Prevention Strategist—Winter 2018 by APIC Publications

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Contents

FEATURES

WINTER 2018

WINNER 8 201 E H T F O OM C R A M GOLD AWARD

Can real-time data drive hand hygiene improvements? By Chris Hermann

Emerging models of ambulatory care By Constance Cutler, Jill Lindmair-Snell, and Brian Dennen

How clean is the linen at YOUR hospital? By Alexander Sundermann, Cornelius Clancy, and Hong Nguyen

6 | WINTER 2018 | Prevention

Process improvement model A3 to reduce HAIs: Looking through a different lens By Jennifer Spivey

CLABSI RCA tool for oncology/hematology patients: How we prioritized which metrics to tackle By Brenna Doran, Suwannee Srisatidnarakul, Sanjeet Singh Dadwal, and Annemarie Flood

Tiger of a different stripe: Oral cavity properties that alter infection risk By Joshua Ulibarri, Damon Pope, and Gary Carter

COVER PHOTO CREDIT: CASPER1774 STUDIO/SHUTTERSTOCK.COM

VOICE

With gratitude

By Janet Haas, 2018 APIC President

The C-suite connection begins: A year in review

The future of certification

By Katrina Crist, APIC CEO

By Joann Andrews, 2018 CBIC President

DEPARTMENTS Briefs to keep you in-the-know • 2018 Heroes of Infection Prevention, Part 2 • Quick observation tools • NAM honors Elaine Larson • C-suite survey: Summary of results

Meet an MPH

Capitol Comments: Congress passes bill funding infection prevention programs

Infection prevention leadership: Recipient of the 2018 Carole DeMille Achievement Award

Q&A with Matthew Ellis

By Rich Capparell, Nancy Hailpern, and Lisa Tomlinson

A Conversation with Terrie Lee

PREVENTION IN ACTION Focus on long-term care and behavioral health outbreaks: Identify the pathogen!

From data to decisions: Interpreting uncertainty: Confidence intervals

By Steven Schweon

By Christina Bronson-Lowe and Daniel Bronson-Lowe

How the infection prevention landscape is changing By Kathryn Galvin and Adrienne Pinto

Making the pitch to executive row—Part 2: Presenting the proposal By William Ward, Jr.

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PRESIDENT’S MESSAGE

With gratitude

BY JANET HAAS, PhD, RN, CIC, FSHEA, FAPIC, 2018 APIC PRESIDENT

“This year we educated infection preventionists and other healthcare professionals at both live and online courses, including hosting more than 5,000 attendees at the 45th Annual Conference.”

AS THE YEAR is coming to an end, it is time for me to express my grati-

tude for a wonderful year as the 2018 APIC President. We had some big projects, such as the revision of the APIC Competency Model, The Role of the Infection Preventionist in a Transformed Healthcare System consensus conference, and the launch of the APIC/SHEA Joint Leadership Development Course. All initiatives are future-oriented and will help guide our practice in the coming years. This year, we educated infection preventionists (IPs) and other healthcare professionals at both live and online courses, including hosting more than 5,000 attendees at the 45th Annual Conference. And don’t forget the newly produced video on the role of the IP, describing our profession for those who might not know what we do, and encouraging others to join us. If you haven’t seen it, check it out here: www.apic.org/IPsSaveLives. Please feel free to use it in your education and recruitment efforts. The APIC Board of Directors and committee members volunteer their time and expertise to keep APIC’s mission moving forward, and I thank them for their dedication, strategic vision, and hard work. We also partnered with the Certification Board of Infection Control and Epidemiology, the Society for Healthcare Epidemiology of America, the Centers for Disease Control and Prevention, the Association of periOperative Registered Nurses, the World Health Organization, the American College of Surgeons, The Joint Commission, and the Pew Charitable Trusts to work on specific issues such as certification, surgical attire, and antimicrobial stewardship. A special thank you goes to the APIC staff members, whose full-time job is to support IPs and the association. It would not be possible to execute APIC’s mission to create a safer world through prevention of infection without their help every single day. Thank you, thank you, APIC staff. Finally, to our members, thank you. Thank you for inviting me to your chapters, thank you for telling me what sessions you thought were great at annual conference, thank you for approaching me with things you’d like to see added or improved in your APIC experience. We have acted on some of these requests: starting a separate listserv for IPs with corporate responsibilities, adding training opportunities for those outside of acute care, and working to translate patient educational materials into Arabic for our chapters in the United Arab Emirates, Egypt, and Saudi Arabia in the coming year. APIC truly is the trusted name for infection prevention and control worldwide, and I’m proud that the mission of APIC will continue under the exceptional leadership of Karen Hoffmann in 2019. I wish her and all of us much success in the coming year. With Gratitude,

Janet Haas, PhD, RN, CIC, FSHEA, FAPIC

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BOARD OF DIRECTORS President Janet Haas, PhD, RN, CIC, FSHEA, FAPIC President-Elect Karen Hoffmann, RN, MS, CIC, FSHEA, FAPIC Secretary Ann Marie Pettis, RN, BSN, CIC, FAPIC Treasurer Sharon Williamson MT(ASCP)SM, CIC, FAPIC Immediate Past President Linda Greene, RN, MPS, CIC, FAPIC

DIRECTORS Dale Bratzler, DO, MPH, MACOI, FIDSA Tania Bubb, PhD, RN, CIC, FAPIC Thomas Button, RN, BSN, NE-BC, CIC, FAPIC Linda Dickey, RN, MPH, CIC, FAPIC Beth Duffy, MBA Annemarie Flood, RN, BSN, MPH, CIC, FAPIC Pat Metcalf Jackson, RN, MA, CIC, FAPIC Irena Kenneley, PhD, RN, CNE, CIC, FAPIC Lela Luper, RN, BS, CIC, FAPIC Carol McLay, DrPH, MPH, RN, CIC, FAPIC Barbara Smith, RN, BSN, MPA, 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.

CEO’S MESSAGE

The C-suite connection begins: A year in review

APIC HAS SPENT THE PAST YEAR working to elevate the role of the infection

preventionist (IP). In March and April, APIC conducted research to gain an understanding of how C-suite hospital executives view the role of the infection preventionist (IP). We are delighted to share a summary of these results, which identify top concerns for hospital executives and indicate that the influence of the IP appears to be increasing in many hospitals. See page 18 for the summary of results. In May, the Society for Healthcare Epidemiology of America’s former executive director, Eve Humphreys, and I authored an article published in Becker’s Clinical Leadership & Infection Control titled “Is your hospital ready for the next outbreak, epidemic, or even another bad flu season?” (www.apic.org/APICSHEAarticles). The article communicates the value of IPs and healthcare epidemiologists in designing and implementing strategies that eliminate preventable infections, while also maintaining fiscal responsibility.

BY KATRINA CRIST, MBA, CAE, APIC CEO

In June, we also authored a Modern Healthcare commentary: “C-suites should see antibiotic stewardship and infection control as one issue,” (www.apic.org/APICSHEAarticles). This article encouraged health system leaders to take the lead in maximizing the effectiveness of these programs by aligning stewardship and infection prevention and funding them adequately. In November, APIC conducted a national consensus conference on The Role of the Infection Preventionist in a Transformed Healthcare System: Meeting Healthcare Needs in the 21st Century. The goal was to take the blinders off and look through the lens of diverse stakeholders, including healthcare executives, to address these future-oriented questions: • How could the IP’s role be reimagined to provide more broad-based, value-driven contributions to the healthcare system? • How can we identify and develop leaders and keep them in the field at all levels of practice? • How can we create stronger partnerships with executive organizations (e.g., ACHE, AONE) to provide much-needed education to emerging IP leaders and executives with responsibilities for infection prevention and control (IPC)? • How can IPs leverage data, emerging technologies, and their unique knowledge and skills to improve effectiveness and patient safety as the healthcare environment expands beyond traditional settings? • How can IPC programs position themselves to leverage their value and create opportunities for revenue generation? As system challenges continue to represent an unprecedented opportunity for healthcare leaders to work toward the elimination of healthcareassociated infections, reimagining the IP’s role is likely to bring us closer and closer to the C-suite.

Katrina Crist, MBA, CAE

10 | WINTER 2018 | Prevention

Prevention W I N T E R 2 018 • VO L U M E 11 I S S U E 4

PUBLISHER Katrina Crist, MBA, CAE kcrist@apic.org MANAGING EDITOR Rickey Dana editor@apic.org CONTRIBUTING EDITORS Julie Blechman, MPH, CHES Elizabeth Garman, CAE Elizabeth Nishiura PROJECT MANAGER Russell Underwood runderwood@naylor.com ADVERTISING Brian Agnes bagnes@naylor.com GRAPHIC DESIGN BK Publication Design

EDITORIAL PANEL Timothy Bowers, MS, CIC, CPHQ, FAPIC Gary Carter, MPH, CIC, CIH, REHS, DAAS Kristine Chafin, MBA, RN, CIC Edina Fredell, MPH, CIC, MT(ASCP) Ruth Freshman, MSN, RN, CIC Kathryn Galvin, MS, MLS(ASCP)CM, CIC Meagan Garibay, RN, BSN, CIC Jessica Hayashi, MS, RN, CIC, CPHQ, FACHE Adrienne Pinto, MSN, RN, CIC Alexander Sundermann, MPH, CIC Christine Young-Ruckriegel, RN, MSN, MPA, CIC

CONTRIBUTING WRITERS Michelle Parisi Colin Richardson

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 DECEMBER 2018 API-Q0418 • 8609

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CELEBRATING EXCELLENCE

The future of certification

BY JOANN ANDREWS, DNP, RN, CIC, 2018 CBIC PRESIDENT

“As IPs, we look to the literature to show us how to protect patients and improve processes. CBIC is committed to providing evidence that certification also improves patient care and increases safety.”

THE FOCUS OF MY PREVIOUS COLUMNS has been on

change and making improvements to position the Certification Board of Infection Control and Epidemiology (CBIC) and infection preventionists (IPs) for the future. The future for infection prevention and control (IPC) lies within each one of us. I have been fortunate to see the future through the eyes and thoughts of those who communicate with CBIC either through email, social media, or in person at the CBIC booth during conferences. I feel privileged to hear stories from the IPs who are trying to provide for greater patient safety in their facilities. In the United States, and internationally, the concerns of IPs are frequently similar: How can I garner the skills and knowledge to assure that we truly “prevent” infections rather than the old paradigm of “controlling” them? In response, many have chosen to pursue the certification in infection prevention and control (CIC ®) as the mechanism that provides for a skilled and prepared IPC workforce able to manage the challenges of the future. As IPs, we look to the literature to show us how to protect patients and improve processes. CBIC is committed to providing evidence that certification also improves patient care and increases safety. You may remember that in 2017, CBIC announced the commissioning of a study to evaluate “The Value of Certification” as part of the 2016-2019 Strategic Plan. I’m happy to let you know that the survey results will be shared in 2019. We want to provide current and future CICs with evidence that obtaining this credential can translate to both personal and professional value. Stay tuned for details as they become available. We thank the more than 4,000 professionals who contributed their thoughts and time during the survey period in May. CBIC will also embark on a new strategic planning process in late 2018. The new Strategic Plan (2019 – 2022) will help to drive the goals established in the past and to envision the future of certification. This is always an exciting opportunity, full of new possibilities as we allow ourselves the time and space to think creatively and join together in alignment with our partners to pursue greater opportunities to protect the public and to meet the mission of CBIC. It’s difficult to believe that 2018 is almost over and the 35th anniversary will come to a close. We have been actively celebrating the 35th anniversary of the CIC, and we are pleased to announce that at this time, CBIC’s website reports more than 7,200 IPs hold the CIC. I have been honored to serve as your president, and I offer many thanks for the hard work that goes on behind the scenes from our superb executive team, and the diligence and foresight from each member of the CBIC Board of Directors. I wish to offer sincere congratulations to all who were recently certified as the world’s newest CICs and to you who recertified this year! You are our heroes—and truly the future of infection prevention.

Joann Andrews, DNP, RN, CIC

12 | WINTER 2018 | Prevention

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BRIEFSTOTOKEEP KEEPYOU YOUIN-THE-KNOW IN-THE-KNOW BRIEFS

Meet the 2018 Heroes of Infection Prevention VISIT THE HEROES OF INFECTION PREVENTION web page to read full profiles and inspirational stories from the heroes: www.apic.org/About-APIC/Awards/Heroes.

Tackling multiple HAIs through collaboration and consistency

Cindy Hou, DO, MA, MBA, FACOI Jefferson Health New Jersey Cherry Hill, New Jersey

DR. CINDY HOU has systematically created and sustained programs that reduce rates of multiple healthcareassociated infections (HAIs) while improving collaboration around patient safety at her hospital system. Named physician chair of infection control for Jefferson Health New Jersey in 2012, Hou quickly determined that she wanted to expand beyond the infection control committee to reduce HAIs. She established a task force to address rising Clostridium difficile (C. diff) rates that same year and followed annually with new task forces addressing central line-associated bloodstream infections (CLABSIs) in 2013, Sepsis on the Floors program in 2014, and catheter-associated urinary tract infections (CAUTI) in 2015. Hou’s multi-disciplinary approach emphasizes leadership involvement and mutual respect to ensure taskforce members’ engagement and long-term participation. “It’s very important to get the right people on board,” Hou said. “You need a physician champion and a nursing champion. Then you need to engage people directly and show

you respect them. We constantly give feedback highlighting areas for improvement, but also recognizing achievement.” Hou holds regular “action-oriented” task force meetings that draw upon every member’s expertise. Her approach has generated impressive results: CLABSI rates at Jefferson Health have decreased from 1.8 in 2016 to 0.4 in 2017. CAUTI cases declined from 27 in 2013 to 17 in 2016. Antibiotic use decreased while the hospital-associated C. diff rate declined from 5.1 to 3.0 in two years. The unique “Sepsis on the Floors” program—emphasizing recognition and management of hospital-onset sepsis—helped to decrease sepsisassociated mortality by 10 percent. Along the way, Hou ensured that the practical and cultural changes she and her teams generated were sustained for each project. “You can maintain interest if the right leaders are involved,” Hou said. “We’ve also been very consistent, expanded our task forces regularly, and continually re-educated. We found that if we just keep talking to each other, we can improve care for our patients.”

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BRIEFS TO KEEP YOU IN-THE-KNOW

Engaging multi-disciplinary expertise to generate sustained improvements BY FULLY LEVERAGING expertise from multiple departments, the infection prevention team at Excela Health effectively tackled rising Clostridium difficile (C. diff) rates at their threehospital system. Team leads JoAnn Grote and Deborah Schotting came to infection prevention from different professional backgrounds, so they understood the benefits of varied professional perspectives and experience. “Our department has four infection preventionists (IPs)—two medical technologists and two nurses,” Grote said. “We feel like this is the ideal mix.” When a steadily rising C. diff infection (CDI) rate led Excela Health leadership to establish an internal target for reducing or eliminating the infection, the infection prevention team welcomed the creation of an interprofessional team to help improve patient safety. The system’s continuous improvement team leveraged LEAN methodology to bring everyone together and achieve their goals. “We knew we needed a broad range of expertise to achieve our goals, and the LEAN facilitator really helped us stay on track,” Schotting said. Excela Health’s CDI LEAN team created a comprehensive campaign

JoAnn Grote, BS, MT(ASCP) Excela Health Greensburg, Pennsylvania

Deborah Schotting, RN, MSN, CIC Excela Health Greensburg, Pennsylvania

focused on early identification and prevention of CDIs through appropriate testing, physician education, isolation/safety zone precautions, antibiotic stewardship, environmental cleaning, and staff and patient awareness. “We leveraged everyone’s strengths,” Grote said. “It wasn’t just about infection control and nursing.” In addition to participation from the nursing, pharmacy, laboratory, and environmental services departments, the Excela Health marketing and communications department

created instrumental tools, team members educated nurses about documentation and process, and the system librarian identified key evidence-based resources. In just over two years, the system achieved a 43.8 percent reduction in healthcare-associated CDIs. “This outcome alone demonstrates the power of a multi-disciplinary team, but the cultural awareness we generated about each healthcare worker’s role in combatting these infections is just as important,” Schotting said.

Quick Observation Tools QUICK OBSERVATION TOOLS (QUOTs) for infection prevention and control (IPC), have been developed by APIC and the Centers

for Disease Control and Prevention. These free, downloadable resources help healthcare facilities quickly identify IPC deficiencies so that corrective action can be taken in real time to protect patients from healthcare-associated infections. These tools are thematically arranged cards, and each contains several questions pertinent to a specific healthcare setting and/or topic. They can be used to accumulate data on IPC practices and are designed to be used in a matter of minutes by anyone working in healthcare today. To learn more and view the available tools, visit: apic.org/quots.

16 | WINTER 2018 | Prevention

Collaboration and creativity generate dramatic CAUTI reduction THE INFECTION PREVENTION and control (IPC) team at University of Louisville Hospital developed a program emphasizing continual education, awareness, collaboration, and engagement to reduce catheter-associated urinary tract infections (CAUTIs) at their facility. The team had made some progress in CAUTI prevention, but “we really wanted to hit a tipping point that would enable us to sustain progress,” Sarah Bishop said. This desire led to a facilitywide 2017 CAUTI-reduction goal. The team created a multi-dimensional campaign comprising quality improvement, education initiatives, and creativity to promote reduction of indwelling urinary catheter usage and increase adherence to a nurse-driven removal protocol. The program includes an annual “CAUTI-Free April,” a month-long campaign during which the team intensifies their focus on CAUTI education. Featuring a “Make Voiding Great Again” theme, the 2017 campaign involved around-the-clock rounding on all hospital units, CAUTI-reduction competitions, and prize drawings recognizing best CAUTI-reduction practices. “It’s a fun way to educate and

Crystal Heishman, MSN, RN, ONC, CIC, FAPIC University of Louisville Hospital Louisville, Kentucky

Leah Oppy, MPH University of Louisville Hospital Louisville, Kentucky

raise awareness where it’s convenient for staff,” Crystal Heishman said. “They would see us, they would laugh, and they would pay attention.” “Data showed that our biggest problem was in the ICU, so we really intensified focus in that area,” Leah Oppy said. “We educated personnel on alterative devices and re-educated on the catheter removal process.” Throughout the campaign, the team emphasized collaboration and relationship-building across departments. “You have to

LaShawn Scott, MSN/Ed, RN, CCRN-K University of Louisville Hospital Louisville, Kentucky

Sarah Bishop, MSN, APRN, CCNS, CIC University of Louisville Hospital Louisville, Kentucky

engage the frontline staff and maintain good working relationships to move the process forward,” LaShawn Scott said. Ultimately, the team’s creativity and passion generated a 34 percent decrease in CAUTIs. Continual education, including through nursing orientation and preceptorships, is helping to ensure they’ve reached their “tipping point.” “It’s worked well because all of us really believe in making education fun while positively impacting patient care,” Heishman said.

