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Contents
FEATURES
SUMMER 2017
When duty callsâ&#x20AC;&#x201C; A partnership between fire and rescue and infection preventionists By Jill Holdsworth
65
6 | SUMMER 2017 | Prevention
How clean is your scope? By Vicky Uhland
71
VOICE On the wings of change
8
By Linda Greene, 2017 APIC President
APIC 2016 scorecard
10
By Katrina Crist, APIC CEO
A reflection on CIC certification
12
By Lita Jo Henman, 2017 CBIC President
DEPARTMENTS Briefs to keep you in-the-know 14 • APIC 2017 award recipients • Introducing the APIC Program of Distinction • Prevent HAIs in ambulatory surgery settings with new AHRQ toolkit • Free resources for consumers and healthcare professionals • APIC MegaSurvey provides foundational data about the infection prevention profession Meet a CIC: Edina Fredell
25
Capitol Comments: Under a new administration and a new Congress, infection prevention needs to continue
26
38
By Rich Capparell, Nancy Hailpern, and Lisa Tomlinson
Infection prevention leadership
31
A Q&A with Jean Parret
APIC Consultant Corner: Care setting focus: Ambulatory surgery centers
35
A Q&A with Linda Miller
PREVENTION IN ACTION My Bugaboo – Food for thought: Listeria monocytogenes
38
From data to decisions: Principles of standard deviation
43
48
By Irena Kenneley
By Daniel Bronson-Lowe and Christina Bronson-Lowe
Identify the pathogen!
48
By Steven Schweon
Moving from wishing to success: Pointers for a successful abstract submission
50
By Jan Ratterree and Julie Blechman
Clean and sterile storage: Issues with ventilation, pressure differential, and humidity
52
By Vicky Uhland
An infection preventionist’s role in sepsis care
54
By Dawn Tomac
Onboarding a novice infection preventionist
59
By Jo Micek ERRATUM – SPRING 2017 ISSUE — Page 26 Omission of resource: Antimicrobial Stewardship Toolkit. Best Practices from the GNYHA/UHF Antimicrobial Stewardship Collaborative. Available at http://www.apic.org/Resource_/TinyMceFileManager/Practice_Guidance/ cdiff/Antimicrobial_Stewardship_GNYHA.pdf
71 w w w.apic.org | 7
PRESIDENT’S MESSAGE
On the wings of change: inspiration, innovation, and implementation
BY LINDA GREENE, RN, MPS, CIC, FAPIC 2017 APIC PRESIDENT
“The infection prevention literature abounds with examples of innovation, including environmental cleaning and disinfection strategies, automated surveillance, new products and equipment, and patient care strategies to reduce infections.”
IN MY FIRST few months as APIC president, one word that I’ve heard repeated
at several forums is the word “change.” Change is constant in healthcare, as organizations must constantly adapt to evolving research, regulations, technology, and economic conditions, as well as internal and external crises. Today’s changing healthcare landscape places a crucial emphasis on patient safety and improving the quality of patient care. Healthcare-associated infections (HAIs) continue to pose a major challenge to healthcare professionals in all healthcare settings across the globe as infection prevention professionals must address new emerging and re-emerging diseases, antibiotic resistant organisms, serious—often life-threatening—diseases such as C. difficile, MRSA, and other HAIs. Read how a Dutch nursing home identified and managed an outbreak of MRSA in the “Identify a Pathogen” column. In addition, as care moves beyond the acute care setting, infection preventionists (IPs) must expand their scope of influence. See the article “An IP’s Role in Sepsis Care” on page 54. These changes in the healthcare landscape often force IPs to move away from their comfort zone as they attempt to integrate new habits that affect values, beliefs, training, and day-to-day work. While change is unavoidable, it is also essential for progress and growth. The following quote from Lao Tzu’s Tao Te Ching underscores this message: “Whatever is flexible and flowing will tend to grow, whatever is rigid and blocked will wither and die.” With this in mind, change is essential for progress. But, if we embrace change, it can be inspiring and energizing, often igniting a passion that is sparked by the challenge of learning new things, growing as professionals, and developing innovative solutions to problems. Often, it is this inspiration that leads to innovation. The infection prevention literature abounds with examples of innovation, including environmental cleaning and disinfection strategies, automated surveillance, new products and equipment, and patient care strategies to reduce infections. Many of these innovations have changed the way we think and practice infection prevention, and have become the new standard of care. You can read about a few of these innovations and strategies in the featured articles. One of our most difficult challenges, however, still remains: implementation. We know that, despite evidence which demonstrates that certain interventions can reduce HAIs, there remain significant gaps in practice. Moreover, some healthcare professionals believe that many infections are not preventable. This type of thinking may be a result of beliefs and ideas that we consciously or unconsciously form from our previous experiences and which guide our thoughts and actions. To change the mindset, we need a fresh approach to communicating and engaging with stakeholders to create what is sometimes referred to as a shared mental model in which there are agreed-upon expectations and anticipated outcomes. The challenge for us begins with turning the mirror toward ourselves and scrutinizing our own beliefs and behaviors, while simultaneously creating awareness and understanding of the beliefs and values of others. As IPs, we must be open, listen, engage, and collaborate with our stakeholders in order to create this shared mental model. This effort is essential to our mission to create a safer world through infection prevention. The APIC 2017 Annual Conference will provide us with many opportunities to learn and grow, all of which will better equip us to navigate the “wings of change.”
Linda Greene, RN, MPS, CIC, FAPIC
8 | SUMMER 2017 | Prevention
Prevention S U M M E R 2 017 • VO L U M E 10 , I S S U E 2
BOARD OF DIRECTORS President Linda Greene, RN, MPS, CIC, FAPIC President-Elect Janet Haas, PhD, RN, CIC, FSHEA, FAPIC Treasurer Sharon Williamson, MT(ASCP)SM, CIC, FAPIC Secretary Linda McKinley, RN, BSN, MPH, CIC Immediate Past President Susan Dolan, RN, MS, CIC, FAPIC
DIRECTORS Dale Bratzler, DO, MPH, MACOI, FIDSA Tania Bubb, PhD, RN, CIC, FAPIC Thomas Button, RN, BSN, NE-BC, CIC, FAPIC Kim Boynton-Delahanty, RN, BSN, PHN, MBA/HCM, CIC, FAPIC Annemarie Flood, RN, BSN, MPH, CIC, FAPIC Irena Kenneley, PhD, RN, CNE, CIC, FAPIC Stanley Healy, MBA, DHA Karen Hoffmann, RN, MS, CIC, FSHEA, FAPIC Pat Metcalf Jackson, RN, MA, CIC, FAPIC Ann Marie Pettis, RN, BSN, CIC, FAPIC Barbara Smith, RN, BSN, MPA, CIC, FAPIC Katherine Ward, RN, BSN, MPH, CIC, FAPIC
EX OFFICIO Katrina Crist, MBA, CAE
DISCLAIMER Prevention Strategist is published by the Association for Professionals in Infection Control and Epidemiology, Inc. (“APIC”). All rights reserved. Reproduction, transmission, distribution, or copying in whole or in part of the contents without express written permission of APIC is prohibited. For reprint and other requests, please email editor@apic.org. APIC makes no representations about the accuracy, reliability, completeness, or timeliness of the material or about the results to be obtained from using this publication. You use the material at your own risk. APIC assumes no responsibility for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. Although all advertising material is expected to conform to ethical (medical) standards, inclusion in this publication does not constitute a guarantee or endorsement of the quality or value of such product or of the claims made of it by its manufacturer.
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CEO’S MESSAGE THE FIVE STRATEGIC priorities as part of Strategic Plan 2020 (www.apic.org) – patient safety, implementation science, competencies
APIC 2016 scorecard
and certification, advocacy, and data standardization—are an important component to measuring APIC’s success. This scorecard provides a snapshot of key metrics. We are making great progress to date with medium to high probability of meeting 11 out of 12 targets by 2020. Eight targets are performing very well, year over year, with high probability of meeting the 2020 targets. Three of the targets are highlighted in yellow denoting a medium probability of meeting these targets by 2020 because they have not met the annual targets. However, we are still working on the development of the Research Training Series as one of the competency strategic priorities with hope of making up the overall numbers by 2020. The other two medium-performing measures will require a more focused effort with a better understanding of how and why members take action on public policy issues as well as the pool of eligible infection preventionists for APIC Fellow status. The most difficult target to achieve by 2020 remains 10,000 CICs. At year-end 2016 there were a total of 6,139 individuals who hold the Certified in Infection Control (CIC) credential. While we continue to grow the number of certified individuals in infection prevention, the loss of those not recertifying due to retirement or leaving the infection prevention field has slowed the projected incremental growth year over year. The good news is that the number of individuals obtaining firsttime certification continues to grow each year. In 2016, 702 individuals were newly certified in infection prevention and control compared to 644 the prior year and 476 in 2014. APIC and our colleagues at the Certification Board of Infection Control (CBIC) are working together to better understand the trends and primary drivers to achieve widespread adoption of the CIC credential. Please visit the Vision and Mission page under About APIC at www.apic.org to view the full scorecard with details on measures, metrics, and outcomes.
BY KATRINA CRIST, MBA, CAE, APIC CEO
Strategic Priority
2020 Target
2016 Cumulative Total
Change from last year (items with an asterisk are non-cumulative)
Patient Safety
1,000,000 consumer interactions
642,762
Patient Safety
60 organizational communications
54
13
Implementation Science
100 courses and published resources*
115*
28
Implementation Science
2,500 facilities
Target exceeded in 2015
IP Competencies/CIC
10,000 CICs
6,139
307
IP Competencies/CIC
1,000 advanced practice designation
165
165
IP Competencies/CIC
450 participants in research training
0
n/a
Advocacy
3,000 subscribers to advocacy update
2,915
339
Advocacy
5,000 clicks on regulatory resources
3,820
241
Advocacy
3,000 clicks on public policy agenda
2,536
2,370
Data Standardization
40 organizations supporting NHSN
Target exceeded in 2015
Data Standardization
3,700 members take action*
1,494*
259,953
S U M M E R 2 017 • VO L U M E 10 , I S S U E 2
PUBLISHER Katrina Crist, MBA, CAE kcrist@apic.org MANAGING EDITOR Rickey Dana editor@apic.org CONTRIBUTING EDITORS Elizabeth Garman Julie Blechman, MPH, CHES PROJECT MANAGER Russell Underwood runderwood@naylor.com ADVERTISING Brian Agnes bagnes@naylor.com GRAPHIC DESIGN Dan Proudley
EDITORIAL PANEL George Allen, PhD, CIC, CNOR, FAPIC Kristine Chafin, RN, MBA, CIC Edina Fredell, MPH, CIC, MT(ASCP) Ruth Freshman, BSN, RN, CIC Brenda Helms, RN, BSN, MBA/HCM, CIC, FAPIC Kari Love, RN, BS, MSHS, CIC, FAPIC May Riley, RN, MSN, MPH, ACNP, CCRN, CIC, FAPIC Steven Schweon, RN, MPH, MSN, CIC, HEM, FSHEA, FAPIC Alexander Sundermann, MPH, CIC Christine Young-Ruckriegel, RN
CONTRIBUTING WRITERS Julie Blechman, MPH, CHES Christina Bronson-Lowe, MS, CCC-SLP, CLD Daniel Bronson-Lowe, PhD, CIC Rich Capparell Katrina Crist, MBA Edina Fredell, MPH, MT(ASCP), CIC Linda Greene, RN, MPS, CIC, FAPIC Nancy Hailpern Jill Holdsworth, MS, CIC, NREMT, FAPIC Lita Jo Henman, MPH, CIC Irena Kenneley, PhD, RN, CNE, CIC, FAPIC Jo Micek, RN, CIC Linda Miller, RN, CIC Jean Parret, RN Jan Ratterree, BSN, RN, CIC Steven Schweon, RN, MPH, MSN, CIC, HEM, FSHEA, FAPIC Dawn Tomac, BSN, RN, CIC Lisa Tomlinson Vicky Uhland
MISSION APIC’s mission is to create a safer world through prevention of infection. The association’s more than 15,000 members direct infection prevention programs that save lives and improve the bottom line for hospitals and other healthcare facilities. APIC advances its mission through patient safety, implementation science, competencies and certification, advocacy, and data standardization. Visit APIC online at www.apic.org. PUBLISHED MAY 2017 • API-Q0217 • 9409
1,494
*non-cumulative; n/a = initiative in development; Green = High probability of achieving 2020 target; Yellow = Medium probability of achieving 2020 target; Red = Low probability of achieving 2020 target
10 | SUMMER 2017 | Prevention
On Track
Prevention
CELEBRATING EXCELLENCE
A reflection on CIC certification
WHILE TRAVELING TO CBIC’s recent Board of Directors meeting, I was struck by the differing
BY LITA JO HENMAN, MPH, CIC
“Regardless of where you are in the journey, I commend your dedication to the profession and, more importantly, to the public by demonstrating your competency in infection prevention through the validated process of CIC® certification.”
speeds at which people moved through the airport. Some were running through the airport trying to get to the next gate. Several were utilizing the technology of moving sidewalks, but even then, there were differences. A few were content to stand on the moving conveyor belt and let the machine move them ahead with minimal effort. Many were walking on the belt, which propelled them further and faster than standing. A couple of people were taking a break and watching the scenery while sitting in rocking chairs that were placed overlooking the runway. Maybe because I was headed off to a CBIC Board meeting, this scene prompted a reflection on CIC® certification. I believe a shared goal of everyone in our profession is to have a skilled and competent infection preventionist (IP) workforce. CIC® certification is the recognized demonstration of infection prevention competency and is endorsed by our professional association, APIC. The tireless help of the item-writing, item-editing, and forms review teams that make up the Test Committee help to create a contemporary exam that is scientifically validated to demonstrate competency. These teams are comprised of hard-working IPs who practice in their field every day. They represent a diverse background, both geographically and from a practice setting perspective. Your peers have generously volunteered their time and expertise to ensure the CIC® exam reflects those key skills and knowledge that are required for every competent IP. Additionally, we receive guidance from a professional testing company that is experienced, and has a worldwide presence to ensure the highest exam quality is achieved and maintained. And, because we hold ourselves to the very highest level of professional demonstration, the certification exam goes through an accreditation process. This is an achievement that only a small percentage of all professional certification exams can claim. If you are not currently certified, where are you in the process of preparing for certification? Are you contemplating the benefits of the exam, like those individuals in the airport who were taking in the information around them? If so, the candidate handbook is a great place to start. It will explain the entire process of becoming certified in detail and provide the information you need to take the next step in the journey toward certification. Perhaps you’ve stepped onto the moving sidewalk and decided that this is the year to become certified and you’ve taken a few steps in preparing. If so, the CBIC website section dedicated to preparing for initial certification is a great roadmap for this part of your voyage. Maybe you’ve scheduled your exam and have picked up the pace as you move closer to the end goal of certification. I would encourage you to approach this just like any other project implementation at work. Create a study action plan and work through it to prepare for the exam. If you’ve moved through the sojourns outlined and will be taking the exam in the next few weeks, I recommend that you review what to expect on the day of your exam, which is found on the testing center website (www.prometric.com/cbic). Regardless of where you are in the journey, I commend your dedication to the profession and, more importantly, to the public by demonstrating your competency in infection prevention through the validated process of CIC® certification.
Lita Jo Henman, MPH, CIC 2017 CBIC President 12 | SUMMER 2017 | Prevention
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BRIEFS TO KEEP YOU IN-THE-KNOW
APIC 2017 award recipients Carole DeMille Achievement Award STEPHEN STREED, MS, CIC, system director
of epidemiology/infection prevention at Lee Health in Fort Myers, Florida, will be awarded the prestigious Carole DeMille Achievement Award for his innovative contributions and commitment to education in infection control. The award, which will be presented during the opening session at APIC’s 44th Annual Conference in Portland, Oregon, is given annually to an infection preventionist (IP) who best exemplifies the ideals of Carole DeMille, a pioneer in the field of infection prevention. Streed has been active in APIC since joining in the 1970s, serving in numerous leadership capacities at the local and national levels, including on the APIC Board of Directors and on the editorial board for the American Journal of Infection Control. He was among the first group of IPs to become certified in infection prevention and control (IPC) in 1983. Recognizing the increased need for education in the growing field of IPC, he co-founded and taught some of the earliest hospital epidemiology and certification preparation courses ever
offered through APIC and leading academic centers. In addition, he developed courses to teach advanced skills and to reach settings with specific needs such as long-term care. A nationally recognized expert on HAI surveillance, Streed has promoted the use of computers to improve the efficiency of infection prevention data collection since the early 1980s. He also was a member of a multi-society professional group that worked with the CDC to author a pivotal white paper, which was used to inform the creation of the U.S. Department of Health and Human Services’ “National Action Plan to Prevent HAIs.” His research also includes the area of new technologies for improving the cleaning and disinfection of environmental surfaces in healthcare facilities. Streed promotes the profession through teaching, coaching, and mentoring and has consistently supported and encouraged his peers at the local, national, and international level to reach for their potential. He has established the Stephen A. Streed Scholarship in Epidemiology at the University of Iowa College of Public Health. At the community level he mentors high school and college students to enlighten them on public health careers and share his passion for infection prevention. Streed has been honored by his peers locally and nationally throughout his 40-year career.
Distinguished Scientist Award PATRICIA STONE, PHD, RN, FAAN, centen-
nial professor and director of the Center for Health Policy at Columbia University School of Nursing, will receive the Distinguished Scientist Award at APIC’s Annual Conference in Portland, Oregon. The Distinguished Scientist Award is given to individuals who have made outstanding contributions to the science of infection prevention and control, as determined by the APIC Research Committee. Stone will be delivering a lecture when she receives the award, Thursday, June 15, and a session with her Columbia University colleagues on Friday, June 16, on the State of the Art in Nursing Home Infection Prevention. Over the past two decades, Stone has focused her research on the impact of organizational factors and various processes of care on patient safety outcomes and healthcare-associated infections 14 | SUMMER 2017 | Prevention
(HAIs). An expert in cost-effectiveness analysis, she has applied her economic expertise to help quantify the financial and personal costs of HAIs, and ultimately the cost-effectiveness of processes of care that reduce the incidence of infections. She is one of only a few nurse researchers who understands the complexity of conducting such comparative and economic evaluations in the context of preventing HAIs and has been the principal investigator on a number of federal and foundation grants to conduct large-scale, national studies to inform effective healthcare policy and practice. Stone has served on a number of national health policy making committees, and her work has been cited by the U.S. Department of Health and Human Services in the “National Action Plan to Prevent HAIs” and in guidelines developed by the Centers for Disease Control and Prevention. Stone’s work and contributions amply demonstrate her serious and ongoing commitment to advancing implementation science and furthering APIC’s mission to “create a safer world through prevention of infection.”
