Best Practices: New Ways to Observe Time-Tested Guidelines

Whether you are a veteran or are new to the field, it may be time to revisit the concept of infection prevention best practices. Its a term used frequently, but what exactly is a best practice these days, especially with the proliferation of legislative mandates, guidelines and recommendations impacting infection prevention programs? Essentially, a best practice is a management concept asserting there exists a specific technique, method, process, or activity that is considerably more effective at delivering a particular outcome than any other. Frequently, best practices are defined as the most efficient and effective method of accomplishing a task, based on repeatable procedures that have proven themselves over time for large numbers of individuals and entities. In its truest sense, a best practice is designed to be evolutionary, based upon current data and ongoing improvement.

The American Productivity and Quality Center (APQC) suggests three themes that resonate throughout successful benchmarking and best-practice transfer efforts:

  • Transfer is a people-to-people process; meaningful relationships precede sharing and transfer.

  • Learning and transfer is an interactive, ongoing, and dynamic process that cannot rest on a static body of knowledge.

  • Benchmarking stems from a personal and organizational willingness to learn. A vibrant sense of curiosity and a deep respect and desire for learning are the keys to success.1

Infection prevention is based on a number of principles and practices relating to the mechanics of the transmission of infectious disease, and despite how it is packaged by any number of healthcare quality-improvement organizations, it is always based on the cornerstones contained in Standard Precautions and Contact Precautions. These precautions have their origin in several key occurrences in infection control history.

In 1958, the Joint Commission and the American Hospital Association issued a statement advising that every accredited facility must have an infection control committee and a monitoring system as part of an official infection control program. In 1970, the Centers for Disease Control and Prevention (CDC) issued its guide to isolation techniques, updated in 1975, 1983 and 1996. In 1980 the CDC released Guidelines for the Prevention and Control of Nosocomial Infections. Expanded guidelines, called universal precautions, debuted in 1985, while body substance isolation guidelines were introduced in 1987. Standard Precautions were instituted in 1996 by the CDC.2

By the early 1980s, the use of the word of techniques had evolved to that of guidance as the CDC made increased use of infection prevention and control experts who served as consultants on the development of various guidelines. Bjerke3 notes, The momentum toward prudent practices was built on well documented modes of transmission espoused in epidemiological studies and on theoretical rationale. Bjerke adds that in 1987, the CDC introduced the concept of Universal Precautions (UP), stating blood and certain body fluids of all patients are considered potentially infectious for HIV, hepatitis B virus (HBV) and other bloodborne pathogens. The UP requirements espoused barrier techniques to block persons from bodily fluid exposure, reiterated the safe handling of sharp medical devices and supported vaccination against HBV. A clarification on UP emphasized that visible blood in body fluids required barrier protection when contact, handling and disposition of these fluids occurred. In 1987, another approach, Body Substance Isolation (BSI), advocated all moist body substances were potentially infectious and gloves should be worn for anticipated contact with these substances.3

Standard Precautions combine the major features of Universal Precautions (UP) and Body Substance Isolation (BSI) and are based on the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Standard Precautions include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered. These include: hand hygiene; use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure; and safe injection practices. Also, equipment or items in the patient environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents. The application of Standard Precautions during patient care is determined by the nature of the healthcare worker (HCW)/patient interaction and the extent of anticipated blood, body fluid, or pathogen exposure. Education and training on the principles and rationale for recommended practices are critical elements of Standard Precautions because they facilitate appropriate decision-making and promote adherence when HCWs are faced with new circumstances. Standard Precautions are also intended to protect patients by ensuring that healthcare personnel do not carry infectious agents to patients on their hands or via equipment used during patient care. Standard Precautions include:

  • Achieving optimum hand hygiene

  • Using personal protective equipment

  • Engaging in the safe handling and disposal of sharps

  • Engaging in the safe handling and disposal of clinical waste

  • Managing blood and bodily fluids

  • Decontaminating medical equipment and devices

  • Achieving and maintaining a clean clinical environment

  • Engaging in the appropriate use of indwelling devices

  • Managing accidents and adverse events

  • Establishing and maintaining good communication with other HCWs, patients and visitors

