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• W2132251518 abstract "Healthcare-acquired infection is considered an adverse event and anaesthetic practitioners share a professional responsibility to ensure that high standards of infection control are maintained. However, there are significant challenges to this undertaking, because as humans we most effectively act upon what we are able to perceive by sight, touch or smell, and in the absence of such stimuli, we rely on external cues to prompt a response. As a result, the battle against healthcare-acquired infection is destined to remain challenging and at times, controversial. The daily working pattern of most anaesthetists takes them from operating theatre to ward and office and back again. In this issue of Anaesthesia, these working patterns are explored with respect to infection control 1. Hee and colleagues report the results of their study, which found that visits to the ward and office did not significantly increase bacterial contamination of scrub suits 1. Their study was designed to identify the impact of wearing operating theatre scrub suits outside the theatre environment by measuring the microbial colonisation of garments. In so doing, the authors attempt to answer pertinent infection control questions, the answers to which may challenge further our attitudes to infection control. While the role of medical dress in the transmission of infection remains poorly established, there are no shortages of studies that contradict the work of Hee and colleagues. Thus Burden et al. 2 demonstrated pathogenic colonisation of hospital uniforms by up to 50% within a single hospital shift. Bearman and colleagues 3 took such findings one step further and by means of a novel intervention using antimicrobial-impregnated scrub suits, successfully reduced the contamination of such garments with methicillin-resistant Staphylococcus aureus (MRSA), when compared with standard scrub suits. Although the impact of scrub suits as vectors for transmission of pathogens is not well defined in clinical studies, consideration of the wider infection control and prevention debate provides us the opportunity to consider how infection control practice and clinical anaesthesia might better co-exist. In 1847, the Hungarian physician Ignaz Semmelweis reduced the incidence of puerperal fever and maternal mortality in childbirth by demonstrating the importance of handwashing during delivery 4. Failure to accept the hypothesis that puerpural sepsis was a disease spread between patients on the hands of physicians can, in part, be laid at the feet of Semmelweis himself. While his data suggested that the pathogen was passed from physician to mother, his argument was fragmented and poorly presented, failing ultimately to influence colleagues and change practice. Semmelweis challenged the popular perception of disease, but failed to deliver a coherent message. Compounding what would become an ineffectual infection prevention and control message was in part its delivery but more importantly, it was delivered to an audience not then ready to accept it. Ironically, in 1865 Semmelweis was admitted to an asylum, where he was to die of septicaemia in the same year. More than 150 years after Semmelweis, doctors are still challenged by new evidence, much of it methodologically sound, some of it less so, and some poor in design and assertion. Anaesthetists assimilate, synthesise and utilise these studies to varying degrees, some practising blind to this evidence, others selecting evidence wisely, while others, like the physicians of old, fail to accept any new evidence at all. If an anaesthetist fails to take adequate infection control measures when placing a central venous catheter, what must we assume? Ignorance of the evidence, disbelief of that evidence, or the belief that his/her personal experience was more important? In 1847, the hubris of Semmelweis's peer group, mortified at the suggestion that a gentleman-physician should need to wash his hands, would result in no improvement in the puerperal sepsis mortality rates for many years. However, for those engaged in clinical practice, making evidence-based decisions remains challenging. Does the work of Hee and colleagues give us the green light to wander freely within the hospital, safe in the knowledge that we carry no harmful pathogens? Should hospital Trusts invest in antimicrobial-secreting theatre scrub suits in an attempt to reduce the impact of harmful bacteria, as suggested by Bearman et al.'s results? Or should free access of movements between theatre and hospital wards be restricted, based on limited evidence of harm? Healthcare-acquired infection rates appear to be falling and this trend may be related to the adoption of more user-friendly systems that represent a carefully fashioned interface between those who produce and those who are required to follow guidelines 5, 6. Such examples include the successful control of MRSA in many European countries over the last ten years, through a variety of measures including root cause analysis, improved hand hygiene monitoring and feedback, screening, publicly available performance tables, patient isolation and government fines. However, as some infection rates decline, other infection rates increase 7. In some countries, control of multi-resistant gram-negative infection has been lost, probably as the result of poor compliance with infection control measures and a lack of antimicrobial stewardship 8. In some centres, the lack of effective antimicrobials in critical care is having a serious impact on patient outcomes. There is a risk that such pathogens as Klebsiella pneumoniae and New Delhi