President’s Distinguished Service Award LINDA DICKEY, RN, MPH, CIC, senior direc-
tor of quality, patient safety, and infection prevention, University of California, Irvine Healthcare, will receive the 2017 President’s Distinguished Service Award at APIC’s Annual Conference. The award is given to an individual whose service within APIC has been judged by peers as exceptional, and who has made major contributions to the profession. A nationally recognized expert on healthcare design, Dickey has been a member of APIC since 1994, and has filled an important role as an ambassador for APIC to other professional organizations that are essential partners for infection preventionists, including the American Society for Healthcare Engineering
(ASHE), the American Society of Heating, Refrigerating and AirConditioning Engineers (ASHRAE), and the Facility Guidelines Institute (FGI). In this capacity, she was influential in the development of a new standard from ASHRAE aimed at mitigating risks of waterborne pathogens. As a member of FGI’s Steering Committee, she ensures that the IP perspective is considered when healthcare facility design and construction guidelines are being developed or revised. She has been recognized for her expertise at the state and national level and has developed numerous tools, checklists and other resources to assist infection preventionists in navigating the sometimes complex and challenging areas of construction and renovation. Dickey serves APIC members as faculty at national, regional, and chapter conferences, and as a contributor to related topics in the APIC Text Online. She has participated in numerous speaking engagements, as well as countless collaborative projects and publications.
Healthcare Administrator Award JODI VANDERPOOL, MBA, LNHA, CPPS, HACP,
system vice president quality operations, St. Luke’s Health System in Boise, Idaho, has been named as the 2017 recipient of the Healthcare Administrator Award. The award, which will be presented at APIC’s Annual Conference, is given annually to a member of a healthcare facility’s executive team who champions infection prevention efforts. Under Vanderpool’s leadership, St. Luke’s focus on quality, patient safety, and infection prevention has significantly increased and become a top priority. She keeps infection prevention front and center with the hospital’s board and administration and has been instrumental in ensuring that the infection prevention department is adequately staffed, and has the resources and education needed to improve the team’s competencies.
2017 APIC GRADUATE STUDENT AWARD
Mary Jo Knobloch, PhD, MPH University of Wisconsin, School of Pharmacy, Social and Administrative Sciences Leadership rounds to reduce healthcareassociated infections: a case study approach
Vanderpool’s support has enabled her infection prevention team to do excellent work and empowered them to share best practices with other facilities. In the area of hand hygiene, she actively assisted in getting a new tool brought on board and hired two part-time employees to coordinate the program, which helped the organization achieve a 90 percent compliance rate in inpatient units in fiscal year 2016. To reduce surgical site infections, she facilitated the development of a general surgery care bundle, which required buy-in and support from leadership and the general surgery group. She advocated at the administration level for a multidisciplinary task force called “Project Zero” to reduce ortho-neuro SSIs, which was so successful that it has since been adopted system-wide and has garnered awards from the state’s quality innovation network. Among the letters written to support her nomination, ‘leadership, dedication, and commitment’ were the most often used words. Her colleagues conveyed that it was a great privilege to experience her support for infection prevention and control on a daily basis.
2017 BLUE RIBBON ABSTRACT AWARDS
Mugdha Golwalkar, MPH Indiana State Department of Health Comparing clinical and epidemiological characteristics of non-B invasive Haemophilus influenzae serotypes in the post-Hib vaccine era Jacob Vinocur, MS, CIC Northern Arizona Healthcare Transmission of Clostridium difficile across multiple healthcare facilities revealed through whole-genome sequencing
2017 IMPLEMENTATION SCIENCE ABSTRACT AWARD
Kathryn Galvin, MS, MT(ASCP)CM, CIC Hartford Healthcare Reduction of catheter associated urinary tract infections (CAUTIs) through a multi-disciplinary approach implementing skill-based validations
(Continued on page 16)
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BRIEFS TO KEEP YOU IN-THE-KNOW 2017 NEW INVESTIGATOR ABSTRACT AWARD
2017 WILLIAM A. RUTALA ABSTRACT AWARD
Marko Predic, BS University of Florida Health Jacksonville Risk factors for carbapenem-resistant Enterobacteriaceae infection
John Rihs, BS Special Pathogens Lab Microbial contamination of heater/cooler units: Mycobacterium chimaera and beyond
2017 BEST INTERNATIONAL ABSTRACT AWARD
The William A. Rutala Abstract Award is supported by a grant from Clorox Healthcare, an APIC Strategic Partner.
Daiane Patricia Cais, MSN Infection Control Team - Hospital Samaritano de São Paulo/Brazil Isolation precautions: active surveillance and multidisciplinary management save costs
2017 HEROES IMPLEMENTATION RESEARCH SCHOLAR AWARDS
Misha Huang, MD Department of Veterans Affairs Barriers and facilitators of procalcitonin implementation to guide antibiotic use Eileen Carter, PhD, RN Columbia University Medical Center Exploring the nurses’ role in antimicrobial stewardship: a multisite qualitative study
2017 APIC/AJIC AWARD FOR PUBLICATION EXCELLENCE
Cori Ofstead, MSPH Ofstead & Associates Persistent contamination on colonoscopes and gastroscopes detected by biologic cultures and rapid indicators despite reprocessing performed in accordance with guidelines Additional author(s): • Harry Wetzler, MD, MSPH • Evan Doyle, BS • Catherine Rocco, MSN, RN, CNOR • Kavel Visrodia, MD • Todd Baron, MD • Pritish Tosh, MD
2017 HEROES OF INFECTION PREVENTION AWARDS
Mary Jo Bellush, MSN, CIC Excela Health Westmoreland Hospital Category: Process and systems improvement Katie Cary, MT(ASCP), CIC Presbyterian/St. Luke’s Medical Center Category: Advocacy and influence Christina Ewers, MSN, BSN Lutheran Medical Center Category: Patient Safety Jamie Swift, BSN, RN, CIC Mountain State Health Alliance Category: Advocacy and influence
(Team) Angela Rupp, MT(ASCP), MS, CIC Ann & Robert H Lurie Children’s Hospital of Chicago Elaine Whaley, MSN, RN, CIC Texas Children’s Hospital Category: Patient Safety Dignity Health Infection Prevention Team Category: Process and systems improvement
The Heroes program is supported by a grant from BD, an APIC Strategic Partner. CHAPTER EXCELLENCE AWARDS
CHAPTER LEADER AWARDS
Member Support (Large) Greater Atlanta Chapter Dallas-Ft. Worth Chapter
Adebisi Adeyeye, DHA, RN, CIC Greater New York Chapter
Synergistic Alliances (Large) Indiana Chapter West Virginia Chapter Clinical and Professional Practice (Large) Northern New Jersey Chapter Clinical and Professional Practice (Small) Western Iowa Chapter Education, Communication, and Information (Large) Minnesota Chapter San Francisco Bay Area Chapter
16 | SUMMER 2017 | Prevention
Donald Chitanda, MPH, CIC Dallas-Ft. Worth Chapter Nancy Christy, MT, MSHA, CIC Washington DC Metro Area Chapter Kathy DiBenedetto, MSN Long Island Chapter Diane Dohm, MT, CIC Badger Chapter Carole Duperre, RN Pine Tree Chapter Juliet Ferrelli, MS, MT(ASCP), CIC, FAPIC Three Rivers Chapter
Annemarie Flood, MPH, BSN, RN, CIC, FAPIC Greater Los Angeles Chapter Alice Hughes, MSPH, MT(ASCP), CIC Mile High Chapter Paula Newman, BSN, CIC Sierra Chapter Sharon Parrillo, BSN, RN, CIC Northern New Jersey Chapter Anne Reeths, MS, RN Northeastern Wisconsin Chapter Mary Thompson, CIC Minnesota Chapter
Prevent HAIs in ambulatory surgery settings with new AHRQ toolkit A NEW TOOLKIT to help surgeons, operating room staff, infection
preventionists (IPs), and other healthcare workers prevent surgical site infections and other surgical complications in ambulatory surgery centers (ASC) is available from the Agency for Healthcare Research and Quality (AHRQ). The Toolkit to Improve Safety in Ambulatory Surgery Centers helps ASCs execute and sustain technical and cultural interventions surrounding the safe surgery checklist, which ASCs should use during each of the three critical perioperative periods for all patients. The toolkit was developed based on the experiences of 665 ASCs that participated in the AHRQ Safety Program for Ambulatory Surgery Centers project, which involved partners including APIC, the Ambulatory Surgery Center Association, and the Institute for Healthcare Improvement. The toolkit incorporates the proven principles and methods of AHRQ’s Comprehensive Unit-based Safety Program (CUSP) with
es It Takam a Te
Everyone in ambulatory surgery centers (ASCs) plays a role in preventing surgical site and other harmful infections.
Surgical site infections are infections that can occur after surgery in the part of the body where the surgery took place.1
Hand hygiene is one of the most important ways to prevent infections. Health care personnel will clean their hands before and after patient care. Other important ways to prevent surgical site and other infections at ASCs are—
Cleaning, Disinfection, and Sterilization • Follow fully the instructions on how to use cleaning and disinfection supplies. • Follow the manufacturers’ and ASC’s instructions for cleaning and disinfecting medical equipment. • Get training each year on high-level disinfection for all the different types of scopes that are reprocessed. • Make sure only highly trained experts perform high-level disinfection and sterilization.
Surgical site infections are—* Dangerous Each year in the U.S., there are about 300,000 surgical site infections. Patients with surgical site infections are 2 to 11 times as likely to die as a result.2
Costly
Environment of Care • Keep the health care environment clean and safe. • Make daily rounds (walk around) in the health care environment to assure cleanliness and patient safety. • Report any environmental care problems as soon as possible so they can be fixed. • Clean hands when moving from a dirty to a clean task on the same patient or after touching the patient or any items in the patient’s environment.
Each year in the U.S., surgical site infections cost between $3.5 million and $1 billion.2
Preventable
Surgical site infections are one of the most common healthcare-associated infections, but most of them are preventable.2 * Because ASCs do not yet report surgical site infection
data, these statistics are based on U.S. hospital data.
Safe Injection Practices
Patients and families should be encouraged to— ▶ ASK staff if they have washed their hands ▶ BE ACTIVELY INVOLVED in care by—— • Avoiding bringing their own medical equipment to the ASC, unless granted special permission to do so • Always cleaning their own hands ▶ CLEARLY SPEAK UP if they have concerns that staff may not be following safe practices or if they observe a safety issue
• Clean hands before handling medications or syringes. • Disinfect the top (rubber septum) of any medication vial with alcohol before piercing it with a sterile needle. • Use a sterile needle and syringe one time on one patient only. • Use an intravenous solution bag and tubing for one patient only. • Prepare medication in clean area, separate from patient care area and away from used items. If medication is used at the bedside, throw it out after it is used on one patient. • Use a single-dose vial of medication whenever possible. • Dedicate a multiuse vial to one patient if medication is drawn up in the patient care area. • Always use a new, sterile needle and new, sterile syringe.
Learn more about infection prevention at ambulatory surgical centers at www.ahrq.gov/haiambsurgery. 1. SHEA, IDSA, AHA, et al. Frequently asked questions about surgical site infections: Patient guide. Accessed April 22, 2016. http://www.shea-online.org/Assets/files/patient%20guides/NNL_SSI.pdf. 2. Anderson DJ, Podgorny K, Berríos-Torres SI, et al. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update. Infect Control Hosp Epidemiol. 2014 Sep;35 Suppl 2:S66-88. PMID: 25376070. doi:10.1086/ S0195941700093267.
guidance, tools, and training materials to support change on the front lines of care. Topics covered in the toolkit include: • Coaching Clinical Teams • Improving Teamwork and Communication • Patient and Family Engagement • Infection Prevention • Endoscopy As part of the project, additional resources were created covering special topics such as endoscopic procedures and hand hygiene. For example, see the infographic below with guidance on preventing infections in endoscopic procedures. The Toolkit to Improve Safety in Ambulatory Surgery Centers is a publicly available resource available on the AHRQ website at www.ahrq.gov/haiambsurgery. Additional AHRQ tools and resources to prevent HAIs are available at www.ahrq.gov/hais.
Preventing Infections in Endoscopic Procedures More than 20 million gastrointestinal (GI) endoscopic procedures are performed annually in the United States. While rare, patients have acquired infections from these procedures due to: • Poor cleaning/disinfection of equipment and/or • Lapses in infection prevention practices and/or • Defective or poorly maintained endoscopic or reprocessing equipment
1 2 3 4 5 6 7 8 9 10 11 12 1314 1516
To help prevent infections, health care professionals in the endoscopy suite should: Verify that ALL staff who perform cleaning and disinfection of GI endoscopes are trained and competent to do so per the manufacturers’ instructions for use (IFU) and facility policy. Have vendors/other expert trainers deliver updated education on the proper cleaning/ disinfection of scopes.
Ensure appropriate personal protective equipment is worn at all times and that the reprocessing room has appropriate ventilation.
Preclean endoscopes in the procedure room immediately after use to remove debris. Do not allow debris to dry.
Transport the soiled GI endoscopes (after the precleaning) to a designated reprocessing area in a manner to prevent contamination of other equipment or surrounds (e.g., in a closed container or cart that is leak-proof, puncture-resistant, and labeled “biohazard”).
Perform leak testing before manual cleaning to ensure the scope does not leak by using a wet or dry process according to IFUs. If using a wet process, attach the leak test device before placing the scope into clean water.
Meticulously manually clean the disassembled scope using sponges/endoscope specific brushes per manufacturer’s IFU. Brush all channels with correctly sized brushes per IFU. For each scope, use a freshly prepared detergent solution and type of water (varies) recommended by IFU to help prevent cross contamination.
Submerge scope during cleaning to reduce aerosolization into the air. Completely rinse scope after cleaning to remove all residue. Dry exterior of scope with lint-free cloth.
Purge all channels with regulated instrument air. Inspect scope visually with lighted magnification after cleaning and before high-level disinfection for possible re-cleaning or repair.
Test high-level disinfection solution for efficacy with manufacturer-specific test strip before each cycle and document results.
Perform high-level disinfection of scopes after thorough cleaning ensuring and documenting correct time and temperature. Ensure use of proper connectors between scope and automatic endoscope reprocessor (AER). Submerge scope either manually or in AER during all cycles of processing.
If risk assessment indicates that alcohol flushing and forced air drying are desirable, follow IFUs for the specific AER, endoscope model, and channel.
Verify and/or document entire cycle completed as programmed, including rinsing and drying, prior to removing scope from AER. If cycle is interrupted, repeat entire cycle.
Identify scope as processed/ ready to use and store scopes vertically (or horizontally in drying cabinet per IFUs) with all valves open and removable parts detached but stored with scope; ensure scopes are not touching cabinet or each other.
Ensure the facility has a written policy regarding storage time before endoscopes need to be reprocessed again.
Encourage patients and families to discuss with their physician the benefits, risks, and alternatives of endoscopic procedures; reinforce importance of asking their physician what to expect after the procedure and when to seek medical attention.
Empower patients and families to insist that all team members wash their hands before providing care; encourage patients and families to perform hand hygiene as well.
References
• Guideline for Processing Flexible Endoscopes. In: Guideline for Perioperative Practice. Denver,CO:AORN,Inc;2016:675-758. • Society of Gastroenterology Nurses and Associates. Standards of Infection Prevention in Reprocessing Flexible Gastrointestinal Endoscopes. 2016: http:// www.sgna.org/Portals/0/Standards%20for%20reprocessing%20endoscopes_FINAL.pdf. • ANSI/AAMI ST79:2015 Flexible and Semi-Rigid Endoscope Processing in Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2015. • Multi-Society Guideline for Reprocessing Flexible Gastrointestinal Endoscopes. Gastrointestinal Endoscopy. 2011;73(6):1075-1084. PMID: 21628008.
AHRQ Safety Program for Ambulatory Surgery AHRQ Pub. No. 16(17)-0019-3-EF May 2017
AHRQ Safety Program for Ambulatory Surgery AHRQ Pub No. 16(17)-0019-03-EF May 2017
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BRIEFS TO KEEP YOU IN-THE-KNOW
APIC has free resources for consumers and healthcare professionals It’s 4 p.m. on a Friday, and you’re running a nursing orientation first thing Monday. Where can you get some good handouts to support your training? Or, the communications department calls and says they have space to fill in the hospital newsletter, and do you have a short infection prevention article you’d like to submit, by the end of the day!? Wouldn’t it be great to find something that’s already been developed so you don’t have to reinvent the wheel? APIC HAS NO SHORTAGE OF FREE RESOURCES to
help educate patients and staff alike, but many members are unaware these resources exist. Headquarters staff and the Communications Committee work hard to create these materials so you don’t have to! Here’s a quick tutorial to help you locate information to download, print, and share. Access these tools on the “Consumer” tab at www.apic.org. MONTHLY ALERTS FOR CONSUMERS
All downloadable materials from Infection Prevention and You are print-ready and free.
Once (or twice) a month, APIC creates an alert targeted to consumers. These short articles provide helpful tips on staying infection-free, in and out of healthcare settings. Download the printer-friendly version and share them with your facilities, families, and friends. Feel free to cut and paste into your organization’s newsletters, etc. www.apic.org/
For-Consumers/Monthly-alerts-for-consumers INFECTION PREVENTION AND YOU WEBSITES
APIC’s multiyear awareness campaign features tailored websites for both consumers (www.apic.org/patients) and non-IP healthcare professionals (www.apic.org/professionals). These websites are designed to clearly and simply convey important infection prevention information. Information includes infection prevention basics, preventing infection in various settings of care, bugs and outbreaks, and preventing infection in the community. The APIC Communications Committee works 18 | SUMMER 2017 | Prevention
diligently throughout the year to update these pages with new information and tools you can use for both consumer and healthcare professional audiences. INFOGRAPHIC POSTERS AND DOWNLOADABLE MATERIALS
All downloadable materials from Infection Prevention and You are print-ready and free. Intended for hospitals, home care, longterm care, and outpatient care settings for the consumer and non-IP audiences, they clearly explain infection prevention topics in visual formats. Download, print, post, and share these infection prevention infographic posters with your infection prevention team, healthcare providers, and patients and families. Place them in public patient care areas. Available infographics include: “Break the Chain of Infection,” “Clean Hands Stop Germs,” the “Do’s and Don’ts” series, “What are HAIs,” “The ABC’s of Antibiotics,” and more! Some posters are available in Spanish, Italian, French, or Portuguese. CONNECT WITH US ON SOCIAL MEDIA. WE WANT TO HEAR FROM YOU!