NAM honors Elaine Larson ELAINE LARSON, PhD, RN, CIC, FAAN, FAPIC, senior associate dean of scholarship and research, Anna C. Maxwell Professor of

Nursing Research, and professor of epidemiology, Columbia University, and editor in chief of the American Journal of Infection Control, is one of three individuals honored by the National Academy of Medicine (NAM) for “extraordinary dedication to furthering science and improving the health of our nation.” Larson received the Walsh McDermott Medal, which is awarded to a member for distinguished service to the National Academies of Sciences, Engineering, and Medicine over an extended period. Learn more at nam.edu/national-academy-of-medicine-honors-three-members-for-outstanding-service-2.

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BRIEFS TO KEEP YOU IN-THE-KNOW

18 | WINTER 2018 | Prevention

MPH PROFILE

A conversation with an MPH infection preventionist LCDR MATTHEW ELLIS, MPH, CIC, REHS INSTITUTIONAL ENVIRONMENTAL HEALTH OFFICER/ PUBLIC HEALTH EMERGENCY MANAGEMENT COORDINATOR U.S. DHHS/INDIAN HEALTH SERVICE PORTLAND, OREGON

Describe your path to getting your MPH degree. I earned my Master of Public Health (MPH) while working full-time as the senior industrial hygienist at the University of Kentucky Environmental Health & Safety Division and as an occupational health specialist at the Lexington VA Medical Center. I was fortunate to complete my MPH Capstone Project on safe patient handling injuries among LEXVAMC healthcare workers, while working at the VA. This was ideal because I was able to incorporate my Capstone Project into an issue I was dealing with at the VA Medical Center. I used it as an opportunity to leverage my data as a basis for improved safety processes.

What inspired you to become an IP? My initial exposure to infection prevention was during my tenure at Air Source Technology, an industrial hygiene consulting firm in Lexington, Kentucky, where we served several healthcare systems throughout the region (e.g., water testing, ventilation studies). One of our clients was the University of Kentucky, during their construction of the new UK Medical Center. (Their major construction activities were next to the then main multi-story air intakes that supplied healthcare specialty services to significantly compromised patients.) I was intrigued by the diligence, attention to detail, and multi-disciplinary team efforts required for an effective infection prevention and control (IPC) program. I went on to participate in, and work with, infection control committees and infection preventionist (IP) staff at the University

of Kentucky and Veterans Healthcare Administration before joining the Indian Health Service.

How long have you been an IP? I have been involved in IP work for more than eight years.

In what ways has your MPH degree benefitted you and your facility? I obtained my MPH early in my career. [Council on Education for Public Health] CEPH-accredited MPH programs include, but are not limited to, required curriculum in biostatistics, epidemiology, environmental health, health policy and management, social and behavioral change sciences, public health and healthcare systems, and evidence-based approaches to public health. Without exception, I believe a strong grasp all of these concepts is critical to an IP functioning at the highest level.

How do you see the MPH degree changing the IP field? The MPH—particularly an MPH with emphasis in environmental health—equips an individual with foundational knowledge in several key IPC areas: cleaning, disinfection, sterilization; prevention of communicable disease transmission; occupational health; outbreak response and management; and several others. In addition, an MPH candidate will have experience with conducting a gap analysis, health assessments, and developing health interventions. While specific infection prevention training and ongoing on-the-job competency development is critical to an IP’s success, I tend to believe that increased w w w.apic.org | 21

MPH PROFILE recruitment of MPHs as IPs may result in greater quantitative analyses of trends and intervention effectiveness.

How did you prepare for the CIC® exam? What helped? I used the resource tools provided by APIC; I particularly valued the test selfassessments to identify areas that required more of my attention. In addition, my Washington State Department of Health

partners were most helpful in sharing resources and study guides.

Why is maintaining a CIC important to you? The CIC is important because it confirms a baseline proficiency of IPC competency and knowledge. Maintaining the CIC credential requires an individual to stay current in the continuously changing and growing field. In addition, the CIC maintenance may

“The MPH—particularly an MPH with emphasis in environmental health— equips an individual with foundational knowledge in several key IPC areas: cleaning, disinfection, sterilization; prevention of communicable disease transmission; occupational health; outbreak response and management; and several others.” expose the individual to areas or processes of IPC that one may not deal with regularly in their current role or health system. It can help ensure a well-rounded IP.

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| Prevention

The CIC does provide additional pedigree to recommendations and may assist with staff buy-in. Along with the CIC credential pedigree, it is important to ensure my technical assistance is always grounded in proven evidence-based best practices and recommendations.

What is the best advice you have ever received?

Managed by an advisory board of laundry, epidemiology, infection control, nursing and other healthcare professionals, Hygienically Clean is the right certification to include in your RFP for linen and uniform service.

920869_TRSA.indd 1 22 | WINTER 2018

Explain how having a CIC has benefitted you.

7/29/18 12:50 PM

A significant portion of my duties are supporting and providing technical assistance to collateral duty IPs, within federal and tribal health facilities, throughout the region. My initial Portland-area IHS supervisor CDR Celeste Davis (ret.) always stressed that we should be attempting to “work ourselves out of a job.” I try to look at my work through that lens when providing IPC training or orientation, technical assistance, and competency development. I try to consistently build IPC capacity within the clinics I serve so that they are equipped to handle turnover in IP staff and maintain continuous readiness for healthcare accreditation requirements and best practices. My recent IPC capacity-building efforts have also targeted healthcare accreditation governing board members, quality and risk professionals, and administrative and clinical leadership.

R U O Y L L A E T I P S E ! D K R O W D HAR NISMS A G R O TANT S I S E R M AND UG L R I F D I O I T L AT MU RFACES IN A B T WORK H T S I VERY N SU S NO E O O C O G S D I N I D Y THE EN LIV TANT SIMPL E B E V HA SINFEC I D R U YO

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CAPITOL COMMENTS

Congress passes bill funding infection prevention programs Next steps: Working on antibiotic resistance and 2020 priorities

F11PHOTO/SHUTTERSTOCK.COM

BY RICH CAPPARELL, NANCY HAILPERN, AND LISA TOMLINSON

“To succeed today, you have to set priorities, decide what you stand for.” –Lee Iacocca

AS IN PREVIOUS YEARS, members of the APIC Board of Directors went to Capitol Hill to speak with their members of Congress to educate them about the role of infection preventionists and the legislative priorities of APIC. There were more than 21 meetings held with representatives from seven states. A major priority during the visits was encouraging Congress to pass the Labor, Health and Human Services, and Education appropriations bill before the beginning of the fiscal year on October 1. This appropriations bill funds key infection prevention programs within the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, and the National Institutes of Health. Additionally, APIC

members encouraged their senators to cosponsor the Strategies to Address Antibiotic Resistance (STAAR) Act, which calls for greater federal attention to combatting antimicrobial resistance. The Board visits were well timed as the Senate was voting on the Labor-HHSEducation and Defense “minibus” the day of their visits to Capitol Hill. After Senate and House passage of the bill with broad bipartisan support, the Departments of Labor, Health and Human Services, and Education will have funding at the start of the fiscal year for the first time in decades.

What is a minibus? Every year, Congress considers 12 individual appropriations bills to fund various w w w.apic.org | 25

CAPITOL COMMENTS

Linda Greene, Tania Bubb, Barbara Smith, Ann Marie Pettis, and Rickey Dana at the office of Sen. Chuck Schumer.

government departments. Ideally, each department’s funding bill is considered individually by a subcommittee with expertise on its issues. However, political disputes often result in these bills getting bogged down by toxic amendments on partisan issues. When months of disagreements delay passage of the bills beyond the end-of-the-fiscal-year deadline, Congress generally gives itself more time by passing a “continuing resolution” keeping the government funded at the current level (level funding) as legislators continue to negotiate. Often, Congress will pass whichever individual bills are seen as non-controversial (e.g., Defense, Legislative Funding) and combine the remaining bills into one large “omnibus” bill and pass it. During President Trump’s first year in office, he signed two omnibus bills (FY 2017 and FY 2018) and indicated reservations about signing another one for FY 2019. So, this year, instead of combining all of the bills into one large omnibus bill, Congress decided to combine several of the bills 26 | WINTER 2018 | Prevention

Carol McLay, Linda Greene, and Karen Hoffmann at the office of Sen. Richard Burr.

into smaller “minibuses.” For example, the Labor-HHS-Education and Defense appropriations were combined into one bill, and the Military Construction and Veterans Affairs, the Legislative Branch, and Energy and Water bills were combined into another.

Why was this year different? Generally speaking, Republicans are more likely to champion additional spending for the Defense budget and Democrats are more likely to advocate for increased spending for the Labor-HHS-Education budget. By combining the priorities of

the two political parties, a compromise proposal gained the support of a large majority of both parties in both houses of Congress. To further encourage this support, a continuing resolution was attached to the bill that funded the remaining government programs until December 7, after the November midterm congressional elections.

What will APIC focus on in the near future? For the last few decades, the LaborHHS-Education appropriation negotiations have generally lasted well past the

September 30 deadline and sometimes even went far into the next fiscal year. However, since FY 2019 funding for infection prevention programs is now decided, there is an opportunity for APIC to focus on other legislative priorities for the remainder of 2018 and the early part of 2019, when Congress will start working on FY 2020 appropriations. APIC has already started to focus on educating members of Congress on the benefits of the STAAR Act and will begin to explore other legislative opportunities as they arise. Additionally, we expect a more difficult environment for FY 2020 appropriations as many members of Congress are expressing their concerns about increasing budget deficits. This will increase the need for more APIC members to contact their members of Congress to have their voices heard in support of infection prevention and control programs. Members are encouraged to visit www.apic.org/advocacy frequently to learn more about APIC’s legislative efforts.

APIC FEDERAL INFECTION PREVENTION PRIORITIES EMERGING AND ZOONOTIC INFECTIOUS DISEASES PROGRAMS

FY 2019 (figures are in millions of dollars)

Antibiotic Resistance Initiative

$168

National Healthcare Safety Network

$21

Advanced Molecular Detection

$30

PREVENTION AND PUBLIC HEALTH FUND (PPHF) Immunizations

$320.5

Epidemiology and Lab Capacity program

$40

Healthcare-Associated Infections

$12

AGENCY FOR HEALTHCARE RESEARCH AND QUALITY (AHRQ)

AHRQ baseline funding

$338

Healthcare-Associated Infections Prevention

$36

NATIONAL INSTITUTES OF HEALTH (NIH)

National Institute of Allergy and Infectious Diseases

$5,523

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INFECTION PREVENTION LEADERSHIP

A conversation with Terrie Lee, RN, MS, MPH, CIC, FAPIC

TERRIE LEE, RN, MS, MPH, CIC, FAPIC, is the director of infection prevention and employee health at Charleston Area Medical Center in Charleston, West Virginia. She received the 2018 Carole DeMille Achievement Award at APIC’s 45th Annual Conference. Terrie’s career has spanned 38 years, with her leadership in APIC nearly as long. She has served as an APIC president, a chapter president, and on several task forces and committees. We asked Terrie to share some insight into her role with APIC and her thoughts on being a leader.

How did you get involved in APIC? I had been a clinical nurse for two years, working in pediatrics; in 1980, I began working in infection prevention and control (IPC), and I needed an external source of information. I was working with another infection control nurse at the time who was very helpful, and she mentioned to me that APIC was a group that I needed to join. So that’s what I did.

How has your experience within APIC translated to your work as an IP?

“In order to have full engagement, you need participation in getting things done. People need to feel valued for their contributions. Not just a cog in a machine.”

Being involved with APIC means that I have been exposed to the latest and future-oriented information about IPC techniques and methods from the top people in the field. And having that access and knowledge base has enabled me to practice at the top of our field. I can remember a few specific times when I would come to work after attending the national conference really invigorated by things we had heard. I would rush back to work and say, “Listen to what I heard” and “We need to make these changes.” Attending APIC’s conferences was the catalyst for some of the changes we would make in my organization.

What does leadership mean to you? I think of it as influencing others so that together we are achieving goals. It

has an aspect of being goal-oriented, and it also depends on the type of group one is leading.

How would you describe your leadership style? There are times when I might be more of a coach or a mentor to others, when I am trying to inspire others to keep moving to achieve certain area accomplishments. But other times it might be something where I’ve been handed something from managers, or administrative leaders, and told, “This is something we need to implement as a department.” It might not be something that I am thrilled about and I have to convince others to engage in it to move things along. It really depends on what kind of goals there are that are being approached as to how I would interact with the people I’m leading.

You described yourself as being adaptable as a leader. What style of leadership do you prefer? I prefer coaching and mentoring others. I’m more comfortable with participative management. Sometimes in the beginning it’s difficult to see those things and you just have to “suck it up, cupcake” and jump in there and say, “Look, this doesn’t seem like a great idea, we wish we didn’t have to do this, but it is something we need to do. Let’s take this first w w w.apic.org | 29

INFECTION PREVENTION LEADERSHIP step.” I like it when the team members begin to say, “Well you know, we could do it this way” or “If we did this, it’s a little more efficient.” I like when people problem-solve, as long as we aren’t losing any critical elements of what needs to be done. I much prefer that everyone is fully engaged. In order to have full engagement, you need participation in getting things done. People need to feel valued for their contributions. Not just a cog in a machine.

Can you describe a challenge you faced as a leader? In a work situation, it is most challenging when you have a message that you either may not fully agree with but you need to get it across, or if you understand it and agree with it but know it’s going to be unpopular and people are not going to be happy with it. Another situation I’ve found to be challenging is when I’m leading a group of volunteers where individuals are serving in a capacity that I believe that, in their minds, they see as a real feather in their cap or looks good on their resume, but when it comes to rolling up your sleeves and getting your work done, it may not be why they’re there. I’ve also seen that difficulty for other leaders who have to manage through volunteers who don’t know how to behave. It’s not like you can sit them down and discipline them or threaten to fire them, because that’s not what you do with volunteers.

What are some lessons or advice you can share from your work and management experiences in IPC? I believe in life-long learning and remaining open to being able to learn. Sometimes it’s almost scary how quickly things change in our field. We learn so much, and if we stop learning or assume that we don’t need to go to a class or go learn about a topic, it can leave us vulnerable to taking measures or actions we should not do. I like to be able to learn from others. The people who work in my team have an area of our field in which they become the go-to-person. I would never pretend to be the expert in all of 30 | WINTER 2018 | Prevention

IPC. I think that helps me to acknowledge that and always be open to learning. If you come across as a leader who knows everything and has no capacity to learn, then you shut off a lot of opportunity for yourself, but you also will affect the attitudes and beliefs of the people around you who are trying to follow you as a leader. It becomes more difficult.

What have been some defining moments of your career? I was in a country several years ago with the International Federation of Infection Control (IFIC). We had a conference where I gave three presentations and a brief welcome address; I was just busy running around the entire week. At the end of the conference, some of the infection control nurses from the country where we were wanted to meet with me. So, we stood and chatted and had our picture taken together. I was happy to stand there and have pictures done. One of them finally reached out, touched me on my arm and said, “You make us so proud.” It stunned me, so I asked, “Why do I make you proud?” She said, “Because you’re a nurse and a nurse is the chair of IFIC” — and it really brought tears to my eyes. It stopped me dead in my tracks. We live in this country with a lot of abilities and freedom, and sometimes we will think that we are not being heard or not being given enough attention for what we’re trying to bring forth. We always have to strive for equality for women, nurses, infection preventionists (IPs), to be heard, but these nurses really saw me just doing what I consider normal activities and it meant a lot to them to see someone in that role. It really spoke to me in a way that nothing else has before or since. What I took from that experience was that when we move in and out of our daily practice, the way we treat other people, speak to them, the way we carry ourselves, and how we are trying to influence people, how we do that is very very important. We never know what little thing we do that might be what influences that person to think, “I do want to do those things” or “Gosh, I’d like to work in their department one day.”

Is there anybody that comes to mind who has helped you along with both your career and leadership journey? My APIC chapter and the national membership. When I first joined APIC, I was a little person from West Virginia sitting in the back of the conference room in New Orleans. While sitting there, I thought, “Look at these people.” They were leaders and getting things done for this big group and helping to spread important messages. I remember thinking, “I hope I get to meet one of those people one day” and then, later on of course, I DID meet people. It’d be very difficult for me to point out just one person, but many of these people I learned from and they mentored me; it just meant the world to me. I am so very grateful to all of them.

Do you have any advice for an IP looking to enhance their leadership skills or get more involved in APIC? Chapter membership is really important. I feel lucky to have been able to participate in a chapter. We get together, share ideas, people talk about the problems they’re having. Stay connected with each other. I will always, ALWAYS encourage people to be connected. I could not emphasize that enough. If you share your idea and someone comes up later and says, “I tried that, and it does work, and we even improved it a little bit more and we did this,” that to me is very exciting to hear — that the knowledge is growing as it is shared. I think it is a very exciting part of what we do. It is really the reason that, as an organization, APIC is able to do what it does.

What are your suggestions to help IPs enhance their leadership skills? I think that it is important to continue self-development regardless of your age or how far along you think you are. If you continue to develop yourself and not grow stagnant, you will be in a better position to lead others. So that means that learning leadership skills, building on your knowledge base, and knowing that you have something to share with others. I would recommend people take advantage of workshops and trainings that become available wherever you live. It will open your mind to do some things you may not have thought about.

