From ritual to reason—with a rational a rational approach for the future: An epidemiologic perspective

American

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Control August 1984

IAL ARTICLE

Cram ritual to reason-with a rmtiarcal h for the future: An iegic perspective Fifth Annual Carole DeMOlle Lecture Marguerite M. Jackson, San Diego, California

R.N., MS.

My topic for this talk is a discussion, from the perspective of a practitioner in a hospital, about using methods from epidemiology as a rational approach for problem solving. I preface my remarks by relating an experience I had several ‘years ago that gave me a great appreciation for epidemiology and the place of nosocomial infections within it. While in the library looking for general information about infection control, I came across a very large book entitled Maxcy-Rosenau: Public Health and Preventive Medicine.’ The book was already in the eleventh edition, so I decided it must be worth reviewing. In the table of contents I found one 1 ‘-/-page chapte? related to my subject in a book with 57 chapters and 1924 pages. It was then that it first became clear to me that nosocomial infections might be at the end of my tunnel vision, but in the big scheme of things it was only one of many conPresented at the Eleventh Annual Educational Conference of the Association for Practitioners in Infection Control, Washington, DC June 4, 1984. Reprint requests: Marguerite M. Jackson, R.N., M.S., Infection Control Team, University of California Medical Center, 225 Dickinson St , H-951, San Diego, CA 92103.

siderations in the field of preventive medicine and public health! I also got a strong message that most activities associated with preventive medicine and public health had a common goal of prevention of morbidity and mortality. In the meantime I had also learned how to do surveillance. The methods that we have been taught include counting all nosocomial infections that occur according to when the infection develops. Surveillance uses a temporal criterion. The surveillance methods we were taught do not distinguish between preventable and unavoidable infections, but count every infection that occurs if the infection meets the time criterion for being called nosocomial. As we have learned more about nosocomial infections, we have learned that between 3.5% and 5% of all hospitalized patients are counted as meeting the surveillance criteria for nosocomial infection. It has also been estimated that at least half of the nosocomial infections we are taught to count are probably not preventable. If the focus of infection prevention and control efforts is really on prevention, why are we still spending so much time counting infections 213

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we can do nothing to prevent? What is the value of counting an outcome again and again and again, when the process to change the outcome is not within our reach? On the brighter side, we also now know that many of the infections we are taught to count are potentially preventable and we know that most of these infections are related to devices and procedures. Wouldn’t it make better sense to concentrate our efforts on the front end of the problemthat is, on risk factors for infection that we now know can influence the outcome for the patient? Using information from published studies, we can learn to differentiate between those factors that make a difference in infection risk and those that don’t appear to affect it. We can also determine which of the factors can be influenced by the facility, the physician, the nurse, and most importantly, by the patient. Such an approach is consistent with the goal of prevention and can best be met by a combination of education and management skills directed at influencing change. I had the opportunity to work with Julie Garner and the Centers for Disease Control (CDC) to develop the “Management Skills for ICNs” course.3 In this course we learned to identify various problems and determine whether change could best be influenced by an educational approach, management strategies, or changes in equipment and supplies. I highly recommend this course to any of you who are interested in increasing your skills in influencing change in your institution. After I learned how to solve problems by using the management skills approach, I began to ask this question frequently: “If the outcome is not affected by the prevention strategy used by the health care provider, why do we cling so tenaciously to the strategy? Is it really a ritual without a reason?” My curiosity about rituals has been peaked recently by my review of several nursing fundamentals textbooks. I have found many practices described in these textbooks that had their origins in the early 1900s. These practices have apparently been passed down from generation to generation of textbooks-unchanged and unquestioned. Why? Perhaps because such practices are done according to custom, often with-

