Maintaining Industry Standards Sensibly
By Kathy Dix
Standard precautions may seem just that standard but oftentimes it is difficult for healthcare workers (HCWs) to follow these guidelines amid the hustle and bustle of a busy medical facility. However, taking a common-sense approach can dramatically improve infection rates, even among the most vulnerable patients.
Judene Bartley, MS, MPH, CIC, is a member of the Communications Task Force for the Association for Professionals in Infection Control and Epidemiology (APIC); she is also the vice president of Epidemiology Consulting Services, Inc., in Beverly Hills, Mich.
Although there has been much controversy over personal protective equipment (PPE) and what is overkill versus what is insufficient for the HCW and the patients protection, Bartley points out that PPE is irrelevant if essentials like handwashing are neglected.
I think there are frequently people who give a quick wave to standard precautions and then go onto adding more PPE, instead of thinking hard about why we emphasize standard precautions, because those are things we should be doing all the time, Bartley says. Its more a question of verifying that people are carrying out standard precautions correctly, before they start adding on gowns, gloves, and other equipment. Hand hygiene, with the addition of the alcohol-based hand rubs, may have helped, so it has increased the attention to hand hygiene.
I think that too frequently, we tend to focus on a particular issue, for example, respiratory protection, which has gotten a lot of attention, instead of thinking of what were doing and what were touching. Theres this disconnect between the fact that we know most things are spread by contact, and yet by not doing the right thing, we could be just as problematic in transmission, because you can transmit things with dirty gloves.
You emphasize basic standard precautions, and ensure that people really understand those, and if theres going to be a step up, perhaps the thing to do is some prevalence study or some observation to see if people know and understand what basic precautions are, she adds. For me, the standard precautions are the hand hygiene, the use of alcohol gel, the use of gloves when youre going to contact body fluids if its wet, use gloves and gowns if you think youre going to soil your clothing, and even the use of a mask if you think there is some opportunity for being really close to the patient. Theres a judgment call that one makes in terms of PPE selection.
Basic precautions have a dual function thinking not only of protecting yourself as the caregiver but also the patient. When you get to some specific infection that may call for contact precautions, the difference between standard and contact precautions is that youre putting on the gown and gloves as you walk in, because you dont want to take the chance that you will touch something with your hands or with your clothing and inadvertently transmit pathogens to the patient ... but I think theres still an emphasis on contact. And you must remove PPE when you leave the room, Bartley observes.
Using a private room for contact precautions when youre doing that means limiting the things that could be contaminated by that particular organism. It limits the transmission so when the patient leaves or when the cleaning is done, youre sure the transmission was confined to that room. But all of that depends on if people are aware of what theyve been touching and contacting related to the patients. Its a thoughtful process that is important in the training of standard and contact precautions.
Bartley points out that she is not trying to underestimate the importance of contact precautions, but adds that there are some basic precautions that should be happening all the time but unfortunately, due to time, or inattention, frequently this is not happening.
Years ago at my hospital, there was a concern for transmission of an organism; as I recall, it may have been Serratia, and we may have had an outbreak at some point. There was concern about whether we were really needed to put everybody in what they called full isolation, which was strict isolation at the time. They wanted signs up, so I put up a sign that said, Standard precautions on every single door on the ICU, trying to make the point that if you need a sign as a reminder, lets start with what that really means. You have to find different ways of reminding staff of what they need to do. Its a constant challenge to find new ways, attractive ways just to get peoples attention, she relates.
Bartley refers to the United States Department of Health and Human Services (HHS) pandemic influenza plan, which includes both strategy and public health guidance for state and local partners. (For details on these recommendations, visit www.hhs.gov/pandemicflu/plan/pdf/S04.pdf.1) In the section relating to recommendations for infection control in healthcare settings, the document states first that contact should be limited between nonessential personnel (or visitors) and the infected patient. Not only that, but they also recommend, Protect persons caring for influenza patients in healthcare settings from contact with the pandemic influenza virus. Persons who must be in contact should:
- Wear a surgical or procedure mask for close contact with infectious patients.
