Are Hospitals in Canada doing enough to reduce infections?

Are Hospitals in Canada doing enough to reduce infections?

 

The short answer:  No!

 

According to the Public Health Agency of Canada (PHAC) :

-  More than 200,000 patients get infections every year while receiving healthcare in Canada; more than 8,000 of these patients die as a result.

-  About 80% of common infections are spread by healthcare workers, patients and visitors.

(http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2013/infections-eng.php )

There is a culture of resistance to do anything that is not absolutely required by law or government/professional standards.

 

There exists in healthcare guidelines for practice that are referred to as “best practice”.  While these can come from variety of professional and/or government organizations, and can vary among them – a general consensus of a minimum standard can be obtained by a meta-analysis of these guidelines as well as current research from other sources.

Canadian sources of interprofessional best practice guidelines for reducing hospital-acquired infections come from Safer Healthcare Now! (SHN) and the Public Health Agency of Canada (PHAC) – with Safer Healthcare Now guidelines currently being updated more frequency than the Public Health Agency of Canada.  But other sources from the United States, the UK, and elsewhere also need to be considered.

Other sources outside of Canada include the Centers for Disease Control and Prevention (CDC) in the United States, the SHEA/IDSA “Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals” from the United States, the Department of Health in the UK, and the World Health Organization (WHO).

Links for all the aforementioned organizations (and the compendium) will be available in the “Links” section at the end of this blog post.

One of the key problems which prevents hospitals from getting where they need to be is the erroneous idea that something that is a “guideline” does not carry the same weight as a law or standard – and therefore does not need to be followed.  This is nothing but a cop-out, a shirking of responsibility, and a negligent failure to follow a consensus of best practices that are most likely to lead to positive patient outcomes.  Hospitals who fail to follow best practices need be called out by patients, families, and employees – in the hope that improvement will follow.  Patients and family members of patients need to inquire if best practices are being followed before a procedure and during the hospital stay.

I will break down where hospitals fall short into two categories:  1)  Failures to follow best practices that can lead to hospital-acquired infections, and  2)  Other breaches in care that can contribute to hospital-acquired infections.

I many cases, I will try to separate each into a general explanation that laypersons can understand, followed by a more technical explanation for healthcare providers (if necessary).

I will also further break each into:  1)  Where hospitals fail, and  2)  What you can do about it.

Not all hospitals fail on every point.  Sadly some probably do.  Those hospitals that are doing well on some of the following issues still have plenty of room for improvement.

 

1)  Failures to follow best practices that can lead to hospital-acquired infections:

 

a)  Your first line of defense against infection is intact skin.  Any procedure performed in a hospital that is going to puncture or cut into your skin increases your risk of infection.  That is why there are best practices that recommend which antiseptic solutions should be used to clean your skin prior to such a procedure to reduce the likelihood of infection.

Best practice and current literature supports the use of a combined solution of 70% isopropyl alcohol (70% IPA) and another antiseptic.  The most recommended second antiseptic is 2% chlorhexidine gluconate (CHG) – as there is a residual antimicrobial (antiseptic) action after it dries that is not seen in 70% IPA or other antiseptics such a povidone-iodine, and there is a much lower incidence of allergic reactions/hypersensitivity to CHG (especially when dye-free formulations are used).  The advantage of using a combined solution of 70% IPA with 2%CHG is the combined strength of both antiseptics as they dry, and the residual antimicrobial action of CHG after it dries.

Where hospitals fail:

- using only a single antiseptic solution (i.e. 70% IPA without 2%CHG  or  2%CHG without 70% IPA).

-  using the proper solution (i.e. 70% IPA / 2%CHG) for some procedures and in some departments (i.e. procedures in the Operating Room) but not for other procedure or in other departments.  [Technical stuff:]  Is the correct solution being used consistently for ALL invasive procedures, and in ALL departments?  Is the correct solution being used for central-line insertions (CVLs), lumbar punctures (aka “spinal taps”), incision and drainage (I&D), implanted devices, arterial lines, cardiac catheterizations, peripheral intravenous insertion, phlebotomy, etc.?   Is the correct solution being consistently used across the institution such as in the Intensive Care Unit (ICU), Cardiac Care Unit (CCU), Emergency Department (ED), Interventional Radiology, Dialysis clinics, Oncology clinics, outpatient clinics, Medical/Surgical floors, etc.?  (There may be a few…very few….exceptions:  70% IPA may be contraindicated in certain procedures such as those involving the oral or nasal mucosa, cornea, inner ear, or meninges.)

