Monday, June 11, 2012

Your infection questions answered














Here are Dr. Michael Gardam's answers to your questions following our interview about infections acquired in hospital. Dr. Gardam is medical director of infection prevention and control at Toronto's University Health Network.

1. Do you believe that it is an acceptable practice to wash with an antibacterial waterless soap instead of using the authentic soap and water? I have heard that in some facilities the doctors/staff are able to see up to three patients and use the waterless alternative in between them and then after the third pt. require that the doctor/staff uses soap and water. As a parent of 1 special needs child and three other children, I always prefer that soap and water be used. Any thoughts?

DR. MICHAEL GARDAM: A LOT OF PEOPLE, INCLUDING SOME HEALTHCARE WORKERS, THINK THAT SOAP AND WATER IS BETTER THAN ALCOHOL GEL AND THAT ALCOHOL GEL IS A BIT OF A CHEAT.

IN FACT, ALCOHOL GEL IS ALMOST ALWAYS SUPERIOR TO SOAP AND WATER: IT KILLS MORE BACTERIA AND VIRUSES, WORKS FASTER, IS LESS DRYING ON THE HANDS, AND CAN BE USED MUCH FASTER AND WHILE YOU ARE MOVING. BECAUSE IT IS SO MUCH EASIER TO USE, HEALTHCARE WORKERS ARE ALSO MUCH MORE LIKELY TO USE IT THAN SOAP AND WATER. SO BOTTOM LINE, ALCOHOL GEL IS A VERY GOOD THING.

2. It is really quite shocking when you think of the "miracles" medicine is capable of and the lengths (and costs) that doctors will go to to save a life yet here is something as simple as soap and water and children are dying needlessly.

I have 2 questions, please.

A. Would a child with a congenital heart condition be more prone to infection?

DR. MICHAEL GARDAM: DEPENDING ON THE HEART CONDITION, THE CHILD MAY BE MORE PRONE TO HAVING HEART INFECTIONS, SPECIFICALLY BACTERIAL INFECTIONS OF THE HEART VALVES (ENDOCARDITIS). ALSO, ANY CHILD THAT REQUIRES HOSPITALIZATION AND OR INVASIVE TREATMENTS LIKE INTRAVENOUS LINES WOULD ALSO BE MORE PREDISPOSED.

B. Is there benefit to prevent infection in the form of prophylactic antibiotics before surgery or probiotics taken while in NICU/PICU?

DR. MICHAEL GARDAM: ANTIBIOTIC PROPHYLAXIS IS DEFINITELY BENEFICIAL BEFORE SOME TYPES OF SURGERIES. THERE ARE VERY CLEAR GUIDELINES AVAILABLE SO IT IS GENERALLY EASY FOR SURGEONS TO KNOW WHETHER THEY ARE USEFUL OR NOT. IN TERMS OF PROBIOTICS, THE JURY IS STILL VERY MUCH OUT ON WHETHER THEY ARE USEFUL--IT ALSO VERY MUCH DEPENDS HOW THEY ARE BEING USED AND WHAT FORMULATION IS BEING USED.

3. Has anyone's child ever gotten an infection from the equipment that is being used in the room? ie the thermometer, pressure cuffs, etc? Like you say not everyone is bold enough to ask for the wipes to clean it or are too embarrassed to do so in front of staff. Even if the staff is washing their hands, don't you feel there should be some standard in place to help stop the spread of infection that is transferred from the equipment and then onto the "clean" hands or that all the equipment is solely for that one pt alone? I know many times they are placed in portable stands and wheeled room to room.

DR. MICHAEL GARDAM: IT IS HARD TO PROVE THAT INFECTIONS CAN BE CAUSED BY POORLY CLEANED, MULTIUSE EQUIPMENT, BUT WE DEFINITELY KNOW THAT BACTERIA CAN LIVE THERE, SO IT IS QUITE REASONABLE TO ASSUME THAT EQUIPMENT MAY BE ONE OF THE MODES RESPONSIBLE FOR PASSING BACTERIA AROUND THE HOSPITAL AND BETWEEN PATIENTS.

ALL MAJOR GUIDELINES STRESS THAT MULTIUSE EQUIPMENT SHOULD BE CLEANED BETWEEN PATIENTS.

4. How do you deal with this scene? When doctors and nurses come into the room the first thing they do is wash their hands and then begin the exam of the child. BUT, then they begin to chart on the computer or use a pen while taking vitals for instance and in turn go back to touching your child? This computer has been used by who knows who that has just touched who knows what and the pens go everywhere -floors , pockets, bathrooms.

How can you stop the spread of infection then and is there an appropriate way to ask that charting/writing be saved for the end of the visit and not during the exam itself?

