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?