Showing posts with label infection prevention. Show all posts
Showing posts with label infection prevention. Show all posts

Tuesday, January 27, 2015

Why your kid's sniffles make me sweat

By Jennifer Philp Zakic

I have a confession: whenever I enter a new place, I scan the room for signs of infection. I look for runny noses, speculate about whether the cough I hear is a “real” cough, and ask people “Do you currently have, or are you getting over, a respiratory virus?”

When I walk into a grocery store, I cringe at the thought of using a cart. I have learned to take Lysol wipes with me everywhere, and this eases my concerns, albeit ever so slightly. I always have a bottle of hand sanitizer near me, and I put it on about every seven minutes when I’m outside the home. I feel explosions of relief in the pit of my throat whenever a friend cancels on me because they suspect a cold is coming on. I rarely go to parties anymore. If I do, I’m the weird girl in the corner who only talks to people she’s known for at least 10 years.

By nature, I’m not a paranoid person. I’m not even a shy person. I have no definitive phobias toward germs. In fact, I’m usually the one who pulls the mystery food out of the fridge at work.

I am simply trying to protect my son, Branko (above right, with sister Nina). His last respiratory infection occurred in August, and it was, not to sound technical, a real doozy. His lungs were so full of junk that he was intubated for a week. It would be really wonderful to never have that happen again.

Our son, Branko, has a complicated medical history. Depending on your proximity to the world of special-needs parenting, his condition would either scare the pants off you, or not shock you in the slightest. He has skeletal dysplasia, caused by a chromosome 12 microdeletion, which affects pretty much every bone in his body. However, the only life-threatening aspect of this condition relates to how his ribs have grown. Funny. They have grown very funny. And small.

To sum it up in the simplest of terms: small ribs = small lungs. The actual cells and alveoli function beautifully but those pesky, funny ribs are restricting the movement of the lungs. As a result, he has spent an extraordinary amount of time in an ICU bed. He has had two unplanned intubations. Oh yeah, almost forgot, his heart stopped for five minutes one time because he had a Rhinovirus, aka The Common Cold.

For strangers or people I haven’t seen in a while, attempting to condense the summary I’ve just given is hard. It’s hard to accurately convey the severity of his situation. I either provide way too much detail—and watch as my listener’s eyes glaze over—or I don’t give enough, and I look like an overbearing and paranoid parent. I would hate to think that people assume I’m avoiding germs just to escape the inconvenience of a runny nose and a lost night of sleep.

Since his last respiratory infection in August, we've kept Branko in quarantine. He just had his first playdate in five months. He rarely sees other children now, and when he does, it will be a one-on-one playdate. It was a difficult decision to make, because he has always had some degree of social anxiety. I feel incredibly guilty for adding fuel to that fire.

At first, we tried to keep going on with our lives as if everything was normal, but this attitude led to some tricky situations. At the park, a friend’s sick child excitedly ran up to Branko’s stroller to say hello. At a birthday party, a friend-of-a-friend casually mentioned that her daughter, who was sitting right beside Branko, had been sick for three weeks.

We quickly realized that most parents have no problem sending their children out into the world with a cold. In an effort to kill hundreds of birds with one stone, we used social media to tell our story. It only took one Facebook post to make people understand that yes, we might run away from you if we see you at the store, and no, it wasn’t anything you did. And it worked. I realized that the people in our lives—friends, acquaintances, friends from former lives—were all really wonderful people. Now they understood. They hadn’t been through it themselves, but they got it.

There are a lot of things we don’t do anymore. We don’t go to birthday parties. We don’t go to the museum. My husband and I avoid crowded places, especially with people who aren’t aware of our situation. And did I mention the hand sanitizer? I own plenty of hand sanitizer.

But Branko still does so much. We have turned his weekly hospital appointments into an adventure. It’s not just a car any more, it’s a safari ride blasting all of his favourite songs. As an exclusive treat, we let him use the iPad in the waiting room, and I’ll admit, those days usually end with a trip to the toy store.

And sometimes, one of us will take him shopping so that the other parent can simply have some peace and quiet. We take him to larger, open, less crowded stores with the idea that fewer people and more space might reduce our proximity to viruses. We keep him busy at home. We reach out to other people when things get tough. We understand the importance of having time to ourselves, without our children. We complain. Some days are darker than others. There are days when I have no idea how long the TV has been on, and other days where I don’t turn it on at all.