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Focus on long-term care and behavioral health outbreaks: Identify the pathogen! BY STEVEN SCHWEON, RN, MPH, MSN, CIC, HEM, FSHEA, FAPIC

CDC/F. A. MURPHY

Hospital 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 (IP) will glean additional knowledge and apply this information to hopefully prevent future infections, and infection clusters, in their facility. This quarterly column will assist the IP with heightening awareness of appropriate interventions for preventing an outbreak.

This digitally-colorized, negative-stained transmission electron microscopic (TEM) image depicted a number of Influenza A virions.

32 | WINTER 2018 | Prevention

erson et al. report that in Australia, during the February 1999 summer season, the director of a 70-bed nursing home notified the public health department that 11 residents, from a census of 69 residents, had developed an acute respiratory illness during the previous 24 hours.1 All the residents had an acute onset of cough, fever, and lethargy. One resident was admitted to the hospital. No staff members were initially reported ill. The residents lived in either a single, double, or four-bed bedroom. A community dining room and recreation room was available. A total of 76 nursing, allied health, and domestic staff members provided resident care. Most of the residents had a dementia diagnosis, which led to challenges when interviewing for additional clinical information. Instead, the nursing home staff assisted with information gathering by describing the presence and onset of symptoms. After obtaining the data, a case was defined as a resident with an acute cough onset, fever (not specifically defined), and lethargy. During the subsequent 10-day period, a total of 35 residents (51 percent) developed an acute respiratory illness and met the case definition. Based on your clinical acumen, you suspect which of the following pathogens as being the causative agent? a. Influenza (flu) b. Respiratory syncytial virus (RSV) c. Bordetella pertussis d. Need additional information The health department recommended obtaining throat swabs from all the ill residents. Screening for flu viruses types A and B; adenovirus; parainfluenza viruses types 1,2, and 3; and RSV was performed. Serology testing for Bordetella IgA and complement fixation tests for antibodies to flu A and B, RSV, and the adenovirus

group was obtained from all the residents, regardless of whether they were symptomatic or asymptomatic. Acute and convalescent flu samples, when available, were also obtained to determine if a rise in titer occurred. Microbiological and serological findings revealed: • Thirteen residents had a flu A diagnosis based on at least a fourfold rise in titer that was obtained from the acute and convalescent samples. • Five residents had a flu A diagnosis based on a single sample with the titer of at least 1:256. • Two residents had a positive flu A (H3N2) viral culture; one of the residents did not have serological evidence of infection. • One resident with a culture confirmed flu A virus also had a diagnostic RSV titer of 512. • Ten residents (nine cases and one noncase) had a positive Bordetella IgA serologic assay. Australian flu surveillance data revealed a low level of flu circulation when the outbreak occurred. The nursing home’s practice was to offer flu vaccinations to

all residents during late March or early April. Of note: • Flu vaccination was not routinely determined upon admission, potentially resulting in under-utilization of the flu vaccine. • The majority of the residents had been vaccinated approximately 10 months prior. • There was no flu vaccination program for the staff. • The staff turnover rate was high, and the use of nursing agency staff was common, which could potentially increase the presenteeism risk due to healthcare personnel (HCP) economics and other personal concerns. Multiple interventions were implemented to curtail the outbreak, including: • Confining the residents to their rooms. • Adding additional staff to assist with cohorting while caring for the sick and well residents. • Closing the facility to new admissions. • Advising visitors of the outbreak. • Infection prevention strategies, e.g., hand hygiene and not visiting if ill, were promoted. • Encouraging staff to self-report illness to their supervisors.

TAKE-HOME MESSAGES • The LTC environment coupled with the resident vulnerability to infectious agents is conducive to flu transmission.2

• O ffering the flu vaccine to every resident continues to be a Centers for Medicare & Medicaid Services requirement.3

• The Centers for Disease Control and Prevention (CDC) recommends all U.S. HCP become vaccinated annually against the flu.4

• Summer flu outbreaks are rare and have been described in the medical literature. Consider adding flu illness to the infection differential when encountering increased respiratory infections that occur beyond the typical flu season in your community.

• A recent study demonstrated more than 40 percent of HCP come to work with flu-like illness.5 The authors note that interventions to thwart presenteeism include addressing HCP misconceptions about working while ill and to reassess the influence of paid sick leave policies.

• The CDC states droplet precautions should be implemented for season influenza.6

w w w.apic.org | 33

PREVENTION IN ACTION • Notifying local hospitals of the outbreak and asking the clinicians to obtain the appropriate studies from any nursing home resident admitted with respiratory symptoms. Note: Antiviral agents zanamivir and oseltamivir had recently been approved but were not utilized in this outbreak. At least 16 percent of the staff members reported an acute respiratory illness that met the case definition. The outbreak persisted for about 10 days before becoming curtailed. The authors note the most likely source for the flu outbreak was a staff member

who reported having an acute respiratory illness and continued to work while symptomatic.1 Additionally, a “concurrent pertussis epidemic among residents” was described and thought to result from a staff member who had a pertussis-like illness in December 1998.1 Steven Schweon, RN, MPH, MSN, CIC, FSHEA, FAPIC, is an infection prevention consultant with a specialized interest in acute care/long-term care/behavioral health/ambulatory care infection prevention challenges, including outbreaks.

References 1. Ferson MJ, Morgan K, Robertson PT, et al. Concurrent summer influenza and pertussis outbreaks in a nursing home in Sydney, Australia. Infect Control Hosp Epidemiol, 2004:25;962-966. 2. Lansbury LE, Brown CS, Nguyen-Van-Tam JS. Influenza in long-term care facilities. Influenza Other Respir Viruses, 2017:11;356-366. 3. Centers for Medicare & Medicaid Services. State Operation Manual. Guidance to surveyors for long-term care facilities. https://www.cms.gov/ Regulations-and-Guidance/Guidance/Manuals/ downloads/som107ap_pp_guidelines_ltcf.pdf. Published November 2017. Accessed July 2018. 4. Centers for Disease Control and Prevention. Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities. https://www.cdc.gov/flu/ professionals/infectioncontrol/ltc-facility-guidance. htm. Updated March 2017. Accessed July 2018. 5. Chiu S, Black CL, Yue X, et al. Working with influenza-like illness: Presenteeism among US health care personnel during the 2014-2015 influenza season. Am J Infect Control, 2017:45;1254-1258. 6. Centers for Disease Control and Prevention. Prevention Strategies for Seasonal Influenza in Healthcare Settings. https://www.cdc.gov/flu/professionals/ infectioncontrol/healthcaresettings.htm. Updated February 2018. Accessed July 2018. Additional Resources Centers for Disease Control and Prevention. Different Types of Flu Vaccines. https://www.cdc.gov/flu/vaccines/ index.htm. Updated October 2018. Kulick P, Taylor D, eds. The Infection Preventionist’s Guide to the Lab. Washington, DC: APIC; 2012.

READ MORE ABOUT INFLUENZA IN THE AMERICAN JOURNAL OF INFECTION CONTROL Duration of influenza outbreaks in longterm care facilities after antiviral prophylaxis initiation: Fraser Health, British Columbia, 2014-2017. Murti M, Fung CK, Chan K, et al. Am J Infect Control, Vol. 46, Issue 9, p1077–1079. Reduction in total patient isolation days with a change in influenza testing methodology. Muller MP, Junaid S, Matukas LM. Am J Infect Control, Vol. 44, Issue 11, p1346–1349. Hospital influenza pandemic stockpiling needs: A computer simulation. Abramovich MN, Hershey JK, Callies B, et al. Am J Infect Control, Vol. 45, Issue 3, p27.

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Interpreting uncertainty: Confidence intervals BY CHRISTINA BRONSON-LOWE, PhD, CCC-SLP, CLD, AND DANIEL BRONSON-LOWE, PhD, CIC, FAPIC

BLOOMICON/SHUTTERSTOCK.COM

WELCOME TO ARTICLE 11 in a series examining statistical concepts relevant to infection prevention. This article and the concept questions refer to publications in the American Journal of Infection Control. Although reading those papers will give you valuable examples of how confidence intervals are used, you do not need to do so to understand this article or answer the questions.

36 | WINTER 2018 | Prevention

esearchers collect just a sample of data because we can’t measure the entire population of interest. From the sample, we calculate a point estimate of a population parameter (A numerical summary characteristic of the entire population, such as a mean). We don’t assume the population parameter exactly equals the point estimate, but only that it’s somewhere in the neighborhood. Confidence intervals (CIs) let us specify the size of the neighborhood.

A CI is a range around a point estimate with a specified confidence level, usually 95%. CIs are written as “point estimate [confidence level, lower limit – upper limit]” (e.g., 4.2 [95% CI, 1.4 – 7.0]). Figure 1 shows how confidence level, number of data points (n), and standard deviation affect CI size. This article assumes 95% CIs and α = 0.05. Say an infection preventionist (IP) wants to reduce her facility’s rates of central line-associated bloodstream infections (CLABSIs). She reads a paper by Wright et al., examining change in CLABSI rates with use of an access valve disinfection cap.1 For each of four hospitals, relative risks (RRs) suggest fewer CLABSIs occur with cap use. These RRs are point estimates. The IP next looks at the CIs

Figure 1. Effect on CIs of varying sample standard deviation only (SSD: top vs. middle) and N only (middle vs. bottom).

Figure 2. RR of CLABSI with cap use vs. baseline. Only the asterisked CI excludes RR = 1 (is statistically significant). Data: Wright et al. (2013).

(Figure 2). What can she conclude? She may think there’s a 95% chance that the true value of the population parameter falls within those CIs, or that there’s a 95% chance that if her hospital used the caps they would see results somewhere within the range of the CI. Though these interpretations of CIs are common, neither is correct. The confidence level describes confidence in the procedure used to construct the confidence interval, not in the specific interval. Imagine standing on a lakeshore. There are many fish in the lake. What location (analogous to a population parameter) best represents all the fish? You can’t w w w.apic.org | 37

PREVENTION IN ACTION

FROM DATA TO DECISIONS CONCEPT QUIZ Question 1 Marra et al. report RRs with 95% CIs, each comparing a postintervention infection rate to its pre-intervention baseline: 0.84 [0.70-1.02] for MRSA and 0.82 [0.72-0.94] for VRE. Were MRSA and VRE infection rates significantly changed by the intervention?

Question 2 Hijas-Gómez et al. compared patients with and without surgical site infection following knee arthroplasty, reporting odds ratios (OR) for several possible risk factors: pre-operative hair removal (2.99 [95% CI, 1.24-7.23]), inadequate preparation (2.28 [95% CI, 0.52-10.00]), and contaminated/dirty surgery (11.29 [95% CI, 2.45-52.08]). Which were significant?

Answers

Figure 3. Fish analogy.

Q1: Only the VRE CI excludes the null-hypothesis value (RR = 1). So the infection rate reduction was significant only for VRE.

38 | WINTER 2018 | Prevention

Q2: Like RRs, ORs have a null-hypothesis value of 1. The CIs for pre-operative hair removal and contaminated/dirty surgery exclude 1, so they were significant.

observe the best fish spot itself; you can only observe fish. You can’t calculate the best fish spot directly; you’ll never observe every fish. So, you get in a boat and record locations for every fish you find. You mark an area around your sample to estimate the best fish spot. You know a method of doing this that will, 95% of the time, include the best fish spot’s true location. Any particular use of the method, though, either does cover the best fish spot or it doesn’t—there isn’t a 95% chance that it does (Figure 3). One attempt covers the best fish spot; one doesn’t. But if it weren’t marked, you wouldn’t know in either case. Likewise, with real data, the CI from a single sample either will or won’t contain the population parameter, but there’s no way to know. The most we can say is, “CIs calculated this way would contain the population parameter 95% of the time.” It’s confidence in the method, not the results. So, what benefit does a CI provide to our IP? First, she can compare the CI to the value suggested by the null hypothesis. If the CI doesn’t include that value, then the null hypothesis is rejected. When comparing two groups’ risk via RR, the null hypothesis value is RR = 1 (When Group A risk = Group B risk, Group A risk/Group B risk = 1). Figure 2 shows that the CIs for individual hospitals’ RRs all

include 1, so the null hypothesis cannot be rejected. The CI based on the pooled data of all four hospitals, because it includes more data, is narrow enough to exclude 1, so that RR is statistically significant. Two-point estimates can also be roughly assessed for statistically significant difference by checking whether their CIs overlap. If they don’t, the point estimates are significantly different. For example, Armellino et al. tracked compliance with a checklist for endoscope disinfection.2 Compliance improved from 53.1% (95% CI, 34.7-71.6; n = 116) to 98.9% (95% CI, 98.1%-99.6%; n = 3,179). Since the CIs do not overlap, this difference is significant. A specific p-value should still be reported, however, as point estimates can differ significantly even if their CIs overlap slightly.3 If you have any questions or comments, please feel free to contact us at IPandEpi@gmail.com.

Christina Bronson-Lowe, PhD, CCC-SLP, CLD, is a speech-language pathologist who has worked in hospitals, inpatient and outpatient rehabilitation, SNFs and home health care.

Daniel Bronson-Lowe, PhD, CIC, FAPIC, has been an infection preventionist, an infectious disease epidemiologist, and a statistics lecturer. He has been an instructor for APIC’s “Basic Statistics for Infection Preventionists” Virtual Learning Lab and is a senior clinical manager with Baxter Healthcare Corporation. References 1. Wright MO, Tropp J, Schora DM, et al. Continuous passive disinfection of catheter hubs prevents contamination and bloodstream infection. Am J Infect Control 2013;41(1):33-38. 2. Armellino D, Cifu K, Wallace M, et al. Implementation of remote video auditing with feedback and compliance for manual-cleaning protocols of endoscopic retrograde cholangiopancreatography endoscopes. Am J Infect Control 2018;46(5): 594-596. 3. Knezevic A. Overlapping confidence intervals and statistical significance. CSCU StatNews 73. https://www.cscu.cornell.edu/news/archive.php. Accessed August 2018. Additional Resources Hijas-Gómez AI, Lucas WC, Checa-García A, et al. Surgical site infection incidence and risk factors in knee arthroplasty: A 9-year prospective cohort study at a university teaching hospital in Spain. Am J Infect Control doi: 10.1016/j.ajic.2018.06.010. Marra AR, Edmond MB, Schweizer ML, et al. Discontinuing contact precautions for multidrug-resistant organisms: A systematic literature review and meta-analysis. Am J Infect Control 2018;46(3): 333-340. Potts, A. (2014). Chapter 13: Use of Statistics in Infection Prevention. In: Patti Grota, et al., editors. APIC Text Online. APIC.

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PREVENTION IN ACTION

How the infection prevention landscape is changing BY KATHRYN GALVIN, MS, MLS (ASCP)CM, CIC, AND ADRIENNE PINTO, MSN, RN, CIC

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nfection prevention and control (IPC) began in acute care facilities. Over time, changes and additions to regulations for acute care hospitals and identification of gaps in alternate

42 | WINTER 2018 | Prevention

care settings helped identify the need for IPC efforts in different arenas. As patient care shifts from acute care to the ambulatory arena, the demand for infection prevention activities in

this setting is drastically increasing. Healthcare-associated infections (HAIs) are not limited to acute care facilities.1 Studies suggest that implementing existing prevention practices can lead to

up to a 70 percent reduction in HAIs. Specialty practices are growing in numbers, and with documented outbreaks, the need for assessment and intervention to reduce the risk of transmission is vital. Outbreaks in ambulatory settings have been documented as a result of improper prevention practices such as reusing syringes.2 In many regions of the United States, ambulatory sites are coming under more scrutiny from all

regulatory bodies, including the department of public health and The Joint Commission. This is a huge gap and opportunity considering how many ambulatory facilities exists. As a result, standards for alternate care settings and staffing to appoint a responsible party for IPC initiatives have started to lead the way to the expanding role of the future infection preventionist (IP). Letâ&#x20AC;&#x2122;s take a dive into a few alternate roles and care settings.