out thinking about reasons for them. Such behavior is, by definition, a ritual. To analyze some of these rituals, I have often used the “5 Ws” of epidemiology approach. This approach uses the questions what, who, where, when, and why? For example, for a number of years my hospital used paper trays with disposable dishes and utensils for some patients on isolation precautions. I didn’t question the practice until about a year ago. After all, we have always done it that way. By using the 5-Ws approach, however, my mind was challenged to ask why we were using the practice. Let’s go through this example together: l What? The practice of using disposable food trays, dishes, and utensils For patients on enteric precautions l Who? and strict isolation l Where? In many hospitals (even though CDC no longer recommends it) l When? Now and for many years past l Why? Perhaps because of the belief that a disposable food tray will interrupt transmission of infection In developing answers to the “Why?” question, I prepared a hypothetical example of the theoretical probability of transmitting an enteric infection from a patient to a hospital employee via a food tray, whether or not the patient is on enteric precautions. The purpose of calculating a joint probability is to estimate, using numerical values, how likely it is that all events will occur in sequence. In developing the assigned subjective probabilities, I have been quite generous. That is, I have estimated that 20% of patients with enteric infections get stool on one or both hands before mealtime and that half of hospital employees put their hands in their mouth after picking up patient trays. You will notice that handwashing is conspicuously absent from the chain of steps. Although handwashing is a known method to interrupt the fecal-to-oral transmission of diseases, what is presented here is the joint probability of transmission without benefit of this intervention strategy (Fig. 1). As you can see at the end of the chain., the likelihood of all steps occurring as listed is, at most, about one chance in 5000. This is but one

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on hand(s)

gets

stool

00

Patient gets Stool on

P(ABOOEF)

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C.2 x .I

=

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x. I x .5 Y .3 x.8)

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Patirnt has infectious agent in stool

Fig. 1. Hypothetical example of joint probability of infectious agent being transmitted from patient to hospital employee via food tray. Asterisks indicate assigned subjective probabilities because true probabilities are unknown. Using this hypothetical example, there is only one chance in 5000 that all events will occur in sequence and employee will become ill from handling patient’s food tray.

example of why transmission of infectious agents is rarely by indirect contact between two people via objects in the environment. The next question is, Do paper (disposable) trays interrupt transmission? Note that these steps can occur with either a paper tray or a regular tray. Through these steps, all trays are often handled the same way. It is usually when the tray is discarded or returned to the kitchen that a paper tray is handled differently than a regular tray. In discussing the paper-tray issue recently with an infectious disease epidemiologist who was involved in the development of some of the early recommendations for hospitals, I was told that one theoretical reason at that time for using paper trays for enteric infections was to reduce the likelihood of kitchen workers con-

taminating their hands and then preparing food for others, thus leading to a possible common-source outbreak. A joint probability could also be calculated for this chain of events that would probably result in even lower odds. In addition, in even the smallest hospitals, persons who work in the dirty-dish area are usually not the same persons who do food preparation such as making potato salad! Returning now to basic problem-solving methods from epidemiology, what is the most effective means of interrupting this chain of transmission so that even that one chance out of the 5000 will not occur? Have the patients wash their hands before eating (Fig. 2). It seems to me that when extreme precautionary measures are taken with such things as trays and trash from patients on isolation pre-

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PATIENT BEFORE

Patient stool

HANDS

MEALTIME

gets on

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WASHES

I A

TOP

Pig. 2. Hypothetical example of interrupting chain of events required to transmit infectious agent from patient to hospital employee via food tray. Asterisk indicates subjective assigned probability because true probability is unknown. Using this hypothetical example, handwashing by patient (with assistance from care providers, if necessary) occurs before patient handles food tray. If this step is taken, chain of events depicted in Fig. 1 will not occur.

cautions, because of the belief that these items might be vehicles for transmission, the beliefs are more often based on rituals from the past than on reasons that have a rational basis today. This same kind of joint probability could be estimated for transmission of infectious agents by such things as patient charts, door knobs, toilet seats, and carpets. What are some other factors to consider with disposable trays? l The patient usually receives cold food. l The hospital spends money on disposable trays, dishes, and utensils. l More trash is generated for the incinerator or sanitary landfill. l Hospital employees are encouraged to have a false sense of security based on ritual, not reason. I have added two additional questions to the

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list of the 5 Ws that are especially pertinent in today’s economy: l What can be measured? l What is the cost : benefit ratio? In the food tray example the cost of providing the disposable items can be measured. The money to be saved by eliminating the practice can be measured in direct costs (that is, the actual cost of the disposable items to the hospital) and estimated in indirect costs, although this estimation is more difficult. In estimating a cost: benefit ratio, the cost of providing the disposable items is relatively high compared to a benefit that is negligible if not negative. I challenge each of you to go back to your facility and question the value of disposable trays, dishes, and utensils for patients on isolation precautions if you are still using this practice. You may be able to save your hospital some money and show that you are a skilled problem-solver during these tight economic times. Another ritual that is still being used by some hospitals is that of “protective” or “reverse” isolation. I have often wondered what the origins were for this practice. In reviewing the 1968 and 1979 editions of the American Hospital Association’s manual, Infection Control in the HospitaL4 recently, I found my answer: l Its purpose is to protect patients with decreased resistance to infection . l The objective is to maintain the patient at a level of asepsis comparable to that in the operating room . . . l Any source of contamination is potentially dangerous to the patient . . In the 1970 edition of CDC’s Isolation Techniques for Use in Hospitals,s it was recommended that gloves, masks, and sterile gowns be worn and that hair and shoe coverings were sometimes indicated. To go along with this recommendation, most nursing textbooks included elaborate diagrams for donning sterile gowns for “protective asepsis.” By the second edition of the CDC manual,6 the need for stede gowns had disappeared from the recommendations except for special circumstances; when the 1983 CDC Guideline for Isolation Precautions in Hospitals7 appeared, the entire category of “protective isolation” had been removed. How did this change happen? By someone asking the 5Ws questions and then doing a