Some days, I am swimming in fear. I try not to get angry when we visit the hospital for Branko’s monthly RSV vaccination. It’s in a very unfortunate location, right next to the children’s walk-in clinic. I try not to be angry with the parent who lets her sick toddler run up to our stroller—the blue one with the sickly looking boy attached to a portable oxygen machine. I try to keep my cool, but it’s really hard.

This past weekend, Branko’s dad took him to his first playdate since August, with one of our oldest and dearest friends. For the first 30 minutes, Branko had a meltdown. He clutched onto his dad’s neck and begged to go home. His little friend was determined to snap him out of it, hiding and reappearing from underneath the furniture. After a few minutes, Branko was laughing. My husband sent me a picture of the two boys playing together on the floor. I exhaled deeply when I saw the picture: this was Branko, being just fine, in a non-quarantined world. I saw a glimpse at our possible future.

We have a difficult decision to make, and that’s when to lift our quarantine, since Branko is eligible to attend Kindergarten in the fall. I often wish that parents of medically fragile kids could look into a crystal ball, or at least have the superpower to see viruses with the naked eye. Until this is possible, I guess I will continue to be the weird girl at the party, scanning the room for runny noses and speaking to a scant handful of people. Please don’t be offended.

Please follow Jennifer Philp Zakic on her blog
Branko Has Funny Bones.

Monday, June 11, 2012

Your infection questions answered














Here are Dr. Michael Gardam's answers to your questions following our interview about infections acquired in hospital. Dr. Gardam is medical director of infection prevention and control at Toronto's University Health Network.

1. Do you believe that it is an acceptable practice to wash with an antibacterial waterless soap instead of using the authentic soap and water? I have heard that in some facilities the doctors/staff are able to see up to three patients and use the waterless alternative in between them and then after the third pt. require that the doctor/staff uses soap and water. As a parent of 1 special needs child and three other children, I always prefer that soap and water be used. Any thoughts?

DR. MICHAEL GARDAM: A LOT OF PEOPLE, INCLUDING SOME HEALTHCARE WORKERS, THINK THAT SOAP AND WATER IS BETTER THAN ALCOHOL GEL AND THAT ALCOHOL GEL IS A BIT OF A CHEAT.

IN FACT, ALCOHOL GEL IS ALMOST ALWAYS SUPERIOR TO SOAP AND WATER: IT KILLS MORE BACTERIA AND VIRUSES, WORKS FASTER, IS LESS DRYING ON THE HANDS, AND CAN BE USED MUCH FASTER AND WHILE YOU ARE MOVING. BECAUSE IT IS SO MUCH EASIER TO USE, HEALTHCARE WORKERS ARE ALSO MUCH MORE LIKELY TO USE IT THAN SOAP AND WATER. SO BOTTOM LINE, ALCOHOL GEL IS A VERY GOOD THING.

2. It is really quite shocking when you think of the "miracles" medicine is capable of and the lengths (and costs) that doctors will go to to save a life yet here is something as simple as soap and water and children are dying needlessly.

I have 2 questions, please.

A. Would a child with a congenital heart condition be more prone to infection?

DR. MICHAEL GARDAM: DEPENDING ON THE HEART CONDITION, THE CHILD MAY BE MORE PRONE TO HAVING HEART INFECTIONS, SPECIFICALLY BACTERIAL INFECTIONS OF THE HEART VALVES (ENDOCARDITIS). ALSO, ANY CHILD THAT REQUIRES HOSPITALIZATION AND OR INVASIVE TREATMENTS LIKE INTRAVENOUS LINES WOULD ALSO BE MORE PREDISPOSED.

B. Is there benefit to prevent infection in the form of prophylactic antibiotics before surgery or probiotics taken while in NICU/PICU?

DR. MICHAEL GARDAM: ANTIBIOTIC PROPHYLAXIS IS DEFINITELY BENEFICIAL BEFORE SOME TYPES OF SURGERIES. THERE ARE VERY CLEAR GUIDELINES AVAILABLE SO IT IS GENERALLY EASY FOR SURGEONS TO KNOW WHETHER THEY ARE USEFUL OR NOT. IN TERMS OF PROBIOTICS, THE JURY IS STILL VERY MUCH OUT ON WHETHER THEY ARE USEFUL--IT ALSO VERY MUCH DEPENDS HOW THEY ARE BEING USED AND WHAT FORMULATION IS BEING USED.

