[40 Jahre Prävention der Krankenhaushygiene in Skandinavien]
Bertil Nyström 11 Former head of Hospital Infection Control, Huddinge Hospital, Stockholm, Sweden
Zusammenfassung
In den frühen 60er Jahren tauchten auch in Skandinavien die ersten Spezialisten für Krankenhaushygiene auf. Die neue Disziplin basierte von Beginn an auf der Zusammenarbeit von Ärzten und dem Pflegepersonal, unterstützt von mikrobiologischen Laboratorien in den Krankenhäusern sowie Sterilisationsabteilungen.
Die Lehren wurden schnell angenommen. Handbücher mit Arbeitsanweisungen erleichterten Schulung und Training. Besonders schnell wurden die automatischen Waschanlagen für Bettpfannen etc oder die Waschmaschinen für medizinische Instrumente akzeptiert, die zunächst mit Hilfe von heißem Wasser, später mit Dampf desinfizierten. Seit vielen Jahren findet man diese Geräte nicht nur in Krankenhäusern, sondern in praktisch allen Einrichtungen des Gesundheitswesens. Das hat dabei geholfen, die chemische Desinfektion von medizinischen Instrumenten deutlich zu reduzieren. Bei der Desinfektion Wärme-empfindlicher Gerätschaften gingen die skandinavischen Ländern unterschiedliche Wege: Finnland bevorzugte die Äthylenoxid-Sterilisation, Schweden entschied sich für niedrigere Temperaturen und Formaldehyd (LTSF), ein Verfahren, das aus England übernommen und in Schweden weiter entwickelt worden war. In den 70er Jahren kam es zu etlichen Hepatitis B Infektionen in Krankenhäusern, vorzugsweise in Dialyse-Einheiten, betroffen waren vor allem Krankenhausmitarbeiter. Die Anforderung, Handschuhe während der Arbeit zu tragen, hat die Zahl der Infektionen drastisch reduziert und auch dabei geholfen, AIDS Infektionen zu verhindern. Die Balance zwischen dem Risiko einer Infektion über Blut und der Unverträglichkeit gegenüber Latex ist allerdings noch nicht gefunden.
In den 80er Jahren wurden die Infektionsstatistiken eingeführt und seit den späten 90er Jahren kämpfen auch wir nun (später als andere Länder) gegen resistente Keime (MRSA, VRE, multi-resistente gramnegative Keime). Seit einigen Jahren sprechen wir auch nicht mehr von der „Krankenhaushygiene“, sondern, auf Grund des erweiterten Anwendungsbereichs, von „Infektionen im Gesundheitswesen“.
Ob wir mit unserem Weg erfolgreich sind in der Abwehr von Infektionen? Wer könnte eine solche Frage eindeutig beantworten? Der Kostendruck im Gesundheitswesen wird sich auf die Infektionsrate negativ auswirken, obwohl der Fortschritt in der Wissenschaft eigentlich zu einer Senkung führen sollte. Wie auf einer Rolltreppe, der nach unten fährt, und auf der man versucht, nach oben zu kommen: Das wirkt, als stände man still, als käme man nicht voran.
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In the beginning of the 1960s hospital infection control was new to the Scandinavian countries. The first positions for infection control doctors and infection control nurses appeared. Hospital infection control was from the beginning a teamwork between physicians and nurses, based in and backed up by hospital-based laboratories of clinical bacteriology, and supplemented with departments of central sterile supply (CSSDs). Patterned on the British Central Sterilising Club similar national associations soon appeared in the Scandinavian countries, covering both hospital infection control and sterilisation of medical devices. The term “club” sounding frivolous to some, they now have more respectable names.
In the beginning of the 1960s automated flushing disinfectors for bed-pans etc., disinfecting by hot water, later on by steam, and automated washer-disinfectors for instruments, also disinfecting by hot water, appeared and were quickly widely accepted. Since very many years you will find them not only in CSSDs and operating departments in Scandinavia, but also in every hospital and nursing-home ward as well as in outpatient clinics and centres and most dentists offices. They helped us to reduce considerably the use of chemical instrument disinfectants. The use of surface disinfectants has become limited to contaminated spillage. For hand hygiene alcohol rubs have been heavily promoted and widely accepted, in combination with soap and water for visibly dirty hands and alone for clean hands. Finnish studies by Ojajärvi et al. have supported the introduction of alcohol for hand disinfection.
