Tales from the Field: Infection Control Don’ts: Tale #1

One of the things I enjoy most about health consultation is the occasional opportunity to be a detective. It really isn’t that exciting, but it is rewarding to take a set of observations and deduce the most rational explanation.

There was this child care center that I had been courting as a consultant for a number of years. I knew the owner pretty well, had taught MAT to a number of their staff, and knew it had a reputation of being a very high-quality center.

My opportunity to be their health consultant finally came and I was on my first visit taking a tour with the Director. We were in a room with crawling and toddling infants and a teacher asked the Director to look at a spot on the child’s abdomen. Since I was there, the Director asked for my opinion as well.

The ‘spot’ looked like a pimple; a slightly raised red bump about 8mm in diameter with a pale white center. I asked about fever and how the child was acting. The teacher reported that she was acting normally, but that this was the fifth child with a similar looking mark. After finishing with this child, the teacher showed me two more children, each with 3-4 lesions. She said one had been diagnosed with MRSA. She wondered aloud if this could be MRSA too and why so many children would have it.

I suggested they have the child seen by her primary care provider and started to ask questions that would help me on the infection control side of things. Such as handwashing and do the children wear onesies especially in the common areas where they are crawling and toddling. I also remembered commenting on one of the teacher’s long, artificial fingernails when I was teaching MAT so I asked about how artificial nails are cleaned.

The Director explained that they run the center in a democratic fashion where the staff gets to vote on policy changes. In this case, the decision was that staff could wear artificial fingernails if they cleaned them with a brush and disinfectant prior to beginning their shift. The way she answered the question led me to ask “They all use the same brush?” She replied in the affirmative and took me to the staff bathroom where there was a single toothbrush sitting in a cup of blue liquid.

Not at all certain that the toothbrush and disinfectant could be the source of a potential MRSA contamination or even colonization of the staff’s fingernails, I still wanted to have the center have this procedure come in line with proper infection control procedures. I commended the Director on seeking staff input on center procedures as this will increase the staff’s compliance. I also pointed out that seeking a compromise by allowing staff to express their individuality, even though it could pose a potential risk, is commendable. I had to be honest, though, that while their intentions were good, the procedure they put in place missed the mark in regard to accomplishing the intended goal.

First I explained that sharing a nail brush (in this case a toothbrush) and disinfecting solution (in this case diluted antibacterial soap) among staff could create conditions where a disease-causing organism contaminates or even colonizes the skin and nails of someone who did not previously harbor the organism. Then I explained that proper skin antisepsis is a two-step process. The hands need to be thoroughly washed and then scrubbed using an appropriate antisepsis product and correct procedure.

The center did adopt a strict policy for hand antisepsis for staff who choose to have artificial nails. There were no further reports of unexplained lesions in the infant population.

Frankly, I think I got lucky in determining the likely culprit in this situation, but it does serve as an example of what well-meaning lay providers can do when they try to adopt health and safety procedures without consulting with a health professional with knowledge of group care environments for children.

APIC Guideline for Hand Washing and Hand, Antisepsis in Health-Care Settings*, Elaine L. Larson and 1992, 1993, and 1994 APIC Guidelines Committee, Association for Professionals in Infection Control and Epidemiology, Inc.

Measuring Hand Hygiene Adherence: Overcoming the Challenges, Division of Quality Measurement and Research: The Joint Commission