Hospital Topics
ISSN: 0018-5868 (Print) 1939-9278 (Online) Journal homepage: http://www.tandfonline.com/loi/vhos20
Infection Control: Training Supportive Personnel on the Environmental Aspects of Infection Control Donald Gibala M.P.H. To cite this article: Donald Gibala M.P.H. (1976) Infection Control: Training Supportive Personnel on the Environmental Aspects of Infection Control, Hospital Topics, 54:5, 1-48, DOI: 10.1080/00185868.1976.9948059 To link to this article: http://dx.doi.org/10.1080/00185868.1976.9948059
Published online: 13 Jul 2010.
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Training Supportive Personnel on the Environmental Aspects of Infection Control bY Donald Gibala, M.P.H. Hospital Environmental Consultant Pennsylvania Department of Environmental Resources Veteran’sHospital, Building 79 Bulter, Pa. 16001
I
have been on either side of the podium too many times and would be lying to you and to myself if, by now, I could not admit to some of the more glaring problems associated with the in-service educational programs in our health-care facilities. We are at fault both as instructors and as audience participants. As instructors, we are often guilty of putting our audiences to sleep; as participants, we sometime block our instructors totally from our minds. And the answer to this unfortunate paradox lies in a unique kind of limbo where few of us really care. Herein lies the problem of communication between student and teacher. Common sense should tell us all that a host of psychological, physiological or environmental factors might also enter into maintaining an active communication between the participant and his instructor; and for the most part, one is likely to find descriptions of these in great numbers throughout the literature. But of most importance, and of more significance in my opinion, is the fact that the student rarely: shows the initiative to ask the question “Why?” Yet, this question serves as a basis for nearly any type of educational training. I t appears reasonable that if one attempts to outline a “how-to-do-it” policy and procedure, he ought to consider a “why-to-do-it” explanation first. This is not to suggest that one must be taught that dirty windows require cleaning so that we can see through them, or that doors must be opened to avoid bumping into door knobs. The inference, however, is that before one can be taught proper policy and procedural methods, the individual must be given substantial reason to want to learn. SEPTEMBER/OCTOBER 1976
MR. GIBALA is employed by the Pennsylvania Department of Environmental Resources as a Regional Hospital Environmental Consultant in the Pittsburgh area. He received his Bachelor of Science degree in Secondary Education from Slippery Rock State College of Pennsylvania and has abo undertaken graduate studies there in Biology. He holds a Master of Public Health Degree in Environmental Health from the University of Pittsburgh. Mr. Gibala has conducted numerous environmental surveys of local health-carefacilities and has organized and presented multiple training courses and seminars in environmental control for supportive and administrative personnel. He has taught classes on the subject at local colleges and universities in the area and has contributed to the literature.
Asking the question “Why?” and having it answered properly is a step in the proper direction, and such a responsibility falls upon the backs of both teacher and student.
The Objectivesand Outline often in the teaching of institutional environmental controls, one must concentrate on instructing supportive personnel on specific control techniques which are applicable to their individual job descriptions. We teach dietary personnel to sanitize dishware in an automatic washer; we explain to nurse aides the proper stripping of beds and handling of soiled linens; we outline step-by-step mopping procedures for the 00
T
1
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housekeeping staff. Regardless of whether we are instructing staff from dietary, nursing service, laundry, central supply, housekeeping and maintenance, or any other department in the health-care facility, we continue to fail as teachers to make proper introduction to this type of subject material and fail to show these supportive personnel the significance of the environmental controls first. How should the instructor build upon the concept of environmental control? Encourage interest by first explaining “why” policies and procedures must be the way they are before explaining “how” policies and procedures should be carried out. This can be done by implementing short-course training programs which place institutional environmental control into its proper perspective. The primary purpose, for having training programs in environmental control should be to orient health-care personnel to the nature of infections which are institutionally-acquired, and to teach methods of preventing of controlling them when the environment is implicated. Just as important are those aspects of environmental safety which directly affect the patient, visitor or employee. As it is with most educators, the development of both general and specific objectives is usually considered a preliminary step in organizing a training program. If one is to organize and present a short course on environmental aspects of infection control to supportive staff, his general objectives should be at least two-fold. He must want the student to: I . develop an understanding of and appreciaiion for ihe relationship between institutional environmental control and ihe prevention and controlof infection.
2. develop ihe same undersianding and appreciaiion for the causes of nosoaomial infeciions and interprei their methods of control.
Specific objectives then become two-fold also and define more precisely, the general objectives already stated. The student would therefore be expected to: 1. develop a basic bacteriological and epidemiological awareness of the iwtiiutional environment and its effeci on ihe controlof infections.
2. develop an awareness of specific environmental conirol problems common to the health-care facility and recognize possible solutions to them.