- not using the combined 70%IPA/CHG solution for all aspects of care and utilization of central (and peripheral) intravenous lines.  [Technical stuff]:  This would include dressing changes/site care as well as lumen access (scrubbing saline locks, central line caps, and injection ports) in intravenous lines. 

-  (Sidebar:  Swabsticks (rather than the tiny pads) should be used for site care prior to and after insertion of a CVL – to keep your hands away from the site.)

What you can do:

- Before your surgery is booked, or before a procedure is being performed, ask the hospital to confirm that the proper solution (i.e. 70%IPA / 2%CHG) is being utilized.  Ask specifically.   Single product antiseptics (i.e. plain 70%IPA or plain CHG solutions) should not be used UNLESS there is a medical reason (i.e. certain procedures in your mouth, eyes, nose, ears or brain may not use 70%IPA).  It is your health.  You have the right to demand that best practice be followed.

- If you develop an infection from an invasive procedure, ask the hospital to demonstrate that they follow best practices and only use the proper solutions consistently throughout their organization – and that they used them on you or your family member.  Most hospitals have Infection Control policies and procedures that cover this.  If not…..they should!

-  If you develop an infection from an invasive procedure and the hospital DID NOT follow best practice and use the correct solution – hold them accountable.

b)   Also related to your skin as your first line of defense, both the CDC and SHEA/IDSA guidelines recommend that patients with central lines (special intravenous catheters inserted into special veins with the catheter tip emptying at or near the heart) be bathed daily with a 2% CHG solution to prevent central line-associated blood stream infections (CLABSI).  The SHEA/IDSA guidelines gives this the highest level of recommendation for Critical Care (ICU, CCU, etc) patients, although logic would dictate the same level of care for all patients with central lines during their hospital stay - regardless of their location in the hospital.  (As the majority of CLABSIs occur in hospital units outside the ICU or in outpatients, this needs to be a serious consideration.)  This is best achieved by bathing patients with washcloths pre-impregnated with 2% CHG.

Also, bathing patients with washcloths pre-impregnated with 2% CHG results in considerably higher skin concentrations with no gaps in antiseptic coverage when compared to having patients bathe or shower with 4% CHG soap prior to surgery – and therefore further lowers the risk of surgical site infections (SSIs).

Additional guidelines recommend bathing patients with high risk surgeries (i.e. “open-heart” surgery and total joint replacements) with washcloths pre-impregnated with 2% CHG in the perioperative period – meaning before, during and after (at least 24-48 hours after) - to reduce the likelihood of SSIs.

Where hospitals fail:

- not bathing patients in Intensive Care settings (ICU, CCU, etc.) with washcloths pre-impregnated with 2% CHG.  The vast majority of Intensive Care patients have central lines during their stay, and all patients with open-heart surgery spend at least the first part of their post-operative period in either CCU or ICU and should also be bathed with washcloths pre-impregnated with 2% CHG.

- nursing staff in hospitals that do not use washcloths pre-impregnated with 2% CHG, often add 2% CHG to a basin of water diluting it to the point of being completely ineffective.

- also, if nursing staff use water to rinse a patient after washing with 2% CHG, you lose the benefit of the residual antimicrobial action of CHG.

What you can do:

- if you or your family member has a central line, especially in a Critical Care setting, insist that you/they are bathed at least daily using a washcloths pre-impregnated with 2% CHG.  (The alternative is to pour a bottle of 2% CHG on the patient and try to rub in to cover all areas adequately – but as stated earlier, bathing patients with washcloths pre-impregnated with 2% CHG results in considerably higher skin concentrations with no gaps in antiseptic coverage.  And using it straight from a bottle may leave you feeling sticky.)

- if you or your family member is having open-heart surgery (or perhaps a total joint replacement) insist that you/they are bathed with a bathing patients with washcloths pre-impregnated with 2% CHG in the perioperative period as mentioned above.  (Especially open-heart surgery!)

c)  Best practice guidelines for the prevention of ventilator-associated pneumonia (VAP) include oral care (cleaning inside your mouth) with CHG mouthwash at regular intervals at a MINIMUM concentration of 0.12%.  The benefits of oral care with CHG appear to be most pronounced in preventing postoperative respiratory tract infections in cardiac-surgery patients – and Initial doses of CHG given the night before and on call for cardiac surgery have been shown to be beneficial.  Hospitals should therefore ensure that oral care with CHG is also part of the care of cardiac surgery patients in CCU, and not just limited to ICU patients.

