A Renewed Focus on the Basics, Stewardship, Collaboration & Tech Experimentation Among Top Strategies for Preventing & Knocking Out Infections
In the mid-1800s, a strange phenomenon gripped the maternity clinic at the Vienna General Hospital in Austria. The labor ward staffed by medical students suffered from a maternal mortality rate five times higher than that of the ward staffed by midwives.
Clinic Director Ignaz Semmelweis studied the two wards’ practices and realized that the medical students were going directly from dissecting corpses in the cadaver lab to delivering babies in operating rooms, spreading infection with every trip. After requiring the students to dip their hands in a chlorinated lime solution upon leaving the cadaver lab, he watched the mortality rates drop from nearly 20 percent to less than 2 percent. This early antiseptic practice earned Semmelweis the moniker of “savior of the mothers.”
It would be decades before Semmelweis’ hand-washing discovery gained widespread acceptance and adoption. Today his story offers two important lessons about infection prevention (IP). First, the most basic preventive measures are the most effective. And second, changing behavior can be among the most important—and challenging—aspects of successful IP. As infectious disease specialist Steven Spires, M.D., says, “It’s not the science of infection prevention that’s difficult, but rather rallying your fellow colleagues to believe the same things you believe.”
Back to the Basics
IP experts say simple, common-sense measures continue to see the most success. According to the World Health Organization and Centers for Disease Control and Prevention (CDC), hand-washing is the simplest, most inexpensive approach to reducing the risk of healthcare-associated infections (HAIs) and preventing the spread of antimicrobial resistance. Multiple studies have linked hand-washing to reduced Methicillin-resistant Staphylococcus aureus (MRSA) rates and ultimately to reduced rates of HAIs.
“I’ve learned that if you do the basic things well, such as proper hand hygiene and following clinical practice guidelines, infections will go down,” explains Spires, who is assistant professor of infectious diseases at Nashville, Tennessee-based Vanderbilt University School of Medicine, and hospital epidemiologist and physician chair of antimicrobial stewardship at Williamson Medical Center in Franklin, Tennessee.
Cheryl Herbert, RN, clinical service line director, supply chain at CHRISTUS Health, agrees. “We work hard on the fundamentals like washing hands and wearing protective barriers like gowns and gloves and changing them frequently,” she says.
Herbert is part of HealthTrust’s IP committee, a branch of the nursing clinical advisory board, which discusses evidence-based practices, new IP initiatives and common obstacles faced by clinicians throughout the membership. These experts also weigh-in on the efficacy of products in categories from hand hygiene to surface disinfectants to nasal sanitizers and share that feedback with HealthTrust.
“We depend on HealthTrust to help us identify cost-effective solutions, but they also provide a helpful forum for members to share our personal experiences with devices and products that work well and those that do not,” Herbert adds. “The clinical, evidence-based focus is essential.”
Exploring New Technology & Design
Some healthcare facilities are also investing in innovative strategies to bolster their IP programs. They’re exploring current trends such as:
• Ultraviolet (UV) light robots. These robots kill germs at a level above routine cleaning and disinfection, some of them emitting light in the deep UV range—the most useful for killing germs. These robots are used in facility rooms after patients with multidrug-resistant organisms are discharged in order to prevent transmission to new patients.
• Real-time location systems (RTLS). These systems integrate sensors with soap and sanitizer dispensers to detect how much they’re being used. When a clinician enters or exits a patient room, a smart hand hygiene dispenser with RTLS technology, or a regular dispenser retrofitted with this technology, can identify if that individual used the dispenser. RTLS can also be used as a tech detective to retrace the steps of infected people to see who they might have come into contact with and where.
• Harnessing data. To limit the spread of infections and identify trends within a facility, data mining programs harness the power of such information to identify and potentially isolate certain patients.
• Rapid diagnostics. Genetic markers are used to identify a specific bacterium within 24 hours and recognize antibiotic-resistance patterns. These tests allow facilities to treat patients for these infections much faster and limit the transmission to other patients.
• Design reconfiguration. According to a 2016 article in Healthcare Design magazine, some facilities are exploring ways environmental improvements can boost infection prevention. Partnering with healthcare engineering experts, facility leaders are looking at the way the soap and sanitizer dispensers are positioned (easily accessible and readily available) and how reprocessing departments are set up (adequate sink and counter space, appropriate airflow, and a clear separation of clean and dirty items). They’re also reducing the amount of porous and other hard-to-clean surfaces, redesigning bathrooms with splash zones to reduce water-related infections, and using functional space planning in areas such as the emergency department to limit the exposure of pathogens to other waiting patients.
• Reprocessing redux. While the widespread infections caused by improper cleaning of endoscopes led some facilities to be wary, many have rebuilt their confidence in reprocessing programs because of advanced sterilization equipment, automated cleaning processes, new guidelines and better training. The reprocessing departments in some larger hospitals have adopted new protocols that quarantine endoscopes after cleaning, then retest them for bacteria before they can be reused. Others are following up manual cleaning processes with a gas sterilization process.
