Summer 2015 • Volume 8 number 2
Lessons
learned
Questions and concerns
regarding safety of
endoscopes and validity of
manufacturer guidance
Emergency preparedness
simulation exercises
Hand hygiene hurdles:
How can we overcome them?
Measles in the U.S.:
Discussions with public
health representatives
COVER PHOTO: Dartmouth-Hitchcock/Mark Washburn
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Contents
Features
Summer 2015
Questions and concerns
regarding safety of endoscopes
and validity of
manufacturer guidance
Questions and answers with experts
58
Spread Knowledge
COVER PHOTO CREDIT: Dartmouth-Hitchcock/Mark Washburn
Lessons learned:
Measles in the U.S.:
Discussions with public
health representatives
With the Cook County Department of Public Health,
Chicago Department of Public Health, and Maricopa
County Department of Public Health
Share Prevention Strategist articles with others.
64
Check out the icons next to each article to help you navigate Prevention Strategist easily and identify
articles to share with others in your healthcare organization or beyond. Audiences include:
Infection Prevention
Colleagues
6 | Summer 2015 | Prevention
Patient Care
Services
Environmental
Services
Quality and Risk
Management
Disaster
Preparedness
C-Suite
Let the sharing begin!
VOICE
Envisioning the future 8
By Dr. Mary Lou Manning, 2015 Apic President
APIC 2014 scorecard: Tracking key metrics toward our goals
10
By Katrina Crist, APIC CEO
Change continues: Are you eligible?
12
By Kathy McGhie, 2015 CBIC President
DEPARTMENTS
Meet a CIC: Nancy Wood, RN, BSN, CIC
15
Briefs to keep you in-the-know
• APIC honors global public health advocate with its
highest infection prevention award
• APIC Strategic Partner: Aramark
• New long-term care infection prevention skills pledge tool
• Chief medical officer from Florida receives APIC’s
2015 Healthcare Administrator Award
19
Capitol Comments: New incentives improve healthcare quality,
cost, and public health
22
40
By Nancy Hailpern, Lisa Tomlinson, and Patricia Gray
Chapter Spotlight: APIC Greater LA
26
Take back your hashtags: An infection preventionist’s guide to Twitter
By Angela Vassallo
Global Insight: Perspective from Australia—Routine culturing and
surveillance of endoscopes
33
By Dr. Cathryn Murphy
Infection prevention leadership: My personal journey
37
By Timothy Bowers
44
PREVENTION IN ACTION
Emergency preparedness and infection control:
Teaming up to create meaningful staff simulation exercises
40
By Kristine Sanger
Focus on long-term care and behavioral health outbreaks:
Clostridium perfringens
44
A family-centered care model to reduce pediatric CAUTI
46
By Steven J. Schweon
By Vicky Uhland
My Bugaboo: Hepatitis C—The silent epidemic
50
By Dr. Irena Kenneley
Hand hygiene hurdles: How can we overcome them?
Q&A with Dr. Timothy Landers
By Vicky Uhland
55
55
w w w.apic.org | 7
PRESIDENT’S MESSAGE
Envisioning
the future
By Mary Lou
Manning,
PhD, CRNP, CIC,
FAAN, FNAP
APIC 2015 PRESIDENT
“APIC is
conducting
a member
MegaSurvey to
determine the
current state of
the infection
preventionist
profession.”
Reference
1. Lee, L, Horth, DM, & Ernst, C. Boundary spanning in action: Tactics for
transforming today’s borders into
tomorrow’s frontiers. Center for
Creative Leadership 2014. Accessed
March 24, 2015. Available at: www.
ccl.org/Leadership/pdf/research/
boundarySpanningAction.pdf.
8 | Summer 2015 | Prevention
The Ebola crisis in the United States highlighted the fact that infection prevention and control programs are generally under-resourced and have limited
surge capacity. This has led to the growing question echoed among infection
preventionists (IPs) and healthcare epidemiologists: “How do we influence
organizational decision-makers to invest in infection prevention and control
programs to assure we have the critical resources to prevent and manage infections
on a day-to-day basis and be prepared to rapidly respond to the inevitable, but
unpredictable, appearance of emerging (and re-emerging) infectious diseases?”
While this question is important, recent national and global events have opened
a large window of opportunity to bring forth a bolder question: “In this era of
rapid health and healthcare transformation, is now the time to reimagine the
strategic role and functions of infection prevention and control programs in an
increasingly complex and interdependent world?”
Reimagination requires inviting new ideas, exploring possibilities, and envisioning the future. As an infection prevention community, we need to span
boundaries outside our own circles to deliberately engage with others to create
partnerships, alliances, and other forms of collaboration to tackle this complex
question. APIC has forged strategic relationships with many organizations and
continues to scan the environment for additional partners, all of whom can
provide insight. As infection prevention leaders, boundary spanning may require
new skills in order to proficiently reach across professions, functions, sectors, or
organizations to build relationships, interconnections, and interdependencies
in search of different perspectives and knowledge. According to the Center for
Creative Leadership, boundary spanning leadership involves creating direction,
alignment, and commitment across five types of boundaries:1
• Vertical: class, seniority, authority, power
• Horizontal: expertise, function, peers
• Stakeholders: partners, constituencies, value chain, communities
• Demographic: gender, generation, nationality, culture, personality, ideology
• Geographic: location, region, markets, distance
Infection prevention and control is an inherently boundary-spanning enterprise. The work of the infection prevention team, while specialized, cannot be
performed independently and requires interdependent and coordinated action
across multiple and overlapping boundaries. However, the engagement is often
related to specific initiatives such as implementing interventions to prevent
healthcare-associated infections or in response to acute events, such as outbreak
investigations. Deliberate strategic relationship-building actions will be required
to bring groups together to achieve the larger purpose of envisioning the future.
During the past decade, infection prevention and control programs have been
presented with an unending series of challenges and expectations. The challenges,
more often than not, have resulted in additional responsibilities, functions, and
workload. Collectively, IPs have responded professionally and graciously sharing
their expertise, talents, and time to meet the many challenges. However, there
comes a time when it is necessary to step back and reflect on where we have
been, where we are now, and thoughtfully consider our preferred future. Toward
this end, APIC is conducting a member MegaSurvey to determine the current
state of the infection preventionist profession. To all who participated, please
accept my sincere appreciation for your time and careful responses. If you have
not yet participated, please do so. With you, I look forward to the results that
will create a baseline of data to map out our desired future.
Let us continue this discussion in Nashville during APIC 2015. I look forward
to connecting!
Mary Lou Manning, PhD, CRNP, CIC, FAAN, FNAP
Prevention
S u m m e r 2 015 • VO L UME 8 , I S S UE 2
Board of Directors
President
Mary Lou Manning, PhD, CRNP, CIC,
FAAN, FNAP
President-Elect
Susan A. Dolan, RN, MS, CIC
Treasurer
Marc-Oliver Wright, MT(ASCP), MS, CIC
Secretary
Connie J. Steed, RN, MSN, CIC
Immediate Past President
Jennie L. Mayfield, BSN, MPH, CIC
Directors
Joseph A. Bosco, III, MD
Kim Boynton-Delahanty, RN, BSN, PHN,
MBA/HCM, CIC
Gail Fraine, RN, MMHC, BSN, CIC
Deborah G. Friberg, MBA, FACHE
Brenda Grant, RN, BSN, MPH, CIC, CHES
Janet Haas, RN, PhD, CIC
Karen K. Hoffmann, RN, MS, CIC, FSHEA
Linda McKinley, RN, BSN, MPH, CIC
Ann Marie Pettis, RN, BSN, CIC
Katherine S. Ward, RN, BSN, MPH, CIC
Kathy Ware, RN, BSN, CIC
EX OFFICIO
Katrina Crist, MBA
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.
Empower patient compliance
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cloths – when patients receive
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*While supplies last. Limit one per customer. Business or institutional customers only.
1. Edmiston CE, Medical College of Wisconsin, Milwaukee, WI. “Evidence for using Chlorhexidine Gluconate Preoperative Cleansing
to Reduce the Risk of Surgical Site Infection.” AORN Journal. Vol 92. No 5. (2010): 509-518.
2. Edmiston CE, et al. “Empowering the Surgical Patient: A Randomized, Prospective Analysis of an Innovative Strategy for Improving
Patient Compliance to the Preadmission Showering Protocol.” Journal of the American College of Surgeons 219.2(2014): 256-264.
3. Hibbing, A., “A Picture Is Worth A Thousand Words,” The Reading Teacher; 2003.
© 2015 Clorox Professional Products Company, 1221 Broadway, Oakland, CA 94612. NI-28708
Patient Reminder Systems:
Offer multiple contact points
shown to enhance compliance for
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Waterproof Instructions Card:
Includes large text and visual icons,
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Online Video Instructions: Easy to
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Learn more and get a free sample* at
www.CloroxHealthcare.com/CHGKit
CEO’S MESSAGE
APIC 2014
scorecard:
Tracking key
metrics toward
our goals
THE FIVE STRATEGIC priorities as part of Strategic Plan 2020 (www.apic.org)
BY KATRINA CRIST,
MBA, APIC CEO
—patient safety, implementation science, competencies and certification,
advocacy, and data standardization—are critical to measuring APIC’s
success. The scorecard below provides a snapshot of key metrics. We are
making exceptional progress to date with high probability of meeting 10
out of 12 targets by 2020.
Two targets have already surpassed the 2020 target. APIC has exceeded
its initial 100,000 consumer engagement target with a huge leap of more
than 120,000 consumer engagement points in 2014 alone. This brought
the 2014 total to more than 155,000. This measurement includes actions
taken by a consumer such as downloading information from the consumer site (www.apic.org/InfectionPreventionandYou), tweeting or sharing
a Facebook post, taking an educational “bug” quiz, or sending an e-card.
It excludes visits to the website absent any further action. This quick level
of engagement was unexpected and is testimony to the public’s interest
and demand for infection prevention and control information.
The other target that exceeded the 2020 goal is reaching 1,000 facilities with APIC-related training and resources for effective infection
prevention and control programming. APIC has reached more than
1,500 facilities with 991 in acute care, 236 in long-term care, and 362
in ambulatory surgery, through collaboration with the Health Research
and Educational Trust on CAUTI and SSI related education. The APIC
Board of Directors is considering resetting these two targets to achieve
even higher impact by 2020.
The most ambitious target to achieve by 2020 will be 10,000 CICs.
Nearly 6,000 infection preventionists (IPs) have done their part already,
but APIC will be mobilizing forces to reach 10,000 to strengthen the role
and value of the IP through greater adoption of this standardized credential
that demonstrates core competency in infection prevention and control.
Please visit the Vision and Mission page under About APIC at
www.apic.org to view the full scorecard with details on measures, metrics,
and outcomes.
