Our fictitious patient, Jack, has developed severe diarrhea and is being treated with metronidazole. He is in a skilled nursing facility for wound care and rehabilitation. The diarrhea is not improving and oral vancomycin is started for suspected C. Diff infection. Stool cultures have been sent out.

The stool culture comes back positive for CRE, or Carbapenem Resistant Enterobacteriaceae.

 Ruth Carrico, PhD, RN, FSHEA, CIC Ruth Carrico, PhD, RN, FSHEA, CIC

Ruth Carrico, PhD, RN, Associate Professor, Division of Infectious Diseases, Department of Medicine, University of Louisville School of Medicine, led participants at the Fifth Annual Clinical Impact Symposium through the next steps of infection control for our patient, Jack.

Carrico first questioned participants about whether, given his situation, Jack should be isolated. The answer? Yes.

“We must assume that a body fluid out of control is caused by something transmissible until proven otherwise,” she said.

Once the stool sample comes back positive for CRE, isolation again becomes critical.

“CRE is an emerging pathogen with limited treatment options – we must isolate this patient,” Carrico said. This is true for patients who are colonized – meaning the bacteria is part of his or her body’s ecology but he or she is not actively infected – and for those who are infected – meaning it’s part of the body’s ecology AND it’s making him or her sick.

“A patient who is colonized can still be a transmitter,” she said.

Carrico went over basic infection prevention and core practices, including:

  • Hand hygiene (remembering that alcohol-based hand rubs are not effective for certain infections, including C. Diff)
  • Aseptic technique (procedure performed under sterile conditions)
  • Safe injection practices (including using aseptic technique when preparing and administering medications; cleansing the access diaphragms of medication vials; one needle, one syringe, one access, one vial, one patient, one time – no sharing; dedicate multidose vials to single patients; dispose of used sharps at point of use)
  • Standard precautions (prevent contact with any body fluids; selection, use and disposal of personal protective equipment; early isolation to prevent transmission opportunities; patient placement and cohorting; promotion of hand hygiene, respiratory hygiene and cough etiquette; environmental controls; policies and procedures)
  • Training and education of healthcare personnel (use principle of adult learning; competency-based for role responsibilities; access to materials; periodic updates; intensified when circumstances warrant, such as an outbreak)
  • Patient and family education (focus on enabling and empowering and preparing them for the next level of care)
  • Environmental cleaning and disinfection (microorganisms have two jobs to do – stay alive, and multiply; recognize that the environment is “living”; right process – disinfect versus sterilize; right product; right practice; right duration; right person, right job)
  • Administrative support (involvement in risk assessment; positional authority; provision of resources; collaborative support; alignment of strategic goals within the organization)
  • Monitoring of practice (process and outcome monitoring)

There are five moments, she said, for hand hygiene at the point of care.

1. Before patient contact
2. Before an aseptic task
3. After body fluid exposure risk
4. After patient contact
5. After contact with patient surroundings

“In my 40 years of healthcare practice, I don’t think I’ve ever met a healthcare worker who wanted to hurt a patient,” Carrico said. “But I’ve met many who were making decisions based on faulty logic.”

This is why, she said, all clinicians and staff have the responsibility to question something they don’t think is right.

So what can we learn from Jack? There are many opportunities for infection prevention, in retrospect, and for preventing infection transmission. These include using aseptic technique when dealing with Jack’s wound, and cleaning equipment between patients when we are checking his blood sugars.

“We have to be thinking about the actions for tomorrow,” Carrico said, “not using the actions of yesterday.”

Ruth Carrico, PhD, RN, FSHEA, CIC