American College of Physicians: Internal Medicine — Doctors for Adults ®


Residents help raise the bar on infection control efforts

Training programs highlight techniques housestaff can use to cut rising rates of hospital-acquired infections

From the October ACP Observer, copyright 2004 by the American College of Physicians.

By Yasmine Iqbal

When Steven Nurkin noticed that doctors' neckties sometimes brushed against patients' bedding during exams, he wondered whether the ties could become contaminated. Sure enough, a sample he made of more than 40 neckties revealed the presence of such bacteria as Staphylococcus aureus.

But when Mr. Nurkin, a medical student at the New York Hospital Medical Center of Queens, presented those findings at the American Society for Microbiology's general meeting last May, he wasn't prepared for the media frenzy that ensued. While his findings stressed that he hadn't found a concrete link between neckwear and disease transmission, headlines screamed that doctors' neckties were carriers of disease.

"It was blown out of proportion," Mr. Nurkin recalled. "Many other studies had found bacteria on beepers, cell phones and other objects, and I just wanted to see if neckties could harbor them as well."

While the media's interest in such preliminary results took some by surprise, it illustrated the intense—and growing—concern about a problem that may affect more than 2 million Americans a year. Rising infection rates, as well as the emergence of drug-resistant pathogens, are pushing the need for better infection control in health care settings to the forefront.

The problem is that rising infection rates often receive a lackluster response from the medical profession. Inadequate hand hygiene and insufficient isolation precautions, after all, are just two of the known—and easily preventable—causes of infections. And while there's a wealth of scrubs, sterilizers and barrier equipment to combat the most common pathogens, many health care workers often fail to take even basic precautions.

An article in the July 6, 2004, Annals of Internal Medicine, for instance, found that less than 60% of physicians in a Swiss university hospital complied with hand hygiene guidelines. The article is online. And Robert A. Weinstein, FACP, chair of the infectious diseases division at Chicago's Cook County Hospital, noted in an accompanying editorial that in the United States, "hand hygiene rates average 40% to 60% on a good day."

Teaching hospitals

Faced with such dire statistics, a number of national health care organizations have unveiled initiatives they hope will help boost infection control efforts. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), for example, has changed its accreditation standards to encourage hospitals to stamp out conditions that can lead to infections. (See "New initiatives take aim at hospital-acquired infections.")

Teaching hospitals are also getting on board by first giving incoming residents infection control education during orientation sessions, then reinforcing that information throughout training. At New York City's Lenox Hill Hospital, chief resident Jason M. Bratcher, ACP Associate, noted that all residents receive specialty-specific infection control training every few months.

"Before every rotation, we meet with nurse managers and other experts to discuss the sterile practices of the area where we'll be working," he said. "We also get frequent reminders from attendings and nurses, especially in the intensive care units."

At the University of Pittsburgh Medical Center (UPMC) in McKeesport, Pa., senior residents helped create a hospital-acquired infection prevention "learning packet." The compendium contains key facts and policies on standard and transmission-based precautions, hand hygiene, management of Clostridium difficile and other issues.

Residents are introduced to the learning tool during orientation, according to senior internal medicine resident Vrushali S. Dabak, ACP Associate. Infection control is then emphasized repeatedly through lectures, signs posted throughout the hospital and surveys. Over time, she said, "It all starts making more and more sense, and we start following the precautions routinely without even thinking about them anymore."

Dr. Dabak and her colleagues played critical roles in the tool's development. They provided insights on how C. difficile was being recognized and treated, how central lines were being used, and how well hand hygiene protocols were being followed. They also suggested ways in which a learning tool could effectively address all three issues.

"We really came to understand why the policies are important and where they come from," she explained. "We also became more vigilant and were better able to guide our fellow physicians."

And at Virginia Commonwealth University, Medical College of Virginia in Richmond, Va., residents are expected to discuss infection control issues as well as diagnosis and treatment during their case presentations. "Linking infection control with a particular case is much more effective than just presenting epidemiological statistics," explained Richard P. Wenzel, MACP, chair of the department of internal medicine.

Tips to prevent infection

While preventing hospital-acquired infections may seem like a daunting task, experts point to simple measures residents can take that can make a big difference.

  • Know your hospital's policies. Familiarize yourself with your hospital'sinfection control policies and ask questions if you're unsure of something, advised Trish M. Perl, ACP Member, director of hospital epidemiology and infection control at Johns Hopkins Hospital in Baltimore.

    She said she recently discovered that many residents didn't know how to use positive air pressure respirators, which must be worn by all health care workers who treat tuberculosis patients.

    "Residents are the most likely to see the patient before the diagnosis," she said. "They would be the first to consider whether the patient has TB." It is therefore critical, she said, that residents know how to take the proper precautions.

  • Practice good hand hygiene. Hand hygiene is the "single most important thing you can do" to prevent the spread of infection, according to Maryanne McGuckin, DrScEd, a senior research investigator and adjunct associate professor at the University of Pennsylvania School of Medicine in Philadelphia. "Too often, physicians don't connect hand hygiene to the rest of sterile technique."

    The CDC's 2002 hand hygiene guidelines, which are online, recommend washing hands or sanitizing them with an alcohol-based hand rub (if they're not visibly soiled) before and after direct contact with patients.

