone else’s cold, but the possibility of it happening is always there.  Sometimes there is a known source, such as a family member, a friend or from someone we interact with at work and usually the attitude is “Aw crap, I caught your cold” and think nothing of it, other than the fact that it’s the perfect excuse to use some sick days from work.  While at other times, we get slightly upset and display this look of disbelief at having caught a cold despite our valiant efforts to prevent it.  But the truth is, everyone knows that the possibility is always there and at times we let our guard down and get careless by choosing to stay near a sick person or by sharing something from a sick person, such as drinking from the same glass.  Why do we do that?  Is it because a cold is not permanent and poses no real danger?  Would our attitudes and habits change if most or all colds were fatal?  Perhaps it is a derivation of this mentality that gives the nursing staff and residents a false sense of security and allows them to get sloppy.

Do Personal Precautions Exist?

            Like the kinds of precautions against infectious diseases that should be followed in the healthcare setting, most people practice some form of precaution against germs and viruses on a personal level every day.  Some people place hand sanitizers around the home and carry those cute free travel size bottles that come shrink-wrapped with a standard size purchase everywhere they go and also wash their hands after using the restroom and before eating.   For the most part, no one wants to catch anything the person next to them has when they’re seen sneezing or coughing.  Actually, I’m sure that many people stop breathing and hold their breath for as long as they can when someone is sneezing or coughing right next to them, all the while looking in the opposite direction, perhaps to keep the germs from adhering to their face or to increase the chances of breathing germ-free air the moment right before they turn blue.  I’ll have to admit that I’ve done it plenty of times myself. 

And then there are the spray disinfectants, such as the popular Lysol brand, which is supposed to be sprayed on all commonly touched surfaces.  For some people, their concern about the spread of germs is so great that they’ll often go so far as to spray everything in sight in the workplace in addition to their home.  In fact, I will never forget the time when a supervisor at the bank I used to work for decided to spray everything he could in the data center the day he got a flu shot and wanted to prevent those who didn’t get one from catching the bug.  Working the second shift, I arrived for work at 3 p.m. to the smell of Lysol everywhere.  He was standing a few feet away from me and talking to my supervisor.  When I happened to use the phone to contact a user, my ear was greeted by an earpiece on the phone that was saturated with Lysol spray, which left my ear quite drenched.  As I yelled out “what the hell?” and used my right shoulder immediately to dry my ear, the guilty supervisor started laughing and told me to simply think of it as a wet kiss.  He had a cleft lip and eyebrows that angled down towards his nose, so while he was laughing, the look on his face made it hard to determine if he was simply being funny or wicked.

            Despite all our efforts we still manage to acquire other people’s germs, and in much the same way as we can when working in a hospital.  Sometimes it is because of careless people who either don’t cover their sneeze or cough, or they cover it with their hands but then touch areas that other people are likely to touch as well.  In a hospital, things like the bed rail that we touch when moving the patient can be a source of contamination.  It sort of makes you wish that every time someone was careless, that bald man in the white t-shirt and white pants with his arms crossed would appear, together with the “Mr. Clean, Mr. Clean” jingle like in the commercial, just to make things right. 

“I feel insignificant, lost, but exultant.  With a soft shock we stop.  I will let the others get out before me.  I will sit still one moment before I emerge into that chaos, that tumult.  I will not anticipate what is to come” (Woolf, 1959, p. 72).  As a sonography student with limited time spent at the various hospitals where my clinical rotations took place, the instances that I have personally come across where the proper precautions for a patient were not followed prior to an ultrasound examination were very alarming.  As such, I can only wonder how many more instances I will see once I am working full time in this field while hoping I don’t acquire anything or even come close.

My Solution

            HCW’s are supposed to comply with the infections control guidelines that are in effect at all times.  Unfortunately, based on the number of people that are dying a year from nosocomial infections, there is a need for the infections control staff to evaluate the departments and individuals that are not complying with their guidelines one hundred percent. 

As the volume of patients that are referred for an ultrasound exam rises, the risk the sonographer performing the exam faces of acquiring a disease or infection from these patients increases as well.  Hospitals usually have an infection control policy in place, but those responsible for ordering an ultrasound exam for their patients do not always adhere to it.  It is clear that hospitals need a way to ensure that every effort is being made to prevent the spread of infections and diseases.  It has become quite obvious that simply receiving a copy of the hospital policy or having the HCW view a computer based training video is not enough.  “Failure to fully implement or adhere to isolation precautions has led to person-to-person transmission from patients to staff, visitors, and other patients, and has involved dangerous pathogens such as Bordetella pertussis, severe acute respiratory syndrome-associated coronavirus (SARS-CoV), Ebola virus, and Mycobacterium tuberculosis” (The Society for Healthcare Epidemiology of America, 2007) . 