Where hospitals fail:

- nursing staff my dilute CHG mouthwash with water because the patient might not like the taste (or the nurse may think the patient might not like the taste).  Diluting the CHG mouthwash makes it ineffective at preventing VAPs.  (That includes dipping the mouth swab in water prior to or after CHG mouthwash is applied – or rinsing or swabbing the mouth with water after CHG mouthwash is used.)

What you can do:

- if you see nursing staff using water with or after using CHG mouthwash on your family member who is on a ventilator – ask them not to!  If you are performing the oral care on your loved one while they are on the ventilator – ensure that you also do not use water.

 

d)  There is a general misconception by the lay public that the hospital environment is always clean or even sterile – when in fact hospitals are dirty places.  Think about it:  every patient is sick or injured – and there is a higher percentage of infectious people in the hospital than in the general public.

This is why there are recommendations for how rooms, departments, and equipment are cleaned – and how frequently.

Not following these guidelines increases the number or bacteria and viruses present in the hospital environment – and increases the risk of hospital-acquired infections.

In Ontario we have provincial guidelines for “Environmental Cleaning for Prevention and Control of Infections” that dictate the method and minimum frequency of cleaning for various areas and equipment throughout the hospital setting.   Some examples of MINIMUM cleaning frequencies include:

- washrooms in Emergency Departments/Urgent Care Centers should be cleaned at least every 4 hours – and more frequently if soiled or contaminated.

- Trauma/Resuscitation room in the Emergency Department should be cleaned after every patient AND at least twice daily.

- other areas in the Emergency Department with heavy soiling should be cleaned after every patient AND at least twice daily.

- departments with high-risk patients (i.e. ICU, CCU, Labor and Birthing rooms, hemodialysis rooms/stations, etc.) should be cleaned after each patient AND at least twice daily.

- patients who are immunocompromised (i.e. Oncology patients), should have their rooms cleaned after each patient AND at least twice daily.

- Neonatal Intensive Care Units (NICU) and high acuity nurseries should be cleaned after every patient AND at least twice daily.

- Patients placed on “Contact Precautions” (Isolation) should have their rooms cleaned after every patient AND at least twice daily.

- Patients placed on “Contact Precautions” (Isolation) for an infection with an organism called Clostridium difficile (C. diff) should also have their room “double cleaned” after discharge from that room.

Where hospitals fail:

- Housekeeping staff are often the most underappreciated part of the team, but are a vital link in preventing infection.  Hospitals do not put enough money, resources, and human resources into Housekeeping Departments – and as a result are, more often than not, not even close to being compliant with the minimum standards for the frequency of cleaning for the aforementioned areas.

What you can do:

- If you or your family member falls into any of the above categories, monitor how frequently the room is fully and properly cleaned (including cleaning all surfaces and "high-touch" points, the washroom,  and mopping the floors).  If the hospital is not meeting the requirements – file a complaint (but not to the over-worked and under-staffed Housekeeping staff) – and keep on top of it.

 

e)  Most hospitals ensure that any policy that may affect patient infection rates involves their Infection Control and Prevention (IPAC) department in the planning, writing or revision of such policies.  These hospitals also ensure that part of the final approval process for ANY policy (whether it involves patient care or not) passes through the hands of the IPAC Committee.  These hospitals also ensure that a member of the IPAC team is an active member of the product and equipment review committee (reviewing all products and equipment coming into the hospital).

Where hospitals fail:

- there are a small number of hospitals in Ontario that sadly do not follow these practices – and relegate their IPAC departments to a reactive entity that only deals with issues as they arise (i.e. monitoring patients on Additional Precautions/Isolation) – rather than also being a proactive entity that is actively involved in policy management and review of products/equipment to ensure that they are compliant with best practices.  (The IPAC Department and/or IPAC Medial Director should essentially be endowed with authority similar to that which the local Public Health Department has out in the community.)

What you can do:

- find out if your local hospital involves IPAC in all aspects of policy management as mentioned above, and if they are active members of the product and equipment review committee.  If they are not – insist that they are.  The purpose of the IPAC department is to protect you the patient.

f)  Current best practice guidelines for hand hygiene in Ontario state that when using alcohol-based hand rubs (ABHRs) in healthcare settings, that a minimum concentration of 70% alcohol should be chosen.  [Technical stuff]:  Concentrations of 70% or higher demonstrate superior virucidal action against certain viruses (such as norovirus) compared to concentrations below 70%.  This is supported by data from both the CDC and WHO.  Also, the addition of CHG to ARBHs can result in persistent antimicrobial activity.