LONG-TERM CARE

It is estimated that 1 to 3 million infections occur annually, and approximately 380,000 people die from these infections in long-term care (LTC).3 HAIs are a major cause of hospitalization and death in the LTC population.3 The Centers for Medicare & Medicaid Services (CMS) now requires LTC settings to implement an IPC program which includes antimicrobial stewardship and an IP to oversee the program.4 This role for an IP will present many challenges and unique opportunities for this aging population due to the medical complexity and care needs. This role will be challenged with surveillance and public reporting of infections, development of policies and

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PREVENTION IN ACTION procedures, continuing education needs, antimicrobial stewardship, and residency requirements to name a few. AMBULATORY SURGERY CENTERS

An ambulatory surgery center (ASC) is a facility where a planned surgery is to take place in which the patient is admitted and discharged on the same day. The surgeries are generally less complicated than those performed in the hospital. National estimates regarding HAIs in ASCs are unknown.7 Surgical site infections (SSIs) still occur, but the rates are not an easy task to track as the patients are discharged within 24 hours and post-procedure follow up can be difficult. CMS currently requires ASCs to have an IPC program, a designated person trained in infection control to lead the program, a method to actively identify infections that may have been related to procedures performed at the ASC, hand hygiene observations, and monitoring of high-level disinfection and sterilization.5,6 This IPC role will be challenged with surveillance, especially patient follow up and public reporting, hand hygiene, environmental hygiene, development of policies and procedures, and continuing education for healthcare personnel.6,7 REMOTE SURVEILLANCE

There is a growing trend for workplace flexibility in healthcare. With the latest technology, we now can have surveillance of infections performed at offsite locations or completed by an outside source or vendor. However, for all facilities, there is less prime office space and more demand to focus on surveillance rather than the everyday tasks of the healthcare world. To compensate for this, some facilities and healthcare systems with the use of clinical surveillance software and data mining technology have led to the development of IP roles that perform remote surveillance from home or offsite locations. An IP completes surveillance needs by reviewing labs, possible devicerelated infections, project-specific measures, and completes public reporting needs. Once the infection is identified for a facility, the local IP at the facility receives notification of the event, performs a root cause analysis, and implements interventions. This role will allow other IPs in the local setting to focus on rounding, education of the healthcare 44 | WINTER 2018 | Prevention

“As patient care shifts from acute care to the ambulatory arena, the demand for infection prevention activities in this setting is drastically increasing. Healthcare-associated infections (HAIs) are not limited to acute care facilities.” team, and other quality improvement initiatives. Another option is to hire consultant IPs to perform remote surveillance. Data is not widely available, but anecdotally, large healthcare systems and small facilities can benefit from implementing remote surveillance and/or commercially available software to filter large amounts of data, increase productivity, and access a broader scope of information including clinical data, pharmacy, radiology, etc., and effect change.8 A downside is the cost to obtain remote surveillance technology for smaller facilities. EXPANDING THE BACKGROUND OF IPS

A multidisciplinary emphasis is a rising trend in improving the quality of care for patients and certainly applicable to IPC. By expanding the scope of an IP to alternate care settings, the necessity to expand the IP pool of staffing to include different perspectives including clinical backgrounds and content experts might be of great value. To certify in infection prevention and control, the Certification Board of Infection Control and Epidemiology requires a post-secondary degree with current IPC responsibilities and the recommended experience of various infection prevention and epidemiology tasks.9 To have a team of IPs include not only nursing or microbiologists, but respiratory therapists, surgical technologists, public health, and others, presents a unique opportunity to view a situation through a different lens. For instance, if you identify an issue in the operating room, who is best to help navigate and influence change? In this scenario, having a surgical background would be beneficial to help initiate change in a partnership with the operating room

leadership and staff. If you identify an issue with a hepatitis outbreak affecting the community, having a public health partner to help coordinate internally as well as with the local public health departments would be beneficial. Imagine the possibilities as the expanding labor pool for IPC helps advance APIC’s mission: healthcare without infections.10 With all of the changes that have occurred in the last 15 years within IPC, think about where we will be in another 15 years. Katie Galvin, MS, MLS (ASCP)CM, CIC, is an infection preventionist for Hartford Healthcare based at The Hospital of Central Connecticut in New Britain, Connecticut. Adrienne Pinto, MSN, RN, CIC, is an infection preventionist for Silver Cross Hospital in New Lenox, Illinois. References 1. Ambulatory Care (Outpatient). Association for Professionals in Infection Control and Epidemiology website. http:// professionals.site.apic.org/settings-of-care/ ambulatory-care-outpatient/. Accessed September 2018. 2. The One and Only Campaign. Centers for Disease Control and Prevention website. http://www. oneandonlycampaign.org/sites/default/files/upload/ image/SIPC_PatientBrochure_FINAL.pdf. Accessed September 2018. 3. Nursing Homes and Assisted Living (Long-term Care Facilities [LTCFs]). Centers for Disease Control and Prevention website. https://www.cdc.gov/longtermcare/ index.html. Updated February 2017. Accessed September 2018. 4. Centers for Medicare and Medicaid Services. Specialized Infection Prevention and Control Training for Nursing Home Staff in the Long-Term Care Setting. https://www.cms. gov/Medicare/Provider-Enrollment-and-Certification/ SurveyCertificationGenInfo/Downloads/ QSO-18-15-NH.pdf. Published March 2018. Accessed September 2018. 5. Centers for Medicare and Medicaid Services. Ambulatory Surgical Center Infection Control Surveyor Worksheet. https://www.cms.gov/Regulations-and-Guidance/ Guidance/Manuals/downloads/som107_exhibit_351. pdf. Published July 2015. Accessed September 2018. 6. Infection Control Assessment of Ambulatory Surgical Centers. Centers for Disease Control and Prevention website. https://www.cdc.gov/injectionsafety/pubsic-assessment-ambulatory-surgical-centers.html. Updated August 2016. Accessed October 2018. 7. Agency for Healthcare Research and Quality. AHRQ Safety Program for Ambulatory Surgery website. https://www. ahrq.gov/sites/default/files/wysiwyg/professionals/ quality-patient-safety/hais/tools/ambulatory-surgery/ sections/ambulatory-surgery-report.pdf. Updated May 2017. Accessed October 2018. 8. Recommended practices for surveillance: Association for Professionals in Infection Control and Epidemiology (APIC), Inc. Lee T, Montgomery O, Marx J, et al. Am J Infect Control. 2007;35:427-440. 9. Eligibility Requirements. Certification Board of Infection Prevention website. https://www.cbic.org/certification/ candidate-handbook/eligibility-requirements. Accessed October 2018. 10. APIC Vision and Mission. Association for Professionals in Infection Control and Epidemiology website. https:// apic.org/About-APIC/Vision-and-Mission. Accessed October 2018.

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PREVENTION IN ACTION

Making the pitch to executive row: Part 2: Presenting the proposal BY WILLIAM WARD, JR., MBA

INFECTION PREVENTIONISTS (IPs) are often asked to provide a business justification for their proposals and “make the pitch” to the executive-level decision makers. This can be a challenge if the IP lacks the business knowledge to effectively articulate the financial benefits of their initiative that will convince decision makers. What should be included in the proposal? What should be said at a review meeting? How do you make the point that the initiative is worthy of pursuing? This two-part article will answer these questions. Part 1 explained how to develop a business proposal. Part 2 discusses how to make a presentation in a way that enhances its chances for approval. Feel free to contact the author with questions or comments at wwardjr1@jhu.edu.

ORGANIZING THE PRESENTATION

While there is no guaranteed way to gain approval of a proposal, you can increase your odds of success by organizing the presentation around three “tells”: First, tell the decision makers what you are going to tell them; next, tell them, and, finally, tell them what you have told them.1 The first “tell” should grab the decision makers’ attention. “We are here today to discuss a proposal that will increase net revenue by $6.5 million” will start the presentation on a positive note. “We’re here to talk about adding six full-time equivalents (FTEs)” will be a turn-off. Remember, money is tight, and a proposal looking to spend more of it is unattractive. Even if the six additional FTEs are going to generate $6.5 million of net revenue, don’t start with a request to spend more money. Decision makers will stop listening right then and there. In contrast, a presentation that starts with the potential to add revenue will probably be welcome and warmly received. In the second “tell,” fully but concisely describe the clinical and operational aspects of the initiative. Start with a 46 | WINTER 2018 | Prevention

tight summary of the description section contained in the formal, written proposal—a few “bullet points” that touch on the essential aspects of the initiative. Next, share the most important financial details from the proposal, such as the incremental net revenue the initiative will generate, the return on investment (ROI), the total and annual average profit to be derived, and so on. Again, avoid using too much detail so you don’t lose your audience’s attention. As in the first “tell,” emphasize the financial benefits to be derived by the organization. Focus on the net revenue or the ROI before raising key points about the operating cost or the size of a potential investment. Also, in the financial discussion, stress that you worked collaboratively with the finance department to develop the revenue and cost estimates. It is far better to say, “These net revenue estimates came from Jill in finance” as opposed to saying, “We think this will generate $6.5 million in net revenue.” Presenting them as finance’s estimates gives them a bit of a “Good Housekeeping Seal of Approval®.” It reduces skepticism and builds a positive feeling about the numbers.

Finally, the third “tell” wraps up the presentation with a positive “Let’s do this!” summary. It very briefly summarizes the meeting: what the initiative entails, and how it benefits the organization clinically, operationally, and financially. Leave a bit of time to solicit any final questions from the decision makers and then conclude by indicating optimism about a favorable decision. CHOOSING THE RIGHT WORDS

When making a presentation, understand what your audience does and doesn’t know, and how they assimilate information. Above all, the presentation must be clear and concise, avoiding jargon and overly clinical or technical language that some administrators may not fully understand. For example, instead of saying “synchronous diaphragmatic flutter,” say “hiccup.” Also, use financial terms correctly or do not use them. For example, don’t confuse gross revenue (the amount billed) with net revenue (the amount collected) or misrepresent an initiative that reduces cost as a revenue increase. If your audience recognizes that you are misusing these concepts, your proposal will lack credibility.

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PREVENTION IN ACTION

Implications of Reduced Infections • • • • • • • • • •

Increasing hand hygiene and improving room cleaning techniques can reduce the incidence of healthcare-associated infections (HAis} in patients at Community Memorial General Hospital. Reducing the infections will reduce the average length of stay from 4.5 days to 4.1 days. This is an 8.8% reduction in average length of stay. A reduced average length of stay will allow us to increase admissions by up to 8.8% if we backfill all of the beds that are emptied. We could easily fill 20% of the emptied beds with new patients. Additional admissions will increase net revenue by $21,450 each. If we can increase admissions by five per month, we can generate an additional $1,287,000 of net revenue. Most of this net revenue will fall to the bottom line because most of our operating costs are fixed - roughly 90%. The average annual profit is $699,000. The Return on Investment is 63.5%.

Figure 1: An overly wordy slide.

themes in a compelling manner. As a bonus, the artwork is visually appealing and reinforces the slide’s message. When presenting the financial aspects of a proposal, the audience will expect to see the numbers. However, the sheer volume of numbers on a slide showing, for example, a marginal profit-and-loss statement (Figure 3) can split the audience’s attention. Some reviewers will be mostly interested in the data on the revenue stream, others will look for operating expenses, and still others will be checking out each year’s bottom-line performance. The discussion may meander as the data take on a life of their own. It is even possible that a reviewer will focus on the significant first-year loss of nearly $400,000 and nix the proposal. To maintain attention in this situation, use an overlay to call out only the important financial values. Start by introducing the slide shown in Figure 3, but then immediately change to a slide (Figure 4) with a box calling out the significant financial effects of the initiative. Instead of dozens of numbers, the decision makers will be looking at only five. The presenters can then discuss just these few indicators, and the decision makers can easily see why the initiative should be resoundingly approved. POLISHING THE PRESENTATION

Figure 2. The simple approach to slide presentation.

USING SLIDES EFFECTIVELY

Many decision makers are “bullet people,” preferring crisp, telegraphic descriptions over lengthy narratives. For this reason, well-designed slides can be a great asset when presenting a proposal. Whether your slides will be projected on screen, distributed as paper handouts, or reviewed on a tablet, apply the “less is more” approach and keep the slide content simple and clear. Figure 1 is an example of a presentation slide that is overly wordy. It presents detailed information in small type that may be difficult to read when projected 48 | WINTER 2018 | Prevention

in a large room. Even if the audience can read the slide, the wordiness is a problem because people who are reading long blocks of text are not going to be listening carefully to what the presenter says. In contrast, the slide depicted in Figure 2 is limited to just four telegraphic points. This type of slide focuses attention on the presenter, who can expound on each point, such as the impact of the proposal on average length of stay (ALOS), the improvement to net revenue and profit, and the strong ROI. While one or more slides may be devoted to the financial analyses, this single slide concisely captures the primary

A good presentation involves more than a the three “tells,” an audience-friendly vocabulary, and a well-designed slide deck. The presenters must be able to speak with authority and enthusiasm about both the initiative and its business impact. They must “connect” with the decision makers. The adage that practice makes perfect applies here. Rehearse with a group of colleagues what will be said and who will say it. Ask them to provide a critique: what was easy to understand, what was unclear, and so on. Avoid memorizing the pitch, which can result in lengthy and agonizing pauses if a presenter forgets a word or two. Instead, run through the presentation multiple times until it is almost second nature. Knowing what each member of the team is going to cover and what he or she will say can help if someone begins to struggle—another presenter can pick up the commentary.

The team should challenge itself when preparing its presentation. An informal SWOT (strengths, weaknesses, opportunities, and threats) analysis of the presentation can be helpful. What are the strong points of the presentation? Which elements need to be improved? What is missing from the presentation? What questions are the decision makers likely to ask? How can the difficult questions be answered? What are the weaknesses of the proposal, and how can the team deal with them? The last thing any presenter wants is to be surprised by a question. Meeting individually with the decision makers before the presentation may identify potential issues and help the team to be more prepared. When asked a difficult question, don’t be afraid to pause a moment to think of an effective answer. If caught off guard, have a short phrase that can be recited from memory and use that time to think about how best to answer the question. For example, saying something like, “Well, that’s an interesting observation. I think the best way to address that is …” Alternatively, a presenter could channel a question to the team’s expert on that particular element: “Great question, Bob, I think Angela can walk us through those calculations.” The time used to field and direct the question can give “Angela” a bit of time to compose her answer. Clearly, decisions must be based on solid data, but don’t forget the human element. A bit of humor used sparingly and appropriately might reduce the stress of a high-level presentation. Storytelling can put a human face on the presentation. In The Leader’s Guide to Radical Management: Reinventing the Workplace for the 21st Century, Stephen Denning advises, “Rather than merely advocating and counter-advocating propositional arguments, which lead to more arguments, establish credibility and authenticity through telling the stories… [Emphasis added].”2 Healthcare is about patients, so offer stories of how the initiative would impact them. For example, when discussing how an initiative would reduce healthcare-associated infections (HAIs), explain it in terms of “grandma” and her experience having suffered an HAI. A stock photo of a typical grandmotherly type might be

Figure 3. Wall-to-wall numbers.

Financial Implications Marginal Revenue Units of Volume Price Collection Rate Marginal Net Revenue

Year1

Year2

Year3

Year4

Years

800 $2,000 82.00% $1,312,000

1,200 $2,000 82.00% $1,968,000

1,600 $2,000 82.00% $2,624,000

2,000 $2,000 82.00% $3,280,000

2,400 $2,000 82.00% $3,936,000

Five Year Torals

Annual Average

8,000

1,600

$13,120,000

$ 2,624,000

Five-Year Net Revenue: $13,120,000 Five-Year Total Profit: $3,495,000 Annual Average Profit: $699,000 Total Equipment Cost: $2,200,000 ;: Return on Investment: 63.5%

Marginal 0 p Marginal Var Units of Vi'C Variable C Total

80,000

Marginal Fix(I Salaries aII Fringe Be:r Operating Deprecita i1 Total

500,000 50,000 75,000 �20,000 45,000

Total Margin

�25,000

Marginal P

�99,000

Accumulated Profit Margin

($373,000)

($210,000)

$489,000

$1,724,000

$3,495,000

Figure 4. Using a callout box to maintain focus on the key financial indicators.

used to illustrate the slide accompanying the story. A FINAL CAUTION

Keep in mind that even the best proposal may be rejected because of circumstances beyond the control of the presenters. For example, an organization will not be able to approve a technology-based proposal if it lacks the funding to do so. Do not be discouraged. Continue to seek out opportunities to reduce infections or improve clinical quality in other ways. Following a rejection, ask for a debrief from one or more of the decision makers to learn what could have been done better and incorporate this learning into the next opportunity.

William (Bill) Ward, Jr., MBA, is an associate professor of health finance and management at the Johns Hopkins Bloomberg School of Public Health, and an associate professor of nursing at the Johns Hopkins University School of Nursing. He is the former director of the Master of Health Administration Degree Program and the Sommer Scholars Public Health Leadership Program. Prior to joining academia, he was a senior healthcare operations and finance executive. References 1. Ward WJ, Jr. Healthcare Budgeting and Financial Management. Santa Barbara, CA: Praeger; 2015. 2. Denning S. The Leader’s Guide to Radical Management: Reinventing the Workplace for the 21st Century. San Francisco, CA: Jossey-Bass; 2010.