  • Providing quality education and training to HCWs

There are three categories of Transmission-Based Precautions: Contact Precautions, Droplet Precautions, and Airborne Precautions. Transmission- Based Precautions are used when the route(s) of transmission is (are) not completely interrupted using Standard Precautions alone. For some diseases that have multiple routes of transmission (e.g., SARS), more than one Transmission-Based Precautions category may be used. When used either singly or in combination, they are always used in addition to Standard Precautions. When Transmission-Based Precautions are indicated, efforts must be made to counteract possible adverse effects on patients (i.e., anxiety and other mood disturbances, perceptions of stigma, reduced contact with clinical staff, and increases in preventable adverse events) in order to improve acceptance by the patients and adherence by healthcare personnel.

Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patients environment. The application of Contact Precautions for patients infected or colonized with MDROs is described in the CDCs 2006 MDRO guideline. Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission. HCWs caring for patients on Contact Precautions should wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patients environment. Donning personal protective equipment (PPE) before room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., VRE, C. difficile and noroviruses).

Because all HCWs could use a little help when it comes to observing the myriad guidelines and recommendations related to preventing and controlling infections, healthcare- product manufacturers are creating comprehensive education and training tools and materials designed to strengthen knowledge and facilitate in-services for busy infection control practitioners (ICPs).

Medline Industries has just introduced a new educational program for its customers that is designed to provide complete training in key areas of infection prevention such as hand hygiene and surgical site infections (SSIs), according to Alecia Cooper, RN, CNOR, an operating room nurse for more than 20 years and vice president of clinical services. Cooper says that in a year when Medicare will no longer reimburse hospitals for care relating to three infections urinary tract infections (UTIs), certain SSIs (primarily mediastinitis after open-heart surgery), and bloodstream infections education is tantamount to patient and HCW safety and to the fiscal health of institutions.

The CDC tells us that hand hygiene is the basis of all infection prevention, Cooper says. So if hospitals will not be reimbursed for care related to infections starting this October, it is our belief that healthcare facilities will be looking for solutions to prevent these never-events from happening because they dont want to lose reimbursement. We looked at the associated costs for each of these infections and they can be staggering for hospitals. Hand hygiene is the No. 1 defense against HAIs, and because HCW compliance is averaging just around 40 percent, we thought it would be a good place to start with our educational program. Subsequent modules from Medline will address SSIs and bloodstream infections, among other HAIs.

Cooper says that Medline brought in a group of infection prevention specialists as its advisory board, supplemented by an additional group of perioperative experts. We asked our experts what the most perfect hand hygiene program would look like, Cooper explains. They wanted us to address the barriers to compliance, including HCWs skin condition, lack of staff education, HCWs lack of time and big workloads, the location of the sinks, and the lack of dispensers and supplies. They also mentioned that role modeling by senior healthcare professionals was important, as was the ability to measure compliance and having a method to validate this compliance. They said

The CDC tells us that hand hygiene is the basis of all infection prevention. accountability was poor, there was a lack of discipline on the floor and few to no consequences for a lack of hand hygiene compliance; they also mentioned many HCWs used the same products for years and that they needed a change to spark interest in hand hygiene again. And finally, they wanted us to address issues relating to attitudes toward hand hygiene, an institutions culture and behavioral modification needed to remove all barriers to proper hand hygiene.

Cooper says all of the barriers to hand hygiene compliance were boiled down to three categories lack of education, behavioral challenges, and poor skin condition and were addressed in the Medline hand hygiene module. The program includes the Healthy Hands product bundle three products bundled and tested for ingredient/materials compatibility that include an alcohol hand antiseptic, a skin repair cream and aloe vera-coated exam gloves. With the products we can eliminate poor skin condition, and the lack of education and behavioral challenges are addressed by the educational program as well as a system of rewards, motivation and competency validation, Cooper explains. Six major components, including education and training materials as well as an infection prevention cost calculator, are packaged in a manual. This training manual has all of the components, including information on evidence-based interventions, that serve as the meat of the program for any kind of staff training, Cooper adds. We have developed eight PowerPoint presentations on a CD representing four total hours of training that can be done in 15-minute segments or as 30-minute lunch and learn sessions, or hour-long classes good for two continuing education credits.