Where hospitals fail:

- having ABHRs with concentrations less than 70%

What you can do:

- ask if all of the ARBHs in the hospital (wall mounted and desk-top) have alcohol concentrations of at least 70%.

 

g)  The care of patients is a multi-disciplinary task – and best practices adopted by and guiding hospitals and incorporated into their policies and procedures need to be multi-disciplinary.  That is not to say that (for example) best practices from a nursing organization (i.e. the RNAO in Ontario) cannot be used in developing best practices and policies for the hospital – but they cannot be the sole or primary guiding force.

Where hospitals fail:

- consider the best practices for central lines.  They are inserted by physicians (but with others involved), they are managed by nursing staff, and utilized by both physicians and nursing staff.   Now look at the prevention of ventilator-associated pneumonia (VAP).  That involves physicians, Respiratory Therapists, and nursing staff.  If a hospital were to promote or be guided by only nursing best practices (usually because nurses make up the largest group of employees) rather than a multi-disciplinary approach – they are leaving out a large part of the process, and they will have less “buy-in” from other involved parties.  Having physician champions for best practices is beneficial in encouraging physician buy-in – and it is much easier to achieve if the best practices adopted by the hospital are multi-disciplinary.  Combining agreed on best practices from the agencies and documents mentioned near the beginning of this blog entry, and creating policies and procedures based on those, is the easiest way to accomplish this.  Additionally, physicians should be involved in the approval process (if not also the creation process) of every clinical policy.
 

What you can do:

- this one is a little harder to intervene from the outside, but you can always ask. 

- get involved in a hospital “Quality” or “Patient Safety” committee that allows the general public as members.

 

h)  Hospitals are required to observe, measure, and report rates of compliance with “Hand Hygiene” protocols by staff and physicians.

Where hospitals fail:

-  When observing staff and physicians, a Hawthorne Effect (improving one’s behavior when being observed) inevitably raises the compliance rates.  Many hospitals realize this and make no efforts to disguise the fact that observations are occurring.  Some hospitals shamefully go as far as announcing that there is someone on the unit observing for hand hygiene to inflate their reported compliance rates.

 

2)  Other breaches in care that can contribute to hospital-acquired infections:

 

a)  The floor, lids of garbage can, and lids of linen hampers in hospitals are all contaminated.

Where hospitals fail:

- using these areas to store or place clean supplies/linen or using them as a work space (i.e. as a table for dressing trays or procedure trays).

- storing, or even placing, pillows on the floor, lids of garbage can, and lids of linen hampers.

What you can do:

- ask staff to dispose of the supplies or linen placed in any of these locations.

- insist that a new pillow case is applied if pillows are placed in any of these locations.

- don’t place your purse, backpack, lunch, coffee, bottled water, coat, or any of your other personal belongings in any of these locations.

 

b)  Nursing or other hospital staff or physicians should all be wiping/disinfecting any injection port on your intravenous (i.e. either saline lock or injection ports on the IV line) before injecting something into them or connecting something to them.

Where hospitals fail:

- not wiping (scrubbing actually) before injecting or connecting.  “Scrub the hub!”

- disconnecting an IV line from a saline lock or IV site flipping the end around and connecting it to the first injection port without first disinfecting that injection port.

What you can do:

- (short of a cardiac arrest or other emergent situation…) – stop them from injecting or connecting if they have not first disinfected the site.  (Although…as healthcare professionals we should still try to do this.  The wipes are kept with the medication and syringes that we use.  Not too hard to grab a handful when we run.  They are also in our crash carts.).

- if they have already injected something in to an IV tubing or connected something to an IV tubing (in a non-emergent situation) without first disinfecting the site – pinch off the tubing and ask them to disconnect it, throw it out, and hang all new tubing.

- report it to the department manager (not the Charge Nurse) and/or the Public/Patient Relations department for the hospital.

c)  All the disinfectants and antiseptics that we use kill bacteria and viruses as they dry – and only if we allow the area to air-dry completely.  Fanning, wiping, or blotting the disinfectant/antiseptic diminishes or negates its ability to be effective.

Where hospitals fail:

- cleaning your skin with CHG, IPA, etc, and not letting it air-dry completely before starting the procedure.

- cleaning your skin with CHG, IPA, etc., and then wiping or blotting the antiseptic off with gauze (even if it is sterile gauze).

- disinfecting equipment and using it before it has air-dried copletely.

