I didn't come here to make friends

So you’re new at this, a new job, new facility? You’re going to need some friends, because you can’t do infection control alone.   You cannot wash people’s hands for them, nor scrub the hub for them.  Which is why I say I don’t really control anything. But you need them--to work with you and for you.

Know thyself

I am an introvert on one of those personality tests.  No kidding--I didn’t need a test to tell me that.  Could I please just work from home where the phone doesn’t ring?   Nope, you gotta be out there and work with PEOPLE.  Other people.  So. many. people. *sigh*

Go ahead and take a personality test.  There’s more than one kind--you’re either one of four types, or one of 16 types.  They usually get me spot on. Know who you are and what you’re style and outlook is, and recognize that other people are one of the other types, perhaps your polar opposite.   Really look at those and see that they are valid descriptions of how other people think and see the world.  Recognize them in others and know how they communicate best. They aren’t that way just to annoy you (darn perky morning people) and you cannot be effective if you don’t know who you are working with.  So learn to identify someone else’s type.

Shut up and smile

It’s tempting to bring your enormous (or slightly less than enormous) body of knowledge to dump on all these new people, but you can’t, because it’s very difficult to do politely and effectively in the beginning.  If you started calling strangers on the phone and telling them about something you read in the paper last week that they should implement in their life right now, they’ll hang up. But if you call your friend with the same story, the expectation is that you are telling them something that is either a) beneficial or interesting to them, or b) a shared interest you can both discuss.  A friend will listen.  Right?

The fastest way to turn people off is by starting every other sentence with how great things were where you used to work.   Your first month on a new job, just close your mouth.   Do a lot of listening and watching.  Ask questions (not, like, “Why would you do something like that?”).  Gather facts.  Learn the system.  Ask if a manager will give you a short tour of their department.  Ask about their concerns.  Write stuff down.  Do not spout advice unless specifically asked, and even then, delay the advice-giving until you have more information. Strangers do not want your opinion, either on the street, or at work.

Just make one friend

You need one friend in each department.  I once worked at a hospital where the facilities director did not want to be my friend.  He did not want to tell me about projects, plans, or issues. So I befriended the maintenance staff, his direct reports.  Everyone was polite and my office was on a common hallway, so some would say hello on their way by.   After some time, a gentleman stopped by and lingered for a moment.  I asked about his son, who had just gotten a new job. After a chat, he said, “you know, down in the *unnamed* department, we are doing *xyz* on the night shift, so that it looks ok for the 6am check.  But it really doesn’t work well all day. I thought you should know.”  Wow.

The understanding was that I was not supposed to know about this coverup/workaround for a system that wasn’t working, but after a period of time, I think he felt he was betraying a friend.  It was understood that I would not say where I got this new information from.  I hope his disclosure came from realizing that my job was to help patients and staff, and not to penalize or police anyone. The value of friends is immeasurable.

Learn to speak another language

To make friends in a foreign department, you need to speak their language and learn their culture.  If you are not a nurse, or not familiar with nursing at this facility, go to the orientation the newly-hired nurses go to, and be a student with them.  It might be a few days, but it’s worth your time.  See the equipment, learn the practices and policies, and meet a small group of new nurses, and the nursing educators (key allies).  Look (and be) humble and willing to learn.  Always.

If you don’t speak Environmental Services, join your local and/or national AHE chapter.  I belong to AHE: they have a ton of great (free) webinars, and I even went through a 2 month online course on ES management--staffing, contracts, flooring, and basic infection control, etc.  It was intended for new ES managers or supervisors, but I learned a lot about the challenges and decisions the industry faces.  I even went to the national conference one year in place of an infection control conference.  It was amazing.  That was 3 years ago, and I still refer to my notes from that conference.

Togetherness, and other warm fuzzy things

AHE had a nice program a while ago, intended for infection control and housekeeping departments to watch and use together.  It was presented jointly through AHE and APIC. There was also one for ICPs and the micro lab.  They are helping you build bridges, and learn about each other.  And nothing says togetherness better than sitting in a conference room watching a webinar about C.diff with an ES manager. Can you feel the love?