Sincerely yours,
Katrina Crist, MBA
APIC CEO
Patient Safety
2020 Target
100,000 consumer interactions
2014
Progress
Change from
last year
155,266
123,163
Patient Safety
60 organizational communications
14
Implementation Science
100 courses and published resources*
65
Implementation Science
1,000 facilities
1,589
IP Competencies/CIC
10,000 CICs
5,944
IP Competencies/CIC
1,000 advanced practice designation
➜ ➜ ➜ ➜ ➜
Strategic Priority
n/a
9
6
1,589
260
n/a
450 participants in research training
n/a
n/a
3,000 subscribers to advocacy update
1,907
334
Advocacy
5,000 clicks on regulatory resources
3,553
➜ ➜
IP Competencies/CIC
Advocacy
1,117
3,000 clicks on public policy agenda
n/a
n/a
40 organizations supporting NHSN
31
2
Data Standardization
3,700 members take action*
1,154
➜ ➜
Advocacy
Data Standardization
*non-cumulative n/a = initiative in development Green = High probability of achieving 2020 target
Yellow = Medium probability of achieving 2020 target Red = Low probability of achieving 2020 target
10 | SUMMER 2015 | Prevention
1,154
On
Track
Prevention
S U M M E R 2 015 • VO L U M E 8 , I S S U E 2
PUBLISHER
Katrina Crist, MBA
kcrist@apic.org
MANAGING EDITOR
Janiene Bohannon, MS
jbohannon@apic.org
ASSISTANT EDITOR
Julie Blechman, MPH
jblechman@apic.org
ADVERTISING
Brian Agnes
bagnes@naylor.com
GRAPHIC DESIGN
Deb Churchill Basso
print20h@naylor.com
PRODUCTION
Heather Williams
hwilliams@naylor.com
EDITORIAL PANEL
George Allen, PhD, CIC, CNOR
Kristine Chafin, RN, MBA, CIC
Megan Crosser, BS, MPH, CIC
Mary L. Fornek, RN, BSN, MBA, CIC
Brenda Helms, RN, BSN,
MBA/HCM, CIC
Linda Jamison, MSN, RN, CIC, CCRC
Irena Kenneley, PhD, APRN-BC, CIC
Kari L. Love, RN, BS, MSHS, CIC
May M. Riley, RN, MSN, MPH,
ACNP, CCRN, CIC
Steven J. Schweon, RN, MPH,
MSN, CIC
CONTRIBUTING WRITERS
Timothy Bowers, MT(ASCP), MS, CIC
Demian Christiansen, DSc, MPH
Katrina Crist, MBA
James Davis, MSN, RN, CCRN,
CIC, HEM
Patricia Gray, RN, BAHSA, CIC
Nancy Hailpern
Irena Kenneley, PhD, APRN-BC, CIC
Timothy Landers, PhD, RN, CNP, CIC
Mary Lou Manning, PhD, CRNP, CIC,
FAAN, FNAP
Kathy McGhie, RN, BScN, CIC
Cathryn Murphy, RN, MPH, PhD, CIC
Frank Myers, MA, CIC
Kristine Sanger, BS, MT (ASCP)
Steven J. Schweon, RN, MPH, MSN,
CIC, HEM, FSHEA
Tammy Sylvester, RN, BSN
Lisa Tomlinson
Vicky Uhland
Angela Vassallo, MPH, MS, CIC
Nancy Wood, RN, BSN, CIC
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 JUNE 2015 •
API-Q0215 • 1061
What do you do for
hand hygiene compliance
at point of care?
“
If you don’t make it [hand hygiene
products] convenient right there at
that second, no one is going to go
around the corner and wash their
hands. It must be available in the
flow of what the employee is doing.
– WILLIAM PARKS, MD
Chief Medical Officer at Memorial
Hermann The Woodlands
”
Point of Care refers to the moments when healthcare
workers are in contact with patients and are at the highest
risk of spreading infections.
Increase hand hygiene compliance, improve HCAHPS
scores, and reduce HAIs (healthcare associated infections)
with these Symmetry Point of Care items:
50 ml Suction Cups*
Over-bed tables, Computers on wheels
550 ml Suction Cups*
Bedside tables, Nurse stations,NICUs
550 ml Wire Brackets
Dietary carts, Phlebotomist carts,
Bedside commodes
*Suction Cups
contain Ion Pure, an
antimicrobial agent
approved by the
FDA, EPA, and NSF.
Lanyards
Healthcare workers
“
Many HAIs [healthcare-associated infections] are transmitted by
health care personnel, and hand hygiene is a primary means to
reduce these infections.
”
– HEALTH RESEARCH & EDUCATIONAL TRUST
affiliate of the American Hospital Association
www.symmetryhandhygiene.com
Celebrating Excellence
Change
continues:
Are you
eligible?
®
In my last column I introduced you to the new content outline that resulted from the 2014 Practice
Analysis survey. The new examination forms based on this outline will be piloted in July 2015. Once
the pilot period is complete, cut scores can be established to determine the standard for passing the
examination until the next Practice Analysis is conducted. You can learn more about cut scores by listening to our podcast, “Passing Rate and Score of the CIC Exam” at www.cbic.org/certification/media.
Review of the Practice Analysis also provided us with a contemporary evaluation of current infection prevention and control practice and prompted us to review and update the eligibility criteria. The
updated requirements demonstrate the changing practice and reflect the full spectrum of healthcare
practices that are involved. We believe the updated requirements expand the profession.
By Kathy McGhie,
RN, BScN, CIC
2015 CBIC PRESIDENT
Eligibility requirements (as of July 1, 2015)
You must meet ALL requirements. You are
accountable for infection prevention and control
activities/program in your setting and this is
reflected in your current job description;
AND
You have a post-secondary degree (e.g., associate’s or baccalaureate degree);
AND
You have had sufficient experience (recommended: two years) in infection prevention
and control that includes all three (3) of the
following:
1. Identification of infectious disease processes
2. Surveillance and epidemiologic investigation
3. Preventing and controlling the transmission
of infectious agents
And at least two (2) of the remaining five (5)
components:
1. Employee/occupational health
2. Management and communication
3. Education and research
4. Environment of care
5.Cleaning, sterilization, disinfection, and
asepsis
Key changes
“Without
continual
growth and
progress,
such words as
improvement,
achievement,
and success have
no meaning.”
—Benjamin Franklin
Work in a healthcare setting is no longer required. Accountability for infection prevention and control activities
must be reflected in your job description. This reflects the variety of work settings of infection preventionists.
The basic education requirement is now a post-secondary associate or baccalaureate degree. It is not
required that this be in a healthcare-related field.
The experience component has been updated to reflect the current content outline. It is our belief that
the application of knowledge and experience gained in a clinical practice setting is an essential component
that supports our mission to protect the public through the development, administration, and promotion
of an accredited certification in infection prevention and control. The assessment of “sufficient experience”
is individual to the candidate and can vary; however, CBIC recommends two years of experience in infection prevention and control. Candidates who are comfortable with their knowledge and experience may
sit for the exam whenever they are ready. However, analysis of our data has demonstrated greater success
amongst candidates with at least two years of experience in the field.
We understand that there will be individuals who do not meet the requirements but still seek certification. Recognizing that practice settings and job descriptions vary greatly, CBIC will continue to have a
candidate appeal and review process for individual assessment of eligibility when requested.
More change will come as we strive to improve.
12 | Summer 2015 | Prevention
Daily Patient Bathing
Don’t just cleanse…
HIBICLENS®
HIBICLENS, a 4% chlorhexidine gluconate solution, delivers high levels of protection from
pathogens.1,2 Patient bathing helps stimulate circulation, promotes range of motion, and improves
patient comfort levels.3 SHEA and IDSA recommend routine bathing of patients with antiseptics such
as HIBICLENS to reduce the risk of infections.4
In recovery, patients have bigger battles to win than fighting hospital-acquired infections. By using
HIBICLENS as part of the daily bathing routine, you can deliver the power of 4% CHG with a product
that is gentle enough for everyday use.5
References: 1. Climo MW, et. al. Crit Care Med. 2009 Jun; 37(6):1858-65. 2. Rupp ME. Infect Control Hosp Epidemiol 2012;33(11). 3. Caroline Bunker Rosdahl.
Textbook of Basic Nursing 2007. 4. Calfee, David MD, et. al. Strategies to Prevent Transmission of MRSA in Acute Care Hospitals. Infection Control and Hospital
Epidemiology. October 2008, Vol. 29, Supplement 1, Page S - 73. 5. Data on file. Mölnlycke Health Care. Study R05-0225.
Hibiclens, the Hibiclens logo and Mölnlycke are registered trademarks of Mölnlycke Heath Care AB.
Distributed by Mölnlycke Health Care US, LLC, Norcross, Georgia 30092.
© 2013 Mölnlycke Health Care AB. All rights reserved. 1.800.843.8497.
CIC PROFILE
®
Meet a CIC
Nancy Wood, RN, BSN, CIC
Infection Prevention Specialist
Canton-Potsdam Hospital
Potsdam, New York
Q:
“My CIC designation gives
people across our health
system a trusted resource.
No one has to deal with
infection prevention
issues alone.”
What inspired
you to become
an infection
preventionist (IP)?
From an early age I knew I wanted to be
either a nurse or a teacher because those
were the two clear career options for women
at the time. After I completed my nurses
training, I worked in medical, surgical, and
case management departments. My nurse
manager, who was also my mentor, recognized my eye for detail and she encouraged
me to apply for the position in infection
prevention. The infection prevention director, who was also a CIC,® inspired me to
reach for my full potential, which included
attending the basic training course and
taking the CIC exam. As I grew in the
profession of infection prevention, I found
that the teacher and the nurse in me were
melding together to form a truly rewarding career. I had without a doubt found
my niche! In my role as an IP, I “pay it
forward” by mentoring our new nurses and
providing education to the nursing staff.
As evidence-based best practices emerge,
I can honestly say I learn something new
every day and I appreciate that professional
stimulation. Once I’ve provided education
to others, I’ve empowered them to deliver
safer care. I still have that eye for detail; I
seem to see things others might miss and
fill in those gaps. Working toward a full
understanding of diseases and how to keep
them from spreading is one of the most
fulfilling parts of my work.
Q:
Why did you pursue
board certification
in infection
prevention and
control (CIC)?
Board certification validates my personal
commitment to infection prevention and
conveys to others that I have mastered the
art and practice of infection prevention and
control. I work in a very rural area in northern New York so I am able to serve as a ready
resource for both my facility and for my
professional colleagues serving other facilities. Infection prevention is a field that’s rapidly expanding; certification demonstrates
commitment to professional growth, staying
current, and sharing best practices.
Q:
How did you
prepare for the
CIC exam? What
helped?
I like that old saying, “You eat an elephant
one bite at a time.” I committed to blocks of
study time, which I scheduled on my calendar.
I did a self-assessment and identified my weak
areas. I then used APIC resources, concentrating on one weak area at a time. I went through
the APIC Certification Study Guide cover to
cover. I reviewed every module in the Study
Guide and completed every test question.
If I got something wrong, I looked it up in
the answer key, and (if needed) I went to the
APIC Text to ensure I really understood the
material. I’m a visually oriented learner, so I
use highlighting a lot. I can recall information
if I have that visual cue.
w w w.apic.org | 15
Q:
In what ways
has your CIC
benefited you?
CIC has benefited me in two important
ways. First, CIC exams test your knowledge in six key areas: disease identification,
surveillance and epidemiology, prevention
and control of infections, employee health,
leadership and education, and research,
which I can then put into practice. These
six areas serve as a framework as I develop
and manage the infection prevention plan
for my facility, keeping in mind key education and communication strategies, as well
as thinking about ways to provide effective education for the new generation of
healthcare workers who have entered the
workforce. Second, recertification every five
years ensures that I stay up to date and that
the knowledge I’m sharing is relevant to
infection prevention and control as we move
forward in a rapidly changing healthcare
environment.
16 | Summer
2015 | Prevention
734814_Cleanis.indd
1
Q:
In what ways has
your CIC benefited
your healthcare
organization?
My CIC designation gives people across our
health system a trusted resource. No one has
to deal with infection prevention issues alone.
Our system is built on collaboration among
our affiliates as well as various community
agencies, such as public health. Responding
to an emergent threat of infection, such as the
recent Ebola virus outbreak, relies on having
already laid the groundwork for collaboration
and seamless lines of communication among
organizations responsible for protecting the
community’s health. CIC is also becoming a
must for healthcare facilities that are pursuing
accreditation status, such as with The Joint
Commission and DNV [Det Norske Veritas]. Q:
Can you share some
study tips for
others who wish
to pursue their CIC
designation?
I have found over the years that ongoing
review of infection prevention publications
like the American Journal of Infection Control
and Hospital Infection Control and Prevention
(among other credible sources) benefits me
when it comes time to take the exam. I frequent the APIC “IP Talk” site daily to stay
abreast of current issues that other IPs are
dealing with in a variety of healthcare settings; this usually prompts me to look at my
own practices. Pursuing CIC designation is
a personally and professionally rewarding
experience. It’s not easy, but it is well worth
the commitment to achieve.