3. Has anyone's child ever gotten an infection from the equipment that is being used in the room? ie the thermometer, pressure cuffs, etc? Like you say not everyone is bold enough to ask for the wipes to clean it or are too embarrassed to do so in front of staff. Even if the staff is washing their hands, don't you feel there should be some standard in place to help stop the spread of infection that is transferred from the equipment and then onto the "clean" hands or that all the equipment is solely for that one pt alone? I know many times they are placed in portable stands and wheeled room to room.

DR. MICHAEL GARDAM: IT IS HARD TO PROVE THAT INFECTIONS CAN BE CAUSED BY POORLY CLEANED, MULTIUSE EQUIPMENT, BUT WE DEFINITELY KNOW THAT BACTERIA CAN LIVE THERE, SO IT IS QUITE REASONABLE TO ASSUME THAT EQUIPMENT MAY BE ONE OF THE MODES RESPONSIBLE FOR PASSING BACTERIA AROUND THE HOSPITAL AND BETWEEN PATIENTS.

ALL MAJOR GUIDELINES STRESS THAT MULTIUSE EQUIPMENT SHOULD BE CLEANED BETWEEN PATIENTS.

4. How do you deal with this scene? When doctors and nurses come into the room the first thing they do is wash their hands and then begin the exam of the child. BUT, then they begin to chart on the computer or use a pen while taking vitals for instance and in turn go back to touching your child? This computer has been used by who knows who that has just touched who knows what and the pens go everywhere -floors , pockets, bathrooms.

How can you stop the spread of infection then and is there an appropriate way to ask that charting/writing be saved for the end of the visit and not during the exam itself?

DR. MICHAEL GARDAM: THERE IS NO EASY ANSWER TO THIS ONE: THE HEALTHCARE WORKERS HAVE IT HALF RIGHT BUT DON'T REALIZE THEY ARE RECONTAMINATING THEMSELVES. WE SOMETIMES DO EXERCISES WITH STAFF WHERE WE COVER A SURFACE WITH PAINT AND HAVE THEM WORK AS THEY NORMALLY DO--IT OFTEN DRIVES HOME THE POINT THAT THEY ARE SPREADING THINGS ALL OVER THE PLACE.

5. Are there any statistics that prove wearing gloves can slow or stop the transfer of infections? While in NICU, many workers would wash their hands and then swiftly put on gloves. However, they would then continue to touch objects in the room, or their faces and then my baby. Also sometimes when reaching for the gloves, it is easy to see that a worker gets more than they need so they then stuff them back into the box. Aren't these gloves now contaminated?? What next?

DR. MICHAEL GARDAM: THERE IS NOT GOOD EVIDENCE FOR USING GLOVES IN NORMAL CIRCUMSTANCES--FOR THE MOST PART THEY ARE MEANT TO PROTECT THE HEALTHCARE WORKER, NOT PATIENTS (EXCEPT OF COURSE STERILE GLOVES DURING PROCEDURES WHICH PROTECT BOTH). SO PUTTING ON GLOVES AND THEN GOING PATIENT TO PATIENT SIMPLY SPREADS THINGS AROUND AS YOU WELL KNOW. THIS IS A MAJOR CHALLENGE WITH HEALTHCARE WORKERS. LIKE MY ANSWER TO THE PREVIOUS QUESTION, SOMETIMES USING A SURROGATE FOR BACTERIA, LIKE PAINT, WILL HELP THEM REALIZE WHAT THEY ARE DOING.

6. This is wonderful, and I applaud Dr Gardam for his attention to this issue. It is, however, possible to get to zero when it comes to central line infections. Cook Children's NICU hasn't had a central line infection in 3 years. The Children's Hospital in Providence has similar stats:

http://www.innovations.ahrq.gov/content.aspx?id=3265

And the Keystone ICU project has had similar results.

http://www.who.int/patientsafety/implementation/bsi/background/en/index.html

So it can be done - with attention to detail, knowledge & the will to change.

Thanks for the great post!

Kate

DR. MICHAEL GARDAM: DON'T GET ME WRONG, SOME TYPES OF INFECTIONS CAN BE DRIVEN VERY CLOSE TO ZERO--CENTRAL LINES ARE ONE OF THEM. OTHER THINGS LIKE C. DIFFICILE ARE SO MUCH MORE COMPLEX THAT ONE CANNOT REALISTICALLY EXPECT TO GET TO ZERO (THERE ARE MANY FACTORS OUTSIDE THE CONTROL OF HOSPITAL STAFF, UNLIKE CENTRAL LINES WHERE THEY HAVE DIRECT CONTROL OVER ALL ASPECTS OF THE LINE). CONGRATULATIONS BY THE WAY--MOST ORGANIZATIONS HAVE NOT ACHIEVED THAT KIND OF SUCCESS.