By defining simple objectives like these, the task of organizing course content tends to clarify itself. For participants to meet the stated objectives, a short course program should be designed to systematically includes at least the following five major subject areas: I . introductory concepts of institutional infection control
2. basic microbiology of the institutional environment
3. epidemiology andthe chain of infection 4. environmental problems in the health-care facility
5. application of environmenial conirols
The degree to which these areas are presented will undoubtedly determine the final effect the program will have upon the student. As a general rule, employees in the supportive role, are very willing to learn when they recognize the sincerity of the instructor to teach. Short-changing the student by excluding, skimming or over-simplifying course material thought to be too difficult appears to be a major mistake frequently made by the instructor. The student will most likely decide for himself what he feels is applicable or not. The instructor’s role, therefore, should revolve around convincing the student that the entire program is worthy of learning and that each area of concentration serves as a building block toward understanding the entire concept of environmental control.
The Concept of Infection Control There are a few introductory points of discussion necessary when relating the concept of infection control to students. The Center for Disease Control in Atlanta, Georgia has outlined three essentials of an infection control program, all of which revolve around the protection of the patient in the healthcare facility. These include an active infection committee, well-maintained surveillance, and effective patient care and environmental control measures. The interrelationships among these three elements as they affect the entire infection control program should be explained thoroughly to the classroom participants. Futhermore, the instructor must initially discuss the three basic components which ultimately result in potential nosocomial infections (pathogen patient environment = infection). Participants should understnad that pathogenic microorganisms exist and are frequently prominent in the health-care facility. It is helpful to cite examples of these microorganisms by either their generic or common name and to distinguish between those which are gramnegative and those which are gram-positive. Bacteriological cultures or microscopic slides of some of the more prominent pathogens make excellent visual aids and are often obtainable in the laboratory for this purpose. One might wish to show the procession of organisms since the dominance of streptococci in the 1920’s, staphylococci in the 1950’s, and gramnegative bacteria in the 1960’s.
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In general, the instructor will find it helpful to discuss patient susceptibility, the overuse of antimicrobial therapy, and to some extent, genetic resistance in microorganisms. Of course, material of this type can be altered to meet the needs of the student. The instructor must use discretion when determining the degree to which technical information like this should be presented, and he should be cautious not to lose the respect of his listeners by over-simplifying or overcomplicating his presentation. It is relevant to include the types of infection one might acquire in the health-care facility. A comparison of urinary tract, surgical, respiratory and ear, nose, throat, skin infections with respect to their prominence, causative agents and potential susceptible hosts can prove effective. Of even more importance, the instructor should cite the actual infection rate in his own health-care facility and demonstrate to the student the significance of such a rate in terms of additional time, cost and inconvenience to both the patient and institution. Factual information of this nature leads to a philosophical challenge for the student. He must begin to decide at this point the relevance of the problem which has been stated to him and whether or not he wants to play a part in developing program solutions. The instructor must, therefore, be extremely influential in convincing the student that the problem of infection control does exist as a serious one, and that it will persist to the extent that it cannot be eliminated entirely. The student, however, should be convinced that he can reduce or a t least control bacterial populations and thus, minimize the chance patients have to contract institutionally-acquired infections. It is important to emphasize a bacteriological rather than an aesthetic approach to the environment and to relate the necessity of a team approach with respect to the unique role of each specific supportive or ancillary department. Unfortunately, these roles are not always completely understood, and frequently inter dep artmental cooperation is not always preset by policy and procedure. It becomes necessary for the student to learn the roles of others in the control of the environment and, ultimately, in the control of infection, regardless of whether or not he feels confident about the subject. When this is accomplished, the instructor has little or no trouble teaching the concepts of environmental control as a means to control infection, and he has little 0 1 no problem showing that the role of one department is just as vital as another’s role when implementing control measures. 46
Microbiology and the Environment Following a thorough introduction to infection control, it i s appropriate to acquaint the participants, to some extent, with basic microbiology. In general, supportive departmental personnel are not well enough aware of this pertinent material and have not effectively been shown its significance to their individual job descriptions. They will be more inclined to enforce infection control measures after having developed a better understandhg of bacteria and the diseases they can cause. Introducing a potentially complicated subject such as this is extremely important when training supportive personnel. Of primary importance is that the student must continually relate what he is learning to the role he has already established by conducting his routine activities during the work day. Therefore, the learning of “technical” microbiology can be best accomplished by utilizing applicable examples which the student will comprehend. Introductory microbiology text books aid the teacher in developing his outline of content material to be presented. He should define general terms such as microbiology, bacteriology, virology, parasitology, etc. and interrelate them with one another. Applying the study of microorganisms to daily life situations is also worthy of explanation. From this the student should be able to understand both the beneficial and non-beneficial effects of microbial life on industry, dairy, agriculture and medicine. In addition, it is valuable to historically review the subject of microbiology by briefly mentioning the many contributions made by Leeuwenhoek, Pasteur, Lister, Koch and others. After an effective presentation of background material such as this has been completed, more technical information regarding microorganisms can be presented. Emphasis should be placed on the student’s need and desire to learn, and material should be presented accordingly. A general outline of material might include the following: classification and binomial system of nomenclature, cell morphology (size, shape and arrangement), cell structure and function, nutritional requirements, acidity-alkalinity adjustment, endospore formation, reproduction and geometric progression, growth curve, physical and chemical agents of destruction, death rate and mode of action, and laboratory techniques. These and many other areas of micro-biology can be taught effectively when adequate time is taken to prepare and present the material. HOSPITAL TOPICS
