It’s another early start in the world of Infection Prevention and Control (IPC) following on from another rather restless night. The thing that has been playing on my mind a lot lately is the perception of vs the reality of IPC, and medicine in general.
Some of this has been sparked by seeing the discussion, opinions and commentary by medical colleagues on twitter linked to IPC response. I’ve been trying to read them as a member of the public would on this public forum. The thing that strikes me more than anything is that it is no wonder people are confused, we all post from a position of absolutes, often from very contrary stand points. What we do very poorly is communicate the nuance, discuss the technicalities and travel any middle ground. Possibly because its so hard in 240 characters, but also I think because we work with an implicit understanding that we know that nuance exists. On the face of it these conversations therefore come off as black and white positions, when in actuality IPC is very much 50 shades of grey, where there is accuracy in many of the positions in between.
So why is IPC not clear cut? Why might you get a different set if rules and experiences from one Trust to another or even one phone call to another? Well the fundamental tool of IPC is risk assessment. Every scenario includes slightly different exposures, different organisms and different patients, all of which will impact on that risk assessment. Just as no two scenarios are ever really the same therefore, no two risk assessments look identical. This also leads to disagreements on things like social media, as the experience, setting and drivers of those commenting are also just as varied.
What Do I Mean When I Talk About Risk Assessment?
Risk assessment is the process we go through to identify what risks are present to patients, and from patients to staff, visitors and carers. It also includes the things we do to control those risks, things called control measures. I want to start out by saying that I believe we are all aiming for the same goal i.e. providing safe high quality clinical care. Like many things there are often multiple options to deliver this goal and individuals may use slightly different processes in order to achieve it. The below is an example of the way that I structure my thinking.
There are 2 main aspects to risk assessment:
- For the patient – if an organism is detected in a site on a patient what risk does that pose i.e. an E. coli urinary tract infection if not managed well in certain patients is a risk of progressing to E. coli blood stream infection
- For other patients, staff and families – what does the detection of an organism mean for others, what counts as an exposure, what would the clinical consequences of acquisition mean for those exposed?
At some point I’ll do a fuller post on risk assessment in IPC and what different options there are for creating your risk assessment tool, but for now these are the kinds of things I consider when putting together risk assessments:
- Routes of transmission – how do infections spread? Water/Surfaces/Contact/Air
- Patient loads – when someone has an organism how much do they have, viruses usually higher numbers than bacteria
- Environmental persistence – how long can an organism survive in water/air/on surfaces
- Infectious dose – how many copies of an organism does it take to give an infection
- Colonised/infectious state – can I carry an organism without harm or does it always make me unwell MRSA vs measles for instance
- Patient susceptibility – is the patient immune i.e. vaccination/prior infection, are they more at risk if they get infected because they have no immune system?
- Timing of infection (community vs hospital acquired)
- Endogenous vs exogenous – is the infection spread from one site to another in the same patient i.e. from nose where doing no harm to a surgical wound? Or has the patient got it from outside?
- Surveillance programmes in place – what kind of searching for organisms is being undertaken i.e. within the environment/based on symptoms, or as part of routine regular testing
When I’m talking about risk assessment for the rest of this blog I’m also going to be including what we call control measures which are linked to that risk assessment. These are things you do to prevent or reduce risk i.e. wearing personal protective equipment, putting patients isolation, prophylaxis etc.
I think we need to acknowledge that as well as different information, there is also an impact from the person handling that information and making the risk assessment. As a Healthcare Scientist I tend to feel much more comfortable focussing on the organism aspects and on control measures such as ventilation. Some of my colleagues will feel more comfortable in other aspects, especially in terms of scenarios such as surgical site infections and dressing management for instance. We all cover the same ground and should have the same core fundamentals, but we should acknowledge that different people will handle information in slightly different ways. This can be a strength, as long as it’s acknowledged.
So Why Do Risk Assessments Change?