There are definitely days where I want to scream, “Why doesn’t everyone just do what I say?!  You hired me for infection control, but you keep trying to implement stupid no-evidence processes that won’t work. Clearly I’m not needed here.”  But I don’t say that (out loud). I consider my audience, ask for everyone’s input, accept that it might take 6 months (instead of 6 minutes) to move something forward, and save the emotional collateral that I’ve built with my new friends to use on another day.  Namaste.

Go ahead, guess my Myers-Briggs personality type: ___________

I been in the lab, with a pen and a pad...

So said Dr. Dre, and he’s a doctor, so he must know something. And I think he’s right.

 I was speaking with a colleague last week who has been an ICP for a few years, and she mentioned that she needs to go get her certification soon.  I’m nervous, she says, pulling her CIC study guide off her desk.  Without really even thinking, I said, Don’t be.  You’re a lab tech.

There are several paths into Infection Control, and I am unique in that I came to it having traveled three routes.  I am a medical technologist, or clinical laboratory scientist. It was my first degree, and it has served me very well.  I am a registered nurse.  I went into nursing when I realized I wanted to know more about those people whose names were on the samples I tested.   I have a Master’s in Public Health/Epidemiology, which was my goal from early on, but life derailed my plans for 15 years until I finally finished it.

So here I am in Infection Control, and on many days I wonder how most people do it without a lab science background.  CAN you do it?  Of course! You can learn anything.   And I recently discovered while reading an ICP salary survey that the overwhelming majority of ICPs have a nursing degree, and far fewer a lab science degree.  So that’s proof right there.  But I wonder how hard it is, and after a very long conversation with our reference lab last week discussing their methodology and requirements for CRE testing, I wonder if some new ICPs struggle trying to learn or get comfortable with the microbiology that is embedded in our daily work.

A huge portion of what I do each day, I do with ease because of my lab tech education.  I review cultures and antibiotic patterns almost mindlessly.  I know where diptheroids  and bacillus are normal and where they might not be.  I’ve never confused the flu with Haemophilus influenzae,  or Enterobacter with enterococcus.  I know what strep groupings are, and the difference between mycoplasma and mycobacteria.  And I don’t need to think about it.

Now nurses know microbiology.  They read patients’ lab reports all the time, and administer antibiotics.  All nurses take a microbiology class.  But it’s often not the same as the kind the lab techs take.  Lab techs take general micro, clinical micro, virology, parasitology, immunology, and bunch of other stuff.  Most of those classes are lectures with labs.  I remember our small class bringing in our own samples for labs—throat swabs, urine and stool cultures, etc.  Almost as much fun as learning phlebotomy on each other.  If your micro class was a long time ago, or was pretty basic, it might be time for a refresher.

I know that if you come to infection control from a lab background, you’ve got other things to learn, like nursing practice, surgery, and sterilization. If you came from a public health background, you’ve got statistics, study design, interventions, and community health practice under your belt, but the clinical application might be your challenge.  And in none of my education did I learn enough about antibiotics to prepare me for how much I need to know now. (Desperately waiting for an ICP-focused, soup-to-nuts, antibiotics course to become available from someone.  APIC? Pharmacists?  Anyone.) [crickets]

Maybe I’m wrong, maybe it’s just my own experience, but I do meet ICP’s (experienced ones) who still seem to struggle with some basic concepts.  Maybe they don’t know what they don’t know.  When I hear that people are evaluating a disinfectant by the number of organisms listed on the label, I know they need a micro class.  Or that they refuse a product because Staph aureus is on the label but MRSA isn’t.  When it’s not clear why non-enveloped viruses are harder to kill than enveloped viruses, you need a micro class.  If your lab lets you know about a change in their test methodology and you don’t know how it affects your infection rates….  When you don’t know which organisms are non-fermenters in a research paper….Why Hepatitis A doesn't need to be in your post-exposure blood panel...The difference between α-hemolytic strep and group A strep in a blood culture... That you’ve failed the CIC exam more than once.  These are all actual things that have come up in conversations I’ve had with ICPs.  