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Epidemiology and the Chainof Infection At this point in the sequence of presentations, the student should have already developed an adequate concept of infection control and the microorganisms which are responsible for causing infections. He is now ready to be introduced to relevant epidemiological concepts which are basic to infection control. By thoroughly defining pertinent aspects of epidemiology to the student and explaining their importance to the concept of infection control in health-care facilities, the instructor should be able to relate the various modes of disease transfer common to the institutional environment. It is important that the student understands who is more commonly susceptible to infection in the heath-care facility and why these individuals are less resistant to infection than others. It is important also to again refer to the types of nosocomial infections most common to the health-care facility along with those micro-organisms specifically responsible for each infection. A general introduction of this type is basic to understanding disease distribution in the healthcare facility and should precede a thorough explanation of the infection “chain” (etiologic agent, reservoir, portal of exit, mode of transfer, portal of entry, susceptible host). It is evident that man is the primary source of infection. The student should be shown the relationship of patients, visitors and employees as potential sources of infection, either as non-active or active disease reservoirs or colonized carriers of the disease. Inanimate articles or fomites, which have become contaminated, are likely sources of infection to be included in this type of discussion. Important also is an explanation of the portals of exit and entry when man is considered the reservoir and susceptible host respectively in the “chain”. Last, and of primary concern in controlling the environment, the student should be introduced to the four main routes of disease transmission (contact, vehicle, airborne, vector-borne), each being thoroughly explained by appropriate examples. The chain of infection is more easily understood by supportive personnel when it is applied to the etiology of specific communicable diseases. For example, by reviewing actual cases of salmonella food infections or staphylococcal intoxications that have occurred in an institutional facility, dietary workers should be able to identify each “link” in the chain. Incorporating the floor, soiled linens, air vents, etc., into a chain of infection will demonstrate to housekeepers, nurse aides, laundry or maintenance workers that they also play significant roles in the SEPTEMBER/OCTOBER 1976
etiology of an infection that may occur in the facility. Numerous examples exist and should be used to the advantage of the instructor. The student thus becomes increasingly aware that each disease has its own etiology and that his role, dependent on that etiology, can be unique with each case in controlling disease distribution or “breaking” the chain of infection.
Environmental Problems and Solutions By this time, the student should begin to understand that he plays a specific role in the environmental control of infection, and he should realize why he must carry out his duties in the prescribed manner set by policy. It is at this time, that the instructor must reinforce these ideas by introducing the participants to a variety of environmental problems common to each department within the institution. It is valuable that participants not only recognize problem areas of their own concern, but that they also be exposed to many of the environmental problems of other supportive staff. This tends to broaden their scope of infection control and emphasizes the need for total cooperation among personnel in the control process. Audio-visual materials are helpful and should be utilized whenever possible throughout the entire course presentation. Several films, film strips, cassettes and many other teaching aids are available at little or no cost from commercial manufacturers, local sales companies, film libraries, colleges or universities and some governmental agencies. The instructor might find this part of his presentation to be most effective by using a slide series which adequately displays problem areas common to each department of the institution. However, a series of this nature should not be considered complete unless both pro and con conditions can be observed. One should not denounce corroded galvanized buckets shown on a slide without also providing a contrasting slide of a clean stainless steel bucket for housekeepers to observe. One should not display slides of exposed soiled linens laying on a chair next to the patient’s bed without also emphasizing the proper storage and collection of soiled linens. With appropriate dialogue, this type of pictorial presentation leaves substantial impact upon the student to the extent that he must re-evaluate his job activities and hopefully, concern himself with the revision of his work habits. In addition, he should be more aware of mistakes in procedures that other supportive workers may be making. 47
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The “why-to-do-it” phase of the training program should be nearly completed at this stage, and the instructor should next consider giving thorough explanation of “how” specific environmental control policies and procedures can most effectively be implemented. Up to this point, training sessions can easily be presented to mixed groups. However, policies and procedures now become unique to the individual’s job description, and it is advisable to teach the remaining sessions on a departmental basis. There is little need to teach laundry workers how to properly handle ice and water carafes on the patient unit. Laundry personnel should be taught specific procedures on separate handling of clean and soiled linens, specific instructions on the handling of isolation linens, and traffic flow patterns in the laundry. It is of little significance that housekeepers know the refrigeration temperatures which are necessary while storing perishable foods in the kitchen walkin coolers. But they should be aware of factors which influence the effectiveness of detergentdisinfectants. They should understand thoroughly the concepts involving bacteriological cleaning of floors and other flat surfaces. They should be shown the most effective control measures for storing, collecting and disposing of solid wastes in the health-care facility. It is unimaginable the number of policies and procedures in each department which involve the bacteriological control of the environment. The instructor’s goal is to define the significance of each of these policies or procedures on infection control and to offer them as potential solutions for maintaining the environment in a safer, more healthful condition.
