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On the wrong scent: banning fresh flowers from hospitals
Letters to the Editor about 40 tonnes/day. Of this, nearly 45–50% is infectious. Segregation of infectious wastes only takes place in approximately 30% of hospitals. At our centre, a 1359-bedded tertiary care referral centre in North India, 2 kg of waste is generated/patient/ day. Moreover, we recycle a lot of waste, especially paper and plastic which constitute approximately 25% of this waste (this being an industry in itself). Another issue to consider is whether intravenous (IV) disposable items such as IV fluid bottles pose any risk, and what is the need for their treatment? As sharps pose the maximum risk,5 we propose that instead of using so many containers, waste should be segregated into infectious and noninfectious. In the infectious category, we should have two colour codes: one for sharps and infectious disposable items such as catheters, tubings and collecting sets, and one for other waste, i.e. Categories 1, 2, 3 and 6 which go for incineration. Indigenously made washing-machine-like models that pulverize and chemically disinfect the sharp infectious waste under negative pressure with air discharge through HEPA filters would be highly economical and practical in our setting. The risk posed by anatomical waste also needs to be addressed. Here also, a washing-machine-like model that minces and digests the tissue with alkali can be used. However, such processes need to be carefully validated before being used routinely. Hydroclave technology may be more suitable for developing countries that are unable to afford gasplasma technology. The Government of India plans to set up common biomedical waste disposal facilities that will cater to a group of small healthcare units and save on capital investment. This option has been legally introduced in India (The Second Amendment of the Biomedical Waste Management and Handling Rules in June 2000). Although the introduction of gas-plasma technology may make the use of incinerators obsolete, India will be continuing to use incinerators until more advanced choices become economically feasible.
References 1. Rutala WA. Infectious waste—a growing problem. J Health Mater Manage 1988;6:62—65. 2. Blenkharn JI. Safe disposal and effective destruction of clinical wastes. J Hosp Infect 2005;60:295—297. 3. Pruss A, Cirouit E, Rushbrook P. Safe management of wastes from health-care activities. Geneva: World Health Organization; 1999.
527 4. Rao HVN. Disposal of hospital wastes in Bangalore and their impact on environment. Appropriate waste management technologies for developing countries. 3rd International Conference 22–25 February 1995, Nagpur, Technical papers vol. II. 5. Tan L, Hawk III JC, Sterling ML. Report of the Council on Scientific Affairs: preventing needlestick injuries in health care settings. Arch Intern Med 2001;161:929—936.
N. Taneja* M. Biswal Postgraduate Institute of Medical Education and Research Chandigarh, India E-mail address: [email protected] Available online 7 February 2006
*Corresponding author. Tel.: C91 172 2742717; fax: C91 172 2744401. Q 2005 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2005.09.026
On the wrong scent: banning fresh flowers from hospitals
Sir, I recently went to visit a friend in hospital with a bouquet of flowers. At reception, I was informed that flowers were banned to comply with health and safety and infection control guidelines. I understand that this approach is taken in some hospitals throughout the UK and Ireland. Whilst it is generally acknowledged that the evidence base for the control and prevention of healthcare-associated infection (HCAI) is often somewhat shallow, common sense and a practical approach can often help us in deciding what is in the best interests of the patient and likely to minimize HCAI, but not likely to cause undue distress or disruption to patients and staff. The literature is sparse with studies linking flowers and any adverse events in hospital. Possible dangers from having fresh flowers or potted plants near a patient in hospital include allergy, accidents arising from water splashing on the floor or cuts when vases or jugs are broken and, finally, infection. Manian reviewed 387 patients for new-onset rhinitis, which occurred in 12.7% of patients, and found that the presence of flowers in the immediate proximity of patients’ beds was highly associated with rhinitis.1
