Big things come in small packages, very small – so small they may even be invisible to the naked eye. Take for instance a huge infection causing multiorgan system failure, disseminated intravascular coagulation, even septic shock refractory to high-dose pressors. This catastrophe may be the end result of exposure to tiny pathogenic microbes that can take down an otherwise healthy 300-pound man, tout suite!
Microorganisms are everywhere. We can’t live without them, but we can’t live with certain ones either. Unless you live in a bubble you are going to be exposed to countless bacteria each and every day. They are in the air we breathe, the water we drink, the beds we sleep in. While it is a given that we all will be continuously exposed to bacteria, having a well-considered strategy to curtail the spread of disease can dramatically decrease the risk that we, our families, and our patients are needlessly exposed to potentially life-threatening organisms.
We all know we are to wash our hands on the way in, and out, of patients’ rooms. This practice is our front line of defense against the spread of numerous potentially lethal diseases. Yet, many clinicians, as well as ancillary hospital personnel, repeatedly fail to abide by this rule, thinking that ‘this one time won’t hurt anything.’ Whether it’s the nurse who rushes into a patient’s room to stop a beeping IV pole or the doctor who eyes a family member in the room and makes a beeline to discuss the discharge plan, all of us have been guilty of entering or leaving a patient’s room without following appropriate infection control standards.
Or, how many times have you followed the protocol meticulously, at least initially, and removed your gown and gloves and washed your hands on your way out the door when the patient remembers another question, or asks you to hand him something that leads to more contact with him or his surroundings? You already washed your hands once, so must you really do it again? After all, what is the likelihood that you pick up (or pass along) any germs anyway? Sometimes, more than we realize. Something as simple as handing a patient his nurses’ call button can expose us to enough C. difficile spores to cause infection in us or others we come into contact with unwittingly. So wash those hands, and wash them again if you touch anything in a patient’s room, even if it is not the patient himself.
Direct observation (AKA “Secret Santas”) can provide invaluable information about adherence to hand hygiene among health care workers and providing feedback is key. This can be unit based, group based, and even provider based. Once collected, this information should be used to drive changes in behavior, which could be punitive or positive; each hospital should decide how to best use its data.
Visitor contact is another important issue and not everyone agrees on how to enforce, or whether to even try to enforce, infection control procedures. The Society for Healthcare Epidemiology of America (SHEA) has several helpful pocket guidelines to address this and other infection control issues. For instance, the society recommends that hospitals consider adopting guidelines to minimize horizontal transmission by visitors, though these guidelines should be feasible to enforce. Factors such as the specific organism and its potential to cause harm are important to consider when developing these guidelines. For instance, the spouse of a patient admitted with influenza has likely already been exposed, and postexposure prophylaxis may be more feasible to her than wearing an uncomfortable mask during an 8-hour hospital visit.
A pharmacy stewardship program is another invaluable infection control tool. With this model, a group of pharmacists, under the direction of an infectious disease specialist, reviews culture results daily and makes recommendations to the physician regarding narrowing antibiotic coverage. I greatly appreciate receiving calls to notify me that the final culture results are in long before I would have actually seen them myself. This allows me to adjust antibiotics in a timely fashion, thus reducing the emergence of drug-resistant organisms or precipitating an unnecessary case of C. difficile.
In addition, written guidelines should be established for indwelling catheters, both urinary and venous. The indication for continued use should be reassessed daily; a computer alert that requires a response is very helpful, as is a call from the friendly floor nurse asking, “Does this patient really still need his catheter?”
Infection control is everyone’s responsibility and we all need to work together toward this common goal.
Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at email@example.com.