Like us on Facebook (facebook.com/ APICInfectionPreventionandYou) and follow us on Twitter (twitter.com/APIC) for the most
up-to-date infection prevention resources. If you have any questions, please email Julie Blechman at jblechman@apic.org.
SAVE THE DATE! During the third week of October, infection preventionists (IPs) take time out of their already busy schedules to celebrate International Infection Prevention Week (IIPW) to raise awareness of the role infection prevention plays in improving patient safety. Mark your calendars now for IIPW, October 15-21, 2017!
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BRIEFS TO KEEP YOU IN-THE-KNOW
APIC MegaSurvey provides foundational data about the infection prevention profession RESULTS FROM THE APIC MegaSurvey, the
largest-ever survey of the infection prevention workforce, describe the core activities and competencies of IPs. The first in a series of articles based on the survey findings was recently published in the American Journal of Infection Control (AJIC). APIC undertook the MegaSurvey in 2015 to create a baseline of data to answer critical questions related to practice and competencies, organizational structure and staffing, compensation, and the demographics of IPs. Results from the APIC MegaSurvey will allow for a better understanding of IP roles and responsibilities by facility type, years of experience, professional development,
and current position, and will provide insight into opportunities for professional development. Of 13,050 eligible APIC members, 4,078 (31 percent) took the online survey in midto late- 2015. Among the key findings: • The majority of respondents (81 percent) have a primary discipline of nursing. • Two-thirds of IPs (66.2 percent) currently work in acute care settings; the remaining portion work in long-term care, ambulatory, outpatient, and other care settings. • Surveillance and investigation were reported as the most frequent activities by IPs, accounting for a quarter (25.4 percent) of infection prevention efforts.
• 43 percent of respondents are certified in infection prevention and control (CIC®). • 37.7 percent are not certified, but indicate they plan to sit for certification in the future. • Individuals with current CIC certification had higher base compensation than those without current certification. Forthcoming articles, developed by the APIC Research Committee, will be published in AJIC. In addition, in-depth reports based on the data, such as the Compensation Report, Organizational Structure Report, and Practices and Competencies Report, are available in the APIC Store located on the website: http://www.apic.org/APICStore/ Products.
NEW MEGASURVEY DATA REPORTS NOW AVAILABLE GET THE LATEST data on IP practices and competencies, organizational structure, and compensation, in reports from the APIC MegaSurvey, the largest survey of the IP workforce. These digital reports may be ordered individually or as a bundle.
The Practices and Competencies Report allows organizations and individuals to compare key aspects of their roles and responsibilities to those of their peers in eight key areas of IP competency, including identification of infectious disease processes, surveillance and epidemiologic investigations, and environment of care.
20 | SUMMER 2017 | Prevention
The Organizational Structure Report provides detailed information about infection prevention and control (IPC) programs in healthcare facilities including acute care, ambulatory surgery centers, long-term care, dialysis centers, Veterans Affairs, behavioral health, military, and others. Results are broken out by primary responsibility of the IP.
The Compensation Report (made available to APIC members in 2016) allows you to benchmark compensation levels and is a useful tool during the recruitment process. All three MegaSurvey reports are now available for purchase at www.apic.org/APICstore/Products.
Infection preventionists (IPs) are experts in identifying sources of infections and limiting their transmission in healthcare facilities.
The Association for Professionals in Infection Control and Epidemiology (APIC) conducted the MegaSurvey in 2015 to collect baseline data related to practice and competencies, organizational structure and staffing, compensation, and the demographics of infection preventionists (IPs).1
1 Landers T, Davis J, Crist K, Malik C. APIC MegaSurvey; Methodology and overview. Am J Infect Control 2017; Article in press.
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BRIEFS TO KEEP YOU IN-THE-KNOW
Introducing the APIC® Program of Distinction IN SEPTEMBER 2016, the APIC Board of
Directors approved the launch of an exciting, landmark program for APIC with the potential to dramatically impact the field of infection prevention and control. The APIC® Program of Distinction, which will launch at the 2017 APIC Annual Conference, is a recognition program that awards a designation of excellence to acute care facilities for infection prevention and control (IPC) programs that meet a set of high-level standards established by APIC. Over the past two years, the evaluation criteria and program structure were developed and vetted by seasoned infection preventionists (IPs), including several
22 | SUMMER 2017 | Prevention 865507_Editorial.indd 1
past presidents of APIC. Similar to the Magnet Recognition Program® and the Beacon Award for Excellence™, the APIC® Program of Distinction is positioned to be the highest level of recognition for IPC Programs, granted by APIC, the leading association for infection preventionists in the country. Facilities that earn the APIC® Program of Distinction designation will receive a hard copy award for their facility’s “recognition wall,” and a digital logo for marketing purposes. APIC will also recognize award winners with communications to state health departments, relevant government agencies, and accreditation organizations, such as The Joint Commission and DNV GL - Healthcare. Interested facilities can complete an application, which is available on
APIC Consulting Services’ website: www.apicconsulting.com. Facilities passing the application phase will move to an onsite assessment with CIC®-certified consultants. During the onsite assessment, the consultants will offer training on best practices to the IPC staff in real time. Final determination for the award will be made after the onsite assessment by a separate team of CIC®-certified IPs. If a facility does not pass the onsite evaluation, a list of identified deficiencies and recommendations is provided. The recognition award is current for a period of three years. The next issue of Prevention Strategist will include more detailed information about the APIC® Program of Distinction. For additional information, please contact Leslie Kretzu, executive director of APIC Consulting Services, at lkretzu@apic.org.
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CIC PROFILE
Meet a CIC
EDINA FREDELL, MPH, MT(ASCP), CIC Infection Preventionist Kaiser Permanente Downey, California
Q:
WHAT INSPIRED YOU TO BECOME AN INFECTION PREVENTIONIST (IP)?
My greatest inspiration to become an infection preventionist (IP) was my change in perspective. I was no longer satisfied helping patients one culture at a time. I wanted to positively affect populations of patients at a time. The “aha” moment came when I stumbled upon the APIC website one day, early on in my MPH program. From the website, I learned two life-changing facts: (1) medical technologists can become infection preventionists, and (2) they are eligible for the certification exam. That was it—infection prevention was how I was going to achieve what I wanted professionally.
Q: Q:
HOW LONG HAVE YOU BEEN AN IP? I’ve been an infection preventionist for two and a half years.
WHY IS MAINTAINING BOARD CERTIFICATION IN INFECTION PREVENTION AND CONTROL (CIC) IMPORTANT TO YOU?
Maintaining my CIC is important to me because it represents the commitment to learning and ongoing education that is at the center of infection prevention practice.
Q:
HOW DID YOU PREPARE FOR THE CIC EXAM? WHAT HELPED?
I prepared for the CIC exam first, by reading the CBIC Candidate Handbook cover to cover. Then, I set my exam date just about 90 days out and calculated the number of pages of the APIC Text I was going to read per day, and worked out how
many days I wanted to just take the practice exams in the APIC Certification Study Guide. I mapped my plan on a calendar to keep track of my progress. I read at night, studied on my days off and on weekends, and listened to Mozart almost exclusively for a week or two before my exam. Also, I paid attention to the test-taking advice the handbook and study guide had to offer.
Q:
IN WHAT WAYS HAS YOUR CIC BENEFITED YOU?
Q:
IN WHAT WAYS HAS YOUR CIC BENEFITED YOUR FACILITY?
Earning my CIC immediately added value to me in my role as a novice IP. My coworkers, friends, and colleagues from my APIC chapter recognized me for the achievement.
Just studying for the exam benefited my facility because it enabled me to answer the random environment of care (EOC) and HVAC-related questions that I would get on the phone. I became a more active participant in EOC rounds, which in turn made the rounds more meaningful to me.
Q:
CAN YOU PLEASE SHARE SOME STUDY TIPS FOR OTHERS WHO WISH TO MAINTAIN OR PURSUE THEIR CIC DESIGNATION?
Read the APIC Text, the CBIC Candidate Handbook, and the APIC Certification Study Guide. Take all the practice exams you can. Look up what you don’t know, and try to understand the rationale behind the correct answers. Always verify any answer you find questionable. w w w.apic.org | 25
CAPITOL COMMENTS
Under a new administration and a new Congress, infection prevention needs to continue BY RICH CAPPARELL, NANCY HAILPERN, AND LISA TOMLINSON
“You have to become involved to make an impact. No one is impressed with the won/loss record of the referee.” —Sergeant John Noble Holcomb, Medal of Honor recipient
THE TRUMP ADMINISTRATION and the 115th
Congress are well underway, and Washington is experiencing a little more than the usual chaos that comes with the quadrennial change in government leadership. Besides confirmation of nominees for a Supreme Court justice and key executive branch positions, other top priorities currently in progress in the legislative and executive branches include repeal of the Affordable Care Act (ACA), tax reform, and a reduction in government regulation. EXECUTIVE ORDERS AND REGULATIONS
As he promised during his presidential campaign, some of President Trump’s first actions after taking office included executive orders (EOs) relating to review and reform of existing regulations. The stated goals of these EOs include reforming, revising, repealing, and reducing regulations; controlling regulatory costs; and reorganizing the executive branch of the federal government. The president’s first act was to sign an EO allowing heads of federal agencies to delay implementation of provisions of the ACA that would impose a fiscal burden on governments, healthcare providers, patients, and any other party impacted by the law. HOW DO EXECUTIVE ORDERS IMPACT INFECTION PREVENTION?
The short answer? Probably not much. As of press time, no healthcare-associated infection (HAI) reporting requirements are under consideration for repeal. 26 | SUMMER 2017 | Prevention
Federal HAI reporting regulations were required by the ACA. The U.S. House of Representatives has voted more than 50 times to repeal sections of the ACA, without success. The most recent effort, the American Health Care Act of 2017 (AHCA), passed the House and is pending in the Senate. However, none of these efforts included repeal of the section of the ACA linking Medicare payment to quality outcomes—the very section that provided the authority for all federal HAI reporting requirements. Programs to reduce hospital readmissions and hospital-acquired conditions were also implemented under this section of the ACA. Some EOs, however, may impact infection prevention efforts. As of press time, the administration has not yet nominated appointees to fill more than 500 federal agency positions. It is expected that many of these positions will not be filled as part of efforts to reorganize and reduce the size of the executive branch. Although this does not have an immediate and direct impact on infection preventionists (IPs), it will eventually be felt as programs without lead staff struggle to meet their missions. EOs and recent legislation are also targeting regulations that impose worker and environmental safety requirements. This could potentially impact OSHA regulations such as the Respiratory Protection Standard, Bloodborne Pathogens Standard, and the expected Infectious Diseases (ID) Standard, as well as regulations related to transportation of hazardous waste. Since repealing existing regulations requires a similar process to implementing new regulations, current requirements are not likely to change any time soon, and APIC would likely have an opportunity to comment on the infection control implications of any such proposal. However, implementation of new regulations, like the OSHA ID Standard, may be delayed. As always, APIC will keep a close watch on all federal government-imposed requirements on infection prevention practice and
TYPES OF FEDERAL REQUIREMENTS • Laws o Example: The Affordable Care Act (ACA). o Enacted by Congress and can only be repealed by other enacted laws. o Laws generally contain a broad outline of the intended requirement, but the operational details are left to the agencies responsible for implementation. • Regulations (also known as rules) o Written by federal agencies. o Drafts (proposed rules) are made available for public comment, and comments are taken into account when the agency writes the final rule. o Regulations may be required by laws (such as HAI reporting requirements) or may be initiated under an agency’s existing authority (such as an OSHA infectious diseases standard). o Repeal of a regulation typically requires a similar process to implementation of a regulation. The repeal or replacement rule must be published for public comment before it is published as a final rule. o Although it occurs less often, regulations can also be temporarily halted by an annual funding bill that specifies no funds may be used to carry out the regulation. That lasts for the year to which the funding bill applies. o Regulations that are required by laws can only be revoked by a repeal of the authorizing law, or halting funds to carry them out. • Executive Orders (EOs) o Issued by the president. o Any EO may be repealed by another president issuing another EO. o Although EOs cannot repeal laws or regulations, they can weaken them by providing new instructions to the implementing agencies.
keep members informed about any changes that will impact their work. LEGISLATIVE ENVIRONMENT: PREVENTION AND PUBLIC HEALTH FUND IS IN DANGER
Repeal of the ACA has long topped the congressional agenda. Within several weeks of the new Congress convening, the House of Representatives unveiled the AHCA. Much of the AHCA focuses on the repeal of ACA taxes and fees, as well as insurance mandates. However, the legislation would also defund some programs created under the ACA. One important program that would be discontinued is the Prevention and Public Health Fund (PPHF). The purpose of the PPHF is to provide expanded
“Since
repealing existing regulations requires a similar process to implementing new regulations, current requirements are not likely to change any time soon, and APIC would likely have an opportunity to comment on the infection control implications of any such proposal.”
w w w.apic.org | 27
CAPITOL COMMENTS and sustained national investments in prevention and public health to improve health outcomes, and to enhance healthcare quality. Since its inception, the PPHF has provided approximately 12 percent of the funding for Centers for Disease Control and Prevention (CDC) programs, including three major areas of infection prevention efforts: • Epidemiolog y and Laboratory Capacity Program: The PPHF has
provided funding to enhance state, local, and territorial grantee capacity for detecting and responding to infectious diseases and other public health threats. • HAIs: The PPHF has invested in public health infrastructure for HAI activities related to monitoring, response, and prevention across all healthcare settings, as well as accelerating electronic reporting to detect HAIs at the state level.
Enhanced Infection Prevention using Ultraviolet Light
• Immunizations: The PPHF is a primary funding source to improve the public health immunization infrastructure to maintain and increase vaccine coverage among children, adolescents, and adults. APIC will continue to work with coalition partners to combat efforts to cut the PPHF and inform members of Congress of the importance of this funding. In addition to the proposed PPHF cuts, the White House has released its FY 2018 “skinny budget,” so called because it would cut non-defense discretionary spending by $54 billion. This includes cutting or eliminating funding to programs that would affect infection prevention in the CDC, the Agency for Healthcare Research and Quality, and the National Institutes of Health. Although presidential budgets are rarely accepted as written, they are considered an important starting point and set the tone for the Congressional appropriations process. Members of Congress on both sides of the aisle have already distanced themselves from the proposed budget. However, it is clear that Congress is looking for places to reduce spending. YOUR VOICE MATTERS
With so many constituencies affected by these cuts, it will be crucial for IPs to have their voice heard in Congress. APIC members are encouraged to visit the Public Policy page of the APIC website (http://
www.apic.org/Advocacy/Government-Affairsand-Advocacy) to learn about ways to be
The Torch for Rooms
an advocate for infection prevention and patient safety. Advocacy could be as simple as sending a pre-written email to your members of Congress or meeting with your legislators, using the Voice for Infection Prevention Toolkit (http://www.apic.org/ Advocacy/advocacy-toolkit) as a planning guide. The method of contacting your members of Congress is not important, but the contact is. Making sure legislators have all the facts before they vote is the only way to sustain funding for infection prevention priorities, and IPs are the best ones to provide this information. When it comes to funding the government, it is true that “the squeaky wheel gets the grease.” Please act now to ensure that infection prevention and control efforts remain high priorities for government funding.
The Lantern for EMS
Infection Control from A to UV www.clordisys.com
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| Prevention
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INFECTION PREVENTION LEADERSHIP
Jean Parret JEAN PARRET, RN, a founder, lifetime member, and the ninth APIC president, continues
to inspire today’s infection preventionists (IP) to “reach for the stars.” Over the past 40+ years, Jean has organized, taught, encouraged, mentored, and advised infection prevention and control professionals in order to advance APIC’s mission locally and nationally, as well as the field of infection prevention at large. Jean was instrumental in the development of the APIC San Joaquin chapter, as well as a number of other local chapters, and remains a living infection prevention legend and source of inspiration. We asked Jean to reflect on her years of infection prevention experience to see what advice she has to offer to the 21st century infection preventionist for advancing the role, and the field, into 2020 and beyond.
Q:
What does leadership mean to you?
Q:
What is your leadership style?
Q:
How did your experience as APIC president translate to your work as an infection preventionist?
Q:
What did you learn during your APIC volunteer experience that you were able to apply to your career?
Q:
What were the defining moments of your career?
Leadership is assessing the situation, setting goals, and establishing a strategy to accomplish goals. Then it involves delegating the necessary steps to be taken to accomplish those goals to one or more people.
“I feel like a proud grandparent as I watch the progress that my ‘children’ have made and how far we have come.”
I took more of a hands-off approach to leadership. I never had more than one person reporting to me, but as I taught and oriented her to what her responsibilities were, I didn’t hover over her and check each decision, but allowed her to plan her own workload. It was a successful partnership.
Prior to my being president, I was the only IP in my area, which consisted of 6 to 12 hospitals. I called the administrators in other hospitals and established a time for several employees to get together and discuss infection control. As I learned something, I shared the information. Soon, other hospitals assigned an infection control nurse, because they saw the benefit of doing so. This interest in infection prevention drove us to petition APIC to form a local chapter, and we became San Joaquin Valley Chapter 19.
