Those
of us working to prevent infections in paediatric hospitals typically view the
environment with a high degree of suspicion.
A bundle of factors predispose infants and young children to acquire
infections from organisms present on surfaces.
Their relatively naïve immune systems and lack of inhibition for
environmental oral interaction, combined with total dependence on others for
care and a tendency for us to surround them with toys and other objects for
distraction, development and amusement, align the odds strongly in favour of
transmission.
of us working to prevent infections in paediatric hospitals typically view the
environment with a high degree of suspicion.
A bundle of factors predispose infants and young children to acquire
infections from organisms present on surfaces.
Their relatively naïve immune systems and lack of inhibition for
environmental oral interaction, combined with total dependence on others for
care and a tendency for us to surround them with toys and other objects for
distraction, development and amusement, align the odds strongly in favour of
transmission.
The
epidemiology of infections in paediatric hospitals differs from adult
hospitals. Health care associated
respiratory and gastrointestinal viral infections are far more common than so
called “super bugs”. These agents are
viable from environmental surfaces from hours to weeks. When you consider how often the side rail of
a crib can be inoculated with pathogens in the context of a baby with diarrhea
requiring frequent diaper changes, the risk for transmission becomes very
clear. You cannot safely leave the side
rail down while removing gloves and cleaning your hands, particularly when you
have a heavily loaded diaper to contend with at the same time. Diapers of sick children need to be weighed
and cannot be immediately discarded, resulting in even more opportunities for
transmission.
epidemiology of infections in paediatric hospitals differs from adult
hospitals. Health care associated
respiratory and gastrointestinal viral infections are far more common than so
called “super bugs”. These agents are
viable from environmental surfaces from hours to weeks. When you consider how often the side rail of
a crib can be inoculated with pathogens in the context of a baby with diarrhea
requiring frequent diaper changes, the risk for transmission becomes very
clear. You cannot safely leave the side
rail down while removing gloves and cleaning your hands, particularly when you
have a heavily loaded diaper to contend with at the same time. Diapers of sick children need to be weighed
and cannot be immediately discarded, resulting in even more opportunities for
transmission.
The
recent focus on Clostridium difficile infection (CDI) has reinforced
what we think we know about the environment in paediatrics and has highlighted
what we don’t know. The morbidity and
mortality of CDI is much lower in children than adults and yet the rate of
infection when directly compared (which epidemiologists know we should not do),
is generally higher. We know that a
larger proportion of infants and very young children are asymptomatically
colonized with C. difficile. For
that reason, it is rare to test infants less than 12 months of age for that
agent as a cause of diarrhea. Recent
studies suggest that C. difficile may be a more important pathogen in
children than previously appreciated.
Until that is better understood, we need to focus on what we do know;
that C. difficile may be present in the stool of more than 60% of
infants and that it may easily contaminate the environment putting certain
paediatric populations at risk for infection.
That knowledge places even greater importance on having sound cleaning
practices in place.
recent focus on Clostridium difficile infection (CDI) has reinforced
what we think we know about the environment in paediatrics and has highlighted
what we don’t know. The morbidity and
mortality of CDI is much lower in children than adults and yet the rate of
infection when directly compared (which epidemiologists know we should not do),
is generally higher. We know that a
larger proportion of infants and very young children are asymptomatically
colonized with C. difficile. For
that reason, it is rare to test infants less than 12 months of age for that
agent as a cause of diarrhea. Recent
studies suggest that C. difficile may be a more important pathogen in
children than previously appreciated.
Until that is better understood, we need to focus on what we do know;
that C. difficile may be present in the stool of more than 60% of
infants and that it may easily contaminate the environment putting certain
paediatric populations at risk for infection.
That knowledge places even greater importance on having sound cleaning
practices in place.
Achieving
optimal cleaning requires an understanding of the complex interplay of
chemistry, human factors and behavioural science involved in cleaning
processes. We are attempting to understand
that better. A recent quality
improvement project (Matlow, Wray & Richardson, Am J Infect Control, 2012
Apr;40(3):260-2) has contributed to our understanding by highlighting the
importance of the attitudes and beliefs of cleaning staff and how their
attitudes and beliefs shape both their intent and actual attention to
environmental cleaning. We learned that
it was largely their internal desire to do a good job, with underlying thoughts
of “what if it were my child in that bed” that drove their practice. We also learned that they did not always feel
appreciated by staff who took for granted the work that they so highly valued. From a practical perspective, we learned that
cleaning staff, professional staff, and infection prevention and control staff
had varied opinions regarding which surfaces are frequently handled and
therefore require consistent attention.
