Foot Care - Infection Control

[nightingale, RN]

Another interesting article on Foot Care. This article, while an older one, refers to the importance of Infection Control for the Foot Care Clinician. I am posting it here because of the lengthy discussions on Foot Care:

http://www.hc-sc.gc.ca/pphb-dgspsp/publicat/ccdr-rmtc/97vol23/23s8/fcindexe.html

INFECTION CONTROL GUIDELINES

Foot Care by Health Care Providers

Introduction

Guidelines, by definition, are directing principles and indications or outlines of policy or conduct, and should not be regarded as rigid standards. These Guidelines should facilitate development of standards but respect the autonomy of organizations and recognize their governing bodies' authority and responsibility to ensure the quality of care provided to their patients/clients.

The guidelines in this document are intended for use by health care providers, including registered nurses, licensed practical nurses, and registered practical nurses, performing routine foot care that is not intentionally invasive. The settings for the provision of foot care may include locations such as the home, seniors lodges, community residences, or continuing and acute care facilities.

Health care providers must follow the scope of practice, standards and regulations of their professional regulatory body in the province in which they are practising (e.g., for nurses providing foot care in Ontario, refer to Nursing Foot Care Standards of the College of Nurses of Ontario).

The number of persons requiring assistance with the care of their feet is increasing with the rising number of elderly persons in the population. The Victorian Order of Nurses for Canada (VON) has estimated that between 15% and 20% of Canadians over the age of 65 who live at home require assistance with care of their feet(1). Inadequate foot care, which may produce foot problems such as ulcers or infections, can result in pain and decreased mobility(2,3). This may lead to a sedentary lifestyle, which has been associated with cerebrovascular disease and impaired cognition(4). The results of a survey conducted by the VON following the nation wide project Keeping Canadians on their Feet(1) revealed that 69.8% of people receiving foot care reported that it helped them to walk.

A. Causes of Common Foot Infections

The origins of common foot disorders can be classified into three broad categories: biomechanical factors (e.g., defects in foot architecture, direct trauma); manifestations of underlying general and systemic disease (e.g., diabetes, arteriosclerosis); and infections (e.g., Athlete's foot, cellulitis). Foot infections may be bacterial, viral, or mycotic (fungal)(3).

B. Foot Problems in Persons Living with Diabetes

Of all the causes of foot pathology, diabetes has undisputed importance. People living with diabetes are vulnerable to foot problems associated with peripheral vascular disease and neuropathy, producing a decreased sensation to pain and touch(5). Diabetes has been diagnosed in 8 million Americans(6) and 1.5 million Canadians(7). Diabetic foot infections are the most common reason for admission to hospital in persons with diabetes. In the U.S., the direct costs of admissions for foot infections in 1983 exceeded $43 million(8). More than half of all amputations in the United States from 1989 to 1992 occurred in people with diabetes; an average of 54,000 amputations were performed each year(7). In Ontario, 45% of all amputations of a lower extremity occur in patients with diabetes, even though these people constitute approximately 5% of the population(9). One group of researchers reported that the development of ulcers as a result of minor trauma, such as an accidental cut from the use of improper footwear, preceded 86% of amputations. Unsafe nail and foot care practices have been shown to contribute to foot trauma(10). It has been estimated that half of all foot amputations can be averted by the prevention, early detection, and treatment of foot infections(11,12).

C. Risk of Infection Following Foot Care

Infection prevention/control standards for health care providers in the routine care of the feet and nails could not be located in published form. A literature review from 1980 to the present using the databases Medline and Cinahl resulted in little information regarding the source of infections precipitated by routine foot care. A selected Internet search for information on foot care/infections found the primary focus to be foot infections associated with diabetes. A plethora of literature exists on medical interventions for foot infections, and the nursing literature tends to focus on foot assessment, care of the feet and nails, and patient education.

Sources and Reservoirs of Foot Infection

The microflora of the foot include organisms that are resident (those that normally inhabit the skin) and those that are transient (those that have been deposited on the skin). People who have been cared for in health care institutions or who have damaged tissue have a greater risk of being colonized with organisms that are not normally found on the foot(13). Approximately 50% of the population have athlete's foot infection some time in their life(14). Micro- organisms may be transmitted from person to person by direct contact, usually through the hands of health care providers(13,15), or indirect contact (by a vehicle such as foot care equipment)(13). Sources of infection can be divided into the following two categories:

i.endogenous sources: caused by flora or infection on the person's own body (e.g., Staphylococcus aureus from the nose or Corynebacterium minutissimum from the skin).

ii.exogenous sources: caused by infected or colonized people or animals and environmental sources (e.g., flora from others such as S. aureus or infections from animals such as Microsporum canis)(16).

Viruses present in the blood of persons receiving foot care may also create a risk of infection for others. Of greatest concern are the bloodborne pathogens hepatitis B virus (HBV), hepatitis C virus (HCV), and the human immunodeficiency virus (HIV)(16). Because sharp instruments used during foot care may puncture the skin and become contaminated with blood, they must be appropriately cleaned and sterilized between use. Sterilization destroys all forms of microbial life. Any microorganism that comes into contact with a mucous membrane, skin that is not intact, sterile tissue, or the vascular system has the potential to cause infection. Instruments used in foot care that may break the skin must be sterile.

