According to the U.S. Centers for Disease Control & Prevention, in the U.S., approximately one out of every 20 hospitalized patients will contract a nosocomial infection, an infection associated with the healthcare environment. The direct hospital costs were estimated between $35.7 to $45 billion affecting 1,735,000 patients, with 99,000 deaths. This does not include indirect and intangible costs such as lost wages, diminished worker productivity, short term and long term morbidity, mortality, income lost by family members, forgone leisure time, time spent by family/friends for hospital visits, travel costs, home care, psychological costs (i.e., anxiety, grief, disability, job loss), pain and suffering, and change in social functioning and daily activities.
Hospitals should prevent or cure disease—not become sources of disease. Given the magnitude of nosocomial infections, training workers, particularly those involved with medical devices, is critical. Reusable medical devices must be thoroughly cleaned, sanitized, disinfected, and, in some cases, properly reassembled.
Avoiding inadequate sanitization or disinfection is a global issue. Contamination may be biologic or non-biologic. Contaminants may be active or dead. Disinfection and sterilization are not enough. Cleaning is essential to assure optimal performance of the device and to avoid environments that can promote the growth of organisms. Effective training encompasses the correct handling and management of medical devices to assure proper operation and reduce exposure hazards to healthcare workers and patients.
How not to train
“Canned” training programs are not sufficient. In-print and online programs may provide the basics and allow for a quick review. Yet, they often do not reflect the literacy, level of education, or language of those being trained. Professional educators emphasize that better learning occurs when students are engaged; tapping a key on a keyboard or viewing a video does not provide a meaningful learning experience. A canned program does not encompass the reality of a specific work environment. Without compelling evidence that the information has to be retained and acted on, actual practices and behavior may not change.
What makes a good training course?
A good course is comprehensive, unambiguous, well documented, integrated, encompassing, and holistic. It “sticks.” Workers learn, understand, and apply the material being presented. They incorporate the information into their daily activities. Therefore, an effective training course has to be appropriately designed to reflect the way the students learn.
The right education program involves considering potential hazards from a number of perspectives. For example, in the clinical setting we have to minimize hazards to workers, patients, and the environment.
A risk hazard approach
Device manufacturers designing effective training courses benefit by going into the field to see how their device is used. This exercise starts at the design stage and moves forward. It is evident that small refinements can make the difference between an easily operated and assembled device and one that is prone to malfunction and contamination. For all devices, it is enlightening to visit the actual site, to see how devices are used, cleaned, sanitized, and disinfected.
Employee exposure can include inhalation and contact exposure. This includes evaluating the impact, individually and collectively, of all cleaning and disinfecting agents. Alternative chemicals that may appear to pollute the air or water less may have adverse impacts on the safety and health of workers or patients, or vice versa.
Evaluating hazards to the patient is even more complex. A chemical may have benign respiratory effects yet may be harmful to the patient. There may be other routes of exposure, particularly where a device comes in contact with blood or tissue. Leachable residue and outgassing must be considered. A device that is not cleaned and sanitized correctly may not function properly. Cleaning directions have to be clear, concise, practical, and achievable. For example, immediate disassembly of a device may be highly desirable because the longer a soil is in contact with a substrate, the more adherent the soil becomes. In clinical environments, patient issues may take priority over immediate disassembly and cleaning of the device. This is where the site visit can be particularly valuable. By evaluating work flow, it is often possible to design an optimal approach that considers immediate patient needs and product safety.
Adequate training
The OSHA interpretation of adequate training is one that might be emulated for a number of applications. For example, instructions for cleaning and reassembly of medical devices as well as instructions for safe handling of chemicals should be provided in a manner and language the employee understands. If an employee cannot read or comprehend instructions, written instructions have no value. Even literate, highly educated technicians and engineers have been known to ignore written instructions or to interpret instructions incorrectly. In the absence of clear, unambiguous instructions that can be followed, technicians are likely to come up with creative, albeit unsuitable modifications. In a healthcare setting, this is another reason for supervisors and those involved in manufacturing medical devices to base instruction on actual observation of employee performance. Obviously, illustrations and photographs should accompany written instructions.