    Dr. McGuckin has also moved to get patients involved. She developed a program that encourages patients to remind caregivers about the importance of hand hygiene.

    In the program, health educators visit patients within 24 hours of admission to tell them about the importance of staff hand hygiene. Patients can then put a sticker on their hospital gown to remind staff to wash their hands. According to Dr. McGuckin, the sticker program has helped boost hand hygiene compliance rates between 35% and 60% at more than 70 health care sites.

  • Make sure attendings wash up. Mentors and senior physicians may not always provide the best example when it comes to infection control efforts. Even the most senior physicians, for example, may not follow hand hygiene guidelines or other important protocols.

    Dr. Bratcher from Lenox Hill Hospital said that while it may be awkward to confront a senior physician—especially your direct supervisor—about noncompliance, it is important to speak up. If you notice attendings repeatedly not sanitizing their hands, try talking to someone like a head nurse, who may feel more comfortable raising the issue with them.

  • Know the location of hand hygiene resources. Sometimes the key to improving compliance is improving access. After personnel at Virginia Commonwealth University installed more hand rub dispensers, Dr. Wenzel reported, compliance jumped from 35% to 70%.

    And while every facility is required to have a certain number of sinks and hand sanitizing stations, make sure you're prepared if one isn't nearby. Dr. Perl, for instance, said she carries a small bottle of sanitizing gel as a backup measure.

  • Don't substitute gloves for hand hygiene. Gloves have the potential to spread germs if you don't change them between patients. Holes in gloves can allow bacteria to travel from physician to patient or vice versa. Always change gloves and sanitize hands between patient contacts.

  • Clean diagnostic equipment that touches patients. This could include stethoscopes, otoscopes and reflex hammers. Sue Crow, RN, MSN, an associate professor of medicine at Louisiana State University Health Sciences Center in Shreveport, La., recommended using two alcohol wipes to clean the bell of your stethoscope. Use one to clean, she advised, and one to disinfect. Dr. Bratcher also suggested rubbing stethoscopes with hand sanitizer.

    You should also observe rules for keeping diagnostic equipment within isolation zones. Patients with highly contagious conditions, for example, may require a dedicated stethoscope.

  • Wear clean clothing. As Mr. Nurkin's necktie study illustrated, clothing can harbor pathogens. Experts recommend donning a gown if you anticipate contact with a highly contagious patient and wearing freshly laundered scrubs every day.

  • Get recommended vaccinations. Athough many hospitals make vaccinations for many infectious diseases mandatory, physicians may neglect to update them. Nearly two-thirds of health care workers, for example, don't get vaccinated against influenza. Make sure you're up-to-date with your vaccinations, and don't put your patients at risk by working when you're sick.

  • Isolate patients immediately if you suspect infection. Screen patients carefully, and always ask if they've recently been sick or hospitalized. Also, put your hospital's isolation policies into effect immediately if you suspect infection.

    Raising the index of suspicion and moving quickly to isolate patients were key strategies that residents used at UPMC McKeesport to lower the incidence of C. difficile. Now, hospitalized patients who develop diarrhea while taking antibiotics are isolated immediately, even before lab tests confirm the diagnosis.

  • Report suspicious findings. If you suspect any kind of infection, know whether you should report it to your attending, infection control nurse or hospital epidemiologist. You may be the first to detect an outbreak, said Dr. Perl, who pointed out that an outbreak of Pseudomonas aeruginosa was caught after a physician in her first year of subspecialty training reported a cluster of mucoid, antibiotic-resistant infections in patients who had no known risk factors.

  • Learn proper disposal and cleanup techniques. Learn the location of disposal containers and who to call when something needs to be cleaned up professionally. Simply wiping up a spill, especially if it contains body secretions, is not good enough.

  • Realize that compliance is everyone's job. "Doctors need to understand that they can create harm by not following basic precautions, and they need to take a conscious, careful attitude toward infection control," said Louisiana State's Ms. Crow.

    Ankur Sheth, ACP Associate, an intern who was taught by Ms. Crow, has taken that advice to heart. "Infection control is a matter of personal responsibility," he said. "I know that I can't prevent all hospital-acquired infections, but I can take the utmost care on my part."

Yasmine Iqbal is a freelance writer in the Philadelphia area.


New initiatives take aim at hospital-acquired infections

Many national and state organizations are placing new emphasis on infection control. Here are a few examples:

  • In 2005, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) will release new accreditation standards requiring hospital leaders to take a more active role in infection control education and to increase the availability of infection control resources. Reducing hospital-acquired infections is also one of JCAHO's national patient safety goals, reflecting the agency's emphasis on ensuring that hospitals adhere to CDC hand hygiene guidelines. JCAHO also wants to ensure that hospitals manage infection-related deaths and injuries as sentinel events.

  • The CDC is heading several research projects to determine how hospitals can decrease infection rates. The agency is also investigating ways to increase adherence to the hand hygiene guidelines it released in 2002.

  • Since 1994, New York state has required all health care professionals to complete infection control training by attending a lecture or taking an online course before getting licensed. Health care professionals must renew that certification every four years.


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