I might sound like a lab snob, thinking that my lab education is soooo much better than your nursing degree.  But I’m not, because I can tell you from experience that I came to infection control far better prepared with a lab degree than a nursing degree.  They are a very nice complement to each other, but if I had to pick one to recommend, it would not be nursing.  I write this so that it might be helpful to someone out there.  

I’ve worked in different environments, but mostly outside of the academic medical centers (by choice).  I went to a meeting once as an affiliate hospital of a large medical center.  We were supposed to send our IP staff.  All the community affiliates sent their one or two ICPs, while the flagship site sent their 7 ICPs, 3 hospital epi MDs, 2 fellows, and their ID pharmacist.  Um, wow.  I can see that if you work in a place with that much support, you might not need to know everything.  But most of us don’t work like that.  We work alone or in pairs.  We may or may not have an ID doc with any hospital epi experience.  He may even be a consultant off-site.  You’re on your own, and you’d better know your stuff.

I’d like to know if CBIC keeps track of who does better on the exam, or is more likely to pass it on the first try—the lab techs, the MPH’s, or the nurses.  I could be totally wrong.  But I’d like to see that data.  You could learn everything from a book.  You could use your CIC study guide and maybe get it all.  But learning for a test, and really getting it, are different and some stuff is just easier to learn in a structured setting.  If you’re thinking a micro class is what you need, find your nearest center of higher education that runs a clinical laboratory science program, and get yourself into that class.  Make sure it includes a lab where you put clinical specimens on plates and you learn to read them and make Gram stains.  Bring a pen and a pad. Then come back and tell me if I was right.  

Have you completed your APIC MegaSurvey yet?  2 weeks left. It's like the census.  Get counted.

You don’t have to be smart to be a surveyor

This list comes out from Joint Commission pretty regularly, twice a year maybe.  It’s the top ten standards that they cite on survey.  Infection control is always there somewhere.   And it sure does stink to be the Facilities director, because most of the rest is Environment of Care.   What strikes me most about the infection control and some of the EOC is that these are easy finds.  You can see them without looking very hard: you really don't have to be some highly-trained scientist or surveyor. For that reason, they should be the issues you see also when you make rounds.

If you are new to Infection Control, there really isn’t a lot of learning time, especially if you work alone.  You need to hit the ground running.  It’s nobody’s problem but yours that you started on the 3^rd day of the month and your monthly or quarterly committee reports are due on the 7^th.  Or that the person who left your job gave 2 weeks’ notice and has been gone for 6 weeks, since a job search takes so long. And that doesn’t even include your mandatory/regulatory reporting.  You probably haven’t left your office since day one.  But you have to.

I learn more by walking the unit than I ever do by perusing the literature, following headlines on Twitter or going to conferences.  What I learn by walking is what the real risks and regulatory risks are in my facility. The second most common TJC IC finding is not developing and implementing an infection control plan specific to your facility.   How can you plan your activities and interventions if you don’t know what the issues are?  Go walk.

I enjoy an early morning stroll, at change of shift, when food trays are being delivered, clinical staff is visiting patients, and morning care is being provided.  I like 7 a.m glucose checks, 8 a.m. med passes, breakfast dining groups, and the setup of the OR for the day.  I like to see the remnants of the night: how much trash or laundry accumulated in soiled utility rooms, food left at the nurses’ station, and fake fingernails on people who never see a supervisor.  Everything that I see, a surveyor sees, too.

I'm a little torn about whether we should expend all our efforts just to satisfy an accreditation agency (like teaching to the test), but I do think they have laid out some very good standards for running a safe facility, and I think that makes it worthwhile work.  If you are TJC accredited, IC 02.02.01 is a number you should know like your Social Security number.  This is the standard that says patients don’t get infections from any of the stuff here (medical equipment, devices, and supplies).  While some of it relates to sterilization, which is more complex, much of it refers to general equipment and supplies. This means stuff is clean and Once Clean,Kept Clean.  How do you clean it?  How do you know it’s clean? How do you keep it clean?  This standard melds nicely with the EC standard for blocked egresses (stuff in the hall blocking fire routes or exits).   If you’ve got stuff in the hall, you’re weak on both of these standards.  There is a process that is not in place.