- disinfecting a bed or stretcher and covering it with linen before it has had a chance to AIR-DRY completely.

What you can do:

- if you see someone try to start a (non-emergent) procedure without letting the antiseptic air-dry – ask them to stop and wait.

- if you see someone wiping or blotting away an antiseptic, ask them to re-clean the area.

- report any concerns to the department manager (not the Charge Nurse) and/or the Public/Patient Relations department for the hospital.

 

d)  Once you skin has been cleaned with an antiseptic prior to an IV insertion or blood test, the area should not be touched.

Where hospitals fail:

-  Some nurses and other healthcare professionals touch the area after it has been cleaned with an antiseptic to feel the vein  “one last time…just to make sure” that they are entering at the correct location.  This action defeats the entire purpose of properly cleaning the skin with an antiseptic.

-  (Also – if, after the IV is inserted or during insertion - usually to stabilize the vein, the nurse or other healthcare professional touches the area that will be under the sterile transparent dressing, the area needs to be cleaned and allowed to air-dry prior to the application of the transparent dressing.)

-  The nurse or other healthcare professionals should not be touching the area – even with a gloved hand.  This is the case for the majority of routine IVs and blood tests.

-  The rare exception would be if the entire procedure was performed as a “sterile procedure” – and without breaches.

What you can do:

-  if you see a nurse or other healthcare professional touch the area cleaned by the antiseptic to “feel the vein”,  ask them to stop and re-clean the area with the antiseptic.

- report any concerns to the department manager (not the Charge Nurse) and/or the Public/Patient Relations department for the hospital.

 

e)  When an intravenous (IV) is inserted into your arm, the site should be covered with a sterile, transparent dressing.

Where hospitals fail:

- sometimes when an IV is inserted in an out-patient setting (i.e. Radiology Department or out-patient clinic) for a short period of time (i.e. to inject “contrast” for an x-ray or a single medication) the staff will simply place a piece of tape over the site.  First, tape is not sterile – and hat site provides direct access to an area that is – your bloodstream.  Second, not only is tape not sterile, it is sticky and picks up lots of dirt – as well as bacteria and virus.  Third, even if the IV is only in for a short time, the very fact that the site is a portal to your sterile bloodstream means that the site must be covered by a sterile dressing.  Bacteria can migrate along the outside of the IV catheter if it is not covered by a sterile dressing.

What you can do:

- don’t let them come near your IV site with tape without first covering it with a sterile dressing (life-threatening situations aside).  Any department that is inserting IVs should have the proper dressing stocked and readily available.

 

f)  If you or your family member has a central line, the more that system is opened to the air – the higher the risk of infection

Where hospitals fail:

- especially in Critical Care settings (i.e. ICU, CCU, etc.), sometimes central lines and arterial lines are opened to the air so the staff can get a soiled patient gown off and a clean one on.

- even if the lines are not opened to the air, they have to be disconnected, and many nurses do not disinfect the site prior to reconnecting because they “were careful” and/or they do not feel the need to cover the other end with a sterile cap as they feed it through the sleeve –again because they feel that they “were careful”.

 

What you can do:

- ask the department manager (not the Charge Nurse) and/or the Public/Patient Relations department for the hospital to arrange for what are often referred to as “telemetry gowns” which have snaps or Velcro along the shoulders of the gown that allow it to be removed without having to disconnect any intravenous lines - espeicially in critical care areas (i.e. ICU, CCU, etc.).

- ask nursing staff to “scrub the hub” before reconnecting.

-ask nursing staff to place a sterile cap on the line before feeding it through the sleeve – and to throw out and replace any contaminated lines (in non-emergent situations).

- report any concerns to the department manager (not the Charge Nurse) and/or the Public/Patient Relations department for the hospital.

g)  Infections caused by cross-contamination can occur if hospital staff do not change their gloves after handling contaminated items or performing contaminating tasks.

Where hospitals fail:

- a staff member cleans up a patient’s stool or urine, and then when they are done cleaning the patient reach for a clean diaper with their contaminated gloves, put the clean diaper on the patient, boost the patient up in bed, cover them with a blanket, give them their call bell and pull the side bed rails up (all with their contaminated gloves).

- Your gloves are contaminated after doing “peri-care”, even if they are not visibly soiled.

What you can do:

- ask the staff member to change their gloves immediately after cleaning a patient of stool or urine – and BEFORE touching anything else.

 

h)  Hospitals have bottles of spray that they use when cleaning up a patient after they were soiled with stool or urine.  These bottles are contaminated as soon as they are used and are therefore “single-patient-use”.