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FEATURE

Can real-time data drive hand hygiene improvements? H BY CHRIS HERMANN, PhD

ospitals and clinics are increasingly embracing real-time data to improve patient safety, the patient experience, and other aspects of healthcare. Even today, data is still typically collected manually, collated, and then distributed in a report format, usually months later.1 This makes responding to the data in a timely and meaningful way extremely challenging at best, and impossible most of the time. Enter the Internet of Things (IoT [the interconnection via the internet of computing devices embedded in everyday objects, enabling them to send and receive data]) and big data. Buzzwords aside, these technological advancements are enabling the capture, analysis, and distribution of data in new and exciting ways, and they’ve had a particularly positive impact on patient safety. Some electronic hand hygiene monitoring and reminder systems leverage technological developments. Smart wearables, such as badge reels, identify individual providers to track hand hygiene performance. Sensors on soap and sanitizer dispensers capture dispenses, as well as room entrances and exits. This data is analyzed in the cloud and can be leveraged in a variety of ways. REAL-TIME FEEDBACK FOR IMMEDIATE ACTION

There is no longer a need to wait a month for the numbers to be crunched and a report generated by hand. Real-time data is, well, real-time. Certainly, it can still be used to go back in time and evaluate what happened in the past, but it’s best utilized to view what’s happening right now. In some cases, it can be used to predict the future. After all, the role of infection preventionists (IPs) should be to prevent infections and not just to compile after-the-fact spreadsheets. 52 | WINTER 2018 | Prevention

Today, electronic hand hygiene technologies offer an in-the-moment reminder when a provider forgets to clean his or her hands. This reminder can take the form of a human voice, beep, vibration, or colored lights. Some interventions go beyond the individual clinician level. And that leads to the future— predictive analytics. For example, if data shows low hand hygiene performance in a particular hospital room a few hours into a shift, an automatic message can be texted to the unit manager. That manager can immediately look into the issue behind the alert and make real-time corrections to improve hand hygiene performance. Some systems even know if a room houses a patient on isolation or with Clostridum difficile (C. diff).2 In these cases, by alerting a manager in real-time, they can take action to remedy a situation and, ideally, prevent a healthcare-associated infection (HAI) from spreading. INCREASED STAFF PRODUCTIVITY

This is a new and profoundly more productive use of staff time compared to direct observation. If “secret shoppers” are conducting general observation, capturing everyone’s hand hygiene performance while lurking in a hallway, that’s not only an inefficient use of personnel; direct observation also systematically overestimates hand hygiene because it captures only a fraction of the entire data set. Observers typically can’t

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FEATURE

READ MORE ABOUT HAND HYGIENE IN THE AMERICAN JOURNAL OF INFECTION CONTROL Guiding hand hygiene interventions among future healthcare workers: implications of knowledge, attitudes, and social influences. Qasmi SA, Shah SM, Wakil HY, et al. Am J Infect Control, Vol. 46, Issue 9, p1026–1031. A nationwide covert observation study using a novel method for hand hygiene compliance in health care. Wu KS, -Shen Chen Y, Lin HS, et al. Am J Infect Control, Vol. 45, Issue 3, p240–244. Point of care hand hygiene—where’s the rub? A survey of US and Canadian health care workers’ knowledge, attitudes, and practices. Kirk J, Kendall A, Marx JF, et al. Am J Infect Control, Vol. 44, Issue 10, p1095–1101.

see inside patient rooms. And direct observation is subject to the Hawthorne Effect, in which clinicians are up to three times as likely to clean their hands when they know they’re being watched (and they typically figure out they’re being observed pretty quickly).3 Technology can capture every hand hygiene opportunity automatically, with no bias and without the Hawthorne Effect. Using automation to conduct routine tasks is nothing new: It is done in just about every industry around the world. But it is a fairly new development in many aspects of healthcare. Hospitals that allow electronic hand hygiene systems to do the heavy lifting of capturing hand hygiene data—and potentially reminding providers to clean their hands when they forget—free up substantial staff time from acting as secret shoppers.2 This doesn’t mean that a human observer is no longer necessary. It makes sense to use people when nuances in 54 | WINTER 2018 | Prevention

behavior and judgment are needed. When a unit manager gets a real-time alert that hand hygiene is low in a C. diff room, for example, she should go observe and discover the root of the problem. It may be that the soap dispenser is broken or empty. Or perhaps the low hand hygiene rates have occurred from one nurse who was not aware that they needed to wash their hands after taking off gloves. Humans can obviously do this type of problem-solving far better than automation. NEW OPPORTUNITIES

IoT sensors allow healthcare organizations to capture and analyze data that was not previously available. Now we can tell how well an organization is performing—and not just in terms of hand hygiene. By knowing which providers are in and out of which rooms, it is possible to identify which clinicians are the busiest. By measuring their behavior, we can identify and solve workflow issues so that everyone on the unit enjoys improved work efficiency. Often, improved hand hygiene goes hand in hand with this increase in efficiency. POSITIVE BEHAVIOR CHANGES

Getting even the most well-meaning clinicians to clean their hands more frequently is a challenge. Behavioral change is hard. But real-time data and in-the-moment reminders can successfully change behavior, especially when the approach is positive and supportive rather than negative and punitive.4 Behavior scientists have demonstrated time and again that the proverbial carrot works better than the stick. For best results in changing behavior, hospitals should not simply install electronic hand hygiene technology and walk away. It is critical to host staff training as well as a data-driven process to manage expectations and ease everyone into the new approach. Team competitions and individual contests with prizes for the best performance—or most improved— can have a remarkable impact on both results and staff morale. With real-time data, it is possible for clinicians to know

“Getting even the most well-meaning clinicians to clean their hands more frequently is a challenge. Behavioral change is hard. But real-time data and in-the-moment reminders can successfully change behavior, especially when the approach is positive and supportive rather than negative and punitive.” where they stand and if they are improving over time. Real-time data will drive hand hygiene improvements and, more importantly, decrease HAIs. Enhancing your hospital’s digital footprint is an important first step toward improved patient outcomes. Chris Hermann, PhD, is the Founder and CEO of Clean Hands – Safe Hands. Dr. Hermann started and led the multi-institution research collaboration that developed the core technology utilized in the CHSH system. He earned a PhD in bioengineering, an MS in mechanical engineering, a BS in biomedical engineering with high honors from the Georgia Institute of Technology and is an MD candidate at Emory School of Medicine. References 1. Srigley JA, Gardam M, Fernie G, et al. Hand hygiene monitoring technology: a systematic review of efficacy. J Hosp Infect. 2015;89(1):51-60. https:// www.ncbi.nlm.nih.gov/pubmed/25480021. Accessed October 2018. 2. Osborn N. Controlled Study Shows Electronic Hand Hygiene Systems Reduce HAIs. Association for Professionals in Infection Control and Epidemiology Annual Conference. June 2018. 3. Srigley JA, Furness CD, Baker GR, Gardam M. Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: A retrospective cohort study. BMJ Qual Saf, 2014;23(12):974-80. doi: 10.1136/ bmjqs-2014-003080 4. Hermann C. New Approach to Hand Hygiene Scores Big in Pilot Project. Healthcare Business Today. https://www. healthcarebusinesstoday.com/new-approach-tohand-hygiene-scores-big-in-pilot-project/. Published August 2017. Accessed October 2018.

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FEATURE

Emerging models of ambulatory care BY CONSTANCE CUTLER, RN, MS, CIC, FSHEA, FAPIC, JILL LINDMAIR-SNELL, MSN, RN, CIC, FAPIC, AND BRIAN DENNEN, MBA, AIA, NCARB

MARK WINFREY/SHUTTERSTOCK.COM

t used to be that an infection preventionist (IP) was responsible for only one location, usually a hospital, but now they have more than one outpatient venue because of acquisitions and mergers. Those days are coming to an end as healthcare evolves in new ways with many outpatient facilities now under the IPâ&#x20AC;&#x2122;s umbrella. If your facility is similar to the authorsâ&#x20AC;&#x2122;, you may have an outpatient pain clinic, cancer care center, immediate/urgent care facility(ies), owned physician offices, offsite endoscopy procedure site, and an ambulatory surgery center, as well as others. All provide new opportunities and challenges, which this article will address to give you an idea how to start and what resources are able to assist you.

56 | WINTER 2018 | Prevention

Healthcare data show increasing shifts from inpatient to outpatient care.1 Figure 1 illustrates this trend, which is predicted to continue into at least the next 10 years. As healthcare facilities compete on value not volume, there are six market forces driving this change (Figure 2):1 1. Compression 2. Care management 3. Contraction 4. Consolidation 5. Consumerism 6. Connectivity There is also a change in all specialties for which patients will be treated as outpatients, ranging from a slight increase (5.6 percent) in colorectal patients to a substantial

increase (44.4 percent) in hematology oncology patients.1 Studies show that revenue derived from outpatients is rising dramatically, as compared to inpatient revenue.2 Outpatient ophthalmology and colorectal surgeons’ offices have also been implicated in disease transmission, as shown in these headlines (Figure 3) that show some occurrences, including a shocking one where anal catheters were reused in 2018. Now that the stage is set for our shifting focus as IPs, we can prepare to take on these new arenas. To start, do your research on historic outbreaks when care was mostly provided to inpatients.

Figure 1. Increasing shift to outpatient care. Adapted from Truven Market Expert. 2017-2027 Total US Market.1

PATIENT-TO-PATIENT TRANSMISSION

As recently as the 1970s, outpatient hemodialysis centers saw clusters of cases of both hepatitis B and C occurring at their free-standing centers. These were addressed by recommendations from the Centers for Disease Control and Prevention (CDC) and other agencies to do blood testing and use separate cleaning protocols and machines on known positive patients. Thankfully, in recent years the numbers of these bloodborne pathogens in dialysis patients have decreased with improved oversight by both dialysis personnel and IPs. Dialysis center issues haven’t completely disappeared, though. An article reviewing hepatitis B virus (HBV) in dialysis centers summarized several outbreaks that occurred from 1992 through 2014. There were 16 outbreaks that involved 118 patients on maintenance dialysis; 10 fatal cases occurred; multiple deficiencies in standard or hemodialysisspecific procedures was the most common route of patient-to-patient transmission of HBV.3 A survey of clinicians found that 12 percent of physicians and 3 percent of nurses indicated syringe reuse occurs in their workplace.4 This, along with other surprising and depressing results, led the CDC to develop the “One Needle, One Syringe, One Time” Campaign. AMBULATORY SURGICAL CENTERS

An assessment performed by the Centers for Medicare & Medicaid Services (CMS) of ambulatory surgical centers (ASCs)

Figure 2. Six types of market forces. Adapted from Truven Market Expert. 2017-2027 Total US Market.1

Figure 3. Infection prevention headlines. Adapted from Truven Market Expert. 2017-2027 Total US Market.1

WHAT CAN AN IP DO? • Review what kind of issues have occurred in the past and with what frequency. • Make the business case that it is “potentially” scary out there but that regular visits from a qualified IP can mitigate the real risks. • Go out and see for yourself what’s actually happening, focusing first on the riskiest areas: - Those performing sterilization of instruments. - Those doing high-level disinfection. - The others “just” providing routine patient care such as using syringes.

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FEATURE

Figure 4. Summary of ASC pilot survey findings. Adapted from Truven Market Expert. 2017-2027 Total US Market.1

showed that practices in those increasingly prevalent areas also pose infection prevention risks, leading to a specialization in ASCs for IPs.5 The actual pilot survey is summarized in Figure 4. ASCs pose unique challenges and an IP may take on responsibility for them, specializing in them. The concept of having surgery and going home on the same day started in 1970, when two physicians opened the first freestanding ASC in Phoenix.6 Surgery in an ASC offers patients a cost-effective and convenient alternative to surgery in a hospital setting. As of 2017, there were approximately 5,500 Medicarecertified ASCs in the United States.7 The shift continues from inpatient to outpatient as CMS adds to the 3,500 procedures approved for payment in an ASC.6 Surgeries that were typically scheduled in hospital operating rooms are being performed in ASCs. In January 2018, CMS no longer required total knee replacement surgery to be performed only in an inpatient setting.8 Since CMS reimburses for surgical procedures, there is an expectation that ASCs follow CMSâ&#x20AC;&#x2122;s Conditions for Coverage (CfC). In 2009, CMS enhanced the CfC by adding specific requirements for an IPC program in an ASC.9 The ASC infection control surveyor worksheet (ICSW) is an 18-page document that assists the CMS 58 | WINTER 2018 | Prevention

surveyor in evaluating healthcare practices during an onsite visit.10 The surveyor will observe at least one surgical procedure and follow a patient from registration through discharge.10 The ICSW will be used to obtain details about the facility including the types of procedures performed, number of procedural rooms, types of contracted or employed services, hand hygiene, medication practices, cleaning and reprocessing of reusable medical devices, environmental cleaning, point of care testing, and the infection prevention program.10 The surveyor will interview or perform observations to acquire enough information to complete the worksheet; however, if a breach in IPC practices is noted, the breach will be documented.10 Infection prevention has become more important as the number of complex surgical procedures that are performed in ambulatory settings increases. If the IP has not previously worked in a perioperative setting, they may not feel comfortable with the environment. It is vital for the IP to inquire and learn about all processes within the ASC. Additionally, to be effective, the IP must develop relationships with anesthesia providers, surgeons, surgical techs, nursing, sterile processing, environmental services, facilities, nursing, and leadership. The IP can use the ICWS to

make sure the ASC is prepared for a regulatory visit any time. In addition to the worksheet, the IP should establish and maintain an environmental rounding program. A multi-disciplinary team can examine the center for potential patient safety and infection prevention concerns. The team should observe medication administration in all areas: aseptic technique, surgical procedures, cleaning of patient care items, reprocessing of medical equipment including transporting, decontaminating, and sterilizing of surgical instruments. Observing these practices can assist the IP in creating a prioritized risk assessment to develop a successful IPC program plan. MICROHOSPITAL

Microhospitals, sometimes known as neighborhood hospitals, are an emerging model of care delivery. Components of a microhospital typically include 8-12 emergency department rooms, a similar count of inpatient beds, and limited diagnostics; they often incorporate procedural and medical office space as well (Figure 5). The characteristics of some health systems that have built microhospitals can be seen in Figure 6. These facilities are typically located in suburban and exurban areas and are predominantly in states without certificate-of-need regulations. Many facilities

share resources, including IPs, with their parent organization. HOSPITAL AT HOME

Another concept which is taking hold is called “hospital at home.” My 90-yearold mother may benefit from this in the near future because she travels to and from physician visits, and an inpatient stay could become unnecessary if this becomes more prevalent. I know she would prefer to receive care this way. These “hospital at home” programs provide hospital-level care and monitoring and lead to quick recovery at a lower cost. To take part in this concept, a patient would be “admitted” from the emergency department and transported home by ambulance, then met there by a nurse with equipment who would provide daily physical rounding.11 METHODOLOGY

The decisions of healthcare networks to move care outside the four walls of the hospital are strategic to increase market share or locations in far-flung areas. The strategies shown in Figure 7 display the methodical approach health systems follow. An article published in the American Journal of Infection Control describes a

Figure 5. Components of aa microhospital. Adapted from Truven Market Expert. 2017-2027 Total US Market.1

ST. VINCENT (Indianapolis)

ST. LUKE’S HEALTH SYSTEM (Kansas City) BAYLOR SCOTT & WHITE HEALTH (Dallas)

Figure 6. Health systems with microhospitals. Adapted from Truven Market Expert. 2017-2027 Total US Market.1

Figure 7. Methodical approach to health systems. Adapted from Truven Market Expert. 2017-2027 Total US Market.1 w w w.apic.org | 59

FEATURE

READ MORE ABOUT AMBULATORY CARE IN THE AMERICAN JOURNAL OF INFECTION CONTROL Health care worker hand contamination at critical moments in outpatient care settings. Bingham J, Abell G, Kienast L, et al. Am J Infect Control, Vol. 44, Issue 11, p1198–1202. Safe Injection Practices: Opportunities for Improvement in Ambulatory Care. Kuznets N, Lerner B, Davidson J. Am J Infect Control, Vol. 46, Issue 6, S4–S5. A pragmatic approach to infection prevention and control guidelines in an ambulatory care setting. Ng J, Le-Abuyen S, Mosley J, et al. Am J Infect Control, Vol. 42, Issue 6, p671–673.

systematic approach to determine how a healthcare system has changed, or would need to change, the staffing models for IPs and support staff required to build and sustain effective IPC programs.12 The challenges may seem insurmountable, especially to a novice IP, but doing your homework and making the business case for increased resources are good first steps. Physically going to see these outpatient/ambulatory facilities is the key, and prioritization based on a risk assessment of infection transmission will assist in breaking this down into manageable steps. It’s possible to survive and thrive because of growing needs for IPC expertise in the current and future healthcare environment. So, what resources does the IP have when facing shifting focus from inpatient to outpatient? Fortunately, there are many, with more coming out from a variety of sources all the time. These areas are all surveyed by accrediting agencies, and even accrediting bodies such as The Joint Commission have developed, and are developing, publications to assist the IP.13 A potential concern 60 | WINTER 2018 | Prevention

I do have, because patients do not always understand the definition of surgical site infections or other HAIs, is if the agency includes the following question in its survey of outpatient and ambulatory surgery centers: “At any time after leaving the facility, did you have any signs of infection?” There’s no need to reinvent the wheel, just educate yourself by attending courses especially designed with a focus on ambulatory surgery centers or other outpatient venues. The basic principles haven’t changed though. If it’s necessary to do for safe inpatient care, it’s necessary to do for safe outpatient care. In conclusion, movement of care is happening and will continue to occur in health systems and hospitals from inpatient to outpatient venues. My hope is that the IP will embrace this change and understand and be able to use the information and resources provided in this article to survive and thrive in this new world of outpatient and ambulatory healthcare. Jill Lindmair-Snell, MSN, CIC, FAPIC, is a system infection prevention manager for Advocate Aurora Health where she is responsible for acute care and ambulatory surgery centers. Jill has more than 25 years of healthcare experience, with the last 11 years in infection prevention and control. She has a Master of Science in Nursing from the University of Phoenix. Constance Cutler, RN, MS, CIC, FSHEA, FAPIC, spent 37 years as a hospital/healthcare system-based infection preventionist, and is now a consultant for Chicago Infection Control, Inc. She has worked in both large and small hospitals, many with extensive networks of outpatient/ ambulatory sites. Connie is a former treasurer and board member on the Certification Board of Infection Control and Epidemiology, and past president of the Chicago Metropolitan Chapter of APIC. She has a Bachelor of Science in Nursing from Creighton University, a bachelor’s in biology from Villanova University, and a master’s in biology from Drexel University. Brian Dennen, MBA, is a director with Ankura’s Healthcare Capital Asset Strategy team. He has served in senior positions in healthcare administration and in project management of major capital initiatives. Brian works with national and regional health systems, academic medical

centers, physician practices, and other healthcare clients on engagements ranging from broad strategic visioning to focused operational initiatives. He has a Master of Business Administration from Northwestern University’s Kellogg School of Management and a Bachelor of Architecture from Iowa State University; he is a licensed architect in Illinois and a member of the National Council of Architectural Registration Boards. References 1. Truven Market Expert. 2017-2027 Total US Market. Accessed September 2018. 2. American Hospital Association. Trendwatch Chartbook 2016: Trends Affecting Hospitals and Health Systems. https://www.aha.org/system/files/research/reports/ tw/chartbook/2016/2016chartbook.pdf. Published 2016. Accessed September 2018. 3. Fabrizi F, Dixit V, Messa P, Martin P. Transmission of hepatitis B virus in dialysis units: a systematic review of reports on outbreaks. Int J Artif Organs, 2015;38(1):1-7. doi:10.5301/ ijao.5000376. 4. Kossover-Smith RA, Coutts K, Hatfield KM. One needle, one syringe, only one time? A survey of physician and nurse knowledge, attitudes, and practices around injection safety. Am J Infect Control, doi.org/10.1016/j.ajic.2017.04.292. Published June 2017. Accessed June 2018. 5. Schaefer MK, Jhung M, Dahl M, et al. Infection control assessment of ambulatory surgical centers. JAMA, 2010; 303(22):2273-9. doi: 10.1001/jama.2010.744. 6. Ambulatory Surgery Center Association. Ambulatory Surgery Centers: A Positive Trend in HealthCare. Published October 2011. 7. Rechtoris, M. 51 Things to Know About the ASC Industry. Becker’s ASC Review. https://www.beckersasc.com/ asc-turnarounds-ideas-to-improve-performance/50things-to-know-about-the-asc-industry-2017.html. Published February 2017. Accessed September 2018. 8. 2018 Final ASC Medicare Payment Rule Released. Ambulatory Surgery Center Association website. https:// www.ascassociation.org/aboutus/latestnews/newsarchive/newsarchive2017/latestnews112017/2017 11finalrule2018. Published November 2017. Accessed September 2018. 9. Temple, M. Chapter 64: Ambulatory Surgery Centers. In: Grota P, ed. APIC Text Online. APIC 2018. 10. Ambulatory Surgery Center Infection Control Surveyor Worksheet. Center for Medicare & Medicaid Services website. https://www.cms.gov/ Medicare/Provider-Enrollment-and-Certification/ SurveyCertificationGenInfo/Downloads/Survey-andCert-Letter-15-43.pdf. 2015. 11. Healthcare solutions: Hospital at home. Johns Hopkins University website. https://www.johnshopkinssolutions. com/solution/hospital-at-home/. Accessed October 2018. 12. Bartles R, Dickson A, Oluwatomiwa B. A systemic approach to quantifying infection prevention staffing and coverage needs. Am J Infect Control, 2018;46(5):487-91. 13. CDC Outpatient Settings Policy Options for Improving Infection Prevention. The Joint Commission website. https://www.jointcommission.org/cdc_outpatient_settings_policy_options_for_improving_infection_prevention.aspx. Accessed September 2018. Additional resources The Environment of Care and Healthcare-Associated Infections. (published by ASHE) Guidelines for Design and Construction (published by Facility Guidelines Institute). OSHA Bloodborne Pathogens and Needlestick Prevention Standard CDC’s Guidelines Library: https://www.cdc.gov/infectioncontrol/guidelines/index.html CDC’s Injection Safety: https://www.cdc.gov/injectionsafety/

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FEATURE

How clean is the linen at YOUR hospital? BY ALEXANDER SUNDERMANN, MPH, CIC, CORNELIUS CLANCY, MD, AND HONG NGUYEN, MD

THE DUTCH PHOTOGRAPHER/SHUTTERSTOCK.COM

ealthcare linens (HCLs) are an essential aspect of every healthcare facility. HCLs are used on every patient population across the spectrum of healthcare delivery. From admission to discharge, patients are in contact with linens during their entire hospital stay. So HCL cleanliness should be highly regulated, right? This article will discuss linen-associated mucormycosis and the regulation of HCL cleanliness. Weâ&#x20AC;&#x2122;ll also review a large multicenter study that we performed to evaluate the current status of HCL hygiene at U.S. hospitals.

