The proof does not have to be in your pudding
Dealing with questions, 'exceptions' to the rules
By Patti Grant, RN, BSN, MS, CIC
Infection Preventionist
Medical City Dallas Hospital
You've no doubt noticed that infection prevention is not convenient for those that work at the bedside. Professional frontline staff may not use the word "inconvenient" to describe their frustrations, yet the verbal message leaves little doubt when accompanied by wearisome body language. When I became an infection preventionist (IP), the word "why" quickly gained the power to instill fear. Too soon, the word why became synonymous with the phrase "triple work with less results" and perhaps remains at the core of my occasional motivational paralysis during "How come?" dialogues.
Another perplexing truth you'll quickly learn is that concrete preventive recommendations are expensive. Something as routinely innocent as putting waterless hand hygiene product at each patient room must be considered against the impact on daily operational budgets. Then, there are the capital budget items, such as converting a positive to negative air pressure room during an emergency department renovation project.
The good news with those situations is there are evidence-based guidelines to quote as references in your quest for patient and/or employee safety. It might take a while since health care fiscal decisions must do more with less (more often); yet common sense, if not regulations, will prevail and help all involved do the right thing. Despite the inherent frustration this truth is solid and perpetual.
But what about those requests that flow in reverse? When health care professionals approach you for an exception to that well-referenced prevention standard? Examples of these exemption requests include:
- Why can't we use new biohazard plastic Ziploc bags to deliver patient medications?
- How come we can't clean, sterilize, and then reuse those spacers we take out of infected hip patients into other infected hip patients? We do store them in peel-packs.
- Show me where it says we can't have negative air pressure (NAP) in a routine surgical suite?
It is beyond the scope of this column to answer those questions in detail; however, there is a single approach to them all. The "You-Show-Me" approach is something I stumbled upon as a last resort about two years after becoming an IP. When faced with exemption requests, your first response is to present the logic uncovered during your literature review as to why it cannot be done that way. If the rationale you impart is frowned upon, and you hear why not again, then it is time to change strategy.
Be honest and admit you have not heard of that approach and can't know everything. Continue in the spirit of teamwork and state, "Since I've been unable to find references for your appeal, please share your published peer-reviewed references and/or guidelines. We just need evidence-based references to support your request into practice. This way during an accreditation survey, visit from the health department, or in a court of law, we have science on our side." The individual(s) will either educate you or accept that the request can't be validated. Either way, the patient is safe and all can agree on the evidence-based literature.
Another angle to this approach — let's say, for the NAP question — is to show the established gold standard and ask, "Please show me where it says having a NAP is acceptable in a routine surgical room. I only find what is required, and that is positive pressure." I was extremely frustrated when trying to help a colleague with this very question, so I called Barbara Moody,an IP with over 30 years experience, and she suggested this approach. I felt silly for not thinking of this myself.
It is OK to admit you can't know everything, and with gentle firmness, clarify, "You can do that once you provide the appropriate documentation for your exception request." So you see the proof does not always have to be in your pudding.
You've no doubt noticed that infection prevention is not convenient for those that work at the bedside. Professional frontline staff may not use the word "inconvenient" to describe their frustrations, yet the verbal message leaves little doubt when accompanied by wearisome body language.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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