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What’s New in the
Patient Safety World
December 2020
Do You Have These
Infection Control Vulnerabilities?
A recent article from Health Europa has some valuable lessons in infection control for everyone. Karolinska University Hospital, affiliated with the world-renowned Karolinska Institute in Sweden, agreed to participate in a study to identify its key areas of risk and reduce the spread of infection Health Europa 2020. Researchers there did bacterial screenings and had 2 individuals (a doctor or nurse plus a second person with another background, such as an industrial designer or psychologist) do direct observation by following a patient through the ward for four hours.
Risk factors
identified by the observers could be specific to individual wards or common to
all the screened wards:
- Parents and siblings on pediatric wards could pose risk for spread
of infection
- Urinary catheters on the urology ward
- Incubators in the neonatology unit
- Breathing apparatus on the thoracic ward
- Immunocompromised or immunosuppressed patients on the hematology
ward
- Incorrect cleaning processes: cleaning staff did not use hand
sanitizer or change their gloves between tasks. Some furniture was
difficult to move, meaning that staff were unable or unwilling to clean
under or behind cumbersome items. Cleaning staff did not appear to have
been fully briefed as to which cleaning tasks were their responsibility
and which tasks fell under the purview of hospital staff, meaning some
surfaces may not have been cleaned at all by either team
- Lack of compliance with necessary infection control processes: staff
were observed wearing the same plastic apron while making beds, dressing
wounds, and feeding patients, leading to a heightened risk of infection
spread
- Widespread overuse, underuse, and misuse of protective gloves
- Patients, their family members and
caregivers were not informed about the importance of good hygiene or how
to establish an effective hygiene routine
- Surfaces in patients’ rooms were described as ‘packed’ with items:
patients’ personal toiletries, specimen bottles, medicine cups and
glasses. Rather than moving these items to clean – or, where relevant,
disposing of them – cleaners simply cleaned around them
- The structure of containers dispensing single-use plastic gloves and
aprons made it difficult for users to take a single apron or pair of
gloves without getting extras – users would simply push the extra items
back into the boxes, thus compounding the issue for the next user and
compromising the hygienic integrity of the aprons and gloves which had
been touched
- Textile draperies were rarely laundered
- Urinary catheter tubes were left on the floor
- Unprotected input ports contaminated with aggregate substances could
be placed near patients’ mouths or near babies’ nappies
- Staff operating patient transports were insufficiently trained on
basic hygiene and disinfection routines
Results of
bacteriologic screenings correlated inversely with the degree of compliance
with basic hygiene routines. Wards with the highest levels of compliance had
the lowest number of surface bacteria, while the highest number of bacteria
were found in the wards with the lowest rates of compliance.
So, what did the
hospital do? It switched its cleaning services contract to a new company and
mandated that its new cleaning contract staff must be trained in the
fundamentals of infection prevention and control, antibacterial measures, and
the necessary standards of hygiene within healthcare environments. It updated
cleaning routines and established checklists to ensure each cleaning task was
documented. Hospital staff were detailed to clean the ‘near-patient
environment’ – the equipment used near the patient and while caring for the
patient, such as the bed, bedside table, bedside lamp
and wheelchair. The hospital’s personnel and the cleaning operatives were
trained or retrained in basic infection control cleaning and disinfection processes.
The fabric drapes, which had represented a significant vector of infection,
were replaced with screens which were less bacteria-retentive and substantially
easier to clean.
The hospital
continued to take monthly culture samples at the sites in each ward which had
initially been identified as having a high bacterial load. A second
observational study conducted nine months after the first found that compliance
with basic clinical hygiene routines had risen by an average of 16 percentage
points. Hospital management found that making staff aware of the initial
screening results had rendered them more motivated to improve their compliance
with hygiene regulations, leading to positive trends in all the wards which
were observed.
Our bet is that
Karolinska University Hospital is not alone in having these infection control
vulnerabilities. In fact, most of them probably exist at many hospitals.
Combining the screening cultures with direct observational methods is likely to
help any hospital identify such risk factors. We’d
also bet that you’ll find even more if you extend your observation to following
patients on intrahospital transports.
References:
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