MRSA as seen through an electron microscope, color added.

It seems that the only times that I get up a full head of steam to sit down and blog is only when I have become angry enough about something to the point of distraction.  So you, the reader, become my punching bag while I work out my mental frustrations.   The absence of a post here usually means one of two things: either I am too tired to write, or I have temporarily become mentally healthy.  Here I sit writing, so I must be ready to climb my soapbox and go on another rampage.

My chosen rant today covers a topic that for some reason seems to be the Achilles heel of most providers.  Normally competent people will become absolute morons, devoid of all common sense when faced with relatively simple care decisions in this area.  Of course, I am referring to infection control.

For the past few years I have had the luxury of teaching and working for a rural 911 service to make my living.  But this current economic crunch has affected me and I have started to pull shifts at a nearby private agency, which means I am back in the business of interfacility transports after a hiatus from this part of the industry for 8 or 9 years.  This rude awakening has been left me bewildered and confused not only about the actions of prehospital providers, but in-hospital staff as well.

Most (yes I said most, and this is not an exaggeration) in-hospital providers who have called for the transport of a patient cannot tell me any details about the isolation precautions about that patient.  From the small sample of calls I have performed in the past few months, it appears that about 20-30% of the in-hospital patients I transport have those signs on the door that everyone loves to see and the big cart outside the room.  However, no one involved in the care of the patient seems to have any clue as to what diagnosis the patient has that requires precautions.  And no, this isn’t an isolated instance.  This is the norm.  Here is a common interaction that I will go through on most of my transports:

Me: “So what are these isolation precautions about? What does our patient have?”

RN: “I don’t know.  MRSA of something.”

RT: “I think it is of the sputum.”

Me: “Okay, shouldn’t we wear a mask and gown in here?  I see a whole cart outside the door, but no one in here is wearing anything?”

Tech: “Oh…you can wear a gown if you are going to get up close to the patient, but most of the time I don’t bother.”  The tech says this as she rolls the patient towards her, and the patient is pressed against her body with no barrier between the patient and her scrubs.

RN: “Yeah, if the patient has a trach like this, we don’t worry about it.  You know what, I think the patient has C-diff too, but I can’t remember.”

RT: “Who cares. Everybody has everything.  Let’s just get this done I’ve got to go give 208 a neb treatment.”

I then give up and look in the chart only to find that the paperwork provided makes vague references to MRSA, VRE, and C-diff but does not say if any of the infections are currently being treated, are colonized, resolved, or still active.  Further inquiry leads nowhere, and actually trying to wear protective equipment illicits snickers from partners and in-hospital staff.  Then we proceed to take our patient down public corridors, opening door handles with our gloved hands that are soiled with bodily fluids.  We finally make it to the public elevator and get into a close quarter environment with random members of the public while we punch elevator buttons with the same soiled gloves.  And at the receiving facility we do everything in reverse.

It is no wonder that there are some hospital departments where every patient has some sort of iatrogenic infection.  And that is what is so bothersome.  I have walked into units where literally every patient in every room has a hospital acquired infection.  And yet the staff refuses to change their policies and actually roll their eyes and laugh at any outsider (namely me) who questions their practices.  Never in my career have I seen so many people so boldly and willfully being ignorant.

I think this mostly comes from an incorrect perception among most hospital staff.  The misperception is that they think gloves and gowns are to protect the care provider.  The name “personal protective equipment’ even suggests this.  However, practices have evolved over the years.  Most of the infections acquired in the hospital are only dangerous to someone with an already weakened immune system.  We are not only wearing gloves and gowns for ourselves.  We are not only wearing them for the patient we are with currently.  We also wear protective equipment to avoid the spread to other patients.  It is this key concept that is lost on most providers.

MRSA is a very common bacterium that may be part of the normal flora of up to 30% of the general population.  In other words these bacteria live in the bodies of about 1 in 3 people without causing any harm.  MRSA likes the warm dark environment of mucus membranes, and so it is very common for MRSA to set up shop in someone’s nasal passages.  In other words, about 1 in 3 healthcare workers has MRSA in their nose and a simple sneeze can dislodge it and infect a patient.  If the bacterium is passed from one nose to the other, it is not a big deal.  But when it is passed to a surgical wound, it can complicate the patient’s recovery, cause longer hospital stays, and even be lethal.

Since MRSA is in the nasal passages of so many people who sneeze and wipe their nose, the surfaces of public places are often covered with this potential pathogen.  Armed with this new knowledge, imagine walking into a hospital room.  The countertops, the table, the drawers, the bedrails are all contaminated with MRSA.

Here is how the infection happens.  A nurse walks into an ICU room wishing to give an injection.  He sees the precaution sign outside the door.  He puts his gloves and gown on, and walks inside the room.  He proceeds to search around in the drawers for a syringe.  Then he roots around in his pockets for a needless connector.  He stops to talk to the patient placing his hand on the bedrail.  He checks the pump.  Then, only after he has contaminated his gloves several times, does he access the patient’s IV to administer the medication.  Then he says, “Oh yeah, while I am in here let’s take a look at that wound.”  This provider will take off his gloves just as he exits the room thinking he has followed procedure and utilized protective equipment appropriately.  Noting could be further from the truth.  If you question this nurse about his infection control practices, he will roll his eyes at you and say, “I’m not going to catch anything.”  He will then walk away in ignorance to spread the infection down the hall.

Here are some rules to live by when taking care of surgical patients:

1. The gloves and gowns that you wear ARE NOT JUST FOR YOUR PROTECTION.  If you think they are, you are missing the point.
2. Think of your personal protective equipment as a layer around your body.  All layers that come in contact with surgical and immunocompromised  patients must be clean.  Touching countertops with gloves and then touching the patient is CONTAMINATING THE PATIENT.
3. You must keep your clothes clean because you will bring those clothes with you and expose them to every patient you see today.  If you walk into a patient’s room, you can contaminate yourself without ever touching the patient.  So the excuse of, “I was just going in there to check on something really quickly so I didn’t put on a gown,” doesn’t cut it.  You have just contaminated your scrubs and will now take that infection to every patient you see today.
4. Do not go into denial.  If infections are spreading from room to room, there is a reason.  YOU ARE THE REASON.  When was the last time you saw a surgical patient get up and go room to room?  They don’t.  You do.
5. Take accountability for your actions.  Most of your co-workers are going to think you are nuts if you actually follow safe infection control practices.  Be evangelical about it and don’t give in to collective ignorance.  Set a good example and do things right, even if you are the only one.

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