Does a Little Bit Really Go a Long Way? Infection Prevention in Ambulatory Healthcare Facilities

Affiliations: Hospital Epidemiology Service and Office of the Deputy Director for Clinical Care, Clinical Center, National Institutes of Health, Bethesda, Maryland. Received November 9, 2010; accepted November 10, 2010; electronically published April 7, 2011. 2011 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2011/3205-0002$15.00. DOI: 10.1086/659402 Does a little bit go a long way, as the old saying goes? The origin of the saying “A little bit goes a long way” is unclear. The relevance of the application of this old saying to various settings and situations is equally unclear. Similarly, the relevance to clinical medicine is totally “uncharted territory.” In her 2001 hit song “A Little Bit,” the pop singer Jessica Simpson sings that “a little bit goes a long way,” but her lyrics also emphasize the need for “a little less talk and a little more do.” In my opinion, the latter statement, not the former, should become the mantra for the managers and owners of US ambulatory healthcare facilities with respect to infection prevention. In this issue of the journal, Shimokura et al present their findings from a study that was designed to identify factors associated with the risk of hepatitis C virus (HCV) transmission in ambulatory dialysis centers. This important study identifies several practices that the authors found to be associated with the risk of healthcare-associated transmission of bloodborne pathogens in these centers. In the study, patient-care practices that were independently associated with a higher prevalence of HCV infection among dialysis patients included the reuse of priming receptacles from one patient to another without disinfection, staff members handling blood specimens immediately adjacent to medications and clean supplies, and the use of mobile carts to deliver injectable medications. Most experts would consider each of these practices to be inadvisable at best and substandard care at worst. Bloodborne pathogen transmission has long been a concern of the hemodialysis community, and as early as the 1970s strategies were designed to prevent hepatitis B virus (HBV) transmission in these “blood-rich” environments. HBV transmission in the dialysis setting was the subject of intense scientific scrutiny in the pre-HBV-vaccine era. Similarly, over the past decade several studies have clearly documented the occurrence of HCV transmission to patients in the dialysis setting. Furthermore, dialysis patients have been shown to have a higher prevalence of HCV infection than the population at large. Previous investigations of the instances of dialysis-related transmission identified inadequate infection prevention procedures in the settings in which transmission occurred but did not identify specific practices associated with the risk of HCV transmission. In my view, one of the most striking findings from the study by Shimokura et al is the astoundingly low level of adherence to what most of us would consider basic infection prevention strategies—virtually across the waterfront—in these dialysis centers. Interestingly, for the patients in these centers even low levels of adherence to basic infection prevention strategies were associated with decreased prevalences of HCV infection. In reading this interesting article, I was struck both by the basic infection control data and by the manner in which these data were analyzed. With respect to the analysis, for example, the cutoff for hand hygiene “success” was greater than 33% adherence, and the cutoff for “successful” changing of gloves between patients was greater than 41% of the time. Even though staff in these centers were made totally aware that observers were there to evaluate the workers’ adherence to infection control guidelines, more than 75% of centers exhibited less than 33% adherence to hand hygiene recommendations, and staff from more than 70% of the centers failed to change gloves more than 41% of the time between patients. Most strikingly, only 28% of the centers had staff who followed both the hand hygiene and gloveuse recommendations more than 17% of the time! Interestingly, although not statistically significant, for each of these comparisons patients from institutions whose staff were (only slightly) more adherent to the recommendations had consistently lower prevalences of HCV infection—demonstrating that a little bit of infection prevention may actually go a long way while simultaneously underscoring the huge need for sweeping improvement in infection prevention procedures in these centers. Thus, from these data one might readily con-