The legal obligation and duty of care of the podiatrist

Humans have always had to fight against diseases. For the longest time, many people died because the causes of disease and how they evolved remained unknown. It was believed that witchcraft, spirits, or the immorality of people were the reasons for disease transmission. Over the past 100 years it became possible to identify that micro-organisms were the cause of disease with the discovery of the microscope by Antoni Van Leeuwenhoek in the 17th century. However, The germ theory itself was not accepted until Pasteur, a French biologist, provided the scientific evidence in the mid 19th century. This theory proved that micro-organisms caused infectious disease. He also discovered the Staphylococcus Aureus and streptococcus and developed vaccinations against rabies and anthrax. He noted that there was a lack of patient education in regards to infection control and misinformation by the physicians. (French Book)

Other medical breakthroughs came from simple observation and common sense. Even before the theory of Pasteur, a Hungarian obstetrician, Ignaz Semmelweiss, 1846 recommended asepsie during the deliveries of his patients. He realised the infectious nature of puerperal fever and noted through clinical observation the importance of hand washing to prevent the spread of infection. He initiated practices to prevent the spread of infection by enforcing hand washing before examining a patient and requiring the cleaning of rooms on a regular basis. As a result, mortality rates in his hospital decreased. He was responsible for the discovery of nonsocomial infections in hospitals and clinics. (Principles of Chiropractic)

These scientific principles and observations were adopted by the health care professions and opened the doors to research into the identification of disease causing germs and potentially life saving treatments. Podiatrists must have an understanding of these micro-organisms and their mode de contamination in order to follow proper treatment techniques thus reducing the transmission of infections and reducing the mortality rates. French

Although the causes of the diseases and how they are spread are no longer a mystery , the medical field faces new challenges because of organisms that resist to certain medications such as antibiotics and present day treatments as well.(French)

As a result, Podiatrists must keep informed of how these diseases are transmitted and continually educate the patient in order to prevent cross-contamination and spread of infection. It should be known that germs are one celled organisms and are found physiologically everywhere. However, micro-organisms called pathogens are harmful and cause disease. These include bacteria, viruses,fungi, protozoa, and prions. The pathogenic micro-organisms listed below are of the utmost importance to Podiatric Medicine.

Bacteria

Bacteria are unicellular micro-organisms and reproduce themselves by mitosis. Staphylococcus is a type of bacteria responsible for purulent infections of the skin, mucous membranes, and wounds. One out of every two infections are due to S. Aureus. This bacteria is resistant and can survive days in dust and dried pus. Persons most susceptible to exposure are the elderly or immunodeficient patients. A large proportion of the population carries this bacteria asymptomatically on their skin, mucous membranes such as nose and throat as well as forehead and hair roots. There is risk of infection when working with wounds or dressing changes. The disinfection of the hands, instruments, and surfaces with a bactericidal agent is one of the most effective method of prevention. Staphylococcus Aureus causes MRSA which a bacteria that resists to antibiotics and are a concern in regards to infection control.

Streptococcus pyrogens are the cause of systemic purulent infections such as strep throat but are frequently found in skin infections. It is transmitted though droplets from coughing or sneezing. Although less resistant it can survive several days in dust and or on infected objects. They are easily eliminated with a disinfectant agent such as….The problem is that these indirect pathogens may cause heart or kidney inflammation. Pseudomonas aeruginosa cause systemic infections producing a greenish blue pus which may lead to sepsis especially when working with wounds. It is often present in water. In the clinical environment they are present in basins, air humidifiers, towels, and cleaning equipment. It is spread by direct contact. The podiatrist should give particular care to objects such as foot and wash basins and enforce the disinfection procedures.

Viruses

Viruses are pathogens that need a host to survive. These include the hepatitis virus that infect the liver and the herpes. These are not living organisms and need a host in order to multiply. The multiplication of the virus occurs once it is implanted in the host. The cell of the host bursts and develops new viruses. The treatment of these types of viruses is difficult to identify because it is hidden in the host cell. Prophalaxis is accomplished through vaccination.

The viruses that are important in regards to podiatry are the Papillomavirus. There are many different types which can infect the skin or the mucous membranes and are the cause of verrucae. Theses cells enter the epidermis and produce new viruses. At the same time the skin cell begins to multiply and divide in an uncontrolled manner. These cells can infect new cells of the same organism or can infect another person. As a result, a foot that carries verrucas leaves traces of virus containing cells on the floor. The cells containing the virus may start an infection on the skin of another person. In the podiatry clinic, the podiatrist must realize that all surfaces who have been in contact with these viruses are considered contaminated including the hands of the Podiatrist and should be disinfected as per protocol.

Hepatic viruses

In podiatry practice Hepatitis B,C,D viruses transmitted by the blood stream are important. There is a possibility to be transmitted by sharps or cuts contaminated with patients blood. Pus also contains these viruses and are an additional source of infection for the podiatrist. Contaminated instruments represent a danger for other patients. Vaccination against the hepatitis B virus in addition to the wearing of gloves represent effective protection against infection and when choosing a disinfectant the podiatrist must make sure that it is effective against the hepatitis viruses.

