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Two Schools of Thought: A Response to the Article, “It All Adds Up”Infection Control Practitioners Question Content
04/01/2005
“IT ALL ADDS UP,” by Kim Wood, RN, MBA, a senior consultant in supply chain performance improvement with Premier, Inc., ran in the February/March 2005 issue of EndoNurse magazine. While the author received several positive responses, there was also response from infection control practitioners questioning some of the article’s content. EndoNurse has printed the following representative query with permission of the author, as well as feedback from Loretta Fauerbach, MS, CIC, director of infection control at Shands Hospital, University of Florida, a national expert on infection control and Association of Professionals in Infection Control and Epidemiology (APIC) board member. Her responses are designated with “LF” int the text below.
Gowns If it is not soiled or otherwise compromised, it’s not necessary to change your gown for each patient. Check out your physicians — you’re likely to see that they keep the same gown on all day, unless it is soiled. There is no good reason to change an unsoiled gown, and the annual savings can be very great if the practice is halted. An average price for a procedure gown ranges from $1.10 to $2.42. The savings will depend on how well the nursing staff observes this new way of thinking. LF: One of the things that we know is that personal protective equipment (PPE) can acquire bacteria, viruses and microbiological contamination without being visibly soiled. Standard precautions would have you not use those between caring for two patients, especially in the endoscopy suite, where you have the likelihood of handling what the Occupational Safety and Health Administration (OSHA) calls “other potentially infectious materials,” like bowel contents.When you look at today’s environment, and you have patients that carry Vancomycin-resistant Enterococci (VRE) in the stool and C. difficile, you certainly can become contaminated in the presence of a patient who is shedding that without even knowing that it’s on your gown. So if you use that same piece of protective clothing to go from patient to patient, you will have carried that from patient to patient. Basically, protective equipment is for interaction with individual patients. Sterile water Sterile water is indicated in some procedures, but often it’s used indiscriminately, for every purpose in the endo lab. Why use sterile water when the procedure isn’t even a clean one? The Society of Gastroenterology Nurses and Associates (SGNA) recommends that sterile water be used for irrigation, sterilizing the water bottle each day, and prior to each Endoscopic Retrograde Cholangiopancreatography (ERCP). A study1 using tap and sterile water concluded that tap water in non-sterile bottles is safe and cost-effective, while another study2 concluded that use of tap water is a more practical approach. LF: Not only does the Society of Gastroenterology Nurses and Associates (SGNA) recommend sterile water for irrigation, so do the multi-society guidelines for reprocessing flexible endoscopes that were published by the Institute for Continuing Healthcare Education (ICHE). The Association for Professionals in Infection Control and Epidemiology (APIC) and the Society for Healthcare Epidemiology of America (SHEA) both agreed on this, as well as the Centers for Disease Control and Prevention (CDC). On July 1, 2003, they very specifically indicate that you should use sterile water, because tap water has been shown to harbor organisms. You don’t expect it to be sterile, but you don’t want to start out with a loading dose of certain water bugs, and then have it sitting there, being used and building up.THE SUCTION CANISTER The suction canister is, perhaps, unsightly — but is that enough of a reason to change it after every procedure, when it may be only fractionally full? There is no possibility of backflow as suction is constant, so this is clearly an esthetic issue, not a clinical one. Some organizations have solved the problem very neatly — disguising it for patients by tossing a bouffant cap or paper towel over the suction canister.LF: This is an esthetic problem and there are no guidelines one way or another, but again, the whole concept of having things in the environment that have been there from another patient and used, you can potentially handle and get a problem.FLUSH CONTAINER Are you using a graduate (costing $0.18 each) as a flush container? Why? When the same job can be performed by an emesis basin (costing $0.08) or even a 16 oz. cafeteria cup (costing $0.02 to $0.04)? The measurement features of the graduate are not utilized, so why pay extra for them?LF: You should have one container per patient. Whatever you are using, you should not take between patients.IV kit vs. swab/tape The typical IV kit contains a number of items that are simply wasted — thrown away because they are not needed. So why automatically break out an IV kit (costing $0.90 to $1.23 each) when simply using an alcohol swab and tape (costing $0.15 for both ) will yield the same result? Remember, an IV that you provide for endo procedures is rarely on the patient for more than an hour, so the long-term antibacterial elements (e.g., tegaderm) that an IV kit includes are simply not needed. LF: The CDC/HICPAC IV guidelines published in 2002 clearly do not list alcohol as your primary access to starting a peripheral IV. Just using an alcohol swab and tape — although they don’t have it in place for very long, you have to be able to cover the port. When you first inject, the patient may ooze. You can use regular gauze — you don’t have to have a kit, but the first choice for prepping a site is chlorhexidine gluconate, second is povidone iodine and third would be alcohol if you can’t use any of the above.Lubricating jelly Individual foil packs of lubricating jelly cost about $0.04 each, and five packs or more can be used in a typical case costing $0.20 per case. In contrast, a 4.5 oz. tube of lubricating jelly costs $0.78, and it can be used for four or five cases, costing $0.16 per