5/12/15 6:09 PM
Visit SDFHC.com/sample for your free trial sample.
Briefs to keep you in-the-know
APIC honors global public health
advocate with its highest infection
prevention award
APIC will honor Cathryn Murphy, RN,
MPH, PhD, CIC, of Queensland, Australia,
with the prestigious 2015 Carole DeMille
Achievement Award.
The award, which will be presented during
the opening session at APIC’s 42nd Annual
Conference in Nashville, Tennessee, is given
annually to an infection preventionist (IP)
who best exemplifies the ideals of Carole
DeMille, a pioneer in the field.
“We are honored to award Dr. Murphy
with the Carole DeMille Achievement
Award for her lifelong dedication to infection prevention,” said APIC 2015 President
Mary Lou Manning, PhD, CRNP, CIC,
FAAN, FNAP. “Cath’s contributions to the
field of infection prevention are expansive
and have contributed greatly to the improvement of infection control practices globally.
As APIC’s only non-North American APIC
president in 2010, she broke down barriers,
proving that there are no borders to infection
prevention and control.”
As an active APIC member for more
than 25 years, Dr. Murphy has played a
fundamental role in advancing APIC’s
mission. She has served on the American
Journal of Infection Control editorial board
for more than a decade, reviewed various
APIC Elimination Guides and position
papers, authored many peer-reviewed articles, and formally mentored IPs throughout
her career. Cath credits and will always be
grateful to APIC, its members, leadership,
and staff as well as previous Carole DeMille
Achievement Award winners for their collective and individual interest and investment
in her professional and personal development
and opportunities.
Dr. Murphy remains committed to building global IP capacity, ensuring that the
profession continues to grow in each of its
facets: clinical, research, governmental, and
academic. Dr. Murphy became Australia’s
first PhD-qualified infection preventionist in 1999. As a founding member of the
Asia Pacific Society of Infection Control
(APSIC) and a regular consultant to the
World Health Organization, she has demonstrated her dedication to globally expanding best practice infection prevention. She
has consulted on infection prevention issues
in Australia, Canada, China, Hong Kong,
France, Japan, Korea, Malaysia, Macau,
New Zealand, Philippines, Singapore, South
Africa, Thailand, the United Arab Emirates,
the United States, and Vietnam.
Currently, Dr. Murphy serves as executive
director of Infection Control Plus Pty Ltd.
The late Carole DeMille was among the
founders of APIC who later became an
internationally recognized authority in the
developing field of hospital infection control.
She was known for her vision and optimistic
approach to present-day infection prevention
methods. The award was established in her
honor in 1979, following her death.
APIC Strategic Partner: Aramark
The winter 2014 issue of Prevention Strategist featured the APIC Strategic Partner Program in the article, “What makes a healthcare company an
ideal candidate to participate in APIC’s Strategic Partner Program.” In this issue, we showcase Aramark, a long-standing APIC strategic partner.
APIC’s Strategic Partnership strengthens Aramark’s commitment to the infection prevention community and has helped support our mission to enrich and
nourish lives of those who serve. Our five-year standing relationship allows us to
gather insights from infection preventionists to help us deliver innovative solutions
that impact patient care. We proudly sponsor national conferences and engage
locally at chapter events to educate IPs on the importance of environmental
cleaning and laundering practices as part of their overall infection prevention
program. We act as a conduit to environmental services to create collaborative
team experiences focused on hard and soft surface bacterial management.
To learn more about
Aramark, visit Booth
#630 at the APIC 2015
Annual Conference or
visit www.aramarkuniform.
com/healthcare.
w w w.apic.org | 19
Briefs to keep you in-the-know
New long-term care infection prevention skills pledge tool
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is available on the APIC website. The tool encourages facility leaders, frontline
staff, residents, and family members to adhere to four key technical skills for
preventing infections in LTC facilities—hand hygiene, environmental cleaning,
standard precautions, and antimicrobial stewardship. The LTC pledge tool was
developed by APIC and Health Research and Educational Trust under contract
to the Agency for Healthcare Research and Quality (AHRQ) as part of the
train-the-trainer materials for the AHRQ Safety Program for Long-Term Care:
HAIs/CAUTI. This AHRQ-funded project focuses on reducing catheterassociated urinary tract infection (CAUTI) and other healthcare-associated
infections (HAIs) in nursing homes and LTC facilities.
LTC facilities can customize the tool by adding their logo in the bottom left-hand corner. Download the tool at www.apic.org/Resources/
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734850_Ivera.indd
5/7/15 8:44 PM
Chief medical officer from Florida
receives APIC’s 2015 Healthcare
Administrator Award
William J. Maples, MD, currently chief
“Dr. Maples is a
passionate advocate
for patient safety and
a vigorous supporter
of infection prevention
and control.”
—Mary Lou Manning, PhD,
CRNP, CIC, FAAN, FNAP
medical officer for Professional Research
Consultants and executive director for The
Institute for Healthcare Excellence in Ponte
Vedra Beach, Florida, has been named
the 2015 recipient of APIC’s Healthcare
Administrator Award. Prior to his current roles, Dr. Maples was the chief quality
officer and senior vice president at Mission
Health System in Asheville, North Carolina
(December 2010-March 2015).
The award, which will be presented
at APIC’s 42nd Annual Conference in
Nashville, Tennessee, is given annually to
a member of a healthcare facility’s executive
team who champions infection prevention
efforts within his or her organization.
“We are honored to present Dr. Maples
with this well-deserved award,” said APIC
2015 President Mary Lou Manning, PhD,
CRNP, CIC, FAAN, FNAP. “Dr. Maples
is a passionate advocate for patient safety
and a vigorous supporter of infection prevention and control. His commitment is
evident through his ongoing efforts to
engage consistently with infection prevention teams, push for improved processes
to protect patients from harm, and tie the
work of infection prevention to broader
quality efforts throughout the Mission
Health System.”
Under his leadership at Mission Health,
the infection prevention department grew
from five infection preventionists (IPs) at
one hospital to a system-wide department
that now includes 12 IPs and spans seven
hospitals. With infection prevention and
control as part of the quality department
Dr. Maples brought a number of process
improvements to IPs, including training
in root cause analysis.
His support is also evident in the investment made in an electronic surveillance
system that minimizes infection preventionists’ time to manually input data. During
the Ebola crisis, Dr. Maples empowered
IPs to take on leadership roles in planning,
training, and logistics, and reinforced their
recommendations with other senior leaders. He made sure that the work of IPs and
the achievements in reducing healthcareassociated infections were understood by
senior leaders as contributing to operational
goals and helping to sustain the system’s
overall financial health.
Dr. Maples’s colleagues agree that he was
instrumental in instilling a true culture of
safety throughout Mission Health System,
instituting weekly leadership rounds to
discuss successes and barriers in achieving the goal of harm reduction. Under his
direction, quality data included infection
prevention metrics and was posted and
reviewed on a weekly basis.
In particular, Dr. Maples committed
resources to prevention of surgical site
infections with the introduction of process
improvement teams focused on colon, spinal fusion, and hysterectomy surgical site
infections. As a result, infections at Mission
Health following spinal fusion and refusion surgeries dropped below the Centers for
Disease Control and Prevention’s National
Healthcare Safety Network weighted benchmark. The team’s focus on reducing immediate-use steam sterilization has also paid off,
with a marked decrease in use of this process
for sterilizing surgical instruments.
w w w.apic.org | 21
CAPITOL COMMENTS
New incentives improve
healthcare quality, cost, and
public health
BY NANCY HAILPERN, LISA TOMLINSON,
AND PATRICIA GRAY, RN, BAHSA, CIC
“Statistics are people with
the tears washed away.”
—Victor Sidel, MD, co-founder,
Physicians for Social Responsibility
22 | Summer 2015 | Prevention
The Affordable Care Act of 2010 led
to development of the National Quality
Strategy, first developed in 2011 with the
three-pronged goal of improving healthcare quality, decreasing healthcare costs,
and creating healthier communities. All
of these goals are being addressed through
regulatory initiatives, most of which impact
Medicare. Since Medicare is the largest
payer of healthcare in the U.S., both the
carrot and the stick it uses to enforce statutory regulations is payment adjustment—
incentives for improved performance and
penalties for static or deteriorating performance or for noncompliance. Performance
is evaluated through the use of measures.
Because measures are a basis of comparison
against a standard, ideally measures would
be developed and endorsed by a consensus
organization, such as the National Quality
Forum (NQF).
Quality
U.S. Secretary of Health and Human
Services (HHS) Sylvia Mathews Burwell
signaled a refocus of the way healthcare
is delivered when, in January 2015, she
announced a timeline for changing the
way Medicare pays for health services.
According to this new timeline, by 2018,
90 percent of Medicare payments will be
tied to value, rather than volume of services provided. Because of the amount
of healthcare facility revenue that comes
from Medicare, this change will impact
all providers and receivers of healthcare.
Infection preventionists (IPs) have and will
continue to play a role in attainment of all
of these goals.
The first challenge is determining what
is meant by value. Terms like “value” and
“quality” are difficult to quantify, and can
mean different things to different stakeholders, depending on various perspectives
as patients, providers, payers, employers,
consumers, or the government. For IPs,
this will mean continued focus on healthcare outcomes by reducing and preventing
healthcare-associated infections (HAIs).
Medicare reimbursement is determined
by compliance with measures, and whether
those measures show improvement in outcomes. The purpose of measures makes
sense—we can’t monitor improvement
without a baseline for comparison. But
another challenge is the large volume of
measures that are used for the variety of
programs within HHS. Measures are used
to determine compliance with electronic
health record (EHR), quality reporting,
value-based purchasing, readmissions
reduction, and hospital-acquired conditions
reduction programs. Some measures are
based on chart-abstracted coding data and
some are reported into NHSN using standardized surveillance definitions. Measures
are constantly being added or removed by
CMS, reported to CDC, adopted for use
by the Agency for Healthcare Research and
Quality (AHRQ), and re-evaluated and
updated by NQF. In addition to federal
requirements, most states require some level
of HAI reporting of measures which may
or may not correspond to federal requirements, adding additional responsibilities
for IPs. Although CMS has made an effort
in recent years to align measures used for
different programs within its jurisdiction,
the number of measures that currently must
be monitored presents a burden to already
under-resourced facilities and departments. In order for measures to be useful in
improving healthcare quality, they must be
aligned between programs, focused on outcomes, and not unnecessarily tax healthcare
personnel. The good news is that current
proposed regulations are making inroads
in all of these areas.
“By 2018, 90 percent of
Medicare payments will
be tied to value, rather
than volume of services
provided.”
Cost
A 2014 report by the Commonwealth
Fund found that although the U.S. has the
most expensive healthcare system in the
world, we rank 11th out of the 11 countries studied (Australia, Canada, France,
Germany, the Netherlands, New Zealand,
Norway, Sweden, Switzerland, the United
Kingdom, and the United States) in health
w w w.apic.org | 23
CAPITOL COMMENTS
“Although CMS has made
an effort in recent years
to align measures used for
different programs within its
jurisdiction, the number of
measures that currently
must be monitored presents
a burden to already
under-resourced facilities
and departments. ”
outcomes. Similarly, the World Health
Organization ranks the U.S. healthcare
system 37th out of 190 nations included in
its rankings of healthcare systems, despite
having among the highest per capita healthcare expenditures.
The traditional Medicare fee-for-service
payment system encourages increased care,
but more care does not necessarily mean
better care. Higher volume of procedures
has meant higher Medicare reimbursement,
regardless of whether the treatment has
good outcomes or not; however, more treatment might also mean longer hospital stays,
increased use of devices, more antibiotics,
which raises both infection risk and costs.