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From ritual

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to reason:

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AGE JEW1

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POPULATION IN MILLIONS

Yr. 2000

An epia’emiologic

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I

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r(i6

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5 0 5 POPULATION IN MILLIONS

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10

Fig. 3. Population age-sex pyramids, United States, 1960, 1980, 2000, 2020. Depression cohort persons were born 1930-1939; baby boom cohort persons were born 1950-1959; baby bust cohort persons were born 1970-1979. Note increasing size of proportion of pyramid representing persons age 60 and greater. (From Bouvier LF: America’s baby boom generation: The fateful bulge. Popul Bull 35:18-19, 1980.)

prospective study to determine whether the practice really made a difference. Nauseef and MakP published their study in the New England Journal of Medicine in 1981; the CDC changed their recommendations in 1983; have you made the change in your hospital yet? Let’s answer these questions: What can be measured? What is the cost: benefit ratio? and add a third: What is the theoretical rationale for the practice? In this example the theoretical rationale for the practice was the belief that establishing an environment like that of an operating room would make a difference in the compromised patient’s risk for infection. Over the years as we learned more about infection prevention strategies and also about infections in compromised patients, it became apparent that most infections were endogenous in origin and that the

organisms causing them did not usually come from the external environment. The purpose of protective isolation was primarily to control the external environment. The intervention strategy didn’t work for infections that were endogenous and that was the vast majority of infections in these patients. What can be measured? Again, direct and indirect costs associated with the practice and the cost savings that would accrue to the hospital if the practice were eliminated can be measured. What is the cost:benefit ratio? The benefit to the patient is probably a negative one due to the psychological factors associated with being in a room alone with the door closed and all care providers dressed like robots. The cost to the hospital can be considerable. It includes supplies, increased personnel time to use gowns,

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gloves, and masks, a private room that might be better used by some other patient, and sometimes ventilation system modifications that are very costly. Why do many hospital personnel and many physicians still cling to the ritual of protective isolation? Some people tell me it is because that is the only way they can be reasonably assured that persons will wash their hands before caring for compromised patients. With the changes in reimbursement and the increasing concerns for cost of care, we can no longer afford to perpetuate costly rituals such as protective isolation. If you or your facility believe you must do something to remind people to wash their hands before caring for compromised patients, the use of special signs provides an alert system at much less cost. Better yet, because handwashing is important when caring for all patients, focusing on the provision of adequate sinks, soap dispensers that work, and plenty of paper towels nearby is an even more desirable approach. What I have presented with these examples are some uses for basic methods from epidemiology as an approach to investigate rituals for which there appear to be no rational reasons. You can probably think of many other practices that are done in the name of infection control that have never been questioned but should be. Another example from basic epidemiology became the theme for an article that was recently published in the American Journal of Nursing.s In preparing this article, Pat Lynch and I spent a good bit of time discussing the differences in care provided to patients who are labeled with a diagnosis considered to be potentially transmissible to others compared to patients not so labeled. In our experience, hospital personnel often use extreme caution when caring for patients who are labeled “infectious” but may be quite careless in handling body substances from patients who are not so labeled. The example we used in this article is typical of situations many of you have experienced: Two patients are admitted to the hospital at the same time. One is diagnosed as having cirrhosis of the liver due to alcohol abuse; the other has cirrhosis of the liver secondary to

