Abstract
Jaynelle F. Stichler, DNSc, RN, EDAC, NEA-BC, FACHE, FAAN
Healthcare-associated infections (HAIs) have been a concern of nurses since the time of Florence Nightingale, who first introduced the concept as important to patient outcomes with the soldiers in the Crimean war. Nightingale's notations about the importance of clean air and ventilation, light, cleanliness, noise, variety, and sanitation are the foundations for the concept of “healing environments” today and the first recognition that infectious diseases could be transmitted from patient to patient, patient to caregiver, and caregiver to patient (Nightingale, 1992).
In Notes on Hospitals (Nightingale, 1863), Nightingale discussed her concerns about the sanitary conditions of hospitals and explained the definition of “infection” as compared to the notion of “contagion.” She suggested that there were four causes of healthcare- or hospital-associated diseases and/or infections: (1) the congregation of the sick under one roof, (2) the deficiencies in space per bed, (3) the deficiency of fresh air, and (4) the deficiency of light. Nightingale stated that the close proximity of numerous patients in the open with minimal space between patients was a cause for increased morbidity and mortality in city hospitals such as the Hotel Dieu in Paris as well as hospitals in London, India, and France. She was also very concerned about the lack of fresh air for patients, who often recovered in putrid-smelling open wards with a lack of sanitation, freshwater, or disposal of human wastes. This book outlined concerns of dumping wastes in open drainage systems that often contaminated the source of drinking water and subsequently spread gastrointestinal diseases among the patients and caregivers. Her book also outlined many recommendations for the design and construction of hospitals to prevent the spread of diseases and to provide a safer environment for patients. Nightingale suggested that the distance from the beds to the windows be minimized and suggested having windows on both sides of the open bed wards to provide improve ventilation for the patients. She was also concerned about the types of materials that were used on the floors and walls and recommended that that the materials used be easy to wash and clean.
Nightingale was the first to be concerned not only about patient safety and hospitals but also about the safety of caregivers. In her book (1863), she mentioned that hospital nurses were particularly at risk for catching the diseases of their patients, and described cases where washer women would “catch” diseases from the hospital laundries. She gave instructions on how hospitals should be drained of sewage, how kitchens should be designed, how to dispose of linen, and how to ventilate open wards. Nightingale was not only the “mother of the nursing profession” but she was also a statistician, politician, and a woman of influence and affluence, able to support many of her recommendations with statistical evidence about the effect of poor hospital design, overcrowding in hospitals, and poor ventilation on the transmission of diseases among patients and caregivers. Because of her social influence, she made significant changes in hospital design that impacted hospitals for over a century. She was one of the first who kept statistical records comparing hospitals' infection, mortality, and morbidity rates.
Nurses today are no less concerned about the “sanitary conditions” of hospitals. All nurses receive basic education in microbiology and infectious diseases, and on-the-job training and orientation regarding care of patients with transmittable infectious disease processes. Most other disciplines have similar orientation and training focused on reducing the cross-contamination of infectious diseases from one patient to another. In spite of hospitals' efforts to inform and monitor nursing and other professionals' practice, hospital-acquired infections continue to be a serious life-threatening risk to both patients and caregivers.
Influence of Hospital Design on the Transmission of Infectious Diseases
Not much changed in hospital design from Nightingale's day until the 1970s, when hospital designers and healthcare leaders encouraged the move from multi-bed, open-ward designs to semi-private rooms. There were a few private rooms on most patient care units, but the influence of single rooms for maternity care with a homelike environment encouraged the design of single-patient rooms on other clinical units as well. In early 2000s, recommendations were made by design industry professionals and a few healthcare leaders for the design of single-patient rooms on all patient care units with the goal of decreasing nosocomial infections, improving patient satisfaction, and providing patient privacy. The new guidelines and recommendations for single room design in critical care settings and general acute care settings have demonstrated effectiveness in reducing the transmission of infectious processes and antibiotic use (Levin, Golovanevski, Moses, Sprung, & Benenson, 2011).
Although there is some emerging evidence that the physical environment can contribute to reducing the transmission of infections, it is widely recognized that design changes must be supported with patient safety initiatives to enculturate the belief among all healthcare providers that the most significant culprit in transmitting infections from one person to another is the human hand. Any design initiative with the goal of decreasing healthcare-associated infections must recognize that hand washing sinks and gel dispensers must be visually obvious and convenient for the caregivers to ensure compliance with hand hygiene.