I learned at that time, rather than ask the administrator if I could visit another hospital for an infection control meeting, I just told them I was going and would be gone for three hours. They respected my initiative (I think). Another thing I learned, or rather started doing, was upon my return from attending an APIC Annual Conference, I wrote a thank you note to the administrator and shared tidbits that I had learned that would be beneficial to various doctors and department heads. Then I copied them on the letter and, in the same note, announced the date of the next conference and asked for permission to attend. That seemed to work quite well. When I began my career, there were no guidelines, no patterns to follow. I married, moved to a new city, left the VA Hospital, and took a new job in a community hospital. None of the staff welcomed me. They were suspicious of me and my job, and told me, “When you are ready to work, we really need nurses at this time.” I drank a lot of coffee, making rounds and meeting department heads, reading everything I thought would help w w w.apic.org | 31
INFECTION PREVENTION LEADERSHIP “You learn from all those with whom you work. I learned so much from so many of the past presidents; and to name just a few, Pat Lynch, Geo Counts, Betty Bolyard, Linda McDonald, Terrie Lee, Deanie Lancaster, and Barb Soule.”
me, and relied on my experience as an operating room nurse to guide my decisions. While I was attending an APIC conference in Houston, several of us took a side trip to Galveston and, while en route, I was encouraged to run for the Board, and I did. I was elected as the last vice president. During that term I served as chairman of the Local Chapters Committee and was used to expand our number of chapters. As I got acquainted with key practitioners (as many were called then), it really was a turning point in my career. And, as I tend to do, when I learned something new, I was driven to share with all of my chapter members. Perhaps my program was not developing fast enough, but I wanted everybody to keep up with what I learned. Also, I spent time writing my “Infection Control Manual” because there was nothing written to assist us, so many used my manual as a pattern.
Q:
You learn from all those with whom you work. I learned so much from so many of the past presidents; and to name just a few, Pat Lynch, Geo Counts, Betty Bolyard, Linda McDonald, Terrie Lee, Deanie Lancaster, and Barb Soule.
Q:
Who helped you along the leadership journey?
They are too numerous to list. Self-starters are attracted to infection prevention and control.
Test To protect
What else is important?
When Chapter 19 was about two years old, we used a product of the APIC Education Committee to hold a two-and-ahalf day conference, so all we had to do was fill in the slots with speakers, which we did. We had challenges, which we overcame, and it occurred to me that other chapters were hosting conferences/seminars and we were competing for attendance, so we needed to meet and compare schedules. I proceeded to invite the presidents and another representative from each of the other four or five chapters to Fresno for a three-hour meeting, which led to the birth of the California APIC Coordinating Council and, ultimately, CACC. That was 38 years ago!
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APIC CONSULTANT CORNER
Care setting focus: Ambulatory surgery centers Q & A WITH LINDA MILLER, RN, CIC
“Any type of clinic, or ambulatory setting, where invasive procedures are performed would benefit from another set of eyes observing the overall ‘culture’ of a center and offering an objective perspective.”
1.
Please provide a brief bio of yourself and your work as an infection preventionist and consultant for APIC Consulting Services.
2.
ver the past year, you have worked with a system of ambulatory O surgery centers (ASC) for APIC Consulting Services; what was your role as the consultant?
I am a registered nurse (RN) and a certified infection preventionist (IP) of 19 years, currently working at Walnut Hill Medical Center in Dallas, a relatively new start-up hospital where I develop and maintain oversight of the infection prevention, employee health, and clinical education departments. As an APIC consultant, I have presented infection prevention and control (IPC) education across the state of Texas, and I’ve also been a member of the APIC Education Committee, and part of the Education for the Prevention of Infection (EPI®) faculty since 2006. I served as section editor for the 2009 APIC Text, and provided peer review and content development for other educational programs for CiNet Healthcare Learning. I have presented multiple abstracts and programs at annual APIC and SHEA conferences, APIC chapter conferences, Texas Society of Infection Control & Prevention (TSICP), Oklahoma Epidemiologists & Preventionists in Infection Control (EPIC), and Premier, Inc.
There are 14 centers within this corporation’s North Texas division. There was a vision to obtain a formal assessment of each center and to standardize practices throughout their division. My role was to lead this effort—the first initiative of its kind for this corporation.
3.
In your consulting role, what type of work did you perform for the client?
Our initial meeting with those responsible for IPC within their facilities revealed an overall desire to know that they were doing the right thing. Most had no formal training in infection prevention, but all shared a respect for its importance and the drive to make any improvements necessary. The scope of the project included on-site assessments, document review, a comprehensive gap analysis, and an educational program. The project continues to develop the knowledge base of the IPs and standardize their documents and practices. Based on the support of and participation in this initiative, the decision has been made to create an IPC coordinator role for the North Texas Division.
4.
an you explain a little more about your onsite assessment work and C system-level consulting support?
After initial telephone consultations with each facility for basic information gathering, such as the number of operating rooms, types of services provided, and accrediting w w w.apic.org | 35
APIC CONSULTANT CORNER
“Attendees of the two-day course included nurses responsible for infection prevention, practicing surgical nurses, quality coordinators, directors of nursing, and even some facility administrators.”
organization, I conducted site visits. During the visit, a full tour was provided with focus on sterilization processes, patient flow, medication management, cleaning and disinfection, and aseptic practices. In addition to the site visits, a documents review was performed for each facility that included IPC plans, policies, checklists, program evaluations, and reports. Once both the site visit and document review were completed, a comprehensive gap analysis was provided to the division quality leaders and to each facility.
5.
uring your work, you provided D a customized ASC training course; what did you do to customize it to the needs of the system?
With little formalized training in infection prevention for those directly responsible for the programs, it was paramount to start with some of the basics: program development, regulatory and accrediting standards, goal development, integration of facility risk assessments, and epidemiology of infectious diseases. Modules from the APIC Academy ASC 101 and 102 courses were reviewed and chosen. The modules were thorough, well written, and comprehensive; little revision was necessary. Only the addition of some state requirements were made, as all these centers are located in Texas. I also provided a strong focus on cleaning, disinfection and sterilization, and challenges in the perioperative setting; and outbreak recognition, investigation, and mitigation. The final day concluded with an exercise in recognizing and addressing breaches in infection prevention practices and how to be a change agent within their facilities. Attendees of the two-day course included nurses responsible for infection prevention, practicing surgical nurses, quality coordinators, directors of nursing, and even some facility administrators. The corporation did a great job of jazzing up the course with catered breakfasts and lunches as well as lots of company swag door prizes for the attendees!
6.
hat were some of W the challenges?
Many of the facilities had appointed someone as responsible for infection
36 | SUMMER 2017 | Prevention
prevention in addition to a current role, and most of these individuals had sought some online training through APIC, but they lacked a cohesive, formalized process for staff development. Their overwhelming response to this initiative was quite positive as they all agreed that they didn’t know what they didn’t know! The knowledge required to do an adequate job in infection prevention is vast, and they wanted to learn it all. They had multiple standard tools, such as risk assessment templates and policy guidelines, but were unsure how to put it all together and how to make it work for them. I took the best of their plans and assessments, and developed some templates and tools for them. They also were operating in silos without support from each other. The class was a perfect opportunity for interacting and developing support systems and learning networks. The momentum we built with the class will continue as we develop the division coordinator role and continue to promote interaction with quarterly meetings and educational offerings.
7.
hat type of ambulatory client W do you think would benefit from a consultant interim IP?
With invasive procedures now being performed across a vast landscape of venues, there is a distinct need for consistency and oversight of processes such as sterilization and medication administration. Any type of clinic, or ambulatory setting, where invasive procedures are performed would benefit from another set of eyes observing the overall “culture” of a center and offering an objective perspective. Staff tend to cease noticing things like skull caps or dangling earrings, masks worn inconsistently, or multiple doses of medication drawn from a single-use vial to avoid waste and save money. Situations where, “it’s the way it’s always been” and “we aren’t having a problem” lead to a perception that rocking the boat and insisting on change is not necessary until there is a problem. My answer to that is, why wait for a problem to arise? If procedures are being performed, there is an obligation to make it as safe for the patient as possible. It is, after all, about the patient.
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PREVENTION IN ACTION
MY BUGABOO
Food for thought:
Listeria monocytogenes BY IRENA KENNELEY, PhD, RN, CNE, CIC, FAPIC
GREETINGS FELLOW INFECTION PREVENTIONISTS! THE SCIENCE OF infectious diseases involves hundreds of bacteria, viruses, fungi, and protozoa. The amount of information available about microbial organisms poses a special problem to infection preventionists (IPs). Obviously, the impact of microbial disease cannot be overstated. Traditionally, the teaching of microbiology has been based mostly on memorization of facts (the “bug parade”). Too much information makes it difficult to tease out what is important and directly applicable to practice. This quarter’s My Bugaboo column features information about the human pathogen Listeria monocytogenes. The intention is to convey succinct information to busy IPs for common etiologic agents of healthcare-associated infections (HAIs). Please feel free to contact me with questions, suggestions, and comments at irena@case.edu.
OVERVIEW
The genus Listeria consists of seven known species, with Listeria monocytogenes (L. monocytogenes) identified as the only human pathogen. Listeria are short grampositive bacilli and have been mistaken for Streptococcus pneumoniae on the gram stain.1 L. monocytogenes bacteria are commonly found in soil, dust, water, sewage, and unpasteurized cheeses such as brie, mozzarella, and 38 | SUMMER 2017 | Prevention
blue cheese, as well as uncooked vegetables. These bacteria most commonly enter the body through contaminated food or water.1 SIGNIFICANCE AND RISK FACTORS
The Centers for Disease Control and Prevention (CDC) estimates that Listeria is the third leading cause of death from foodborne illness, or food poisoning, in the United States. An estimated 1,600 people get sick from
Listeria each year, and about 260 die.2 Foods contaminated with L. monocytogenes can cause outbreaks of meningitis. Meningitis caused by this bacteria occurs most often in newborns, older adults, and people with long-term illnesses or impaired cell-mediated immunity. Each year, about 10 percent of cases of bacterial meningitis in the United States are caused by L. monocytogenes.1 Meningitis is a serious illness, causing death in some cases. Listeriosis
◊ Listeria can hide unnoticed in the equipment or appliances where food is prepared, including in factories and grocery stores.
and poultry products by following USDA guidance. ◊ Having a robust public health system that provides the tools and resources needed to promote food safety. ◊ Learning more about which polices and practices work best.
Detecting more outbreaks points the way to prevention
Faster detection and response saves lives and protects people
Number of infections per million people
Outbreaks from Listeria in the 1990’s traced to hot dogs, and later to deli meats, led to changes that made processed meats safer and reduced the number of such outbreaks. But, Listeria infection rates have not gone down since 2001.
9
Listeria Outbreaks
1988: Single deadly case of Listeria linked to hot dog… New laws and industry changes
8 7
Days from outbreak detection to first public warning
New technology (PulseNet) detects more outbreaks, disease goes down
5
Cantaloupe
1985
2011
Progress needed to meet the 2020 goal, FSMA enacted in 2011
Progress stalls, outbreaks continue
6
Soft Cheese
4 3
31
2
7
1 0 1990 2
1995
2000
2005
2010
2015
2020
SOURCES: New England Journal of Medicine, 1988; Morbidity and Mortality Weekly Report, 2011
SOURCES: JAMA, 1995; CDC, 2012
is food poisoning caused by eating foods contaminated with the L. monocytogenes bacterium. In pregnant women, the infection can result in miscarriage, premature delivery, serious infection of the newborn, or even stillbirth.1 There have been cases of listeriosis that were hospital-acquired; however, almost all of the reported cases were in the immunocompromised populations. No clustering of cases in time or place occurred, and no case had an obvious source for hospital acquisition of listeriosis. Because the incubation period of listeriosis is long (11-70 days) and fecal carriage not uncommon (5-10 percent), colonization could have been acquired before hospitalization and infection developed in the hospital, possibly even triggered by increased immunosuppression. Another possible explanation is consumption of contaminated food brought in from sources outside the hospital.1-4
Year
2016
2015
EPIDEMIOLOGY
Listeriosis is associated with the consumption of contaminated food products or through transplacental spread from mother to neonate. There are sporadic cases and epidemics reported throughout the year, with more cases occurring during the warmer months. Neonatal infections can be severe, including bacteremia, meningitis, and meningoencephalitis. Disease symptoms in healthy adults include a mild influenza-like illness; however, progression of listeriosis disease can develop into primary bacteremia and meningitis in high-risk groups.1-3 There are 12 known serotypes of L. monocytogenes (1/2a, 1/2b, 1/2c, 3a, 3b, 3c, 4a, 4b, 4c, 4d, 4e, and 7), three of which (1/2a, 1/2b, and 4b) cause 95 percent of human illness; serotype 4b is most commonly associated with outbreaks. The table to the right lists recent multistate outbreaks reported to the CDC from the following contaminated food sources:4-11
2014
Contaminated Food Product
Related Severe Outcomes
Frozen vegetables
9 hospitalized 1 death
Raw milk
2 hospitalized 1 death
Packaged salads
19 hospitalized 1 death
Soft cheeses
28 hospitalized 6 pregnancy-related 1 fetal loss 3 deaths
Ice cream
10 hospitalized 3 deaths
Caramel apples
34 hospitalized 11 pregnancy-related 1 fetal loss 7 deaths
Bean sprouts
5 hospitalized 2 deaths
Cheese
4 hospitalized 3 pregnancy-related 1 fetal loss 1 death w w w.apic.org | 39
PREVENTION IN ACTION
Who has a higher risk of getting Listeria food poisoning? Lessons from Listeria outbreaks: Food poisoning can happen to anyone. Each year, about 48 million people in the US (1 in 6) get sick from eating contaminated food. It can be especially dangerous for pregnant women and their newborns; older adults; and people with immune systems weakened by cancer, cancer treatments, or other serious conditions (like diabetes, kidney failure, liver disease, and HIV/AIDS). Listeria is a prime example of how germs that contaminate food can cause sickness and death in these groups.
Pregnant women, fetuses, and newborn infants
People with weakened immune systems
Listeria can pass from pregnant women to their fetuses and newborns. It can cause miscarriages, stillbirths, and newborn deaths.
Listeria can spread through the bloodstream to cause meningitis, and often kills. The weaker your immune system, the greater the risk. Contaminated celery LISTERIA OUTBREAK: Pre-cut celery
Chancy cheese
in chicken salad served at hospitals
LISTERIA OUTBREAK: Queso fresco
sickened 10 people who had other
(a type of soft cheese) sickened 142 people, killed 10
serious health problems. Five of them
newborns and 18 adults, and caused 20 miscarriages.
died as a result.
What foods are risky?
Adults 65 or older Listeria can spread through the bloodstream to cause meningitis, and often kills.
When it comes to Listeria, some foods are more risky than others. Meet some of the other foods where Listeria is known to hide.
The older you are, the greater the risk. Tainted cantaloupes LISTERIA OUTBREAK: Contaminated
Raw Sprouts
Soft Cheeses
whole cantaloupes sickened 147 people in 28 states and caused one of the deadliest
Raw Milk
foodborne outbreaks in the US. There were
(unpasteurized)
33 deaths, mostly in adults over 65, reported during the outbreak. SOURCE: CDC, 2013
40 | SUMMER 2017 | Prevention
Deli Meats and Hot Dogs (cold, not heated)
Smoked Seafood 3
3
Timeline for Linking a Case of Listeria Infection to an Outbreak Diagnosis
Person becomes sick
PFGE completed
Person seeks healthcare
Public health lab receives isolate
Person is exposed to Listeria
1-3 weeks After a person eats food contaminated with Listeria, symptoms usually begin within a few weeks, but may not occur for up to one month. For pregnant women, it may take up to two months for symptoms to appear.
1-2 days Most people who develop listeriosis seek medical care within two days of developing symptoms.
WGS completed CDC lab receives isolate
1-3 days
1-2 weeks
1-4 days
A health care provider sends a specimen of blood or spinal fluid to a clinical lab. The lab detects Listeria in the person’s specimen one to three days after it is received. The clinical lab reports the Listeria infection to the local public health department.
The clinical lab ships an isolate of the person’s Listeria to the state public health lab. This step can take a week or longer, depending on how soon the lab prepares the shipment and transportation arrangements.*
Next, the state public health lab conducts pulsed-field gel electrophoresis (PFGE) on the Listeria isolate, and uploads the PFGE pattern to PulseNet’s national database. This can be done in four days but can take longer if the lab has limited staff or resources or is responding to multiple emergencies. Some state public health laboratories can perform whole genome sequencing (WGS) at the same time they are completing PFGE.
1-2 weeks
Case reported as part of outbreak
4-5 days
Some state public health labs ship the Listeria isolate to CDC for WGS. Delivery can take 1 to 2 weeks.
After receiving the isolate, CDC performs WGS, which usually takes 4 to 5 days.
Source: CDC
*Not all states require clinical laboratories to forward Listeria isolates to public health laboratories, so some isolates are not sent.
WHAT IPS NEED TO KNOW
Learn more about Listeria at www.cdc.gov/listeria.
CS261814B
According to the Healthcare Infection Control Practices Advisory Committee’s (HICPAC) Guideline for Isolation Precautions in Healthcare Settings, hospitalized cases of listeriosis caused from L. monocytogenes require Standard Precautions as person-toperson transmission is rare. However, cases of cross-contamination in neonatal settings have been reported.12 LABORATORY TESTING
Listeria infection is diagnosed through blood or stool cultures; spinal fluid can also be tested for Listeria. Early diagnosis and treatment of listeriosis in high-risk patients is critical, as the outcome of untreated infection can be devastating. This is especially true for pregnant women due to the increased risk of spontaneous abortion and preterm delivery. Depending on the risk group, rates of death from listeriosis range from 10-50 percent, with the highest rate among newborns in the first week of life. Methods typically used to identify diarrhea-causing bacteria in stool cultures interfere or limit the growth of Listeria, making it less likely to be identified and isolated for further testing.2,3 Because there are few symptoms that are unique to listeriosis, providers must consider
a variety of potential causes for infection, including viral infections (like flu), and other bacterial infections that may cause sepsis or meningitis.2,3 WHO MUST REPORT?
