The Potential Perils of Mandatory Infection Prevention Efforts

Surgical caps- non grata here!

This is a subject that I have been pondering for quite some time- the potential negative consequences of mandating infection prevention interventions that are based on little (if any) evidence.      

We have been criticized about our bare below the elbows (BBE) initiative at VCU Health.   Admittedly, there is little high quality evidence to confirm that bare below the elbows results in few or hospital-acquired infections.  Bare below the elbows is based on biological plausibility, simplicity and likelihood of not causing harm. There is one important nuance: BBE is not mandatory at VCU Health.  It is an infection prevention adjunct, a recommendation.  By way of nudges, reminders and the modeling of BBE by influential team members, the practice has taken hold and has become essentially normative behavior, with compliance typically > 70%.

Surgeons are understandably upset about the banning of skullcaps in the OR, as recommended by AORN. Non-compliance with this AORN standard potentially exposes health systems to regulatory action from JCAHO or CMS. Skullcaps have been banned at VCU Health and the move has not been popular.

A recent paper published in Neurosurgey from the University at Buffalo (my medical school and internal medicine residency alma mater) assessed the pre/post  impact of banning skull caps on surgical site infections.  Not surprisingly, the absence of skullcaps (substituted by bouffant caps) did not impact the surgical site infection rate.  Mike Edmond recently posted a clever blog on the skullcap feud on the HAI Controversies site.

Infection prevention, in my opinion, is as much a science as it is and art.   The science should dictate and prioritize the interventions.  Implementing infection prevention strategy requires a more artful approach- one  that is heavy on dialogue, collaboration, reciprocal relationships and the ability to persuade, otherwise nothing gets accomplished.       

Mandating poorly supported infection prevention practices potentially jeopardizes relationships, the collaborative mission of patient safety and undermines the credibility of an infection prevention program.  

Mandates should be used selectively and when truly supported by high quality evidence. 

Pick and choose your battles wisely, collaborators and allies matter.