Critical Thinking Neither Black nor White: Shades of Grey

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Critical Thinking Neither Black nor White
Shades of Grey

• Karen Hope, M.Sc., Regional Manager
• Infection Prevention and Control, Calgary Health
  Region
• Danielle Goulet, R.N., M.Sc.
• IPC Program Coordinator, Laval Hospital, Quebec
  City

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Objectives

• Develop a strategy to deal with uncertainties
  about infection prevention and control practices
• Facilitate decision-making about preventive
  measures by recognizing the specific features of
  each institution and clientele
• Present concrete examples of grey areas in IPC
  based on
• the nature of the infectious agent
• the health status and behaviour of the patient
• architectural and logistical constraints

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Decision-Making Process

• Deciding means making a choice between various
  alternatives following a cognitive process.

Depending on the persons degree of expertise and
the number of factors to consider, decisions can
take many forms and require different amounts of
time.
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Levels of Decision Making

• Events affecting an individual
• Patients, staff
• Decisions about isolation, PPE
• Often made on a case-by-case basis
• Events affecting a group (post-exposure f/u)
• How far to go?
• Process sometimes mandated by external agencies
• Program or system change
• Require extensive stakeholder input
• Screening programs
• Cleaning and sterilization processes
• Design

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Data Collection

• What is the healthcare context?
• Type of institution
• Short-term or long-term care centre, private
  residence, etc.
• General care, university centre, specialized
  care, rehabilitation
• Type of clientele
• Adults, children, seniors
• Origin of clientele
• Local, regional, supra-regional

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Data Collection

• What is the problem situation?
• How do we usually intervene in such a situation?
• Routine
• Protocol
• Why isnt the routine working?
• What does the literature say?
• What resources are available?
• What are the preconditions for the decision and
  what impacts will it have?

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Available Resources

• Reference materials
• Standards (WHO, CDC, PHAC, CSA, AAMI)
• APIC curriculum
• Peer-reviewed journals (e.g. APIC, ICHE, JHI,
  CJIC)
• Online resources such as PubMed, Medline
• Best practice guidelines from other centres
• Standard of care across the continuum

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More Resources

• Peer networks
• Interest groups (CHICA-Canada, AIPI)
• Websites, discussion boards
• Communities of practice
• Provincial networks
• Mentors
• Senior IPC colleague in your program
• Colleague from professional organization/local
  chapter
• Other IPCs encountered at conferences or through
  courses

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Support for Decision Making

• Organizational support
• Build a support network within your organization
• Important to have a relationship with medical IPC
  designate to build credibility with physicians
• Work in teams wherever possible so you dont feel
  like you are out on a limb
• Provide clear evidence to back your decision
• Seek assurance that your expertise is valued and
  that decisions are supported by senior
  management, particularly if liability/political
  issues are involved

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Weighing the Pros and Cons

• You may have to lose a battle in order to win the
  war!
• An integrated approach that incorporates all the
  various infection prevention measures
• Be prepared to explain the rationale behind your
  choices
• Know the possible impacts of a measure on other
  aspects of the organization

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Analysis Chart
BLACK
WHITE
-----------------------------------------
-------------
GREY

• Determine risk of transmission within the
  setting to make practical decisions about
  isolation. This could mean incurring a higher
  level of transmission risk in order to offset
  risks in other areas.

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Events Affecting an Individual

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Events Affecting an Individual

• Example 1
• Colonization vs. infection
• with BMRs
• MRSA
• ESBL
• VRE
• When to discontinue isolation?

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Deciding Factors

• Factors to consider when deciding whether to
  discontinue isolation
• Organism (MRSA, ESBL, VRE)
• Site of colonization (urine, sputum, skin, stool,
  mucus)
• Threshold
• Acuity of unit (ICU versus medical/surgical ward,
  mental health)
• Cognitive and physical status of patient (total
  care, continent, ability to comply with
  instructions, personal hygiene)
• Appropriate treatment
• Availability of private rooms and bathrooms
• Status of possible roommates
• Impact of isolation on patients care
  (rehabilitation)
• Liability

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ESBL
A patient with ESBL in urine on a rehabilitation
unit has completed antibiotic treatment but is
still colonized. Discontinue isolation?