The module provides for competency validation through use of a visual-cue product that helps HCWs learn how to sanitize their hands properly, and after participants have completed the course, they receive a certificate and a professional-looking pin bearing the programs logo. Its a great motivational tool, Cooper says. Everyone will want one and wont want to be the only one without one. It demonstrates to others their commitment to good hand hygiene practices.

Especially appealing to ICPs is the modules cost calculator. ICPs say they have to justify to their administrators everything they need and every dollar they want to spend, so we are able to give them a tool that helps in this process, Cooper says. We include a brochure that compares the cost of an infection to the cost of preventing an infection. Inside is a CD containing an Excel spreadsheet where they log their admissions, number of beds, number of infections by category, increased costs from length of stay and other data and it will compare them to the national averages. Then they put in their budget, and it will tell them how many infections they need to reduce to make their program self-funding. We also made it into a 12-month program, so if they plug in their data, it will chart graphically the number of infections and what the incremental cost of each of those infections is.

Cooper says the modules are designed to ease the workload of harried ICPs and deliver tools that can empower their infection prevention efforts. What they are doing now is obviously not working as well as it should because according to the statistics, infection rates continue to rise, Cooper says. So if somethings not working they should consider adopting a comprehensive program and try not to cut corners. You cant spend so much at a hospital that you put yourself out of business, but you have to do things for your staff that make them feel important. And its nice if you can supply products that make the staff feel better, including gloves that are therapeutic, or hand hygiene products with emollients. Caring for them in turn helps them care for their patients and boosts compliance.

Cooper says she believes best practices today are being driven in part of the desire for improved transparency in healthcare. Infection rate data is going to be increasingly available, so you can compare numbers and drill down regarding what other hospitals did," she says. "That can become a best practice of sorts. Another way to determine a best practice is to adopt bundles of interventions, putting practices, processes and products together, and then measuring the results. Best practices are whatever processes and programs that give you the best results that can be measured.

Kimberly-Clark Health Care is providing its customers with a new 22- minute DVD called MRSA: Time for Action, which features the expert perspectives of William Jarvis, MD, of Jason & Jarvis Associates and formerly of the CDC, and Marie E. Fornof, RN, BSN, CIC, of Denver Health. The video features Jarvis and Fornof sharing their insights as to why multidrug-resistant organisms (MDROs) have prevailed in the hospital setting and why they are becoming more prevalent in the community. Its a journey that takes viewers through the imperatives of MDRO control and prevention, especially considering that approximately 60 percent of HAIs are MRSA infections, according to Jarvis.

The Kimberly-Clark video addresses a number of pertinent topics, including factors contributing to the rise of MRSA and its prevalence; the differences between healthcare-associated and community-associated infections, as well as the differences between infection and colonization; risk factors for MRSA transmission; comprehensive control and prevention strategies; the importance of observing Contact Precautions; and the value of rapid MRSA testing.

The training video is facilitated by Kimberly-Clark sales representatives and is available to customers and non-customers. It is accompanied by a study guide that must be used in conjunction with the video for credit which has been approved by the American Association of Critical Care Nurses (AACN) for one contact hour. Upon completion of the study guide, healthcare professionals will be able to demonstrate awareness of the growing prevalence of healthcare-associated MRSA (HA-MRSA) and community-acquired MRSA (CA-MRSA), discuss the risk factors associated with MRSA, identify the reservoirs for and the modes of MRSA transmission, and discuss strategies to identify and reduce or eliminate MRSA transmission. The materials will be available online around mid-February.

Kimberly-Clark is always working to deliver clinical solutions and educational resources that caregivers can depend on to prevent, diagnose and manage a wide variety of healthcare-associated infections, says Suzanne Pear, RN, PhD, CIC, associate director for infection prevention practices at Kimberly-Clark Health Care. K-C hopes that the MRSA guide will help educate hospital professionals of the growing prevalence of HA-MRSA and CA-MRSA and provide them strategies to identify and reduce the transmission of MRSA in their own facility.


1. American Productivity and Quality Center.

2. Best Practices: Evidence-Based Nursing Procedures. Springhouse, Lippincott Williams& Wilkins. 2006.

3. Bjerke NB. Standard Precautions. Infection Control Today. August 2002.