Conducting adequate training includes figuring out what the employee actually understands; this requires skill and, sometimes, tact. For example, a skilled technician had enviable manual dexterity but limited math skills. His job required him to measure a component, using a technique he could not fathom. His way of coping was to peer at the measuring instrument, then guess the measurement by writing a decimal point with a string of zeros that looked similar to what his colleagues achieved, followed by a few numbers. Eventually, the guessing game was detected. Since he was a skilled craftsperson, rather than removing him from the job, the solution was to remove the metrics from his job. Could an online quiz have caught the problem? Perhaps. Even better, in the example of the mathematically challenged employee, observation of the technician and an assessment of his available skills and talents was a more productive solution.
Who controls training?
Matthis makes compelling arguments for moving safety training out of the hands of health and safety professionals and into the hands of production management. He points out that such a move eliminates the artificial boundary between safety and productivity. It makes production management responsible for employee safety. It would seem that there is an important process in building and maintaining the training program; and this involves setting up practical procedures. In healthcare, this means a true collaboration among production management, workers, product safety professionals, environmental professionals, facilities management, medical device manufacturers, and manufacturers of cleaning agents and disinfectants. Matthis advocates a culture of safe production. Such a culture, it would seem to us, involves replacing training with well-designed instruction and education.
If a culture of holistic quality sounds costly, consider the costs of the status quo. Training in the healthcare setting can be a matter of economic prosperity versus failure for the facility, of success versus suffering for the patient, of life versus death for patients, families, and healthcare workers. The unproductive heat of friction generated by department conflicts is costly. Changes in reimbursement policies put the onus on the facility. The health, financial, and ethical consequences of mistakes in healthcare are catastrophic.
References
1. Scott, R.D. The Direct Medical Costs Of Healthcare-Associated Infections In U.S. Hospitals and the Benefits of Prevention. Division of Healthcare Quality Promotion, National Center for Preparedness, Detection, and Control of Infectious Diseases, Coordinating Center for Infectious Diseases. Centers for Disease Control and Prevention. March 2009.
2. Klevens RM, Edwards JR, Richards CL, Horan T, Gaynes R, Pollock D, Cardo D. Estimating healthcare-associated infections in U.S. hospitals, 2002. Public Health Rep 2007; 122:160-166.
3. Adapted from Haddix A.C. and Shaffer P.A. Prevention Effectiveness: A Guide to Decision Analysis and Economic Evaluation. Oxford University Press, 1996.
4. Fouke, E.G. “OSHA Training Standards Policy Statement,” April 17, 2007.
https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=25658&p_table=INTERPRETATIONS
5. Matthis, T.L. “Should the Safety Department Manage Safety?” Industry Week, May 2013. http://www.industryweek.com/safety-dept
6. Stone, P.W. “Changes in Medicare reimbursement for hospital-acquired conditions including infections,” Am J. Infect Control, Nov. 2009, 17A – 18A.
7. Bilodeau, R. “Engineering a Culture of Safety,” Controlled Environments Magazine, July/August 2013
http://www.cemag.us/articles/2013/07/engineering-culture-safety#.UfGSDhauZuE
Barbara Kanegsberg and Ed Kanegsberg (the Cleaning Lady and the Rocket Scientist) are experienced consultants and educators in critical and precision cleaning, surface preparation, and contamination control. Their diverse projects include medical device manufacturing, microelectronics, optics, and aerospace. Contact: [email protected]
Steve Derman has an extensive broad-base of experience in occupational health and safety, industrial hygiene, and biosafety with healthcare applications. He is a nationally recognized speaker, technical expert, and author on issues related to health, safety, environmental, and regulatory affairs and serves on numerous occupational hygiene, healthcare, safety, and regulatory committees. Contact: [email protected]
This article appeared in the September 2013 issue of Controlled Environments.