- Use contact and airborne precautions, including the use of N95 respirators, when appropriate.
- Wear gloves (gown if necessary) for contact with respiratory secretions.
- Perform hand hygiene after contact with infectious patients.
A footnote defines masks as follows: Surgical masks come in two basic types: one type is affixed to the head with two ties, conforms to the face with the aid of a flexible adjustment for the nose bridge, and may be flat/pleated or duck-billed in shape. The second type of surgical mask is pre-molded, adheres to the head with a single elastic and has a flexible adjustment for the nose bridge. Procedure masks are flat/pleated and affix to the head with ear loops. All masks have some degree of fluid resistance, but those approved as surgical masks must meet specified standards for protection from penetration of blood and body fluids.
When you get down to what should be the PPE, theyre basically talking masks, Bartley confirms. Basically its transmitted by contact, and while theres some concern about small particle aerosols, that is all very speculative. Its based on some animal studies. Bottom line, it says to isolate if you can, but protect persons caring for influenza in healthcare settings and wear a surgical procedure mask. They reference the use of N95s when appropriate, and this refers to when you might have someone you are intubating, and producing a fine aerosol. That same language was clarified by the World Health Organization; they published a guideline for pandemic influenza last March, and they recently updated it to say exactly the same thing. If youre talking about being within three feet or so of an infected patient, you would use a surgical or procedure mask. Either is protective, and I think that brings us back to a common sense approach.
Bartley references a long-term controversy regarding N95 masks and tubercule bacilli, which, she says, comes down to almost the same issue as influenza. Were talking about how we are exposed to patient secretions. Laboratory studies, she says, cannot assess what actually happens during patient care. When youre taking care of a patient, youre not getting a perfect bolus of so many particles coming at you at a certain predictable concentration; when a patient is coughing, you are getting sputum. Most of the time, that can be controlled with a tissue if the person is able, and if theyre not, then the worker wears the mask, because theyre really protecting themselves against a spray. For tuberculosis (TB), the same thing still has to happen. When theyre coughing up tubercule bacilli, they still have to form and dry and become a spore and become airborne before you can have this long distance transfer of tubercule bacilli that could cause problems later. If you capture TB at the beginning, if you have someone who is active, if theyre able to control their secretions with disposable tissues, theyve really reduced the risk that theres going to be tubercule bacilli that can turn into spores that can transfer. Thats why for almost any organism, including TB, when youre dealing with real patients in the real world, in a real-life hospital situation, what youre really trying to do is control the source of the infection as close to the source as possible in this case, the patients mouth. When youre wearing a mask, youre protecting yourself from spray. Diseases transmitted via the respiratory route do not necessarily require eye protection, but other secretions may have pathogens that can transmit to the eye. It makes perfect sense to me that for influenza, when were talking about large droplets transmitted within three feet, we would protect your mouth and nose from spray coming from a patient who is coughing heavily.
There are differences between TB and influenza, she allows, but that does not mean that protection should be compromised. It does make a difference when were talking about a true airborne disease like TB, vs. influenza or other types of diseases transmitted by large droplets, she says. Even SARS was primarily large droplets. One of the few instances that still has people concerned comes back to the fact that they were looking closely at when patients are being intubated or suctioned or theres something aerosolized during a nebulizer treatment with a fine spray. The difficulty is that they were using things like a powered air purifying respirator (PAPR). The question is, how much did people touch?
Lets say your hands were covered with gloves, but you didnt take the gloves off, so they may have been contaminated with secretions. But now youre touching the PAPR, and who knows what you might have touched in the process. When youre in the room with a patient, theres a lot of moisture. You have to have something moist that will hold the secretions long enough for the organism to survive. Thats one plus of wearing a mask, because youre less likely to touch your nose or your mouth, but that doesnt mean your hands are not contaminated from the patient. Pay attention to what youve touched, and when you remove your gloves, use hand hygiene, and perhaps reglove. The problem with PAPRs is that theyre reusable, and you dont know how well people clean their hands. When they touch them, then touch the patient, that could be the route for the organism to enter through a mucous membrane.
