Glitter or Gold?  Infection Control Practices Under the Microscope  Patricia Lynch, RN, MBA APSIC, Singapore
Dogma: Statement or rule that is strongly believed <ul><li>1. Dogma proven to have value by good science </li></ul><ul><li...
All Dogmas Have Key Elements <ul><li>They ALWAYS sound believable </li></ul><ul><li>They have a distinct flavor: “I’m righ...
4th Decennial International Conference, 2000 <ul><li>369 participants were presented with dogmatic statements in all 3 cat...
Results of Dogma Votes <ul><li>Majority agreed with statements with proven efficacy </li></ul><ul><li>Even split between t...
So, What’s the Problem? <ul><li>Rituals in fundamentals training for nurses </li></ul><ul><li>We nurses often aren’t train...
Isolation <ul><li>Isolation of infected patients is the most effective way to decrease nosocomial transmission of infectio...
Isolation Considerations <ul><li>1.  Where do organisms come from  that reach new patients who  didn’t have them before? <...
Early Isolation Controversy <ul><li>Smith IB. Contagious nursing technic: Its place in the course of a general hospital. A...
What is the Goal? <ul><li>Decrease infection (hard to do: host response is paramount) </li></ul><ul><li>OR </li></ul><ul><...
Goal: Decrease Transmission <ul><li>When people acquire organisms that are new to them, infection risk rises. Risk for acq...
Cross-transmission: Does it Happen Frequently? <ul><li>1.  All of you have personal experience </li></ul><ul><li>2.  25-40...
Controversies About Cross-Transmission <ul><li>Is it more efficient to reduce transmission  by containing organisms from k...
What Decreases Cross-Transmission? <ul><li>Clean gloves just before mucous membrane, non-intact skin: infections and colon...
What Decreases Cross-Transmission? <ul><li>Gown and gloves: Decreased RSV transmission.  LeClaire. N Eng J Med 1987:329 </...
Should Everything From Isolation Rooms be Reprocessed? <ul><li>If true, everything from ALL rooms because so few sources f...
Is “Protective Isolation” effective for Immunocompromised? <ul><li>Where do the organisms come from? </li></ul><ul><li>Wha...
Isolate if multidrug-resistant organisms in stool? <ul><li>Uncontained stool is a big source for organisms. (fecal inconti...
Inanimate Environment Plays Little or No Role…?? <ul><li>Same organisms reappeared in new hospital, same infections.  Maki...
Special Cleaning for Rooms of Patients + for MRSA <ul><li>Insufficient evidence.  </li></ul><ul><ul><li>MRSA is neither mo...
Culture Roommates of Known MDRO Patients? <ul><li>Not an effective intervention for transmission--too late. </li></ul><ul>...
Close Doors of Patients in Contact/Droplet Isolation?   <ul><li>No evidence. No good rationale. </li></ul><ul><li>“ Remind...
Reminder Signs for Precautions? <ul><li>No decrease in blood exposures among staff caring for AIDS patients due to signs ....
Handwashing is the Single Most Important... <ul><li>Critical: items & procedures for  tissue: sterile & major effort </li>...
True Statements About Handwashing <ul><li>Important public health practice </li></ul><ul><li>Hands do become colonized </l...
Alcohol Hand Sanitizers <ul><li>Reduce skin flora </li></ul><ul><li>Decrease infection rates in health care facilities </l...
Response to Dogma  <ul><li>1. Don’t make dogmatic statements: always cite references or clarify thought processes </li></u...
Response to Dogmatic Statements <ul><li>“ I don’t have time to…” </li></ul><ul><li>“ I’ve never stuck myself doing…”  </li...
Highest Value, Least Dogma <ul><li>Reprocessing supplies & equipment </li></ul><ul><li>Skill & sterility for invasive proc...
