That prestigious medical journal, The Wall Street Journal, recently had an article “Ten Steps to Preventing Infection in Hospitals”. It contained some traditional interventions (hand hygiene, use of checklists, use of all-inclusive kits for common procedures like central line insertion, use of good oral care to prevent VAP, daily chlorhexidine baths, state reporting of infection rates, and use of rapid testing to identify various pathogens. But, probably because the WSJ is primarily still a business journal, it highlighted several new promising technologies in infection control.
One was a solution with fluorescent markers that was used to demonstrate for cleaning staff the areas they did not clean well. Staff did a great job cleaning toilets but a poor job on door knobs, light switches, telephones, nurse call buttons, bedrails, etc. Showing the results to the cleaning crews significantly improved their performance.
Another is a special unit being developed at Johns Hopkins called SUDS. This is a shower-sized cubicle that fogs equipment with disinfectants and seems to do a better job at getting at hard-to-reach things like EKG wires.
And another is data mining and computer surveillance for infections, using algorithms plus data from hospital admission, discharge and transfer systems and laboratory data to identify patterns and identify opportunities to intervene earlier to prevent infections.
Simon, Stephanie. Ten Steps to Preventing Infection in Hospitals. Too many patients get sick in the very places that are supposed to heal them. The Wall Street Journal. October 27, 2009
Speaking of healthcare-associated infections, Joint Commission currently has a webinar on HAI’s available for free on its website. The webinar takes about an hour and spends a great deal of time explaining the National Patient Safety Goals (NPSG’s) related to HAI’s and what is expected of healthcare organizations for 2010 and how to meet the standards. It is a good review of what are considered evidence-based measures currently considered effective in prevention of various HAI’s. It also explains how expectations from the Infection Prevention and Control Chapter and Leadership Chapter impact on the survey process and the role infection prevention and control plays in high reliability organizations.
NPSG 7 Healthcare-Associated Infections From the Bedside to the C-Suite
The BMA this past summer published a useful position paper on approaches to reduce HAI’s.
They noted a 2005 Cochrane Review that showed restrictive interventions to improve antimicrobial prescribing (eg. formulary restrictions, authorization from infectious disease consultants, selective reporting of lab susceptibilities, etc.) are much more effective than “persuasive” interventions (like education, opinion leaders, audit and feedback, etc.). Strategies incorporated into structural changes (eg. CPOE) may have good potential to improve prescribing practices.
They provide sample guidelines from some UK healthcare trusts. These include practical (yet often neglected in the US) considerations such as always requiring the indication for the antimicrobial be clearly documented, record a stop date or review date, use narrow-spectrum drugs where appropriate, re-evaluate any necessary broad-spectrum coverage for de-escalating to narrow-spectrum coverage wihin 48 hours, and moving to oral therapy as soon as appropriate.
Of course they discuss hand hygiene and the many barriers to compliance (understaffing, poor design of facilities, confusing or impractical guidelines, insufficient commitment and enforcement by infection control personnel). They note that single interventions to improve hand hygience compliance are seldom successful so multifaceted approaches are necessary. They do acknowledge for hand hygiene the importance senior staff and physicians serving as role models but they stress structural changes such as easy access to alcohol-based hand rubs at points of care and improved design of those (eg. use of elbow-operated or no-touch taps). And the also talk about behavioral techniques and social marketing techniques in hand hygiene campaigns.
Though they acknowledge that educational efforts may help reduce indwelling device and catheter related infections, they stress high impact interventions such as use of care bundles like the IHI VAP prevention bundle. However, they stress the importance of ensuring that each element of the care bundle be well-defined and based on strong evidence. They also stress the importance of good sterile technique for insertion and ongoing management of such devices (including such things as ready access to sterile supplies).
Perhaps the biggest difference for recommendations in the UK compared to the US is related to dress codes. They stress a “bare below the elbows” dress code in which short sleeves are required and no wristwatches or jewellery are allowed. Neckties and traditional “white coats” are also discouraged and items like pens or scissors should not be kept in outside pockets. Many trusts also include provisions for changing uniforms before leaving facilities. However, they admit that the evidence base for these strict dress codes is soft and there remains a need to balance risk of microbial transmission against the need to maintain an appearance of professionalism.