7. Thanks for your comments, Kate. I'd like to know where we can find similar data in Canadian hospitals. I have heard that the "number of days since last infection" is an incredible motivator for staff and administrators.

Dr. Gardam, is this information available for Canadian hospitals? If so, where would it be found and if not, why not?

DR. MICHAEL GARDAM: WHATEVER CANADIAN DATA EXIST, TYPICALLY COME FROM THE CANADIAN NOSOCOMIAL INFECTION SURVEILLANCE PROGRAM (CNISP) AND THEIR PAPERS ARE AVAILABLE ON LINE THROUGH THE PUBLIC HEALTH AGENCY OF CANADA WEBSITE:

http://www.phac-aspc.gc.ca/nois-sinp/survprog-eng.php

 IT IS HARDER TO GET GOOD CANADIAN DATA HOWEVER BECAUSE HEALTHCARE IS CLEARLY A PROVINCIAL RESPONSIBILITY AND IT IS QUITE HARD TO GET THE PROVINCES ALL LINED UP TO REPORT STUFF TO THE FEDERAL GOVERNMENT--SIMPLY PUT, THERE IS NO REQUIREMENT TO DO SO.

8. Hi Louise and Dr. Gardam!

I have a friend whose baby was a preemie and it got an infection in the NICU, he got brain damage and also he got blind, I see my friend suffer because this could be preventable and nobody apologized, they just told her it happens all the times, but in her heart always will be that feeling that her son could be in a different condition if they followed the sanitize rules. And in my cases my son got a surgery G-tube placement plus a fundoplication and I could not believe that the surgeon has very long nails and also she did not take the nail polish off. And because I felt embarrassed to say something I did not say anything when in my mind. And unfortunately my instinct was right, she did a not good performance. The surgery was wrong and up  until today my son has consequences of that wrong surgery.

The problem is not just that there is a lot of negligent management in the hospitals. The main problem in the first place the doctors do not accept their mistakes and they blame the parents. I complain to the College of Physicians and Surgeons against 12 doctors and after back and forth showing clear mistakes with test and papers. The college just decide to cover the negligent doctors saying they did what they could. God knows how difficult it is for a parent to forget and forgive such kind of mistakes, and more when to see that your son almost died because of this and second that today still has a consequence of these mistakes.

DR. MICHAEL GARDAM: YES, YOUR SAD STORY IS ONE I HAVE HEARD OFTEN--WE CONTINUE TO TREAT HEALTHCARE ASSOCIATED INFECTIONS AS A COST OF DOING BUSINESS ALTHOUGH THE SYSTEM IS STARTING TO WAKE UP AND REALIZE THAT MOST OF THESE ARE ENTIRELY PREVENTABLE. ALL INFECTION GUIDELINES RECOMMEND THAT HEALTHCARE WORKERS HAVE SHORT NAILS WITH NO OR ONLY CLEAR POLISH.

9. What are the top things you would recommend parents with medically fragile children who are in the hospital frequently or for long periods do to protect their children?

We have 2 former preemies (a 4 year old who was trached & vented, and a 1 year old currently trached and vented) - the NICU was pretty low infection, but my daughter's 70 day PICU stay over this winter resulted in a line infection, c. Diff, and 3 other infections... which seems excessive, since she was on contact precautions the entire stay (originally admitted for suspected RSV; caught the first infection before they'd cleared precautions for the virus, and each successive infection came before the last one was cleared). Very frustrating.

DR. MICHAEL GARDAM: THERE IS NO EASY ANSWER TO YOUR QUESTION--INFECTIONS CAN OCCUR THROUGH A VARIETY OF MECHANISMS--THROUGH DEVICES LIKE CENTRAL LINES, URINARY CATHETERS OR ENDOTRACHEAL TUBES (USED WHEN THEY ARE ON A VENTILATOR), SURGICAL WOUNDS, UNCLEAN HEALTHCARE WORKER HANDS, DIRTY EQUIPMENT, DIRTY BEDS OR SURROUNDINGS, OVERUSE OF ANTIBIOTICS ETC. SO THERE IS NO ONE BIG FIX.

