Keeping a healthcare environment free of infections is an admirable goal. But for over a century we’ve known achieving this objective is as hard as a Mission Impossible assignment. Unfortunately, there is no Ethan Hunt to save the day. Instead, the job is tasked to thousands of hard working professionals who do their best to keep every patient safe.
Most of the focus in the art of infection prevention and control has centred on spread. But this is only part of the equation. To have an outbreak, you must first have an origin. Understandably, this has not been given much mental or experimental work. After all, the origin is usually the index case. But recent evidence suggests this limited view must be expanded to include not just the patient, but the visitors as well.
Take Methicillin Resistant Staphylococcus aureus (MRSA). It was first described in 1961 in England. It once was thought to be solely a healthcare associated infection but changed in the 1980s when it became clear the bacterium was spreading in the community. Instead of being only a patient, a visitor could bring in the bug and transmit it to others. Yet, even with this evidence, the focus remained solely on spread particularly among staff.
The situation didn’t change much until some twenty-five years later when antibiotic-resistant strains were found in veterinarians. They obviously didn’t pick these up from human patients. Instead, this revealed MRSA was in livestock. Although the idea of a pig or cow isolate causing an outbreak in a healthcare facility seemed highly unlikely, it was still given consideration in 2009.
In the last six years, that mindset has changed as livestock associated MRSA (LA-MRSA) has become a significant concern in many countries, such as the Netherlands. In the UK, the situation became even more concerning as researchers found one particular clone, CC398, was found not in veterinarians, or those without any contact with animals. Instead, they found the strain in agriculturally independent individuals, including neonates.
The likelihood the bacteria naturally found its way to the children is quite low. Somebody had to bring the infection to the kids. That falls within the context of spread. But this still leaves the question as to the origin of the bacterium in the first place. One might believe it was probably due to a farm worker showing up for treatment. Yet, earlier this year, researchers in the US revealed simply living near a farm locale may be enough to end up in colonization. This opens up the possibility a visitor or some other interested party could have brought the infection to the healthcare facility and shared it.
The premise isn’t all that difficult to believe. Consider this: every person shed millions of bacteria each hour. If any of these happened to be MRSA, they could deposit anywhere in a healthcare facility and be picked up by patients and staff members. What’s worse is all of this happens under the radar. There are no observational mechanisms in place to monitor people not employed within a facility. An outbreak could initiate even if a perfect infection prevention and control system is in place.
The MRSA example is just one of many potential infectious agents capable of originating from visitors. Others include the influenza virus, Clostridium difficile, Mycobacterium tuberculosis, Carbapenem-resistent Enterobacteriaceae, and norovirus. All of these can easily be imported into a healthcare facility by a visitor and spread.
The answer to preventing this route of infectious spread is to ensure visitors and others play their role. But the concept of controlling visitor actions has been anathema for years. That’s now changed as the Society for Healthcare Epidemiology of America has taken a stand. They’ve released the first ever infection prevention and control guidelines for visitors. With these in place, healthcare facilities now have the ability to widen the scope of patient safety to include those who may be spreading infections without even realizing it.
Of course, guidelines alone are not sufficient. We need to figure out how to adopt and implement them. The best place to start is hand hygiene as it may help to contain 80% of the spread. Granted, trying to get everyone to clean their hands may be hard to achieve. But it’s worth the effort. After all, without this critical addition to the equation, we may never reach our common goal of zero.
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