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chronic hepatitis B infection. Personnel caring for the patient with the hepatitis B infection are very careful with his blood, may wear gloves to start an IV infusion, and clean up spills with a sodium hypochlorite solution. Personnel caring for the other patient are much less attentive to the blood spills, do not wear gloves when exposure to blood is likely, and forget to wash hands after they are soiled with body substances. Several days after the two patients are admitted, the one with alcoholic cirrhosis turns out to be hepatitis B surface-antigen positive. Exposure to his blood had already occurredthe person starting his IV infusion had a fresh cut on her hand and got the patient’s blood in it. She is quite concerned now about her personal health and wants the employee health service to do something for her. The illustrations we developed to go with this scenario are those of the “iceberg” phenomenon and the “spectrum of infection”-two commonly used examples from the epidemiology of infectious diseases. With the iceberg phenomenon, patients identified as infectious are only the tip of the iceberg; many other patients may be potentially infectious for the same disease but are not identified as such. With the spectrum of infection, patients are often able to transmit infection long before symptoms appear and infection is diagnosed. This is true of viral diseases and many bacterial diseases in which colonization of body substances precedes manifestation of symptoms. Our message in this article and one message for you today is our recommendation for teaching personnel about the potential for organisms to be present in all body substances from all patients. We suggest focusing educational efforts on increasing the attention of direct care providers to assessing each patient for secretions, excretions, blood, and other body fluids that may be potentially infectious and determining whether these substances are available to soil hands during care activities. We suggest that personnel wear gloves when it is likely that their hands will become soiled and we stress the need for handwashing after contact with all body substances, whether or not gloves are used. We believe that is a commonsense ap-

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preach to patient care that decreases the likelihood of using a double standard for patients who are labeled and those who are not. This approach may also increase the hospital’s glove use, and we hope it will decrease the use of ritualistic practices associated with many different diagnoses. To move to another area where basic epidemiology can be used to determine outcomes other than infections or costs, I turn to the calculation of rates. We have used incidence and prevalence rates for infection statistics for years. Baseline rates have been established for the nation through CDC’s National Nosocomial Infections Study (NNIS) and Study on the Efficacy of Nosocomial Infection Control (SENIC); most of us have established our own institutional rates through surveillance activities. Another area where calculation of rates can be very useful to the hospital is for such things as medication errors, slips and falls, needlestick injuries, and other events. The key is in establishing a denominator, or the population at risk. For example, using only numerator data to compare one nursing unit to another for medication errors doesn’t take into account differences between the units in numbers of medications given. If a rate calculation is used to compare the units, a much better estimate can be made of the need for intervention strategies. The same is true for slips and falls. Two such injuries in a month in a department of 10 is quite different from two such injuries in a month in a department of 100. The number of employees at risk can be obtained from the personnel department; comparing the numerator and denominator to generate an incidence rate is easy. Does your facility use rates or merely numerators for such risk management activities? Back in the early days of infection control programs, rate calculations were essential for establishing baseline rates for nosocomial infections. Because the Joint Commission on Accreditation of Hospitals has now recommended that hospitals establish quality assurance programs, hospitals have promptly done so. Establishing baseline statistics for such programs is an essential step in their development. In many hospitals the program and the positions within it are poorly defined: the outcome mea-

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sures are often unclear; and educational programs for quality assurance personnel are varied and inconsistent in their quality. Many ICPs have found that taking leadership positions in quality assurance programs fits with their background in epidemiology and their interest in professional growth and advancement. This change in position for ICPs will undoubtedly be a continuing trend in the future. Turning our attention to health care needs for the future and how infection prevention and control programs may fit into the picture, I return again to Maxcy-Rosenau.’ In reviewing the book, I came across another fascinating way to display population data: the population pyramid (Fig. 3). Such visual depictions of populations give a sense of the magnitude of future needs such as health care, schools, and facilities for the aging. When population pyramids are compared to one’another,‘O they show how the population changes over periods of time as each age cohort moves up the pyramid. It is well known that the proportion of older adults in our population is increasing rapidly; this was predicted a number of years ago. The National Center for Health Statistics estimates that by the year 2020 (36 years from now) one of every five or six persons in the United States will be over the age of 65 years. That means 16% to 20% of the population, compared to only 4% of the population in the year 1900, and about 11% of the population today. By the year 2000 (only 16 years from now), there may be as many as 6 million people 85 years of age or older. These changes are largely due to the conquest of infectious diseases in infants and children and the striking decrease in adult death rates from such illnesses as heart disease and strokes. What does this mean to infection prevention and control programs? It means that hospitals will be seeing older and sicker patients every year. Coupled with the changes in the reimbursement system for health care and the potential for earlier discharges from the hospital, personnel will have increasing need to know about the social, economic, and chronic health problems of this segment of the population. In an article published by Gross et al.” recently, decade-specific risk for nosocomial infections was calculated. The investigators de-