What is that stuff?  IV poles, extra beds, little linen carts?  Is that stuff clean, ready for the next patient use?  How do you know?  Even if it is clean, how long can it stay there before a) it’s no longer clean, or b)you’re violating fire code and impacting safety?  Is it marked to show that it’s clean, or is it in a designated clean area?  These are all easy questions, and easy findings for a surveyor because THEY CAN SEE IT.

Some TJC standards are more obscure.  Patient Rights and Provision of Care standards require chart reviews, staff interviews, and deep thought.  Not infection control—if it’s dirty, everyone can see it.   The same goes for damaged equipment.  I do some work in a therapy facility.  Lots of mats and bolsters and pads.  Lots.  Any rip or puncture is fodder for a citation.  We get plenty of damage from all of the adaptive equipment patients have.  Once an upholstered piece is damaged, it needs to be repaired or replaced, because dirt or liquid can get into the cushion, and there’s always some horror story about a patient that sits on something only to have the prior patient’s body fluids ooze out (this might be IC urban legend, but I have no doubt it did happen somewhere).   We are about to try CleanPatch (an approved patching system for mattresses, etc.  I don’t promote any product or represent anyone, just telling you what I’m doing).  I’m excited to try it.  Duct tape is NOT a solution. The patch is good for a year, which gives you time to work the re-upholstery or replacement cost into your budget for the next year.   Rips and tears are easy to see, and if you have tape holding things together or covering rips, that's not good.

Do I think little punctures are a big deal in my outpatient settings, where the patients are fully clothed, and sometimes their shoe tears a spot near where other people’s feet will go?  No.  But that’s the difference between Real Risk and Regulatory Risk.  Real risk is low in that case, but it’s an easy finding for a surveyor.  Another easy one is the base of an IV pole: sometimes these poles get a quick wipe before going into the closet, but stuff drips all over the base.  Gross.  Probably real risk.  And easy to see.

Tape is another easy find.  Sometimes respiratory or physical therapy will put a cute little piece of leopard-print duct tape on the floor to mark distance for exercise tolerance or walking.  But the edges are adhesive and they trap dirt and you really can’t clean it.  Tape is bad.  I once worked in a LEAN facility, where they improved efficiency and process sometimes by marking stuff with tape—like squares on the floor where certain supplies go, or a counter top (imagine outlining the place where your stapler goes in red tape on your desk).  Apparently nobody spoke to Infection Control.  If you put tape on stuff, you can’t clean it well.  So they had implemented this enormous process improvement system throughout the whole organization, and, well….awful.

Watch your nursing assistants checking blood sugars in the morning.  Are they cleaning the glucometer between patients?  The real risk here is very real.  Make sure it’s happening.  Peek into supply rooms.  If you work in a small facility or clinic, the infrastructure for materials or supply management may not be strong.  Expired supplies are a big deal.  Easy to find, you just check the expiration dates.  No-brainer.

The other benefit to walking is that staff do ask questions once they see you and get to know you.  Sometimes it leads you down a rabbit hole of infection control violations, but I try to look smiley and non-threatening so they do approach.  “Are you the Infections Nurse?” Cringe. Yes, I say.  I learn a lot.  Most of which I later wish I didn’t know.

So go be the surveyor.  You may find that the “big” stuff that we associate with serious illness, like central line infections and VAPs are practically non-existent in your facility, but the little things, lots and lots of little things, are the real problem.  And they will sink your accreditation ship, sometimes for good reason: real risk to patients.

Off With Their Gowns!

Ok, I’m doing it. Reading and thinking, thinking and reading.  No more precautions for patients colonized with MRSA and VRE.  No more screening swabs.  Jumping in, both feet.   Because I think it’s the right thing to do. Now.    I love my guidelines, I do.  I love HICPAC and all those people who put all that work in; who put out a consensus recommendation for areas where there was little data.   And it sounded like a good idea, a great idea.  Why WOULDN’T you wear gowns for these scary organisms?  It sounded good.