SUMMARY It is not enough to organize programs of this nature methodically and to assure total coverage of applicable material during presentations, nor is it enough for students to attend training sessions or even accept the learning process. In a philosophical sense, it is evident that teaching truly is selling ideas and that learning is accepting or rejecting those ideas. Both the wise salesman and suspicious customer admit that gimmickry can’t compete with sincerity. It is vital, that both teacher and student demand respect for each other’s role and that communication be maintained along mutual interests. The entire concept of environmental control crosses over each and every’ departmental jurisdiction in the health-care facility and, thus, becomes the natural common bond between student and teacher.
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REFERENCES 1. American Hospital Association. Infection ’ Control in the Hospital. Third edition, The Association, Chicago, 1974. 2. Benenson, AS., editor. Control of Communicable Diseases in Man. Twelfth edition, American Public Health Assoc., Washington, D.C., 1975. 3. Bennett, J.V.; SchecWer, W.E.; Maki, D.G.; and Brachman, P.S. Current National Patterns - United States. In Proceedings of the International Conference on Nosacomial Infections A.H.A., Chicago, 1971. pp. 42-49. 4. Benson, M. Infection Control. In Environmental Aspects of Hospitals: Vol. 1, Infection Control. P.H.S. pub. No. 930-C-15. Public Health Service, U.S. Dept. of Health, Education and Welfare, Washington, D.C., 1967. pp. 25-41. 5. Bond, R.G.; Michaelson, G.S.; and DeRoos, R.L. Environmental Health and Safety in Health-Care Facilities. MacMillan Publishing Co., New York, 1973. 6. Boring, J.R. Principles of Bacteriology. In Environmental Aspects of Hospitals. Vol. 1: Infection Control. P.H.S. Pub. No. 930-(3-15. Public Health Service, U.S. Dept. of H.E.W., Washington, D.C. 1967. pp. 8-13. 7. Brachman, P.S. Principles of Epidemiology. In Environmental Aspects of Hospitals. Vol. 1: Infection Control. P.H.S. Pub. No. 930-C-15. Public Health Service. U.S. Dept. ofH.E.W., Washington, D.C. 1967. pp. 14-24. 8. Fox, J.P.; Hall, C.E.; Elveback, L.R. Epidemiolom -. of Man and Disease. MacMillan Co., New York,-1970. 9. Isolation Techniques for Use in Hospitals. P.H.S. Pub. No. 2054. Dept. 0fH.E.W.. Washington, D.C., 1970. 10. Outline for Surveillance and Control of Nosocomial Infections. Center for Disease Control, Atlanta, May, 1974. 11. Koren, H. Environmental Health and Safety. Pergamon Press, Inc., New York, 1974. 12. Mallison, G.F. Introduction to Microbiology of the Institutional Environment. Reprint from Proceedings of the Fourth Annual Technical Meeting and Exhibit of the American Association for Contamination Control. XV-1. 1965. pp. 1-9. 13. Pelczar, M.J. and Reid, R.D. Microbiology. McGraw-Hill Book Company, New York, 1972. 14. Top, F.H., editor. Control of Infectious Diseases in General Hospitals. American Public Health Association, New York, 1967. 15. Williams, R.E.O. Changing perspectives in Hospital Infection. In Proceedings of the International Conference on Nosocomial Infections. A.H.A., Chicago, 1971. pp. 1-10,
Coming in the Next Issue of TOPICS Measure Your Nursing Supervisor Leadership Behaviors, by Harry E. Munn, Jr., Ph. D. A composit profile was obtained by tabulating the data from 150 nursing supervisors at the 3rd National Hospital Nursing Supervisor Management Conference in 10s Angeles. Discharge Medication Counseling (The Role of the Clinical Pharmacy Specialist in the Out Wtient Pharmacy and Ambulatory Treatment Center.) By Charles E. Weber, Jr., Pharm.D. and Mike R. Sather, R. ph., M. S. Evaluation of Emergency Room Triage Performed by Nurses, by Susan L. Albin, M.S., Sylvia WassertheilSmoller, Ph. D., Sheldon Jacobson, M.D. and Bertrand
The Dream Process In Management Planning, by J. Richard Kerr, Administrator.
