As part of our training, I need to learn about Infection Prevention.  This involves on-the-job training as well as attendance at teaching days run by the Healthcare Infection Society.

Infection Prevention/Control often gets a bad wrap. Partly because, I’m not going to lie, it can be quite dry to learn about and then the perception is that it is merely pedantry…

In reality, it’s obviously not! The things that have stuck with me when learning about it so far are:

1. Similar to Public Health, Infection Prevention has the ability to impact upon the wellbeing and care of MANY patients with, for example, only one intervention
2. It does actually take quite a lot of people/management skills- how do you convince people to make changes when human beings prefer to stick with what they’re doing?

Take for example, handwashing. Nowadays this is so ingrained into our practice that we even expect our patients to call us out if we lapse. This is because we have the evidence to back it up. Handwashing/sanitation practices revolutionalised healthcare and continues to do so across the globe. (We should never take access to clean water for granted). If you want to look at the positive impact of infection prevention you almost don’t need to look further. From a Public Health point of view, sanitation/water kickstarted epidemiology when Jon Snow (not of dragon-related story-stardom) isolated the source of a cholera outbreak to an infested water pump. It’s also a key part of planning when setting up Refugee Camps and when planning new hospitals and waste water management. All that stuff is technically part of Infection Prevention.

So actually quite interesting stuff really…

So, ok, we’ve got handwashing. We accept it. But that aside, what does the Infection Prevention team do in already-made, non-cholera-infested, generally happy and clean hospitals in the UK…?

The answer is that they often have an overview that keeps patients safe in often challenging situations. They help with the logistics of opening/closing wards/bays/side rooms to prevent the spread of infections like influenza and resistant organisms. They investigate recurrent infections on wards if they occur to ensure that standards are maintained. They liaise with theatres and ITU and engineers to ensure adequate and safe ventilation systems- by which I mean air flow and air conditioning- to essentially avoid bugs being blown into wounds during operations! Far from being Bare Below the Elbow pedants, their job is varied and often tricky- in the most part because they often need to affect change.

Imagine, for example, that a number of patients get post-operative wound infections. Audit reveals that one surgeon in particular has higher rates than others. Thankfully, doctors that WANT to cause harm are very few and far between, but of course that also means that we tend to take pride in their work. Now as infection Prevention, you have to tell a surgeon they need to change their practice, that they’re potentially causing harm. That’s tough. For the surgeon and the IP team.

Changing behaviour is so difficult that we had a series of lectures on it within our training. The key learning points I took away are, I think, applicable very generally:

1. Create a sense of urgency. People won’t feel the need to change without stimulus. Call things an “outbreak,” make posters, involve patient stories, speak to teams and explain why it is important you need to work together to achieve their aims and yours for patient benefit.

2. Build an effective team

3. Change happens if changing offers an advantage- this is where audit data comes in. If, for example, the surgeon above sees that their infection rates are higher than everyone elses, and that evidence suggests Intervention X may impact on that, that surgeon is more likely to engage in the change process.

This sort of thing doesn’t just apply in hospitals of course. Change and people management are key skills in many jobs. One of the best Infection Prevention senior nurses I’ve met is a very sensible, pragmatic and evidence based person that understands people management to affect change.

So what about the Bare Below the Elbows (BBE) thing…?

For international readers, a few years ago in the UK the Department of Health decided that all practising Healthcare Staff needed to ensure that they were not wearing clothes/jewellery/watches at work. This means, no lab coats, no blazers or jackets too. Is there any evidence to it? Well, let’s start with a story.

Years and years ago, the medical community found itself in trouble. Faith in it was lapsing as scientists proved and disproved medical practice. As a result, evidence-based medicine evolved, as did wearing white coats. We aligned ourselves with science. Ironically though the white coats thing wasn’t evidenced based, at least not for cleanliness- it was more like a PR stunt!

A sense of urgency had been created and a response was needed. This was pretty much the same story with the BBE policy- it might make sense that keeping your wrists and hands clutter free makes them easier to wash but the evidence supporting a reduction in infection is lacking. In the US, white coats with long sleeved (banned in the UK) are regularly used without evidence of higher infection transmission as a result.

 

 

 

 

In keeping with behaviour though, it does do something else. It makes you think about washing your hands/wrists for a start. It also makes your wardrobe full of short-sleeved clothing! Some sites and articles that I’ve found do point out though that this intervention can quickly become the focus rather than handwashing. So the point is, Infection Prevention need to stay on message rather than focusing solely on whether you’re BBE or not.

And what about Scrubs? Again, it’s hard to find evidence that conclusively states that wearing scrubs or not wearing scrubs does much in terms of spreading infection. Personally though, I am a fan of them. Not so much due to infection control issues but actually for uniform reasons.

Uniforms do create a sense of commaraderie I think and it means not risking having bodily fluids spilt on your own clothes!! It also means I wouldn’t have to spend time and money finding boring work clothes that I are both professional and that I don’t mind getting dirty. The problem we have in the UK is that outside of theatres and ICU, we’re not very set up for scrubs- we tend not to have locker rooms as doctors although this does vary in each hospital… Finally, speaking of scrubs, I need to give a shout-out to Kara. I don’t tend to advertise but they kindly featured me on their blog recently and are a new venture of a family-owned UK business that is growing rapidly. Anyone looking for scrubs fashion here, they’re a good bet to look at (website listed below).

So, conclusion..

1. People management is an essential part of Infection Prevention
2. Remember Public Health/epidemiological principles too and that as a result, a number of patients can be affected often with minor interventions
3. Work WITH Infection Prevention
   

References

KARA UK for Scrubs:  www.karagroup.co.uk
Michael Edmond. Bare below the elbow and implications for infection control. http://www.infectiousdiseaseadvisor.com
Karen Hebert. Are YOU getting naked? careers.bmj.com
Bearman G, Bryant K, Leekha S et al. Expert Guidance: Healthcare personnel attire in non-operating room settings. Infect Control Hosp Epidermiol. 2014; 35(2):107-121. doi: 10.1086/675066

Image of lady at water pump from Red R site. http://www.redr.org.uk
Picture of hospital. http://www.idsociety.org