We also better understand some of the tensions between family centered
care and achieving high standards of cleanliness. Families of patients are integral to the care
of their children. They are nearly
always present. While present, they
bring belongings from home, needed for extended lengths of time. We don’t always have adequate storage space and
so personal belongings become clutter and impede cleaning.
optimal cleaning requires an understanding of the complex interplay of
chemistry, human factors and behavioural science involved in cleaning
processes. We are attempting to understand
that better. A recent quality
improvement project (Matlow, Wray & Richardson, Am J Infect Control, 2012
Apr;40(3):260-2) has contributed to our understanding by highlighting the
importance of the attitudes and beliefs of cleaning staff and how their
attitudes and beliefs shape both their intent and actual attention to
environmental cleaning. We learned that
it was largely their internal desire to do a good job, with underlying thoughts
of “what if it were my child in that bed” that drove their practice. We also learned that they did not always feel
appreciated by staff who took for granted the work that they so highly valued. From a practical perspective, we learned that
cleaning staff, professional staff, and infection prevention and control staff
had varied opinions regarding which surfaces are frequently handled and
therefore require consistent attention.
We also better understand some of the tensions between family centered
care and achieving high standards of cleanliness. Families of patients are integral to the care
of their children. They are nearly
always present. While present, they
bring belongings from home, needed for extended lengths of time. We don’t always have adequate storage space and
so personal belongings become clutter and impede cleaning.
Similar
findings arose from our “housekeeper for a day” program (Streitenberger, et al,
2012, poster; 8th Annual Paediatric Patient Safety Symposium) in
which assorted hospital staff were partnered with a member of our cleaning
staff to learn from and to work with them to clean patient rooms. One medical leader commented that he felt
immediately “invisible” to professional staff but he became more accessible to
patients and families who seemed pleased to see him and perhaps more willing to
initiate conversation than he was accustomed to in his usual role. One senior leader became aware of the pride
and diligence of the staff member with whom he was partnered. She was reluctant to let him do the cleaning;
not because it was a job beneath his usual position but because he wouldn't do
it well enough and she would have to clean up behind him. All of the participants gained more
appreciation for the competing demands and interruptions of the cleaning role
and better understood how physically demanding it could be. Most importantly, staff could all identify
simple ways in which they could make cleaning easier and how they could include
cleaning staff as team members with a common goal. At least short term, there was less clutter,
better communication, fewer unnecessary interruptions, and a renewed sense of
pride among cleaning staff following the program. We intend to include this program as part of
our best practice for optimal cleaning.
findings arose from our “housekeeper for a day” program (Streitenberger, et al,
2012, poster; 8th Annual Paediatric Patient Safety Symposium) in
which assorted hospital staff were partnered with a member of our cleaning
staff to learn from and to work with them to clean patient rooms. One medical leader commented that he felt
immediately “invisible” to professional staff but he became more accessible to
patients and families who seemed pleased to see him and perhaps more willing to
initiate conversation than he was accustomed to in his usual role. One senior leader became aware of the pride
and diligence of the staff member with whom he was partnered. She was reluctant to let him do the cleaning;
not because it was a job beneath his usual position but because he wouldn't do
it well enough and she would have to clean up behind him. All of the participants gained more
appreciation for the competing demands and interruptions of the cleaning role
and better understood how physically demanding it could be. Most importantly, staff could all identify
simple ways in which they could make cleaning easier and how they could include
cleaning staff as team members with a common goal. At least short term, there was less clutter,
better communication, fewer unnecessary interruptions, and a renewed sense of
pride among cleaning staff following the program. We intend to include this program as part of
our best practice for optimal cleaning.
On the surface (no pun intended), cleaning
appears to be a straightforward task once you choose the right tools. The complexity is only revealed when all of
the many drivers associated with the practice are taken into account. It should never surprise us that what seems
to be straight forward is rarely that way in the complex environments in which
we work.
appears to be a straightforward task once you choose the right tools. The complexity is only revealed when all of
the many drivers associated with the practice are taken into account. It should never surprise us that what seems
to be straight forward is rarely that way in the complex environments in which
we work.
Rick Wray
Rick Wray has worked at The Hospital for Sick Children (SickKids) for 30 years, the last 16 of which have been in Infection Prevention and Control. Rick is currently the Director of Quality, Safety and Infection Prevention and Control. Rick has been an active member in the Canadian Infection Control Community and has been involved with CHICA-Canada both as a board member and president.
