Home > RNJ > 2009 > March/April > Editorial: Battling a Powerful Foe

Editorial: Battling a Powerful Foe
Elaine Tilka Miller, DNS RN CRRN FAHA FAAN Editor

Although we have made great strides in combating nosocomial infections, deadly and debilitating bacteria and viruses are still powerful obstacles to our timely achievement of rehabilitation outcomes. Despite a mandate for universal precautions and the increased availability of antimicrobial gels and solutions in our workplaces, nosocomial infections still present a formidable challenge.

Data recently reported from 648 U.S. hospitals indicate that Clostridium difficile (CD)—a more virulent and deadly strain of CD than we’ve seen in the past—is spreading among hospitalized patients at a rate 6.5–20 times higher than previously estimated (Consumers Union, 2008). Annually, this bacterium increases patient care costs $6.5 million on average. In addition, CD is most prevalent among patients who are older than 60 years with chronic health problems (e.g., renal failure, diabetes, heart failure) and reside in long-term facilities, which describes a large segment of our rehabilitation patient population (Consumers Union; Mylotte, Graham, Kahler, Young, & Goodnough, 2001).

Rehabilitation professionals work in a variety of care settings and are aware that nosocomial infections affect body systems such as the urinary tract, respiratory system, and skin and soft tissue (Calfee, 2008). In a study of 176 veterans with spinal cord injuries and disorders, LaVela and colleagues identified that 59% of patients had at least one nosocomial infection that resulted in more frequent hospitalizations and shorter survival rates (2007). These findings underscore the need to increase efforts to prevent nosocomial infections and reduce long-term adverse patient outcomes.

What is it about the rehabilitation setting that affects the presentation and prevalence of nosocomial infections? Is it the tendency for longer lengths of stay than acute care hospitals, more limited access to infection control measures (e.g., delayed diagnosis, delayed isolation procedures, inadequate numbers of infection-control clinicians), or care focused on rehabilitation rather than prevention of nosocomial infections? Are nosocomial infections just formidable opponents that thrive on a patient population that has chronic conditions?

How do we as rehabilitation nurses combat this ever-present menace? Research suggests the answer is complex and affected by many factors that are difficult to measure, quantify, and control. With CD, infections tend to occur after patients take antibiotics that trigger changes in the intestinal tract or when clinicians do not wear appropriate protective gear (Cosumers Union, 2008). Plus, there appears to be evidence that alcohol-based antibacterial gels do not kill the spores for this bacterium. Interestingly, although correctly performed hand washing with soap does not kill the spores, the friction created is more effective in physically removing these bacteria. Because nosocomial infections increase patients’ length of stay and total care costs, it is pivotal to determine actions that will identify, treat, and prevent nosocomial infections more systematically. Do we need a better-prepared and astute staff, as well as patient and family members, to observe symptoms of a developing or actual infection? Do we need to make “indicators of infection” another vital sign so staff, patients, and their families understand its importance?

What creative strategies or bedside research must be performed to improve our practice and combat this frequently obscure, but daunting, opponent? What successes or failures pertaining to the identification and management of nosocomial infections can serve as stepping stones to stimulate greater discussion, partnering, and tangible actions to prevent or fight the prevalence of nosocomial infections? There are a myriad of possibilities to shape our battle plan:

  • Develop a nosocomial resource team with one member from each unit or department. By partnering with a larger number of individuals, there will be an expansion of knowledge, follow-through, surveillance, and problem solving to identify, treat, and prevent nosocomial infections.
  • Disseminate information regarding how resource teams are formed, their successes (as well as failures), and their steps for creating sustainable programs.
  • Encourage teams of staff members with varying levels of expertise to develop research questions centering on nosocomial infections, perform research or quality improvement projects, refine practice guidelines and protocols, and then disseminate outcomes through publications.
  • Focus each month on a different nosocomial infection that may be prominent and have an educational program for staff, patients, and family members as well as posters and other visuals as reminders of ways to prevent infections and increase our ability to recognize the signs and symptoms.
  • Include patients and family members in the prevention and problem-solving process to reduce the incidence of nosocomial infections. Have a system-wide celebration when goals are accomplished or progress is made.
  • Examine the widespread use of broad-spectrum antibiotics and actions that will enhance prescribing more appropriately.
  • Evaluate the effectiveness of environmental cleaning using reliable and valid measures.

Given the prevalence of nosocomial infections in all settings, many actions can be taken to fight this perilous foe. However, inaction is not an acceptable alternative. As you fight this battle, remember to share the results of your efforts. By working together, we can subdue this recurring attack on our patients.


Calfee, D. P. (2008). Clostridium difficle: A reemerging pathogen. Geriatrics, 63(1), 10–21.

Consumers Union. (2008). New report shows high C-difficile infection rate at U.S. hospitals. Retrieved January 19, 2009, from www.consumersunion.org/pub/core_health_care/006279.html.

LaVela, S. L., Evans, C. T., , Miskevics, S., Parada, J. P., Priebe, M., & Weaver, F. M. (2007). Long-term outcomes from nosocomial infections in persons with spinal cord injuries and disorders. American Journal of Infection Control, 35, 393–400.

Mylotte, J. M., Graham, R., Kahler, L., Young, B., & Goodnough, S. (2001). Impact of nosocomial infection on length of stay and functional improvement among patients admitted to an acute rehabilitation unit. Infection Control Hospital Epidemiology, 22, 83–87.