In the 1960s the Nordic countries went different ways in sterilisation of heat-sensitive medical devices. Finland opted for ethylene oxide sterilsers, while in Sweden we picked up the low temperature steam and formaldehyde (LTSF) principle from the UK and developed it further. In the beginning the process was difficult to control, with cold and wet spots in the chamber creating great variations in the content of gaseous formaldehyde. These problems were mastered during the 1970s, and since then the method has been reliable and widely used, also in the other Scandinavian countries. In the beginning the sterilising temperature was 78oC. This is now lowered to 65oC or lower. Already in the 1970s Sweden adopted guidelines for formaldehyde residues on sterilised products, and a method for measuring them based on work by Handlos in Denmark. In the last years plasma sterilisers have been introduced as an alternative for sterilising heat sensitive medical devices.
In the 1970s severe outbreaks of hepatitis B occurred in hospitals, mainly in dialysis wards, and affecting also hospital staff. The introduction of gloves for work in contact with blood greatly helped to put an end to these outbreaks among staff members, and also from the beginning helped to prevent widespread outbreaks of AIDS among staff. Still blood-borne infections are the most important risk for work-related infections in hospital staff. The balance between risks for blood-borne infections and for latex and glove powder intolerance is a remaining problem.
In the beginning development in infection control was mainly directed towards rational and evidence-based infection control procedures concerning e.g. surgery, vascular catheters, urinary tract catheters, ventilators, baby incubators, and to collect these into regional or national handbooks. These handbooks greatly facilitate teaching. In the beginning of the 1980s the SENIC study was published from the US, demonstrating that an even balance between procedure development and infection rate surveillance was optimal for successful hospital infection control. Slowly an increased interest in infection rate surveillance began also in the Scandinavian countries, and by now a reasonable balance seems to be on its way.
Not until the late 1990s and the early years of this century MRSA, VRE and multi-resistant gramnegatives have become increasing problems in Scandinavia. We do not quite know why they turned up so late, though we wish to believe that it was due to good compliance with effective infection control routines, good availability of single-patient rooms, and a rational use of antibiotics. Neither do we know why they turned up when they did. We again like to suspect decreased compliance with infection control procedures because of an increasing work-load for a decreasing number of staff, an increasing reduction of the number of single-patient rooms, a less discriminate use of antibiotics in nursing homes and outpatient care, and an increasing flux of mainly elderly patients between the home, nursing homes and hospitals.
Up to the mid 1990s the term hospital infection control was universally used in Scandinavia.
But important changes occurred in the healthcare system. The number of hospital beds decreased, staff was reduced even more, ambulatory care increased, and with an ageing population nursing homes increased in importance. Therefore, it was natural to change the term “hospital infections” to “healthcare-associated infections” to point to this widening of the territory for infection control.
The development in Scandinavia is of course far from unique. Most other European countries have similar experiences. Have we over the years been successful in preventing healthcare-related infections? This is unfortunately a difficult question to answer, partly because of a relative lack of relevant and comparable surveillance data over a long time period. Also, progress may be hidden. Medical progress as well as diminishing resources due to a shrinking economy in the public sector have the potential to increase the rate of healthcare-associated infections, while progress in infection control should reduce it. When you walk downwards on an escalator moving upwards, it easily appears that you stand still.
Curriculum Vitae
Dr. Bertil Nyström
Figure 1 [Fig. 1]
Dr. Nyström studied medicine at the Karolinska Institute, Stockholm, Sweden where he graduated 1957. He continued his carrier with specialist studies in clinical bacteriology at the Department of Clinical Bacteriology, Karolinska Hospital, Stockholm. He became head of Hospital Infection Control, Karolinska Hospital, Stockholm from 1965 until 1977, and after these 12 years moved to Huddinge Hospital, Stockholm from 1977 to 1996.
Bertil Nyström has been Chairman of CEN/TC 204 in the years 1995 to 2000. He was member of the International Advisory Board for Hygiene + Medizin, Journal of Hospital Infection and Infection Control and Hospital Epidemiology. He has published some 150 papers within the fields of control of healthcare-associated infections, disinfection and sterilisation.