The majority of healthcare dollars are
spent on end-of-life care. Healthcare of the
future will have to change its focus away
from “sick care” and more toward preventive care, and hard decisions will be made
about effectiveness of treatment options.
Reducing costs will also mean providing care in the most appropriate settings,
often outside the traditional walls of the
hospital environment. This will mean
expanding infection prevention to other
types of facilities—ambulatory care, longterm care, rehabilitation, behavioral health,
and other settings. It will also mean an
expanded focus on traditional roles of the
24 | Summer 2015 | Prevention
IP, including educating staff and patients,
developing policies and procedures geared
to non-hospital settings, and monitoring
compliance with infection prevention
practices across the continuum of care. A
necessary step will be the IP’s involvement
in developing EHRs that are interoperable across care settings and providers, as
well as with government-based systems,
such as NHSN. It will require focus in all
facilities and at all levels on improving care
transitions.
Population health
Keeping the population healthy will
reduce healthcare costs by keeping people
out of healthcare facilities. In addition
to improved behaviors such as increasing physical activity and improving diets,
preventing infections from spreading in
a population also includes compliance
with vaccine recommendations, antibiotic
stewardship from the farm to the hospital, hand hygiene, and other practices that
have long been the concentration of infection prevention and public health. Sharing
information through EHRs can ensure better knowledge of where potential infection challenges exist in order to prevent
them. The spread of community-acquired
infections can be decreased through basic
infection prevention education of personnel in schools, community centers, daycare
centers, and other places where populations
congregate and knowledge about how infections are spread, and about appropriate protective practices and equipment. Expanding
partnerships with public health agencies
will be an important step in improving
and sustaining infection prevention for the
future of population health.
Summary
As healthcare continues to change in all
aspects of care delivery, IPs will need to
continue to play a key role in improving
healthcare quality in all environments, promoting the use of meaningful, value-driven
infection-related measures that accurately
reflect healthcare outcomes. As always, IPs
will continue to pursue healthcare without
infection in order to create a safer world
through the prevention of infection.
Nancy Hailpern is APIC director of
Regulatory Affairs, and Lisa Tomlinson is
APIC vice president of Government Affairs
and Practice Guidance. Patricia Gray, RN,
BAHSA, CIC, is network manager, Infection
Prevention and Control, for HonorHealth in
Scottsdale, Arizona, and APIC representative
to the National Quality Forum.
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Chapter Spotlight: APIC Greater LA chapter #3
Take back your hashtags
An infection preventionist’s guide to Twitter
By Angela Vassallo, MPH, MS, CIC
“Whether we choose to be
part of the conversation on
social media in regards
to infection prevention
or not, the world’s ability
to share news and get
information instantaneously
has already left the station,
and we’re late to the train.”
26 | Summer 2015 | Prevention
Have you ever been to Los Angeles? If you
have, you probably remember the beautiful weather, the picturesque views from
the canyons to the ocean, the lean and
well-dressed people, and of all things—
the traffic. It can take us Angelenos two
hours to go 10 miles during rush hour. So
as a result, we’ve become experts at finding creative and crafty ways to get where
we need to go in a rush. We often start
off meetings and parties comparing how
attendees arrived to our new destination.
“You took the 101? Seriously. Are you mad?
How long have you lived in LA? Oh, well
that explains it; you’re still a new transplant.
I recommend you try the Cahuenga Pass and
then make a turn at...” And so our days go,
attempting to connect with one another
in the City of Angels.
Now imagine you are a member of
the second largest APIC chapter in the
U.S.—Greater Los Angeles (GLA), chapter #3 and your monthly meetings are
held on Tuesdays at noon in downtown
Los Angeles. And hence, you understand
our predicament. Our chapter serves Los
Angeles County, which has more than
100 hospitals and more than 10 million
people in a 4,000 square mile radius.1 We
have more than 200 members, including
infection preventionists (IPs), epidemiologists, nurses, microbiologists, pharmacists,
doctors, and vendors.
With this in mind, our chapter uses
social media to engage members and
others in our community around the
infection prevention conversation. Once
you get the hang of it, you’ll see it’s an
easy and beneficial way to obtain timely
infection prevention information, engage
with peers, improve communications during disasters, and ensure IPs are represented
in the public eye.
Getting creative to
improve communications
APIC GLA is constantly looking for better methods to communicate quickly and
efficiently with such an expansive, diverse
audience. We decided that the easiest and
cheapest way for us to promote infection
prevention in our community and engage
our members was to improve our online
presence.
By early 2014, APIC GLA was the first
APIC chapter to create Facebook and
Twitter accounts. As fate would have it,
national APIC was in the midst of improving its online presence, as well as that of
local chapters at about the same time. Thus,
we worked with national APIC to develop
our own APIC GLA website: http://community.apic.org/greaterlosangeles/home.
You don’t need to love social media to use
it and benefit from it. Although I constantly
refer people to our new, shiny website, I’m
not a Facebook or Instagram lover. I am,
however, a recent Twitter convert. I think
there is a major difference in the usefulness of these applications—especially with
regard to daily infection prevention work.
Facebook, Instagram, and Pinterest seem
Angela’s Twitter cover photo shows her during interview with comedian Judy Greer on public restrooms for the web series, “Reluctantly Healthy” at
https://screen.yahoo.com/reluctantly-healthy/dirty-truth-public-restrooms-040000010.html.
to be most useful for communities to chat,
share pictures and invitations to events, and
exchange ideas. I often look at national
APIC’s Facebook page (www.face book.com/
APICInfectionPreventionandYou) to see what’s
happening in our community. But if I have
a question that I need answered right now,
I go to Twitter. Social media applications
can be brilliant tools for staying connected
in today’s world.
Twitter is an immediate and concise way
for people to get information. In a recent
CID article, Twitter was promoted as “the
only platform that allows one to connect,
engage, learn, and educate oneself and others in real-time on a global scale.” 2 When
I read these words, I envisioned myself
tweeting with interesting people about
exciting infection prevention/infectious
disease topics while in my pajamas on the
sofa at night—no make-up and minimal
effort on my part. Yes, please! Sign me up
tout de suite.
Let me give you a couple of examples to
illustrate my point further. Although my
hospital is only four blocks from UCLA,
I found out about the recent CRE outbreak with ERCP duodenoscopes first on
Twitter when UCLA tweeted the information. Several hours later when I came
home from work that day, I saw it on the
evening news. Keep in mind that by the
time I saw it on the evening news, I had
already known about it for hours and had
already communicated with my peers at
UCLA to get more information and offer
them a hand. Next case in point, during
the 2014 Ebola outbreak in West Africa,
I used Twitter to get up-to-the-minute
information. Healthcare workers, governments, news agencies, and pretty much
everyone who had a major stake in the
outbreak were tweeting information as
it happened. I remember seeing the news
on Twitter that Dr. Kent Brantley and
Marian Wrightbold were being flown to
the U.S. as they boarded the plane. And
by the time I got home that night to watch
the evening news, it was, to be frank, old
news. The Internet had already exploded
with conversations about Ebola in the U.S.
w w w.apic.org | 27
Chapter Spotlight: APIC Greater LA chapter #3
Organizations to
follow on Twitter
APIC  @apic
AJIC  @ajicjournal
CDC  @cdcgov
WHO  @who
CBIC  @cbic
(They tweet CIC and SARE test
questions on a weekly basis)
APIC GLA  @apicglac
APIC DFW  @apicdfw
APIC Kentucky  @kyapic42
I PS  @ips_infection
(Infection Prevention
Society in the UK)
I PAC  @ipaccanada
(Infection Prevention and
Control Association in Canada)
ID Week  @idweek2015
SHEA  @shea_epi
IDSA  @idsainfo
28 | Summer 2015 | Prevention
before the evening news could even air
the ‘breaking’ story.
Whether we choose to be part of
the conversation on social media in
regards to infection prevention or not,
the world’s ability to share news and
get information instantaneously has
already left the station, and we’re late
to the train. No one really reads the
newspaper anymore and most people
don’t wait for the evening news to learn
what is happening in the world right
now. I understand how social media
can seem like one more thing to do in
your already overloaded life. However,
social media can enhance our work as
IPs. At work, I am constantly looking
for information and asking questions,
and I know you are, too.
The issues you are facing at work
today could be easily and quickly discussed on Twitter, in addition to APIC’s
IPTalk—as long as you are maintaining confidentiality and understanding
that all information has limitations.
Wouldn’t it be helpful to quickly write
a question down and within seconds
have people respond with answers?
Imagine the immediate usefulness of
Twitter during a survey or response to
a disaster.
Top six reasons to use Twitter as an IP
1
2
3
4
I f used appropriately, it could be a virtual listserv available 24/7. In addition
to using IPTalk (www.apic.org/MyAPIC),
all you would have to do is look at Twitter
to get your answers on hot topic infection
prevention issues at that very moment.
Warning: there is no guarantee that the
answers will be accurate. So do your own
research and check sources.
It could be used to improve communication during disasters. Right after the
first plane hit the World Trade Center,
I was frantically trying to call my father
who works in downtown Manhattan.
Cell phones were jammed for hours and
families like mine sat in panic waiting to
get through. It still chokes me up today.
He later got through to let me know that
he was fine. But I’ll say it now because
I say it all the time—I wish our family
had been using Twitter on 9/11.
Viral forecasting/digital epidemiology
are changing the way we understand
how diseases move and mutate. Dr.
Nathan Wolfe presented the APIC 2013
Annual Conference closing plenary on
this very topic.
You can instantly network with your
peers. I’ve met some really interesting
and helpful IPs in Canada and the UK
“The more IPs
join and
use social media
sites, the more
represented we’ll be in
the public eye.”
5
6
on Twitter. Shout-out to our IP peer in
Toronto, Canada (@barleychironda),
the most prolific IP tweeter in the world!
You would be staying up to date—
even to the very minute—when
infection prevention issues occur
around the world.
The more IPs join and use social media
sites, the more represented we’ll be in
the public eye. Perhaps you’ve heard the
phrase “the world is getting smaller.”
Infectious diseases that exist in one part
of the world are everyone’s problems.
So why not use social media to position ourselves as experts in our field
and showcase the great work IPs do on
the frontlines of infection prevention
to control and prevent these infections?
10-step Twitter 101
1
2
Create an account with a username
and password. Go to Twitter (https://
twitter.com) and think of a catchy user-
name for yourself. It’s what people see
when they are reading your tweets. For
instance, @suegk0123 is much less compelling than @suethehandwashingIP.
Create a compelling bio. It will be read
when someone looks at your account.
Here’s an example of how mine has
evolved over the past year. When I
created my account last year it was, “ following interesting things and fascinating people.” Then, I decided to make it
more interesting. So now it is, “small but
mighty epileptic epidemiologist.” Perhaps
it is a bit TMI (too much information
about me), but which person would you
rather follow?
Follow people/organizations who
interest you and watch what they
tweet in your “timeline.” Find
Twitter mentors and follow them.
Ask them questions. Watch how they
engage their followers. There certainly
is an art to it.
Then, when you feel ready—send your
first tweet. Try to say something useful in a 140 characters or less. It’s not
as easy as one might think, is it? Keep
in mind that when Shakespeare said,
“Brevity is the soul of wit,” he probably had no idea that Twitter would
one day be invented. In other words,
being concise is something we’ve been
grappling with for generations, and
Twitter is helping us achieve it.
Tweet messages with key hashtags
(This # is called a hashtag) so that
when people search a #phrase, your
messages will appear. The hashtag is
what I inaccurately referred to as the
3
4
5
Learn more at the
APIC 2015
Annual Conference
Want to learn more about social media? Don’t
miss this #APIC2015 session!
How the Los Angeles APIC Chapter Uses
Social Media: Tweeting Our Way Through
LA—One Infection at a Time
Sunday, June 28, 3–4 p.m.
