by Suzanne Pear, RN, PhD, CIC

For example, during cardiopulmonary resuscitation – a situation considered high risk for blood and body fluid exposure and under Standard Precautions calls for the presumptive wearing of gloves, gowns, masks and eye protection5,6 – the percentage of staff wearing these items was noted in one study to be 75%, 20%, 90% and 50% respectively.² Considering the potential consequences that these breaches in barrier precautions may pose to clinicians, patients and institutions, it is essential to understand what obstacles to compliance may be present in the healthcare setting and how to overcome them.

Even in a situation of heightened infection transmission awareness such as the 2002-2003 severe acute respiratory syndrome (SARS) outbreak in Toronto, compliance with barrier precautions remained problematic.^4,7 In reviewing exposures which resulted in at least 17 HCW infections and one death, when Standard Precautions should have been used (i.e., during high risk procedures or settings), 73% occurred when Standard Precautions were not used at all and 10% when Standard Precautions were only partially used. An additional 17% of HCW exposures occurred when Transmission-based Precautions should have been implemented (i.e., patients were known/suspected to be infected with SARS) but barrier precautions were either not used or only partially used.8 Observations conducted six weeks into the Toronto outbreak noted rates of Standard Precautions compliance at 54% and Transmission-based Precautions compliance at 82%. Of the 15 SARS-infected HCWs interviewed, all reported high risk exposures with known/suspected SARS patients and frequent lapses in hand hygiene after PPE removal as well as contaminating themselves (face and clothing) with dirty gloves or while removing PPE.⁷ Additional breaches in Standard Precautions and Transmission-based Precautions included not changing PPE between patients and reusing clinical equipment without cleaning after use on a known/suspected SARS patient.⁴

It is difficult to imagine a scenario that could engender greater HCW compliance with barrier precautions use than the highly publicized and frighteningly lethal SARS epidemic, so it may be instructive to review the factors identified which contributed to the breakdown in infection prevention and control practices that put these clinicians, their co-workers and their patients at risk for serious illness and possible death. Notably, only 60% of the infected HCWs interviewed reported having received formal infection prevention and control training and most of them were unclear about PPE donning and doffing procedures and sequence, which were viewed as time-consuming and complicated.4 This level of knowledge may actually be higher than the norm considering a 2002 report noting that only 7% of U.S. medical students rotating through emergency medicine training had been taught about barrier precautions9 and a 2005 survey which identified that only 25% of the physicians and nurses from a large and well-regarded teaching hospital had received official infection prevention and control training.¹⁰

The interviewed clinicians also cited fatigue as a major contributing factor to lapses in infection prevention and control practices, which would be expected in an outbreak situation, but may also routinely exist in many understaffed and turbulent intensive care units (ICUs) and medical-surgical floors.¹¹ Concomitantly, as noted with other hand hygiene and PPE compliance reports, decreased Standard Precautions/Transmission-based Precautions compliance accompanied increased patient acuity and attendant frequency of contact.¹²

Although knowing does not always equate with doing, education is an essential, initial and ongoing component of any practice improvement process. Ensuring that staff at every level of the clinical ladder is adequately trained during the on-boarding process, retrained annually and as needed on critical infection prevention and control practices requires significant system commitment of time and other resources. One strategy that may go a long way to making that commitment a reality is to first educate the chief or C-suite – the administrative, medical and nursing leadership – on the issues and implications of infection prevention and control practice compliance and non-compliance. Predictors of Standard Precautions training adequacy in a multi-state survey identified "management commitment to Standard Precautions training programs, leadership support, frequency of providing bloodborne pathogen (BBP) information and safety climate as important institutional predictors of assessed training adequacy."¹³

Fatigue, the other major compliance barrier reported by the SARS staff, could easily be regarded as an unavoidable consequence of an outbreak situation. However, it could also be viewed as a synonym for "burn-out"¹⁴, "excess patient work-load"15, or "staffing shortage"16, all of which are being reported with increasing frequency as an everyday occurrence. The global demand for physicians and nurses17 shows no signs of abating, along with the aging of both the patient population and the clinicians caring for them. This too is a system issue – a global, national and local healthcare system issue – calling for effective, long-term strategies. Creative short-term and interim ideas must be identified to deal with this human resource reality in a healthcare environment that is also coping with increasing patient acuity and greater demand for both patient and worker safety.

Educating the C-suite about the relationships between staffing and patient outcomes, the cost-benefits of adverse events avoidance and lower staff turnover is essential to creating a top-down culture of safety and system-wide, active, on-going compliance to best practices. There are no easy or quick solutions to improving infection prevention and control practices in today’s healthcare environment. The barriers to compliance are moving targets that must receive continual attention. However, no one has ever identified frequent, best-practices education as being too-much of a good thing. A first step might be to see what the infection prevention and control knowledge level is among the administrators and clinicians in your institution; it would certainly be a step in the right direction.

References

1. Siegel JD, Rhinehart E, Jackson M, Chiarello L. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings. Am J Infect Control 2007;35(10 Suppl 2):S65-164.

2. Chiang WC, Wang HC, Chen SY, Chen LM, Yao YC, Wu GH et al. Lack of compliance with basic infection control measures during cardiopulmonary resuscitation-Are we ready for another epidemic? Resuscitation 2008.

3. Gammon J, Morgan-Samuel H, Gould D. A review of the evidence for suboptimal compliance of healthcare practitioners to standard/universal infection control precautions. J Clin Nurs 2008;17(2):157-167.

4. Ofner-Agostini M, Gravel D, McDonald LC, Lem M, Sarwal S, McGeer A et al. Cluster of cases of severe acute respiratory syndrome among Toronto healthcare workers after implementation of infection control precautions: a case series. Infect Control Hosp Epidemiol 2006;27(5):473-478.

5. Christian MD, Loutfy M, McDonald LC, Martinez KF, Ofner M, Wong T et al. Possible SARS coronavirus transmission during cardiopulmonary resuscitation. Emerg Infect Dis 2004;10(2):287-293.

6. Teja VD, Lakshmi V, Sudha T. Impact of the human immunodeficiency virus infection on emergency medicine department in a tertiary care hospital in India. Indian J Med Microbiol 2004;22(3):159-165.

7. McGeer A. Institute of Medicine. Healthcare Workers and PPE: Lessons from SARS. PPE for HCWs during an influenza pandemic. Preparing for an influenza pandemic 2007;

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13. McCoy KD, Beekmann SE, Ferguson KJ, Vaughn TE, Torner JC, Woolson RF et al. Monitoring adherence to Standard Precautions. Am J Infect Control 2001;29(1):24-31.

14. van SG, Leake B. Burn-out in hospital nurses: a comparison of acquired immunodeficiency syndrome, oncology, general medical, and intensive care unit nurse samples. J Prof Nurs 1993;9(3):169-177.

15. Korn R, Mansfield M. ED overcrowding: an assessment tool to monitor ED registered nurse workload that accounts for admitted patients residing in the emergency department. J Emerg Nurs 2008;34(5):441-446.

16. Isgur B. Healing the health care staffing shortage. Trustee 2008;61(2):18-21, 1.