你家的听诊器，卫生吗？

dearhang

翻译丨莫延花（青海省中医院）
审核丨唐文瑞（湘潭市中心医院）/陈志锦（东莞市厚街医院）





 听诊器卫生不合格可致患者感染


您可以指导医生消毒，但如何让他们清洁或擦拭听诊器才是正确的呢？


这是在美国感染控制与流行病学专业协会(APIC)的官方杂志—《美国感染控制杂志》7月刊上发表的由新版质量改进项目提出的问题。


最新的研究报告发现，卫生保健提供者在不同患者之间很少执行听诊器的卫生，尽管它对预防感染具有重要意义。疾病预防控制中心的感染控制指南规定，可重复使用的医疗设备，必须在不同患者之间进行消毒，如听诊器。


2017年APIC会长、注册护士、国会议员、最高司令员琳达·格林说：“听诊器全天被重复使用，每次接触患者后会被污染，因此必须将其视为潜在的传播媒介。没有消毒的听诊器可能造成严重的患者安全问题，类似于忽视手卫生。”


该报告描述了一项质量改进试点项目，该项目的发起人在一家三级保健学术教学医院分别对医学生、住院医师和主治医师进行了为期四周的听诊器卫生的观察，包括使用酒精棉球、酒精凝胶或消毒湿巾擦拭听诊器。在工作人员中对听诊器卫生的基线观察发现，听诊器卫生为零。该项目还研究了手卫生，包括使用酒精凝胶进行手消毒或用肥皂和流动水洗手。 


然后，该研究团队试图让临床医生了解听诊器卫生的重要性，并强调临床医生在每个病人之间进行听诊器卫生的期望。他们还暗示，可能会在后续阶段继续进行监测。尽管如此，结果还是一样的：听诊器卫生零发生。


作者评论说：“虽然该项目有几个局限性，但它确实突显了听诊器卫生的执行情况。标准教育可能不是解决这个问题的答案。尽管在大规模随机试验中进行了研究，但通过行为和文化改变手卫生仍然是一个挑战。听诊器卫生的实施需要更加一致的努力来改变文化和习惯。 我们认为，听诊器卫生应该纳入所有医院的手卫生措施中，同时增加问责制”。







传统上，手卫生比听诊器卫生更受关注，但微生物数据显示，单次检查后的听诊器污染与医生惯用手的污染程度相当。从听诊器中培养的潜在病原菌包括金黄色葡萄球菌、铜绿假单胞菌、艰难梭菌、耐万古霉素肠球菌。事实上，瑞士最近的一项研究发现，听诊器能够传播潜在的耐药细菌，包括耐甲氧西林金黄色葡萄球菌(MRSA)。


根据其他地方研究中报告的听诊器卫生情况，该研究团队预计取得的成果有限。他们预计到听诊器的卫生率较低，并且听诊器卫生已经被列在了二年级医学生期末评估的清单上，体现出在医疗机构中完成一个完整病历和体格检查的能力，但令人惊讶的是，竟然没有一人实施听诊器卫生。






原文：


Failures in stethoscope hygiene can lead to patient infections


You can lead a doctor to disinfection, but how do you get them to clean…or wipe ….or swab a stethoscope?


That’s the question raised by a new quality improvement project published in the July issue of the American Journal of Infection Control, the official journal of the Association for Professionals in Infection Control and Epidemiology (APIC).


It is the latest report to find that healthcare providers rarely perform stethoscope hygiene between patient encounters, despite its importance for infection prevention. Infection control guidelines from the Centers for Disease Control and Prevention state that re-usable medical equipment, such as stethoscopes, must undergo disinfection between patients.


“Stethoscopes are used repeatedly throughout the day and become contaminated after each patient exposure, so they must be treated as potential vectors of transmission,” said Linda Greene, RN, MPS, CIC, FAPIC, 2017 president of APIC. “Failing to disinfect stethoscopes could constitute a serious patient safety issue similar to ignoring hand hygiene.” 


The report describes a quality improvement pilot project in which the authors observed stethoscope hygiene (alcohol swabs, alcohol gel, or disinfectant wipes) at the start of a four-week rotation for medical students, resident physicians, and attending physicians at a tertiary care academic teaching hospital. The baseline observation of stethoscope hygiene among staff found zero occurrences. The project also looked at hand hygiene, which can include alcohol gel or soap and water.


The team then sought to educate clinicians about the importance of stethoscope hygiene, and emphasized the expectation for clinicians to conduct stethoscope hygiene between each patient encounter. They also hinted that they might monitor during the follow-up phase. Despite this, the result was the same: zero occurrences of stethoscope sanitation. 


The authors commented: “While the project had several limitations, it does highlight how rarely stethoscope hygiene is performed. Standard education may not be the answer to this problem. Behavioral and cultural modification to improve hand hygiene still remains a challenge, despite being studied in large randomized trials. Stethoscope hygiene implementation will need more consistent efforts to change culture and habits. We believe that stethoscope hygiene should be included in all hospital hand hygiene initiatives along with increased accountability.”


Hand hygiene has traditionally received much more attention than stethoscope hygiene, but microbiology data shows that stethoscope contamination after a single exam is comparable to that of the physician’s dominant hand. Potential pathogens cultured from stethoscopes include Staphylococcus aureus, Pseudomonas aeruginosa, Clostridium difficile, and vancomycin-resistant enterococci. In fact, a recent Swiss study found that stethoscopes were capable of transmitting potentially resistant bacteria, including methicillin-resistant Staphylococcus aureus (MRSA).


The team anticipated a poor result, based on the low rates of stethoscope hygiene that has been reported in studies elsewhere. “We anticipated low stethoscope hygiene rates, but were surprised that no one performed stethoscope hygiene, despite the fact that it is on the checklist for second-year medical students’ final evaluation demonstrating competency in performing a complete history and physical at our institution.”
图文编辑：小小牧童
审稿：卢先雷 陈文森