•A
ngela Vassallo, MPH, MS, CIC, director, Infection Prevention/Epidemiology,
Providence Saint John’s Health Center,
Santa Monica, California.
• Jessica L. Silvaggio, MPH, CDC/CSTE
Applied Epidemiology Fellow, Los Angeles
County Department of Public Health, Los
Angeles, California.
• Crystal R. Moohn, BS, associate director, Membership & Component Relations,
Association for Professionals in Infection
Control and Epidemiology, Washington,
District of Columbia.
Visit www.apic.org/ac2015 to learn more.
w w w.apic.org | 29
Chapter Spotlight: APIC Greater LA chapter #3
6
‘pound sign’ for several months until a
younger, savvier tweeter corrected me.
Tweet messages with meaningful
links. An example would be to put a
link in your tweet to the FDA’s explanation for the Olympus ERCP scope
outbreak. The characters used in a web
address do not count toward your 140
count maximum. Isn’t that awesome?
7
etweet using “RT” and not by
R
just clicking on the “retweet” button. This is a more advanced practice, but I thought you should know
nonetheless. Start your tweet with
“RT:” and then copy the person’s
message that you want to retweet
with quotations into your new tweet.
When someone searches this topic
8
9
WILLOUGHBY WICS SERIES
W
by hashtag or looks at the original
tweeter’s profile, your profile will be
connected and people will get exposed
to you. Voilà—you are now part of
the conversation.
Tweet messages directly to people
with whom you want to engage in
a conversation or who you think
might follow you/share information
with you. You do this by putting their
@username in your message.
Update your photo and improve your
bio from time to time to keep things
fresh and interesting. I’m not suggested you pose for the perfect angle and
“selfie” yourself into oblivion. But when
you change things up, it makes people
want to hear what you have to say.
Embrace the constant change!
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30 | Summer 2015
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| Prevention
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12/05/15 3:15 PM
I hope I’ve convinced you to create a
Twitter or some sort of social media account
and join us in the #infectionprevention conversation online. We need to take ownership
of our own hashtags such as, #infectionprevention and #handhygiene. And remember
to use the #APIC2015 hashtag this year for
the annual conference in Nashville. Right
now, conversations about infection prevention issues occur all day long with very few
IPs involved. We are the experts, yet we have
very little representation on social media. So
get out there IPs and take back your hashtags!
P.S. #thanksforlettingmerantaboutsocialmedia.
Angela Vassallo, MPH, MS, CIC, director of
infection prevention/epidemiology at Providence
Saint John’s Health Center in Santa Monica,
California, is president of the APIC Greater
Los Angeles (GLA) Chapter #3. Under Vassallo’s
leadership, APIC GLA was the first APIC chapter to use Twitter and Facebook. Vassallo was
nominated as Healthcare Manager of the Year
(2014) by the Los Angeles Business Journal.
References
1. L.A. County population pushes past 10 million, highest in
nation. Los Angeles Times. March 27, 2014. Available at:
http://articles.latimes.com/2014/mar/27/local/la-me-ln-lacounty-population-10-million-20140327.
2. Goff DA, Kullar R, Newland JG. Review of ‘Twitter’ for Infectious
Diseases Clinicians: Useful or a Waste of Time? Clin Infect Dis.
2015 Feb 4. doi: 10.1093/cid/civ071.
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1. Levin J, et al., Cooley Dickinson in AJIC 2013, 41:746-748. 2. Simmons S, et al., Cone Health
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GLOBAL INSIGHT
Perspective from Australia:
Routine culturing and surveillance
of endoscopes
By Cathryn Murphy, RN, MPH, PhD, CIC
Since 1995, Australia’s two leading gastro-
enterological associations have recommended
routine surveillance of endoscopes, (including
duodenoscopes) and automated endoscopic
reprocessors.1 Like many infection prevention
and quality control measures in Australia, this
recommendation is not mandated by legislation, regulation, or accreditation criteria. The
extent to which various Australian states and
territories have adopted it is unmeasured and
there is no publically available repository of
data relating to endoscopic culture. Regardless,
the author is aware anecdotally that Australian
infection preventionists and gastroenterological
specialists, in general, accept and comply with
the recommendations.
In 2011, the Queensland government, in collaboration with the then Gastroenterological
Nurses College of Australia, developed a
web-based training module on endoscope
reprocessing.2 The module contains detailed,
practical advice regarding implementation of
the endoscope culturing quality monitoring.
It specifies recommendations for:
• Standardized culturing timing, specimen
collection, and frequency according to
scope type including loan scopes;
• Action in the event of positive culture of an organism of epidemiologic
significance;
• Suspension of endoscopic services until
clearance;
• Determination of the need for a lookback
or patient recall; and
• Repeat reprocessing, repeat culturing, and
endoscope clearance.
To date, Australia’s long history of culturing endoscopes has been contrary to North
American practice.3 Policy makers, regulators,
and researchers have considered the increasing
trend among other countries to recommend
routine culturing. Debate has focused on the
return on investment (e.g., the likelihood that
routine endoscopic culture provides a timely
indication of faulty endoscopes, incomplete or
incorrect reprocessing, and the extent to which
culturing potentially reduces the likelihood of
iatrogenic pathogen transmission).
The debate remains unresolved with
opponents citing that in one three-year
period in New Zealand, the culture of
more than 7,000 endoscopes yielded
only one occasion of improper reprocessing and nine other occasions of damaged
w w w.apic.org | 33
GLOBAL INSIGHT
endoscopes. Additional recent debate has
considered the sensitivity and specificity
of new methods to monitor reprocessing
adequacy.4 However, recent U.S.-based
endoscopic-related outbreaks and transmission of multidrug-resistant organisms
seem to have spearheaded U.S. adoption
of an endoscopic culturing regime similar
to Australia’s.5
Australia’s FDA-equivalent, the Therapeutic
Goods Administration, has also recognized
deficiencies in endoscopic reprocessing
identified by two separate and unrelated cases
of items remaining in endoscopes despite
the scopes having been subjected to multiple
cleaning and reprocessing cycles.6 Clearly, culturing endoscopes is an incomplete method of
mitigating risks associated with poor quality
reprocessing. Correlating contamination of
a specific component, channel, or intricate
part of the endoscope through sampling
of flushed sterile water may be imprecise.
Rather, when coupled with standardized work
practices, staff who are knowledgeable about
the intricacies and complexities of endoscope
reprocessing and also comply fully with best
practice recommendations can be reassured
that the quality of their work will be subject
to periodic review as measured by the act of
routine endoscopic culture.
Coordinating, over-seeing, interpreting,
and acting upon periodic endoscopic culturing
is part of the typical infection preventionist’s
role and function in Australia. To date, it has
served us well, although we acknowledge it
is most easily undertaken in large teaching
hospitals with onsite microbiology laboratory
services. For smaller standalone facilities such
as day-only endoscopy suites that are similar
to U.S. ambulatory care services, compliance
with the endoscope culturing recommendations may initially require provision of some
services and loan scopes by external providers.
The author welcomes questions from APIC
members seeking additional information
about Australian practices. Useful information
is also available on the Gastroenterological
Nurses College of Australia (GENCA) and
Queensland Health websites as listed in the
reference list below.
Cathryn Murphy, RN, MPH,
PhD, CIC, is executive director
of Infection Control Plus Pty Ltd
in Queensland, Australia. Dr.
Murphy served as APIC’s first
and only non-North American
elected president in 2010. She is an internationally recognized infection prevention expert who
has worked in infection prevention continuously
since 1989 in senior positions in clinical, research,
government, and academic settings.
References
1. Gastroenterological Nurses College of Australia – (GENCA). Infection Control in Endoscopy. 2010. Accessed 5 April, 2015 at www.
genca.org/public/5/files/Endoscopy_infection_control%20(low).
pdf.
2. 6.4 Microbiological Testing. Queensland Government, 2014.
Accessed 5 April, 2015 at www.health.qld.gov.au/EndoscopeReprocessing/module_6/6_4.asp.
3. Petersen B. Commentary: Monitoring of Endoscope Reprocessing:
Accumulating Data but Best Practices Remain Undefined. Infection
Control and Hospital Epidemiology 2014;35:995-7.
4. Fernando G, Collignon P, Beckingham W. ATP bioluminescence
to validate the decontamination process of gastrointestinal endoscopes. Healthcare Infection 2014;19:59-64.
5. Interim Protocol for Healthcare Facilities Regarding Surveillance
for Bacterial Contamination of Duodenoscopes after Reprocessing.
Accessed 5 April, 2015 2015 at www.cdc.gov/hai/organisms/cre/
cre-duodenoscope-surveillance-protocol.html.
6. Endoscopes reprocessing procedures. Australian Government,
2014. Accessed 5 April, 2015 at www.tga.gov.au/publicationissue/medical-devices-safety-update-volume-2-number-5-september-2014#endoscopes.
34 | Summer 2015 | Prevention
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5/8/15 4:40 PM
Infection Prevention Leadership
My personal journey
By Timothy Bowers, MT(ASCP), MS, CIC
I
’ve been greatly affected by those around me and owe much of my career to the right
people giving me the right focus at the right time. I’m going to tell you about my start
as a medical technologist, finding infection prevention, and realizing it was more than
just a job—it has been an incredible personal and professional journey.
My start as a medical technologist
My path to finding medical technology was a complete
and utter accident. A very average student in high school, I
took an extra class in exploring medical careers. Our class
toured the lab and observed a laboratorian handling an
engorged organ when it ruptured. Blood went everywhere,
and I was immediately in love!
I went on to earn my bachelor’s degree in medical
technology, and for some of my elective classes I took
leadership development, which was very motivating in a
personal capacity as I hadn’t had the opportunity to use
those skills professionally.
Upon completion of my clinical rotations, my first position was in Thomas Jefferson University Hospital clinical
microbiology. I originally wanted to be in blood banking,
but I’m glad I took the path I did. The lab leaders were very
supportive in allowing me to learn all of the areas including bacteriology, virology, and serology. They were also
supportive of the development of an educational program
when the American Society for Clinical Pathology started
requiring us to maintain our certifications.
A first—and scary—
step to work on leadership skills
I took my micro experience and some of the leadership learned in undergrad and developed an educational
system for the lab so we could keep up our skills and
maintain compliance with those new regulations. It
was the first time I was able to interact with laboratory administration and with individuals outside of
microbiology. The previously mentioned supportive
staff played roles in preparing for the initiative. It was
petrifying. I stammered, hesitated, worried, and lost sleep
over connecting with these individuals. It lead to doing
significant research for the meetings so I couldn’t be
caught off guard, which occasionally happened anyway,
but gave me the ability to educate administration on
the thought processes behind the initiative. In short, it
was one of the best learning experiences in my career at
that point. It also coincided with beginning my master
of science in health policy.
Finding my way into infection
prevention and control
I applied for my first infection prevention and control
position toward the end of my master’s course work. Many
of the experiences from my program were included in the
job description. When researching what the job entailed,
it peaked my interest intellectually. I got the job, and it
meant big changes for me, and the real life transition was
scary. I was out of the lab, in a new health system, dealing
with nurses, physicians, and occasionally patients! Starting
out in infection prevention and control was rough, and for
a while it didn’t look like it was going to last. Thankfully,
early on the two seasoned infection preventionists (IPs) at
the facility really helped me stay on track. They mentored
w w w.apic.org | 37
PREVENTION IN ACTION
“As Mark Twain noted,
‘Never argue with a fool,
bystanders cannot tell
the difference.’ I believe
that professionalism isn’t
never being yelled at; it is
never yelling back.”
38 | Summer 2015 | Prevention
me on the technical aspects as well as the
soft skills (e.g., communication and interpersonal skills) needed to be effective. I’ll
never forget my first important lesson on
soft skills. My first draft email outside the
department was five paragraphs, three colors, bold, underlined, and italics. Luckily,
I asked the lead IP to review it before I hit
“send.” The lead IP helped me get it down
to four sentences and one color (and taught
the word ‘concise’ to me).