HOSPITAL TOPICS
ISSN: 0018-5868 (Print) 1939-9278 (Online) Journal homepage: http://www.tandfonline.com/loi/vhos20
Infection Control: Training Supportive Personnel on the Environmental Aspects of Infection Control Donald Gibala M.P.H. To cite this article: Donald Gibala M.P.H. (1976) Infection Control: Training Supportive Personnel on the Environmental Aspects of Infection Control, Hospital Topics, 54:5, 1-48, DOI: 10.1080/00185868.1976.9948059 To link to this article: http://dx.doi.org/10.1080/00185868.1976.9948059
Published online: 13 Jul 2010.
Submit your article to this journal
Article views: 2
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=vhos20 Download by: [Monash University Library]
Date: 11 November 2015, At: 19:08
Downloaded by [Monash University Library] at 19:08 11 November 2015
Training Supportive Personnel on the Environmental Aspects of Infection Control bY Donald Gibala, M.P.H. Hospital Environmental Consultant Pennsylvania Department of Environmental Resources Veteran’sHospital, Building 79 Bulter, Pa. 16001
I
have been on either side of the podium too many times and would be lying to you and to myself if, by now, I could not admit to some of the more glaring problems associated with the in-service educational programs in our health-care facilities. We are at fault both as instructors and as audience participants. As instructors, we are often guilty of putting our audiences to sleep; as participants, we sometime block our instructors totally from our minds. And the answer to this unfortunate paradox lies in a unique kind of limbo where few of us really care. Herein lies the problem of communication between student and teacher. Common sense should tell us all that a host of psychological, physiological or environmental factors might also enter into maintaining an active communication between the participant and his instructor; and for the most part, one is likely to find descriptions of these in great numbers throughout the literature. But of most importance, and of more significance in my opinion, is the fact that the student rarely: shows the initiative to ask the question “Why?” Yet, this question serves as a basis for nearly any type of educational training. I t appears reasonable that if one attempts to outline a “how-to-do-it” policy and procedure, he ought to consider a “why-to-do-it” explanation first. This is not to suggest that one must be taught that dirty windows require cleaning so that we can see through them, or that doors must be opened to avoid bumping into door knobs. The inference, however, is that before one can be taught proper policy and procedural methods, the individual must be given substantial reason to want to learn. SEPTEMBER/OCTOBER 1976
MR. GIBALA is employed by the Pennsylvania Department of Environmental Resources as a Regional Hospital Environmental Consultant in the Pittsburgh area. He received his Bachelor of Science degree in Secondary Education from Slippery Rock State College of Pennsylvania and has abo undertaken graduate studies there in Biology. He holds a Master of Public Health Degree in Environmental Health from the University of Pittsburgh. Mr. Gibala has conducted numerous environmental surveys of local health-carefacilities and has organized and presented multiple training courses and seminars in environmental control for supportive and administrative personnel. He has taught classes on the subject at local colleges and universities in the area and has contributed to the literature.
Asking the question “Why?” and having it answered properly is a step in the proper direction, and such a responsibility falls upon the backs of both teacher and student.
The Objectivesand Outline often in the teaching of institutional environmental controls, one must concentrate on instructing supportive personnel on specific control techniques which are applicable to their individual job descriptions. We teach dietary personnel to sanitize dishware in an automatic washer; we explain to nurse aides the proper stripping of beds and handling of soiled linens; we outline step-by-step mopping procedures for the 00
T
1
Downloaded by [Monash University Library] at 19:08 11 November 2015
housekeeping staff. Regardless of whether we are instructing staff from dietary, nursing service, laundry, central supply, housekeeping and maintenance, or any other department in the health-care facility, we continue to fail as teachers to make proper introduction to this type of subject material and fail to show these supportive personnel the significance of the environmental controls first. How should the instructor build upon the concept of environmental control? Encourage interest by first explaining “why” policies and procedures must be the way they are before explaining “how” policies and procedures should be carried out. This can be done by implementing short-course training programs which place institutional environmental control into its proper perspective. The primary purpose, for having training programs in environmental control should be to orient health-care personnel to the nature of infections which are institutionally-acquired, and to teach methods of preventing of controlling them when the environment is implicated. Just as important are those aspects of environmental safety which directly affect the patient, visitor or employee. As it is with most educators, the development of both general and specific objectives is usually considered a preliminary step in organizing a training program. If one is to organize and present a short course on environmental aspects of infection control to supportive staff, his general objectives should be at least two-fold. He must want the student to: I . develop an understanding of and appreciaiion for ihe relationship between institutional environmental control and ihe prevention and controlof infection.
2. develop ihe same undersianding and appreciaiion for the causes of nosoaomial infeciions and interprei their methods of control.
Specific objectives then become two-fold also and define more precisely, the general objectives already stated. The student would therefore be expected to: 1. develop a basic bacteriological and epidemiological awareness of the iwtiiutional environment and its effeci on ihe controlof infections.
2. develop an awareness of specific environmental conirol problems common to the health-care facility and recognize possible solutions to them.