HIV

HIV is caused by the immunodeficiency virus. It is acquired by adults and is spread by the blood and body fluids. The virus attacks auto immune cells which is weakened and defenceless towards the pathogens. The delay from the time of infection and the appearance of symptoms can take years. Unfortunately, there is no vaccination against this type of virus. The only method of protection is to avoid contact with it. However, progress has been made in regards to treatment but this is still not a curable disease. In Podiatry the risk of contamination with direct contact with blood and body fluids.

Fungi

Fungi are classified as dermatophytes, moulds, and yeast. They can cause mycoses. The pathogens can be much bigger than bacteria but still remain invisible to eye sight. They produce enzymes that can spread through wounds or abrasions through an enzymatic process and can infect directly or indirectly objects or skin. In any case, the best barrier is intact skin. Podiatrists must “provide safe care in accordance with the standards of practice and must follow the standards of infection care when working with patients.” There are protocols to protect the patient and podiatrist against germ contamination and infection. These protocols must be followed regardless of diagnosis or infectious status. They define the guidelines to minimize infection “Failure to comply with infection control standards can be very harmful. The elder persons, children and immunodeficient patients are the most susceptible. Micro-organisms are a threat to this patients and can be harmful. There may also be a major outbreak of infection in the clinical environment which may cause health care to be disrupted. “(Health Care Act 2008: code of practice for NHS on prevention of infection)

The guideline for protection in the clinical environment include:

Care of self

Health care providers must protect themselves and patients. A uniform with short sleeves is required because it offers the health care professional and the patient protection from possible contamination. It should be washed in hot water and as a single item. To prevent cross contamination, it should be worn in the clinic only and when the Podiatrist leaves the clinical environment he is required to change his clothes. Shoes should be easy to clean and and cleaned immediately if contaminated with blood or body fluids. It is recommended to use detergent and hot water. Other protective equipment such as plastic aprons and gloves for example will depend on the risk assessment at that time of the clinical visit and will be used according to protocols. Wearing gloves at all times is a personal option. However, they cannot be cleaned and must be discarded after each procedure. Immunizations must be up to date and the Podiatrist must have received a Hepatitis B vaccine series and have their antibody level checked.

Environmental cleaning

The podiatrist must insure that the working environment is properly cleaned to prevent risks of infection. The work environment is a place of contamination and the guidelines for cleaning must be followed to prevent the risks of infections. It is absolutely necessary to clean and disinfect the work place on a daily basis. The floor should be cleaned with safe agents. Between patients the area must be cleaned with wipes. Any particles on the floor must be vacuumed. The vacuum should have a filter to reduce contamination from dust particles. Equipment should be cleaned and spills must be immediately with the proper detergents. (Health Protection Agency 2007)

Hand washing

This is a fundamental and most effective method of infection control and is done before and after patient contact; after touching soiled or contaminated dressings before putting on protective clothing. Jewellery and watches must be removed. Hands should be washed with soap and water and decontaminated with surgical scrubs and dried with towels. They should be washed before putting on gloves and after removing them. Follow the guidelines for hand washing solutions depending on the tasks involved. Creams should be applied to protect from dryness and irritation. (Health Protection Agency 2007)

Sharps

Sharps must be handled with caution and disposed of to prevent risk of needle stick and exposure to blood pathogens. They should be disposed of properly. These are one time used items and should never be recapped. They should be disposed of in a sharps container and labelled with the source of contamination. In the event of a sharp injury, the guidelines for treating it must be followed and reported to the proper persons.

Patient care equipment

It is important that all instruments are cleaned, disinfected and sterilised correctly to protect the patient and Podiatrist against contamination by possible germs. On a daily basis there are many risks of infection and cross contamination. These risks exist in cases of inflammation, wounds, superficial scrapes and skin contact with pathogens (fungi, herpes, etc.).

Germs can be transmitted by blood, dust, aerosols and hands and contaminated instruments. In order to reduce the risk of cross contamination, it is necessary to disinfect and sterilise the equipment after using; The instruments should be washed in a detergent before being sterilized. The choice of the detergents is based on the resistance to germs, the type of environment, and the type of objects being disinfected as per the clinical guidelines. In most clinics, instruments are sent to central sterilisation department . These must be packaged and the date of sterilisation must be clearly indicated. Because of growing concerns over prions more and more clinics and hospitals are using sterile single use instruments.

Home

Special consideration in regards to home care is of importance to the Podiatrist because there is high risk of infection due of lack of environmental control. Podiatrist must reduce infection risks as much as possible. The Podiatrist must wash hands when possible and it is recommended to bring one’s own supplies such as liquid soap, towels, and alcohol rubs. It is a legal duty to dispose of wastes in safe storage containers and out of reach of children and pets. A follow up appointment in the clinic is recommended as soon as the patient is able to do so. (Health Care Agency 2007)

Conclusion

Podiatrists, whether in a clinical or home environment, has the legal responsibility to protect himself and the patients from risks of infections by following protocols, clinical guidelines and educating the patients in regards to infection control and prevention.