States may vary, so if IPs do not know who notifies the health department, they should ask their supervisor at the hospital or contact the health department. For example, in Ohio, Listeria is a Class B reportable disease that must be reported to the health department by the end of the next business day. Healthcare providers (physicians, hospitals, IPs) with knowledge of a case or who suspect a case of this disease are required to report. Laboratorians that examine specimens of human origin with evidence of diseases are required to report.13 PREVENTION GUIDELINES
Immunocompromised patients vary in their susceptibility to nosocomial infections, depending on the severity and duration of immunosuppression. Generally, these patients are at increased risk for infection from both endogenous and exogenous sources. Ideally, if Standard Precautions for all patients are followed, and transmissionbased precautions for a specified patient
If a person’s Listeria infection is linked to an outbreak, the case will be reported as part of the outbreak.
are applied properly, the end result will be a reduction in exposing the compromised host to pathogenic organisms. Rigorous handwashing protocols must be followed at all times to protect these vulnerable patients. Healthcare workers, as well as community members, benefit from programs offering food safety education and risk communication. This is especially true for specific subgroups, such as doctors, educators, IPs, and others who either work with food safety or mediate risk communications with the public or other stakeholders. The U.S. Food and Drug Administration’s (FDA) website includes information for health professionals and educators on the latest advisories regarding pathogens and diagnoses of foodborne illness.15 For food recalls, the FDA recognizes that people must be given answers to three key questions: (1) What is the product? (2) What is the concern? (3) What do I need to do? Listeriosis can be prevented by practicing safe food handling (adapted from the CDC).1-3 1. SHOPPING SAFETY
• Bag raw meat, poultry, or fish separately from other food items. w w w.apic.org | 41
PREVENTION IN ACTION
• Drive home immediately after finishing your shopping so that you can store all foods properly. 2. FOOD PREPARATION SAFETY
• Wash your hands before and after handling food. • Wash hands after using the bathroom or changing diapers. • Wash fresh fruits and vegetables by rinsing them well with running water. • If possible, use two cutting boards; ■ One for fresh produce. ■ One for raw meat, poultry, and seafood. • Wash your knives and cutting boards in the dishwasher to disinfect them. 3. FOODS STORAGE SAFETY
• Cook, refrigerate, or freeze meat, poultry, eggs, fish, and ready-to-eat foods within two hours. • Make sure your refrigerator is set at 40°F (4°C) or colder. • Listeria can grow in the refrigerator, so clean up any spills in your refrigerator, especially juices from hot dogs, raw meat, or poultry.
READ MORE ABOUT LISTERIA MONOCYTOGENES IN THE AMERICAN JOURNAL OF INFECTION CONTROL Application of quantitative microbial risk assessment for selection of microbial reduction targets for hard surface disinfectants, Ryan M, Haas C, Gurian P, et al., American Journal of Infection Control, Vol. 42, Issue 11, p1165–1172. Biofilms on environmental surfaces: Evaluation of the disinfection efficacy of a novel steam vapor system, Song L, Wu J, Xi C, American Journal of Infection Control, Vol. 40, Issue 10, p926–930.
42 | SUMMER 2017 | Prevention
4. COOKING AND FOOD SAFETY
• Use a clean meat thermometer to determine whether foods are cooked to a safe temperature. • Reheat leftovers to at least 165°F (74°C). • Do not eat undercooked hamburger, and be aware of the risk of food poisoning from raw fish (including sushi), clams, and oysters. • Keep cooked hot foods hot (140°F [60°C] or above) and cold foods cold (40°F [4°C] or below). • Follow labels on food packaging. ■ Food packaging labels provide information about when to use the food and how to store it. ■ Reading food labels and following safety instructions will reduce your chance of becoming ill with food poisoning. • When in doubt, throw it out! If you are not sure whether a food is safe, don’t eat it. • Reheating food that is contaminated will not make it safe. • Don’t taste suspicious food. • It may smell and look fine, but still may not be safe to eat! 5. R ECOMMENDATIONS FOR PREGNANT WOMEN
• Do not eat hot dogs, luncheon meats, or deli meats, unless they are reheated until steaming hot. • Do not eat soft cheeses unless the label states they are made from pasteurized milk. • Common cheeses typically made with unpasteurized milk can cause listeriosis. These include: ■ Camembert, feta, brie, blue-veined cheeses, and Mexican-style cheeses such as “queso blanco fresco.” • You can have hard cheeses and semisoft cheeses such as mozzarella, along with pasteurized processed cheese slices and spreads, cream cheese, and cottage cheese. • Do not eat refrigerated pâté or meat spreads. ■ Only eat these foods if they are canned. • Do not eat refrigerated smoked seafood unless it is an ingredient in a cooked dish such as a casserole. Examples of refrigerated smoked seafood include: ■ Salmon, trout, whitefish, cod, tuna, and mackerel. ■ Only eat canned fish such as salmon, tuna, or shelf-stable smoked seafood.
■
Do not drink raw (unpasteurized) milk or eat foods that contain unpasteurized milk.
Irena Kenneley, PhD, RN, CNE, CIC, FAPIC, is a professor at Case Western Reserve University, Frances Payne Bolton School of Nursing in Cleveland, Ohio. She is also a member of the APIC Board of Directors. References 1. Murray, P.R. Rosenthal, K. S. & Pfaller, M. A. (2013). Medical Microbiology, Seventh Ed. Philadelphia, PA: Elsevier Saunders. 2. CDC (2016). Listeria (Listeriosis) Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/ listeria/index.html 3. CDC (2016). Foodborne Diseases Active Surveillance Network (FoodNet). Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/foodnet/reports/ index.html 4. CDC (2016). Multistate outbreak of Listeriosis linked to frozen vegetables. Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/listeria/outbreaks/ frozen-vegetables-05-16/index.html 5. CDC (2016). Multistate outbreak of Listeriosis linked to raw milk. Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/listeria/outbreaks/rawmilk-03-16/index.html 6. CDC (2016). Multistate outbreak of Listeriosis linked to packaged salads. Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/listeria/outbreaks/ raw-milk-03-16/index.html 7. CDC (2015). Multistate outbreak of Listeriosis linked to soft cheeses. Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/listeria/outbreaks/ soft-cheeses-09-15/index.html 8. CDC (2015). Multistate outbreak of Listeriosis linked to Creameries products. Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/listeria/outbreaks/ice-cream-03-15/index.html 9. CDC (2014). Multistate Outbreak of Listeriosis linked to commercially produced caramel apples. Retrieved from: https://www.cdc.gov/listeria/outbreaks/caramelapples-12-14/index.html 10. CDC (2014). Sprouts investigation of human Listeriosis cases. Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/listeria/outbreaks/beansprouts-11-14/index.html 11. CDC (2014). Cheese Recalls and Investigation of human Listeriosis cases. Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/listeria/outbreaks/ cheese-10-14/index.html 12. CDC (2007). 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, Appendix A. Healthcare Infection Control Practices Advisory Committee (HICPAC). Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/ hicpac/2007IP/2007ip_appendA.html 13. Ohio Communicable Disease Reporting Requirements (2015). Retrieved from: http://www.odh.ohio.gov/pdf/idcm/ intro1.pdf 14. Siegman-Igra Y, Levin R, Weinberger M, et al. Listeria monocytogenes Infection in Israel and Review of Cases Worldwide. Emerging Infectious Diseases. 2002;8(3):305310. doi:10.3201/eid0803.010195. 15. FDA (2017). Food Safety and Nutrition Resources for Healthcare Professionals. U. S. Food and Drug Administration. Retrieved from: https://www.fda.gov/Food/ResourcesForYou/ HealthCareProfessionals/default.htm
PREVENTION IN ACTION
FROM DATA TO DECISIONS
Principles of standard deviation
Welcome to the fifth installment in this series. Over the course of our two previous articles, we have discussed how the spread of the values within a data set can be examined using frequency distributions, ranges, and quantiles. (See the “From data to decisions” articles in the winter 2016 and spring 2017 editions of Prevention Strategist.) This article will focus on one more measure of data dispersion: standard deviation.
BY DANIEL BRONSON-LOWE, PhD, CIC, AND CHRISTINA BRONSON-LOWE, MS, CCC-SLP, CLD
n infection preventionist (IP) is analyzing data pulled from audits of patient room cleaning. Her data consists of percent compliance with cleaning requirements every time a patient room is prepared for the next occupant. When she builds a control chart to assess the data, she discovers that the compliance last month was below the lower control limit. (See Figure 1) She takes this to a committee meeting and expresses her concern with this apparent shift in cleaning compliance. A member of the committee, who is not familiar with control charts, asks what the upper and lower control limits represent, and how the IP knows that a data point outside of those limits is important. “Well,” says the IP, “it works like this…” w w w.apic.org | 43
PREVENTION IN ACTION Figure 1: Example Control Chart
Room Cleaning Audits - Average Compliance 100 Upper Control Limit
Average Percentage Compliance
90 80
Average
70 60 50
Lower Control Limit
40 30 20 10
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Figure 2: Deviations from the Mean
Mean
Data Points
Figure 3: Impact of Standard Deviation
Mean Mean
Deviation refers to the distance between a data point and the mean of its data set (see Figure 2). A data point can have a positive deviation (if greater than the mean), a negative deviation (if less than the mean), or no deviation (if equal to the mean). Given that the mean is at the center of the data, if you add up the deviations of all of the data points in a data set, they will cancel each other out, yielding zero. The standard deviation is essentially the average deviation value. (There are a few differences from the usual way an average is calculated, to ensure you don’t always get “0.” If you are interested in the math, see any of the additional references listed below.) Standard deviation uses deviations to create a summary measure of how far the data points spread out around the data sets mean. A small standard deviation indicates the data cluster tightly around the mean. A larger value indicates the data are spread out more widely. Two data sets with the same mean can have noticeably different standard deviations if they have different frequency distributions (see Figure 3). Thus, it is good practice when reporting a mean to include the standard deviation so that your readers have a better idea of the data characteristics. This concept of standard deviation plays a key role in many useful data tools, including the empirical rule and control charts. The empirical rule (see Figure 4), also known as the 68-95-99.7 rule, states that for normally distributed data: • Approximately 68% of the data points will fall within 1 standard deviation of the mean; • Approximately 95% will fall within 2 standard deviations of the mean; and • Approximately 99.7% will fall within 3 standard deviations of the mean.
Frequency
Smaller Standard Deviation
TERMINOLOGY
Larger Standard Deviation
Data Values 44 | SUMMER 2017 | Prevention
• µ = the mean of a population • (x ˉ ) = the mean of a sample • σ = the standard deviation of a population • s = the standard deviation of a sample • SD or s.d. = general abbreviation for standard deviation
Figure 4: Empirical Rule
“Standard deviation uses deviations to create a summary measure of how far the data points spread out around the data sets mean.”
99.7% 95% 68%
-3s
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-1s
x
+1s
+2s
+3s
CONCEPT QUIZ An IP has decided to examine the weights of surgery patients at her facility. The mean (xˉ ) of her data set is 212 pounds, and the standard deviation(s) is 42 pounds. The data set has the following frequency distribution: Activity 1 Complete the x-axis of the frequency distribution by calculating and filling in the values for each of the standard deviation indicators (e.g. -1s, +1s, +2s).
-3s
-2s
-1s
x
+1s
+2s
+3s
212 Activity 2 Approximately what percent of the data points will fall between 128 and 296 pounds? Activity 3 Approximately what percent of the data points will fall between 170 and 212 pounds?
Answers on page 46
Not only does this provide an estimate of where data are located with respect to the mean, it also paints a picture of how rare certain events will be. Specifically, data points in this data set: • Will be more than 2 standard deviations away from the mean only about 5% of the time; and • Will be more than 3 standard deviations away only about 0.3% of the time (i.e., 3 times in 1000). This rule is the basis for the upper and lower control limits in a control chart. Some control charts place these limits 3 standard deviations above and below the mean; other control charts incorporate the standard deviation into formulas to help account for a small sample size or a varying population. In the end, however, the concept behind how the control limits are used remains the same: data points that are beyond the control limit are very unlikely to naturally occur as part of the original data set being examined. This suggests there is something different about that data point. For example, it may represent a change in the process being measured. Depending on what is being measured, data points beyond the control limits can be a good thing. Hand hygiene compliance higher than the upper control limit or an infection rate below the lower control limit would be great news. Our IP with the room cleaning data is using control limits 3 standard deviations from the mean, so she can point out that there is only a 3 in 1,000 chance that the cleaning compliance would randomly drop that low. The implication is that it is more likely that something in the cleaning process has changed for the worse. Perhaps new housekeeping personnel have been brought on board but have yet to be fully trained, changes in housekeeping duties have left them with less time to complete the room cleaning, or something else entirely has w w w.apic.org | 45
PREVENTION IN ACTION
occurred. The chart doesn’t identify what happened, but it can indicate that an investigation may be warranted. It is worth noting that standard deviation calculations also play a role in inferential statistics, as they form the basis for working up confidence intervals, p-values, and various statistical tests. If you have any questions or comments, please feel free to contact us at IPandEpi@gmail.com. Daniel Bronson-Lowe, PhD, CIC, has been an infection preventionist, an infectious disease epidemiologist, and a statistics lecturer. He is now the instructor for APIC’s “Basic Statistics for Infection Preventionists” Virtual Learning Lab and a senior clinical manager with Baxter Healthcare Corporation. Christina Bronson-Lowe, MS, CCC-SLP, CLD, is a speech-language pathologist and PhD candidate who has worked in hospitals, inpatient and outpatient rehabilitation, SNFs, and home health care.
Answers 1.
-3s
-2s
-1s
x
+1s
+2s
86
128
170
212
254
296
+3s
338
2. Approximately 95% 3. Approximately 34%
Additional Resources • Potts, A. Chapter 13: Use of Statistics in Infection Prevention. In: Patti Grota, et al., editors. APIC Text Online. APIC; 2014. • Potts, A. Chapter 2: Use of Statistics in Infection Prevention. In: Monika PogorzelskaMaziarz, editor. Fundamental Statistics & Epidemiology in Infection Prevention. APIC; 2016.
• Centers for Disease Control and Prevention. Principles of Epidemiology in Public Health Practice: An Introduction to Applied Epidemiology and Biostatistics, 3rd Edition. 2012. (http://www.cdc.gov/ophss/ csels/dsepd/SS1978/SS1978.pdf) • Khan Academy (www.khanacady.org)
The APIC/JCR
Infection Prevention and Control Workbook Third Editioon
Edited by: Barbara M. Soule RN, MPA, CIC, FSHEA, FAPIC Kathleen Meehan Arias, MS, MT(ASCP), CIC
46 | SUMMER 2017 | Prevention 865506_Editorial.indd 1
21/04/17 8:26 PM
Rediscover the power of the bath. Find out more about how the HIBI® Universal Bathing System (HUBS) can transform your infection prevention protocols in your facility. Visit Hibiclens.com/HUBS today.
The Mölnlycke Health Care, Hibiclens and HIBI trademarks, names, and logo types are registered globally to one or more of the Mölnlycke Health Care Group of Companies. Distributed by Mölnlycke Health Care US, LLC, Norcross, Georgia 30092 © 2016 Mölnlycke Health Care AB. All rights reserved. 1-800-843-8497. MHC-2016-25164
PREVENTION IN ACTION
Focus on long-term care and behavioral health outbreaks:
Identify the pathogen! BY STEVEN SCHWEON, RN, MPH, MSN, CIC, HEM, FSHEA, FAPIC
H
ospital outbreaks are reported more often in the medical literature than occurrences in the long-term care (LTC) or behavioral health setting. By studying and learning from outbreaks in the LTC/behavioral health setting, infection preventionists (IPs) will glean additional knowledge and apply this information to hopefully prevent future infections, and infection clusters, in their facilities. This quarterly column will assist the IP with heightening awareness of appropriate interventions for preventing an outbreak. An “oldie but goodie” outbreak article describes a robust hygienic program to prevent a pathogen—which is responsible for skin infections, pneumonia, and bacteremia—from being transmitted in both hospitals and nursing homes. Based on your education and clinical savvy, you suspect this pathogen to be: 1. Clostridium perfringens 2. Mycobacterium tuberculosis 3. Coxiella burnetii 4. Methicillin-resistant Staphylococcus aureus (MRSA) Hoebe et al., depict the very strict hygienic practices in the Netherlands to prevent the spread of MRSA.1 This article, from 1999, describes the screening and strict isolation of patients who are colonized or suspected to be colonized with MRSA. A patient positive with MRSA generates a “hygienic emergency,” with the implementation of additional hygienic precautions to prevent further transmission. Additionally, 48 | SUMMER 2017 | Prevention
all MRSA strains are collected and typed by the National Institute of Public Health and the Environment. As MRSA continues to be detected in hospitals, its appearance also has been found in nursing homes. After an index case was found to be MRSA-positive in a 175-resident Dutch nursing home, a trace contact investigation was launched, with the intent of identifying possibly additional MRSA cases. The authors used the “ring-principle” technique, where individuals with close or prolonged exposure to the pathogen were identified and tested first for MRSA. Due to its competitive pricing, a commercial laboratory in a different country processed the cultures. As a result, positive MRSA cultures were detected with the initial set of testing, which then extended the number of nursing home individuals who were tested. Dutch guidelines for controlling MRSA in nursing homes consist of numerous recommendations that address the colonized
CDC/James Archer
residents and employees. Additionally, there are environmental hygiene recommendations to be implemented. An outbreak management team met daily to manage the MRSA increase. Team members consisted of the director of the nursing home, nursing home physician, two departmental managers, nursing home press officer, hospital hygienist, occupational physician, and public health physician. Interventions included: • Strict hand disinfection for all persons in the nursing home;
TAKE HOME MESSAGES:
1
MRSA is a gram-positive organism that is resistant to many antibiotics and can cause skin infections, pneumonia, and bacteremia. Additional information is available at: https://www.cdc.gov/mrsa/.
2
The authors note the importance of verifying the diagnosis. This is important to ensure the outbreak organism has been correctly identified and to eliminate laboratory misidentification or error as the possible source for the increase.
3
Seeking expert guidance from the public health department and other infectious disease experts whenever an outbreak or a possible outbreak is occurring will augment operational, management, and control issues.
which indicated a minimal number of positive cases, this was a surprising elevated number of individuals who were carriers. The authors raised doubts with the initial positive MRSA culture results from the commercial laboratory and re-cultured the positive individuals. The cultures were processed within the Netherlands, and all the individuals were found to be MRSA negative. No explanation is given as to why the commercial laboratory misidentified all the isolates. The false MRSA outbreak had aggravating consequences for the employees and residents, attracted media attention, and resulted
in a governmental directive that emphasized quality microbiological testing. Reference 1. Hoebe CP, Wagenvoort JT, Bilkert-Mooiman MJ, and van Leeuwen WJ. An alleged outbreak of Methicillin-Resistant Staphylococcus aureus in a Dutch nursing home. Eur J Clin Microbiol Infect Di. 1999. Available at: https://www.researchgate.net/ publication/12716221_An_Alleged_Outbreak_of_ Methicillin-Resistant_Staphylococcus_aureus_in_a_ Dutch_Nursing_Home. Accessed November 26, 2016.