DR. MICHAEL GARDAM: THERE IS NO EASY ANSWER TO THIS ONE: THE HEALTHCARE WORKERS HAVE IT HALF RIGHT BUT DON'T REALIZE THEY ARE RECONTAMINATING THEMSELVES. WE SOMETIMES DO EXERCISES WITH STAFF WHERE WE COVER A SURFACE WITH PAINT AND HAVE THEM WORK AS THEY NORMALLY DO--IT OFTEN DRIVES HOME THE POINT THAT THEY ARE SPREADING THINGS ALL OVER THE PLACE.

5. Are there any statistics that prove wearing gloves can slow or stop the transfer of infections? While in NICU, many workers would wash their hands and then swiftly put on gloves. However, they would then continue to touch objects in the room, or their faces and then my baby. Also sometimes when reaching for the gloves, it is easy to see that a worker gets more than they need so they then stuff them back into the box. Aren't these gloves now contaminated?? What next?

DR. MICHAEL GARDAM: THERE IS NOT GOOD EVIDENCE FOR USING GLOVES IN NORMAL CIRCUMSTANCES--FOR THE MOST PART THEY ARE MEANT TO PROTECT THE HEALTHCARE WORKER, NOT PATIENTS (EXCEPT OF COURSE STERILE GLOVES DURING PROCEDURES WHICH PROTECT BOTH). SO PUTTING ON GLOVES AND THEN GOING PATIENT TO PATIENT SIMPLY SPREADS THINGS AROUND AS YOU WELL KNOW. THIS IS A MAJOR CHALLENGE WITH HEALTHCARE WORKERS. LIKE MY ANSWER TO THE PREVIOUS QUESTION, SOMETIMES USING A SURROGATE FOR BACTERIA, LIKE PAINT, WILL HELP THEM REALIZE WHAT THEY ARE DOING.

6. This is wonderful, and I applaud Dr Gardam for his attention to this issue. It is, however, possible to get to zero when it comes to central line infections. Cook Children's NICU hasn't had a central line infection in 3 years. The Children's Hospital in Providence has similar stats:

http://www.innovations.ahrq.gov/content.aspx?id=3265

And the Keystone ICU project has had similar results.

http://www.who.int/patientsafety/implementation/bsi/background/en/index.html

So it can be done - with attention to detail, knowledge & the will to change.

Thanks for the great post!

Kate

DR. MICHAEL GARDAM: DON'T GET ME WRONG, SOME TYPES OF INFECTIONS CAN BE DRIVEN VERY CLOSE TO ZERO--CENTRAL LINES ARE ONE OF THEM. OTHER THINGS LIKE C. DIFFICILE ARE SO MUCH MORE COMPLEX THAT ONE CANNOT REALISTICALLY EXPECT TO GET TO ZERO (THERE ARE MANY FACTORS OUTSIDE THE CONTROL OF HOSPITAL STAFF, UNLIKE CENTRAL LINES WHERE THEY HAVE DIRECT CONTROL OVER ALL ASPECTS OF THE LINE). CONGRATULATIONS BY THE WAY--MOST ORGANIZATIONS HAVE NOT ACHIEVED THAT KIND OF SUCCESS.

7. Thanks for your comments, Kate. I'd like to know where we can find similar data in Canadian hospitals. I have heard that the "number of days since last infection" is an incredible motivator for staff and administrators.

Dr. Gardam, is this information available for Canadian hospitals? If so, where would it be found and if not, why not?

DR. MICHAEL GARDAM: WHATEVER CANADIAN DATA EXIST, TYPICALLY COME FROM THE CANADIAN NOSOCOMIAL INFECTION SURVEILLANCE PROGRAM (CNISP) AND THEIR PAPERS ARE AVAILABLE ON LINE THROUGH THE PUBLIC HEALTH AGENCY OF CANADA WEBSITE:

http://www.phac-aspc.gc.ca/nois-sinp/survprog-eng.php

 IT IS HARDER TO GET GOOD CANADIAN DATA HOWEVER BECAUSE HEALTHCARE IS CLEARLY A PROVINCIAL RESPONSIBILITY AND IT IS QUITE HARD TO GET THE PROVINCES ALL LINED UP TO REPORT STUFF TO THE FEDERAL GOVERNMENT--SIMPLY PUT, THERE IS NO REQUIREMENT TO DO SO.

8. Hi Louise and Dr. Gardam!

I have a friend whose baby was a preemie and it got an infection in the NICU, he got brain damage and also he got blind, I see my friend suffer because this could be preventable and nobody apologized, they just told her it happens all the times, but in her heart always will be that feeling that her son could be in a different condition if they followed the sanitize rules. And in my cases my son got a surgery G-tube placement plus a fundoplication and I could not believe that the surgeon has very long nails and also she did not take the nail polish off. And because I felt embarrassed to say something I did not say anything when in my mind. And unfortunately my instinct was right, she did a not good performance. The surgery was wrong and up  until today my son has consequences of that wrong surgery.

