Lax controls, staffing woes cited in infections
Lax controls, staffing woes cited in infections
Breaches in infection control measures and inadequate staffing were linked to an increase in surgical site infection (SSI) rates in an outpatient surgery suite performing breast biopsies, an infection control professional reports.
There have been few studies conducted on infection rates in outpatient settings, but the limited data appear to support the general epidemiologic perception that the risk and overall incidence is very low. (See Hospital Infection Control, December 1995, pp. 149-153.) A recent study to the contrary was presented recently in Washington, DC, at the annual conference of the Society for Healthcare Epidemiology of America (SHEA) by Letha Johnson, RN, infection control coordinator at Ben Taub General Hospital in Houston.
Performing a retrospective review to determine the incidence of SSIs for patients undergoing a breast biopsy procedure, Johnson and colleagues reviewed charts from 121 patients who had breast biopsy procedures performed in an ambulatory care clinic. Finding a surprisingly high 6.6% infection rate for the procedure, they then reviewed practices in the clinic. Among the identified factors possibly contributing to the increased SSI rate were lack of traffic control in the procedure area, failure to use surgical scrubs, poor housekeeping practices, and inadequate staffing. In general, the clinic had lapsed into a more "casual" atmosphere despite the invasive nature of the procedure being performed, she tells Hospital Infection Control.
"Our [ambulatory] area was designed for this type of procedures, so that wasn't the problem," she says. "The problem was that everyone was relaxed in their operative technique. The staff has to be educated just like they are in an OR setting."
Among the specific findings were that infection control in the procedure area may have been compromised because nurses assisting physicians also had responsibilities to cover the front desk -- creating an in-and-out flow of traffic during procedures.
"It was definitely a staffing problem," Johnson says.
The procedure was moved back into a hospital operative suite, and the rate for the next 100 consecutive cases fell sharply to 1%, she adds.
"We are hoping that we can do some corrective measures so we can move the procedure back into the [ambulatory] setting," she says.
Though ambulatory settings may generally pose low risk to patients, there is growing concern that situations may vary widely due to lack of guidelines and standardization in the emerging health care arena. As a result, the Centers for Disease Control and Prevention in Atlanta is trying to beef up surveillance in the area, says William Jarvis, MD, chief of the investigations and preventions branch of the CDC's hospital infections program.
"One of the things we have noticed, particularly in the surgical ambulatory care settings, there is really not much knowledge about infection control, and there are not a lot of regulations or even recommendations for those settings," he says.
That concern was echoed during the SHEA keynote address by William Schaffner, MD, chairman of the department of preventive medicine at Vanderbilt University in Nashville, TN.
"In our institution, we discovered recently that a whole array of procedures in the operating theater are now being done in the outpatient department," he told SHEA attendees. "Not in the outpatient department operating room, but in clinic rooms. Not clinic rooms that had been renovated, but just rearranged. . . . I called three of my colleagues and discovered that similar things were happening in their institutions, and as far as we could tell, there were no national guidelines [or] recommendations expressed in this area."
Still, another cautionary tale relayed by Schaffner suggested that enacting guidelines is no panacea, particularly as procedures move out of the infection control sphere of influence of the hospital. As an example of how infection control problems thought solved may dramatically reappear, he cited the spate of hepatitis B virus outbreaks recently reported by the CDC in five freestanding hemodialysis clinics.1 (See Infection Control Consultant in Hospital Infection Control, July 1995, pp. 87-90.) The HBV outbreaks were attributed to breaches in existing infection control guidelines, including failure to immunize susceptible patients, failure to identify and isolate HBV-infected patients during hemodialysis, and sharing of staff, equipment, and supplies among patients.
"Note that these were all self-standing hemodialysis centers with no obvious physical or consulting relationship with hospitals -- which are the reservoir of experience and knowledge in infection control," Schaffner told SHEA attendees. ". . . I see this as one of the challenges we face, and I am a little afraid that we are behind the wave. I am also concerned that there may be more of these infection control misadventures out there before we gather sufficient attention to it to give it the resources that it deserves."
Reference
1. Centers for Disease Control and Prevention. Outbreaks of hepatitis B virus infection among hemodialysis patients --California, Nebraska, and Texas, 1994. MMWR 1996; 45:285-289. *
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