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Infection Control Practices Under the Microscope

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Lecture about infection control practices by Patricia Lynch during the 6th International Infection Control Conference 2006

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Infection Control Practices Under the Microscope

  1. 1. Glitter or Gold? Infection Control Practices Under the Microscope Patricia Lynch, RN, MBA APSIC, Singapore
  2. 2. Dogma: Statement or rule that is strongly believed <ul><li>1. Dogma proven to have value by good science </li></ul><ul><li>2. Dogma neither proven to have value or proven to not have value: controversial </li></ul><ul><li>3. Dogma proven to not have value but is still practiced and believed </li></ul>
  3. 3. All Dogmas Have Key Elements <ul><li>They ALWAYS sound believable </li></ul><ul><li>They have a distinct flavor: “I’m right” “You’re wrong” “Everybody knows…” </li></ul><ul><li>They invite emotional responses </li></ul>
  4. 4. 4th Decennial International Conference, 2000 <ul><li>369 participants were presented with dogmatic statements in all 3 categories: proven, proven not, controversial </li></ul><ul><li>Participants voted electronically & votes were immediately counted </li></ul><ul><li>78% were from USA </li></ul>
  5. 5. Results of Dogma Votes <ul><li>Majority agreed with statements with proven efficacy </li></ul><ul><li>Even split between those that require further research to prove efficacy: some agreed & some didn’t </li></ul><ul><li>Many respondents still agree with dogmas proven to not have efficacy </li></ul>
  6. 6. So, What’s the Problem? <ul><li>Rituals in fundamentals training for nurses </li></ul><ul><li>We nurses often aren’t trained in critical review of literature or recommendations </li></ul><ul><li>The research isn’t very good </li></ul><ul><li>Dogmatic statements generate polarized positions, not easily changed </li></ul>
  7. 7. Isolation <ul><li>Isolation of infected patients is the most effective way to decrease nosocomial transmission of infectious agents among patients. </li></ul>
  8. 8. Isolation Considerations <ul><li>1. Where do organisms come from that reach new patients who didn’t have them before? </li></ul><ul><li>2. Where are the intervention locations? </li></ul><ul><li>3. Does “isolation” hit those locations effectively? </li></ul>
  9. 9. Early Isolation Controversy <ul><li>Smith IB. Contagious nursing technic: Its place in the course of a general hospital. AJN 1924; 24:213-15. </li></ul><ul><li>Discussion over containment as the major strategy. </li></ul>
  10. 10. What is the Goal? <ul><li>Decrease infection (hard to do: host response is paramount) </li></ul><ul><li>OR </li></ul><ul><li>Decrease transmission of infectious agents among the patients (measure that by colonization not infection) </li></ul>
  11. 11. Goal: Decrease Transmission <ul><li>When people acquire organisms that are new to them, infection risk rises. Risk for acquiring ^when new organisms are placed in normally sterile body sites or on MM or NIS </li></ul><ul><li>The contribution of a bacterially isolated environment in the prevention of infection in seriously burned patients. </li></ul><ul><li> Burke. Ann Surg 1977; 186:377-85. </li></ul>
  12. 12. Cross-transmission: Does it Happen Frequently? <ul><li>1. All of you have personal experience </li></ul><ul><li>2. 25-40% of NI were from cross- transmission. Weinstein. Am J Med 1991:179 </li></ul><ul><li>3. 23% of patients. acquired C. diff within days; C. diff persisted on hands and surfaces. McFarland. N Eng J Med 1989:204 </li></ul><ul><li>4. Value of marker organisms: canaries </li></ul>
  13. 13. Controversies About Cross-Transmission <ul><li>Is it more efficient to reduce transmission by containing organisms from known infected patients </li></ul><ul><li>OR </li></ul><ul><li>by protecting susceptible sites on all patients and containing moist body substances from all sites on all patients? </li></ul>
  14. 14. What Decreases Cross-Transmission? <ul><li>Clean gloves just before mucous membrane, non-intact skin: infections and colonization decreased significantly. Lynch. AJIC 1990:1-12 </li></ul><ul><li>Clean gloves & gown: febrile days, colonization, infection decreased. </li></ul><ul><li>Klein N Engl J Med 1989:1714-21. </li></ul>
  15. 15. What Decreases Cross-Transmission? <ul><li>Gown and gloves: Decreased RSV transmission. LeClaire. N Eng J Med 1987:329 </li></ul><ul><li>Gloves: C. difficile outbreak ended. Johnson. AJM 1990:137-40. </li></ul>
