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.]