It wasn’t until completing APIC’s EPI
101® course and applying what I’d learned
at our facility that I really started becoming
engaged in the job and connecting the dots.
I was also fortunate to have an incredible
first experience with a supportive structure in place already. Nurse managers and
nurses helped fill in patient care science and
procedures; attending physicians allowed
participation in teaching rounds to absorb
the medical education given; our medical
director educated me on disease processes;
the other practitioners in the department
helped fill in the multitude of gaps that
existed, as well as keeping me focused on
the task at hand. I was finally flourishing
in my position as an IP. I then went on to
earn my board certification in infection
prevention and control (CIC®).
Taking it to the next level
With a few years of experience under my
belt and my new CIC certification, I had the
audacity to apply for the ultimate test of my
development. One of the few director positions in the area, responsible for more than
one hospital, became available and I applied.
It wasn’t academic medicine and it was in
a different state with a further commute. I
wasn’t in infection prevention very long and
still had a lot to learn. There were so many
reasons not to apply, and yet I sent in my
resume. I thought it was a long shot, but I
got an interview.
The interview lasted all day and involved
many different individuals, including
the infectious disease/Infection Control
Committee chairman. We ended up debating every question asked for more than an
hour. It was intense. There was no yelling,
but we took opposite positions on almost
every aspect of the job. I supported my
positions with as much information as possible (e.g., NHSN definitions, CDC recommendations). I left the interview thinking if
nothing else it will help me be successful in
my next interview, if it were to ever happen.
Regardless of our differing opinions, I
was offered the position because (as the
infectious disease/infection control chairman noted) of the way I handled differing
opinions and communicating my position
with literature. This interview was one of
the best, most terrifying, experiences of
my life. My previous experiences set me
up for a successful interview and it set the
course for many more leadership learning
opportunities I would soon experience in
my new position.
Bowers’ leadership tips
Gaining respect from colleagues and leadership isn’t something that occurs overnight. Looking back, and asking colleagues
who know me best, there are a few things that stand out in terms of their opinion of what I do that makes me a leader and
worthy of their respect.
Tip 1 Tip 4
Learn from your mistakes. Learn from previous mistakes,
especially in communication. If your message doesn’t seem to
be resonating with the intended audience and you’re not getting
results, then take a hard look at what you’re doing or how you could
improve the delivery of the communication. Are you providing all the
relevant information? Is the mode of delivery appropriate (e.g., email
or in-person meeting)? Is he/she the correct person to receive the
message? Is your tone appropriate? Completely remove all ego and
concentrate on what’s important—effective communication.
Remain calm under pressure. As Mark Twain noted,
“Never argue with a fool, bystanders cannot tell the difference.”
I believe that professionalism isn’t never being yelled at; it is
never yelling back. People notice a calm demeanor and will
respect you for it.
Tip
5
Tip 2
Find great mentors. They may not search you out, but you
Justify everything with evidence and science. The
connection with leadership depends on your technical ability to
understand the issues, as well as your ability to communicate
to those who don’t understand infection prevention on the same
level. That skill will separate leaders from technical experts.
Always come to a meeting armed with evidence/science and
prepare on your communication tactic ahead of time.
should search for them. Many non-traditional roles have influenced
me greatly throughout my career. Administrative assistants,
graduate medical education surgical residents, co-workers,
colleagues, and in my current position my staff have helped
continue to push my development. Some gave me a goal to attain,
some showed me how to be a leader, others showed me behaviors
to reduce or eliminate. Some have illustrated the fall from grace. On
that last note, be humble (oh, the irony!).
Tip 3 Tip 6
Don’t let fear hold you back. Sometimes we are our own worst
enemies. Try to suppress the inner voices that tell you that “you can’t”
or “it’s not possible.” Make an effort to act confident, even if you don’t
feel it. Walking with nurses or nurse managers into a room to suppress
staff’s fear or misconception is something I’ve done on several occasions.
Watching surgeries seems tame, but walking into a room with a very
unlikely rule-out Ebola case can be just as frightening if you’ve never done
either. Think of everything as a learning opportunity. “Do something every
day that scares you.” —Baz Luhrmann (Mary Schmich)
Constantly be a student of your skills. Keep up with
AJIC and ICHE for IP skills, but actively work on your leadership
development—especially those crucial soft skills.
Leadership is a lifelong venture that should be sharp when you need it, even if that need is not every minute of
every day.
Timothy Bowers, MT(ASCP), MS CIC, is corporate director of infection prevention & control for Inspira Health Network
in Vineland, New Jersey. He is also a member of APIC’s Communications Committee.
w w w.apic.org | 39
PREVENTION IN ACTION
Emergency preparedness
and infection control:
Teaming up to create meaningful
staff simulation exercises
Tips for success
By Kristine Sanger, BS, MT(ASCP)
A
s an infection preventionist (IP) turned
emergency preparedness professional, I
see many similarities within the fields
and even more opportunities to collaborate. One
of those opportunities is in the realm of disaster simulation exercises. For years, emergency
preparedness professionals have been designing
disaster simulation exercises on many levels to test
the preparedness of their organizations. Most are
testing surge capacity and emergency departments
(ED). I rarely see simulation exercises go beyond
the ED, but they should. The safety of patients
relies on it. Simulation exercises should include all
departments of the hospital, clinic, or long-term
care facility. A great place to start is teaming up
with the infection prevention department.
Nursing staff initial clean up during a norovirus exercise at an outpatient surgery center.
40 | Summer 2015 | Prevention
When planning a simulation exercise,
consider six very important things:
Plan for success. The Homeland Security
Exercise Evaluation Program recommends
a progressive approach to simulation exercises.1 This entails beginning the process
small with a discussion-based exercise and
to gradually increase the capacity and
capabilities of the exercise as your staff
becomes more familiar with the process.
All too often, staff are put to the test with
a plan with which they are uncomfortable
and/or unfamiliar, and the exercise ends
up only frustrating staff rather than acting
as a learning opportunity.
Manage expectations. Sometimes when
simulation exercises are developed, the
scope of the exercise is lost during the
many hours of organizing and in the
many minds that are participating. Too
often, the functions to be tested become
more than what is manageable and the
1
3
2
4
5
6
number of participants is more than what
is beneficial to the entire exercise. This
is often referred to in the exercise world
as “avoiding Armageddon.”
Develop clear, well-written objectives.
Objectives need to be the full driving force
behind the development of any simulation
exercise. A good objective is clear, concise,
and focused on performance. For example,
if you want to test your plan to respond
to an outbreak of measles in your campus
childcare center, you need to determine
which tasks within the plan are to be tested
and stick to them. A good objective in
that example would be, “By the end of
the exercise, participants will have notified
the health department and the daycare
customers of the risks and exposure within
12 hours of the initial case identification.”
Again, this should be based on what is
written in the current plan.
Involve new people. The ED is the
single most tested department when
it comes to disaster simulation exercises. This is appropriate because the
ED will likely be the one department
that is always affected by a disaster, but
they aren’t the only ones. In a shooting
event, the operating room will be in
high demand; in an Ebola outbreak,
all departments will be needed. The
purpose of a simulation exercise is to
provide practice for a real event. All
people in your facility will benefit from
this practice.
Get creative. Don’t fall into the trap of
always doing the same familiar community exercise. This leads to frustration,
non-participation, and an attitude of
apathy with the exercise itself.
Know the regulatory requirements of
your audience. If your facility is regulated by The Joint Commission (TJC),
know what TJC expects and requires
for yearly compliance. If the Centers for
Medicare & Medicaid Services are the
regulators, become familiar with their
requirements. You are much more likely
to gain buy-in from staff and leadership
if your simulation exercise is going to
Learn
more about
emergency
preparedness
at APIC 2015
Abstracts
• 021—Measles Emergency Response:
Lessons Learned from a Measles Exposure
in an 800-bed Facility
• 023—The Creation and Rapid Deployment of
a Preparedness Plan for Ebola Virus Disease:
Lessons from a Large Healthcare System
Workshops
• 3102—Emergency Preparedness:
The Infection Preventionist (IP) as Part of
the Team
Concurrent session
• 3200—Infection Prevention Emergencies
on Friday Afternoon at 4:30!
To learn more, visit
www.apic.org/ac2015.
w w w.apic.org | 41
PREVENTION IN ACTION
4
5
Exercise actor using oatmeal to simulate an uncontrolled vomiting episode.
contribute to compliance with the regulatory agencies of your organization.
2
Getting creative with infection
prevention simulation exercises
There are many creative ways to merge
the expertise of infection prevention in
simulation exercises. Listed below are just
a few that are quick, easy ways to engage
new groups and promote infection prevention in simulation exercises. All of the ideas
listed could be done in a discussion-based
exercise or elaborated further in a full-scale
scenario.
1
harmacy: Test an infectious disease expoP
sure plan by having staff pull all supplies
needed in the event of an anthrax exposure.
42 | Summer 2015 | Prevention
3
aternity: Test your infectious disease
M
exposure plan and your media relations
plan by having staff respond to a sibling
visit with measles. Add to the scenario
that the patient had been in the hallway
visiting area with other patients and that
the sibling had been coughing at the
time. Have simulation participants collect names of all patients that had been
exposed, the staff that had been exposed,
and discuss how it might affect staffing for
the immediate future. It’s likely that staff
members would have children at home
who would be at risk, so another more
public exposure could also be added to the
scenario to gauge staffing rates.
Food services: Test a power outage in the
kitchen. Ask the staff to provide details
of how to know when food is not cooled
properly and potentially dangerous to
serve. Prepare menu plans for the next five
to seven days with only the supplies that
they have in house in case of prolonged
power failure and a need to shelter in
place.
Environmental services: Test an infectious disease exposure plan with a norovirus incident scenario (oatmeal makes it
very realistic). Have staff go through the
clean-up process with proper personal
protective equipment. This could be done
with other infectious diseases as well.
Operating room/maintenance: Test the
knowledge of infection control procedures
by creating a flood in the supply room,
an HVAC shutdown, a loss of steam, or
a construction barrier failure. Talking
through these procedures could help
introduce staff to the idea that infection
prevention starts with the environment.
The most important thing to consider
when planning a simulation exercise
is who you are training and what you
want them to learn. After completing
any simulation exercise, success should
be measured and documented. In addition, appropriate training should be provided in response to opportunities for
improvement. As long as the simulation
exercise is designed and followed up on
based on audience and objectives, the
success and learning of the well-planned
exercise will be undeniable. Being prepared for unexpected events on all levels
creates an environment of patient safety
that your staff and patients will appreciate
and expect.
Kristine Sanger, BS, MT (ASCP),
is director of Hospital Training
and Exercise Programs, Center
for Preparedness Education at the
University of Nebraska Medical
Center in Omaha, Nebraska and associate executive
director of the Association of Healthcare Emergency
Preparedness Professionals (AHEPP). She is also
a member of APIC’s Emergency Preparedness
Committee.
Reference
1.Federal Emergency Management Agency. 2013.
Homeland Security Exercise and Evaluation Program. Available at: www.fema.gov/media-librarydata/20130726-1914-25045-8890/hseep_apr13_.pdf.
Accessed March 24, 2015.
2
1
4
3
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process. We launder our microfiber products with a sanitizer that protects fibers while eliminating
99.9% 1 of pathogens. And that’s just step one of our innovative four-step system. So you can always
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organisms during the wash cycle: Pseudomonas aeruginosa, Klebsiella pneumoniae,
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1
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aramarkuniform.com/healthcare
PREVENTION IN ACTION
Focus on long-term and behavioral health outbreaks—
Identify the pathogen:
Clostridium
perfringens
By Steven J. Schweon, RN, MPH, MSN, CIC, HEM, FSHEA
H
ospital outbreaks are reported more often in the medical literature than
occurrences in the long-term care (LTC) or behavioral health setting. By
studying and learning from outbreaks in the LTC/behavioral health setting,
infection preventionists (IPs) will glean additional knowledge and apply this information to hopefully prevent future infections, and infection clusters in their facilities.
