Infection prevention. It’s that Clark Kent working behind the scenes to save lives before Superman saves lives. Working behind the scenes is an infection prevention practitioner. Usually a nurse, he or she has been trained to prevent infections in healthcare facilities. Remembering what we were taught in nursing school and medical school (along with common sense) equips everyone with the tools to prevent unnecessary healthcare acquired illnesses and impacts lives in an unseen fashion. With each process that is forgotten during our daily working lives in healthcare, it is like unleashing billions of enemy bacteria to invade our patients. If only we could see with our naked eyes the influence our actions have over these viruses and bacteria when we sanitize our hands, scrub the hub, and vaccinate our patients. And if only we could plainly see the repercussions if we do not believe our influence is real and we do not take these actions.
Building an infection prevention program or maintaining and improving existing ones for healthcare organizations, including hospitals, clinics, surgery centers, and dental offices, is not glamorous. It is difficult to see the outcomes, but you have to know the saved lives are there. You can’t see the saved lives directly. They can only be seen when you have knowledge regarding the rationale for the efforts of the infection prevention practitioner. This is why it is so difficult to convince healthcare workers to keep infection prevention at the top of their minds all day long, day in and day out. The only way to accomplish this is with repetition, and when I say repetition, I mean in different, inventive ways. Infection prevention is not a fix it and forget it discipline. This rationale has been built through years of studies, trials, and tribulations. Learning from the successes and the mistakes of the past has made us better in the long run.
From the unwitting gentleman hoping to walk again with his new hip who develops a post-surgical infection, to the frail woman who develops Clostridium difficile after receiving antibiotics for a viral infection, and to the countless critically ill patients who develop other nosocomial infections, the breakdowns in process that result in failure are very similar. Lack of time and lack of adequate knowledge and preparation are almost always involved. In a perfect world where time and knowledge are unlimited for both the healthcare provider and for the patient, a well-thought out infection prevention plan can prevent up to and maybe more than 50% of these infections. What used to be infection control is now better termed infection prevention to delineate the real objective of our efforts at preventing rather than just simply controlling the spread of bacteria and viruses in our facilities.
Some facilities bristle at the oversight of governmental and non-governmental organizations and the data reporting that is required for this oversight. Sometimes this resistance is warranted or justified because the outcome of this oversight in the form of penalties can be burdensome economically for hospitals and nursing facilities. It is important to remember that this reporting is necessary in order to accumulate the data for the system as a whole to recognize these trends overall and microscopically by facility.
Undoubtedly, not all healthcare associated infections are preventable. The human body normally is a cesspool of bacteria that live symbiotically on every surface inside and outside. Therefore, when the skin meets the surgeon’s knife or when the patient lies in their hospital bed, there lies the potential for invasion by these bacteria. Up to 40 percent of people are colonized with methicillin resistant Staphylococcus aureus (MRSA) and 6-10% of people are colonized with Clostridium difficile. Hospitalized patients may be dehydrated which puts them at risk for urinary tract infections. They are in a weakened state and are inherently prone to developing pneumonia. Urinary catheters cannot be removed from every patient and the bacteria only need to travel a matter of inches to reach the bladder from the outside where billions of bacteria stand looking for a warmer, more moist, more habitable place to live than the dry skin.
The many interventions that have demonstrated minimizing these risks have been studied for centuries ever since Semmelweis demonstrated that washing hands decreased deaths from childbearing in the 1800s. While his theories, despite proven results, were discredited in Austria and throughout the rest of Europe, they were supported in his home country of Hungary and countless Hungarian women lived through childbirth because of his policies of washing hands with chlorine solution. Like Semmelweis, you will encounter opposition to your efforts in the name of energy, time, and cost. However, the fruits of your labor are palpable if you are observant.