By defining simple objectives like these, the task of organizing course content tends to clarify itself. For participants to meet the stated objectives, a short course program should be designed to systematically includes at least the following five major subject areas: I . introductory concepts of institutional infection control
2. basic microbiology of the institutional environment
3. epidemiology andthe chain of infection 4. environmental problems in the health-care facility
5. application of environmenial conirols
The degree to which these areas are presented will undoubtedly determine the final effect the program will have upon the student. As a general rule, employees in the supportive role, are very willing to learn when they recognize the sincerity of the instructor to teach. Short-changing the student by excluding, skimming or over-simplifying course material thought to be too difficult appears to be a major mistake frequently made by the instructor. The student will most likely decide for himself what he feels is applicable or not. The instructor’s role, therefore, should revolve around convincing the student that the entire program is worthy of learning and that each area of concentration serves as a building block toward understanding the entire concept of environmental control.
The Concept of Infection Control There are a few introductory points of discussion necessary when relating the concept of infection control to students. The Center for Disease Control in Atlanta, Georgia has outlined three essentials of an infection control program, all of which revolve around the protection of the patient in the healthcare facility. These include an active infection committee, well-maintained surveillance, and effective patient care and environmental control measures. The interrelationships among these three elements as they affect the entire infection control program should be explained thoroughly to the classroom participants. Futhermore, the instructor must initially discuss the three basic components which ultimately result in potential nosocomial infections (pathogen patient environment = infection). Participants should understnad that pathogenic microorganisms exist and are frequently prominent in the health-care facility. It is helpful to cite examples of these microorganisms by either their generic or common name and to distinguish between those which are gramnegative and those which are gram-positive. Bacteriological cultures or microscopic slides of some of the more prominent pathogens make excellent visual aids and are often obtainable in the laboratory for this purpose. One might wish to show the procession of organisms since the dominance of streptococci in the 1920’s, staphylococci in the 1950’s, and gramnegative bacteria in the 1960’s.
+
+
Continued on page 46
2
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Continued from page 2
In general, the instructor will find it helpful to discuss patient susceptibility, the overuse of antimicrobial therapy, and to some extent, genetic resistance in microorganisms. Of course, material of this type can be altered to meet the needs of the student. The instructor must use discretion when determining the degree to which technical information like this should be presented, and he should be cautious not to lose the respect of his listeners by over-simplifying or overcomplicating his presentation. It is relevant to include the types of infection one might acquire in the health-care facility. A comparison of urinary tract, surgical, respiratory and ear, nose, throat, skin infections with respect to their prominence, causative agents and potential susceptible hosts can prove effective. Of even more importance, the instructor should cite the actual infection rate in his own health-care facility and demonstrate to the student the significance of such a rate in terms of additional time, cost and inconvenience to both the patient and institution. Factual information of this nature leads to a philosophical challenge for the student. He must begin to decide at this point the relevance of the problem which has been stated to him and whether or not he wants to play a part in developing program solutions. The instructor must, therefore, be extremely influential in convincing the student that the problem of infection control does exist as a serious one, and that it will persist to the extent that it cannot be eliminated entirely. The student, however, should be convinced that he can reduce or a t least control bacterial populations and thus, minimize the chance patients have to contract institutionally-acquired infections. It is important to emphasize a bacteriological rather than an aesthetic approach to the environment and to relate the necessity of a team approach with respect to the unique role of each specific supportive or ancillary department. Unfortunately, these roles are not always completely understood, and frequently inter dep artmental cooperation is not always preset by policy and procedure. It becomes necessary for the student to learn the roles of others in the control of the environment and, ultimately, in the control of infection, regardless of whether or not he feels confident about the subject. When this is accomplished, the instructor has little or no trouble teaching the concepts of environmental control as a means to control infection, and he has little 0 1 no problem showing that the role of one department is just as vital as another’s role when implementing control measures. 46
Microbiology and the Environment Following a thorough introduction to infection control, it i s appropriate to acquaint the participants, to some extent, with basic microbiology. In general, supportive departmental personnel are not well enough aware of this pertinent material and have not effectively been shown its significance to their individual job descriptions. They will be more inclined to enforce infection control measures after having developed a better understandhg of bacteria and the diseases they can cause. Introducing a potentially complicated subject such as this is extremely important when training supportive personnel. Of primary importance is that the student must continually relate what he is learning to the role he has already established by conducting his routine activities during the work day. Therefore, the learning of “technical” microbiology can be best accomplished by utilizing applicable examples which the student will comprehend. Introductory microbiology text books aid the teacher in developing his outline of content material to be presented. He should define general terms such as microbiology, bacteriology, virology, parasitology, etc. and interrelate them with one another. Applying the study of microorganisms to daily life situations is also worthy of explanation. From this the student should be able to understand both the beneficial and non-beneficial effects of microbial life on industry, dairy, agriculture and medicine. In addition, it is valuable to historically review the subject of microbiology by briefly mentioning the many contributions made by Leeuwenhoek, Pasteur, Lister, Koch and others. After an effective presentation of background material such as this has been completed, more technical information regarding microorganisms can be presented. Emphasis should be placed on the student’s need and desire to learn, and material should be presented accordingly. A general outline of material might include the following: classification and binomial system of nomenclature, cell morphology (size, shape and arrangement), cell structure and function, nutritional requirements, acidity-alkalinity adjustment, endospore formation, reproduction and geometric progression, growth curve, physical and chemical agents of destruction, death rate and mode of action, and laboratory techniques. These and many other areas of micro-biology can be taught effectively when adequate time is taken to prepare and present the material. HOSPITAL TOPICS