This quarterly column will assist the IP with heightening awareness of appropriate
interventions for preventing an outbreak.
“While everyone
is susceptible
to Clostridium
perfringens food
poisoning, the very
young and elderly
are at the greatest
risk for infection and
complications, with
illness lasting up to
two weeks.”
44 | Summer 2015 | Prevention
A recent Morbidity and Mortality Weekly Report
(MMWR) describes 42 residents and 12 staff
members at a state psychiatric hospital who experienced vomiting, abdominal cramps, and diarrhea.1 Within 24 hours, three patients had died.
The three patients who died were taking medications with anti-intestinal motility side effects. An
investigation revealed that eating chicken served
at dinner was associated with illness.
Based on your education and training, you
suspect the following pathogen(s):
❶ Norovirus
❷ Astrovirus
❸ Staphylococcus aureus
➍ Clostridium perfringens
Clostridium perfringens enterotoxin was
detected in 20 of 23 stool specimens from ill
residents and staff members. This organism was
also found in the chicken.
An investigation revealed the chicken was
cooked approximately 24 hours before serving.
It was not cooled properly, per the facility policy,
and there was a delay with the required temperature checks. Additionally, the chicken was
removed from cooling at three different times for
additional preparation steps, before being served
as cold chicken sandwiches or chicken salad. The
state sanitarians inspected the hospital kitchen
and found no violations of the sanitary code.
Background on Clostridium perfringens
Clostridium perfringens is a Gram-positive,
spore forming bacterium that is found on raw
meat and poultry, environmental sources, and
in the intestines of humans and animals.2 Some
strains produce a toxin in the intestines that
causes gastroenteritis. The Centers for Disease
Control and Prevention (CDC) estimates this
organism causes nearly one million cases of foodborne illness annually.2 Clostridium perfringens
infection usually has a sudden onset, lasts for
less than 24 hours, and results in diarrhea and
abdominal cramps.2 Fever or vomiting does not
usually occur. The infection is not transmitted
person-to-person; use of Standard Precautions is
sufficient when caring for the patient. The incubation period is six to 24 hours.3 This organism
is also the causative agent for gas gangrene and
PHOTO COURTESY: CDC.
This illustration depicts a photomicrographic view of a Gram-stained
culture specimen from a patient with gas gangrene, and revealed the
presence of numerous Clostridium perfringens Gram-positive bacteria.
side effects, may have impaired gastrointestinal motility; this will delay elimination of the toxin and may result in severe
intestinal damage and possible death.
Any food that has been left out too
long may result in illness, despite a normal
appearance.
❺
Steven J. Schweon, RN, MPH,
MSN, CIC, HEM, FSHEA, is
an infection prevention consultant with a specialized interest
in acute care/long-term care/
behavioral health/ambulatory
care infection challenges, including outbreaks.
References
1. Centers for Disease Control and Prevention. Fatal foodborne
Clostridium perfringens illness at a state psychiatric hospitalLouisiana, 2010. MMWR. 2012;61(32). Available at: www.cdc.
gov/mmwr/pdf/wk/mm6132.pdf. Accessed March 27, 2015.
2.CDC. Clostridium perfringens. Food safety. 2014. Available at:
www.cdc.gov/foodsafety/clostridium-perfingens.html. Accessed
March 27, 2015.
3.U.S. Department of Health and Human Services. Clostridium
perfringens. 2015. Available at: www.foodsafety.gov/poisoning/
causes/bacteriaviruses/cperfringens/. Accessed March 28, 2015.
can be
used for
biological warfare.
While everyone is susceptible to Clostridium
perfringens food poisoning, the very young
and elderly are at the greatest risk for infection
and complications, with illness lasting up to
two weeks.
Diagnosis and treatment
Clostridium perfringens food poisoning is
diagnosed by either detecting the bacterial
toxin in the feces or determining the number
of spores per gram in the stool. Antibiotics are
not recommended for treating the infection.
Rehydration therapy is used to replace fluids
and electrolytes lost due to diarrhea. There is
no vaccine available to prevent illness.
How does food poisoning occur?
Common food sources containing this
organism include beef, poultry, gravies,
and dried or pre-cooked foods. Although
this organism may be part of the normal
intestinal flora, illness is due to ingesting
food contaminated with a large number
of Clostridium perfringens organisms that
produce enough toxins in
the intestines and cause illness.2
Spores germinate between 54–140 degrees
Fahrenheit; the bacteria grow very rapidly
between 109–117 degrees Fahrenheit.
To prevent illness, foods should be cooked
thoroughly at the recommended temperatures, then kept either warmer than 140
degrees Fahrenheit or cooler than 41 degrees
Fahrenheit, which prevents spore growth.2
Food that is reheated must also be prepared at the recommended temperature; otherwise, live bacteria may become ingested.
Take home messages for the LTC/
behavioral health IP:
It is critical to strictly adhere to recom❶mended
food cooking and storage tem-
peratures to prevent illness.
During environmental rounds in your
facility’s kitchen, review temperature logs
to ensure policy compliance.
Include Clostridium perfringens as a
possible pathogen when suspecting food
poisoning on the milieu or in a LTC unit.
Patients taking psychiatric medications,
or other medications with anticholinergic
❷
❸
❹
Learn
more at the
APIC 2015
Annual
Conference
Attend Steven Schweon’s session at
APIC 2015, June 27–29 in Nashville,
Tennessee.
Outbreaks on Behavioral Health
Units: What Happens When Intensive
Inpatient Psychiatric Therapy Meets
Communicable Diseases
Monday, June 29, 9:30–10:30 a.m.
Learning objectives:
• Identify one reason an outbreak may
go undetected in a behavioral health
setting.
• State two evidence-based best
practices to prevent outbreaks.
• Describe one intervention to halt
an outbreak.
w w w.apic.org | 45
PREVENTION IN ACTION
A family-centered
care model to
reduce pediatric
CAUTI
By Vicky Uhland
W
hen the staff of Akron Children’s Hospital in Akron, Ohio, decided
to implement a catheter-associated urinary tract infection (CAUTI)
prevention program, they knew they faced some challenges. Unlike
most adult CAUTI prevention programs, pediatric CAUTI initiatives require
both patient and family participation. Fortunately, Akron Children’s already had
a robust patient- and family-centered model of care delivery when it enacted its
CAUTI prevention program three years ago. And the team, co-led by infection
prevention staff, had the added benefit of being able to participate in the Ohio
Children’s Hospitals’ Solutions for Patient Safety—a pioneering pediatric collaborative to prevent serious harm from hospital acquired conditions including
healthcare-associated infections (HAIs).
“Between 2012
and 2013, the burn
center reduced
catheter days by
75 percent, from
618 to 245. The
number of CAUTIs
dropped from
seven in 2012 to
two in 2013. The
burn center has
Akron Children’s is the largest pediatric healthcare system in northeast Ohio, with about 800,000
patient visits a year. It operates two hospitals and has
about 80 locations across the region. The hospital
has earned Magnet designation for excellence in
nursing care. In 2012, Akron Children’s infection
prevention team, including Cheryl Christ-Libertin,
DNP, CPNP-PC, RN-BC, NE-BC, evidence-based
practice coordinator, and Tina L. Bair, MSN, RN,
46 | Summer 2015 | Prevention
CIC, manager of infection prevention and control,
evaluated nursing sensitive quality indicators and
found that the burn center and pediatric intensive care unit (PICU) had the highest CAUTI
numbers—mainly because they served many critically ill patients who required catheters. Using the
Rosswurm-Larrabee model for planned change in
practice based on evidence, the team first developed
a pilot study for the Paul and Carol David Regional
gone more than
330 days without
a CAUTI.”
Akron Children’s nurse provides patient- and familycentered care for quality outcomes.
photo courtesy: Akron Children’s Hospital.
Burn Center. The surgeons and nursing staff
helped individualize the infection prevention plan to the burn injured patients and
measured reliable use of the insertion and
maintenance bundles, as well as strategies
to reduce catheter days.
In 2013, they joined efforts with the Ohio
Children’s Hospitals’ Solutions for Patient
Safety network and spread the work to
the PICU. Key drivers to prevent CAUTI
included use of clinical criteria for catheters,
use of insertion and maintenance bundles,
and daily evaluation of the need for the
catheter. Interventions tested encompassed
everything from a catheter removal decisionmaking algorithm to a patient information
handout for family members. In 2013, Bair
and an administrative intern instituted a
hand hygiene improvement program using
Lean Six Sigma methodologies.
The results have been impressive. “We
were recognized as a top-five network hospital among the more than 80 hospitals in the
National Children’s Hospitals’ Solutions
for Patient Safety network for reduction
of catheter days,” Christ-Libertin said.
Between 2012 and 2013, the burn center reduced catheter days by 75 percent,
from 618 to 245. The number of CAUTIs
dropped from seven in 2012 to two in
2013. The burn center has gone more
than 330 days without a CAUTI. And
the 2013 CAUTI rate of 1.27 notably
outperformed the National Healthcare
Safety Network’s pooled mean of 4.10.
American Burn Association (ABA) verification surgeons took note and called
the center to discuss its strategy. The successes were shared at the ABA regional
and national conferences. The PICU
pediatric intensivists and nursing staff
reviewed progress toward established goals
monthly. The team also reduced catheter
days and established highly reliable use
of the bundles (greater than 95 percent).
They reduced CAUTI from five in 2012
to two in 2013. The PICU shared its successes at the American Nurses Association
Quality Conference.
Pros and cons of an RN-driven catheter
removal algorithm
The team implemented a decision-making
algorithm that determined when catheters
should be used or removed. The algorithm,
which Christ-Libertin said came from published literature, focused on RN-driven catheter removal.
During the trial period, the nurses completed the algorithm and recorded their
decision about catheter removal for each
patient. Then the providers recorded what
their decision would be. Christ-Libertin said
the infection prevention team was looking for
95 percent agreement, and got 90 percent.
“We found that nurses wanted to keep the
catheters in more often,” she said. “The providers wanted to take the catheters out more often.”
So the team decided to abandon the
algorithm. “Unlike in the adult world, our
pediatric intensivists and acute care nurse
practitioners are onsite and round at three
scheduled times a day in the PICU. The nursing staff and providers use a shared team
decision-making approach.” Christ-Libertin
w w w.apic.org | 47
PREVENTION IN ACTION
Read more about CAUTI in
the American Journal of
Infection Control
Using electronic medical records to increase the efficiency of catheter-associated urinary
tract infection surveillance for National Health and Safety Network reporting, Shepard, John
et al., American Journal of Infection Control, Volume 42, Issue 3, e33-e36.
Nurse-directed catheter removal protocols to prevent catheter-associated urinary tract
infection: Strategies for implementation, Hebden, Joan N., American Journal of Infection Control,
Volume 42, Issue 6, 670.
A comparison of the microbiologic profile of indwelling versus external urinary catheters,
Grigoryan, Larissa et al., American Journal of Infection Control, Volume 42, Issue 6, 682-684.
Impact of catheter-associated urinary tract infection bundle on other health care-associated
infections, Cheng, Wei-YaLin, Yu-HsiuLai, Chih-ChengChao, Chien-Ming et al., American Journal of
Infection Control, Volume 43, Issue 2, 197-198.
Risk factors for catheter-associated urinary tract infection in Italian elderly, Vincitorio, Daniela
et al., American Journal of Infection Control, Volume 42, Issue 8, 898-901.
Introducing a catheter-associated urinary tract infection (CAUTI) prevention guide to patient
safety (GPS), Saint, Sanjay et al., American Journal of Infection Control, Volume 42, Issue 5, 548-550.