62 | WINTER 2018 | Prevention

WHAT IS MUCORMYCOSIS?

Mucormycosis is an invasive fungal infection due to a member of the Mucorales class. The disease is also known as zygomycosis. Mucorales are common in the environment, like most molds. However, we in infection prevention know that most common environmental microbes can cause disease in the immunocompromised host. Mucorales generally do not affect healthy

individuals but may cause disease in severely immunocompromised hosts or those with poorly controlled diabetes. Mucormycosis is challenging to diagnose as cultures may not grow out the mold. Moreover, the disease is very difficult to treat as Mucorales are often resistant to antifungal drugs. The best option is surgical debridement of the affected area along with antifungal treatment. Even with aggressive intervention, the morbidity and mortality remain high. HEALTHCARE-ASSOCIATED MUCORMYCOSIS

Outbreaks of healthcare-associated mucormycosis have been increasingly recognized.1 Of note, recent reports have traced the source of outbreaks back to HCLs. The first report described an outbreak in a hospital where there were five cases of mucormycosis in one year, a burden of disease that was not present in previous years.2 Investigators examined various possible sources. Cultures taken of linen at both the hospital and linen facility revealed Rhizopus spp., a Mucorales. These investigators concluded HCLs were the plausible source. The hospital switched linen providers and no further cases were detected. The second report detailed six cases of mucormycosis over a two-month period.3 Environmental evaluation pointed to HCLs as the source. The linen facility attempted mold decontamination at the HCL agency but was unsuccessful. The hospital switched linen providers, and no further cases were detected. Lastly, a third report detailed an outbreak of four cases of mucormycosis over a one-year period.4 Environmental cultures for Rhizopus spp were negative except from the linen carts. Appropriate cleaning of all HCL carts was put in place and no further cases were detected.

HEALTHCARE LINENS— WHAT DEFINES HYGIENICALLY CLEAN?

Indeed, HCLs may often be a source of pathogens to our patients, but what defines them as “clean”? The Centers for Disease Control and Prevention (CDC) acknowledges that HCLs may be a source for pathogens, but concludes that the risk of disease transmission is negligible. Given this, CDC does not suggest routine culturing of HCLs, nor is there any federal regulation of HCL hygiene. However, the Textile Rental Services Association (TRSA), a private trade group, offers a third-party accreditation for “hygienically clean” HCLs. The standard uses quarterly microbiologic testing of HCL at linen facilities to prove that HCL is “hygienically clean” which is defined as

READ MORE ABOUT FUNGAL LAUNDRY IN THE AMERICAN JOURNAL OF INFECTION CONTROL Reduced health care-associated infections in an acute care community hospital using a combination of self-disinfecting copperimpregnated composite hard surfaces and linens. Sifri CD, Burke GH, Enfield KB. Am J Infect Control, Vol. 44, Issue 12, p1565–1571. Do donated linens put patients at risk for fungal infections during hospitalization? A pediatric case investigation and subsequently implemented process changes. Westerling G, Davis M, Khuon D. Am J Infect Control, Vol. 46, Issue 1, p118–119.

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“For hospitals housing large populations of immunocompromised hosts, infection preventionists (IPs) should regularly survey their nosocomial mucormycosis rate. If the rate is above their baseline, then pre-emptive epidemiologic evaluation of a possible outbreak is recommended. If the source is unclear, HCLs and HCLcontaining carts should be among the factors to be investigated.” “free of pathogens in sufficient numbers to cause human illness.” But what is “sufficient numbers”? Currently, there are no scientifically defined levels of what this standard should be. THE MOULD STUDY

Given the lack of conclusive data on HCL hygiene, we sought to take a first step in getting a snapshot of the current state of HCLs in the U.S. We began the Mucorales on Unclean Linen Discovery (MOULD) study of large transplant and cancer centers in the U.S. to determine how contaminated HCLs are with Mucorales and other pathogenic molds. We recruited 15 large transplant and cancer centers distributed across all U.S. time zones. Our dedicated linen team traveled to each hospital and cultured HCLs immediately upon arrival at the facility. Using Replicate Organism Detection and Counting (RODAC) plates, we cultured seven pieces of each linen type (flat sheet, fitted sheet, blanket, bath blanket, washcloth, pillow case, patient gown). One RODAC plate was stamped once on the single piece of linen, and a second RODAC plate was stamped 10 times in different areas on the same piece of linen. Here, 64 | WINTER 2018 | Prevention

Figure 1. HCL Culture positivity by hospital. Note: Pathogenic mold defined as Mucorales, Aspergillus spp, Fusarium and dematiaceous molds.

we looked to analyze the recovery of molds by varying methods of RODAC sampling. In total, we had 98 RODAC plates sampling 49 pieces of HCL from each hospital. Furthermore, we gathered meteorological data from the nearest National Oceanic and Atmospheric Administration station. We took the RODAC samples back to our lab for incubation and identification of molds. We adapted the TRSA and German certification standards to define ‘hygienically clean’ as no growth of Mucorales on ≥90 percent of linen items. With this threshold, there could not be five or more items with Mucorales to be considered hygienically clean. Our results, displayed in Figure 1, showed that many HCLs (median 14 percent, range 3-27 percent) were contaminated with Mucorales. Moreover, 20 percent (3/15) of hospitals did not meet our standard for hygienically clean HCL. The RODAC method sampling results also showed varying yields of molds indicating the method may not be a reliable test to sample HCLs. Furthermore, our data showed that higher humidity in the preceding two days to cultures was a statistically significant factor for higher rates of Mucorales contamination. SHOULD YOU CULTURE YOUR HCL?

We sought to give a general overview of the contamination rate of HCLs with

Mucorales. Our findings are not yet correlated with clinical rates of infections, so what should be done? We in infection prevention will often employ certain measures to reduce the risk of disease to some of our most immune-suppressed population, e.g., positive pressure rooms, neutropenic precautions.5 However, some of these measures do not have conclusive evidence to support the practice. Given the evidence of our MOULD study, we believe there should be follow-up studies to correlate clinical infection data with our results. Also, an efficient microbiologic test needs to be developed that has standardized criteria for result interpretation. Furthermore, there is a need for established genomic surveillance tools to aid in the investigation of mold-related outbreaks as genomic testing is the gold-standard of outbreak investigations. For hospitals housing large populations of immunocompromised hosts, infection preventionists (IPs) should regularly survey their nosocomial mucormycosis rate. If the rate is above their baseline, then pre-emptive epidemiologic evaluation of a possible outbreak is recommended. If the source is unclear, HCLs and HCL-containing carts should be among the factors to be investigated. It should be noted that HCLs can also transmit other pathogens such as Bacillus species. One study revealed a correlation between HCLs contaminated

with Bacillus species to phylogenetically related Bacillus bacteremia in patients.6 However, given the ubiquitous nature of Bacillus species and often contaminated blood cultures, Bacillus is often disregarded as an unimportant finding. The authors conclude that IPs should be aware of increases of Bacillus bacteremia, similar to what we suggest with nosocomial mucormycosis rates. “I HAVE MOLD ON MY LAUNDRY AND THERE IS ASSOCIATION WITH HCL. SHOULD I SWITCH PROVIDERS?”

As described in one study, the attempt to decontaminate the linen agencies of mold failed, and hospitals had to switch laundry providers. However, in our multicenter study, one laundry facility was able to enact environmental remediation to significantly reduce the Mucorales contamination of the HCLs. IPs should work closely with their HCL laundry facility to ensure a clean environment that is separated from the outside environment.

Indeed, reasonable standards need to be developed for HCL laundries to abide by in order to produce hygienically clean HCLs. IPs, other stakeholders in HCL agencies, and clinicians caring for vulnerable patient populations should collaborate to ensure optimal patient safety standards of HCLs. Alexander Sundermann, MPH, CIC, is a senior infection preventionist at the University of Pittsburgh Medical Center Presbyterian hospital. As an IP, he specializes in the cardiothoracic population, emergency room, pharmacy compounding practices, and central line-associated blood stream infections. Cornelius Clancy, MD, is chief of infectious diseases at the VA Pittsburgh Healthcare System, and tenured associate professor of medicine and director of the Mycology Research Program at the University of Pittsburgh. He is a member of the Infectious Diseases Society of America’s Antimicrobial Resistance Committee and the Antibacterial Resistance Leadership Group’s Gram-negative Resistance Committee.

M. Hong Nguyen, MD, is director of the Transplant Infectious Diseases and the Antimicrobial Management Program at the University of Pittsburgh Medical Center, and tenured professor of medicine at the University of Pittsburgh. Her NIH-funded research laboratory has pioneered work in animal models of Candida, resistant gram-negative, and other infections, fungal and bacterial antimicrobial resistance, and rapid infectious diseases diagnostics. References 1. Davoudi S, Graviss LS, Kontoyiannis DP. Healthcareassociated outbreaks due to Mucorales and other uncommon fungi. Eur J Clin Invest, 2015;45:767-73. 2. Duffy J, Harris J, Gade L, et al. Mucormycosis outbreak associated with hospital linens. Pediatr Infect Dis J, 2014;33:472-6 3. Cheng VC, Chen JH, Wong SC, et al. Hospital outbreak of pulmonary and cutaneous zygomycosis due to contaminated linen items from substandard laundry. Clin Infect Dis, 2016;62:714-21 4. Teal LJ, Schultz KM, Weber DJ, et al. Invasive cutaneous Rhizopus infections in an immunocompromised patient population associated with hospital laundry carts. Infect Control Hosp Epidemiol, 2016;37:1251-3. 5. Fenelon LE. Protective isolation: Who needs it? J Hosp Infect, 1995;30(Suppl):218-22 6. Cheng VCC, Chen JHK, Leung SSM, et al. Seasonal outbreak of Bacillus bacteremia associated with contaminated linen in Hong Kong. Clin Infect Dis, 2017; 64:91–7.

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FEATURE

PROCESS IMPROVEMENT MODEL A3 TO REDUCE HAIS:

Looking through a different lens BY JENNIFER SPIVEY, MSN, RN, CNOR, CIC, FAPIC

66 | WINTER 2018 | Prevention

TOMERTU/SHUTTERSTOCK.COM

n a session presented at the APIC 2018 Annual Conference by Jennifer Spivey, MSN, RN, CNOR, CIC, FAPIC, and Heather Hohenberger, MSN, RN, CIC, CNOR, CPHQ, FAPIC, infection preventionist (IP) were provided with a common structure, principles, concepts, and quality behaviors necessary to drive excellence. GE Change Acceleration Program training, known as GE CAP, recognized something profound GE has a large number of tools to help gain A3, but the main thing you need to understand at this point is that revisiting the Gemba (the direct observation) to share the “Plan” moving forward is critical to success.1 This A3 problem solving is a way of thinking in order to solve problems, not just a tool to determine the cause. It’s a highly structured, step-by-step way of solving problems by identifying the root cause and following the steps of true Plan-DoCheck-Act (PDCA). It helps to deepen the understanding of the problem or opportunity, and it gives strong insight into the best way of addressing the problem. The A3 problem-solving method is borrowed from the Toyota Motor Company and adapted to manufacturing and healthcare. This method has been demonstrated to be of value in healthcare in every department that wishes to reduce waste and eliminate errors through the creation of standard work and can be used by the IP to reduce healthcare-associated infections (HAIs) in a systematic approach. At Toyota, a leader became frustrated with equipment downtime and other problems that were recurring quite often. He noticed that his highly trained engineers and managers were spending much time in their office, instead of at the front line, where the work is actually done. When a problem arose, these same managers and engineers would come to him, tell him what happened and the solution they were putting in place. The problem was that these “solutions” often did not work. To teach his team of managers and engineers, he instituted a rule that whenever equipment went down for 30 minutes or

many years ago. They found that 62 percent of all improvement efforts fail from the lack of attention to the cultural and people sides of change. They summarized this learning into the following equation now known as the Formula for Results. The equation is simply Q * A3 = E (Q stands for the Quality of your solution; A to the 3rd stands for Acceptance * Accountability * Alignment, and E stands for Effectiveness).

more, the plant manager was to go directly to the floor and work with the engineers overseeing the equipment to complete a “breakdown report” (eventually becoming an A3) to ensure problem solving to the root cause and prevent such recurrences. The report then had to be presented to him so he could then see how his team thinks and coach as necessary—all while solving the problems.2 As already indicated, there are specific steps to A3 problem solving, including the left side of the template, that are all about planning in addition to the first five steps below: 1. The first step is defining the issue or problem statement. Once that issue is identified, you want to measure its impact to understand why it’s worthy of your time. 2. Once you know the problem and see it has an impact worthy of addressing at this time, you would form an effective team and set a SMART goal (specific, measurable, actionable [or agreed upon], realistic, and time bound). 3. With all of this in place, it’s time to focus on the process, as all work is a process. Once we deeply understand the process, the next step is to identify the real root cause or causes of the problem. 4. After we identify the root causes, we must select the appropriate counter measures. In other words, what we are going to do to fix the problem. 5. At this point, we are done with the “P” or Plan phase, or the left side of the A3 paper and the Plan phase of PDCA, and ready to jump into doing, checking, and adjusting.

The A3 format, also referred to as Lean thinking, is a way for the IP to look with “new eyes” or a different lens at a specific problem identified by direct observation or experience. The A3 offers structure that begins always with defining the issue or problem through the eyes of the patient and caregivers directly involved. The patientcentered way of stating the problem makes the resolution of the problem indisputable. After all, why are we here if not to produce ideal service of product for the customer or patient? But more importantly, do you already use A3 thinking? If you are a clinician, I would presume that you already use A3 thinking when you take care of patients every day. Physicians, especially, are trained in this manner, so let’s see how A3 thinking is applied when treating a patient. When moving down the template, from left to right, the clinician demonstrates A3 thinking: 1. Chief complaint is the same as Problem Statement. 2. Physical assessment is the same as Measurement/Background and Current Condition (where the clinician is checking vital signs, listening to heart and lungs, the full physical assessment). 3. Diagnostic tests: blood work; CT Scans, X-rays, etc., are where you are delving deeper for root cause of the illness. This is known as Root Cause Problem Analysis in A3 land. 4. Treatment plan is where you begin to apply solutions (new medicines, therapies, even surgery) as you now understand the problem and its most likely root cause These are simply the Countermeasures/ Action Plan of A3. w w w.apic.org | 67

FEATURE

5. A follow-up visit (or even rounding on the patient the next day in the hospital) is the Check phase of A3/PDCA, where the patient returns or is monitored to see if the treatment (a.k.a. countermeasure) is actually working. 6. Finally, adjustments are made to the treatment plan based on whether or not it is working. This is the Act/Adjust phase of A3/PDCA where the same is done for process.3 Ask yourself, why not treat process problems the same way we treat patients? Using the A3 template and model, you have all identified parts on one page with the plan to mitigate the root cause and the action plan in a comprehensive package. For example, it can make the IPs business case for a new Foley kit with proper steps labeled out to be more concise to demonstrate why you are needing the executive teams support to act on certain issues and make process changes based on well-defined problem solving to justify the changes needed to drive evidence-based practice. The key, however, is to realize that it is a way of thinking to look at problems, such as changing these kits to improve HAIs and then continue 68 | WINTER 2018 | Prevention

rapid-cycle PDCAs or reiterative process until you sustain improvement. Even if you get a new Foley kit, which is expected to decrease variability for the insertion bundle, you may need to use the PDCA cycle to check and adjust as needed in order to sustain improvements. At this point, we are ready to move to the right side, which is the action phase of countermeasures, to respond to the root cause. When people say, “We use PDCA,” do you think they are honestly respecting the plan phase like this, as Dr. Deming emphasized? If we use the A3 systematic thinking, just know that selecting the countermeasure, testing it, and adjusting it all falls on the right-hand side and finalizes the first PDCA cycle. It gives us an opportunity to not just “P, P, D, D,” (plan, plan, and do, do), instead, we need to check our actions after each countermeasure applied, and readjust and make efforts to ensure we indeed have the root cause to make sustainable efforts in our HAI reductions. The A3 will allow the IP to document on one A3 size paper, which the process was named for. It’s 11x17,” which is the international paper size known as “A3.” So voila, now you know why it’s called A3.