• Questions to consider
• Is patient catheterized? Are potential roommates
  catheterized?
• Does patient have good hygiene?
• Is ESBL present in large quantities?
• Is isolation negatively impacting patients rehab
  activities?
• Are there standards available to guide your
  decision? What if they are inconsistent?
• If patient was in ICU, would that influence your
  decision?

Resources ESBL Toolkit from CHICA/APIC/ICNA SHEA
position paper (1997) Prevention of Antimicrobial
Resistance
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MRSA
Renal patient previously colonized with MRSA,
nasally and rectally, had 2 sets of negative
cultures, 1 week apart. Isolation was
discontinued prior to discharge.
The patient was readmitted 2 months later with an
MRSA bacteremia. Isolation was reinitiated.
Positive nasal and rectal cultures were also
obtained.

• Do you continue to screen?
• What if the patient reverts to negative again?
• Quality of cultures? Taking antibiotics?
• Do you decide to maintain isolation precautions
  indefinitely despite negatives?
• Limited number of private rooms, patient is
  compliant and has good hygiene.

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Events Affecting an Individual

• Example 2
• CDAD Recurrence of symptoms after a negative
  test?
• Can you discontinue isolation?

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CDAD
A patient with CDAD just completed a course of
antibiotics and is still diarrheal, but staff
sent another stool specimen and results came
back as negative for CDAD.

• Do you discontinue isolation?
• What is normal bowel function for the patient?
• Is the patient on any other drugs that might
  impact bowel function?
• What is the likelihood of a false negative
  result?
• Discontinue isolation but keep in a private room?
• Is the patient in need of total care or using the
  bathroom on his own? Personal hygiene?

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Events Affecting a Group

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Events Affecting a Group

• Example 1
• Patient with disseminated shingles (zoster) seen
  in ED and not placed on airborne/ contact
  isolation
• Post-exposure follow-up
• Who is exposed and requires follow-up?

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Susceptible HCWs

• Virus can be transmitted from lesions.
• Aerosolized virus from skin, and possibly from
  respiratory tract, may cause transmission through
  indirect contacts (JID 2008).
• Exposure criteria
• Direct or indirect contact of mucous membrane
  with vesicle fluid
• In an enclosed airspace, same room or having gt 5
  minute face-to-face contact
• Is there easy access to immune status?
• Nurses, physicians
• Housekeeping staff, phlebotomists, DI
  technicians, etc.

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Patient Follow-up

• Is it feasible to follow up all patients who were
  in ED at same time as the index case?
• How to determine susceptibility?
• If not, who to follow?
• Immunocompromised
• Pregnant
• Admitted patients
• Can you narrow the circle to those in immediate
  proximity?
• Does the design of the ED influence your decision
  (spatial separation, ventilation)?
• Would you not follow up patients and assume that
  the likelihood of airborne transmission is
  negligible and the risk is too low?

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Program or System Change

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Program or System Change

• Example 1 Screening program for BMRs (MRSA and
  VRE)
• MSSS guidelines (Quebec)
• Screening indications (based on the regions
  endemicity)
• Known carriers
• Direct transfers from another institution
• Prior hospitalizations
• Using additional precautionary methods
• Isolation for users at greatest risk
• Known carriers
• Transfers from hospital centres or outside
  Quebec, etc.
• Others?

Ref
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• Following an analysis
• Type of HC
• Clientele
• Local epidemiology
• Resources
• Infrastructures
• Etc.

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Encouraging Results

• MRSA in regression since introduction of protocol
  in 2006.
• No cases of nosocomial VRE since 2000.

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Oops, what do we do now?

VRE...
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Problem Situation

• Why and how
• Index case identified?
• Suitable screening indicators?
• Effective preventive measures?
• Risk of recurrence?
• Yes
• No
• I dont know!
• What should we do?
• Nothing, its just bad luck
• Pray it wont happen again
• Adjust the BMR protocol to reflect new data

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Gauging the Impacts

• HC specializing in cardiology and pneumology
• 16,000 admissions/year
• 10,000 hemodynamic assessments/year
• 2,000 electrophysiology studies
• Numerous inter-hospital transfers
• What do we screen for and who do we isolate?
• Do we have the necessary human, financial and
  organizational resources?
• Do we need to make any changes in the way we
  organize care (emergency, admissions, patient
  care units)?