But then….there was evidence.  And a little more evidence.  And then there were real people, in real hospitals, big hospitals, who showed that the gowns didn’t matter like we thought they did.  MRSA infections, all infections in fact, are going down.  We know more than we did 10 years ago when HICPAC published those guidelines.  We know more, we do more, we think more.  We wash, and we disinfect, we have bundles, we’ve reduced our devices (if you don’t poke holes in patients they get less infections). But total gowning and gloving did not change VRE transmission rates.  This tells me there is something we don’t know about VRE. It may have reduced MRSA transmission--in an ICU setting, with sick susceptible patients with lots of devices and openings. 

What does that mean for me, out in the community hospital, rehab setting, long term care, behavioral care?  If the effect was small in the highest risk population, how small is it in lower-risk settings?  Really small, I think.

Those gowns are expensive.  They have a money cost, an environmental cost, and a patient care cost.  You’ve got to produce a risk-benefit calculation of some kind.  Like breast cancer screening:  I get it—you don’t want to deny YOUR loved one something you think is effective.  But you can’t have person-based medicine.  You’ve got to think of the population.  Maybe you miss one cancer, maybe one patient gets an infection, but you do it for the greater good. 

When I get dozens of questions about something from staff, I know that our policy isn’t clear or isn’t founded on something that makes sense.  I get tons of questions about precautions, like these:

Mr. Smith had MRSA 2 years ago.  He had 3 negative swabs (2 days, 2 weeks, 3 months apart, or whatever).  Then he was positive on screening before his hip surgery.  But we swabbed him when he was transferred here and he’s negative.   Is he cleared, or on precautions? 

                On. I think.

Mrs. Brown had VRE in her urine, but we treated it.  Precautions?  

                On.  It’s probably still in her rectum, even though out of her urine.

Mr. G had MRSA in the leg.  They amputated it last month.  Precautions?

                I don’t know.

I can’t do this all day.   I want staff to take care of all patients well.  I want them to not spread MSSA or MRSA or Pseudomonas.  Really.

We know that patients carry MRSA intermittently.  So that 3 negative swabs thing doesn’t always make sense.  Also, when one person has MRSA in a household, chances are good that others have it.  Including the dog.  So patients go home, get recolonized, come back.  3 more swabs?  What if they leave before the third swab?

Screening on admission to the ICU?  We used to do that.  One day a floor nurse said to me, “That ICU is gross.  So many patients come out of there with MRSA.”  Um,  no.  That’s the only place we screen them.  They had the MRSA on your floor, you just didn’t know it until they went to the ICU. 

It’s a lot of craziness, and my stomach knots just writing this, because this is how I spend my day.  It tells me something isn’t right.  When science makes sense, staff can reason the answer for themselves, by talking through it.  They will come to the correct answer.  When it doesn’t make sense, it leaves them with questions all the time.

Although the latest research says ICPs spend most of their time reporting infections rather than fixing them, I found time to bring current research and opinions to Infection Control Committee, talk about our specific population, and today I updated the MRSA and VRE policies.   When we are afraid of something and don’t understand it, we stick to what seems to be logical. For a long time, gowns were that thing.  It made sense.  We were protected (until we realized nobody could take the gowns off without contaminating themselves).   I personally like precautions because my staff washes their hands more when leaving a precaution room.  They must feel like it’s extra dirty in that room.

I did have someone ask me if we should wait on this, until our hand hygiene rates were better.  No, I said.  I’m telling you the gowns don’t work like we thought they did.  If we had been sprinkling cinnamon on the MRSA patients, and then we found out it didn’t really work, would we wait for better hand hygiene to stop sprinkling cinnamon?  No, because cinnamon doesn’t work, regardless of hand hygiene. And I can’t see dressing everyone in gowns just to increase hand hygiene rates.  That’s expensive, and not very practical.  I’ll deal with hand hygiene separately.

