The (Im)possible role of an Infection Preventionist in the Management of Infections
So what would you do if asked to reduce your hospital’s infection rate by 4 infections, maybe as many as 10 infections per month, to reduce your hospitals composite SIR (Standardized Infection Ratio) score? Center for Medicare and Medicaid Services (CMS) mandates reporting of Multidrug Resistant Organisms (MDROs) to National Health Safety Network (NHSN). Many hospital systems have made it a priority to reduce their rates to below national benchmarks as set by NHSN. Since so many components and so many parties are involved in patient care, how can the Infection Preventionist (IP) have any control of or impact on reducing the infection rates throughout their facilities?
If we take the fastest growing infection in our hospitals, C. difficile (C. diff), we are faced with even a more daunting task. The C. diff rates are impacted by many factors including antibiotic utilization, presence or absence of culture driven antibiotic use, Proton Pump Inhibitors (PPI) usage, community C. diff incidence pressure, patient age, employed testing methodology and environmental contamination. For each factor, the Infection Preventionist must participate in leading and driving the appropriate standards of practice. The IP must encourage de-escalation of antibiotic usage and insist on culture specific and Minimum Inhibitory Concentration (MIC) appropriate antibiotic usage and dosages; remind healthcare providers as to the association of PPIs with increase occurrence of C. diff, make a case for alternative treatment therapies; utilizing the C. diff algorithm and timing test sample procurement appropriately...not retesting within 30 days of previous diagnosis, not testing for proof of cure, not testing times 3, not testing if specimen is formed; and perhaps most difficult, controlling the possible environmental contamination and transmission. Studies have shown that C. diff spores have between a 30-50% chance of being transmitted to the next occupant even after environmental cleaning, but newly Environmental Protection Agency (EPA) approved products that kill C. diff spores could help drastically reduce these rates.
The Infection Preventionist has to be able to assess where they can make the largest impact and have the most control to effect change to reduce the hospital’s Hospital Acquired Infection (HAI) rates. Together, the IP and the Infection Prevention Committee (IPC) need to determine where the highest risk for infection exists in their institution, and which are the most problematic organisms. Are the HAIs associated with devices, Surgical Site Infections (SSI’s), or with a location such as the Operating Rooms (OR’s), high precaution/isolation rooms, regular patient rooms, or public areas? Nationally, reducing device infections has been targeted by the use of insertion bundles and removing the devices promptly if no longer necessary in the care of the patient.
The IP and IPC can work directly with stakeholders to tackle specific problem areas. Nurse
driven protocols for removal of Foleys has helped in reducing Catheter Associated Urinary
Infections (CAUTIs). These rates in general have been trending down (2016, CDC.gov). SSI’s are highly variable and are really hospital dependent emphasis being on Cardiac procedures, Total joints, Colons and Hysterectomies. Hysterectomies are often impacted by the use of robotics or not, and one of the most important outcome indicators is the prep being used for vaginal procedures. Since CHG is not labelled for vaginal preps, iodine based preps are used. The data suggests that the iodine preps are six times less able to reduce bacterial load, this increases the chance of infection; further, technique is critical to doing the preps correctly. Only with close coordination with the surgical staff and individual surgeons can the IP impact these areas.
A more approachable focus for the IP is managing the disinfection of the ORs between cases; and cleaning at the end of day/shift. Rapid turn-around time of the ORs impacts the chemicals used, especially if a patient is C. diff positive. The IP has to validate the cleaning and sporicidal capabilities of the agents used, with emphasis on dwell time of disinfectant. OR competencies for between case cleaning are critical as the OR staff is usually responsible for this activity.
Checklists are critical in minimizing transmission of infectious agents by reminding staff when
opportunities exist for PPE and handwashing. End of the day cleaning for the ORs should be
carefully monitored using fluorescent markers or ATP. Surprisingly, high touch areas are not
always defined for the Environmental Services (EVS) and items such as leads are often forgotten in both the ORs and Cardiac Cath labs. Use of checklists can overcome these problems and make sure all steps for disinfecting and managing the space are followed.
Approaches to total room disinfection need to be brought to the table in the quest to lower
overall infection rates as hospitals usually are reservoirs of infectious agents whether on hard
surfaces, in the drains and water supply, equipment and staff clothing, and other soft fabrics.
Recent data suggests that non-touch cleaning and disinfection has real advantages. Making
sure that the disinfection products used are EPA registered for the specific organisms found in the hospital is another way to maximize every disinfection tool. Checklists and work with the EVS Director can put plans in place to overcome the most common mistakes such as not
changing microfiber rags frequently and making sure they go from cleanest to dirtiest, but using the best possible products provide an advantage even when applied in imperfect conditions.
Since IPs are not numerous, monitoring the activities of EVS techs is largely impossible without use of the proper products and setting up systems and checklists.
Recent advances in total room disinfection systems with a broad range microcidal activities,
should be considered in the pursuit to reduce overall HAI rates. Data suggests that these
devices will have a significant impact on reducing the overall endemic load and will actually
reduce the transmission of organisms remaining on surfaces or hard to reach areas compared with spray and wipe techniques. Recent evidence in Delaware hospitals has seen a marked reduction of C. diff with the use of a non-wipe, activated peroxide based system, (Paxton 2016).
When seemingly impossible HAI reduction goals are set, the IP can engage allies within the
hospital community to address specific problem areas, create checklists to help standardize
processes when they cannot be everywhere at once, and advocate for the use of the best
possible non-wipe disinfection products to meet the overall goal of reducing infections and
HAIs in their hospitals and improve patient outcomes.