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Epidemiology and the Chainof Infection At this point in the sequence of presentations, the student should have already developed an adequate concept of infection control and the microorganisms which are responsible for causing infections. He is now ready to be introduced to relevant epidemiological concepts which are basic to infection control. By thoroughly defining pertinent aspects of epidemiology to the student and explaining their importance to the concept of infection control in health-care facilities, the instructor should be able to relate the various modes of disease transfer common to the institutional environment. It is important that the student understands who is more commonly susceptible to infection in the heath-care facility and why these individuals are less resistant to infection than others. It is important also to again refer to the types of nosocomial infections most common to the health-care facility along with those micro-organisms specifically responsible for each infection. A general introduction of this type is basic to understanding disease distribution in the healthcare facility and should precede a thorough explanation of the infection “chain” (etiologic agent, reservoir, portal of exit, mode of transfer, portal of entry, susceptible host). It is evident that man is the primary source of infection. The student should be shown the relationship of patients, visitors and employees as potential sources of infection, either as non-active or active disease reservoirs or colonized carriers of the disease. Inanimate articles or fomites, which have become contaminated, are likely sources of infection to be included in this type of discussion. Important also is an explanation of the portals of exit and entry when man is considered the reservoir and susceptible host respectively in the “chain”. Last, and of primary concern in controlling the environment, the student should be introduced to the four main routes of disease transmission (contact, vehicle, airborne, vector-borne), each being thoroughly explained by appropriate examples. The chain of infection is more easily understood by supportive personnel when it is applied to the etiology of specific communicable diseases. For example, by reviewing actual cases of salmonella food infections or staphylococcal intoxications that have occurred in an institutional facility, dietary workers should be able to identify each “link” in the chain. Incorporating the floor, soiled linens, air vents, etc., into a chain of infection will demonstrate to housekeepers, nurse aides, laundry or maintenance workers that they also play significant roles in the SEPTEMBER/OCTOBER 1976
etiology of an infection that may occur in the facility. Numerous examples exist and should be used to the advantage of the instructor. The student thus becomes increasingly aware that each disease has its own etiology and that his role, dependent on that etiology, can be unique with each case in controlling disease distribution or “breaking” the chain of infection.
Environmental Problems and Solutions By this time, the student should begin to understand that he plays a specific role in the environmental control of infection, and he should realize why he must carry out his duties in the prescribed manner set by policy. It is at this time, that the instructor must reinforce these ideas by introducing the participants to a variety of environmental problems common to each department within the institution. It is valuable that participants not only recognize problem areas of their own concern, but that they also be exposed to many of the environmental problems of other supportive staff. This tends to broaden their scope of infection control and emphasizes the need for total cooperation among personnel in the control process. Audio-visual materials are helpful and should be utilized whenever possible throughout the entire course presentation. Several films, film strips, cassettes and many other teaching aids are available at little or no cost from commercial manufacturers, local sales companies, film libraries, colleges or universities and some governmental agencies. The instructor might find this part of his presentation to be most effective by using a slide series which adequately displays problem areas common to each department of the institution. However, a series of this nature should not be considered complete unless both pro and con conditions can be observed. One should not denounce corroded galvanized buckets shown on a slide without also providing a contrasting slide of a clean stainless steel bucket for housekeepers to observe. One should not display slides of exposed soiled linens laying on a chair next to the patient’s bed without also emphasizing the proper storage and collection of soiled linens. With appropriate dialogue, this type of pictorial presentation leaves substantial impact upon the student to the extent that he must re-evaluate his job activities and hopefully, concern himself with the revision of his work habits. In addition, he should be more aware of mistakes in procedures that other supportive workers may be making. 47
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The “why-to-do-it” phase of the training program should be nearly completed at this stage, and the instructor should next consider giving thorough explanation of “how” specific environmental control policies and procedures can most effectively be implemented. Up to this point, training sessions can easily be presented to mixed groups. However, policies and procedures now become unique to the individual’s job description, and it is advisable to teach the remaining sessions on a departmental basis. There is little need to teach laundry workers how to properly handle ice and water carafes on the patient unit. Laundry personnel should be taught specific procedures on separate handling of clean and soiled linens, specific instructions on the handling of isolation linens, and traffic flow patterns in the laundry. It is of little significance that housekeepers know the refrigeration temperatures which are necessary while storing perishable foods in the kitchen walkin coolers. But they should be aware of factors which influence the effectiveness of detergentdisinfectants. They should understand thoroughly the concepts involving bacteriological cleaning of floors and other flat surfaces. They should be shown the most effective control measures for storing, collecting and disposing of solid wastes in the health-care facility. It is unimaginable the number of policies and procedures in each department which involve the bacteriological control of the environment. The instructor’s goal is to define the significance of each of these policies or procedures on infection control and to offer them as potential solutions for maintaining the environment in a safer, more healthful condition.
