Protecting the patients of tomorrow: Hospital-based infection control (Proceedings)

Veterinary hospitals, by their very nature, create a high risk environment for the transmission of infections agents – bringing together animals from many different farms with varying levels of compromise.  Outbreaks of healthcare-associated infections commonly occur in veterinary hospitals with 82% of American Veterinary Medical Association (AVMA) accredited veterinary teaching hospitals (VTHs) reporting such events within the previous 5 years [1].  In addition, 50% reported the occurrence of zoonotic infections during the previous 2 years [1].  In order to practice high-quality patient care, infection control should be integrated into the patient management plan to protect the people, the patients, and the hospital.

While veterinarians are in a profession recognized to increase the lifetime risk for contracting a zoonotic infection, there is a general disregard for utilizing those practices known to be effective prevention measures.  Among AVMA member veterinarians, only 55.2% of small animal practitioners and 28.1% of large animal and equine practitioners reported always washing their hands prior to eating, drinking, or smoking at work; and only 48.4% of small animal practitioners and 18.2% of large animal and equine practitioners reported always washing their hands between patient contacts [2].  Despite veterinarians expressing concern about risks associated with gastrointestinal parasites and gastrointestinal bacteria, 71.2% and 70.9%, respectively, of small animal practitioners, and 35.7% and 39.8%, respectively, of large animal practitioners, reported not using appropriate personal protective equipment (PPE) when evaluating an animal with gastrointestinal signs [2]. 

Clearly, the biggest challenge in veterinary infection control is simply to do it.  Why don't practitioners use best practices with respect to infection control in the practice of veterinary medicine?  While there is a paucity of information in the literature specific to veterinarians, we can glean something from evaluations of this issue in human medicine.  Consider the barriers which may affect effective implementation of practice guidelines – such as knowledge, attitudes, and behavior.  In a systematic literature review, there were multiple factors contributing to each of these barriers including intrinsic factors such as a general lack of familiarity or of awareness with published practice guidelines, a lack of agreement with specific guidelines or with guidelines in general, a belief in a lack of expected outcome, a lack of self-efficacy, and the habit or routine of previous practices; and extrinsic factors such as guideline characteristics, patient influences, and environmental factors (e.g., time and available resources) [3]. 

While some of these barriers may be relatively simple to overcome (i.e., time and available resources), what it really comes down to is social cognitive behavior – specifically knowledge, motivation, intention, perception of a threat, outcome expectancy, perceived behavioral control, and social pressure – and understanding what motivates a particular behavior [4].  Case in point – Ignaz Semmelweis, (1818-1865), the father of hand hygiene, deduced in 1846 that patients were dying due to “pathogenic causes” associated with deficient hand hygiene practices by physicians [5].  While the prevention strategy he implemented was epidemiologically sound, it was not well received by colleagues and in fact he was relieved of his hospital duties [4].  So why the failure?  Not only did this event occur before the germ theory even existed, but his observations were also not reported in a timely fashion, thus there was a general lack of knowledge leading to disbelief by his colleagues.  Rather than educating his colleagues on the threat and expected outcome, he chose a more autocratic approach to intervention implementation.  Had he approached this in a different manner – taking into account social behavior theory – results may have differed.

An infection control culture is part-in-parcel with creating a workplace safety culture through the integration of behavior based safety programs and the organization's safety culture [6].  Behavior-based safety programs use a bottom-up approach that rely on continuous processes which are data-driven and setting-specific.  These programs define critical behaviors, set performance goals, monitor performance, provide feedback, and strive to reinforce the desired behavior.  Organization safety culture uses a top-down approach that is a more subjective, self-sustaining process that typically uses surveys to identify and assess personnel assumptions and beliefs.  Findings are then used to stimulate organizational change through participation of personnel including leadership.  A strong safety culture should have 3 components; 1) norms and rules which explicitly define risks and provide guidelines; 2) individual and group attitudes that place safety as highly important and that motivates personnel to act in this regard; and 3) use reflexivity to continuously understand risk and its mitigation [7].

In practice, fostering an infection control culture can be very difficult – everything we ask personnel to do is inconvenient.  It takes time to wash your hands before and after every patient contact, it takes time to don and doff PPE.  So how do veterinary practices develop a strong safety culture of infection control and worker safety when it comes down to influencing behaviors and attitudes?  The Ecological Model of Behavioral Change suggests that behavior is both affected by and affects several levels of influence including intra-personal factors (e.g., knowledge, attitudes, beliefs), inter-personal factors (e.g., social identity, support network, peer group pressure), community factors (e.g., social networks and norms), and institutional factors (e.g., administrative support) [4].  When applying this to organizational culture – consider that this is a multidimensional concept with core assumptions being at its deepest level, followed by beliefs and values, and finally norms at its most superficial level [7].  As such, it will take a multifaceted approach to implement change.  For example, if a facility wants to embark on a hand hygiene campaign it must first gain personnel involvement and ownership of the issue with a commitment to a solution.  Individuals within the organization may champion the cause, providing verbal instruction and training on proper procedures based on the best evidence currently available, in addition to demonstrating best-practices in their daily practice.  Management must be committed to the cause, providing resources such as hand hygiene stations and financial support for the effort.  In addition, the facility may choose to endorse the program through the development of slogans and posters to promote effective hand hygiene practices.  In this way the “culture” of the facility can gradually change to one where the expected norm is one of excellent hand hygiene practices where personnel ensure effective implementation through social influences, alteration of individual beliefs and intentions, and ultimately, permanent changes in behavior.

References

Benedict, K.M., Morley, P.S. and Van Metre, D.C. (2008) Characteristics of biosecurity and infection control programs at veterinary teaching hospitals. J Am Vet Med Assoc 233, 767-773.

Wright, J.G., Jung, S., Holman, R.C., Marano, N.N. and McQuiston, J.H. (2008) Infection control practices and zoonotic disease risks among veterinarians in the United States. J Am Vet Med Assoc 232, 1863-1872.

Cabana, M.D., Rand, C.S., Powe, N.R., Wu, A.W., Wilson, M.H., Abboud, P.A. and Rubin, H.R. (1999) Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 282, 1458-1465.

Pittet, D. (2004) The Lowbury lecture: behaviour in infection control. J Hosp Infect 58, 1-13.

Cork, D.P., Maxwell, P.J.t. and Yeo, C.J. (2011) Remembering Semmelweis: hand hygiene and its importance on today's clinical practice. Am Surg 77, 123-125.

DeJoy, D.M. (2005) Behavior change versus culture change: Divergent approaches to managing workplace safety. Safety Science 43, 105-129.

Clarke, S. (2000) Safety culture: under-specified and overrated? International Journal of Management Reviews 2, 65-90.