Did We Listen to our Infection Control Fathers and Mothers?

Here's a great post I received from a newsmail group, written by Chris Cahill, MS BS RN, Infection Prevention and Control Consultant
"As many of you know I spent about 12 years working for the California Department of Health Services (CDHS) surveying hospitals for compliance with state and federal infection control regulations and investigating outbreaks of healthcare-associated infections. What I saw in these hospitals was sickening and although I wrote many deficiencies for an unsanitary environment and other regulations and many letters to the licensing agency that I worked for, my complaints of filthy hospital environments fell on deaf ears. As I was recovering from a long overdue surgical procedure this year I dusted off a 1987 edition of Prevention and Control of Nosocomial Infections edited by Richard P. Wenzel and a 1992 edition of Hospital Infections edited by John V. Bennett MD and Philip S. Brachman MD. In the preface Bennett and Brachman commented: "Infection control staff are not always successful in influencing a change in the behavior of hospital care personnel. We must continue to emphasize the adoption of recommended procedures that will control and prevent infections and the elimination of those that are not effective and counterproductive." That was a powerful statement than and it is as true today and it was over 12 years ago. Why, after all these years and after all the published research is infection control so unsuccessful in influencing behaviors for preventing healthcare-associated infections? I believe there are several reasons each worthy of lengthy explorations. However, I shall try to highlight what I think is important. You may disagree; so be it. Several years ago the Institute for Healthcare Improvement (IHI) recommended against pre-operative shaving. What a revelation! Infection control professionals ran frantically from operating room to operating room eliminating razors. But what happened during the 30 + years between the original research that showed pre-operative shaving increased the incidence of surgical site infections (Seropian. Am J Surg. 1971;121:251) and the IHI recommendations? It is not as though hospital infection control committees came into existence just as the IHI began their campaign to reduce surgical site infections. Appropriate administration of surgical antimicrobial prophylaxis is another IHI recommendation. There has been a multitude of published research over the years showing that most prophylactic antibiotics need to be given within one hour of the surgical incision. The IHI strongly suggested the implementation of this recommendation. However it was not until the federal government dangled extra dollars that compliance with this recommendation increased. Or did it? Again where were the doctors assigned to the hospital's infection control committee all these years? Did they just come for lunch? Did they audit surgical prophylaxis? Did they tell the chiefs of the surgical services that antibiotic prophylaxis in their hospital was administered inappropriately? Why did patients have to be put at increased risk for a surgical site infection all those years when the research proved a relationship between appropriate antibiotic timing and selection and a positive surgical outcome? The topic of heated discussion today is methicillin-resistant Staphylococcus aureus (MRSA). The media and the public are driving the train leaving those of us who know something about the epidemiology of MRSA in their dust. The politicians are being lead to believe that active surveillance testing and contact precautions for all MRSA positive patients are the only answers to our transmission prevention prayers. The IHI has recommendations to prevent MRSA infection. One of the recommendations supports decontamination of the environment and equipment. "MRSA survives well in the hospital environment. Personnel who come in contact with contaminated objects or surfaces may contaminate their hands. Patients who are placed in rooms previously occupied by a patient colonized with MRSA occasionally acquire this organism, either via the hands of personnel or through their own direct contact with persisting organisms in their immediate environment. Thorough, regularly scheduled cleaning and disinfection of the environment are essential. Accordingly HICPAC (Healthcare Infection Control Practices Advisory Committee of the Centers for Disease Control and Prevention (CDC)) recommendations include fastidious environmental cleaning and disinfection as a priority for all hospitals." But is this last sentence a true statement? Here is what HICPAC says: "Although microbiologically contaminated surfaces can serve as reservoirs of potential pathogens, these surfaces generally are not directly associated with transmission of infections to either staff or patients." Further HICPAC states: "Although S. aureus has been isolated from a variety of environmental surfaces (e.g., stethoscopes, floors, charts, furniture, dry mops, and hydrotherapy tanks), the role of environmental contamination in transmission of this organism in health care appears to be minimal. This is music to a hospital administrator's ear. Who would be foolish enough not to take advantage of significantly reducing the environmental services department staffing if the CDC says clean when it looks dirty and as for discharge/transfer rooms make it look clean. The shame and blame is directed solely at the HICPAC/CDC staff who authorized the release of the recommendations and who should now voluntarily withdrawn, or with haste, revise the section of this document related to the cleaning [and disinfecting] the hospital's environment. We deserve better recommendations; it is the taxpayer's dollars that pay the experts expenses to these meetings three times each year and as a consumer of health care we deserve quality recommendations. Lastly, bathing patients seems to have been eliminated from daily nursing care. Some day there may be a machine to perform this procedure. In the 1987 edition of Prevention and Control of Nosocomial Infections, Elaine Larson comments: "it might be useful for patients at increased risk for infection... to use an antibacterial skin cleaning agent for bathing during hospitalization. Some investigators have demonstrated dramatic reductions in skin carriage of staphylococci and other skin flora when total washes with antibacterial soaps are done. This recommendation was published in 1981. (Brandberg A, Anderson J: Whole body disinfection by shower-bath with chlorhexidine soap. In Maibach H, Aly R (eds) Skin Microbiology: New York, Springer-Verlag, 1981). Some of the research published by our infection control fathers and mothers has long been forgotten, or if written into a hospital procedure it is ignored by nursing and ancillary department managers. Infection control professionals are never aware of that ignored step in a procedure until they have to cope with the deadly consequences of an outbreak of hepatitis C virus in the outpatient endoscopy center or testing hundreds of patients for bloodborne pathogens after an exposure to improperly reprocessed endoscopes or an outbreak of hepatitis B virus in diabetic long-term care patients exposed to community glucometers. We (collectively all of us who have dedicated our lives to infection prevention and control) have had little outside support along the way. The Joint Commission (JC) has been relatively mute and their surveyors, who are the patient safety watch dogs rarely find significant deficient practices. They know tracers but can not review a policy or procedure to determine if evidence-based standards (new and old) of infection prevention and control have been put into practice by patient care staff. The federal government won't spend a dime to train state inspectors to survey for infection control but they are more than willing to refuse payment to hospitals for that healthcare-associated urinary tract infection primarily caused by non-compliance with approved hospital infection control procedures. Infection control professionals are at the mercy of those with higher academic degrees and higher salaries. Infection control committee chairpersons are, for the most part relatively ineffective because they are independent consultants and depend on staff physicians for their livelihood. And anyone who interferes with a staff physician's practice, especially a surgeon might well be looking for work elsewhere. Yes, we, the experts, need to take a little trip back in time and consider what our fathers and mothers (Wenzel, Bennett, Brachman, Jarvis, Goldman, Larson and host of others) taught us about infection surveillance, prevention and control. We need to take control and we need to demand immediate better staffing to influence compliance with evidence-based standards. The public and the legislators are driving our train and right now there are no station stops. If you do not like my comments please do not respond. If you have constructive criticism I would love to hear from you." How can we contact you, Chris?