#PreventionReady: Infection Sources Hide in Unexpected Places

6 minutes

Small things, big impact

“This finding is likely to pose an immediate threat to life of all patients receiving care at the facility.” Those of us who have encountered a finding like that understand its magnitude. Nobody wants to see that on a CMS statement of deficiencies or accrediting organization report. In the past, I think some of us might have assumed it implied a significant breakdown – a level of negligence the accrediting agency spotted overtly on patient care units or in the records. But that’s not always the case, and especially not now.

I have been finding – more often than not – that very small things have a tremendous effect on the outcome of an inspection.


Diversion from routine activities

Hospitals are functioning in circumstances that are anything but routine. As a result, time and attention have been drawn away from some of the more routine, yet extremely necessary, activities and oversight needed in healthcare facilities. As healthcare professionals, we know that pointing to workforce shortages won’t remedy the situation. It’s a simple fact that workforce shortages exist, and we must figure out a way to prioritize activities for the health and safety of patients.

Exacerbated by COVID-19, sufficient staffing is a struggle – more than ever before – and it’s only getting worse. By 2030, there is an anticipated shortage of 5.7 million nurses, according to the World Health Organization. 1

Over the past few months, I’ve visited over a dozen hospitals, looking at and assessing policies and practices intended to impede the spread of infection, readying clients for impending surveys by regulators now laser-focused on infection prevention. In fact, I just completed a deep-dive analysis of sterile processing for a client and found many challenges across many areas.

While specifics vary by facility, some issues are more prevalent than others. Environment of care (EOC) rounds, for example, are either being conducted less frequently or have been dropped altogether. Routine tracer activities or infection prevention inspections in many organizations have been pushed to the back burner.

If you think your facility doesn’t have small issues that could trigger a big finding, think again.


Every little thing

So, when you’re ready to do something about it (read: “immediately”), where do you focus your efforts? I’d suggest three areas based on my recent findings.

The ubiquitous risk: DUST

Findings of high dust are ubiquitous – just like the stuff itself! I would argue that all surveys (actual or mock) could result in high dust findings somewhere in the facility. As a consultant, I’m never surprised to find a dusty windowsill or traces of dust on hard-to-reach surfaces. Minor accumulations might not pose much of a threat to patient wellbeing, but they can and do result in citations.

However, I have been finding dust (sometimes copious amounts) in places that could lead to patient harm:

  • On procedure lights over operating room and emergency department beds

  • On cabinets and shelves in the sterile core

  • In sterile processing, on the lights over instrument assembly stations

Dust drifting down into an abdominal cavity or a wound being sutured, or onto a tray being prepared for an invasive procedure, could pose a threat to patients. Without performing frequent environmental rounds in these high-risk areas, you can’t ensure a sound terminal-cleaning process.

Faulty Filters

Another culprit: filters, specifically filters on automated endoscope reprocessors (AERs). The cleaning and high-level disinfection processes for endoscopes are tedious and fraught with potential errors. Without meticulously completing each step, you expose yourself to serious adverse outcomes. There have been numerous outbreaks related to these processes.

Most scope processing is done by trained, competent staff. However, the issues I’m seeing lately are with preventive maintenance of AERs themselves. There are often multiple internal and external filters associated with these complex machines that need to be replaced monthly, quarterly, annually – whenever it’s dictated by the machine’s instructions.

Most scope processing is done by trained, competent staff. The issues I’m seeing lately are with preventive maintenance of AERs themselves.

Some filters are replaced by endoscopy staff, while others are replaced by plant operations or biomedical staff, creating the risk of dropping the ball on one or more filter changes. When this happens, it doesn’t matter how meticulously the scopes are cleaned, because beyond-use filters are placing all endoscopy patients at risk for infection. This underlines the importance of following instructions. Speaking of which…

IFUs: small abbreviation, big findings

Almost all equipment and surgical instruments have Instructions for Use (IFUs). Some IFUs are simple and straightforward, while others are complex, confusing, and change over time. Take the scope cleaning and disinfection processes for example. There are IFUs for the scopes themselves, for the AERs, and for the items used to clean the scopes. So, you have IFUs for IFUs, and that’s a lot to keep up with.

Case in point: Scopes need to be cleaned according to the scope IFUs, while the reusable scope cleaning apparatus needs to be cleaned between scopes via its own IFU. The IFUs for ultrasonic instrument washers are straightforward; however, the IFUs for the daily ultrasonic washer quality check vials is quite complex. For some, one vial is used, for others, up to twelve are required. You get the idea—precisely following each IFU is critical.

Disturbingly, I’ve found that IFUs for some instruments are often updated by the manufacturer and that many staff have never read the current IFUs for their equipment. They’ve relied on learning from their seniors (who might not have read the IFU themselves). This on-the-job training cycle can cause serious issues and may lead to legacy errors that persist for years.

IFU training methods (or lack thereof) often lead to legacy errors. It’s a cycle that can cause serious issues that persist for years.

The bottom line is staff in each department must have access to – and thoroughly follow – all IFUs. Anything less puts your organization and your patients at risk.


Better SAFE(R) than sorry

These issues can put patients in harm’s way, land facilities in regulatory hot water – potentially losing accreditation – and negatively affect the bottom line. You should take these matters seriously. The Joint Commission (TJC) certainly does.

TJC’s Survey Analysis for Evaluating Risk® (SAFER™) Matrix identifies and communicates risk levels cited during surveys. On this matrix, Infection Control findings (which dust, filters and IFU neglect can lead to) make up around 60% of the higher-level findings (higher level findings are 25% of all findings). These higher-level findings lead to “Condition-Level type Deficiencies,” which typically require one or more on-site follow-up surveys to resolve.

Uncorrected findings of this level can lead to preliminary denial of accreditation and eventually loss of accreditation and termination from the Medicare/Medicaid program. That’s a reality no one wants.


Focus on the why

Facilities are most often placed in regulatory peril due to serious, often systemic, problems, such as staff competency issues, patient care lapses, medication management vulnerabilities, and improper care of behavioral health patients.

But seemingly small things – like dust, filters, and IFUs – can also cause big problems, especially now as surveyors are doubling down on infection prevention.

Identifying the what is easy (example: finding dust where it shouldn’t be) but determining why something is happening is the key to achieving a sustainable solution, often requiring process redesign and direct oversight for a time.

But, if you’re reading this blog, I assume you are in the business of keeping people safe, just as I am, which means we must focus on every little thing – even (and especially) those seemingly small things – to ensure our patient’s care because sometimes it’s the small things that cause big problems.

© 2023 Chartis Clinical Quality Solutions. All rights reserved. This content draws on the research and experience of Chartis consultants and other sources. It is for general information purposes only and should not be used as a substitute for consultation with professional advisors. It does not constitute legal advice.

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