The Presenteeism Problem: "It's My Allergies . . . Honestly!"

As we discuss HAI prevention, there are the "Big 6" HAIs (CLABSI, CAUTI, SSI, C. diff, MDROs, and VAP [although that one has been put on probation]) that get all the attention and resources.  However, other infections acquired in healthcare settings have less visibility but cause substantial harm.  One such HAI is healthcare-acquired respiratory viral infections (HARVI).  HARVI due to influenza has gotten increasing attention, especially in light of healthcare personnel (HCP) vaccination discussions (no worries, friends, I'm not stoking that debate again), but other viruses are increasingly recognized as causes of harm among our patients and colleagues (especially in light of better diagnostic tests).

In the current issue of ICHE, Len Mermel and Eric Chow provide an interesting perspective on one key aspect of HARVI transmission - HCP working while ill/symptomatic.  In their commentary, they argue that sick leave and work restriction policies that use fever as the parameter to keep HCP at home is too lenient, as infections due to many respiratory viruses may not cause fever but can still pose a substantial transmission risk.  They also call for a culture change surrounding presenteeism/working while ill, as too often the pressures to stay at work (limited sick leave especially with vacation days bundled into sick days in a single allocation, desire not to burden colleagues, importance of not handing over care to patients and maintaining the doctor-patient relationship) outweigh the push to stay home.  Policies, they appropriately argue, should be non-punitive with redundancy to allow coverage more readily.  Thanks to them both for raising some very important and provocative questions.

As I read their commentary, however, I kept going down various rabbit holes focused on implementation: 

• How do you assess HCP with resp. symptoms for infection vs. non-infectious entities like allergies (there's no POC test to rule out allergic rhinitis)?  This would be a huge issue at my hospital, as we sit in the allergy belt of the country where spring leads to a chorus of runny noses.
• What are the untended consequences of broader "stay at home" policies?  In units with highly-specific patient populations, you may run out of the experienced, skilled HCP and rely on coverage HCP, who may not be as comfortable or familiar with protocols, treatment regimens (e.g. a non-trauma nurse covering in the trauma unit).  Does that lead to unintended harm (arguably yes, if HCP shortages occur)?
• What about the utility of masking those with respiratory symptoms and no fever (not mentioned in the paper)?  Does that reduce transmission as effectively?  As part of the broader culture change, should expectations for masking to improve acceptance be part of the conversation?

Finally, such discussions and debates highlight the need for more implementation guidance and research on HARVI prevention. Hey, SHEA, time for a new Compendium chapter?

A semi-terrible, semi-no good, semi-very bad week in a semi-private room

A close family member became ill while traveling, and required emergent hospitalization. So I boarded a flight to provide support during what ended up being a weeklong hospitalization: the first two days at a small (~50 bed) local hospital, the rest at a large (>500 bed) tertiary care hospital. 

Overall, we were pleased with the care, and will likely rate the large hospital favorably (which I presume is common, given that this facility has a 5-star CMS rating). However, as others have pointed out, it would be very instructive for every health care worker to spend time each year as a patient or family member. Despite spending much of our professional lives in hospitals and seeking empathy with patients and their loved ones, nothing can replace being thrust into the patient/family role. So here are a few observations from the experience: 

There is nothing private about semi-private rooms. Multiple patient rooms are inimical not just to infection prevention, but also to privacy, confidentiality and basic human dignity. We learned much more than we ought to about the person in the neighboring bed, and vice versa. Add to that the additional interruptions, alarms (see below), and frequency with which HCWs moved from one bed to the other without performing hand hygiene, and I am more convinced than ever that single patient rooms should be the standard in all health care facilities. And “semi-private” should be replaced by “non-private” or “multi-patient” as a descriptor of hospital rooms.

Hospitals are aural assault zones. Most hospitals now have “quiet” or “hush” campaigns, laudable efforts to reduce noise. But noise from the hallways is a very small part of the problem. Seemingly everything in the hospital room makes noise! The IV pump (even when it isn’t alarming, in some cases), the NG suction, the various alarms (IV pump alarms, bed alarms), compression devices, intercom messages, code announcements… I’ve long had a pet peeve about IV pump alarms, but my concerns now encompass many additional noise sources—a long overdue solution is to re-route the pump alarm elsewhere (nurses’ station, pager), which also obviates the ridiculous step of requiring the patient (or family member) to press their call button to inform their caregiver that their IV pump is alarming. Engineering solutions to reduce noisy interruptions are essential.

Expecting patients to “speak up” and advocate for themselves is unrealistic. Acute care hospitalization is a traumatic experience, and once admitted the focus of the patient (and family) is simply on surviving the hospitalization and getting home. The default approach is often passive acceptance and deference to the treating caregiver. It’s not just that you don’t want to upset your doctors and nurses, but you also strongly want to believe that they are doing the right thing(s). We hesitated on more than one occasion when, in retrospect, it would have been better to speak up sooner, or more directly (on two occasions it might have prevented a complication). If even physicians are slow to point out problems or ask questions, how can we expect others to do so?

Finally, a kind word, a smile, and some ice chips can make a massive difference! Kindness may not be the only thing that matters (the right diagnosis and treatment is also kind of important), but it goes a long way.

Speaking of smiles, this sticker on our IV pump provided one during the first hospitalization, and helped explain why the pump was so noisy...it was Y2K non-compliant! A real confidence-booster!