Standard infection control precautions with all patients have been long recommended, but there is a surprising lack of definitive data about what role they actually play in protecting the patient and the healthcare worker.
Of course, the struggle to improve hand hygiene, glove use, needle safety, and the donning of gowns if indicated has been documented with mixed results in various studies over the years.
Now a national study enrolling some 100 hospitals and units this year seeks to answer some big-picture questions, including the effect of a facility’s perceived safety culture on standard precautions adherence. Another question is whether high compliance with standard precautions actually translates to lower worker blood exposures and needlesticks, and fewer healthcare associated infections (HAIs).
“The aims of the study focus on three really important public health problems: high [exposure] rates to healthcare workers, high rates of HAIs, and low levels of standard precautions adherence,” says Amanda Hessels, PhD, MPH, RN, CIC, CPHQ, associate research scientist Columbia University School of Nursing in NYC. “Another study aim is designed to test whether a more positive patient safety environment is associated with a greater portion of standard precaution adherence.”
Associations on Board
It has become a common adage that “you can’t have patient safety without worker safety,” which certainly makes intuitive sense. In attempting to link the two, Hessels and colleagues have drawn the support of some major organizations and agencies, including the Association for Professionals in Infection Control and Prevention (APIC) and the Association for Occupational Care Professionals in Healthcare (AOHP).
“The gap this study is addressing is that there is a focus on the healthcare worker and occupational health safety, and then there is the other side—the folks that look at patient safety,” she says. “As a registered nurse myself, I [understand] that whether or not I adhere to standard precautions could impact not only my safety, but my patients’ safety as well. These are really overlapping goals, and [this research] is a unique way to leverage both of these priorities.”
In that regard the researchers are reaching out not only to infection preventionists, but also to their employee health colleagues. Of course, in some small facilities that may be the same person.
“I am hearing from occupational health professionals who are interested in this,” she says. “They are also very interested in understanding factors that influence healthcare workers’ behaviors—whether it is an active decision or an oversight. What are the factors that influence those behaviors?”
The three-year study, “Impact of Patient Safety Climate on Infection Prevention Practices and Healthcare Worker and Patient Outcomes,” is being funded by the National Institutes of Occupational Health (NIOSH) and the CDC.
As this story was filed, the researchers were recruiting participants with experience in nursing or in recording infection prevention observations or similar training. Participants will receive basic training on standard precautions at the onset to ensure everyone understands and is using the same basic principles.
“The training is to reiterate their existing knowledge base and refresh their understanding of the standard precautions recommendations, which are some 20 years old, so that we are all on the same page initially,” she says. “In collecting these observational data we will be training a national cadre of nurses, infection preventionists and others to do something similar to what they do in their day to day work, which is observational surveillance. We’re going to for the first time use tools that are standardized and have some reliability and validity so we can compare across sites.”
As IPs are aware, standard precautions recommended by the CDC apply to all patients. Those precautions include hand hygiene and the use of gloves, gowns, masks, eye protection, or face shields, depending on the anticipated exposure.1 In addition, using safe injection practices and handling equipment in a manner to prevent transmission of infectious agents are recommended. Respiratory hygiene was also added to standard precautions after the emergence of SARS in 2003, directing patients to cover coughs and sneezes when they first present to a healthcare setting.
People across the nation are contacting Hessels because “they want their team on board to undergo this training and to assist,” she says. “In other words, there is more than one person per site that is interested in participating. I think that is a unique and a very telling finding about how very important this [topic] is to folks on the frontlines of preventing both healthcare workers’ exposures and hospital associated infections.”
CLABSIs, CAUTIs, BSIs
The HAI outcomes data collected in the study will include central line associated bloodstream infections, catheter associated urinary tract infections, and hospital-onset MRSA bloodstream infections. The study will also use the AOHP’s Expo-Stop tool to collect occupational exposures to blood through splashes and needlesticks.
“It’s very similar to the OSHA 300 log,” Hessels says. “We wanted to capture data with minimal burden on respondents,” so researchers targeted data that already was required to be reported, or was of value and easy to collect. “The outcomes that we are looking for [with that tool] are bloodborne pathogen exposure rates,” she notes.
