SUMMARY: Claimants who are hospitalised for treatment of their Personal Injuries run a significant and fairly predictable risk of contracting infections. Handwashing between patients would most reduce hospital infections. Stethoscopes, blood-pressure cuffs and other medical equipment spread infection. Proving medical or nursing negligence in this area is rarely possible.
Infection complicates accidental injury and surgery with predictable regularity.
When infection contributes materially to the Quantum of Damages following accidental personal injury, claimant counsel may wonder about a subrogated claim for medical malpractice.
Nosocomial (hospital) infection complicates the stay of 5-15% of inpatients1 and kills around 2000 Canadians each year2.
However, medical malpractice plaintiff counsel know the frustration of rarely being able to prove medical or nursing negligence as a cause.
It is usually impossible to show Causation, particularly long after the event.
Furthermore, community standards of compliance with guidelines for preventing cross-infection are so poor as to torpedo most such Causes of medical malpractice Action.
If new clients are still hospitalised, consider urgent collection of cross-infection evidence
Handwashing between patients would most reduce hospital infections.
As the United States Centers of Disease Control and Prevention (CDC)1 has said, "Handwashing is the single most important means of preventing the spread of infection."
Bacteriological sampling showed that a third of physicians' and a sixth of nurses' hands were contaminated with pathogenic bacteria3.
The spectrum of germs was indistinguishable from that found on patients' skin.
As we have reported previously failure regularly to wash hands between patients represents actual community Standard of Care in North American hospitals4.
Establishing that community Standards of Care in preventing cross-infection are unacceptable would require an Appeal to the Supreme Court of Canada
At best, less than three-quarters of registered nurses comply, and figures from most studies, including those for physicians, are considerably worse.
There is not even any question that adequate hand washing effectively removes the dangerous transient bacteria from the hands.
Well-reasoned estimates5 suggest that a one-and-a-half to twofold increase in compliance with standard handwashing policy would reduce nosocomial infection rates by 25-50%.
However, as we noted previously changing the habits of hospital caregivers is the problem: heightened scrutiny, educational and motivational efforts have only limited and temporary benefit6,4.
Surgical gloves not only develop microscopic holes during normal use, but their wearers frequently contaminate previously clean surfaces before they remove the gloves7, and soil their own hands during glove removal8.
Casual observation will show that some nurses and physicians treat the wearing of surgical gloves as a substitute for handwashing, rather than an adjunct.
Stethoscopes, blood-pressure cuffs and other medical equipment spread infection.
A recent study9 from Brazil has confirmed previous findings that potentially dangerous bacteria can be cultured from most stethoscopes in clinical use.
The commonest germ isolated is Staphylococcus Aureus, including the Methicillin-Resistant (MRSA) variety.
This potentially-lethal infection is an increasing hospital problem, in intensive care units in particular, and now occasionally appears in the community.
Once hospital cross-infection is recognised to have taken place, isolation precautions significantly reduce subsequent transmission to other patients.
Simply wiping stethoscopes with 70% alcohol between patients would probably make a material difference to cross-infection - but the precaution has not yet been adequately tested or instituted as a routine.
Blood-pressure cuffs, including those that are not visibly contaminated by blood or other body fluids, readily demonstrate colonisation with potentially harmful bacteria10,7.
The mere isolation of such germs does not prove that inanimate objects like stethoscopes and blood-pressure cuffs are important vehicles of hospital cross-infection.
There are very few such studies, despite the enormity of the problem, but routine use of a single blood-pressure cuff has been shown11 to explain patterns of cross-infection in a neonatal special care nursery.
Disposable covers for blood-pressure cuffs have been designed and are commercially available12...but are not yet in regular use.
Other environmental contamination
Hospital beds, linen, side-tables, and nurse's gowns and uniforms have been shown to be readily and regularly contaminated by Staphylococcus Aureus and other potentially dangerous germs13, including those that can cause epidemic diarrhea and vomiting.
A third of "clean" sampled surfaces of anesthesia and monitoring equipment in operating rooms were found by forensic testing to be contaminated by blood14 .
In another study, only a quarter of artificially-ventilated patients were carriers of a particular pathogenic germ on admission to a medical intensive care unit.
Within an average of 5 days, nearly half the remainder had acquired the germ15.
PERSONAL INJURY LITIGATION
The significance of this somewhat depressing picture to claimant and defence counsel is that hospitals in general, and emergency rooms and intensive care units in particular, are dangerous places for those who have suffered personal injury.
Proving medical or nursing negligence in this area is rarely possible.
Although the injury damages may be compounded by infection contracted during hospital treatment, proving a novus actus interveniens caused by medical and nursing negligence is rarely possible.
Occasionally, eye-witnesses of a particular physician's unusually poor hygiene will provide strong circumstantial evidence.
Exceptionally, investigation of nursing, medical or surgical care of a couple of patients who were treated simultaneously will reveal a pattern that explains cross-infection on balance of probability.
Potentially preventable cross-infection in our hospitals will remain at its unacceptably high level until known and simple procedures are conscientiously applied by care-givers16.
Meantime, counsel will continue to grapple with secondary damage that occasionally exceeds that of the original personal injury.
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