Steven Schweon, RN, MPH, MSN, CIC, HEM, FSHEA, FAPIC, is an infection prevention consultant with a specialized interest in acute care/ long-term care/behavioral health/ambulatory care infection challenges, including outbreaks.
READ MORE ABOUT MRSA OUTBREAKS IN THE AMERICAN JOURNAL OF INFECTION CONTROL
• Use of apron, gloves, and mouthpiece during all medical activities; • Disinfection of contaminated materials and rooms; • Team nursing for colonized residents; • Sick leave for colonized employees; • Informational meetings for all employees, patients, and relatives; and • Development of a media plan. Ten days after the index case tested positive, 9 employees and 20 residents were also found to be colonized with MRSA. Based on current MRSA prevalence data,
High rate of multidrug-resistant organism colonization among patients hospitalized overseas highlights the need for preemptive infection control, Hayakawa K, Mezaki K, Sugiki Y, et al., American Journal of Infection Control, Vol. 44, Issue 11, e257–e259. Outbreak in newborns of methicillin-resistant Staphylococcus aureus related to the sequence type 5 Geraldine clone, Leroyer C, Lehours P, Tristan A, et al., American Journal of Infection Control, Vol. 44, Issue 2, e9-e-11. An JH, Kim YH, Moon JE, et al. American Journal of Infection Control, Published online: February 24, 2017. Review of a major epidemic of methicillin-resistant Staphylococcus aureus: The costs of screening and consequences of outbreak management, van der Zee A, Hendriks WD, Roorda L, et al., American Journal of Infection Control, Vol. 41, Issue 3, p204-209. Unrelated strain methicillin-resistant Staphylococcus aureus colonization of health care workers in a neonatal intensive care unit: Findings of an outbreak investigation, Mangini E, Srinivasan P, Burns J, et al., American Journal of Infection Control, Vol. 41, Issue 11, p1102-1104.
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PREVENTION IN ACTION
Moving from wishing to success:
Pointers for a successful abstract submission BY JAN RATTERREE, BSN, RN, CIC, AND JULIE BLECHMAN, MPH, CHES
H
ave you ever attended a scientific conference and seen the rows and rows of abstract posters, wishing yours was among them? Abstracts are concise research papers that help advance the field of science and add to the body of evidence-based literature. Each year, APIC posts a Call for Abstracts. At this time, members of the infection prevention community may submit their research for consideration as a poster or oral session for Annual Conference. Abstracts are then peer-reviewed for quality of research, educational or scientific content, presentation logic, and impact on the infection prevention and control field. APIC invites the authors of accepted abstracts to present their posters to Annual Conference attendees. This year, the APIC 2017 Annual Conference Committee accepted more than 200 abstracts in the form of oral and poster presentations. Being selected as an abstract presenter not only advances the infection prevention field, it advances your career as well. Oral presentation at the state, regional, or national level, or poster presentation at the national level, are criteria for the Fellow of the Association for Professionals in Infection Control and Epidemiology (FAPIC) credential. So…how can you change from wishing for an accepted poster to celebrating your success? The solution is simple: Plan your work and work your plan. Plan to submit an abstract on your research project before you start the work, 50 | SUMMER 2017 | Prevention
and then work your project according to the plan. This might seem like a circular way to conduct your research, but it does work. The following three steps can help you successfully submit abstract.
1
Utilize the APIC resources in planning your abstract and begin planning with the rules. Review carefully the Call for Abstracts on the APIC Annual Conference website. The most common mistakes are made by not following the rules.
2
Another excellent tool for planning your work is the APIC Video “Writing Scientific Abstracts” by Kate Gase, MPH, CIC, FAPIC. Kate describes the basic sections of the abstract. Review the video throughout the entire research and writing process. (https://tinyurl.com/APICabstractvideo)
3
While planning, seek a mentor who has previously presented at conference to review your work. Mentors can help guide you from the beginning planning stages, through study implementation, and writing stages. Visit MyAPIC (http://community.apic. org/myapic/home) to get connected with a mentor, or reach out to members of your local APIC chapter.
The most common reasons APIC Annual Conference abstracts are rejected: • It has been previously published. • The entry was faxed or mailed, and not electronically submitted. • The abstract was submitted after the deadline. • Brand or trade names are used in the abstract. • It is longer than 300 words. • It is poorly written. Make sure you also familiarize yourself with abstract awards (see Abstract Award and Criteria on page 51). Quality work, combined with meeting the criteria for an award, can elevate your work from successful acceptance to award winning recognition. Use the same basic work management tool and reach for the stars! We look forward to seeing your quality abstract submissions for the APIC 2018 Annual Conference, which will take place June 13-15, 2018, in Minneapolis, Minnesota! Visit the conference website for more information. Jan Ratterree, BSN, RN, CIC, is the chair of the Abstracts Subcommittee of the 2017 Annual Conference Committee. She has 28 years of experience in nursing, management, and staff education, followed by over 10 years as an infection preventionist. Julie Blechman, MPH, CHES, is the APIC communications manager and a handwashing enthusiast.
ABSTRACT AWARD AND CRITERIA
ANATOMY OF AN ABSTRACT
Blue Ribbon Abstract Award (up to four winners) The Blue Ribbon Awards are given to a limited number of abstracts considered to be of exemplary scientific and/or educational quality.
Abstracts must use a traditional four-section format as follows: Background: Provide a brief background and describe study objectives, hypothesis tested, and/or problem addressed. • This section should be written in present tense and answers the question: “What is the importance of this study?” • A traditional format includes a description of the importance of the field, definition of the problem, and outline of the research question and objective. Methods: Describe study design, including setting, sample, sample size, subjects, intervention, and/or type of statistical analysis. This section should be written in past tense. • A traditional format indicates the study design, subjects, and time frame; outlines the study variables; and defines the statistical analysis. • Do not include any numbers outside of time frame or the number of facilities (if a multicenter study) in this section. Reserve all numbers for the results section. Results: Summarize essential results as clearly as possible with appropriate statistical analysis. This section should be written in past tense. • Ensure that each result has a method included in the methods section. • Ensure that each method outlined in the methods section has a corresponding result in the results section. • If you have too many results, you need to limit the methods provided in the abstract. • You can have more methods in the poster than you do in the abstract. Just provide the most important result in the abstract. • The results should be described in the same order as the methods described in the methods section. Conclusion: Interpret the study findings. Conclusions must be supported by the results. Concisely summarize implications of the results. • This section answers the question “So what?” and is written in present tense. • Do not state “Future studies are needed” or “A randomized trial is needed”—the goal is to provide implications in this section. More studies are always needed. • Ensure that all conclusions are supported by the results.
Implementation Science Abstract Award (one winner) The Implementation Science Award is presented for an abstract that is innovative, employs sound methodology, and represents a potentially significant contribution to the principles and practices of infection prevention. New Investigator Abstract Award (one winner) The New Investigator Award recognizes outstanding scientific research by an APIC member presenting for the first time at the APIC Annual Conference. Best International Abstract Award (one winner) The Best International Abstract Award recognizes research from outside the United States that demonstrates exemplary scientific merit and is of high interest and relevance to the infection control community. William A. Rutala Abstract Award (one winner) This is given in the name of William A. Rutala, MS, PhD, MPH, CIC, for the best abstract on the subject of disinfection, sterilization, or antisepsis.
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Clean and sterile storage:
Issues with ventilation, pressure differential, and humidity BY VICKY UHLAND
bout three years ago, The Joint Commission began focusing in on ventilation issues that affect hospitals’ or ambulatory surgery centers’ clean and sterile storage. According to George Mills, MBA, FASHE, CEM, CHFM, CHSP, director of engineering for The Joint Commission’s Department of Engineering, nothing specific precipitated this action. But he and his colleagues had noticed that when they did onsite surveys, more than 50 percent of the hospitals had clean and sterile storage ventilation problems. “In our list of the top 10 most-identified standards during our tri-annual full surveys, EC.02.05.01 (utilities systems), specifically at EP 15 and EP 16 (ventilation, air changes, and filtration), is always in the top three,” Mills said. Along with ventilation issues, Joint Commission surveyors also noticed other problems related to clean and sterile storage—specifically, pressure differential and humidity. Mills attributes these findings to three main factors: 1. Weather changes that affect the outside air and the air handling equipment. 2. Aging infrastructure, including equipment that is so old that it tends to slip out of balance. 3. Reduction in the number of workers who monitor clean and sterile storage issues such as ventilation, pressure differential, and humidity. Interestingly, Mills said the rise of makeshift clean and sterile storage areas in suites or other repurposed rooms is not an issue, as long as the area is a designated, and properly 52 | SUMMER 2017 | Prevention
maintained, area of a clean or sterile suite. This can include an area in a facility that is no more than 10,000 square feet, with two exits, and doors that latch. “An intensive care unit can be a suite; an operating room can be a suite; the emergency department can be a suite as well,” Mills said. He noted that hospital safety drawings should reflect the suite boundaries. TWO LEVELS OF DEFICIENCY
In the first half of 2016, Joint Commission data showed that 56 percent of hospitals had EP 16 (ventilation) requirements for improvement, compared with 26 percent of ambulatory surgery centers. Mills stated that while the number of violations hasn’t noticeably decreased since The Joint Commission began its heightened focus on clean and sterile storage surveying, the severity of the violations has. If a facility receives a standard-level deficiency finding, it needs to repair the problem and then show 60 days’ worth of compliance, such as tracking humidity levels and pressure differentials. “It could be daily,
weekly, or monthly tracking, depending on an assessment of sustainability,” Mills said. If a facility is cited with a condition-level deficiency, it will be re-surveyed within 45 days to evaluate the corrective actions. According to Mills, depending on the immediate threat to life that the violation may propose, The Joint Commission could institute a preliminary denial of accreditation. “We take it very seriously,” he said. However, if the hospital successfully corrects the issues during the survey, the condition-level deficiency may be reduced to a standard-level deficiency. This might prevent a hospital from having to shut down an operating room, although it will still need to provide evidence of standards compliance after survey. HOW TO ACHIEVE CLEAN AND STERILE STORAGE
Mills offers the following tips for infection preventionists to avoid receiving either type of deficiency finding in clean and sterile storage areas. Humidity - There’s a difference in humidity requirements for sterile supplies prepared
“It’s also important to note that pressure and ventilation are intertwined; if there’s a problem with one, that’s often an indicator that there’s a problem with the other.”
by the hospital, and supplies prepared by a manufacturer. Humidity range for commercial supplies is 35 to 60 percent. The Joint Commission follows the American Society of Heating, Refrigerating and AirConditioning Engineers’ (ASHRAE) recommended humidity range of 20 to 60 percent found in ASHRAE 170-2008, including Addendum (d). In 2013, the Centers for Medicare & Medicaid Services (CMS) issued a waiver adopting the same ASHRAE document. “Hospitals were spending a ton of money humidifying areas, with little impact on the sterility outcome,” Mills said. But this new recommendation caused problems, Mills articulated, because manufacturers’ labels still say 35 to 60 percent. “A California state agent was doing a survey in 2014 in a central sterile supply room and came across packs with the 35 to 60 percent label, but found that the room was in the 20 to 60 percent range. CMS had to react and was ready to rescind the new 20 to 60 range,” he said. In response, the Association for the Advancement of Medical Instrumentation (AAMI) called a meeting in October 2014 of more than 30 organizations involved in relative humidity measurements. One of the things they discovered was that it would take five years for manufacturers to change their humidity labels.
So for now, The Joint Commission is requiring that sterile supply rooms be kept at 35 to 60 percent humidity, but once the supplies are taken off the racks and rolled into an operating room, they are no longer stored, but in use and can be in the 20 to 60 percent range as the supplies move from storage to in-use. Due to differences in humidity and temperature from an older building to new, and various regions of the world, some hospitals may have greater difficulty in achieving compliance. Pressure differential - Mills said a simple way to determine if there’s a pressure differential problem in a room is to take a tissue and hold it at the bottom or edge of the door and see which way it blows. It’s also important to note that pressure and ventilation are intertwined, he added. If there’s a problem with one, that’s often an indicator that there’s a problem with the other. A visual pressure monitor is always useful; however, visual or digital monitors are only required in high-class ICRA containments. Ventilation - The key is to have teams regularly inspect your facility’s heating and ventilation systems and mitigate any problems. “People ask how often they should do it,” Mills said. “The answer is very simple: As often as you need to.” If your building is 40 or more years old, this may be daily. For
buildings that are 20-40 years old, maybe it’s weekly or monthly. For brand new buildings, start with daily rounds until a baseline has been established, he said. Mills points out that the life expectancy of an air handler is about 25 years, and a boiler is about 30 years. “Don’t expect tired old equipment to deliver what it did 20 to 30 years ago,” he said.
READ MORE ABOUT CLEAN AND STERILE STORAGE VENTILATION IN THE AMERICAN JOURNAL OF INFECTION CONTROL Evaluation of hydrogen peroxide vapor for the inactivation of nosocomial pathogens on porous and nonporous surfaces, Lemmen S, Scheithauer S, Hafner H, et al., American Journal of Infection Control, Vol. 43, Issue 1, p82–85. Easy as I, II, III... Instrument Processing Room Designs, Rhodes LM, Busby R, Dorroh M, et al., American Journal of Infection Control, Vol. 41, Issue 6, S71-S72.
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An infection preventionistâ&#x20AC;&#x2122;s role in
sepsis care BY DAWN TOMAC, BSN, RN, CIC
R
eliable sepsis care is a challenge for most facilities. Identifying sepsis too early leads to misuse of broad-spectrum antibiotics, but the alternative is identifying too late, which can lead to multisystem organ dysfunction, loss of body function, loss of a limb, pain, and for some, death. Public knowledge of sepsis and the warning signs is an issue as most do not seek treatment soon enough. Federal health entities have escalated campaigns to educate the medical community and the public. The Centers for Disease Control and Prevention (CDC) launched a new website to promote sepsis awareness. The Centers for Medicare & Medicaid Services (CMS) and The Joint Commission introduced a Sepsis Core Measure for all Joint Commission-accredited U.S. hospitals. So, should infection prevention and control (IPC) staff take on the journey of improving sepsis care? The answer is yes, as IPC staff are skilled in working with teams of individuals across disciplines, including physicians. Developing a reliable sepsis care program became an Avera Health strategic initiative in 2013 as it was both a primary driver of hospital mortality and the health system had cost opportunities related to sepsis care. At the same time, the Minnesota Hospital Association (MHA) was funded by CMS to launch the Leading Edge Advanced Topic (LEAPT) project. Avera Health joined this program with their Avera eCare telemedicine program as a mentor
54 | SUMMER 2017 | Prevention
site, along with Avera Marshall Regional Medical Center and Avera St. Mary’s Hospital as intervention sites. Avera eCare delivers access to a wide range of medical specialists and provides referrals to specialty care for communities with underserved populations. They provide intensive care unit (ICU), emergency department (ED), pharmacy, senior care, consult, and correctional health services in eight states. Identifying when an infection becomes sepsis is crucial to early care. Avera Marshall Regional Medical Center is a 25-bed critical access hospital (CAH) in Marshall, a city in rural southwestern Minnesota. Avera St. Mary’s Hospital is a 60-bed acute care facility in Pierre, South Dakota that services an area considered frontier. These facilities were chosen to test process change and improve sepsis care in remote or rural areas. A physician dyad of an infectious disease specialist and a hospitalist, along with myself as an infection preventionist (IP), led the Avera System program, disseminating it to 32 hospitals and providing education support to 20 long-term care facilities. Sepsis was listed as the most expensive condition to treat in the United States in 2011, costing an estimated 20 billion dollars.¹ This can be attributed to the fact that hospitalizations due to septicemia increased by 148 percent between 2000 and 2009.² It was ranked as the second most common principal diagnosis for admission in 2014, with more than 1.5 million hospital sepsis admissions.3 As our team developed a program to improve sepsis care, four interventions were identified as part of the project: 1. Nurse-driven screening protocol. 2. Physician order sets for 3-hour and 6-hour bundles. 3. Transfer Trigger Tool. 4. Education using Seeing Sepsis Tools developed in conjunction with the MHA LEAPT project using the 100-100-100 rule. The pilot project involved developing an electronic tool box using performance improvement concepts and small tests of change. The initial pilot project utilized a nurse screening assessment in paper format so that immediate feedback and rapid cycle change could occur. This assessment utilized the findings and suspected infection prompts to identify at-risk patients. This transitioned to the electronic medical record and was set as a standard assessment for patients. The nurse screening tool was initially formatted after the 100-100-100 rule from MHA (Figure 1). It has since been changed due to the CMS reporting requirements, but the concept is still used for
awareness education. If the patient’s temperature is ≥ 100, heart rate is ≥ 100, and blood pressure ≤ 100, and the patient just does not look right, the screen is flagged as positive. A positive screen for sepsis requires the nurse to notify the physician immediately. It was an easy rule for staff to remember. This concept was also simple to teach to patient care technicians or nursing assistants who often obtain patient vital signs. This concept, along with the electronic assessment, created a way for patients to be screened in a timely fashion. PHYSICIAN ORDER SETS
Physician order sets were arranged by infection type. Antibiotics that had been deemed most appropriate by the sepsis team were placed first on the list rather than being listed alphabetically. This resulted in a clear switch in ordering patterns and an increase in preferred formulary drugs being utilized. Order sets were designed so that the definition of sepsis was visible when the physician opened the order set, including all the elements required for sepsis care. Physicians could eliminate the problem of accidentally omitting key lab and treatment protocols by using the sets. The sets were also aligned with antimicrobial stewardship team recommendations based off resistance trends in the community.
Figure 1: MHA awareness tool4 w w w.apic.org | 55
PREVENTION IN ACTION
Figure 2: Transfer trigger tool4
“The pilot project involved developing an electronic tool box using performance improvement concepts and small tests of change. The initial pilot project utilized a nurse screening assessment in paper format so that immediate feedback and rapid cycle change could occur.”
