Lessons from the Poor Cousin

Trent - Ebola PPE

I reckon every specialty has its unfashionable discipline.  I’m not trying to down-play the significance of these conditions to people with them, or to the infrequent specialist who likes these less popular areas.  But functional bowel disorders for the gastros, myalgic encephalopathy for the rheum guys – let’s face it, they’re not exactly the Bowel Run of the Stars.

For infectious diseases, I reckon that it’s infection control.

In some hospitals, infection control is a nursing discipline – the infection control practitioners are nurses, and infectious diseases physicians sit outside that branch of the cursed organisation chart.  And because IC is a nursing job, and because some doctors think that nothing that nurses do can possibly be important, IC is dismissed as officious nursing busywork.

In other hospitals, IC sits under the infectious diseases unit.  There is a physician (or a group of them) responsible for infection control, who lend doctor “credibility” to the infection control procedures.  This is despite the fact that we know that nurses are actually better at it than doctors are.

Even in centers with medically-led infection control, we know that compliance rates with guidelines are lower than we would like.  There’s even been research on why that might be.

I don’t understand it.  And I understand even less the different standards healthcare workers apply to infection control standards.

Healthcare workers looking after people with HIV are pretty paranoid about blood or bodyfluid exposure – despite the risks for non-needlestick occupational exposures being almost unmeasurably small [pdf].  And we know that this can influence HCW attitudes towards people living with HIV.

Sadly, even in 2015, my HIV+ patients tell me stories about healthcare workers ignoring the principle of standard precautions and flipping out, wanting double gloves to touch people, or – even worse – shifting responsibility back onto patients (“If you bleed, you need to clean it up”).

I’ve similarly had personal experience of overwhelming staff anxiety – despite my reassurances – that recommended PPE for Ebola was inadequate – despite the fact that it has proven to be relatively difficult to acquire nosocomially.

Which brings me to respiratory precautions.

Unsurprisingly, acute respiratory illness is not an uncommon reason for presenting to the emergency department.  But the application of droplet precautions to patients in emergency departments (and after the subsequently get to the wards) is – in a word – appalling. Every single time I do a ward round, I find people who I would have put on precautions but are not.  I have been involved in cleaning up after quite a few episodes where patients with measles are sent all around the hospital, potentially exposing many hundreds of people.

Which brings us to MERS. If you’ve been following the news, you’d know there’s an outbreak in South Korea. If you see this quite excellent infographic (suggest opening it in Chrome so you can get auto-Google-translate), you can see just how important health care facilities are in the spread of MERS in Korea.

How is this possible?   Well, it’s pretty simple (and quite sad).  People with respiratory illnesses aren’t put under respiratory precautions.  Because it’s just a cold, or there are no isolation rooms, or we can’t find a mask, or it would block up our isolation rooms, or any of the myriad of reasons that supposedly smart doctors (and nurses) come up with for not using precautions.  In many cases, it’s not even that overt – people just don’t think about it, because, as we’ve established, infection control just seems to not be that important.

After all, it’s not like we’ve had a previous outbreak of a Severe (Acute) Respiratory Syndrome – during which outbreak healthcare workers accounted for 20% of cases, and a good proportion of the deaths.

So.

If you’re a patient with a respiratory illness, don’t be surprised or offended if your doctor or nurse comes in wearing a mask.  It’s to protect them and to protect other vulnerable patients in the hospital.  After all, they haven’t seen you yet, so how do they know you haven’t got MERS?  Don’t be afraid to pipe up – “I’m coughing – should you wear a mask”.  We need to normalise the use of personal protective equipment so it becomes part of the routine.  Nobody would think it would be reasonable if a surgeon just “didn’t think antiseptic prep was important, so I just forgot about it”.

And if you’re a healthcare worker, remember that “prevention is better than cure” also applies to infection prevention and not just diabetes and weight loss.  Because you might have had your flu vaccine, but it’s not going to help you much if your hospital is the epicentre of the next novel respiratory virus outbreak.  And by the time we work that out for you, it may well just be too late.

 

[Featured photo is me, testing out some Ebola PPE, thanks to Ian Mackay from Virology Down Under for the link to the MERS diagram]

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