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termined that in patients from the age of 50 years and upward, the rate of nosocomial infections rose logarithmically and peaked at greater than lOO/ 1000 discharges (or 10% of all discharges) after 70 years of age. Although the elderly (those more than 60 years old) made up only about one quarter of their study population, almost two thirds of the nosocomial infections during that time period were in persons over the age of 60 years. In discussion of what this means for infection prevention and control, they note that many of these patients are exposed to devices such as Foley catheters and nasogastric tubes that automatically increase the likelihood of acquiring an infection. Even if these infections are from the patient’s own flora, focusing on these devices and discouraging their use unless clearly indicated for medical reasons may reduce some of the risks for infection in these patients. The methods I have presented for using epidemiology for problem solving are but a few of the many applications of this fascinating subject. The APIC Curriculum for Infection Control Pructice12 suggests others and directs the reader to many additional references. The remainder of the decade poses many challenges for each of us working in a health care field, and we can learn many lessons from the field of epidemiology. To summarize, I would like to close this talk by sharing a story told to me by a good friend and former infection control colleague, Sandra Emerson.

INFECTION

o!

She laughed merrily as she responded, “Oh, honey, my baking pan was too small for a whole ham so I cut the ends off to make it fit. I had that same baking pan for 40 years.”

My message for this presentation is reflected by this story and by the title of the lecture. I challenge you to find the logical reasons for practices and discard the rituals. Use methods learned from epidemiology for solving many different problems with many different outcome measures. I believe this is a rational approach for the future and perhaps the only one that will withstand the challenges presented to hospitals and the health care system in the coming years.

1. Last

2.

3.

4.

5.

6.

7.

A newlywed couple was preparing their first dinner for company. They had selected ham as the entree. The young wife got out the ham and a baking pan and carefully cut both ends off of the ham. Her husband asked, “Why are you cutting the ends off before you bake the ham?” His wife’s response was, “Well, that’s just the way you have to fix a ham. I learned that method from my mother.” The young man was quite curious about the origin of this practice-especially since his mother had never fixed ham that way -so he asked the question of his mother-in-law during their next visit. His mother-in-law’s response was the same as his wife’s, “Well, that’s just the way you have to fix a ham. I learned that method from my mother.” A few weeks later, the whole family was together and the young man had occasion to ask his wife’s grandmother about the origin for the custom.

Journal CONTROL.

8.

9. 10.

JM, editor: Maxcy-Rosenau: Public health and preventive medicine, ed 11. East Norwalk, Corm, 1980, Appleton-Century-Crofts. Dixon RE, Mallison GF: Nosocomial infections. In Last JM, editor: Maxcy-Rosenau: Public health and preventive medicine, ed 11. East Norwalk, Conn, 1980, Appleton-Century-Crofts, pp 290-306. Centers for Disease Control: Management skills for infection control nurses: A criterion referenced instruction program. Atlanta, 1982, Centers for Disease Control. American Hospital Association: Infection control in the hospital, ed 1 and ed 4. Chicago, 1968 and 1979, The Association. Centers for Disease Control: Isolation techniques for use in hospitals. Atlanta, 1970, CDC, Department of Health, Education, and Welfare. Centers for Disease Control: Isolation techniques foi use in hospitals, ed 2. Atlanta, 1975, CDC, Department of Health, Education, and Welfare. Centers for Disease Control: Guideline for isolation precautions in hospitals. In Guidelines for the prevention and control of nosocomial infections. Atlanta, 1983, CDC, Department of Health and Human Services. Nauseef WM, Maki DG: A study of the value of simple protective isolation in patients with granulocytopenia. N Engl J Med 304:448-453, 1981. Jackson MM, Lynch P: Infection control: Too much oi too little? Am J Nurs 84:208-210, 1984. Dever GEA: Demographics: Epidemiological tools.

In

Epidemiology

in health

services

management.

11.

Rockville, Md, 1984, Aspen Systems Corp., chap 9, pp 237-287. Gross PA, Rapuano C, Andrignolo A, Shaw B: Nosocomial infections: Decade-specific risk. Infect Control 4:145-147, 1983.

12.

Jackson MM, Check0 PJ: Epidemiology

and statistics.

In Soule BM, editor: The APIC curriculum control practice. Dubuque, Iowa, 1983, Publishing Co, set 1, pp 9-127.

for infection Kendall/Hunt