I WOULD RECOMMEND THE FOLLOWING THOUGH:

1. BECOME AN INFORMED CONSUMER--IF YOU FEEL COMFORTABLE DOING SO, ASK WHAT THE HOSPITAL IS DOING TO PREVENT THESE THINGS. THERE IS NO DOUBT THAT HAVING A FAMILY RIDE SHOTGUN FOR A HOSPITALIZED PERSON IS A VERY GOOD DEFENCE. WHEN MY FATHER WAS HOSPITALIZED A FEW YEARS AGO, I GENTLY CHALLENGED WHY HE CONTINUED TO HAVE A URINARY CATHETER DAY AFTER DAY. I ALSO POINTED OUT THAT HE WAS AT HIGH RISK FOR GETTING AN INFECTION BECAUSE OF IT. I WAS TOLD NOT TO WORRY BY HIS NURSE BECAUSE THAT WAS WHAT ANTIBIOTICS WERE FOR.

2. CLEAN YOUR OWN HANDS AND THOSE OF YOUR CHILDREN IF THEY ARE OLD ENOUGH.

3. I PERSONALLY SUGGEST TRYING TO CLEAN YOUR CHILD'S IMMEDIATE ENVIRONMENT ALTHOUGH THIS IS OFTEN VERY TRICKY TO DO DEPENDING ON THE CIRCUMSTANCES.

4. ONLY IF YOU FEEL COMFORTABLE, YOU CAN TAKE IT UP A NOTCH AND DIRECTLY TALK ABOUT HEALTHCARE WORKER HAND HYGIENE AND CLEANING. I HAVE SEEN THIS GO HORRIBLY WRONG WHERE PATIENTS AND FAMILIES HAVE BEEN YELLED AT SO BE CAREFUL. THIS IS NOT AN EXCUSE--YOU ARE ENTIRELY WITHIN YOUR RIGHT TO TALK ABOUT THESE THINGS.

Sunday, June 3, 2012

Hospital infections kill, are preventable


Barb Farlow sent me this video called Gabby. It's about a couple who lost their daughter to a preventable infection she picked up in a newborn intensive care unit (NICU). The video was produced by the Perinatal Quality Collaborative of North Carolina. Barb is on the Stop Infections Now Collaborative of the Canadian Patient Safety Institute. Watch the video.

The images above are from a piece in the New England Journal of Medicine.

The top one is the handprint of a health-care worker after examining a patient's stomach. The pink colonies are methicillin-resistant Staphylococcus aureus (MRSA), a virulent type of bacteria that doesn't respond to standard antibiotics. The bottom image is the worker's hand after washing.

MRSA bacteria can enter the body through a surgical wound, IV, catheter or breathing tube. MRSA infections in the bloodstream, heart, lungs and urine can be deadly. Those pretty-pink handprints can kill.

One in 10 hospital patients will develop a common or antibiotic-resistant infection after being admitted. In a small Canadian study of hospitalized children, 9 per cent developed an infection while in hospital.

When an IV, catheter or breathing tube isn't inserted and cared for properly, bacteria that normally resides on the skin without problems can gain entry and cause infection. You may also pick up a superbug like MRSA or C. difficile from the environment -- by touching a dirty bed rail, light switch or a person who hasn't washed their hands.

Health-care associated infections (HAI), as they're now called, are the fourth leading cause of death in Canada.  Between 9,000 and 12,000 Canadians die each year as a result, says Dr. Michael Gardam, medical director of infection prevention and control at Toronto's University Health Network. I spoke to Dr. Gardam to learn more.

BLOOM: How many infections acquired in hospital are preventable?

Dr. Michael Gardam: Ten years ago we would have said at least a third of them, but now we would say the vast majority. We used to consider many of these infections as the cost of doing business but now realize they can be dramatically reduced.

BLOOM: Is lack of handwashing among professionals the main cause?

Dr. Michael Gardam: Handwashing has certainly gotten a lot of attention. The World Health Organization and others say poor hand hygiene is responsible for at least 50 per cent of these infections. But you can also catch an infection from the environment. For example, a health-care worker's hands may be pristine but a person could pick up C. difficile from the bed rails. Or a patient can develop C. difficile in a room where a previous patient had it, if the room isn't cleaned properly.

