In pursuit of truth IPC needs to become experts in error prevention, detection and correction (Part 1)

In Evonne T Curran’s latest two part blog she reflects on her life working in infection prevention and control (IPC) and how guidelines have been used and how IPC professionals need to become experts in error, prevention, detection and correction.

“IPC nurses do not control infection, we have to get everyone else to do it for us.”

I used to think that if infection prevention and control (IPC) professionals had a tag line it would be “Guidelines ‘r’ us”.  I recall an influential IPC nurse clarifying the situation, “IPC nurses do not control infection, we have to get everyone else to do it for us.” Thus, it is our (IPC’s) job to write the guidelines, advocate for healthcare workers (HCWs) to be furnished with that which is needed to comply, and monitor compliance, using both surveillance of infections and observations of practice. Look and you will see the obvious flaw. We are both setting the examination paper (what must be practiced) and interpreting via infections and observations (compliance with what we consider is best IPC practice). Should IPC get it wrong we misdirect prevention activity – everywhere.  

Evolution of IPC guidelines

I began in IPC in 1987 before the World Health Organization (WHO) were involved in IPC guidelines. There were professional IPC guidelines for specific pathogens, and for hand hygiene and other IPC practices, adapting or adopting from America’s Centres for Disease Control was commonplace. However, things shifted with time. Every IPC team at first wrote their own manual for their own area. To save time some IPC teams collectively produced manuals, and eventually in Scotland (2012) there was a single national IPC manual. The WHO got involved in 2009 with their paradigm-shifting, hand hygiene guideline.  Alongside changes in who produced what guidance, the emphasis shifted as to the type of evidence to be used.

Mechanistic evidence about transmission falls out of favour

Mechanistic evidence which had usefully identified how transmission happened fell out of favour when guidance methodologies were standardised. Up to that point there had been good mechanistic evidence for pathogens such as Staphylococcus aureus spreading in healthcare environments.  Evidence for what worked in prevention was thin – and impractical for settings without necessary requirements (single rooms). Evidence from randomised controlled trials (RCTs) was favoured – but at that point IPC RCTs were few. It was also nonsensical at times (and unethical) to use RCTs to answer questions such as how does x pathogen transmit?

Lack of evidence for new pathogens led to poor quality guidance

In addition, the continuous emergence of novel pathogens or organisms with novel resistance patterns meant that guidance writers often started with an absence of evidence. That said respiratory transmission evidence was present – just incorrectly interpreted in IPC guidance. Outbreak evidence was considered of poor quality. Deductive reasoning and mechanistic evidence were all undervalued – even when it was the evidence from outbreaks, mechanistic studies and deductive reasoning which confirmed the pandemic pathogen was – and could only be –  airborne.  Evidence from RCTs on transmission was unavailable.

Compliance with guidelines measured despite limited evidence to support them

As stated, IPC professional societies produced pathogen specific guidelines on behalf of members (or on behalf of Departments of Health). The Departments of Health accepted these guidelines and in pursuit of improvements set about measuring compliance with them – even naming and shaming Trusts’ / Boards’ compliance. However, there was an absence of evidence to support the premise advocated by Larson, (1995) that the “individual person [w]as the primary source of spread” (nor, was/is there evidence that most HAIs were caused by a lack of hand hygiene).  This false premise has been pursued for 30 years – without success.

Although approved guidance methodologies were followed, other errors appeared. For example, the professional MRSA guidelines used 275 citations but just 1 to support an erroneous statement that its only by HCWs’ hands that MRSA is spread. The cited paper confirmed what was written in the MRSA guideline. These authors presented no evidence but cited another paper which again confirms what was said in the guidelines; however, the author presented no evidence (or citation) to support the statement (see Extracts & Figure 1). Guidelines had become more capacious – but this did not lead to an absence of errors in transmission assessments and thus prevention.

Part 2 of this blog coming soon!