Elements of the study are designed to offset the Hawthorne effect, which essentially means people change their behavior when they know they are being observed.
“Collection of observational data is considered the gold standard,” she says.
“But there is a terrific interplay in looking at data in concert—different types of data, observational data, electronically obtained data. For these data, the Hawthorne effect is being minimized by the observer collecting data on routine healthcare in a manner in which they are situated in a space or a place where they are not interacting with either the healthcare workers or the patients. They are really part of the ‘environment’ and just collecting data during the standard work flow. This is really a snapshot of activities and behaviors.”
One of the observational tools used in the study was described in a recently published paper2 by Hessels and colleagues.
“It is important to standardize definitions of behavior, and we are using a tool that we previously evaluated and tested,” she says. “The standard precautions tool was developed specifically for the [published] study. It’s like a checklist, and it is adapted from the design, content, and testing of the WHO hand hygiene observational tool. We used a format that is familiar to the IPs, with some of the same sort of nomenclature regarding encounters, the types of observations, and so forth. We added that to other items of the standard precautions recommendations.”
The observational study will assess compliance with the standard precautions measures, including the following:
- Use appropriate hand hygiene before touching a patient, after touching patient, and after contact with the patient environment and surroundings.
- Don gloves before touching blood, body fluids, secretions, excretions, contaminated items, patient mucous membranes, and nonintact skin, and during invasive procedures.
- Remove gloves immediately following the procedure or indication for glove usage.
- Don a gown when performing procedures and patient-care activities when you will come into contact with clothing or exposed skin with blood or body fluids, secretions, and excretions.
- Remove the gown immediately following the procedure or indication for gown usage.
- Don a mask, eye protection (goggles), or a face shield during procedures and patient-care activities likely to involve droplets, aerosolization, splashes or sprays of blood, body fluids, and secretions, especially during suctioning and endotracheal intubation.
- Immediately place used sharps in a puncture-resistant container.
Strange FINDING
Another data collection tool to assess patient safety culture in the study was developed by the Agency for Healthcare Research and Quality (AHRQ).
“We have adapted this tool to include questions to respondents about their standard precaution practices and their [work] environment,” Hessels says. “The tool asks them to really rank their perceptions of their cleanliness in their work environment, their ability to adhere to certain practices such as safe needle handling, the use of gown and gloves, and so forth.”
The tools were trialed in the recently published study, and Hessels hopes the larger research now taking shape will shed light on a confounding finding in the current paper. Though the published pilot study may have been underpowered, it appeared that workers reporting positive measures for teamwork and safety culture had lower compliance with standard precautions. That is counterintuitive, to say the least, and researchers aim to solve this conundrum during the upcoming trial.
“This is limited by the number of observations as well as the number of sites that we surveyed,” she says. “So one of our hopes with the study that we are undertaking now is that we will have more data to analyze and interpret the conclusions to see if that still holds up so to speak with more people. Was it just an oddity that we found in this pilot study? That’s why you want to repeat studies across more sites to get larger power with a better data sample.”
Though it’s only speculative at this point, could workers who feel comfortable with their team and their hospital safety culture somehow let their guard down in terms of standard precautions compliance? In the paper, Hessels and co-authors raise the possibility of some unmeasured “psychosocial and individual factors” that might account for the finding.
In talking with colleagues and drawing on her experience as a direct care nurse to try to understand the study data, Hessels speculated whether a team’s comfort level might have fed into the compliance results. “Do you sort of let your guard down when there are more people around?” she wonders. Would a team member think, “‘OK, Sally’s got it,’ or ‘Julie is taking care of it, and I don’t need to do this.’ Is there some comfort in that [presumption], where we are less attentive to either preventing the infection in patients or of protection of ourselves?”
REFERENCES
- CDC. Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for Isolation Precautions 2007: http://bit.ly/2nLb3h7
- Hessels AJ, Genovese-Schek V, Agarwal M, et al. Relationship between patient safety climate and adherence to standard precautions. AJIC 2016;44:1128-1132.