Now, I’m not a total idiot.  I know about rates of clothing contamination with MDROs.  (But I also know about clothing contamination after wearing the gown).  I know about rates of transfer of MDROs from clothing to patients.  What I don’t know is whether that small rate causes infection, and if so, how many.  I want gowns, I do.  I want them for draining wounds, soiled linen, and anything suspicious.  I want masks—for tracheostomy care, anything involving a suction canister, and anything that might be contagious. That is something that makes sense, that staff can think about and come to the right conclusion.

 But this "one practice, one organism" thing (vertical interventions) doesn’t make sense.  There is a lot of good, thoughtful, scientific debate out there right now, looking at the studies we have and asking what that means for regular ICPs out in the world.  There are people on both sides of this (here, here, and here).  But I have to say, if you’ve got MRSA or VRE infection problems (excluding super-vulnerable populations), you’ve got other problems.

I once read a testimonial for a product that aided in reducing CLBSIs.  The ICP stated that her facility had something like 60 CLBSIs a year, and this new product brought that number down to, whatever, 10 or something.  My first thought was not “What a great product”; it was “What on earth is going on there that you had 60 CLBSIs?!  You’ve got bigger problems.”  You’ve got education problems, orientation problems, practice problems, policy problems.   You mean to tell me you did everything possible according to current EBP and you had 60 CLBSIs?  No way.   If it was an alcohol cap product for your lines, then I know you weren’t scrubbing the hubs, or not with the right product.  If it was an insertion product, your clinicians were screwing up insertion.  

Anyways. Rates of infection that are well beyond any norm point to other issues, in my opinion.  Hand hygiene, environmental cleaning, something isn’t right.  And the gowns aren’t going to fix it.

What are you doing at your facility, and why?

Have you housebroken your C.diff yet?

Whenever I start reading the journals, which I do a lot, I think about how new research affects my practice.  Lately I’ve been mulling over the studies that discuss environmental contamination and C.difficile.  So here’s what I’ve assembled in my brain so far:

1.  It seems that many patients in hospitals who develop CDI have a strain of the bacteria that doesn’t match any other known patient with CDI when the organism is typed.  So all these cases we call “hospital-acquired” may not really be—even if it was x number of days after admission. (Yes, I know this doesn't consider the role of antibiotics.)
2. When samples are taken from the environment of known CDI patients, some of the found strains don’t match the patient.
3.  Asymptomatic carriers of toxigenic C.diff contaminate their environment.

So it appears that there is literally a crapload of C.diff all over the hospital.  So maybe you’re like me and your housekeeping staff is using one disinfectant for the regular rooms and then the special disinfectant for the C.diff rooms, right? And maybe you’ve got one of those silly million-dollar UV robots that administration was lured into buying, and your EVS staff are pushing that thing all over the dang facility, making sure to get the C.diff and precaution rooms.  

But you don’t know which rooms those are anymore!  It seems the truth is that C.diff is in way more places than you thought, because you apparently forgot to train your C.diff to stay in those specific rooms where the patient had CDI.  I can’t imagine how C.diff got from one room to another, because I’m sure your hand hygiene rates are pretty close to 100%, right?  Soap and water every time in those rooms, right? And you didn’t even consider the asymptomatic carriers who are shedding in the room next door. 

Me neither.

So for a while I’d been bouncing around the idea of a one-and-done disinfectant for exactly this reason.  I tell my staff “Precautions patients are just the ones we know about.”   We aren’t testing everyone for everything.  Wouldn’t you rather have a product that takes care of everything, even when you don’t know what or where the ‘everything’ is?  I would.

So maybe this is the post that I would have called “I heart Vendors”.  Because I do.  When I started in IC, my predecessor turned over the business cards of all our sales reps, pointing out who I’d need to keep in touch with.  I know some people avoid them, but I took every call and every meeting during my first year in IC, and I still do.   I want to hear about their product.  Really.

Your vendors or sales reps know their product, they know what it can do, they know what the research says it can do, and they know exactly how it compares to their competitor.  They know what it costs for you to buy and maintain, and how that compares to what you’re doing now.  They have formulas, and white papers, and samples.  The time it would take me to get all that info on my own is, well, ….well, it’s not even possible, given my schedule most of the time.   Yes, it comes with marketing and a sales pitch.  But if you’re educated, you know what’s valuable information and what isn’t.  