528 This is probably a much underestimated complication of fresh flowers. It may arise because a patient is in a confined space, i.e. a single room or bay, where air circulation may be minimal. If there are many flowers present, there may be a lot of pollen disseminated in the patient’s immediate vicinity. Accidents arising from spilled water or broken vases are just as likely to occur with crockery containing drinks or food as with vases or jugs containing fresh flowers. This is a catering and not an infection control issue. Where a patient receives many bouquets or floral arrangements and this causes an additional burden on nursing staff, healthcare assistants or other staff, the number of floral arrangements per patient can be restricted to a reasonable number. The potential burden of infection arising from fresh flowers or potted plants relates to organisms that may colonize the water, the soil associated with potted plants, or directly from the plants/flowers themselves, and subsequently acquired by the patient. LaCharity and McClure have reviewed the evidence for plants as vectors of infection in acute care.2 Although many potential pathogens have been isolated from flowers and water, e.g. Pseudomonas aeruginosa, there are no studies that convincingly link the presence of these organisms to infection in patients. However, many burns and haematology units do ban flowers despite the absence of a clear association linking organisms in flowers with HCAI. Isolation in high-efficiency particulate air filtered rooms without carpets, flowers or potted plants, and the banning of certain foods such as pepper have all been recommended to prevent fungal infections in immunocompromised patients.3 This is on the basis that haematology patients, especially those following bone marrow transplantation, are profoundly immunocompromised, and organisms in the environment that are normally harmless may represent a potential risk. Despite the absence of ‘concrete evidence’ linking flowers with infection, it is an understandable approach given the potentially severe implications of serious infection in this group of patients. However, for the vast majority of patients in hospitals or in other healthcare facilities, fresh flowers or potted plants do not represent a risk of infection. Possible allergy is more likely and should be considered. Fresh flowers often bring much
Letters to the Editor pleasure and joy to patients who are ill and who may be depressed. Indeed, for terminally ill patients, it may be their last chance to see flowers and inhale their scent. Furthermore, infection control teams and their institutions would be better advised to focus on those areas where there is clearly a potential risk of infection from the environment, e.g. Legionella spp. in water, Aspergillus spp. in building dust, and methicillin-resistant Staphylococcus aureus in poorly cleaned clinical areas. Until convincing evidence is produced to link fresh flowers or potted plants with HCAI, we should not ban them from hospitals. Before concluding, I must admit a prejudice; I am a keen if barely competent gardener, and the scent and sight of freshly cut flowers are great sources of pleasure!
References 1. Manian FA. New onset rhinitis symptoms among hospitalised patients: are flowers a culprit? Infect Control Hosp Epidemiol 2001;22:111—113. 2. LaCharity L, McClure ER. Are plants vectors for transmission of infection in acute care? Crit Care Nurs Clin N Am 2003;15: 119—124. 3. Johnson E, Gilmore M, Newman J, et al. Preventing fungal infections in immunocompromised patients. Br J Nurs 2000;9: 1154—1164.
H. Humphreys* Department of Clinical Microbiology, RCSI Education and Research Centre, Beaumont Hospital, Dublin 9, Ireland E-mail address: [email protected] Available online 31 January 2006
*Tel.: C353 1 8093710/3708; fax: C353 1 8093709. Q 2005 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2005.10.009
References 1. Rutala WA. Infectious waste—a growing problem. J Health Mater Manage 1988;6:62—65. 2. Blenkharn JI. Safe disposal and effective destruction of clinical wastes. J Hosp Infect 2005;60:295—297. 3. Pruss A, Cirouit E, Rushbrook P. Safe management of wastes from health-care activities. Geneva: World Health Organization; 1999.
527 4. Rao HVN. Disposal of hospital wastes in Bangalore and their impact on environment. Appropriate waste management technologies for developing countries. 3rd International Conference 22–25 February 1995, Nagpur, Technical papers vol. II. 5. Tan L, Hawk III JC, Sterling ML. Report of the Council on Scientific Affairs: preventing needlestick injuries in health care settings. Arch Intern Med 2001;161:929—936.