Albert Einstein said, “If I had an hour to save the world, I would spend 59 minutes defining the problem and one minute finding solutions.”4 In healthcare, too often, we just do it and jump to conclusions prior to spending time on identifying the problem with those who are closest to the work, and not throw out solution bombs to a quick fix that is not sustainable. Jennifer Spivey, MSN, RN, CNOR, CIC, FAPIC, is an independent infection prevention consultant, and past infection prevention system consultant performance excellence and quality operations for St Vincent Health Indiana Statewide Market. References 1. Von Der Linn B, Overview of GE’s Change Acceleration Process (CAP). https://bvonderlinn.wordpress. com/2009/01/25/overview-of-ges-changeacceleration-process-cap/ Accessed September 2018. 2. Liker JK. The Toyota Way: 14 Management Principles from the World’s Greatest Manufacturer. Madison, WI: McGraw-Hill; 2004, 6. 3. Aim 4 Excellence, Ascension Improvement Model for Excellence, A3 Problem Solving for HealthCare Facilitator’s Guide. Ascension Health. 2017; Right side.1-43. Left side 1-38. 4. Quote Investigator. I Would Spend 55 Minutes Defining the Problem and then Five Minutes Solving It. https:// quoteinvestigator.com/2014/05/22/solve/; Accessed September 2018.“The

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CLABSI RCA TOOL FOR ONCOLOGY/HEMATOLOGY PATIENTS

How we prioritized which metrics to tackle BY BRENNA DORAN, PhD, BS, MA, CIC; SUWANNEE SRISATIDNARAKUL, RN, MSN, CIC; SANJEET SINGH DADWAL, MD; AND ANNEMARIE FLOOD, MPH, BSN, RN, CIC, FAPIC

ity of Hope National Medical Center is a free-standing, PPS-exempt, comprehensive cancer center located in Southern California. City of Hope performs more than 700 stem cell transplants each year, with two-thirds of in-patient days comprised of hematology/hematopoietic stem cell transplantation (HSCT) patients. This highly immune-compromised population is at greater risk for acquiring healthcareassociated infections (HAIs). City of Hopeâ&#x20AC;&#x2122;s focus is on central line-associated infections (CLABSIs), as they carry high risk of mortality and morbidity.1 To put this in perspective, per the National Healthcare Safety Network (NHSN) calculated standardized infection ratio, our facility should expect 55-62 CLABSIs per year.2,3 Among immunocompromised patients, BSIs may result from translocation of gut microorganisms as normal flora and mucosal integrity can become deranged during treatment.4 Mucosal barrier injury laboratory-confirmed bloodstream infection (MBI-LCBIs) is a subset of the NHSN CLABSI definition. The MBILCBI definition was developed to identify events where the primary source of infection

70 | WINTER 2018 | Prevention

may be the gastrointestinal tract. Organisms must be on a published eligibility list to meet the MBI-LCBI definition. There is little discussion in the literature regarding epidemiological and clinical risk factors for patients who would fit MBI-LCBI definition but for a qualifying organism. We recognized, as a product of our case reviews, a portion of the CLABSIs we identified would meet MBILCBI criteria if the organism identified from the blood culture was on the MBI organism list. As MBI-LCBIs are considered to be seeded from a break in the mucosal barrier, we postulated that CLABSIs from patients who were neutropenic would not be as preventable. Moving forward, we defined CLABSIs matching MBI-LCBI criteria absent of the organism as sine qua non, but for CLABSI (SQN-CLABSI). We looked to develop a tool that would identify the myriad risk factors of our patient population and allow us to assess added CLABSI risk factors. We used the root cause analysis (RCA) methodology as it is an evidence-based practice shown to be a useful tool to help reduce infections.4-9 This information, in turn, would allow us to refine our recommendations to the frontline staff.

CLABSI RCA

Patient Information Name MRN Age Gender

Date of CLABSI Organism Date of Insertion Duration of Line

Admission Date Discharge Date Unit Service Primary dx

Hx of MDRO

Added Associated Risk Score /3

Type of line Location of Line Number of lumens

Patient Risk Factors

Day -7 Day -6 Day -5 Day -4 Day -3

Fever, Chills, Hypotension Neutropenic Oral/ GI Mucositis Parentral Nutrition Chemo 14 days prior Transplant Date Tranplant Type Engraftment Date GVHD Bacteremia prior 30 days

Patient Care History

Score

Total Score Diarrhea > 1L

Grade

Added Associated Risk Score / 10

Total Score

House-wide & Unit Demographics Hand Hygiene Compliance Contact Isolation PPE Glow Germ Compliance CLABSI Bundle Audit Total Bathing CHG

Day -2 Day -1 Day 0

House

Expectation 90% 95% 95% 95% 95% 95%

Unit

Score

Total Score

Day -7 Day -6 Day -5 Day -4 Day -3 Day -2

Complete Bath CHG Dressing Change q7d Claves q4d Tubing q4d Impregnated CHG/ patch q7d PICC Securement Changed PICC external length

Added Associated Risk Score /4

Day -1 Day 0

Expectation ≥8 ≥8 ≥1 ≥2 ≥2 ≥1

Score

Added Associated Risk Score /3

Comments

Total Associated Risk for CLABSI / 20 Figure 1. CLABSI RCA mock-up template 2018.

Unlike CLABSIs, MBI laboratory-confirmed bloodstream infections (LCBIs) are not expected to be prevented by improved central venous catheter (CVC) maintenance care. The ability to differentiate between CLABSI and MBIs provides a more

accurate picture of preventable CLABSI burden and identify tailored strategies to reduce infections associated with a CVC. Due to the volume of CLABSIs, we needed a process to prioritize which of the cases to focus on and better manage w w w.apic.org | 71

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READ MORE ABOUT CLABSI IN THE AMERICAN JOURNAL OF INFECTION CONTROL Central line–associated bloodstream infection rate elevation: Attributable to National Healthcare Safety Network surveillance definition changes, ongoing opportunities for infection prevention, or both? Corley A, Cantara M, Gardner J, et al. Am J Infect Control, Vol. 45, Issue 9, p1030–1032. Suwannee Srisatidnarakul, Annemarie Flood, And Brenna Doran

our workload. After a review of the literature, we created the RCA tool (Figure 1 previous page), dividing it into four sections:

compliance values for both the facility as a whole and the unit the patient was housed during the seven retrospective days before the CLABSI event.

PATIENT INFORMATION

PATIENT CARE HISTORY

The patient information included basic demographics such as admission, discharge date, unit, date of CLABSI, and duration of the central line prior to CLABSI event.

The patient care history looked at nursing-sensitive indicators the seven retrospective days before the CLABSI event for that patient including bathing with CHG, central line dressing change, and central line care related components. The items included in the patient risk factors, house-wide and unit demographics, and patient care history sections were selected as they were found to increase the risk of infection.6-9 In order to effectively prioritize the opportunities identified from the RCAs, we needed to assess the nature of the added risk and identify which could be improved by enhancing patient care.4-9 The added risk for each section was tabulated into an overall total associated risk for CLABSI score out of a total of 20 points. The purpose of the tool and total associated risk for CLABSI score is threefold: (1) to assist in identifying CLABSI events which may have been seeded from an intrinsic source but does not meet the NHSN MBI-LCBI definition, and those

PATIENT RISK FACTORS

The patient risk factor section looked at specific clinical details such as date and type of transplant, history of graft versus host disease, bacteremia, chemotherapy in the last 14 days, and seven-day retrospective look-back of neutropenia, mucositis, and parental nutrition from the date of the CLABSI. HOUSE-WIDE AND UNIT DEMOGRAPHICS

The house-wide and unit demographics focused on broader metrics such as hand hygiene compliance, contact isolation PPE compliance, environmental services room cleanliness (determined by using fluorescent ink) compliance, CLABSI bundle audit, bathing, and chlorhexidine gluconate (CHG) soap 72 | WINTER 2018 | Prevention

Are antimicrobial peripherally inserted central catheters associated with reduction in central line–associated bloodstream infection? A systematic review and meta-analysis. Kramer RD, Rogers MA, Conte M, et al. Am J Infect Control, Vol. 45, Issue 2, p108–114. Effectiveness of an Interprofessional Team Approach at Reducing CLABSI in a Community Hospital. Mason B, Suresh S. Am J Infect Control, Vol. 45, Issue 6, S100.

associated with the CVC; (2) identify facility-wide and unit-level risk factors; and (3) identify missed components of patient care processes. The infection preventionist scores all four sections and tabulates an associated risk score. Since we began using this tool in the beginning of 2017, we have been able to identify trends from the unit and facility level, and tailor infection prevention processes and education to support frontline staff. LESSONS LEARNED

What we gleaned from the creation and use of the CLABSI RCA tool is using current NHSN surveillance definition better applies to the general population as that nearly half of our CLABSIs occurred in patients with

profound neutropenia, but did not have a MBI qualifying organism.10-11 Unique populations such as the immunocompromised oncology/hematology patients have risk factors for HAIs such as prolonged neutropenia, recent chemotherapy, and graft versus host disease, which are not experienced in general patient populations and cannot be modified. Caring for cancer patients is highly challenging; the CLABSI RCA tool for oncology/hematology patients enhances the care provision by guiding providers to focus on modifiable factors in patients who are otherwise terminal. In order to be effective in reducing preventable CLABSIs, we needed to create a new RCA tool to assist in differentiating between preventable and non-preventable CLABSIs and provide a methodology to evaluate nursing-driven process and identify opportunities for improvement. Since we started the RCA process, we have had an opportunity to collect trends on some on our patient-level risk factors and focus on specific nursing sensitive indicators. Most interesting is the percentage of SQN-CLABSI versus CLABSIs from 2017 to 2018 (Figure 2 below). Historically, we have postulated approximately 50 percent of our CLABSIs would have met our SQNCLABSI definition. In 2017, the first

year we trended the data, 54 percent of our CLABSIs met SQN-CLABSI. During 2017, we began reporting out our trending findings and worked with front-line nursing, education, and leadership to improve nursing sensitive indicators as identified through our RCAs. During 2018, our year-to-date CLABSIs is less than 2017 and we have observed a higher percentage of SQN-CLABSI at 76 percent. It is too early to determine the statistical significance of the observed trends at this time. However, the CLABSI RCA tool does provide insight into the effectiveness of some of our initiatives and provides the ability to track the improvement process. Lastly, and most significant for us, it allows us to glean a better understanding on our progress of reducing the CLABSIs we believe are truly preventable. Brenna Doran, PhD, BS, MA, CIC, is the senior infection preventionist for City of Hope National Medical Center in Duarte, California. She has been in the field of infection prevention for more than eight years and has worked as clinical microbiologist and lecturer in biological sciences. Suwannee Srisatidnarakul, RN, MSN, CIC, is the infection preventionist for City of Hope National Medical Center in Duarte, California. She has been in the field of

infection prevention for more than 10 years, and has worked as an ICU nurse, PICC nurse, dialysis nurse, and nursing educator. Sanjeet Singh Dadwal, MD, is a clinical professor of medicine in the Division of Infectious Diseases at the City of Hope National Medical Center in Duarte, CA. He is also the director of the antimicrobial stewardship program and the co-lead infectious disease on the transplant disease team. Annemarie Flood, MPH, BSN, RN, CIC, FAPIC, is the senior manager of the infection prevention program for City of Hope National Medical Center in Duarte, California. She has been working in the field of infection prevention for more than 18 years. Annemarie currently serves on the APIC Board of Directors. References 1. H ow-to Guide: Prevent Central Line-Associated Bloodstream Infections. Cambridge, MA: Institute for Healthcare Improvement; 2012. 2. National Healthcare Safety Network Patient Safety Component Manual. Centers for Disease Control and Prevention. https://www.cdc.gov/nhsn/index.html. Published January 2018. Accessed September 2018. 3. The NHSN Standardized Infection Ratio. Centers for Disease Control and Prevention. https://www.cdc. gov/nhsn/2015rebaseline/index.html. Updated July 2017. Accessed September 2018. 4. Epstein L, See I, Edwards JR, et al. Mucosal barrier injury laboratory-confirmed bloodstream infections (MBI-LCBI): descriptive analysis of data reported to National Healthcare Safety Network (NHSN), 2013. Infect Control Hosp Epidemiol, 2016;37(1):2-7. 5. Dudeck MA, Weiner LM, Allen-Bridson K, et al. National Healthcare Safety Network (NHSN) report, data summary for 2012, Device-associated module. Am J Infect Control, 2013;41(12):1148-1166. 6. Yokoe DS, Anderson DJ, Berenholtz SM, et al. A compendium of strategies to prevent healthcareassociated infections in acute care hospitals: 2014 updates. Infect Control Hosp Epidemiol, 2014;35(S2), S21-S31. 7. P reventing central line–associated bloodstream infections: Useful tools, an international perspective. The Joint Commission. http://www.jointcommission.org/CLABSIToolkit. Published November 2013. Accessed September 2018. 8. Ling ML, Apisarnthanarak A, Jaggi N, et al. APSIC guide for prevention of central line-associated bloodstream infections (CLABSI). Antimicrob Resist Infect Control, 2016;5(1):16. 0. M arschall J, Mermel LA, Fakih M, et al. Strategies to prevent central line–associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol, 2014;35(7):753-771. 10. O’grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control, 2011;39(4):S1-S34.

Figure 2. Percentage of SQN-CLABSIs vs CLABSIs; 2017-2018.

11. Kato Y, Hagihara M, Kurumiya A, et al. Impact of mucosal barrier injury laboratory-confirmed bloodstream infection (MBI-LCBI) on central line-associated bloodstream infections (CLABSIs) in department of hematology at single university hospital in Japan. J Infect Chemother, 2018;24(1):31-35.

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FEATURE

Tiger of a different stripe

ORAL CAVITY PROPERTIES THAT ALTER INFECTION RISK BY JOSHUA ULIBARRI, DDS; DAMON POPE, DMD; AND CAPTAIN GARY CARTER, MPH, CIC, CIH

f the presence of blood indicates a likely breach of sterile tissue, why isn’t a dental operatory considered a procedure room? Why isn’t a sterile field required for routine dental procedures? Why isn’t the ventilation configured to meet the requirements of a sterile environment?

READ MORE ABOUT DENTAL HYGIENE SETTINGS AND INFECTION PREVENTION IN THE AMERICAN JOURNAL OF INFECTION CONTROL Effects of mandatory continuing education related to infection control on the infection control practices of dental hygienists. Kelsch N, Davis CA, Essex G, et al. Am J Infect Control, Vol. 45, Issue 8, p926–928. Staphylococcus aureus and the oral cavity: An overlooked source of carriage and infection? McCormack MG, Smith AJ, Akram AN, et al. Am J Infect Control, Vol. 43, Issue 1, p35–37. Evaluation of an ethical method aimed at improving hygiene rules compliance in dental practice. Offner D, Strub M, Rebert C, et al. Am J Infect Control, Vol. 44, Issue 6, p666–670.