Cleaning and environmental hygiene are discussed. They note that traditional cleaning protocols had always focused on things like floors and toilets and paid less attention to “near-patient high-touch” sites (eg. bed rails, bedside lockers, infusion pumps, door handles, switches, etc.). That focus needs to be reversed. (Hey! We just heard that this month in the Wall Street Journal! See our November 2009 What’s New in the Patient Safety World column “Ten Ways to Prevent Healthcare-Associated Infections”). They also point out that “deep cleaning” (eg. intense cleaning with a detergent followed by a steam cleaner) has not been shown to be effective.
They note there is a relationship between both bed occupancy and bed turnover (Wow! You mean there is a silver lining to the downturn in occupancy all our hospitals have seen during the economic downturn!). They note that a facility with a 90% occupancy rate could expect a 10.3% higher MRSA rate than one with an occupancy rate below 85%. Longer turnover intervals are negatively correlated with MRSA rates and may be even more important than the occupancy rates. High occupancy rates increase the proximity of patients to each other, make it more difficult to clean thoroughly when one occupant in a room remains after the other is discharged or transferred, and probably increase the movement of patients from one room to another. These have been factors in the trend toward single room designs for new hospitals (see our June 2009 What’s New in the Patient Safety World column “Are Single Hospital Rooms Controversial?”).
They have a good discussion of screening and isolation, noting that screening is only applicable where colonization is associated with an increased risk of transmission, where an effective rapid screening tool is available, and where the microorganism can be successfully eliminated following identification. They conclude that the evidence shows MRSA screening can be effective in certain hi-risk populations (eg. patients transferred from SNF’s, patients previously infected, etc.) or in hi-risk units (eg. ICU’s) but note that the evidence for universal screening is not yet strong. There are also downsides to isolation (see our March 25, 2008 Patient Safety Tip of the Week “More on MRSA” and also a recent editorial by Millar in the BMJ).
They also discuss the impact of performance targets that may compete with good infection control measures (eg. admission rates, wait times, LOS, financial, etc.) - obviously more ETTO’s (see our September 15, 2009 Patient Safety Tip of the Week “ETTO’s: Efficiency-Thoroughness Trade-Offs”).
Sections on the importance of management and leadership, teamworking, culture of safety, clinical governance, systems for tracking and providing audit/feedback, and staffing issues in prevention and control of hospital infection are also included.
They conclude with a section on issues for future research
British Medical Association.Tackling healthcare associated infections through effective policy action. 08 June 2009
Davey P, Brown E, Fenelon L, Finch R, Gould I, Hartman G, Holmes A, Ramsay C, Taylor E, Wilcox M, Wiffen PJ. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD003543. DOI: 10.1002/14651858.CD003543.pub2 (first published online: October 19. 2005)
Millar M. Should we screen low risk patients for meticillin resistant Staphylococcus aureus? BMJ 2009;339:b4035 (Published 8 October 2009)
Surgical fires made the headlines again recently with the death of an Illinois woman following a surgical fire.
ECRI has just released its “New Clinical Guide to Surgical Fire Prevention”. This appears in the October issue of their subscription journal Health Devices. Though the subscription is a bit pricey, facilities can purchase just one issue for about $300. This one is probably worth the price.
The 2009 key change in clinical practice is discontinuing the open delivery of 100% oxygen during procedures done during sedation. They discuss ways to minimize the concentration of oxygen being used in a variety of scenarios.
Surgical fires are uncommon enough for staff to be poorly trained at both prevention and response once one actually occurs. Yet they are frequent enough that most OR staff will encounter one or more in a lifetime. Only with meticulous steps to minimize fire risk, identification of fire risk for each individual case, training and drills will OR staff be prepared to do what it takes to prevent fires and know their roles in responding immediately if a fire occurs.
CBS11TV.com Illinois Woman Dies After Catching Fire During Surgery.
Sep 17, 2009 3:15 pm US/Central
ECRI. Surgical Fire Prevention. 2009 update.