The problem is not just that there is a lot of negligent management in the hospitals. The main problem in the first place the doctors do not accept their mistakes and they blame the parents. I complain to the College of Physicians and Surgeons against 12 doctors and after back and forth showing clear mistakes with test and papers. The college just decide to cover the negligent doctors saying they did what they could. God knows how difficult it is for a parent to forget and forgive such kind of mistakes, and more when to see that your son almost died because of this and second that today still has a consequence of these mistakes.

DR. MICHAEL GARDAM: YES, YOUR SAD STORY IS ONE I HAVE HEARD OFTEN--WE CONTINUE TO TREAT HEALTHCARE ASSOCIATED INFECTIONS AS A COST OF DOING BUSINESS ALTHOUGH THE SYSTEM IS STARTING TO WAKE UP AND REALIZE THAT MOST OF THESE ARE ENTIRELY PREVENTABLE. ALL INFECTION GUIDELINES RECOMMEND THAT HEALTHCARE WORKERS HAVE SHORT NAILS WITH NO OR ONLY CLEAR POLISH.

9. What are the top things you would recommend parents with medically fragile children who are in the hospital frequently or for long periods do to protect their children?

We have 2 former preemies (a 4 year old who was trached & vented, and a 1 year old currently trached and vented) - the NICU was pretty low infection, but my daughter's 70 day PICU stay over this winter resulted in a line infection, c. Diff, and 3 other infections... which seems excessive, since she was on contact precautions the entire stay (originally admitted for suspected RSV; caught the first infection before they'd cleared precautions for the virus, and each successive infection came before the last one was cleared). Very frustrating.

DR. MICHAEL GARDAM: THERE IS NO EASY ANSWER TO YOUR QUESTION--INFECTIONS CAN OCCUR THROUGH A VARIETY OF MECHANISMS--THROUGH DEVICES LIKE CENTRAL LINES, URINARY CATHETERS OR ENDOTRACHEAL TUBES (USED WHEN THEY ARE ON A VENTILATOR), SURGICAL WOUNDS, UNCLEAN HEALTHCARE WORKER HANDS, DIRTY EQUIPMENT, DIRTY BEDS OR SURROUNDINGS, OVERUSE OF ANTIBIOTICS ETC. SO THERE IS NO ONE BIG FIX.

I WOULD RECOMMEND THE FOLLOWING THOUGH:

1. BECOME AN INFORMED CONSUMER--IF YOU FEEL COMFORTABLE DOING SO, ASK WHAT THE HOSPITAL IS DOING TO PREVENT THESE THINGS. THERE IS NO DOUBT THAT HAVING A FAMILY RIDE SHOTGUN FOR A HOSPITALIZED PERSON IS A VERY GOOD DEFENCE. WHEN MY FATHER WAS HOSPITALIZED A FEW YEARS AGO, I GENTLY CHALLENGED WHY HE CONTINUED TO HAVE A URINARY CATHETER DAY AFTER DAY. I ALSO POINTED OUT THAT HE WAS AT HIGH RISK FOR GETTING AN INFECTION BECAUSE OF IT. I WAS TOLD NOT TO WORRY BY HIS NURSE BECAUSE THAT WAS WHAT ANTIBIOTICS WERE FOR.

2. CLEAN YOUR OWN HANDS AND THOSE OF YOUR CHILDREN IF THEY ARE OLD ENOUGH.

3. I PERSONALLY SUGGEST TRYING TO CLEAN YOUR CHILD'S IMMEDIATE ENVIRONMENT ALTHOUGH THIS IS OFTEN VERY TRICKY TO DO DEPENDING ON THE CIRCUMSTANCES.

4. ONLY IF YOU FEEL COMFORTABLE, YOU CAN TAKE IT UP A NOTCH AND DIRECTLY TALK ABOUT HEALTHCARE WORKER HAND HYGIENE AND CLEANING. I HAVE SEEN THIS GO HORRIBLY WRONG WHERE PATIENTS AND FAMILIES HAVE BEEN YELLED AT SO BE CAREFUL. THIS IS NOT AN EXCUSE--YOU ARE ENTIRELY WITHIN YOUR RIGHT TO TALK ABOUT THESE THINGS.

2 comments:

Thanks so much Dr. Gardam!!

Thank you Louise and Dr Gardam
This series was quite interesting to read.
Dr Gardam's last comment saddens me as the suggestion that parents be careful to avoid being yelled at really encapsulates my experience.
I am very, very tired of being the victim of a culture so lacking in professionalism that parents would be yelled at for asking about something that Dr Gardam points out is within their rights to question.