Although much fuss has been made over community-acquired methicillin-resistant staphylococcus aureus (CA-MRSA), Bartley points out that CA-MRSA and hospital-acquired MRSA do not act differently from normal Staphylococcus aureus in terms of how they are killed in the environment; the only difference between these resistant and non-resistant types is how they are killed within the patient. So the organisms are transmitted in the same way, she points out.
We expect the transmission to be the same, so whether were talking about staph or some other organisms such as Pseudomonas these are all transmitted by touch. When there are things transmitted by touch, if there is moisture on your hands or on something youre touching, they tend to survive longer than if theyre on dry, hard stainless steel. Most of them are easily killed by hot water, soap, certainly alcohol, but we forget what weve touched after weve touched secretions. Thats my own pet peeve that people think in terms of protecting themselves with gowns and gloves, but what they have done in the process is use those dirty gloves to contaminate other things that someone else thinks is clean.
That, Bartley says, brings her full circle, back to the hand hygiene. If you think youve soiled your hands or gloves when you go on to do another procedure for a patient, remove those gloves, clean your hands, then put on a clean pair of gloves. There are many of us who think that we could prevent a tremendous amount of transmission if we really used hand hygiene and gloves almost universally and carefully when we handled any kind of patient secretion, whether its sputum, a wound, or urine.
Facilities that already have a good handle on hand hygiene and standard precautions have another challenge, she says. If you have a facility looking to improve, and theyve already done well with their standard precautions, it allows you to focus more closely on what it takes to get you to a zero infection rate. Thats where I think things are exciting today if we can take one more step. In Michigan, weve had a project called the Keystone ICU project. We have looked at infection prevention in every intensive care unit (ICU) in every hospital across the state. We have the data from CDC saying that if we do certain things, we can prevent infection. We looked at bloodstream infections, caused by many different kinds of organisms, and said, Lets bundle all these precautions together. They developed a checklist for putting in a catheter. You should wash your hands, put on gloves, put a full drape on the patient, prep the skin. So what they have is a culture shift in the ICU, where everyone on the team agrees that everyone must do all these things all the time. Its not just the physician who gets to make the call; anybody on the team can call and say I didnt see you wash your hands and we cant move ahead until you do. Almost 55 percent of the hospitals have gone almost six months without a single bloodstream infection. I think its mind-blowing, because as much as we thought some things were not as preventable as others, it shows that if you do all the right things, all the time, you can achieve tremendous infection prevention.
Hand hygiene is the first step, she notes. The next step is ensuring that patients do not get infections when they have medical devices inserted. Whether its an IV catheter, a Foley catheter, a chest tube, thats where we put little tracks going into the patient that permit organisms to get in, she adds. Here, they did everything right, they tracked it, and everybody has agreed to do it, and when they did it, this is what happened. Now theyre doing the same thing with ventilator-associated pneumonia. They are bundling how the patients head should be elevated, etc., and if someone misses a step, theyre called out. It makes for tremendous team spirit, for tremendous morale. If you can imagine, across the entire state, 120 ICUs having this kind of success in preventing infection, you can bet people are excited. To me, instead of chasing after trying to put on PPE Im not saying theres anything wrong with protective clothing, but its the issue of knowing what youre doing when you do it, paying attention that youre putting the glove on and taking it off at the right time, knowing what youve touched, what youve done.
Bartley adds that HCWs should cement a ritual of hand hygiene as a matter of respect, and as a habit. I would love to see healthcare workers hitting that alcohol and rubbing their hands so the patient can see them doing that when they walk into the room, she hopes. If that were a universal approach across the board, I bet we would reduce transmission of contact organisms tremendously. Often were so much in a hurry, thats when the mistakes occur and it doesnt take but one chance to ruin it for a patient.
Note: The Healthcare Infection Control Practices Advisory Committee (HICPAC) has drafted guidelines for isolation precautions that were closed for comment in February 2005. It is APICs understanding that the guidelines will be available sometime early in 2006, according to David Love, director of communications at APIC.