  16. 16. Should Everything From Isolation Rooms be Reprocessed? <ul><li>If true, everything from ALL rooms because so few sources for infectious agents are recognized. </li></ul><ul><li>If not true, different criteria apply: </li></ul><ul><ul><ul><li>1. Everything likely to be soiled </li></ul></ul></ul><ul><ul><ul><li>2. Everything likely to be touched just before contact with MM or non-intact skin. </li></ul></ul></ul>
  17. 17. Is “Protective Isolation” effective for Immunocompromised? <ul><li>Where do the organisms come from? </li></ul><ul><li>What are the intervention locations? </li></ul><ul><li>Does isolation hit those locations? </li></ul><ul><li>Protective isolation neither reduced infections nor increased longevity. It did decrease quality of life. Nauseef & Maki. NEJM 1981;304:448-53 </li></ul>
  18. 18. Isolate if multidrug-resistant organisms in stool? <ul><li>Uncontained stool is a big source for organisms. (fecal incontinence, diarrhea) </li></ul><ul><li>If transmission from MDRO patients occurs, then the same precautions should be used for all patients: MDROs aren’t the problem, they signal the problem. </li></ul><ul><li>Precautions should be based on uncontained stool, not culture results. </li></ul>
  19. 19. Inanimate Environment Plays Little or No Role…?? <ul><li>Same organisms reappeared in new hospital, same infections. Maki. NEJM 1986;7:535-37. </li></ul><ul><li>Pts colonized quickly </li></ul><ul><li>Risk > with room and roommate </li></ul><ul><li>Answer: Major role played by articles that touch MM or non-intact skin </li></ul><ul><li>McFarland. NEJM 1989;320:204-8. </li></ul>
  20. 20. Special Cleaning for Rooms of Patients + for MRSA <ul><li>Insufficient evidence. </li></ul><ul><ul><li>MRSA is neither more transmissible nor more pathogenic; it is a good “marker” for transmission. </li></ul></ul><ul><ul><li>If MRSA is transmitted from the environment of patients known to be infected, precautions are indicated for all: culture detects only a small fraction of cases. </li></ul></ul>
  21. 21. Culture Roommates of Known MDRO Patients? <ul><li>Not an effective intervention for transmission--too late. </li></ul><ul><li>For early Rx? </li></ul><ul><li>Roommate selection is VERY important but must be based on physical indicators for transmission: unmanageable drainage, incontinence, etc. </li></ul>
  22. 22. Close Doors of Patients in Contact/Droplet Isolation? <ul><li>No evidence. No good rationale. </li></ul><ul><li>“ Reminds staff…” No evidence for that, either </li></ul>
  23. 23. Reminder Signs for Precautions? <ul><li>No decrease in blood exposures among staff caring for AIDS patients due to signs . Gerberding. Does knowledge of HIV decrease occupational blood exposure? Am J Med 1991 (Suppl):308 </li></ul><ul><li>Failure to use precautions except for patients with signs . </li></ul><ul><li>Lynch. Implementing & evaluating BSI. AJIC 1990; 18:1-12. </li></ul>
  24. 24. Handwashing is the Single Most Important... <ul><li>Critical: items & procedures for tissue: sterile & major effort </li></ul><ul><li>Semi-critical: mucous membranes & non-intact skin: disinfected & major effort </li></ul><ul><li>Non-critical: intact skin: clean </li></ul>
  25. 25. True Statements About Handwashing <ul><li>Important public health practice </li></ul><ul><li>Hands do become colonized </li></ul><ul><li>Hands do get dirty </li></ul><ul><li>“ Handwashing is the single most important…” statement is from the 1950s </li></ul><ul><li>In very few hospital situations is handwashing “most important”. </li></ul>
  26. 26. Alcohol Hand Sanitizers <ul><li>Reduce skin flora </li></ul><ul><li>Decrease infection rates in health care facilities </li></ul><ul><li>Probably in non-institutional settings </li></ul><ul><li>Fendler EJ, Ali Y, Hammond BS et al. The impact of alcohol hand sanitizer use on infection rates in an extended care facility. Am J Inf Cont 2002;30:226-33 </li></ul>
  27. 27. Response to Dogma <ul><li>1. Don’t make dogmatic statements: always cite references or clarify thought processes </li></ul><ul><li>2. Assist those who do make dogmatic statements to think through the process and identify all the possible correct answers </li></ul><ul><li>3. List in your own facility the dogmatic statements that dominate infection practices and use teamwork to eliminate them </li></ul>
  28. 28. Response to Dogmatic Statements <ul><li>“ I don’t have time to…” </li></ul><ul><li>“ I’ve never stuck myself doing…” </li></ul><ul><li>“ I don’t need to take precautions--he isn’t infected…” </li></ul><ul><li>“ She isn’t infected--she just has diarrhea” </li></ul>
  29. 29. Highest Value, Least Dogma <ul><li>Reprocessing supplies & equipment </li></ul><ul><li>Skill & sterility for invasive procedures </li></ul><ul><li>Skill & cleanliness for MM & non-intact skin </li></ul><ul><li>Reduce impact from environmental sources: cleanliness, hand hygiene </li></ul>

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