To encourage the nursing staff and residents to adhere to the infections control policy at all times and help prevent the transmission of infectious diseases between a sonographer and the patient, I propose the following:

Increase the frequency in which the Joint Commission performs their accreditation review.  Hospitals with the best track record would be granted a longer period of time between reviews, while hospitals with poor results are subjected to more frequent, unannounced reviews.

Documentation of each time a patient arrives for an ultrasound exam without the proper contact precautions.  This should include the basic patient information such as their name, medical record number (MRN), the type of exam they were scheduled for, date, and the person responsible for ordering the exam.   Totals can be submitted to the infections control staff for evaluation.

Document the number of patients that have acquired nosocomial infections and identify who was responsible.  Patients that have become infected but are still asymptomatic may be allowed to roam the area unprotected and wind up spreading it to other patients, most of who may be scheduled for an ultrasound exam.

Hold the person that was not compliant accountable with severe penalties, such as dismissal from the workplace or if a student resident, suspension from the program or the hospital itself.  Simply reminding them to follow the rules will not be enough.

In an effort to be proactive, the sonographer should look up the patient information before the exam and make a note of any precautions that might be available online in the patient’s records.  However, when labs are extremely busy, the time it may take to pull up this information may not be feasible. But if time allows and such an instance is discovered, then the person responsible would still be reported and the sonographer will have averted accidental exposure.

The infections control staff can create a survey for the HCW’s that order the ultrasound exams for their patients.  This survey can request information such as anything that prevented them from sticking to the guidelines and could be sent anonymously.  It should also include a section to allow ideas and suggestions to either replace or enhance certain aspects of the current protocol.

Have the visitors complete a compliance request form that informs them of the importance of adhering to the guidelines.  Pamphlets should be available with information and pictures that depict various diseases and their appearance at different stages.

            Changes that can be made at the hospital would include:

A separate waiting area that is specifically for patients with any kind of contact precautions should be created.  Partitions must be erected and must also be wide enough to accommodate stretchers and wheelchairs.  Each section within the partition should have adequate ventilation to filter the air in that area, with a sign or electronic message that displays the type of precaution the patient has.  Access to and away from this area should be via a route that is isolated from any other patients.

Many patients that are in a lot of pain feel very irritable, lack patience, cannot remain still, are verbally abusive, do not cooperate, and sometimes will not even allow the sonographer to complete their exam.  When these patients are on precautions and are required to wear a precautions gown, mask or gloves, very often they will take it off and ignore suggestions to put it back on.  For these times when the patient does not want to cooperate and removes their contact barriers, the gown that the sonographer wears, which is exactly the same as the one that the patient would wear, should have a built in glove that prevents separation between the gown and the glove at the level of the wrist.  Contamination can occur due to the normal separation in this area when scanning large and heavy patients that require the sonographer to reach over the patient or when handling the patient, such as helping them onto the stretcher and then back onto their wheelchair.  

Going to a restaurant is voluntary. Going to the hospital is not. And inadequate hygiene in hospitals is far deadlier than in restaurants. The Centers for Disease Control and Prevention estimates that 2,500 people die each year after picking up a food-borne illness in a restaurant or prepared food store. Forty times that number—100,000 people—die each year, according to the CDC, from infections contracted in health-care facilities (McCaughey, 2007).

The frequency of once every three years for an inspection by The Joint Commission is insufficient.  Far less people die from contaminated food, but yet restaurants are inspected at a higher frequency than hospitals – three times a year in some states such as Los Angeles –  and their inspections occur unannounced. In addition, restaurants in Los Angeles must display the grade they received from their inspection somewhere near the front door for everyone to see. 

“After Los Angeles instituted this inspection system, the number of people sickened by food-borne illnesses fell 13%, according to the Journal of Environmental Health” (McCaughey, 2007).   A similar inspection system should be implemented by the Joint Commission.  Hospitals with the worst record in patient deaths from nosocomial infections should fall under a category that calls for unannounced, yearly inspections.  Failure to improve after three years would be reason enough to close or limit the services that they can provide. 

Striving to achieve one hundred percent compliance in following the infections control guidelines would be very beneficial to the HCW’s, the patients and the hospital.  If nosocomial infections could be eliminated altogether, the volume of patients that need care would be reduced and it would save lives, which is what a hospital is supposed to be known for in the first place.

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