SUMMARY It is not enough to organize programs of this nature methodically and to assure total coverage of applicable material during presentations, nor is it enough for students to attend training sessions or even accept the learning process. In a philosophical sense, it is evident that teaching truly is selling ideas and that learning is accepting or rejecting those ideas. Both the wise salesman and suspicious customer admit that gimmickry can’t compete with sincerity. It is vital, that both teacher and student demand respect for each other’s role and that communication be maintained along mutual interests. The entire concept of environmental control crosses over each and every’ departmental jurisdiction in the health-care facility and, thus, becomes the natural common bond between student and teacher.
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REFERENCES 1. American Hospital Association. Infection ’ Control in the Hospital. Third edition, The Association, Chicago, 1974. 2. Benenson, AS., editor. Control of Communicable Diseases in Man. Twelfth edition, American Public Health Assoc., Washington, D.C., 1975. 3. Bennett, J.V.; SchecWer, W.E.; Maki, D.G.; and Brachman, P.S. Current National Patterns - United States. In Proceedings of the International Conference on Nosacomial Infections A.H.A., Chicago, 1971. pp. 42-49. 4. Benson, M. Infection Control. In Environmental Aspects of Hospitals: Vol. 1, Infection Control. P.H.S. pub. No. 930-C-15. Public Health Service, U.S. Dept. of Health, Education and Welfare, Washington, D.C., 1967. pp. 25-41. 5. Bond, R.G.; Michaelson, G.S.; and DeRoos, R.L. Environmental Health and Safety in Health-Care Facilities. MacMillan Publishing Co., New York, 1973. 6. Boring, J.R. Principles of Bacteriology. In Environmental Aspects of Hospitals. Vol. 1: Infection Control. P.H.S. Pub. No. 930-(3-15. Public Health Service, U.S. Dept. of H.E.W., Washington, D.C. 1967. pp. 8-13. 7. Brachman, P.S. Principles of Epidemiology. In Environmental Aspects of Hospitals. Vol. 1: Infection Control. P.H.S. Pub. No. 930-C-15. Public Health Service. U.S. Dept. ofH.E.W., Washington, D.C. 1967. pp. 14-24. 8. Fox, J.P.; Hall, C.E.; Elveback, L.R. Epidemiolom -. of Man and Disease. MacMillan Co., New York,-1970. 9. Isolation Techniques for Use in Hospitals. P.H.S. Pub. No. 2054. Dept. 0fH.E.W.. Washington, D.C., 1970. 10. Outline for Surveillance and Control of Nosocomial Infections. Center for Disease Control, Atlanta, May, 1974. 11. Koren, H. Environmental Health and Safety. Pergamon Press, Inc., New York, 1974. 12. Mallison, G.F. Introduction to Microbiology of the Institutional Environment. Reprint from Proceedings of the Fourth Annual Technical Meeting and Exhibit of the American Association for Contamination Control. XV-1. 1965. pp. 1-9. 13. Pelczar, M.J. and Reid, R.D. Microbiology. McGraw-Hill Book Company, New York, 1972. 14. Top, F.H., editor. Control of Infectious Diseases in General Hospitals. American Public Health Association, New York, 1967. 15. Williams, R.E.O. Changing perspectives in Hospital Infection. In Proceedings of the International Conference on Nosocomial Infections. A.H.A., Chicago, 1971. pp. 1-10,
Coming in the Next Issue of TOPICS Measure Your Nursing Supervisor Leadership Behaviors, by Harry E. Munn, Jr., Ph. D. A composit profile was obtained by tabulating the data from 150 nursing supervisors at the 3rd National Hospital Nursing Supervisor Management Conference in 10s Angeles. Discharge Medication Counseling (The Role of the Clinical Pharmacy Specialist in the Out Wtient Pharmacy and Ambulatory Treatment Center.) By Charles E. Weber, Jr., Pharm.D. and Mike R. Sather, R. ph., M. S. Evaluation of Emergency Room Triage Performed by Nurses, by Susan L. Albin, M.S., Sylvia WassertheilSmoller, Ph. D., Sheldon Jacobson, M.D. and Bertrand
The Dream Process In Management Planning, by J. Richard Kerr, Administrator.
HOSPITAL TOPICS