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DRAFT
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Organizational Support
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Results

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GROUP EXERCISE

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Isolation Management

• What can we do if infrastructures are inadequate?
• No single room or toilet
• Who uses the toilet?
• Who needs to use the commode?
• Where should the excretions be emptied?
• Organization of case cohorts
• What do we do when there are no walls? Confine
  patients to their bed?

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Deciding Factors

• Desired type of isolation
• Geographic isolation
• Advantages Set up a physical barrier, facilitate
  isolation, use dedicated equipment, decrease
  potential breeding grounds
• Disadvantages Mix of clienteles who have
  different needs, more specialized staff required,
  huge increase in equipment requirements
• Isolation by section
• Advantages Patients assembled in several rooms
  in the same section of a unit or department
• Disadvantages Multiple breeding grounds, more
  frequent audits
• Isolation by specific unit with dedicated staff
• Advantages Patients continue to receive
  specialized care, specific staff members assigned
  to a group of patients with the same type of germ
• Disadvantages Additional resources required,
  multiple breeding grounds

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Deciding Factors

• Type of rooms available
• Single with private toilet
• Single with shared toilet
• Multiple occupancy with shared toilet
• With or without sink
• Condition of the patient/resident (leaky, drippy,
  gooey)
• Patient population
• Medical/surgical ward, critical care,
  rehabilitation, geriatric, mental health,
  pediatric

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NOW ITS YOUR TURN

• Exercises

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Now its your turn

• Use of personal protective equipment
• Are visitors required to gown up when contact
  precautions are in place?
• Are patients required to wear PPE when they leave
  their room?
• Do patients need a mask if they are immune
  (chicken pox, zoster)?
• During MRSA colonization or infection, is it
  necessary to wear a mask?

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Now its your turn

• Tuberculosis patients
• Should they wear an N-95 mask? What about their
  visitors?
• Post-exposure of staff Is contact tracing really
  cost-effective?
• Transporting patients
• Who wears a gown, gloves and mask?
• Do the same procedures apply to wheelchairs and
  stretchers?
• Do measures have to be enforced everywhere?
• Right to confidentiality?

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Now its your turn

• Hand hygiene
• Should healthcare workers requiring a wrist
  bandage be withdrawn from their duties or not?
• What about wrist watches?
• What if they can cover the cast or dressing with
  a glove?
• What about physicians? Who will restrict them
  from working?
• Can they perform certain tasks that are less
  risky?
• Should healthcare workers use the sink in the
  patients room or not?
• Advantage Sink is in close proximity
• Disadvantages It is often cluttered with patient
  toiletries or acts as a receptacle for equipment
  such as IV bags, etc.

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Now its your turn

• Patients transported on stretchers
• What measures should be taken for the patient?
  What about the transporter?
• Do measures vary depending on the method of
  transport?
• Walking
• Wheelchair
• Stretcher
• Cleaning and disinfection
• Can cleaning and disinfecting be carried out
  while the patient is in the room?
• Chlorine or other products What is the best
  choice? One procedure or various procedures?
• Should all unused disposable materials be
  discarded?
• Should unfinished protected consumables (liquid
  soap, paper towels, etc.) be thrown out?

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Now its your turn

• Construction and renovation
• When is it possible to compromise?
• Standards vary. Which should we adopt?
• Sterilization and disinfection
• What about instruments that fall into two
  Spaulding categories?
• Biologic indicator malfunction What do we do if
  all other parameters are sufficient?

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Conclusion

• Know where to find resources
• Build a support network both inside and outside
  your organization
• When making a decision, outline all the
  information (scientific, legal, political) that
  will influence your choice and explain your final
  rationale
• Try to maintain a level of consistency dont
  flip-flop or you will lose credibility
• Have confidence in your knowledge you have
  specialized expertise

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Word of Thanks

• Many thanks to Isabelle Tremblay for assisting
  Karen and Danielle with translation and providing
  valuable input on the presentation.