Antecedentes de la educación media fortalecida

In Chapter 1, I briefly outlined one of the major global strategies for reducing HAI: The ‘5 moments of hand hygiene’ (Sax et al., 2007). The WHO has adopted this strategy as part of its multimodal approach to improve hand hygiene in global healthcare settings. This approach includes five essential elements: systems change (to ensure healthcare workers have access to hand hygiene facilities); regular education on the ‘5 moments for hand hygiene’; evaluation

and feedback on hand hygiene compliance; reminders for hand hygiene in the workplace and; a safety climate that raises awareness of HAI and hand hygiene (WHO, 2009, p. 96). This aligns with the ‘simplification and alignment’ approach described in the previous paragraph. Here, HAI is delineated as largely a problem of hand hygiene compliance that can be solved or tamed through simplified, linear rules and education. These strategies have their place and can work well in controlled environments, but they also have their limits. The 5 moments, for example, are described as an “evidence-based, field-tested, user-centred approach [that] is designed to be easy to learn, logical and applicable in a wide range of settings” (WHO, 2017). Despite this, clinicians continue to have highly variable behaviours and attitudes around hand hygiene practices, which have contributed to suboptimal compliance as well as challenging the sustained success of the approach (Pittet et al., 2004; Stewardson et al., 2016).

Furthermore, observing and reporting hand hygiene is open to multiple biases (Joint Commission, 2009), and recent research shows that more intense hand hygiene practices rarely correspond in straightforward ways with lower HAI rates (Azim & McLaws, 2014; Marimuthu, Pittet, & Harbarth, 2014). This body of research suggests that our assumptions about what works in IPC may be out of step with the reality and scope of infection risk, notwithstanding the rigour and evidence invested in our guidelines.

Other approaches to reduce acquisition and transmission of MROs in hospital include: antibiotic stewardship, surveillance and reporting of infections, appropriate environmental cleaning, aseptic technique for invasive procedures, the use of personal protective equipment, and standard and transmission based precautions (NHMRC, 2010), including source-isolation which is particularly pertinent to this thesis. In hospitals, transmission precautions are

implemented for patients who have communicable diseases or are identified as infected or colonised with MROs – to prevent transmission via direct or indirect contact with the patient or the patient’s environment. The CDC recommends that: patients be placed in source-

isolation, either in single rooms (when available) or cohorted with patients who have similar MROs; staff use personal protective equipment, such as gloves and gowns, when inside source-isolation rooms; staff use dedicated or disposable patient care equipment where possible; cleaning and disinfection of equipment between patients when common use is unavoidable; and frequent cleaning is carried out in source–isolation rooms (Siegel et al., 2007).

Debates around the efficacy of source-isolation suggest that the clarity of these guidelines does not always translate to clear outcomes. One CDC literature review reports significant HAI reductions found in several studies, but it concedes that there are several factors limiting the ability to generalise the results (Siegel et al., 2007). Other studies have found no effect after implementing active surveillance and/or expanded contact precautions (De Angelis et al., 2014; Huskins et al., 2011; Kho et al., 2008). Furthermore, a number of studies have

measured staff compliance with source-isolation rules, usually using survey and covert staff observation methods, and have found inadequate adherence to guidelines (Clock, Cohen, Behta, Ross, & Larson, 2010; Franca et al., 2013; Jessee & Mion, 2013; Morgan et al., 2013). Despite growing concern and conflicting data from studies investigating the effectiveness of these interventions, recommendations still focus on improving components of contact and source-isolation precautions through identifying and rectifying non-adherent practices (Cohen, Cohen, & Shang, 2015).

For their part, Morgan et al. (Morgan, Kaye, & Diekema, 2014) state there is “little evidence that [source-isolation measures] prevent MRSA […] infections in endemic, non-outbreak settings” (p. 1395). They suggest that improved use of standard precautions (most commonly hand hygiene) may be a better alternative, implying that a simpler set of rules, requiring less training and easier monitoring of compliance, may have a greater effect on transmission

reduction. There are other researchers who recognise that knowledge does not necessarily predict IPC behaviours (Allen & Cronin, 2012; Pittet et al., 2004). They suggest that ‘social cognitive models’ be deployed to the cause of raising clinician compliance with IPC rules. These models posit individuals’ attitudes, beliefs and personal traits to be the principal determinants of their in-clinic behaviours.

The common thread weaving through all these endeavours and their recommendations is this: privileging individual human cognition in the forms of both knowledge and motivation as the mainspring(s) of optimal infection control. Accordingly, these endeavours aim to ensure that clinicians ‘know what to do’, and to amend any resistance or avoidance in line with the rules of IPC. This privileging of individuals’ cognitive capacities, however, ignores the complex circumstances in which clinicians and patients often find themselves. General knowledge and personal motivations might not be commensurable with emergent complexities such as competing clinical demands, patients’ intricate service trajectories, different staff’s priorities and concerns, the unclear nature of infection risk, and the diffuse and deferred impacts of actual infection (Iedema et al., 2015). Rather than relying solely on the knowledge/evidence approach to dealing with infection risk, we need to tease out the implications of what it means for clinicians and patients to have to compose and orchestrate IPC conduct amidst high levels of complexity.