“Visual inspection in sterile processing is important, but the industry is starting to use technology aids like borescopes to inspect other equipment like endoscopes, bronchoscopes and ureteroscopes to ensure these items are clean,” says infection prevention consultant Jacqueline Daley, HBSc, MLT, CIC, CSPDS, FAPIC.
Germ-killing technologies like these can make a difference, but Spires cautions that such measures should only be pursued after implementing IP fundamentals. “A lot of the new IP initiatives and gadgets are reserved for second-tier problems. Once you’ve done everything backed by evidence and data and are still having a problem, then you pay for technologies,” he adds.
Surveillance & Stewardship
Even new technologies, robust sterile processing procedures and a hospital wide dedication to evidence-based practice aren’t enough to prevent all HAIs. A holistic IP strategy also depends on the priority given to antibiotic and antimicrobial stewardship programs.
America’s overprescription of antibiotics has led to multidrug-resistant organisms and the rise of Clostridium difficile, or C. diff, infections in both hospitals and communities as a whole. “Because the germs are more difficult to kill, maintaining the environment and the equipment becomes more challenging as well,” Herbert explains.
Prescribing antibiotics judiciously both lessens pharmacy costs and improves patients’ overall resistance to infections. The goal of antibiotic stewardship, Spires explains, shouldn’t be to eliminate antibiotic use completely, but rather to “make sure antibiotics are used optimally, so that patients aren’t getting over-treated but are getting the right drug, at the right dose, for the right duration.”
For IP experts, a key part of their work involves monitoring for resistant organisms. “Infection preventionists do a lot of active surveillance,” Daley explains. “We work with pharmacists to mine the data and look at antibiotic use patterns and incidences of outbreaks. Infection prevention has a very critical and active role to play in the impact of overuse of antibiotics.”
Antibiotic stewardship can counterbalance the sluggish cycle of drug development. While it doesn’t take long for bacteria to develop drug resistance, new antibiotics can take years to hit the market between research, development and approval. “With the limited number of available drugs, it’s to our benefit to be smart about how we use them and not over-prescribe or overuse them,” Daley says.
Collaboration
As Semmelweis discovered, it’s not enough to know the science behind infection prevention; there must be buy-in from other healthcare practitioners. “You have to change some level of behavior,” Spires adds. “Just because it’s the right thing to do doesn’t mean everyone is going to do it.”
For instance, though most healthcare providers are aware of hand hygiene’s importance, high levels of compliance can be difficult to achieve. According to a study published in the Joint Commission’s January 2015 issue of Journal on Quality and Patient Safety, reasons for noncompliance include forgetfulness, busyness, inconvenience, hand irritation and ineffective education around the topic.
“With hand hygiene, we need to be hardwired so that we do it without even thinking about it,” Michael Edmond, M.D., MPH, professor of internal medicine in the division of infectious diseases at Virginia Commonwealth University, told Infectious Disease News. Edmond compared the process of washing hands to wearing seat belts, something that most people do now on a subconscious level. “When a behavior like that is hardwired, you can always sense when you didn’t do it because you start to feel uncomfortable. It’s a long process to get to that point.”
Direct monitoring, accountability policies and a culture of reinforcement will help train clinicians to get in the habit of washing their hands every time they walk in and out of patient rooms. IP habits also have to be augmented across hospital departments—something that requires commitment and collaboration.
Beyond encouraging individual behavioral changes, leaders must tap into their team’s collective wisdom when it comes to IP problem-solving. When his hospital encounters a problem like a surgical site infection outbreak, Spires forms a team of surgeons, nurses and stakeholders from the lab, pharmacy and materials department. “We all get to look at each other in the face, understand the problem and then come up with a solution together.”
Spires also underscores the importance of involving community healthcare workers in IP initiatives. “Even with an exceptional antimicrobial stewardship program, there are only so many things we can control in the hospital,” he says. “When you have people from the community harboring infections and bringing them into the hospital, then we’re only touching a fraction of the problem. We have to stop infections at the source.”
One way to do this, Spires says, is to develop a task force that includes community stakeholders—from local physicians to nursing home caregivers.
Collaboration is also essential on the purchasing side. “From an IP sourcing standpoint, HealthTrust really listens to the input from our clinical boards, especially our IP committee,” says Lindy Barry-Brown, RN, nursing portfolio director at HealthTrust. At one clinical board meeting, for example, UV phone disinfectants were under discussion. A member suggested a supplier, and another member shared that they had tried the product without results.
“We listen and learn as our members share their experiences with protocols and technologies, see what the clinical experts and research say, then formulate a strategy to get the membership what they need,” she says.
Through commitment and collaboration, hospitals can prevent infection and provide better care for patients. Daley adds, “That’s a lot of what everything in infection prevention boils down to: teamwork, collaboration and mutual respect.”
For a host of hand hygiene educational resources for healthcare professionals, visit www.cdc.gov/handhygiene/providers. The Association for Professionals in Infection Control and Epidemiology has helpful tools for IP programs on its website at apic.org. For information on HealthTrust’s portfolio of sterile processing tools and equipment, visit the member portal.
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