So anyways, I think it’s time to move to a new disinfectant, since my C.diff is not housebroken and apparently roams all over the place when I’m not looking. Does yours?

[Related: A source for info on each type of disinfectant.  Disinfectant report cards on Talk Clean to Me blog.]

Florence, and her arch nemesis, Typhoid Mary: Part 3 of Basic Infection Control

I was momentarily distracted by thoughts of being the next Infection Control pop star, but I’ve recovered.  The 3^rd basic principle of infection control that I follow is Keep the Sick Away from the Well.   This means patient-to-patient, patient-to-staff, and staff-to-staff.   If you are not also the Employee Health nurse (as many ICP’s are), then you should have a very close working relationship with your Employee Health department.  You will need them any time a sick staff member exposes others, or patients expose staff, or for myriad questions about when a certain person can return to work after having a certain illness.

Keeping sick patients away from each other strangely is sometimes not second nature to hospital staff.  One day I come in to review the list of overnight admissions.  I see 5 with a diagnosis of either N/V/D or viral gastroenteritis.  I check the census report and see that all 5 have roommates.  And not each other.  I call the floors:

Me: “How’s Mr. Smith in 404?”

RN: “Nausea, vomiting, diarrhea.  Needs hydration.”

Me: “Any likely cause”

RN: “Yes, the diarrhea.”

Me: “No, not the cause of the dehydration.  The cause of the GI symptoms.”

RN: ”Oh, I don’t know.”

Me: “Could you check the progress notes?  Does he have Crohn’s, opiate withdrawal, chemo, new tube feeds?”

RN: “No.  It says ‘likely viral gastroenteritis. Sudden onset on Thursday, no proximal cause. Check C.diff.’  His Cdiff was negative this morning.”

Me: “Ok, so if he might have something viral and contagious, we want him to have a private room so it doesn’t spread to the other patient.”

RN: “But it’s not C.diff”

Me: “No, but if it’s viral, he probably got it from someone else, right?  That means it’s something you can catch.”

Educate, educate, educate.  Then do it again, and speak slowly.

So we went through a rough winter that year, and had to send out a memo to supervisors and nurses telling them that viral gastroenteritis patients should be isolated.  This was big news, because it wasn’t MRSA, VRE, or C.diff.  I find that some clinical staff have trouble remembering how people catch stuff.  Chain of infection.  Healthcare 101.  They are looking for a hard list of specific organisms that they can match to their lab results to see if a patient gets precautions, rather than putting the list down and thinking about disease transmission.  

Four months later, GI bug starts circulating again, and a nurse calls my office to ask if “we’re still doing that thing with the gastroenteritis patients.”  Um, yeah, that thing where we don’t infect other patients unnecessarily? Keeping the sick away from the well?  Basic nursing?  Yeah, I tell her. We’re gonna keep doing that.  No lie. 

It’s like when ICPs are asking if you’re still screening for Ebola.  Do you mean are we still taking an accurate travel and health history on our patients, staying informed about world events that may affect us, and moving obviously ill patients out of the general waiting rooms?  Yup, still doing that.  Healthcare 101.

Same goes for respiratory stuff.  Patient hacking up a lung in 204.  I can hear it from the hall.   What’s he got?  RN: “Just a cough and a fever.  His culture was negative.” 

Me: “Put him on droplet precautions so that anyone coming in there knows to put a mask on.”

RN: ‘But his culture was negative.’

Me:  “There are two dozen things that a sputum culture doesn’t test for (mycoplasma, adenovirus), and some are contagious.  It doesn’t matter that we didn’t identify it specifically.  Nobody else wants to catch it.”

Again, it’s not on a list.  Or worse, they can’t interpret the list (Haemophilus influenzae is not the flu).  Separate the sick from the well.  Unless you’re sure it’s lung cancer, protect yourself and others.  I call this Precautionary Precautions.  Protect the poor housekeeper or chaplain who enters that room.  Really, just put the sign there so people can put a mask on.  Empower staff to do this.  You can take the sign down when you are sure it’s something else.  Really.  You can.  But make sure you don’t give whatever it is to the poor old guy in the next bed.