N. Taneja* M. Biswal Postgraduate Institute of Medical Education and Research Chandigarh, India E-mail address: [email protected] Available online 7 February 2006
*Corresponding author. Tel.: C91 172 2742717; fax: C91 172 2744401. Q 2005 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2005.09.026
On the wrong scent: banning fresh flowers from hospitals
Sir, I recently went to visit a friend in hospital with a bouquet of flowers. At reception, I was informed that flowers were banned to comply with health and safety and infection control guidelines. I understand that this approach is taken in some hospitals throughout the UK and Ireland. Whilst it is generally acknowledged that the evidence base for the control and prevention of healthcare-associated infection (HCAI) is often somewhat shallow, common sense and a practical approach can often help us in deciding what is in the best interests of the patient and likely to minimize HCAI, but not likely to cause undue distress or disruption to patients and staff. The literature is sparse with studies linking flowers and any adverse events in hospital. Possible dangers from having fresh flowers or potted plants near a patient in hospital include allergy, accidents arising from water splashing on the floor or cuts when vases or jugs are broken and, finally, infection. Manian reviewed 387 patients for new-onset rhinitis, which occurred in 12.7% of patients, and found that the presence of flowers in the immediate proximity of patients’ beds was highly associated with rhinitis.1
528 This is probably a much underestimated complication of fresh flowers. It may arise because a patient is in a confined space, i.e. a single room or bay, where air circulation may be minimal. If there are many flowers present, there may be a lot of pollen disseminated in the patient’s immediate vicinity. Accidents arising from spilled water or broken vases are just as likely to occur with crockery containing drinks or food as with vases or jugs containing fresh flowers. This is a catering and not an infection control issue. Where a patient receives many bouquets or floral arrangements and this causes an additional burden on nursing staff, healthcare assistants or other staff, the number of floral arrangements per patient can be restricted to a reasonable number. The potential burden of infection arising from fresh flowers or potted plants relates to organisms that may colonize the water, the soil associated with potted plants, or directly from the plants/flowers themselves, and subsequently acquired by the patient. LaCharity and McClure have reviewed the evidence for plants as vectors of infection in acute care.2 Although many potential pathogens have been isolated from flowers and water, e.g. Pseudomonas aeruginosa, there are no studies that convincingly link the presence of these organisms to infection in patients. However, many burns and haematology units do ban flowers despite the absence of a clear association linking organisms in flowers with HCAI. Isolation in high-efficiency particulate air filtered rooms without carpets, flowers or potted plants, and the banning of certain foods such as pepper have all been recommended to prevent fungal infections in immunocompromised patients.3 This is on the basis that haematology patients, especially those following bone marrow transplantation, are profoundly immunocompromised, and organisms in the environment that are normally harmless may represent a potential risk. Despite the absence of ‘concrete evidence’ linking flowers with infection, it is an understandable approach given the potentially severe implications of serious infection in this group of patients. However, for the vast majority of patients in hospitals or in other healthcare facilities, fresh flowers or potted plants do not represent a risk of infection. Possible allergy is more likely and should be considered. Fresh flowers often bring much
Letters to the Editor pleasure and joy to patients who are ill and who may be depressed. Indeed, for terminally ill patients, it may be their last chance to see flowers and inhale their scent. Furthermore, infection control teams and their institutions would be better advised to focus on those areas where there is clearly a potential risk of infection from the environment, e.g. Legionella spp. in water, Aspergillus spp. in building dust, and methicillin-resistant Staphylococcus aureus in poorly cleaned clinical areas. Until convincing evidence is produced to link fresh flowers or potted plants with HCAI, we should not ban them from hospitals. Before concluding, I must admit a prejudice; I am a keen if barely competent gardener, and the scent and sight of freshly cut flowers are great sources of pleasure!
References 1. Manian FA. New onset rhinitis symptoms among hospitalised patients: are flowers a culprit? Infect Control Hosp Epidemiol 2001;22:111—113. 2. LaCharity L, McClure ER. Are plants vectors for transmission of infection in acute care? Crit Care Nurs Clin N Am 2003;15: 119—124. 3. Johnson E, Gilmore M, Newman J, et al. Preventing fungal infections in immunocompromised patients. Br J Nurs 2000;9: 1154—1164.
H. Humphreys* Department of Clinical Microbiology, RCSI Education and Research Centre, Beaumont Hospital, Dublin 9, Ireland E-mail address: [email protected] Available online 31 January 2006
*Tel.: C353 1 8093710/3708; fax: C353 1 8093709. Q 2005 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2005.10.009