Transfer Trigger Tool Anticipate ICU admission or transfer to another hospital (within two hours) if: • Lactate > 4 mmol/mL OR • Unresponsive to 30 ml/kg fluid (no increase in UOP or BP) OR • Two or more signs or symptoms organ dysfunction: o Respiratory: SaO2 < 90% OR increasing 02 requirements o Cardiovascular: SBP < 90 mmHg OR 40 mmHg less than baseline or MAP < 65 mmHg o Renal: urine output < 30 ml/hr, creatinine increase > 0.5 mg/dl from baseline or ≥ 2.0 mg/dl o CNS: Altered mental status, GCS ≤ 12 o Hematologic: platelets < 100,000, INR >1.5, PTT > 60 secs o Hepatic: Serum total bilirubin ≥ 4 mg/dl or plasma total bilirubin > 2.0 mg/dl or 35 mmol/L o Hypotension (SBP < 90 mm Hg, MAP < 70, or SBP decreases > 40 mm Hg) OR • Progression of symptoms despite treatment TRANSFER TRIGGER TOOL
The Avera Health system is very rural and comprised mostly of CAHs, some of which are hours from an acute care hospital. Identifying when to transfer the sepsis patient to a higher level of care is key to survival. Delayed transfer could result in poor patient outcomes. The transfer trigger tool (Figure 2) utilizes lactic acid and other assessment findings to identify time-critical decision points for transfer.⁴ Reliable sepsis care does work, and IPs can contribute greatly to the success of these
READ MORE ABOUT SEPSIS IN THE AMERICAN JOURNAL OF INFECTION CONTROL
programs. The system had 843 cases, with a 16.13 percent mortality rate from July 2012 to July 2013. From July 2015 to June 2016, the system had 1,944 cases with a mortality rate of 8.18 percent. As a result of bringing a team together with physician leadership, our health system achieved a 49.29 percent reduction in mortality since 2012. IPC staff have the ability to work across continuums and use advocacy skills to improve care. Dawn Tomac, RN, BSN, CIC, is the director of quality and safety initiatives for Avera Health. She is a registered nurse with 30 years of experience who has practiced in the area of infection prevention since 1996, and certified since 1998. References
Breakthrough Reduction in Sepsis Mortality with National Collaborative Utilizing Robust Process Improvement Methodology, Blanchard E, Musheno D, American Journal of Infection Control, Vol. 42, Issue 6, S17-S18.
1. Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project Statistical Brief No. 160 August 2013. National inpatient hospital costs: the most expensive conditions by payer, 2011. Available at: https://www.hcup-us.ahrq.gov/reports/ statbriefs/sb160.jsp
Mortality in intensive care: The impact of bacteremia and the utility of systemic inflammatory response syndrome, Brooks D, Smith A, Young D, et al., American Journal of Infection Control, Vol. 44, Issue 11, p1291-1295.
2. Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project Statistical Brief No. 161 September 2013. Trends in Septicemia Hospitalizations and Readmissions in Select HCUP States, 2005 and 2010. Available at: https://www. hcup-us.ahrq.gov/reports/statbriefs/sb161.pdf
Epidemiology of bloodstream infections caused by methicillin-resistant Staphylococcus aureus at a tertiary care hospital in New York, Yasmin M, El Hage H, Obeid R, et al., American Journal of Infection Control, Vol. 44, Issue 1, p41-46.
3. Agency for Healthcare Research and Quality Healthcare HCUP Fast Stats – Most Common Diagnosis for Inpatient Stays 2014 HCUP Fast Stats - Most Common Diagnoses for Inpatient Stays. Available at: https://www.hcup-us.ahrq.gov/faststats/ NationalDiagnosesServlet
A polyclonal outbreak of bloodstream infections by Enterococcus faecium in patients with hematologic malignancies, Alatorre-Fernández P, Mayoral-Terán C, Velázquez-Acosta C, et al., American Journal of Infection Control, Vol.45, Issue 3, p260-266.
56 | SUMMER 2017 | Prevention
4. Minnesota Hospital Association Sepsis and Septic Shock: Early Identification Saves Lives. Available at: http://www. mnhospitals.org/quality-patient-safety/quality-patientsafety-initiatives/sepsis-and-septic-shock/#/videos/ view/39
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PREVENTION IN ACTION
Onboarding a novice infection preventionist BY JO MICEK, RN, CIC
I
t is essential in our current healthcare environment to pause and consider what the future will bring. Regulatory agencies are recognizing the importance of infection prevention and control (IPC) in healthcare. This awareness has increased the need for infection preventionists (IPs) across the continuum of care. Ideally, we would have a wealth of experienced IPs readily available to assume those roles as positions are posted. Unfortunately, that is not always the case. Currently, many of us who are fortunate to have a position available are turning to healthcare professionals who do not have IPC experience. The APIC MegaSurvey demonstrated that 41 percent of the respondents were 56 years of age or older, which begs us to consider not only the development but also the retention of novice practitioners. I don’t think I will ever forget my first day as an infection control nurse. Please keep in mind, most people at the time thought this was a job that “old nurses” or “nurses who can’t handle working on the floor” were relegated to since they either didn’t or couldn’t handle the rigors of bedside nursing. Sound familiar? I had been a bedside
nurse for more than 10 years, doing a variety of bedside nursing. I loved it and felt I was very good at what I did. I became restless and wanted more. I was hired to work with a team of two other nurses and a consulting infectious disease physician for a 500+ bed urban acute-care hospital. After the welcome and general orientation to my office and
other staff members, my true orientation began in earnest. These professional, caring, hardworking individuals began speaking Martian! Okay, maybe not, but to me it was a very different language, and I began to feel some inner misgivings on whether this was a mistake. At the end of the first week I looked back and didn’t know why I was still there. (Continued on page 63)
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60 | SUMMER 2017 | Prevention
4
16
29
1
37
34
33
35
76-79
42
Surgical Site Infection
Intravascular Infection
Urinary Tract Infection
Infection in Indwelling Medical Devices Pathogens and Diseases
Pediatrics
84-87
22
17
2
Competency and Certification of the IP Performance Measures
Microbial Pathogenicity and Host Response Pathogens and Diseases
18
Patient Safety
WEEK THREE
NHSN - Surgical Site Training Modules
36
70-75
Pneumonia
WEEK TWO
NHSN - CLABSI, CAUTI Training Modules
Pathogens and Diseases
Risk Manager
PI Director
FacilityAPIC specific Text Policy & Contact Chapter Procedures Person
21 Risk Factors for Facilitating Transmission of Infectious Agents Legal Issues 8
Accrediting and Regulator Agencies
Infection Control and Prevention Program Isolation Precautions (Transmission-based precautions) Quality Concepts
WEEK ONE
Orientation Biblography and Curriculum
Isolation Rounding
Hand hygiene audits 10 observations
Method to collect device days
Method to alert/follow ventilator-associated events
MDRO alerts
Clinical Observation Isolation Rounds (all/ designated units)
Review curriculum and attend general orientation
Clinical Education
Clinical Project(s)
Emergency Mgmt Coordinator (119)
Quality Council
Plant Services (112,114, 115, 116)
Lab (25, 26, 108)
Shadow Surgery (68)
Shadow Environmental Svc (31, 107)
Department Orientation [shadowing workers in the department]. APIC Text Chapter must be read prior to shadowing.
Safety Committee
AJIC case studies/internal cases
AJIC case studies/internal cases
Other References
Surveillance/Epidemiology x
x
x
x
x
x
x
x
x
x
x
x
Education x
Collaboration/Consultations x
x
x
x
x
Program Management x
x
x
x
x
x
x
x
x
Performance Improvement x
x
x
x
x
Leadership x
x
x
x
Implementation Science x
x
x
x
x
Research x
x
x
x
Technology
Professional & Practice Standards
Occupational Health
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41
40
59
Neonates
Geriatrics
Intensive Care
Report Hand Hygiene rates
Hand hygiene audits 10 observations
Shadow ICU(s)
Shadow OB & NICU (41, 43)
Shadow Emergency Dept
AJIC case studies/internal cases
Orientation to TJC/regulatory submission website
AJIC case studies/internal cases
AJIC case studies/internal cases
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Other References for Use: Ready Reference to Microbes APIC: Disinfection, Sterilization and Antisepsis ed. Wm Rutala; 2017 Guidelines for Perioperative Practice; ANSI/AAMI Standards ST79; SHEA Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Settings; Control of Communicable Diseases Manual; Committee on Infectious Diseases, American Academy of Pediatrics, David W. Kimberlin, MD, FAAP, Michael T. Brady, MD, FAAP, Mary Anne Jackson, MD, FAAP, Sarah S. Long, MD, FAAP; Mandell, Douglas, and Bennettâ&#x20AC;&#x2122;s Principles and Practice of Infectious Diseases; Infusion Therapy Standards of Practice, Infusion Nurse Societ y.
NHSN - Denominators
27
30
Hand Hygiene
Sterile Processing Dept (31,32,106)
80 -82 Hand hygiene audits 10 observations
Shadow Wound Nurse
92
Education (3,5,6)
Dialysis
39 Hand hygiene audits 10 observations
Dietary (Chapt 109,83)
47
Aseptic Technique
NHSN-Submission for SAMS card/access to NHSN WEEK SIX
Regulator Oversight * Accreditation body * CMS * State * Local Skin and Soft Tissue Infections Pathogens and Diseases
WEEK FIVE
NHSN - VAE Training Modules
Nutrition and Immune Function Dialysis
67 ATP testing of environmental high touch surfaces
Shadow Respiratory Therapist
44
Infection PreventionImmunocompromised Respiratory Care Services Pathogens and Diseases
88-91
Shadow Oncology OP clinic
43
Perinatal Care
Shadow Employee Health (100)
28
Purchasing
7
Standard Precautions Isolation Rounding
Hand hygiene audits 10 observations
Product Evaluation
WEEK FOUR
NHSN - LABID Training Modules
x
x
PREVENTION IN ACTION
Employee Name:
Date of Hire:
Job Title:
Due Date: JOB RESPONSIBILITIES
PRECEPTOR Score at 4 weeks __/__/__
Score at 80 days __/__/__
ND-never done LE-limited experience RE-review education PI-perform independently HAI Definitions * NHSN [including numerator & denominator] * SHEA compendium * State required surveillance * Device day collection method MDRO * LAB ID NHSN * Alert communication * Transmission based precautions Infection Prevention Work Practice Monitoring * Isolation work practice * Hand hygiene * Other internal metrics as identified in risk assessment Occupational Health [refer to professional practice standards] from: * HCW exposure to BBF procedure * Exposure protocol * Incubation periods * HCW recommended immunizations Education * Orientation * Annual * Just in time * A lternate methodology (webinar, phone conferencing, blog, etc.) Policy and Procedure Development and Management * IP department specific * Writer * Reviewer (subject matter expert) Regulator oversight * Accreditation body * CMS * State * Local Program development/Mgmt * Risk assessment * FMEA * Goal setting * Implementation Communicable Disease Reporting Outbreak Investigation New Product * Evaluations * Recall responsibiliteis Emergency Management * HID area * Pathogens of concern
62 | SUMMER 2017 | Prevention
Date Completed
Method
Level
O-observed V-verbalized C-cognitive N/A - not applicable
Novice Proficient Expert
Initials
Comments:
LOOKING FOR MORE IP FORMS AND CHECKLISTS? Forms & Checklists for Infection Prevention, Volume 1, APIC’s newest book, provides a convenient and helpful collection of infection prevention tools for key process and reporting activities. You’ll find forms, checklists, tools, posters, and other resources in six subject areas: IP programs, IP education, surveillance, precautions, performance improvement, and environment of care. Content includes: • Orientation tools and position descriptions; • Data collection and analysis tools for investigations; • Needs assessments, gap and root cause analyses, and action plans; • Cleaning and rounding checklists including staff training; • And more! Available in print or digital format at the APIC Store at www.apic.org/store. So much to absorb, and when would they figure out my secret—I was not qualified to do this! ...and so my journey began. I promised myself at that time to never forget how that felt. Fast forward to now: I am on the other side, and now I’m the one responsible for hiring and the development of professionals in the role of infection preventionist. The tools and information available to set novice IPs up for their professional journey in infection prevention are readily available online, on your phone, on websites, in publications: a truly vast amount of very good information. The goal is not only to train new professionals, but to
provide them the opportunity to grow to love this profession. To some degree, change is a constant in our role. Rapidly developing technology, evolving clinical practice, new regulations, and ever-increasing surveillance requirements are challenges we face as skilled professionals, and it can be overwhelming for a seasoned IP. As I revised the orientation packet for a novice IP, I decided my goal was to give them the tools to be successful, but ultimately to assist them to be aware of the unique perspective we bring to these challenges. To empower, enlighten, and engage them to succeed without overwhelming them. APIC has provided several fundamental comprehensive tools to assist with this process. I am referring to the “The Roadmap for the Novice Infection Preventionist,” APIC Competency Model, and Professional Practice standards, which serve as cornerstones for a successful orientation process. I looked at the breadth of information I needed to share and was concerned because I did not want to overwhelm a new orientee. More than that, I wanted them to have fun as they learned and became the subject matter expert needed for their role. How could I do that for them and get them engaged as quickly as possible? This curriculum is based on the above listed tools, and also includes some of my most frequently accessed websites and resources. It is a six-week orientation and transitions them from bed or bench-side professional to budding IP. Providing a curriculum and solid resources for references forms the groundwork. Giving them time to read and research the subject matter is what will foster independence and critical thinking. The schedule assists in navigating through pertinent information and aligns with shadowing in different areas in the hospital. As bedside care providers we expect sterile instruments, clean linen, food at the right
“The tools and information available to set novice IPs up for their professional journey in infection prevention are readily available online, on your phone, on websites, in publications: a truly vast amount of very good information. The goal is not only to train new professionals, but to provide them the opportunity to grow to love this profession.”