A lot of hospital infections happen because we're doing something to you -- inserting a catheter or IV. Did the worker properly wash your skin? Are they checking the IV site daily to see if it's red or sore, and are they discontinuing the IV if you don't need it? If the IV isn't cared for properly you can develop an infection from your own skin flora. That can cause a skin infection or get into your blood and cause life-threatening sepsis.

Surgery is an area that's well-studied on how to prevent infections. There are multiple things you can do to decrease the infection rate, but the system is still fairly slow to adopt all of them.

There are times when we can do everything perfectly and the person still might get an infection. But many times we are not doing things perfectly. With most patients who get an infection, we can identify things that weren't done properly.

BLOOM: How big a problem are these infections for preemies or for children with disabilities or chronic conditions who may be hospitalized frequently?

Dr. Michael Gardam: Infection is one of the main causes of death in preemies and there are multiple reports of child deaths from infection acquired in the NICU. They've linked these infections to handwashing and to the environment as well. For example, nurses wearing artificial nails have been linked to deadly outbreaks: fungal infections can get under the nail and then be passed on to these remarkably susceptible children. Their skin isn't normal, they have multiple IVs and are often intubated and once they're colonized with organisms it's easy for those organisms to walk right in.

Children with disabilities would be at the same risk as other children who are having IVs or catheters or breathing tubes put in. What increases the risk are pre-existing conditions that affect the immune system -- like diabetes. Of course the more you're in the hospital, the more likely you are to catch something.

BLOOM: What kind of disabilities can be caused by serious infections?

Dr. Michael Gardam: Brain infections can lead to permanent brain damage and lung infections can cause chronic lung problems.

BLOOM: Would a family be informed that the infection their child had was preventable?

Dr. Michael Gardam: Usually not. Not because the staff are lying, but because they see these infections as a cost of doing business, and it's not just health-care workers, it's all of society. Let's say a loved one is in the ICU and the doctor comes out and tells the family "We gave him the wrong dose of this drug and he went into cardiac arrest and died." I'm sure the family would think of this as a mistake, an error, and might talk about suing. But if the same doctor comes out and says "Your loved one caught an infection in the ICU and we gave him antitbiotics but they weren't strong enough and he died," people accept that kind of news. Infections are still seen as things that happen.

BLOOM: But you've just said that most are preventable?

Dr. Michael Gardam: It's a brand new world for us. We're waking up and realizing that these things are preventable. Twelve years ago when I trained in infection, doctors were saying there was no way of ever preventing central-line infections, they were simply the cost of doing business. And now we know they can be prevented. We'll never get to zero but we can bring them down remarkably.

BLOOM: So why would a health-care worker not do everything possible to eliminate them?

Dr. Michael Gardam: Let's say I'm a surgeon and my infection rate is 2 per cent. If I do your surgery I can say there's a 98 per cent chance that you'll be fine. If I do all of these infection practices I may be able to say there's a 99 per cent chance you'll be fine. Some surgeons are looking at probability and stats rather than individuals. They're not thinking about the one patient who gets an infection for whom it's 100 per cent. The surgeon will be upset if one of his patients gets an infection, but he won't put two and two together. We're changing, but at a snail's pace.

BLOOM: What would you recommend parents of preemies or children with disabilities who are hospitalized do to try to prevent their child from getting an infection?

Dr. Michael Gardam: Well, when I was hospitalized in my own hospital a year ago, I washed my hands multiple times a day with alcohol gel, which is generally better than soap. I did this because many of the things you can contract in hospital you pick up because you're touching stuff. So as a parent, encourage your kid to clean their hands frequently and clean your own hands. I also used a container of disinfectant wipes to clean my room. I would wipe down my IV pole and the bed rails and the reason I did that is because no one else was doing it. Most hospitals have these wipes available. Clearly some people might take exception to a family cleaning up the room, but that's what I did.

You can let the health-care worker know that you understand most hospital infections can be prevented and you'd like to work with them to protect your child. The trick is to get the point across without directly challenging the health-care worker.

You can ask health-care workers to clean their hands, but the power differential there is absolutely unequal and to some extent you're at their mercy. When I'm rounding with residents, I tell them to always wash their hands in front of the patient, even if they've just washed their hands.

BLOOM: Do you get pushback on that?

