Reducing the Risk of Cross-Contamination from Vaginal Exams
Cross-contamination is a primary concern for all clinics. The transmission of disease from patient to patient (or from doctor to patient) should be something we are all worried about. Some forms of cross-contamination can even be fatal, such as HIV or hepatitis B and C, although the transmission of STDs in this context is rare. Healthcare-associated infections, also called HAIs, are a major public health issue that seems to be getting worse over time.
The Cost of Infectious Agents
In March 2010, a hospital in Dallas may have exposed as many as 73 women to infectious agents because of improper sterilization of a reusable speculum. The incident at Parkland Memorial has become a notorious example of why hospitals have to be more careful. They also had problems with cross-contamination in the delivery room.
For vaginal exams, there is a particular risk because of the serious infections that can be involved. However, because the infection can also spread to sexual partners. One study showed that UTIs and related urinary complaints are more common during the first 7 weeks after a pap smear, with an increased risk of 11%. It also showed a marginal increase in instances of candidal and bacterial vaginitis. Increase in UTIs is believed to be caused by the physical insertion of speculum or fingers into the vagina. Another concern is that normal sterilization procedures don’t kill all strains of HPV, including HPV16, the most common strain to cause cancer. This means that paradoxically pap smears, if proper procedures are not followed, may cause a slight increase in cervical cancer risk.
What Causes Cross-Contamination
Human error or equipment failure causes most cross-contamination. The complexity of disinfecting equipment increases the risk of human error as there are many steps in which a mistake can be made. This is especially true if treating a lot of patients in a single day or if fatigued.
Ways to Reduce Cross-Contamination
There are three things used in a vaginal exam that can cause contamination: the speculum, light, and doctor’s hands. Here are some of the most important things that clinics can use to reduce cross-contamination during pelvic exams.
Use single-use speculums where possible. Reusable speculums have to be thoroughly cleaned, decontaminated, and sterilized between patients. There are risks every time. This may be due to a doctor not removing bodily fluids before sterilization. Further, equipment failure could cause this. The potential risk of residue from decontamination agents coming into contact with sensitive vaginal tissue can cause irritation. Single-use plastic speculums are generally safer because they eliminate these risks. However, after sterilization, they should never be reused. A few speculum types are only available in metal, and these need to be thoroughly disinfected between uses. Metal speculums should only be used for patients who require an unusual speculum type. This might be the case for women with a narrow vaginal opening, a history of trauma, or genital alterations.
Ensure that doctors, nurses, and other staff change gloves between patients, whether they are doing manual vaginal or ovary exams or not. They should also still follow best practices on handwashing, even when wearing gloves. Cross-contamination can occur between people who touch the same surface. Make sure to use a glove dispenser that is designed to reduce the risk of contaminating gloves when dispensed. Wash hands before donning gloves. Also, avoid latex gloves, as some patients may have an undiagnosed latex allergy. At the very least have the option for non-latex gloves as needed.
Never Reuse Products
Never reuse paper gowns or examination table covers without a paper cover. This might seem basic, but when in a hurry it can be easy not to remember to replace it.
Use the right cleaning supplies, and when using disinfectants make sure to follow the directions. Some disinfectants need to stay on the surface for as long as 10 minutes. Follow all directions when using benchtop sterilizers. Again, human error is the largest cause of cross-contamination.
If performing a rectovaginal exam, change gloves between examining the vagina and examining the anus. Cross-contamination in either direction can cause an infection.
Use the Correct Light Sources
If using a separate external light source, take care. These light sources, when handled carelessly, do not disinfect easily. Do not leave the light source on a countertop or in a drawer. The standard procedure is simply to wipe down with alcohol-based swabs between patients, which may not be enough. Using a disposable speculum with a built-in light source significantly reduces contamination risk. It also improves your visibility, allowing you to see changes to the vaginal wall more easily.
Improved training on pap smear and manual exam techniques may reduce the risk of introducing bacteria into the urethra and causing a UTI. As bimanual exams seem to be the most strongly associated, avoiding their use in lower-risk patients could significantly reduce the risk.
If using a vaginal probe for ultrasounds, then a new probe cover should be used for each patient and the probe should be disinfected to a high level between patients. There’s strong evidence that even brand new probe covers/condoms often have holes in them. There is also evidence that normal condoms are better for this than more expensive probe covers, resulting in significantly less leakage and infection.
Learn More About Reducing Cross-Contamination
In general, allow enough time for each patient to make room for hand washing and other routine infection prevention activity. When rushed, people make more mistakes. Thus, doctors should allow a longer visit than originally planned. Staff should also avoid working when fatigued or under the weather.
Avoiding cross-contamination when conducting pelvic exams is vital, especially given the risk of transmission of certain strains of HPV between patients. Doctors should follow all of the normal protocol for avoiding transmission of infections. Clinics should seriously consider the use of disposable speculums when possible, avoiding reusable devices for most patients and situations. To find out more about our reusable speculums with built-in LED light source, contact obp today.