temperature, and our supplies to be readily available. As they read about these services and shadow different areas of the facility, it links them to the healthcare team and gives them the opportunity to ask questions about operations, infection prevention risks, and safety. Prior to shadowing, we review the chapter and I ask them to have at least three questions to ask the person they are shadowing; then we debrief after their experience. It is a great time to discuss any issues, concerns, or successes from that location. I have found that as we take this journey together, we intertwine the role of teacher and student. New eyes bring questions that challenge our current practice, work flow, and processes. A fresh perspective can bring innovative thinking and questioning to the forefront. The classic question of “why we do things the way we do?” can help to validate and also help us to improve our programs to meet new challenges. Jo Micek, RN, CIC, is a registered nurse with more than 30 years of infection prevention experience as a consultant, educator, mentor, and manager. She participates locally, statewide, nationally, and internationally providing services across the healthcare continuum. One of her favorite roles is mentoring and challenging new practitioners as they grow in their roles as infection preventionists. Additional Resources 1. Anderson, P. Teaching Infection Prevention Using Concept Mapping Learning Strategies. AJIC. 2013, Volume 41, Issue 6, Supplement, S58. 2. Burnett, E. Outcome competences for practitioners in infection prevention and control. AJIC. 2011, Volume 39, Issue 12: 67–90 3. Gase, K. Advancing the Competency of Infection Preventionists. AJIC. 2015: Volume 43, Issue 4, 370-379. 4. Goss, L. Validating Healthcare-associated Infection Designation in a Large Healthcare System: Advancing Competency of the Infection Preventionist. AJIC. 2014; Volume 42, Issue 6, Supplement, S13. 5. Murphy, DM. Competency in infection prevention: A conceptual approach to guide current and future practice. AJIC. 2012; Volume 40: Issue 4, 296-303. 6. Landers, T. APIC MegaSurvey: Methodology and overview. AJIC. 2016 published online January 23, 2017 7. National Health Safety Network (NHSN), https://www.cdc.gov/ nhsn/ 8. The Society for Healthcare Epidemiology of America (SHEA) Compendium of Strategies to Prevent HAIs https://www.sheaonline.org/index.php/practice-resources/priority-topics/ compendium-of-strategies-to-prevent-hais 9. Association for Professionals in Infection Control and Epidemiology (APIC) Professional Practice http://www.apic.org/ Professional-Practice/Practice-Resources 10. Association for the Advancement of Medical Instrumentation (AAMI), http://www.aami.org/index.aspx 11. Center for Disease Control and Prevention (CDC) https://www. cdc.gov/
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WHEN DUTY CALLS A PARTNERSHIP BETWEEN FIRE AND RESCUE AND INFECTION PREVENTIONISTS BY JILL HOLDSWORTH, MS, CIC, NREMT, FAPIC
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WHEN DUTY CALLS
E
mergency medical services (EMS) providers are on the front line of pre-hospital care, affecting our patients in ways they might not be aware. From the moment EMS arrives on scene, until they leave the patient in the care of the emergency department (ED) staff at the hospital, many opportunities exist to transmit bacteria, contaminate indwelling devices, and cross-contaminate. Lieutenant Robert Presgrave of Virginia’s Prince William County Health and Safety said, “Strengthening the inseparable link between the health and safety officers and hospital infection preventionists (IPs) only further enhances employee and patient safety, infection prevention, and quality of care.” As the hospital IP, there are many opportunities to improve the health and safety of the community you serve and prevent infections when you form a partnership with your local fire and rescue organization. So where do we start? It may be overwhelming at first to get fire and rescue to start thinking like an IP. It may also seem like a giant task to the IP to figure out where to start! A good starting point would be to volunteer to review current policies and procedures with the safety team as well as their current Exposure Control Plan. From there, you will understand where the priorities of the organization lie, as well as what gaps you immediately can identify. Being strategic about the topics to start with is key in keeping them engaged and excited about the new information. Start small (contact time for disinfectant, handwashing, etc.), and slowly build into more complex topics (microbiology, lab testing procedures, transmission of disease). BLOODSTREAM INFECTIONS
Paramedics often, if not routinely, start an intravenous (IV) line in the field because of the potential to push fluids and/or meds urgently. Some even think they are doing the hospital a favor by starting the IV line. What they may not know is that many hospitals have policies related to removing EMS lines within a certain time period after the patient arrives. Why is this? EMS lines are sometimes inserted in non-ideal situations, skin prep is questionable, and the line can’t be considered a suitable line to draw blood cultures from due to the risk of contamination. Do EMS professionals know this? More importantly, do they know how they can improve their practice? Some have heard that the hospitals remove their lines, but teaching them the “why” behind this practice can actually improve their own insertion and skin prep techniques simply through awareness. Reviewing appropriate skin prep obstacles with patient hygiene, as well as proper technique, can be a life-saving initiative the IP can perform in partnership with leaders in the EMS community. The IP can offer to observe the IV insertion technique, do a ride-along to watch practice and risk of cross-contamination, and go over skin prep: cleaning versus disinfection of the skin. Scenario: A patient is brought in via EMS transport; an IV is started en route. The patient was found lying in a park, skin very dirty. The paramedic cleansed the skin once before starting the IV (the alcohol swab was very dirty after cleaning once). The patient has blood cultures drawn at the hospital, which come back contaminated. Now, treatment is delayed; prophylactic antibiotics may have already been started, making repeat cultures questionable. Did the 66 | SUMMER 2017 | Prevention
medic introduce bacteria into the bloodstream through inadequate skin cleansing before starting the IV? How can this be improved? What would happen if the same patient had a central line placed in the ED shortly after arriving, and 48 hours or more later, blood cultures were taken and they were positive, with signs and symptoms of a bloodstream infection. How can you be sure the practice in the field didn’t affect the bloodstream infection and potential CLABSI? CLOSTRIDIUM DIFFICILE TRANSMISSION IN THE COMMUNITY
Hospitals are working diligently on decreasing the incidence of Clostridium difficile (C. diff) in the community through antibiotic stewardship efforts, but what about decreasing the spore transmission through our community health providers who transport patients to our hospitals? Many EMS agencies complete many transfers from long-term care facilities, skilled nursing facilities, and dialysis centers. These patients should be considered at high risk for C. diff transmission, especially when loose stools are present. For ambulance units, bacteria contamination can easily happen all over the back of the ambulance, and even to the front via the steering wheel and other items by the hands of the driver.1 If not cleaned adequately, the spores could remain in the unit for many months, passing off to other members of the community, other EMS employees, and to the families of the patients. Improper cleaning and handwashing
@iStockphoto.com/vm
Dirty lines and false alarms: Blood culture contamination in the emergency department BACKGROUND Contaminated blood cultures cause unnecessary treatments, increased costs on the hospital and patient, and increased length of stay. The unnecessary use of antibiotics may lead to further antibiotic resistance. Methods to reduce blood culture contamination include proper decontamination of the intravenous line insertion site prior to line insertion, and decontamination of an indwelling line hub prior to blood culture collection. These critical steps may be missed in the pre-hospital setting and during initial contact of an emergent patient in the emergency department. METHODS This is a retrospective examination of blood culture results of all emergency department patients in a 766-bed tertiary-care, university hospital over a 13-month period. National Healthcare Safety Network (NHSN) definitions of a contaminated blood culture were used to determine the outcome of all blood draws. To learn the results and conclusions of this scientific abstract, visit this poster at the APIC 2017 Annual Conference. Abstract poster hours are as follows: Wednesday, June 14, 10:30 a.m. – 5:30 p.m.; Thursday, June 15, 8 a.m. – 5:30 p.m.; and Friday, June 16, 8 a.m. – 1 p.m. The author will be standing by this poster on Wednesday, June 14, and Thursday, June 15, from 12:30 – 1:30 p.m. Sundermann, poster session EC-061
of EMS personnel can actually lead to increased incidence of C. diff in the community. How can IPs help? Through education and auditing, process improvement, and awareness. These can all go a long way with understanding why we use so much bleach, why handwashing is a must, and how they can directly impact the health of the community through these simple steps.2 Scenario: The hospital has ramped up the C. diff prevention efforts and are using bleach on all discharges in the ED. The medic units consistently find that they are bleaching their uniforms and complain to operations that they want to stop using bleach. Their request is granted and a memo goes out stating that the medic units will no longer use bleach-based products. In a high incidence of C. diff community, the medic units now spread C. diff throughout the community through improper cleaning technique for potential and confirmed C. diff infections. SURFACE DISINFECTION PRACTICES
As IPs, we are constantly monitoring and improving the surface disinfection practices in patient rooms, procedure rooms, and all over the facility to decrease the chance for cross-contamination. An extension of this would be to improve the disinfection practices in the patient room used to transport the patient to our facility, aka, the ambulance.3 Where do we start? Assist with education on contact times for the agency’s disinfectants and take an inventory of
all the products being used in the organization. Make suggestions for more efficient and easier to use products, and consolidate products between career and volunteer staff/stations. Environmental cleanliness audits can be conducted by putting fluorescent markers on surfaces in the ambulance and checking with a black light after the crew cleans the ambulance. Reviewing the standard procedure for cleaning or assisting with creating a standard procedure (i.e., when to clean the ambulance and what items should be included) can be beneficial. Scenario: Patients being transported to your hospital ED are being transported in ambulances that have not had appropriate cleaning practices. As a result, bacteria, viruses, and spores are being picked up by the patients, potentially causing infections that may not show up until later in their hospital stay. This could potentially cause hospital-associated infections (HAIs) as a result of poorly cleaned ambulance units. EQUIPMENT CLEANING STANDING PROCEDURE
Patient equipment is often used on patients in the back of the ambulance, or in the field, and replaced back into the jump bag without proper cleaning. This also presents the risk of contamination inside the jump bag as well, so cleaned items are re-contaminated when placed in their respective pockets. The IP can review the various items being used by EMS and make suggestions for easier w w w.apic.org | 67
WHEN DUTY CALLS to clean items, such as vinyl jump bags versus cloth, disposable laryngoscope blades versus reusable—with high-level disinfection (HDL) required—and even the type of sharps containers being kept inside jump bags versus under the main seat. Scenario: A patient fell in the kitchen and called 911. The medic team brings their bag and equipment into the kitchen to care for the patient. The patient’s kitchen is contaminated with Pseudomonas, which now has contaminated the jump bag and the medic’s hands. The medic team uses several pieces of medical equipment, which they did not clean after use, and puts it back in the bag in various pockets. The inside of the jump bag, the outside of the bag, and all of the equipment are now contaminated and contribute to spreading bacteria to other patients, to the inside of the ambulance, and lead to contaminating a central line that the medic accidentally touched while providing care. The jump bag is also made of cloth and cannot be effectively cleaned. The IP can educate the team on the importance of cleaning all equipment after use, having a jump bag that can be cleaned, and the risks of contamination downstream.
we serve. The IP has performed environmental cleaning audits, provided targeted education for the Infection Control Safety Officers, sits on task forces responsible for providing organizationwide education, and provides recommendations to improve HLD processes for reusable medical equipment. The IP also serves in the capacity of consultant and mentor when situations arise that require process improvement, education, or questions answered. As partners, the IP and EMS safety officers work together to improve processes, policies, and knowledge gaps. This relationship has benefited not only the fire and rescue standard of practice, but ultimately benefits the patients and residents in the community. As a result, this partnership will lead to the safest possible care of the patients in our community, as well as ensuring bacteria isn’t transmitted during pre-hospital care, leading to development of an HAI after admission.
A MODEL PARTNERSHIP IN NORTHERN VIRGINIA
2. McGuire-Wolfe C, Haiduven D, Hitchcok CD. A multifaceted pilot program to promote hand hygiene at a suburban fire department. Am J Infect Control 2012: 40:324-327.
In Northern Virginia, a unique partnership has been formed in Prince William County between the Fire and Rescue Office of Health and Safety and the local hospital IP. What started as improving the exposure notification and testing process has turned into a county-wide improvement strategy to prevent HAIs and provide the safest continuum of care possible for the community
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References 1. Rago J, Buhs K, Makarovaite V, Patel E, Pomeroy M, Yasmine C. Detection and analysis of Staphylococcus aureus isolates found in ambulances in the Chicago metropolitan area. Am J Infect Control 2012: 40:201-205.
3. Valdez M, Sexton J, Lutz EA, Reynolds K. Spread of infectious microbes during emergency medical response. Am J Infect Control 2015: 43:606-611
Jill Holdsworth, MS, CIC, NREMT, FAPIC, is an infection control manager and the Association for the Advancement of Medical Instrumentation Protective Barriers Co-Chair.
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PATIENT CARE
ENVIRONMENT OF CARE
INTERVENTIONAL CARE
HOW CLEAN IS
YOUR SCOPE? BY VICKY UHLAND
I
n 2015, the American Journal of Infection Control (AJIC) published a study on endoscopes conducted by researchers from the Mayo Clinic and St. Paul, Minnesota-based Ofstead & Associates. The conclusion? Despite following cleaning and high-level disinfection (HLD) processes in accordance with national guidelines and institutional protocols, the researchers found that viable microbes and residual contamination on the endoscope surfaces persisted throughout the stages of reprocessing.
“We had a physician and one of the researchers observe each step of the cleaning and disinfection process. We confirmed the techs did everything by the book, and the scopes were still contaminated,” said Cori Ofstead, MSPH, president and CEO of Ofstead & Associates. “So we started wondering: ‘Is there something about the scopes that makes them impossible to clean?’” She noted that the endoscopes used in the study were about five to six years old and had been through more than 2,000 procedures each. Were the scopes simply
too old and beat up to get completely clean? Ofstead and her research team, along with a colleague from the University of Minnesota, decided to find out. NEWER SCOPES, RIGOROUS REPROCESSING STILL RESULTED IN CONTAMINATED SCOPES
In a study published in the February 2017 issue of AJIC, the researchers tracked reprocessing effectiveness for 20 gastroscopes and colonoscopes from an ambulatory-care facility that only used each scope once a day, w w w.apic.org | 71
HOW CLEAN IS YOUR SCOPE?
on average. The scopes ranged in age from three months to two years. The scopes were divided into a control group and an intervention group. Over a seven-month period, the controlgroup endoscopes underwent a bedside precleaning process that involved wiping external surfaces and flushing channels with detergent immediately after procedures. This was followed by leak testing, manual cleaning, and HLD with a solution of 2.5 percent glutaraldehyde in automated endoscope reprocessing (AER) machines. The intervention group process was the same, except for an extra cleaning step done in the AER and the type of disinfectant used. For this group, the endoscopes underwent automated cleaning with detergent before HLD with five percent peracetic acid (PA) solution. This was based on evidence that glutaraldehyde can cause protein fixation, and PA can remove that protein buildup. Reprocessing technicians also did adenosine triphosphate (ATP) tests on both the biopsy port and suction-biopsy channels of the intervention-group scopes. If ATP levels were high, the scope was manually recleaned and tested again. Whenever the second test failed, the scope went through two AER cycles, with retesting after the first cycle. At baseline, after two months, and at the end of the study, the researchers did microbial cultures, ATP tests, and protein biochemical tests on all the reprocessed scopes from both the control and intervention groups. They also visually examined each scope with a borescope—a tiny endoscope that can look inside bigger endoscopes. According to Ofstead, “It’s like doing a colonoscopy and upper GI procedure on a scope—both the upper and lower GI sections.” Despite the rigorous cleaning and disinfection methods, at the final assessment, the researchers found that all 20 endoscopes had visible irregularities, including fluid, discoloration, scratches, or debris in the channels. And 60 percent of the scopes had microbial growth. This occurred in both the control and intervention scopes. Every endoscope had ≤10 CFU except 1 intervention AC with 15 CFU. Two potential pathogens were found (Corynebacterium and Methylobacterium extorquens). 72 | SUMMER 2017 | Prevention
In addition, 20 percent of the endoscopes in each group had ATP and protein residue levels above benchmark, which indicated that cleaning procedures were not effective. ATP levels were also higher in gastroscopes than colonoscopes. WHAT CAN INFECTION PREVENTIONISTS DO?
While this study may be disheartening, Ofstead said there are steps infection preventionists (IPs) can take to help improve scope reprocessing in their facilities. • The Society of Gastroenterology Nurses and Associates (SGNA) and the Association of PeriOperative Registered Nurses (AORN) guidelines, along with the Association for the Advancement of Medical Instrumentation’s (AAMI) Standard 91 say that visual endoscope inspections, using lighting magnification, should be done after every reprocessing and before an endoscope is used on a patient. “This is a quick, easy solution,” Ofstead said. She suggests setting up an inspection station in the reprocessing room and designating someone to do a visual inspection on “every scope, every time.” • Verify biochemically that scopes are clean before HLD. Otherwise, the debris can harden onto a scope and become difficult to remove. “Tests for ATP, hemoglobin, and protein are quick to do and not very expensive,” Ofstead said. • Consider doing more frequent scope assessment and repairs, especially for new scopes. “Facilities can identify early on if a scope gets damaged so it can be repaired before contamination builds up,” she said. • Have a checklist of protocols for scope cleaning and use, and do unannounced audits at least once a month. This includes checking the processes used at bedside, precleaning, leak testing, manual cleaning, disinfection, and drying. • Regularly check material usage logs and ordering history in the reprocessing units. Per Ofstead, this can tell you if the staff is doing the proper tests and using the right amount of materials. For instance, the reprocessing team should be using test strips to see if the disinfectant is at the proper strength. Looking at the date on a bottle of test strips, checking how many
reprocessing cycles occurred since that date, and counting the number of strips in the bottle can tell you if the recommended amount of testing occurred. In addition, keep an eye out for new endoscope designs, such as scopes that can be disassembled or have single-use components—including a single-use channel for cystoscopes. Ofstead said single-use bronchoscopes and ureteroscopes are now available, and there will be a single-use colonoscope on the market within the year. Her company has received research funding from both the ureteroscope and colonoscope manufacturer, as well as the companies that make the reprocessing and monitoring equipment used in the 2017 study.
READ MORE ABOUT ENDOSCOPE REPROCESSING IN THE AMERICAN JOURNAL OF INFECTION CONTROL Persistent contamination on colonoscopes and gastroscopes detected by biologic cultures and rapid indicators despite reprocessing performed in accordance with guidelines, Ofstead CL, Wetzler HP, Doyle EM, et al., American Journal of Infection Control, Vol. 43, Issue 8, p794-801. Contamination of a purified water system by Aspergillus fumigatus in a new endoscopy reprocessing unit, Khalsa K, Smith A, Morrison P, et al., American Journal of Infection Control, Vol. 42, Issue 12, p1337-1339. Analysis of the air/water channels of gastrointestinal endoscopies as a risk factor for the transmission of microorganisms among patients, Ribeiro MM, de Oliveira AC, American Journal of Infection Control, Vol. 40, Issue 10, p913-916. Correlation between the growth of bacterial biofilm in flexible endoscopes and endoscope reprocessing methods, RenPei W, Hui-Jun W, Ke Q, et al., American Journal of Infection Control, Vol. 42, Issue 11, p1203-1206.
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INDEX TO ADVERTISERS BEDPAN WASHER MEIKO ���������������������������������������������������������������������9 www.meiko.us
DISINFECTION APPLIANCE Hygie Canada ��������������������������������������������������������24 www.hygiecanada.com
INFECTION RESISTANT COATING The Sherwin-Williams Company ������������������������� 34 www.sherwin-williams.com/pro
CLEANING, DISINFECTION, & STERILIZATION Halosil International ����������������������������������������������57 www.halosil.com Molnlycke Health Care ������������������������������������������47 www.Hibiclens.com/HUBS PDI, Professional Disposables International ���������70 www.pdihc.com/skinplussite Steriliz, LLC �������������������������������������������������������������3 www.rduvc.com Tru-D Smart UVC ��������������������������������������������������30 www.tru-d.com Virox Technologies Inc. �����������������������������������������33 www.virox.com/peroxigirl
HAND HYGIENE DebMed ����������������������������������������������������������������11 www.debmed.com
IV DRESSING CareFusion ������������������������������������������������������������23 www.bd.com/ClearChloraShield
INFECTION CONTROL PRODUCTS
LABORATORY SERVICES Special Pathogens Laboratory ������������������������������32 www.specialpathogenslab.com
CLOSED SYSTEM NEEDLE SAFETY DEVICES B. Braun Interventional Systems Inc. ���������������������������� Inside Back Cover www.bisusa.org
INFECTION PREVENTION PRODUCTS & SERVICES BD Diagnostics ��������������������������Outside Back Cover www.bd.com Eloquest Healthcare ����������������������������������������������37 www.mastisol.com
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74 | SUMMER 2017 | Prevention 865508_Editorial.indd 1
DQE, Inc. ���������������������������������������������������������������73 www.dqeready.com Healthmark Industries Co. ������������������������������������73 www.hmark.com Nanosonics Limited ����������������������������������������������13 www.nanosonics.us SEAL Shield ���������������������������������Inside Front Cover www.sealshield.com
INFECTION PREVENTION SOLUTION CONSULTING Xenex Disinfection Services ����������������������������������58 www.xenex.com
MEDICAL DEVICES & INSTRUMENTS Retractable Technologies, Inc. ������������������������������29 www.vanishpoint.com NASAL ANTISEPTIC 3M �������������������������������������������������������������������������5 www.mmm.com Global Life Technologies Corp. �������������������������������4 www.nozin.com SKIN PREPARATION CareFusion ����������������������������������������������������������� 64 www.bd.com/ChloraPrep-Skin
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References: 1. Centers for Disease Control and Prevention. Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae—2014. MMWR Recomm Rep. 2014;63(RR-02):1-19. 2. Hirvonen JJ et al. Comparison of BD Max Cdiff and GenomEra C. difficile molecular assays for detection of toxigenic Clostridium difficile from stools in conventional sample containers and in FecalSwabs. EJCMID. 2015;34(5):1005-1009. 3. Mortensen JE et al. Comparison of time-motion analysis of conventional stool culture and the BD MAX Enteric Bacterial Panel (EBP). BMC Clin Pathol. 2015;15:9. 4. Le Guern R et al. Evaluation of a new molecular test, the BD Max Cdiff, for detection of toxigenic Clostridium difficile in fecal samples. J Clin Microbiol. 2012;50(9)3089-3090. 5. Bauman M. Transitioning from culture to molecular: implementation and integration of BD Max Enteric Bacterial Panel at Cincinnati Children’s Hospital. ADVANCE Healthcare website. http://laboratory-manager.advanceweb.com/ SharedResources/Downloads/2015/051815/bd_advertorial.pdf. Updated June 2015. Accessed June 1, 2016. 6. Felder RA et al. Process evaluation of an open architecture real-time molecular laboratory platform. J Lab Autom. 2014;19(5):468-473. © 2016 BD. BD, the BD Logo and BD MAX System are trademarks of Becton, Dickinson and Company. BD, 7 Loveton Circle, Sparks, MD 21152-0999 USA Tel: 1.800.638.8663 bd.com/ds