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If you have these same questions, or maybe you haven’t really explored the nuances of a dental environment regarding infection control, you are not alone. Accreditation focus is increasing in dental infection control, and dental clinics are being held to the same infection control standards and guidelines as medical environments. However, there are significant differences between the dental environment and the medical environment regarding the understanding of healthcare-associated infections (HAIs) and how to control them. The infection preventionist (IP) would be well-equipped to know these differences and to know the accreditation requirements. Dental HAIs have not been clearly defined and differ from medical definitions that include “breach of sterile tissue” as a fundamental requirement for most parenteral infections. The oral environment, on the other hand, has gradations of mucosal tissue abrasions and breaches, where there is no clear “breach” of sterile tissue. Further, saliva has known immunological properties as well as physicalchemical properties that exert a protective effect against infection (see Figure 1). These oral cavity characteristics should drive a different approach for dental HAI surveillance and follow-up protocols, but there is little guidance on how

surveillance in the dental environment should be conducted, or how follow-up protocols should be standardized. This article seeks to present key differences between the oral environment and the sterile tissue environment and how those differences impact the practice of infection control. ORAL MICROBIOLOGICAL AND IMMUNOLOGICAL ENVIRONMENT

As with all surgeries, dental personnel and patients have the potential for exposure to bacterial, fungal, and viral organisms. Therefore, the use of personal protective equipment (PPE) is required and proper sterilization protocols are used for reusable instruments. But, in contrast to other surgical sites, special characteristics of the oral environment create subtle yet important differences when it comes to infection prevention and control (IPC) for providers and patients. From an IPC perspective, the oral cavity has several features that make it different from any other area of the body. To begin with, there are approximately 500‒1,000 different species of bacteria and multiple species of fungi that make up the normal flora of a healthy oral cavity.1 A sterile environment has none. Thus, it is impossible to create a strict

• 0 bacterial species • Regular host defense system

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• 500-1000 bacterial species • Regular host defense system • Lysozymes • Histatins • Secretory immunoglobulin A

Figure 1. Comparing the oral environment to sterile tissue breach.

sterile environment when performing any dental procedure compared to performing a general surgery. Another major factor that sets dental infection control apart is the unique microimmune system that exists in the mouth. According to the seminal text on the topic, Molecular Oral Biology, oral bacteria that occupy the ecological niche provided by both the tooth surface and gingival epithelium have evolved mechanisms to sense their environment and evade or modify the host. A highly efficient host defense system constantly monitors microbial colonization and prevents invasion of local tissues.2 The primary component of this defense is saliva and its constitution, which allows for a unique functionality of the mouth when it comes to surgical site healing and resistance to infection. Salivary fluid has been shown to decrease clotting time compared to other areas of the body by salivary proteins neutralizing anticoagulant factors in the blood.3 Saliva also has many antimicrobial properties preventing general infection. The most prominent immunologic in saliva is secretory immunoglobulin A (IgA), which has shown to

neutralize pathogenic microorganisms and prevent adhesion.4 IgA, accompanied by lower levels of other antibodies, provides a robust adaptive immunological barrier to infectious organisms in the mouth. In addition, there are many non-immune immunologic components of saliva that add to the immunologic protection it provides. Specifically, lysozyme enzymes and histatin proteins are present in high quantities that damage critical components of infectious organisms leading to cell death.5 Clinically, the composition of the oral environment and the functionality of saliva results in healing and the absence of infection that is not typically seen in other areas. The vast majority of intraoral surgical site incisions will heal by primary intention; thus, sutures are not required nor do scars develop. Furthermore, intraoral post-operative surgical infections are rare, even in the presence of co-morbidities or medications that affect immune function. When the public thinks of a surgery they envision a trip to a hospital operating room where they will be sedated and cut open. This perspective describes an invasive procedure. By definition, a medical

procedure is invasive when a break in the skin or mucosa is created and there is contact with the non-intact skin, mucosa or internal body cavity beyond a natural or artificial body orifice. This seems self-explanatory but becomes much more complicated when comparing the mouth to the rest of the body. If going strictly by the above definition, almost all dental procedures would be considered invasive including routine fillings and cleanings because they involve creating a break in tissues, enamel in the case of a filling and the gingival mucosa in the case of the majority of cleanings. Most people would not consider teeth cleaning an invasive surgery, but why not? The answer is not actually in the manipulation of tissues because this occurs whether having a tooth extracted or an appendix removed, but in how our bodies at large react to surgeries and how that differs in the mouth. As previously discussed, the mouth is equipped with its own unique immune system that is a combination of innate, adaptive and mechanical immunological processes that make the oral cavity resistant to local site infections and a barrier to systemic infections. However, very w w w.apic.org | 75

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Surgical infection control

Joint replacement surgery

Dental implant surgery

Pre- surgical shower with antibacterial soap

Yes

Pre-surgical antibiotics

Yes

During surgery antibiotics

Yes

Table 1. Comparing infection controls between medical and dental procedures.

little data exist to support these facts. In a system with financial limits, as is the case with dental practice, it is not prudent to invest a significant amount of resources to something such as dental infections that simply do not occur with any type of consistency to affect patient outcomes. For example, well-researched and defined IPC precautions exist between a joint replacement procedure and the placement of a dental implant. However, both involve incision and displacement of soft tissues, exposure and removal of bone and placement of a prosthetic device in that bone. The differences in IPC precautions are shown in Table 1. Because of the similarities of prosthetic joint placement and a dental implant, pre-operative antibiotic prophylaxis has been suggested for both. However, strong evidence exists that preoperative antibiotics have little, if any, effect on post-operative dental implant infections.6 This illustrates the need for more research to definitively illustrate why these differences occur. DENTAL UNIT WATERLINE RISK

As for meaningful infection risks in the dental environment, waterline biofilm is a likely one. Even in the presence of the protective nature of the oral cavity dental unit, waterlines have been identified as the certain cause in a few documented infections. As such, there has recently been a heightened focus on dental waterlines and the potential risks that they may bring to dental patients. The Centers for Disease Control and Prevention (CDC) has found that there are more than 200 species of microorganisms cultured from dental unit waterlines. The CDC has randomly tested dental unit waterlines and found that colony counts of some of these waterlines have been 400 times higher than 76 | WINTER 2018 | Prevention

their local water source. Colony counts from untreated waterlines can exceed 1,000,000 CFU/mL. There have been a wide range of microorganisms that have been isolated from dental unit waterlines, including protozoa, free-living amoebae, fungi, and nematodes. There have been human pathogens detected as well, such as Legionella pneumophila, Mycobacteria species, Pseudomonas aeruginosa, and Staphylococcus species. 7,8 Lately there has been a growing connection between dental patients’ illness, infection and fatalities in connection with dental unit waterlines. In 1995, a 65-yearold orthodontist died after developing pneumonia caused by Legionella. Legionella was later isolated from a dental unit waterline.9 In 2011, an 82-year-old woman died after contracting pneumonia which was traced back to a contaminated dental unit waterline.10 In 2015-16, there were multipatient outbreaks of non-tuberculous aquatic Mycobacteria in pediatric dental practices in Georgia and California. All infected children at both locations underwent pulpotomy treatment, and all cases were traced back to improperly treated dental unit waterlines. In 2016, 20 patients from another Georgia practice were confirmed to be infected with Mycobacterium abscessus (M. abscessus). All 20 patients were severely ill, requiring at least an average of seven days in the hospital. Seventeen

patients required surgical excision and 10 received outpatient intravenous antibiotics. All water samples from seven dental units had more than 500 colony-forming units (CFU/ml) with the average being (91,333 CFU/mL). M. abscessus was detected in all water samples.11,12,13 The Environmental Protection Agency (EPA) microbiologic standards for drinking water are having a heterotrophic plate count of no more than 500 bacterial colonies per milliliter with 99.9 percent of Giardia lamblia and viruses killed/inactivated. In 1993 the CDC recommended that dental unit waterlines should have less than 500 CFU/mL of bacteria, while more recently the American Dental Association (ADA) has come out with the recommendation of 200 CFU/mL.14 Protecting patients from infections caused by dental unit waterlines is a threefold process. It takes a successful dental unit waterline set up, proper monitoring, and proper treatment of the dental unit waterlines. First, you need a dental waterlines system that is updated and avoids designs that can contribute to waterline contamination. Due to the small tubing, dental unit waterlines are conductive to rapid formation of biofilm. Some characteristics to avoid when designing a dental unit waterline are long lengths of narrowbore tubing, dead legs, gauges, control blocks, and valves. Dental unit waterline water quality can be monitored by either in-office chairside testing or laboratory testing. There are two main types of chairside testing methods. They are heterotrophic plate counts and microorganism cultures. Convenient kits are available for either of these methods. Advantages to chairside testing kits are that they are convenient and easy to use. Disadvantages to these methods include underestimation of counts and certain phenotypes of

“Dental HAIs have not been clearly defined and differ from medical definitions that include ‘breach of sterile tissue’ as a fundamental requirement for most parenteral infections. The oral environment, on the other hand, has gradations of mucosal tissue abrasions and breaches, where there is no clear ‘breach’ of sterile tissue.”

INFECTION PREVENTION CONTROLS USED IN DENTAL SETTINGS Standard Precautions and Personal Protective Equipment Engineering and Work Practice Controls Hand Hygiene Operatory Turn Around / Housekeeping policies and procedures Instrument processing policies and procedures Dental unit waterline maintenance and disinfection Management of Infectious Waste policies and procedures Laundry policies and procedures Hepatitis B Vaccination policy and procedures to include vaccine and titer testing at no cost to employees Post-exposure evaluation and follow-up policy and procedures Table 2. Basic infection controls in the dental environment.

bacteria fail to grow. Laboratory testing may produce more accurate results and give you a third-party confirmation to the test, but will end up costing more and may take longer to get the test results. The frequency of water testing should be according the manufacture instructions of the treatment system that you are using. This may be once a year, once a quarter, once a month, or once a week. There are a variety of chemical treatment options for dental waterlines. They include hydrogen peroxide, pure iodine, silver ions, chlorine dioxide, ozone, sodium hypochlorite, peracetic acid, and chlorhexidine gluconate.15-17 INFECTION CONTROL SURVEILLANCE, STANDARDS, AND PRACTICES

Though uncertainty exists regarding the level of HAI risk within the dental environment, regulatory risk is high given the many oversight organizations to which clinics are accountable. These organizations and their requirements include the following: states’ Dental Practice Act licensing requirements, Accreditation Association for Ambulatory Health Care (AAAHC) and The Joint Commission (TJC) healthcare facility accreditation

standards, Occupational Safety and Health Administration (OSHA) regulations, Centers for Medicare & Medicaid Services [CMS] regulations, CDC guidelines, and the ADA guidelines. The basic controls required in dental environments are summarized in Table 2. Two primary sets of requirements specifically pertaining to infection control that are particularly scrutinized by accreditation organizations such as the AAAHC and TJC are the American National Standards Institute (ANSI)/Association for the Advancement of Medical Instrumentation (AAMI)/ST79:2017, “Comprehensive guide to steam sterilization and sterility assurance in health care facilities,” and CDC’s Guideline for Infection Control in Dental Clinics. Further, the legal requirements in OSHA’s Bloodborne Pathogen Standard (29 Code of Federal Regulations 1910.1030) are always under scrutiny. While ANSI/AAMI ST79:2017 sets forth the primary standards for table-top sterilization processes, it becomes rather onerous for dental clinics when it comes to ventilation requirements and storage of sterilized instruments. Many dental clinics opt to follow ANSI/AAMI ST79:2017 for

table-top sterilization pre-cleaning, cleaning, wrapping, sterilizing, and monitoring, but choose to adopt the CDC’s Guideline for Infection Control in Dental Clinics for ventilation and storage requirements. In either case, dental personnel who sterilize instruments must be qualified and provided with ongoing training, according to the CDC Guidelines.8 To show that personnel are “qualified,” accreditation surveyors generally want to see recurring competency assessments, usually performed annually. Surveillance of dental procedure HAIs is becoming more common, but very little historical data exists other than those suggesting waterline contamination and biofilm composition can lead to HAIs. This is almost certainly because, as previously stated, waterline contamination is the only area in dentistry that has created enough public risk to drive research. Because of this lack of scientifically validated factors contributing to HAIs in dentistry, surveillance protocols are not fully developed. Therefore, follow-up protocols mainly involve monitoring the patient for a developing infection after certain, not all, particularly invasive procedures. STANDARD PRECAUTIONS IN THE DENTAL ENVIRONMENT

Standard precautions in the dental setting are required, just as in any environment where blood, body fluids, nonintact skin, and mucous membranes exist. Since saliva has always been considered a potentially infectious material, mask, gloves, gown, and eye protection are required for the protection of the dental employee. Uncertainty exists, however, regarding when to change the gown. In the medical environment, clearly the gown must be changed between patients, but in the dental environment, given the oral properties that reduce infection risk, there is no evidence that changing gowns between patients is necessary to reduce infection risk to the patient, unless the patient is already under contact precautions and undergoing an emergency dental procedure. The CDC states the following, with the intent of protecting the employee: “[Dental personnel] should change protective clothing when it becomes visibly soiled and as soon w w w.apic.org | 77

FEATURE

as feasible if penetrated by blood or other potentially infectious fluids. All protective clothing should be removed before leaving the work area.”8 The CDC Guidelines and OSHA Bloodborne Pathogen Standard should be consulted for more information on employee protection. CONCLUSION

Given the altered infection risk driven by the oral environment host defenses, controversy exists regarding the extent to which dental clinics need to follow some of the established standards and guidelines. In terms of HAI risk, one size does not fit all regarding the type of environment in which procedures take place, specifically the oral environment versus a sterile field, yet there are myriad laws, standards, and guidelines that are required to be followed even if some of them are not appropriate for the altered level of HAI risk in the dental environment. Current scientific literature lacks a complete treatment of dental environment HAIs and appropriate controls. This paper is a call for further scientific investigation regarding rates of infection and exposure characteristics of HAIs in the dental environment. With additional

knowledge, control methods can be modified to be specific for the dental environment, thus preventing overly burdensome requirements that might very well result in unintended consequences and increased accreditation risk. Joshua Ulibarri, DDS, is the acting clinical director and dental chief of the Acoma-CanoncitoLaguna Service Unit at Albuquerque Area Indian Health Service.

6. Ahmada N, Saadb N. Effects of Antibiotics on Dental Implants: A Review J Clin Med Res. 2012:4(1):1-6. 7. Depaola LG, Mangan D, Mills SE, et al. A review of the science regarding dental unit waterlines. J Am Dent Assoc. 2002:133:1199-1206. 8. Centers for Disease Control and Prevention. CDC Guidelines for Infection Control in Dental Health-Care Settings – 2003. https://www.cdc.gov/mmwr/preview/ mmwrhtml/rr5217a1.htm. Accessed August 2018. 9. William HN, Baer ML, Kelly JI. Contribution of biofilm bacteria to the contamination of the dental unit water supply. J Am Dent Assoc. 1995:126:1255-1260. 10. Ricci ML, Fontana S, Pinci F, et al. Pneumonia associated with a dental unit waterline. The Lancet. 2012:379:684.

Damon Pope, DMD, is a national dental infection control consultant at the Indian Health Service.

11. Peralta G, Tobin-D’Angelo M, Parham A, et al. Notes from the Field. Mycobacterium abscessus Infections Among Patients of a Pediatric Dentistry Practice — Georgia, 2015. MMWR Morb Mortal Wkly Rep 2016:65:355–356.

Captain Gary Carter, MPH, CIC, CIH, REHS, DAAS, is the principal institutional environmental health consultant at the Environmental Health Support Center for the Indian Health Service.

12. Perkes C. 7 children hospitalized after treatment at Anaheim dental clinic, 500 more could be affected. The Orange County Register. https://www.ocregister. com/2016/09/14/7-children-hospitalized-aftertreatment-at-anaheim-dental-clinic-500-more-couldbe-affected/. September 2016. Accessed August 2018,

References 1. Aas JA, Paster BJ, Stoke LN, et al. Defining the Normal Bacterial Flora of the Oral Cavity. J Clin Microbiol. 2005:43:5721–5732. 2. Rogers AH. Molecular Oral Biology 2008. University of Adelaide Australia: Caister Academic Press; 2008. 3. Volker JF. The effect of saliva on blood coagulation. Am J Orthod Oral Surg. 1939:25:277-281. 4. Sollecito TP, Abt E, Lockhart PB, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints. J Am Dent Assoc. 2015:146(1): 11–16.e8. 5. de Almeida PV, Gregio AM, Machado MA, et al. Saliva Composition and Functions: A Comprehensive Review. J Cont Dent Pract. 2008:9:72-80.

13. Hatzenbuehler LA, Tobin-D’Angelo M, Drenzek C, et al. Pediatric Dental Clinic-Associated Outreak of Mycobacterium abscessus Infection. J Ped Inf Dis Soc. 2017;6:e116-e122. 14. Centers for Disease Control and Prevention. The Safe Drinking Water Act. http://www.cdc.gov/healthywater/ drinking/public/regulations.html. Accessed August 2018. 15. American Dental Association. Dental Unit Waterlines. https://www.ada.org/en/member-center/oral-healthtopics/dental-unit-waterlines Accessed August 2018. 16. Centers for Disease Control and Prevention. Guidelines for Infection Control in Dental Health-Care Settings, 2003 MMWR 2003;52:1-66. 17. Organization for Safety, Asepsis and Prevention. OSHA and CDC Guidelines: OSAP Interact Training System, Selfinstruction Workbook. OSAP. 2017:4-9 - 4-11.

INDEX TO ADVERTISERS CLEANING, DISINFECTION, & STERILIZATION

CLOSED SYSTEM NEEDLE SAFETY DEVICES

*B. Braun Interventional Systems Inc. ��5 www.bisusa.org

Smart Facility Software ��65 www.smartfacilitysoftware.com

CS Medical, LLC �� 40 www.csmedicalllc.com

DISINFECTION APPLIANCES

umf Corporation ��Inside Back Cover www.perfectclean.com

Avadim Health Inc. ��61 www.theraworx.com

Diversey ��19 www.sdfhc.com

Micro-Scientific Industries, Inc. ��9 www.micro-scientific.com HAND HYGIENE

*GOJO Industries ��Outside Back Cover www.healthcare.gojo.com

*BD ��55 www.bd.com

Molnlycke Health Care ��13 www.molnlycke.us

INFECTION CONTROL PRODUCTS

*PDI, Professional Disposables International ��31 www.pdibethedifference.com Steriliz, LLC ��3 www.steriliz.us Surfacide ��20 www.surfacide.com Tru-D Smart UVC ��35 www.tru-d.com Virox Technologies Inc. ��39 www.viroxaccel.com

78 | WINTER 2018 | Prevention

Healthmark Industries Co. ��27 www.hmark.com Medentech ��23 www.better-than-bleach.com *Medline Healthcare ��24 www.medline.com *Nanosonics Inc ��14 www.nanosonics.us SEAL Shield ��50 www.sealshield.com

INFECTION PREVENTION PRODUCTS & SERVICES

USHIO America, Inc. �� 34 www.ushio.com IV CARE SOLUTIONS

*3M Vascular Care Pathways ��11 www.3m.com MEDICAL DEVICES & INSTRUMENTS

Retractable Technologies, Inc. �� 45 vwww.vanishpoint.com NASAL ANTISEPTICS

Global Life Technologies Corp. ��Inside Front Cover www.nozin.com TEXTILE & SOFT SURFACES

TRSA ��22 www.trsa.org

*denotes an APIC strategic partner – www.apic.org/partners

WHAT GETS MEASURED GETS DONE

The Joint Commission can now issue a RFI for

any observed failure of an individual to perform hand hygiene during direct patient care.1

< 3%

Direct Observation

97% OF HAND HYGIENE OPPORTUNITIES ARE MISSED IN DIRECT OBSERVATION2

PURELL SMARTLINKTM Technologies electronically monitors hand hygiene 24/7. When combined with clinical interventions, scientifically proven PURELL® formulations, and advanced dispensing platforms, our solution is proven to increase hand hygiene performance 82% over baseline.3 For more information on how you can more effectively measure hand hygiene as a first step in getting results, call 1-800-321-9647 or visit www.gojo.com/SMARTLINK

> 97%

Hand Hygiene Opportunities NOT captured by Direct Observation

1 2 3

The Joint Commission Requirement Update Boyce JM. Measuring healthcare worker hand hygiene activity: Current practices and emerging technologies. Infect Control Hosp Epidemiol 2011;32(10)000-000. GOJO Customer Data on File – January 2015 – July 2016