Nurses Are Instrumental in Creating Safety Cultures
Recent changes by the Centers for Medicare and Medicaid Services (CMS) to the inpatient prospective payment system and concern about preventable HAIs has captured the attention of nurse and other hospital leaders. There are strong financial disincentives and penalties for hospitals that are above benchmarked rates of healthcare-associated conditions including hospital-acquired infections. Recognizing that nursing has strong influence on the prevention of HAIs, the American Nurses Association (ANA) developed the National Database of Nursing Quality Indicators (NDNQI), outlining 14 indicators that are specific to nursing and forming the monitoring scorecard that compares more than 1,100 hospitals nationwide on each of the nurse-sensitive indicators. The indicators outline structures, processes, and outcomes that reflect the quality of nursing care of patients. It should be noted that one indicator, nosocomial infections, includes urinary catheter-associated urinary tract infections (UTIs), central line-associated bloodstream infections (CLABSIs), and ventilator-associated pneumonias (VAPs), which nurses can influence in their specific care processes. It should also be noted that the working conditions (staffing levels) and environment (unit design, availability of equipment and resources) in which nurses deliver patient care are also considered to be sensitive indicators that can influence patient outcomes (Patrician, Loan, McCarthy, Brosch, & Davey, 2010; Stone, Clarke, Cimiotti, & Correa-de-Araujo, 2004).
It has also been demonstrated that the nurses' level of knowledge and judgment play a critical role in the prevention, mitigation, and creation of adverse events, and that nurses' specialty certification and clinical expertise are important contributors to decreasing hospital-acquired UTIs (Kendall-Gallagher & Blegen, 2009; Ribby, 2006) and VAPs (Fox, 2006). With this in mind, a number of hospitals have developed mandatory education for all employees regarding their role in infection control and have created learning modules to ensure nurses' competence in preventing healthcare-associated infections. With the financial penalties for HAIs, the data suggests that the greatest financial opportunity for hospitals is to prevent the infections from happening in the first place (Virkstis, Westheim, Boston-Fleischhauer, Matsui, & Jaggi, 2009).
Recognizing that hand washing is the single most effective way to prevent healthcare-associated infections, hospitals invest heavily on cultural change strategies and self-assessment to improve compliance with hand washing among all professionals. Safety campaigns are often launched to increase awareness about the causes of HAIs and the necessity of hand washing and to encourage patients and families to raise concerns when they observe professionals initiating care without washing their hands (Cam, 2004; Cole, 2009). The main barriers to hand washing compliance are high occupancy, poor staffing levels, inappropriately placed hand gels and hand washing sinks, and the failure of staff to see the consequences of their actions or inactions, since the actual infection appearing in patients may occur after discharge from the hospital. Safety campaigns, in-service education, and frequent discussions about the importance of hand hygiene, the use of gloves in care processes, and other interventions to reduce transmission of infectious diseases will improve the safety culture among all staff.
Over the past year, I have witnessed the nursing and medical care of a family member in two hospitals near my home. I have been amazed at the difference in how the nursing staff, physicians, and housekeeping staff approached infection control in the two hospitals. In both hospitals, hand gel dispensers were located immediately adjacent to the entry door of the patient room. Glove boxes were also located at the door and on the headwall in the patient room. The only sink for hand washing was located in the patient bathroom and in locations in the hallway. Therefore, the environmental conditions were the same in both hospitals.
While at one of the hospitals, I observed volunteers coming into the patient room each day with microcidal-infused cloths to wipe down all frequently touched surfaces including the hand gel dispenser lever, door handles and push plates, the patient's overbed table and bedside table, all medical equipment, the patient bed side rails, the trash and linen hampers, and the seating and sofa bed for visitors. I was amazed at this action and as a family member witnessing the cleaning process, I was reassured that this hospital was serious about their mission and vision to ensure patient safety by reducing the potential for HAIs. I began to think about all of the times that I, as a nurse, had pushed the lever for the hand gel to be dispensed without recognizing how contaminated the lever was from other previous users. Observing the daily wipe down of all frequently used and touched surfaces made me more conscious of surfaces that could potentially transmit infections and influenced my belief that this hospital provided a higher quality of care as compared to the other hospital.
Nurses' Exposure to Infectious Diseases
While this editorial, and this special supplemental issue of HERD, focuses on patients and healthcare-associated infections, nurses and other healthcare workers are also threatened by a wide range of potential work-acquired infectious diseases. Nurses are exposed to blood and body fluids and blood-borne pathogens in their work with most exposures involving needle sticks, splashes or sprays of fluid to the eyes or mouth, or direct contact with infected blood or non-intact skin. It is estimated that there are 600,000 to 800,000 work-related needle stick injuries each year in the United States, and studies indicate that high workloads and poor organizational climate are the major contributors to needle stick injuries or near misses among hospital nurses (Stone et al., 2004). The actual design of the patient room with the location of sharp boxes for the disposal of uncapped needles and other sharp devices and the location of contaminated supply disposal units would likely decrease the incidence of such injuries. Nurses' perceptions of unsafe working conditions may negatively affect recruitment and retention of qualified staff. Nurses must be assured that their health and safety concerns are also important as hospital leaders emphasize the importance of reducing hospital-acquired infections for patients and families.
Clinical nurses are a critical resource for decreasing the risk of healthcare-associated infections in the surveillance of care practices that could increase the transmission of infections and for the enculturation of safety practices that are essential for reducing healthcare-associated infections for patients and providers.