by Malia Kirby

Back before I chose to study and practice Oriental medicine, I figured microbiology was where it's at and, to tell the truth, I'd still be perfectly happy looking through a microscope, making Gram stains, and identifying the assorted "bugs" that tend to give most people the willies because I'm a nerd like that. In my days working in a hospital setting, I expected to be exposed to an assortment of communicable diseases that would require me to choke down antibiotics, have annual TB tests, and endure the occasional nasal swab (which feels more like they're taking a sample of brain). That's part of the job and, at the time, I was willing to be compliant with that. Once I'd had enough of hospital politics to make me consider a change in career and I had received my acceptance letters from the TCM schools I applied to, I thought my days of following infection control procedures were over. Thanks to Oriental medicine there would be no more gloves, no more donning N-95 masks, and, best of all, no more prophylactic doses of Cipro in my future.

After beginning school, however, I started to rethink my opinion on the matter. During one of my observation clinics, as the intern treating that day was pulling needles out of a patient (who happened to have hepatitis C) it was noticed that a used needle had gone missing on the floor somewhere. In my final year of school, one patient reported that he and his whole family had recently been diagnosed with tuberculosis and he didn't want to take the prescribed antibiotics. Last winter, I was exposed to pertussis once again. Somewhere between that re-exposure and my most recent practitioner call inquiring how to best treat a case of MRSA (I've taken five in the past two weeks alone), I decided to sit down and write about how we can best protect ourselves and our patients from the communicable diseases we're most likely to see.

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Universal Precautions
In a hospital setting, universal precautions are like bread and butter: washing your hands between patients, using protective devices appropriate to the level of exposure (including gloves, gowns and eyewear), using current disinfecting guidelines, and using safe injection procedures. In the acupuncture clinic, however, most of the time that amounts to washing your hands between your patients, disinfecting your table(s), and using easily washed linens or disposable table paper for each patient because we're less likely to come into contact with blood with the exceptions being bleeding the jing-wells, spider nevi, and other assorted points, which requires glove use. Fortunately for us all, modern Oriental medicine no longer expects us to inspect the urine, phlegm, and fecal matter of our patients as the doctors of old had for their patients, so for the most part, a majority of our profession never really worries about utilizing universal precautions. What you may not know is that the CDC's universal precautions also give recommendations on how to remove your used and soiled gloves, how you should handle your soiled laundry and dispose of your table paper, that we should remind patients to cover their mouth when coughing/sneezing, and believe it or not, even how used Kleenex should be disposed of. It sounds anal-retentive, I know, but it is really just an application of common sense.

To properly dispose of your used gloves, hook a finger underneath the opening edge from the outside of the glove. Slowly pull the glove off of your hand so that the glove turns inside out and any blood or fluids on the glove are now inside the glove. Hold the used glove in the palm of the still-gloved hand, making a loose fist. Hook a finger from your non-gloved hand from the inside of the glove. Slowly pull the glove off of your hand so that the glove turns inside out, holding the other glove and any blood or body fluids on the inside. Dispose of used gloves in the trash or, in the case of heavily soiled gloves, in an appropriately marked biohazardous waste container. You can use your sharps container, or if you happen to practice in a hospital setting, you'll recognize that trash container by the red trash lining marked with the biohazard symbol on the outside.

To properly dispose of your soiled table papers or soiled linens, they should be handled in a manner that reduces your chance of exposure to you, your other patients, and to the environment, gloving up if necessary. For the average treatment, this generally means that you can wad them up and throw them away (in the case of paper) or toss them into the laundry bag provided by the cleaning company you've contracted with. Let's say for demonstrative purposes, that you've bled and cupped your patient's shoulder and removal of the cup proved to be messier than usual, resulting in blood all over your table linen. Instead of simply balling up the linen and tossing it in the laundry bag, you should make sure to fold the contaminated area into the inside of the sheet before transferring it to the laundry bag so that you won't be dripping blood down your hallway or across your carpet. After your linens are properly secured in the laundry, you should then use a 10% bleach solution to disinfect your table before covering it with clean linens. Be sure your bleach solution is fresh, ie, not more than 24 hours old, and of course, don't forget to clean and autoclave your cups.

Here's the tricky part: if you use universal precautions in your clinic for one patient, you must use standard precautions on all of your patients. By law, you cannot glove up for a patient who reports that he or she has a bloodborne pathogen and ignore glove use for the rest of your patients as it can be construed as prejudice and you can be sued. If you are doing any bleeding on a patient, do yourself a favor and make sure you use gloves every single time. No exceptions.