Where hospitals fail:

- in outpatient settings such as the Emergency Department or clinics, or in other areas such as the Recovery Room – staff may perceive it as a waste to throw these bottles out after only using them once – so they are reused on multiple patient – and toss them in a bin or drawer of clean supplies until needed again (thus contaminating those supplies as well).  Using this contaminated bottle while cleaning a different patient will cross-contaminate them.

-  These bottles cannot be simply wiped down, as they have too many crevices and grooves to effectively decontaminate them by wiping – even with hospital-grade disinfectants.   Harmful pathogens such as E. coli, C. diff., etc. can all hide in the external parts of the spray nozzle.

What you can do:

- First of all, this whole problem should horrify you….  (Yuck!)

- then, ask if the spray bottle is new and never used before.  Ask the staff how they know this.  (Is there a seal on the bottle?)

- ask staff to throw out the contents of a bin or drawer if a used bottle is placed in there – and have the bin or drawer disinfected.

- ask the department manager (not the Charge Nurse) and/or the Public/Patient Relations department for the hospital what is being done to ensure that none of the aforementioned cross-contamination could occur.

- ask the department manager (not the Charge Nurse) and/or the Public/Patient Relations department for the hospital to purchase pre-moistened wipes that are designed for this purpose for department such as the Emergency Department, Recovery Room, and outpatient clinics.

 

i)  All vaccines need to be stored in a monitored refrigerator or freezer (depending on the vaccine) – and a “cold-chain” maintained until it is administered to the patient.  Influenza vaccines need to remain refrigerated until administered.

Where hospitals fail:

- most hospitals have a blitz at the beginning of flu shot season to maximize the number of employees and physicians that receive a flu shot.  This is often accomplished by holding a drop in flu shot clinic away from their Occupational Health Department (where their vaccine refrigerator is) and roaming “flu shot carts”.  If the cold chain for the Influenza vaccine is not maintained and the vaccine is left out (say in a drop-in flu shot clinic without a vaccine fridge or a roaming cart out for 30 minutes or more at a time), the efficacy of the vaccine will be decreased or possibly negated entirely.  Since Influenza is contagious 24 hours before the first symptom appears, not having employees properly vaccinated places patients and their families at risk – as well as other employees and their families.

What you can do:

- ask if your hospital is maintaining a proper “cold chain” for all vaccines – including those given to employees during the flu shot blitz.

- when you get your flu shot (or any vaccine) and you don’t see them take it our of the vaccine refrigerator – ask.

 

j)  When you are tested for Influenza, a specimen is collected via a swab (called a nasopharyngeal or “NP” swab) is utilized.  Immediately after collection, the NP swab for Influenza testing must be stored in a specimen refrigerator at a temperature between 2-8 degrees Celsius – and a “cold chain” maintained until the specimen is process.  Not refrigerating the specimen and maintaining the cold chain may result in what is called a “false-negative” result – meaning if you actually had Influenza that test would say you did not.  This may mean that you may not receive the treatment you need – and you could then also spread it to your loved ones.

Where hospitals fail:

- not refrigerating the specimen/swab after collecting it

- not maintaining a cold chain for the NP swab.  (i.e. not taking it immediately to the Laboratory after removing it from the specimen refrigerator, or not placing it in a specimen refrigerator once it arrives in the Laboratory.)

What you can do:

- if you or your family member are swabbed for Influenza, ask if they will maintain a “cold chain” for the specimen until it can be processed.

- call or write the Public/Patient Relations Department in your local hospital and ask if the hospital ensures that a cold chain is maintained for Influenza swabs after they are collected – and if this is done consistently throughout the organization.

-  [Technical stuff]:  (As a side bar, swabbing the nares rather than the nasopharynx is not proper technique – and will most likely yield false-negative results.)

k)  Microfiber (MF) mops mop pads provide a cleaning surface 40 times greater than conventional string mops and increased absorbency.  MF mops demonstrate superior microbial removal compared to cotton string mops used with a detergent cleaner.  MF mops reduce the risk of room-to-room cross-contamination when compared to conventional string mops.

Also, as noted in Ontario’s best practice document “Environmental Cleaning for Prevention and Control of Infections”:  MF mops weigh less than conventional mops, reducing the physical effort required to clean floor surfaces.  The MF system cleans more effectively with a lesser amount of cleaning solution, reducing the overall effort needed to clean a floor and the time required for the floor to dry, minimizing slip hazards.  MF mops eliminate the need to empty large, heavy buckets of contaminated cleaning solution associated with the use of conventional string mops.  They also eliminate the continual lifting of heavy mop heads into and out of the cleaning bucket.  Use of MF mops has been shown to prevent injury and muscle strain generally associated with mopping tasks.