case. LF: Although it is cheaper for a big tube vs. individual packets, what I would have to say is that if you contaminate that larger tube and cause an outbreak, what have you saved? You usually take the lubricant to the bedside for insertion. You could have a tube that you filled up away from the patient when you’re prepping up, but would you or would you not have enough? Again, it’s that concept of if it’s in the patient’s field, it can become contaminated. You don’t want to take it from patient to patient.Suction can disposal A good practice is to wear PPE, dump the contents of the suction canister into a hopper, and discard the canister in a regular trash bag (not a red biohazard bag). Suction cans are not hazardous waste and do not require that treatment. The average cost to dispose of a biohazard bag is $0.25 per pound, and a canister weighs approximately 10 pounds when full. Thus, the savings are approximately $2.50 per canister. In addition, it’s not necessary to use a solidifier, which can represent an additional cost savings of $1.32-$3.02 per disposal. Dispense with these powder pellets to save substantially on every disposal. LF: You’re putting your healthcare worker at risk asking them to drain or dispose of the fluid. There’s splash-back. They would have to put on full protective garb — goggles or face shield, gloves and a gown — to be able to dump the suction can. There’s are costs associated with that. Many states say that if you have increased fluids more than a certain amount in a red bag, you have to either gel it or add absorbent to the bag to absorb potential leakage.We also invited Kim Wood, RN, MBA, author of “It All Adds Up,” to respond to the concerns. As a performance improvement consultant, I meet every day with professionals in the OR and other departments whose administrators want them to change their behavior. It’s my job to convince them that the better performers embrace change, seeking ways to improve patient care quality while reducing or containing costs. Therefore, I know it’s necessary to persuade skeptics who are reluctant to change practices they may have followed for years without question. People see things and interpret them differently, but it all comes down to what practices an organization supports. Where organizations have adopted the suggestions in my article, infection control (IC) rates have not changed from previous levels. And it’s always wise to rely on the clinical judgment of excellent nurses and supervisors to make important decisions in close calls. In responding to Ms. Fauerbach’s comments on some of the points in my article, I also consulted colleagues in Premier’s Safety Institute. I thank them for their gracious assistance. GOWNS: The CDC Standard Precaution says: “Wear a gown (a clean, nonsterile gown is adequate) to protect skin and to prevent soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. Select a gown that is appropriate for the activity and amount of fluid likely to be encountered. Remove a soiled gown as promptly as possible and wash hands to avoid transfer of microorganisms to other patients or environments.” Obviously a soiled gown should be removed promptly. (However, shoe covers and hats, etc., are considered PPE — for the worker’s protection — and are not changed after each patient in GI or in OR.)The issue really is — what does soiled mean? CDC does not say soiling must be visible, and I think good clinical judgment indicates when there is otherwise a risk.STERILE WATER: SGNA’s Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Scopes for Reprocessing Endoscopes: “Tap water and/or water that has been filtered by passage through a 0.2 micron filter or water of equivalent quality (i.e., suitable for drinking) should be available in the reprocessing area. Bottled sterile water may be used.” In addition, SGNA “supports the following position”: “Sterile water should be used in the water bottle for all endoscopic procedures.” Those are the only two SGNA statements/ recommendations/positions that address the use of sterile water v. tap water during this procedure. Sterile water must always be used during ERCP, of course, as it is an invasive procedure.SUCTION CANISTER: Suction canisters are designed to be closed systems to prevent chance cross-contamination. My suggestion (to avoid a potential esthetic problem by covering the canister with a bouffant hat or even taping a paper towel around it) acknowledges the issue of “infection perception” and honors the current patient safety culture.FLUSH CONTAINER: The one-way valve on the equipment ports is designed to prevent cross-contamination. Proper syringe technique is what is required for patient safety. Good aseptic technique is always recommended in handling these items. Many facilities keep a second larger bottle/container with enzymatic in it to flush the scope at the end of case and use the same flush all day. Even if cross-contamination occurs in this container, the scope is being terminally cleaned.IV KIT VS. SWAB/TAPE: CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections do recommend chlorhexidine-based preparations but also say alcohol or betadine may be used. The latter are fast-drying while chlorhexidine (which has a superior kill rate) can take as long as five minutes to dry. That can be an issue in busy situations. But the issue here is about the swab used — an IV kit is not needed.LUBRICATING JELLY: Most organizations already use the larger tube; I included this tip in the article only because a few could still save money by adopting the recommendation. Proper technique has the lubricating jelly placed on a non-sterile 4x4, which is then placed at the patient’s bedside. Tubes cannot be refilled once empty they are disposed into trash — so they will not be contaminated.SUCTION CAN DISPOSAL: Any confusion I may have inadvertently created can be easily cleared up. Only staff with the proper PPE should empty canisters — ever.The staff in the GI lab cleaning scopes wear PPE. Or, send the canisters in a case cart to the decontamination area of SPD, since these employees wear the proper PPE.
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