metallo-β-lactamase (NDM) carbapenemase producers will spread in numbers and increase in virulence if the environment is favourable 9, 10. While the effect of a theatre dress code on rates of wound infection is difficult to prove, poor adherence is symptomatic of a broader disregard for the possibility of involvement in the spread of pathogens between patients and the environment. A tightly run theatre suite with an enforced dress and access protocol is more likely to engender scrupulous infection control and low rates of infection. In response, healthcare organisations have invested heavily in developing clinical guidelines based on both the available evidence and expert opinion to bring clarity, mitigate against poor clinical decision-making, and ensure a consistent and co-ordinated institutional response. Guidelines become policies and varying grades of evidence become conflated and blurred with ‘expert opinion’, and ultimately can impact in a negative way on our daily clinical practice. If poorly developed, such guidelines attract criticism and ultimately cynicism from those charged with ensuring high-quality care. The perception is that such guidance evolves in a ‘vacuum’ and is often insensitive to the interactions between those engaged in healthcare and their complex working environments 11. Poorly constructed guidelines on infection control and prevention, therefore, might – like other guidelines – be seen as stand-alone edicts, unrelated to daily activities and unwieldy to many anaesthetists: we might have time to deliver a high-quality anaesthetic or alternatively concentrate on adherence to an infection control policy, but not both! It has been suggested that the credibility of clinical guidance has been lost and what remains is an unwieldy attempt to corral activity based on limited evidence. Operating theatre dress code is usually subject to local policy guidelines and may vary widely between institutions in the absence of good supporting evidence or national/international consensus, despite efforts of professional bodies to offer guidance 12. Developing credible guidance requires an understanding of the barriers that exist in the workplace, and the proper engagement with staff to bring about responsive guidance that offers both the opportunity and the motivation to change practice 13. Recapturing credibility and the inevitable ground lost may lie in the science of ergonomics and a behavioural approach. Bridging the gap between people and policies may offer a more readily accepted solution. The World Health Organization (WHO) surgical checklist 14 and a critical care central venous catheter ‘care bundle’15 are examples of well-crafted interventions, in the form of simple checklists, that have influenced and shaped workplace activity. Such simple checklists, which have a strong supporting evidence-base, when incorporated into everyday practices have demonstrated improved patient outcomes. When applied intelligently, such methods reduce variance in clinical practice and promote a move towards system-based care, avoiding an over-reliance on the action of individuals. In 2006, Pronovost and colleagues reported on the impact of a simple checklist intervention of infection control measures that ultimately reduced catheter-related bloodstream infections in patients within intensive care units by up to 66% across the US state of Michigan. In that study, researchers demonstrated the need for change, supported staff to achieve it and actively engaged in clinical leadership, to make this checklist intervention the norm of practice. Key to its success was the active engagement by the researchers in delivering a ‘living, breathing’ change, woven into the fabric of daily intensive care activities. This large-scale quality improvement project had important consequences for public health, and the methodology was readily adopted by other nations, including the UK 16. When there is failure to embrace a checklist philosophy, however, the process may be as doomed as the unread clinical guideline from which it was borne. In a recent observational study assessing the impact of the introduction of the WHO surgical checklist in 101 hospitals across Ontario, Canada, failure to demonstrate mortality or other benefit cautions against ‘top-down’ policy implementation 17. In an accompanying editorial 18, Leape argues that participating hospitals saw no outcome benefit in the intervention, as they had failed to participate in the process of change. Clinical practice, it was argued, is not a technical issue associated with a checklist, but rather a problem of human behaviour and interaction. Today, in the fight against healthcare-acquired infection, all healthcare workers acknowledge that we must put the patient's wellbeing first. The challenge for the future will be to do the right thing well, time and time again. Importantly, we must avoid cynicism, which might be seen as a personal defence against engaging with the new infection challenges that lie ahead. Today, the so-called ‘Semmelweis effect’ is a metaphor for the reflex-like tendency to reject new evidence or new knowledge because it contradicts established norms or beliefs. If healthcare policy makers are to learn from the ‘Semmelweis experience’, they must work hard to promote clinical evidence in better ways and prioritise systems of staff engagement through novel and meaningful workplace interventions. No external funding and no competing interests declared." @default.
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• W2132251518 title "Learning from Semmelweis: engaging in sensible infection control" @default.
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