Practice Management - Clean is as clean does

February 20, 2015
By Amber Hogan Mitchell

Why innovative engineering is needed to reduce transmission of germs

In the August 2014 issue of HCBN, “Fighting dirty: the war on germs” author Gus Iversen explores the ability that health care systems now have to reduce the transmission of superbugs that can cause infection or illness in patient populations by practicing “medicine in the cleanest environment(s) possible.” He highlights several new commercially available technologies including “germ zapping” robots and antimicrobial scrub uniforms. The proverbial elephant in the room, however, is lower than acceptable compliance rates with protective actions like hand hygiene and the use of personal protective equipment (PPE). As such, we find ourselves relying more and more on advances in technology for fighting the war on bugs — engaging in stealth fighting tactics rather than hand-to-hand combat.

Longstanding practices like hand hygiene (to include the proper use of gloves) and wearing PPE, protect both health care worker and patient alike; they serve as a disruption to a superbug’s cycle of life — either washing them down the drain or preventing them from taking a free ride. In his article, Iversen identifies that hand hygiene compliance rates fall below 50%. Newly available data through the International Safety Center illustrate that compliance with PPE use is even lower. In fact, the highest risk types of exposures to health care workers are blood and body fluid splashes to the eyes, nose, and mouth. These exposures essentially have the ability to infuse harmful viruses or bacteria into a new host. From a group of nearly 60-plus U.S. hospitals that contributed to The Center’s Exposure Prevention Information Network, of the blood and body splashes that occurred simultaneously to the eyes, nose, and mouth, in only three of 152 cases were personnel wearing the appropriate PPE. That’s a measly 2 percent!

Defining clean in health care
A focus only on clean environments and bug zapping technologies is only as successful as their ability to kill what they can manage to kill. There must be something first that eliminates the heft of blood and body fluids, whether that is PPE or some other form of engineering like sharps safety devices, closed system suction canisters, or fluid repellent barriers for soft or mobile surfaces. Because antimicrobial technologies alone are not effective against all of the bugs that live in a spray of blood or a pint of vomit, they must often rely on two or more mechanisms of action where fluids can be repelled and whatever bugs are left can then be killed.

Expecting a single technology to reduce levels of body fluids would be the equivalent of a household placing a pan with half of Sunday’s leftover pot roast in a dishwasher and asking that dishwasher to miraculously digest the leftovers — roast, veggies and all — while also cleaning, sanitizing, and drying it.

When thinking about safety in a health care environment, we first think about clean. Clean surfaces, clean floors, clean linen, clean bodies, and clean hands. Clean can be as simple as free from visible soil. Clean gets rid of that spray of blood or that pint of vomit. The next step is where technologies like UV, ozone, hydrogen peroxide, and myriad antimicrobials can work on whatever microscopic contamination is left. We cannot sanitize, disinfect, or sterilize without first having clean. Products that claim to do both or all are simply not real.

The “positive deviance” of clean
Health systems, hospitals, health care workers, executives, researchers, and manufacturers need to work collectively together. Diverse working groups with cross-functional backgrounds that are focused on solutions for a cleaner, safer health care environment is now a phenomenon growing in public health and health care called “positive deviance.” Positive deviance is an asset-based, problem-solving, and community-driven approach that enables a community to discover uncommon successful behaviors and strategies, and develop a plan of action to promote their adoption by all.

The practice has been used in infection prevention in innovative ways, using feedback techniques where all groups within the health care facility participate. These groups include those without traditional clinical roles. For instance, in one urban hospital, it was the clergy that identified a possible way to break the chain of transmission when visiting patients from one room to the next, by wrapping their holy book in between visits. In the forward to the book, “The Power of Positive Deviance” Dr. Atul Gawande offers the following:

Along the way, you will sometimes feel worn down, your cynicism taking over. But resist. Look for those in your community who are making health care better, safer, and less costly. Pay attention to them. Learn how they do it. And join with them.

Ultimately, clean is as clean does.

About the author: Amber Hogan Mitchell, DrPH, MPH, CPHleads Vestagen Technical Textiles’ regulatory affairs, scientific, and educational initiatives. She specializes in regulatory and policy issues related to safe, quality healthcare. She was the OSHA National Bloodborne Pathogens Coordinator and has several Secretary of Labor Excellence awards.