There are several other advantages for hospitals – i.e. reduced chemical usage and disposal, reduced water usage, drier floors, reduced cleaning time (with faster turn-over for room cleaning), decreased laundry requirements, and longer product lifetime and washing lifetime (improving their cost effectiveness).

Where hospitals fail:

- allowing potential room-to-room cross-contamination by using conventional string mops instead of microfiber technology.  (Note:  There is the initial cost associated with replacing old system for new system, but this may be offset with decreased use of cleaning and disinfecting agents.)  (Sidebar: MF mops should not be used in greasy, high-traffic areas such as kitchens.)

What you can do:

- call or write the Public/Patient Relations Department in your local hospital and ask if the hospital can switch to microfiber mops to prevent room-to-room cross-contamination.  (They are also better for the environment.)

Last thoughts:

For patients, family members, and the general public:

-  when you see a breach in best practice – call it out!

-  as we are all potential patients, we could all send this blog entry to our local hospitals and ask for specific accountability to demonstrate compliance with all the best practices mentioned – and to address any breaches.

- write to your MPP, federal and provincial Ministers of Health, MP, etc and ask why the government is not doing more to promote these best practices and also hold hospitals accountable for them.  The government also needs to ensure that it removes any roadblocks that prevent hospitals from implementing them.

- ask the media to investigate your local hospital with regards to the issues mentioned in this blog post.

- (NOTE: These are best practices for hospital/healthcare settings - and do not necessarily reflect how patients should be cared for in the home - as hospitals are quite a bit more contaminated than your home.)

 

For hospitals:

a)  The process to update your policies and procedures to incorporate these (and any other) best practices needs to be streamlined to prevent delays in patients receiving the best care you can give them.

b)  If products do not meet best practices, and cannot be used elsewhere for different tasks, don’t wait until they are used up.  Remove them.

c)  2% CHG without 70%IPA still needs to be stocked in your hospital as it is used as a procedural antiseptic for areas such as oral and nasal mucosa, the cornea, the inner ear, and the meninges.  It is also used in the Emergency Department for wound cleansing of open wounds (i.e. wounds that need to be sutured, dirty wounds, etc.).  The important point is that all staff and physicians need to be educated about the presence of both products and the appropriateness of when to use each.

d)  You may also need to keep the plain70%IPA pads in stock for cleaning the testing area of point-of-care-testing equipment or Laboratory equipment – if necessary.

e)  Purchase dye-free formulations of all products containing CHG to decrease the change of allergic/hypersensitivity reactions.

f)  Stay on top of best practice guidelines from the aforementioned organizations – and be ready to adapt.  Signing up for alerts from sources such as Medscape are free and helpful in achieving this, but you also need to keep going back to best practice organization websites and documents as well.

g)  Focusing on patient satisfaction and involvement is great, but if we are not doing our best to deliver quality and safe patient care – we are missing the entire point.  As I have seen mentioned elsewhere, we don’t want patients to think, “Hey they cut my wrong leg off and gave me an infection…..but hey…they were sure nice about it when they told me!”

h)  Yes quality care costs money upfront.  Yes the government arguably doesn’t care that you are saving them money down the road by improving patient outcomes – but we should be looking for ways to improve, not cherry-picking studies and research that makes us think that we can avoid implementing these best practices.  In response to these issues, it is my hope that hospitals will look at ways to improve their best practice, not look for ways around them.  Due diligence.

 

For nursing programs (BScN) and continuing education/specialty programs (i.e. Emergency Nursing, Critical Care Nursing programs, etc.):

- Every one of your students should graduate knowing about Safer Healthcare Now –as well as other sources of best practices.  (Safer Healthcare Now also has other best practices not specifically related to hospital-acquired infections that they should also be familiar with.)

-  Currently…..most do not!

 

For the media:

- you and your families are all potential patients as well.

-  you should also contact local hospitals and ask for specific accountability to demonstrate compliance with all the best practices mentioned – and to address any breaches.

- confidentially interview front-line staff to assess hospitals for compliance and breaches.

 

For Accreditation Canada:

- why are you not assessing whether hospitals are compliant with Safer Healthcare Now (as a minimum standard) – and how some have may have excelled even further beyond these?!?  [This will be addressed further in a later blog entry!]