Foot Care Equipment

Foot care equipment is transported in the nurse's carrying bag to the foot care site. The assembled foot care equipment should contain:

a set of sterilized foot care instruments for each patient/client

disposable paper towel on which to place instruments during procedure

commercial puncture-proof sharps container

skin antiseptic

hand washing soap and disposable towels

waterless hand washing agent

container to transport used instruments

one pair of non-sterile medical gloves (latex, vinyl, nitrile etc.) for each patient/client

foot emollient (lotion or cream)

protective equipment (eye shield, disposable face mask and disposable apron, gown or towel)

sterile gauze or Band-Aid®

Cleaning Foot Care Equipment

All items should be washed in warm water with a detergent. Personnel who are cleaning the equipment should wear general purpose household gloves. Files and hinged instruments should be cleaned with a small brush (e.g. toothbrush) while the instrument is held under water to prevent splashing. An ultrasonic cleaning device may be used as an additional step in the cleaning process. Washed items should be left to dry. Cleaned instruments should be placed in packaged sets prior to sterilization.

Recommendations

The overall goal of infection prevention practices for foot care is to eliminate the risk of the transmission of pathogens between clients and between clients and the health care worker. Foot trauma during the foot care procedure should be avoided to eliminate the client risk of acquiring infections. The following recommendations should be implemented when providing foot care.

a.All foot care equipment for re-use must be capable of being cleaned in a detergent and water to remove organic matter.

b.Single-use items such as emery boards, orange sticks and rotary tool disks should be discarded after use. If a client's own equipment is used, it must be kept clean and dry.

c.All instruments used in foot care must be sterile before use on a client/patient. Instruments that must be sterilized prior to use, often packaged in sets, may include the following: nail nippers foot dresser file Black's file rasp scalpel handle (for attachment of blade) nail probe callus parer

d.The recommended methods of sterilization for foot care instruments include dry heat; autoclave (steam under pressure); or chemisterilant with exposure time as stated on product's label. Methods of cleaning, disinfection and sterilization are detailed in text and tabular form in the Health Canada publication Infection Control Guidelines for Cleaning, Disinfection, Sterilization and Antisepsis in Health Care(17).

e.Glass bead sterilization is not an effective method of sterilization and should not be used(17-19).

f.Boiling water(20) and microwave ovens are not effective methods of sterilization and should not be used(17).

g.Hand washing is the single most important procedure for preventing infections(17). Hands must be washed with soap and water before beginning the foot care procedure. Hands should be washed before glove use and after glove removal. Foot care clinics should be arranged with consideration for the availability of hand washing sinks. Waterless hand washing agents may be used if a sink is not available(17).

h.Non-sterile medical gloves should be worn throughout the procedure to prevent exposure to bacteria, fungi and viruses(21).

i.Gloves must be changed for each patient. The hands should not be washed with gloves on.

j.Eye shields or glasses should be worn to protect the health care provider from nail clippings or debris(17,21).

k.A disposable face mask should be worn to reduce the possibility of inhaling organisms that may be aerosolized during filing of nails. The inhalation of nail dust has been associated with conditions such as conjunctivitis, rhinitis, and an occupational lung disease called "podiatrist's lung"(22-24). Masks should fit snugly and be worn for one patient/client only.

l.If the foot of the person receiving care is positioned on the lap of the health care provider, the clothing of the health care provider should be protected by a disposable gown, apron, or a clean towel.

m.The use of a foot soak prior to foot care is controversial(25); however, the feet should be clean. Feet should be washed with a mild soap and warm water. If the foot basin is used it should be washed with soap and water, rinsed, and dried thoroughly between clients.

n.A skin antiseptic should be used to wipe areas of the feet that will be touched by a foot care instrument (e.g., before removing calluses). If cotton balls are used, a disposable container should be used to wet the cotton balls with the antiseptic. Alternatively, prepackaged swabs should be used.

o.Emollients, such as lotions/creams, are often used to massage and moisturize the foot(26). It is desirable to use small, single use lotion bottles that can be left with the client(17). If the bottle containing the lotion is used on more than one client, care must be taken to keep the contents free from contaminants. Squeeze the lotion onto the gloved hand without touching the bottle opening.

p.If towels are used during foot care clinics, the towel should be used for one client only. Clients should not walk with bare feet. Plantar warts are more frequently associated with users of public showers, sports centres, and gymnasia(27,28).

q.If the integrity of the skin is accidentally breached, the area should be wiped with a skin antiseptic and covered with a loosely applied sterile gauze or a Band-Aid®. Constrictive adhesive dressings should not be applied to toes(29). A protocol should be developed for the daily monitoring and documenting of the wound healing process.

r.If used, blades on foot care instruments should be disposed of in appropriate sharps containers at the completion of each foot care treatment. Blades must not be re-used.

s.All health care workers providing foot care should be aware of protocols for the prevention of the transmission of bloodborne pathogens, e.g., recommendations for hepatitis B immunization and management of accidental exposure to blood(30-32).

Summary

These recommendations have been provided to assist health care providers in performing foot care with the intention of decreasing the transmission of pathogens and resulting infections. It is important that providers of foot care implement these recommendations into their daily practice so that infections associated with foot care can be prevented.

[liddibeth]

Thanks for this,

Here in NL, the healthcare authorities have set autoclaving as their standard.For private practitioners with their own businesses, I am wondering if the health canada standards are to ensure that the instruments are sterilized to destroy the germs & viruses then can be stored in a dininfected container, dry, until used? e.g sterilized with chemosterilants, rinsed and dried.

or if the chemosterilant is ised, does this have to be done just prior to use?

I would be gratefull for any help with this.

I did email HC, but got a reply to view the website and questions to the ARNNL di not give any guidance. A member the Provincial infection control group( not their official rep) for the Health care authorities just insisted that autoclaving is the standard.

I can afford a steam sterilizer, but not necessarily one that dries the packages, so any advice will be welcomed.