Contact Precautions
Contact precautions are for all the diseases out there that are contracted by skin-to-skin contact and/or a physical transfer of the organism. According to the Yale New Haven Hospital Infection Control Manual, that includes diseases such as MRSA and other antibiotic-resistant bacteria, chicken pox and shingles, herpes simplex, scabies, impetigo, any significant boils or abcesses, most cases of explosive diarrhea with incontinence, and RSV (which, in most cases, looks like the common cold in adults but can be deadly in infants) (1). Of course, the list also includes hemorrhagic diseases, but the chances of a patient walking into your office with a raging case of Ebola are rather slim.

Patients reporting any of these conditions should preferably be placed in a single-person room, rather than being treated in an open, multi-treatment room as you commonly see in community acupuncture practices. If you have a community acupuncture practice and don't have single-patient rooms available to you, the CDC recommends having greater than three feet between your tables to reduce the chances of contact with the pathogen at hand. Donning disposable gowns and gloves (Personal Protection Equipment, or PPE) are required before entering the patient's room as is the immediate disposal of the PPE before leaving the room. You'll also need to use your 10% bleach solution to clean your table--but here, you can't use it on any of your other tables. You must throw it away. Any equipment you might use should soak in an EPA approved disinfectant, or better yet, autoclaved if possible before being used on any other patient. The room should also be thoroughly cleaned before using it for another patient.

Other considerations not listed by the CDC would include not needling or bleeding patients with MRSA or other antibiotic resistant bacteria strains to avoid creating new routes of infection. Localized infections (such as boils) are much more manageable than systemic infections (in the bloodstream). Make sure these patients are still in the care of a physician and if they aren't, you should make sure to strongly recommend that they seek appropriate care and chart it.

Droplet Precautions
This set of precautions is designed to prevent the spread of diseases where close respiratory & mucous membrane contact occurs, but is no longer infectious over long distances. Diseases that fall into this category include influenza, pertussis (aka, whooping cough), mumps, parvo, rubella, pneumonia & walking pneumonia, bacterial meningitis, and strep throat until 24 hours of antibiotic therapy has been completed (1).

If you have a patient reporting any of these diseases, again, you should place your patient in a single-patient room if possible. If not, your tables should be more than three feet apart and if you don't already have some sort of privacy screening in place between patients, using them here is highly recommended as a physical barrier from droplet sprays from sneezing and coughing. If it's just you and your patient, you will need to use a mask to protect yourself. If you're in a community acupuncture office, you may need to require your patient to wear one to protect you, your patients, and your staff.

Airborne Precautions
These help prevent the spread of diseases where the pathogen is still infectious when suspended in the air over long distances. You'll need to use airborne precautions with patients who have active tuberculosis (but not latent), SARS, chicken pox & shingles, and measles (1). In hospitals, these patients are kept in single-patient rooms where the air pressure is kept at a level so that when the door opens, air from that room doesn't rush into the hallway or into surrounding rooms. Since that isn't feasible in most of our offices, you'll want to pick up some N-95 respirators (or higher), commonly referred to as "duckbill" masks since they're often bright orange and in the shape of a duck's bill. These masks are easily molded to your face to help prevent microbes from sneaking in around the edges.

You've Got to be Kidding Me!
Are these guidelines anal-retentive? You bet. Will some of your patients complain? Probably, so it will be vital to do everything you can to help reassure your patients that they're not being singled out or quarantined. Other patients will appreciate that you're doing your best to reduce their chances of contracting what others are suffering through and a good bedside manner will go a long way here (see Shawn's post entitled The Importance of Bedside Manner for more on this topic). If that's the case, then why should you pay close attention to infection control guidelines if some of your patients will be annoyed by it, not to mention that it's a huge pain in your butt? Consider how easy it is to contract pinkeye from another person and ask yourself this: how happy would you be if you picked it up from your doctor's office because they weren't properly disinfecting their rooms and equipment? Would you continue to see that particular doctor, or would you start shopping around for a new physician? Now consider what would happen to your entire client base if it turns out that you have been the cause of a MRSA outbreak because you haven't been responsible in protecting your patients by following CDC guidelines as closely as possible. A number of the diseases requiring more than universal precautions are also on the lists to be state &/or nationally reported (no, we aren't responsible for reporting because we can't diagnose disease in western allopathic terminology), so if your office happens to be the source, it will be tracked back to you. Be forewarned.

We may be a form of alternative medicine, but alternative or no, this is still healthcare, folks. As practitioners, the second we accept a patient's case, we are responsible for their health and their lives. It's time we take that responsibility seriously.

References
1. http://www.med.yale.edu/ynhh/infection/contact/reqcnt.html

Other Sources
Clean Needle Technique Manual for Acupuncturists, 6th ed. NAF Publications. 2009.
http://www.cdc.gov/hicpac/2007IP/2007ip_part3.html