Infection Tragedy Reminds Us to Involve Employees in Hospital Infection Control

The May 2014 issue of the Pediatrics Infectious Disease Journal is shedding new light on the tragic deaths of five young children at New Orleans Children’s Hospital in 2008 and 2009 following their contraction of a fungal infection spread by contaminated linens. This should remind us that no precaution should be overlooked in the fight against infection and that no hospital is immune.

The children, all of whom contracted cutaneous Mucormycosis within an 11-month period, were in different wards throughout the hospital.  The flesh-eating infection they acquired was caused by a fungi typically found on plants and certain animal parasites.

According to court records, the linens were:

• From an unaccredited laundry service where mold might have been a factor
• Delivered without protected wrappings (bags or cellophane) at the hospital’s request
• Unloaded at the same dock where medical waste was removed
• Moved through the hospital in waste carts
• Used as “cleaning rags” to wipe down bathrooms
• Thrown into trash carts after use

Investigators from the Centers for Disease Control concluded that the hospital linens were the only form of exposure common to all the patients.  A recent New York Times article, “A Deadly Fungus and Questions at a Hospital,” also suggested that lapses in the hospital’s infection controls and sloppy handling of contaminated linens were likely to blame.

Fortunately, the people with the widest access to the hospital – environmental services and other support staff can serve a critical link in infection control efforts.  TeleTracking has long contended that the underutilization or misutilization of environmental services and staff can be a significant problem that sometimes goes under the radar in hospital efforts to contain infections.

For example, since most infection control alerts are done manually and take a significant amount of time, transporters and EVS personnel often don’t get word that they are entering an isolated room. They can then become inadvertently exposed to infection and become unwitting carriers of infection.  This exposure could happen several times a day or week in some hospitals.

Housekeepers and transporters have more potential exposure to a larger number of patients than virtually anyone else in the hospital. And so does some of their equipment.

Say an infected patient goes to radiology, but the transporter doesn’t know about the infection. As a result, the “special” cleaning needed to rid the wheelchair of germs may not be performed. Now that wheelchair becomes a potential rolling epidemic since it will be handed off to the next transporter, and the next and the next.

The eight-hospital Methodist Health System in San Antonio has made infection control one of its top priorities. Using a feature in TeleTracking’s Capacity Management Suite™ system, no bed is assigned to a patient unless an infection status is entered into the automated patient tracking solution.  Even if the patient has no known infection, placement personnel must still indicate an infection attribute of “none” in order for the placement request to go through.

Listen to a compilation of client testimonials on decreasing hospital acquired infections by clicking here:  https://www.youtube.com/watch?v=L5hC_a8j3EA

This process assures that infection status is automatically relayed to all staff levels, so EVS and transport workers are automatically alerted to infection status of beds and patients via the electronic communication devices that they carry and are thus able to take necessary precautions for infection control.

Methodist, however, even went a step further by implementing TeleTracking’s RTLS (real-time locating system) to track all moveable medical devices and equipment and the people who have had contact with them.

This same technology is also the foundation of a government-funded innovation program called “Safe Hands” now underway at New Cross Hospital, part of The Royal Wolverhampton NHS Trust of the United Kingdom.  “Safe Hands” uses RTLS to monitor hand hygiene by ward, locate equipment across the Trust hospitals, and generate a live bed state.  The RTLS system provides real-time patient locating visibility with on-screen alerts and audible alarms when a patient is leaving the ward unaccompanied or alone in an isolated area.  The RTLS system can also indicate if equipment has been cleaned or not.

Clare Nash, the “Safe Hands” program director, sees the project as a revolutionary step forward in healthcare and “the biggest of its kind in any hospital in the world.”

One of the most stunning statistics involving hospital acquired infections (HAIs) came from a recent survey by the Association for Professionals in Infection Control and Epidemiology (APIC). The association’s membership reported that only 30 percent of their hospitals provided an adequate budget for preventive measures.

We’d love to hear your thoughts on this topic.

If you’re interested in reading more about this topic, download our whitepaper, “Overlooked and Underprotected” by clicking here.