One of the reasons Semmelweis’s theories were rejected was, at the time, it was a shock to physicians that they themselves could be part of the cause of a patient’s death. The same attitude plays out now in a subconscious level. This is because prevention involves spending energy, time, and money to prevent something that has not occurred yet. Spending that energy involves admission that actions without prevention are causing the morbidity or mortality of the patient. Our medical system is more geared toward action regarding something that has already occurred rather than prevention of a future unpredictable event. If we can show administrators the predictability of that event we will have won half the battle. There are many initiatives that can cause a slight turn in the tide toward prevention and it is with this tide that we need to continue educating.
As with any subject, misinformation is rampant. From our few providers who refuse influenza vaccination to the older providers who insist on placing patients on prophylactic antibiotics for urinary tract infections, you will see it frequently. The longer you work at this as your life’s work, the easier it will be to confidently redirect and inform even your most staunch critic. While the internet is our friend for informing patients, it can also be just as much foe for misinforming them. I hear on the internet almost daily someone who espouses either conspiracy theories or believes that science is almost never to be trusted.
I encourage every one of our readers to learn about the process of six sigma engineering. Six sigma is the brainchild of Jack Welch at General Electric and involves reducing errors to six standards of deviation. The real genius behind it involves critical reasoning and problem solving. It is really the basis of the scientific theory, that you can rely on reason and logic. Its goal is creating a system where human error is reduced to the lowest rate possible. DMAIC is the process. Define your problem, Measure the problem, Analyze the data for root causes, Improve the process, then Control the process with prevention.
Every perceived outbreak or infection prevention breakdown can be isolated using this system and a solution can be discovered. However, the most important process is the accumulation of data and the processing of it in a readable format. This needs to be compiled monthly and monitored daily. I have seen so many infection prevention practitioners holed up in their offices for 2 days before the infection prevention meeting, compiling their reports. If the data is available daily then it can be entered into the spreadsheet daily and monitored daily for trends. With daily monitoring, the cramming before the meeting is unnecessary.
One mistake that is often made in any analysis, is starting with what is believed to be the improvement, and building the analysis, measurement, and defining of the problem around that. For example, administrators of the lab want to remove a lab or change a lab because they have seen a single study or cost analysis. So they schedule a meeting to discuss it and build the analysis around the fact that they want to remove the lab and end up finding an excuse to remove it and either ignore or don’t look for the data that does not fit with their scheme.
Starting with the problem and finding the solution from there has been the format of infection prevention since the very start of the discipline. It was in the early to mid 1800’s that we saw the dawn of infection prevention, such as when John Snow discovered that by removing the pump handle from the Broad Street water pump, he was able to limit a cholera outbreak that was killing hundreds of London citizens. This water pump was located too close to untreated sewage. He was right about its impact and he saved thousands of lives due to his efforts. This fact that we have the power to protect ourselves from what previously was thought to be God’s wrath or bad humors has been a relatively recent belief in our history.
Fast forward to the present day. With our ever-increasing medical discoveries, just as we are improving surgical and pharmaceutical processes, so also are we improving the prevention processes that save lives. The cleaning processes and disinfection processes in our facilities have progressed to better chemicals and to the point of the almost-gold standard of ultraviolet light cleaning. Better and more effective vaccines are available every year. Better studies are able to enlighten us which interventions are most successful.
However, there are still 722,000 infections with 75,000 deaths due to preventable infections in the healthcare industry proving that our work is far from over. You will find ignorance and misinformation around every corner, even in what would seem like the most educated people. As a society, we have been taught there is an easy fix for everything that doesn’t take much effort and we use technology as a crutch. There is no simple solution to any problem.
To all of our nurses, doctors, and administration staff you need to listen to your infection prevention practitioner. Everyone will need to work smarter not harder because no amount of surveillance will change the culture of our hospitals without the even more challenging tasks of educating, convincing, and leading. You will also need to bring the best and most up to date infection prevention tools to the game. Computer surveillance tools , personal protective equipment, disinfection equipment and chemicals, and novel educational tools.
Some of our next stories will help educate our staff regarding each of these issues so that everyone can save lives.