As you can see from above, risk assessments are anything but straight forward. They include a lot of information, some of which you won’t always have at the start. There are some scenarios where we have quite a lot of information where responses are pretty much standardised and you would think everyone would do very similar things i.e. detection of MRSA in a surgical patient. Even for something like this that happens often and we have quite a lot of good information about what the risks and the control actions might be, there isn’t a one size fits all approach. In paediatrics we manage these patients differently to how they might be treated when they become adults. This is because their risk of continuing to carry MRSA as they interact more with people and the environment means that trying to remove it with antibiotics and chemicals (decolonisation) may be less effective and they may also have delicate skin which means using these chemicals may cause skin problems. So even in a straight forward situation, setting and scenario matters.
We often get asked why the way we manage something in my hospital may look different to how it might get managed somewhere else, even at another children’s hospital. This can be for a number of reasons. I may have access to resources in terms of cubicles or diagnostics that enable me the option of managing a scenario differently. My Trust is in England and the guidance in other parts of the devolved nations may be different i.e. Scotland and England don’t always do things the same way. Finally, my Trust also looks after children who have complicated conditions and who may have little to no immune system, so the consequences for patients if I get it wrong may be higher than somewhere seeing other types of patients. Setting, not just organism matters.
The other thing is bear in mind is that information and settings are not static. Often in medical dramas something is either X or Y, all of the information comes at the same time. This isn’t how things work in real life, information comes in pieces and the decisions you make about the next question you ask are actually as important as how you manage actions based on the data already in your possession. In some ways House was right…….it could be Lupus.
Although I don’t want this post to be about SARS CoV2, it is a good example of the fact the more information you have the more your decisions might change and you know more about where your risks are. Omicron has led to different risk being recognised when compared to Delta, because of impacts such as staff shortages, but also because of the amount of it that is currently circulating. This has impacted testing decisions and risk vs benefit discussions linked to patient harm. This is particularly challenging as these judgements about risk are actually being made with incomplete data sets as we don’t have the luxury of waiting it out. This makes at least this IPC professional uncomfortable, as lets be honest you are unlikely to love IPC if you aren’t in someway risk averse as a personality type. You don’t always have the luxury of time however and therefore we need to act, do the best we can with the information we have and make sure we also capture the learning as we go to enable improved decisions next time.
So, resource matters. Everything about IPC comes with a cost. The thing is not all of those costs are financial.
Some examples of when even interventions, like putting patients in isolation can be challenging or have adverse consequences for everyone involved:
- Its hard to know once you put someone into isolation when the right time is to take them out
- Putting patients into isolation has been linked with decreases in staff time, increase in perceived concerns over care, and increase in prescribing errors
- In paediatric patients isolation can affect inpatient developmental milestones.
- In adults isolation has been linked to increased levels of anxiety and depression
- Isolation can negatively impact on staff caring for patients due to isolation from colleagues and strain of dealing with sick patients single handed
Risk assessments therefore are influenced by who bears the cost. Individuals often pay the price of keeping others safe. This is a social contract that we see playing out on a much larger scale during the pandemic. Other methods to impact risk assessments, such as installation of mechanical ventilation, have a high financial cost that not all centres are able to afford. It is naïve therefore to say that any of these choices are easy, someone somewhere always bears the cost and the impacts of decisions.
After all of the above what is it that I want you take away?
- Firstly IPC is anything but easy or straight forward, no matter what some of the reporting or social media commentary makes it appear. Decisions are complicated and every single one comes with impacts, be it for patients or budgets.
- Secondly, the right decision for one centre may not therefore be the right decision for another. Comparison between one centre or one set of scenarios and another are not always valid, as the needs of the patient population or risks involved are unlikely to be identical.
- Lastly, risk assessments change, they change as scenarios change, they change as more information becomes available. This isn’t a failing, this is responding to evolving situations and although difficult this is a strength
IPC is not black and white, it is 50 shades of grey and dealing with this is both the strength of the amazing people working in this field and the daily challenge they face, embrace and respond to!
All opinions on this blog are my own