-  Accreditation Canada should be looking into all issues in this blog post, and others in this blog.

 

For the federal and provincial governments:

-  why are you not doing more to promote these best practices and also hold hospitals accountable for them?

- what roadblocks that prevent hospitals from implementing them can you remove?

For Infectious Disease physicians and Infection Control Practitioners:

-  Fever is an important indicator of infection, however many patients in hospital are taking acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) (i.e. ibuprofen, naproxen, ketoprofen, indomethacin, etc.) which may mask a fever due to the medication's antipyretic effects.

-  Many patients are taking frequent or regular doses of acetaminophen or NSAIDs - especially in critical care settings.

-  Be aware of any medications with antipyretic effects that patients are taking and keep this in mind if the patient does not have a fever but has other indicators of possible infection.

 

Links:

 

Safer Healthcare Now! (SHN) - http://www.saferhealthcarenow.ca/EN/Pages/default.aspx  (click on the “Interventions” tab and then find the “Getting Started Kit” for each intervention.)

Public Health Agency of Canada (PHAC) - http://www.phac-aspc.gc.ca/index-eng.php (use the “A-Z Index” or the “Search Box” to find what you are looking for.), or….

http://www.phac-aspc.gc.ca/dpg-eng.php (Disease Prevention and Control Guidelines)

Centers for Disease Control and Prevention (CDC) –

www.cdc.gov (use the “CDC A-Z Index” or search box to find what you are looking for.), or….
http://www.cdc.gov/hai/ (The CDC’s Hospital-Associated Infections (HAI) page.)
(The new revised CDC SSI guidelines are due out anytime now.)
 

SHEA/IDSA  - “Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals” - http://www.shea-online.org/PriorityTopics/CompendiumofStrategiestoPreventHAIs.aspx (The AHA, APIC, and the Joint Commission also contributed to the compendium.)

 

The UK Department of Health – https://www.gov.uk/government/organisations/department-of-health (considerably more difficult to navigate since they changed their website, but they are very helpful if you e-mail questions)

Central Venous Catheter Care Bundle:  http://webarchive.nationalarchives.gov.uk/20120118164404/http://hcai.dh.gov.uk/files/2011/03/2011-03-14-HII-Central-Venous-Catheter-Care-Bundle-FINAL.pdf
Peripheral Intravenous Catheter Care Bundle: 
http://webarchive.nationalarchives.gov.uk/20120118164404/http://hcai.dh.gov.uk/files/2011/03/2011-03-14-HII-Peripheral-intravenous-cannula-bundle-FIN….pdf
(If you have trouble open these two documents, they can also be found as PDF documents at this link:  http://www.nric.org.uk/IntegratedCRD.nsf/f0dd6212a5876e448025755c003f5d33/04b8fc5e0feeb226802576d1005b7d25

World Health Organization (WHO) –  www.who.int

http://www.who.int/patientsafety/en/  (Patient Safety page)
http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf (Hand Hygiene document)

Government of Ontario - Provincial Infectious Disease Advisory Committee (PIDAC):  http://www.publichealthontario.ca/en/BrowseByTopic/InfectiousDiseases/PIDAC/Pages/PIDAC_Documents.aspx  (Best Practice Documents.)

 

Other useful links:

The Joint Commission - http://www.jointcommission.org/Topics/Clabsi_toolkit.aspx and http://www.jointcommission.org/assets/1/18/CLABSI_Monograph.pdf (Central Line-Associated Bloodstream Infection Toolkit and Monograph.)

Cincinnati Children’s Hospital’s Evidence-Based Care Recommendation – “Daily Bathing of Children in Critical Care Settings with Chlorhexidine Gluconate” - http://www.cincinnatichildrens.org/WorkArea/DownloadAsset.aspx?id=108335 taken from:  http://www.cincinnatichildrens.org/service/j/anderson-center/evidence-based-care/recommendations/default/  and  http://www.cincinnatichildrens.org/service/j/anderson-center/evidence-based-care/default/ 

Association for Professionals in Infection Control and Epidemiology (APIC) - http://www.apic.org/

Infection Prevention and Control Canada (IPAC-Canada) - http://www.ipac-canada.org/

Infusion Nurses Society (INS) - http://www.ins1.org/i4a/pages/index.cfm?pageid=1 (Excellent resources on central line and peripheral IV care.)

Canadian Vascular Access Association (CVAA) - http://www.cvaa.info/  (Excellent resources on central line and peripheral IV care.)