How to deal with unclear infection prevention guidelines

Written by Tinker Ready at HealthLeaders Media

A team of physicians from the University of Iowa Hospitals and Clinics has put forward a strategy that aims to standardize infection prevention guidelines for procedures performed outside the operating room.
The team contends that for most procedures, from skin biopsies to chest tube insertions, there is no authoritative guidance on infection prevention.

Writing in the American Journal of Infection Control, it also notes that there is little published evidence for existing practices.

The strategy emerged from a hospital epidemiology leadership meeting, says Vincent Masse, MD, the study's lead author.

They discussed a scenario whereby an interventional radiologist had been asked to wear a surgical hat and a mask while doing a fine needle aspiration. The radiologist had not worn the protection in 20 years of doing the procedure.

So the clinician asked what the hospitals policy was.

"Not only were we unable to provide evidence to support this practice, but we also had no comprehensive policy regarding infection prevention practices for medical procedures performed outside an operating room," the authors write.

Masse and his fellow researchers looked at what kind of research had been done.

"We realized that there is very little data for most procedures and there is no simple model to follow," he said.

Little Guidance

The researchers reviewed the available literature: textbooks, technical notes, and practice guides, but described them as unhelpful.

The Spaulding Classification guides the disinfection of devices and equipment, but does not go far enough, in the eyes of the study authors. "It would be nice if there were a similar model for outside-the-OR procedures," says Masse.

"Most of these sources referred, at some point, to 'your local policy'," they write.

The 5-Tiered Proposed Model

So Masse and his team used the data they could find combined with their own clinical experience to produce a five-tiered classification of procedures, encompassing "clean, aseptic, sterile-superficial, sterile-invasive," and "surgical-like procedures."

Each tier lists examples of procedures and whether gloves, masks, surgical gowns, and hats are needed. A skin biopsy is listed as "aseptic," which does not call for a surgical drape. A bone marrow biopsy is listed as "sterile superficial" and does require a drape.

Aaron Glatt, MD, is the chair of medicine at South Nassau Community Hospitals in on Long Island, NY, and a spokesman for the Infectious Disease Society of America.

He says that while it is not data-driven, the paper presents a sound first attempt at offering guidance. "Sometimes, there is just no data available to tell you what is optimal."

Clinicians often make decisions based on what would be appropriate in similar, but not identical situations. And while it is good to allow individual physicians to make the call, some may not be providing optimal care, Glatt says.

Don't Overdo It

The tiered system needs more review, but appears to offers a logical alternative.

"It's always easy to be very stringent – to say do everything, treat every procedure like it's the OR," he said. "But, that's not cost-effective, it's burdensome, and sometimes difficult to do. "

Susan Bleasdale, MD, is the medical director of infection prevention and control at the University of Illinois Hospital & Health Sciences System in Chicago.

She thinks the paper overstates the lack of guidance for procedures outside of the operating room, and notes that the Spaulding Classification guide the practices and equipment needed to protect both the providers and the patient.

Those guidelines describe require precautions such as hand hygiene and the use of PPE – personal protective equipment.

The study authors do note that Standard Precautions cover procedures such as a lumbar puncture. There are also guidelines calling for barrier precautions for central venous catheter placement and steps for the prevention of catheter-associated urinary tract infections.

For most procedures, "healthcare personnel do as they were trained, and pass the details along when they train someone new. This is true for the technical elements and the type of personal protective equipment used," they write.

The authors are clear that the paper is "intended to be a starting point for future efforts and not to be definitive."

Masse describes it as the group's "honest opinion…This is a very focused assessment. It's not a systematic literature review. I'm happy to get it out there. It's an idea to start a discussion."