The other part of this is sick staff.  They are tough to deal with.  When a sick employee shows up to work, they need to be sent home.  But everyone in administration has to be ok with that as a company practice.  It’s a commitment to patient safety, and if it’s strong enough, you won’t have sick staff coming in at all.  Also, you need to make yourself a part of the conversation if your organization is switching how it counts and pays sick time (one pot of time, or separate sick and vacation time.   The type of sick time the company has makes a difference in how people use it (or don’t use it), a handful of economics studies show).

But when it happens, someone has to decide who has the authority to send someone home.  And it’s a really a lousy position for a nursing floor to have made that shift’s assignment, and then have to send someone home.  They would have been better off if the nurse/LNA/whoever had called in before the shift so they can get coverage.  So a lot of managers or supervisors look the other way when someone is sick.  I approach sick staff directly, and question their presence at work.  But I have zero authority to send anyone home.  I hope the discomfort of having me in their face makes them think twice.  

I’ve also had a sick staffer say “I was already out the last 2 days.  I’ll get written up if I take another.”  This is an unfortunate misunderstanding of our sick time policy.   You cannot be out sick more than 3 times (3 events) in a certain period.  This is ONE event that has lasted more than 3 days (not 3 events), like breaking your ankle.  As the next flu season approaches, I might include this in a memo to staff.  People should not come to work sick, in fear of losing their job, or because they don’t understand the policy.  Know your policies, know who has authority to enforce them, and establish the standard that it is not okay to come in sick and spread illness, like Typhoid Mary (who was actually an asymptomatic carrier, but whatever). 

 [Related: New statistical methods for identifying probable patient zero in an outbreak.  Would have been helpful for finding Typhoid Mary sooner.]

Totally distracted by Twitter

If you're an IP and you're not on Twitter, then, um, you need to be.  I honestly get most of my ID news this way, links to journal articles that I may not have gotten to, thoughts and opinions from leaders in the field, and a super fast heads-up when stuff happens.  Also, it's just nice to know there are others out there.  And sometimes, it's just fun.

So, I occasionally daydream about having a film noir poster in the style of Bad Blood (Taylor Swift) with some kind of alter ego (like, Infektor or something), even though I'm a little old for the leather suit (not practical for the Practical ICP).   And it's a good song, and a cool video.

And sometimes something just tips you off, like @IP_Crystal98, an IP from somewhere in America who I follow on Twitter, sort of by chance.  And she says something about a parody of 'Bad Blood' called 'Bad Bugs' about antibiotic resistance.  She mentions @zdoggmd who makes cool medical music videos on YouTube, and soon I'm thinking....

So here's some alternate lyrics to Bad Blood, credit to Crystal for the idea, and IPs welcome to comment and suggest better ones.  This would be THE video for APIC 2016.  We just need some young attractive IPs for the video (wait, are there any young IPs?  I'm working on that. You should be, too.)

Cause baby now we got bad bugs

You know we used to have good drugs

So take a look what you’ve done

Cause baby now we got bad bugs

Now we got problems

But I know we can solve them

You really used too much

And baby now we got bad bugs

Hey

Did you think about this? Using every drug on the list

Couldn’t you wait for results? Using all of those empirics

Did you have to treat her?  Asymptomatic, just no need.

Did you educate him? Or just write the script so you can leave

Oh, its so sad to think about the good times, you and i

Did you think he’d be fine? Increased resistance from the last time

So don’t think it’s in the past, these kinda bugs they last and they last.

Now did you think it all through? All these things will catch up to you

And time can heal but you don’t, so if you’re writing for Invanz, just don’t

Bactrim don’t fix bullet holes

Don’t give Z-packs just for colds

If you treat like that, bugs get bold

Bactrim don’t fix bullet holes

Drug pipelines are getting cold

ASB? No cipro

When your patients ask, just say NO!

Cause baby now we got bad bugs

You know we used to have good drugs

So take a look what you’ve done

Cause baby now we got bad bugs

Now we got problems

But I know we can solve them

You really used too much

And baby now we got bad bugs