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.
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:
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.)
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
http://www.who.int/patientsafety/en/ (Patient Safety page)
http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf
(Hand Hygiene document)
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/
Canadian
Vascular Access Association (CVAA) - http://www.cvaa.info/ (Excellent resources on central line and
peripheral IV care.)
