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A seasoned infection preventionist discusses issues that weigh on her mind.
By Deborah Paul-Cheadle, RN, BSN, BHCS, CIC
I have been an infection preventionist for 18 years. I am constantly thinking about the how, why and when, living and dreaming infection control, just like all of my co-preventionists. I am passionate about the objective of infection prevention. Currently, the press is full of the need to reduce healthcare-acquired infections (HAIs). I am not going to bother cutting and pasting the national HAI rates. We are already very familiar with them.
When I read my first "press release" on the nations goal to reduce HAIs, I thought, "Finally, maybe with political and administrative support, we can accomplish this goal."
Now, I push the delete button, and toss into the recycle bin when I see that published. Why? Well, I feel like Dr. Ignaz Semmelweis ... sometimes closer to the insane asylum than not! And I know I am not alone in these feelings.
I attended the Fifth International Decennial Conference on Healthcare-Acquired Infections held in Atlanta this year. It was worth every penny. I came back with exciting, cutting-edge processes that could help us eradicate HAIs. But you see, there is no money to implement these processes. And the stance of infectious disease physicians is, "This or that is not proven to reduce HAIs." Show me this data... data that takes much time and money to collect validate and publish.
I decided that approaching a state senator to request funding to help with obtaining funding and support in a study that could show whether eliminating organisms in the environment does impact HAIs. A flashing whiter-than-white smile embedded in a beautifully tanned face listened to my story and request, with pathetically feigned interest. When I had finished, he informed me that there were really no funds available for this. So what is the money funded by Congress to help hospitals eliminate HAIs really for?
It seems that we again are tasked with a monumental, possibly impossible, task to accomplish without financial support or the "scientific data" that proves a positive outcome. We are left with history. So, the premise of this diatribe is to explore some infection prevention history as it has shaped our current practice, and to explore the potential for using it to obtain support for the implementation of other approaches in the efforts for prevention of HAIs.
Case No. 1 is the cornerstone of infection prevention, and involves Dr. Ignaz Semmelweis and Dr. Oliver Wendell Holmes. Both physicians identified the link between unwashed hands and HAIs. Two hundred years later, we are still doing hand hygiene education and audits.
Case No. 2 is the cornerstone of epidemiology, John Snows pump handle. Once it was removed by a towns sheriff without the support of the town council or physicians, the cholera epidemic stopped.
Case No. 3 illustrates the need for every hospital to have an infection control nurse. A major hospital experienced a Staph aureus outbreak in a hospital nursery. Healthy infants died from healthcare-acquired Staph aureus infections Staph aureus carried to them on nurses hands.
Case No. 4 includes two cornerstones for surgical suite sterility. First, Joseph Lister, in a series of delicate and intricate experimental research projects, proved that when the atmospheric germs are absolutely excluded, no changes in exposed tissue occur: "In the interior of the grape, in the healthy blood, no such germs exist; crush the grape, wound the flesh, and expose them to the ordinary air, and then changes, either fermentative or putrefactive, run their course. But place the crushed fruit or the wounded animal under conditions which preclude the presence or destroy the life of the germ, and again no change takes place; the grape juice remains sweet and the wound clean." The application of these facts to surgical operations, in the able hands of Joseph Lister, has revolutionized surgical practice.
The second is the German surgeon, Gustav Neuber, who understood the need to protect more than the incision site to prevent infection. Neuber also asserted that the surgical environment must be protected as well. Neuber advocated for non-porous surfaces on walls and flooring that could be cleaned; a minimal amount of operating room furniture; shelves and tables constructed of glass and metal for improved sterility; plus heat sterilization (boiling) of instruments. In 1887 at the International Surgical Congress in Berlin, Neuber addressed his peers, condemning the wooden operating theater of old as being impossible to clean. He criticized the decorative wall hangings and curtains, and he said the corners where the walls and floors joined were dust catchers. He exposed direct contact hazards to the patient wooden tables and cracked flooring were labeled pus traps and he scorned the practice of performing one procedure after another without re-sterilizing the instruments.
Although Neuber made enemies, his message gained attention in the United States, and progressive American surgeons who traveled abroad brought home his revolutionary thinking.
Do we need to recreate what has historically been proven? If getting the surgical suite as "sterile as possible" is important, than I advocate that reducing environmental burden by having a patients room as "clean as possible" when they are admitted into the hospital is also important. If there is new technology that provides this, we could be negligent in not using it.
As infection preventionists, we should stand up and say, "We believe that the presence of biological load in a patients environment can increase the potential for the patients acquisition of pathogens present in this environmental burden, and that if it is possible to eradicate all organisms from the patients environment consistently and completely, that a major step forward could be made in patient safety in the prevention of healthcare-acquired infections, is plausible and reasonably conclusive."
Semmelweis, Snow, Nightingale, Lister and Neuber spoke up with plausible reasonably conclusive concepts, and revolutionized healthcare. They also made enemies amongst most of there colleagues. And the antagonist needed to die off before patients were safer in hospitals.
Thank you for your time reading this cathartic piece of mine. The institution at which I am employed has agreed to explore and invest in newer technologies for environmental disinfection. This is not a "community standard" for us. The other hospitals in our area are waiting for the "proof."
I cannot provide proof, and I may never be able to provide proof, but someone has to step out and do what makes perfect sense. Stay tuned. I will let you know any and all outcomes from this step out behind Semmelweis and that sheriff whose name I do not know.
Deborah Paul-Cheadle, RN, BSN, BHCS, CIC, is the lead infection preventionist at Metro Health Hospital, in Wyoming Mich. She has been involved in infection control and prevention for 18 years. In her prior nursing career, she spent 15 years in surgical/medical/trauma/pediatric and neonatal ICUs, as well as emergency nursing.