Dr. Michael Gardam: Yes, I do. But I tell the residents that it doesn't matter whether you just did it, the patient cares about seeing it done and it's not about you. A woman was telling me about her son who was hospitalized for Crohn's disease and the IV team came in to start the IV and she knew they hadn't cleaned their hands. And she was struggling over how she could bring it up in a way that they wouldn't be offended and potentially not start her son's IV. What do you do? You don't want to be perceived as a difficult person. In the end you don't say anything because you're afraid.

BLOOM: I'm having a hard time wrapping my head around the idea that doctors and nurses know what to do to prevent these infections and they're not doing them.

Dr. Michael Gardam: There are major cultural impediments. If you ask health-care workers why they don't follow these known practices you'll hear "I don't have time" or "I'm too busy" or "I wasn't educated properly" or "Frankly, no one else is doing it that way." But it doesn't take long to do these things. There's a disconnect between their actions and what happens to their patients.

When a patient has been in hospital for days and gets an infection, you can't really pinpoint one person who's responsible. It's systemic. Multiple people occasionally don't follow all of the practices, which leads to multiple circumstances when a person could develop an infection. So while the health-care worker feels sad that a person got sick or may have even died, they don't know it was a result of their action.

BLOOM: What are other barriers to getting compliance with infection control?

Dr. Michael Gardam: A prevalent behaviour in doctors in general is that they have their one piece of the puzzle -- like surgery -- and others can deal with the rest. So as a doctor, I kind of understand how a surgeon would say: "I'm going to do the best operation possible," but not look at it holistically, in terms of feeling responsible for the entire care the patient receives in the hospital before and afterwards.

For example, if the room isn't cleaned properly the patient may become ill but a surgeon may not see that as part of the patient's care. There's a sense of "The operation went fine, our job is done." One thing we're doing now to close the loop at UHN is to treat all serious infections as adverse events, where an incident report is filled out and the people responsible have to report back on what things were not in place to prevent that infection.

BLOOM: Why doesn't a teaching hospital commit to a policy of zero tolerance for staff who don't follow all prevention practices?

Dr. Michael Gardam: Doctors wield enormous power and are typically not hospital employees. You might be able to do that to a hospital employee, but not a doctor who works "at" the hospital but not "for" the hospital. Let's says there's a surgeon at a teaching hospital who's a brilliant researcher and she's getting the hospital's name out there. Are you going to take away the hospital privileges of someone like that because she doesn't buy the corporate values about infection prevention? Not following these practices shouldn't be tolerated, but it's difficult for hospitals (to enforce). The tide is starting to turn, however, and more and more physicians are getting called on such behaviours.

BLOOM: I'm astounded that people wouldn't willingly follow these practices?

Dr. Michael Gardam: People get stuck in certain types of behaviours. They may do things that they know aren't good, but education may not motivate them to stop.

One doctor who's become a 'born-again' patient safety guy told me he resisted the whole central line practice bundle. "I refused to do it because I felt my patients weren't getting infected," he said. "Then they started sending out infection rates by the doctor's name and I was a negative outlier. Everyone else was doing it and I felt like an idiot." In this case no amount of book evidence had an effect because the surgeon needed real-life evidence in front of his face. He knew he should be putting in a line in a different way but it didn't seem relevant to him.

BLOOM: What can we do to change the culture?

Dr. Michael Gardam: We're not perfect, but in the last six years we've seen significant organizational change at UHN. The way we've done it is to engage frontline staff and have them own quality improvement initiatives. We don't lead these initiatives ourselves. Hand hygiene improved when infection control got out of the hand hygiene business.

We tell stories of patients and we ask staff to tell their own stories about patient infections. Sometimes we ask a group of staff to design a system to do the opposite of what we want it to do: How would you ensure that every child on this unit got a urinary tract infection and it would be severe? List all the ways that would happen. Are there any things on the list that you're currently doing? Is there something you'd like to see change? Usually there are a few people who want to make a change and they'll lead these changes.

BLOOM: I'm still astounded that you need to be a 'psychologist' to get these changes made when we know they can save lives.

Dr. Michael Gardam: Health-care workers are people and they have the same issues as everyone else. A lot of this is deeply-ingrained behaviour. To help us along, we need the public to say "We're not taking this anymore" and it's a tricky line to walk. If you push too hard health-care workers may shut you out and feel offended. By the same token, we need to hear the message.

It's not about the health-care provider, it's about you, the patient.

If you'd like to ask Dr. Gardam a question about infection prevention, post it here and we'll do a follow-up blog with answers.