Emergence of extended-spectrum ß-lactamase-producing Escherichia coli in catheter-associated urinary tract infection in neurogenic bladder patients, Takaba, Kei et al., American Journal
of Infection Control, Volume 42, Issue 3, e29-e31.
Clinician practice and the National Healthcare Safety Network definition for the diagnosis of
catheter-associated urinary tract infection, Al-Qas Hanna, Fadi et al., American Journal of Infection
Control, Volume 41, Issue 12, 1173-1177.
What we don’t know may hurt us: Urinary drainage system tubing coils and CAUTIs—A
prospective quality study, Kubilay, Zeynep et al., American Journal of Infection Control, Volume 41,
Issue 12, 1278-1280.
Trends in catheter-associated urinary tract infections among a national cohort of hospitalized adults, 2001-2010, Daniels, Kelly R. et al., American Journal of Infection Control, Volume 42,
Issue 1, 17-22.
Learn more at the
APIC 2015 Annual Conference
Attend these CAUTI sessions at APIC 2015, June 27–29 in
Nashville, Tennessee.
• 3205—“Plastic” Rounds: A Nurse-Centric Approach to
Reducing Catheter-Associated Urinary Tract Infection (CAUTI)
and Central Line-Associated Bloodstream Infection (CLABSI).
• 3500—NHSN CLABSI and CAUTI Surveillance 2015.
• 3002—Proper Collection of Blood and Urine Cultures: Potential
Impact on Central Line-Associated Bloodstream Infections
(CLABSI)/Catheter-Associated Urinary Tract Infections (CAUTI)
Surveillance.
• 3103—Using CUSP to Prevent CAUTI: Key Lessons Learned
from a Large National Clinical and Fellowship Project.
said. “We found that discussion in rounds can
replace the algorithm.”
The clinical staff added review of the number
of urinary catheter days to its rounding tool that
details the topics to be discussed during rounds.
Changing procedures and staff buy-in
After realizing that operating room (OR)
staff places more than half of all catheters used
in the hospital, the infection prevention team
expanded its CAUTI prevention program to
Surgical Services. The OR and PICU teams
began evaluating pre-connected catheter systems, which were not widely used in children’s
care.
Because the OR has restricted space, the
OR education coordinator led staff practice
with inserting the systems on training mannequins. This had the added benefit of helping
staff develop a best-practices insertion method
without interference with a surgery. In addition,
all new nurse hires receive simulated insertion
training, and all nurses complete ongoing education on catheter insertion, maintenance, and
CAUTI prevention best practices. The anesthesia team evaluated practices and reduced catheter days for patients with epidural catheters.
Christ-Libertin said not all nurses were comfortable with the new catheter methods. “We
actually needed more buy-in from hospital staff
than from patients’ families,” she said. “The
literature tells us that nurses and providers may
believe that CAUTI are fairly benign and don’t
cause much harm. Competing priorities for care,
catheter [care] can get lost.”
The team also developed a patient information handout on CAUTIs, detailing things like
the definition of a CAUTI, symptoms of a UTI,
what staff will do to prevent a CAUTI, and
what patients and families can do. The handout
review process included review by the hospital
Parent Advisory Council. Christ-Libertin said
the handout guides staff on information to
review with families on the topic of CAUTI.
“At the heart of patient- and family-centered
care is the recognition that parents are the constants in their children’s lives. They hold the
most complete understanding of each child’s
past, present, and future,” Christ-Libertin said.
“Our biggest insight is that we may think we
know the best thing for the patient, but unless
we involve them and their families, we won’t
know for sure.”
Vicky Uhland is a medical writer for Prevention
Strategist.
48 | Summer 2015 | Prevention
PREVENTION IN ACTION
My bugaboo
Hepatitis C
—The silent epidemic
A microbiological
overview of
Hepatitis C
50 | Summer 2015 | Prevention
Greetings fellow infection preventionists!
The science of infectious diseases involves hundreds of bacteria, viruses, fungi, and protozoa. The amount of information available about
microbial organisms poses a special problem to infection preventionists (IPs). Obviously, the impact of microbial disease cannot be overstated.
Traditionally, the teaching of microbiology has been based mostly on memorization of facts (the “bug parade”). Too much information makes it
difficult to tease out what is important and directly applicable to practice. This quarter’s My Bugaboo column features information about the human
pathogen Hepatitis C. The intention is to convey succinct information to busy IPs for common etiologic agents of healthcare-associated infections.
Please feel free to contact me with questions, suggestions, and comments at irena@case.edu.
BY IRENA KENNELEY, PhD, APRN-BC, CIC
T
he Hepatitis C virus (HCV) has been referred to as the “silent epidemic” because estimates
indicate that approximately four million Americans are infected with this bloodborne pathogen. In the USA, the incidence of HCV fell between 1992 and 2003, but no further decreases
have been documented since that time.1
Liver failure caused by HCV is one of the
most common reasons for liver transplants
in this country. Approximately 75 percent of
people infected with HCV become chronically infected and will remain infected indefinitely. Furthermore, HCV infected persons
may not be aware of their chronic infection
because they have no signs or symptoms.
Unfortunately, these infected people serve
as a source of transmission to others.1,2
Hepatitis C is an RNA virus in the
Faviviridae family. In the past, it was known
as “non-A non-B” virus.1
Clinical significance and epidemiology
HCV infection shares many characteristics of Hepatitis B virus (HBV) disease,
but is much more likely to become chronic.
Severe symptoms can occur with HCV; however, there have been reported cases in which
there was no damage to the liver. Chronic
liver disease with no overt symptoms is much
more common.1,2
Cancer may occur as the direct result of
HCV infection. Worldwide, HBV infection is
the most common cause of liver cancer; however, in the U.S. it is more likely to be HCV.1
Background
HCV occurs in all ages, although the highest incidence of acute HCV is found among
persons 20–39 years. African Americans and
whites have similar incidence rates of acute
disease with higher rates in persons with
Hispanic ethnicity. Vertical transmission is
also possible.2
Outbreaks of HCV infection have
occurred in outpatient settings, hemodialysis units, long-term care facilities,
and hospitals. Both healthcare workers
and patients are potentially at risk. This
risk has been associated with unsafe
injection practices, reuse of needles,
fingerstick devices, syringes, and lapses
in infection prevention and control
protocols.1,3
Risk factors for HCV infection
Recommendations have been developed for persons considered at higher risk
for HCV infection. These laboratory tests
include routine blood work/serum testing
for anti-HCV antibodies. Risk factors are
listed in Table 1 on the following page.1,3
“The Hepatitis C virus (HCV) has been referred to as the ‘silent epidemic’ because
estimates indicate that approximately four million Americans are infected with this
bloodborne pathogen.”
w w w.apic.org | 51
PREVENTION IN ACTION
Table 1.
Risk factors for HCV infection
Contact with a person with confirmed or suspected
HCV infection
Employment involving contact with human blood
Persons born between 1945–1965
Receipt of blood transfusion or blood products
Persons who currently inject drugs or who have injected drugs in the past, even if once
or many years ago
Dialysis or kidney transplant
Recipients of clotting factor concentrates before 1987
Injecting drug use
Recipients of blood transfusions or donated organs before July 1992
Number of different male sex partners
Long-term hemodialysis patients
Number of different female sex partners
Persons with known exposures to HCV (e.g., healthcare workers after needlesticks,
recipients of blood or organs from a donor who later tested positive for HCV)
Hospitalization and/or surgery
Intravenous infusions or injections received in an
outpatient setting
HIV-infected persons
Residence in a long-term care facility
Children born to infected mothers (do not test before age 18 months)
Dental work/oral surgery
Patients with signs or symptoms of liver disease (e.g., abnormal liver
enzyme tests)
Acupuncture/tattooing/body piercing
Puncture with a needle or other object contamination
with blood
Laboratory testing
HCV is usually diagnosed with a blood test
for antibodies to the virus. The clinical signs
and symptoms of acute disease caused by the
hepatitis viruses are similar. This makes serologic testing necessary to establish a diagnosis
in persons with jaundice or other signs and/or
symptoms of acute hepatitis. Persons with acute
HCV infection generally exhibit the following: anorexia, nausea, malaise, vomiting, dark
urine, clay colored or light stools, and abdominal pain. Centers for Disease Control and
Prevention (CDC) encourages implementation
Donors of blood, plasma, organs, tissues, or semen
and use of standardized diagnostic hepatitis panels for testing symptomatic patients,
including all serologic markers mandatory
by state laboratory reporting requirements.
Serologic markers include IgM anti-HAV,
HBsAg, IgM anti HBc, and anti HCV.1,2,3
Asymptomatic chronic HCV infected persons should be tested for infection based on
risk factors for infection and/or elevated liver
enzymes, such as ALT and AST. A positive
test result for HBsAg or anti-HCV by enzyme
immunoassay (EIA) should be verified by a
supplemental antibody assay. Detection of
Additional resources
• CDC—Viral Hepatitis: Index of information from the CDC on hepatitis viruses, including
hepatitis B virus and hepatitis C virus. www.cdc.gov/hepatitis/index.htm
• CDC—Protecting Healthcare Personnel www.cdc.gov/HAI/prevent/ppe.html
• CDC—Hepatitis B and the Healthcare Worker: CDC answers frequently asked questions
about how to protect healthcare workers www.immunize.org/catg.d/p2109.pdf
52 | Summer 2015 | Prevention
HCV RNA by reverse transcription polymerase chain reaction verifies HCV infection.1
Infection prevention and control
There is currently no vaccine available for
HCV. There is also no effective post-exposure prophylaxis. Implementation of primary
prevention practices that have proven to be
effective to reduce the risk of HCV infection
include: standard precautions, hand washing,
and educating of healthcare personnel about
safe injection practices. Secondary prevention activities are focused on outbreak investigation and the reduction of liver disease
and other manifestations of HCV-related
chronic infections.1,3,4
The current treatment regimen for HCV
is ribavirin plus pegylated interferon therapy. These treatments are not considered
curative, but may prevent further damage to
the liver. In 2011, two new protease inhibitor drugs were approved for treating HCV.2
Recent advances in HCV therapy have
given those infected an improved chance for
longer life—essentially considered a “cure.”
Cure means the HCV is not detectable in
the blood three months after treatment ends.
A new regimen that has been approved by
the Food and Drug Administration (FDA)
includes sofosbuvir, which was the first drug
that did not need to be used with interferon
therapy. Protease inhibitors have also been
approved by the FDA in the treatment of
chronic HCV infection: simeprevir, boceprevir, and telaprevir. HCV treatment in adults
is changing constantly with the advent of new
therapies and other developments.5,6
Reporting
The CDC recommends that all states
and territories conduct surveillance for
acute viral hepatitis, including Hepatitis
A, B, C, and non-ABC. Case reports are
transmitted weekly by state health departments to the CDC. However, the statebased databases of persons reported as
anti-HCV positive vary considerably and
have not been standardized.1,7
To date, information on cases of viral
hepatitis reported nationally has been maintained by the CDC in two surveillance systems. Information collected by the National
Notifiable Disease Surveillance System
(NNDSS) includes diagnosis, event dates,
and basic demographic data. Additional
information is collected by the Viral
Hepatitis Surveillance Program (VHSP),
which includes clinical and serologic test
results, and risk factors for infection.1,7
Irena Kenneley, PhD, APRN-BC,
CIC, is associate professor at Case
Western Reserve University,
Frances Payne Bolton School of
Nursing in Cleveland, Ohio.
References
1. Centers for Disease Control and Prevention. Guidelines
for Viral Hepatitis Surveillance and Case Management.
Atlanta, GA. 2005. Available at: www.cdc.gov/hepatitis/
PDFs/2005Guidlines-Surv-CaseMngmt.pdf.
2. Cowan MK. (2013). Microbiology Fundamentals: A Clinical
Approach. McGraw Hill: New York NY.
3. Centers for Disease Control and Prevention. Health Care
Settings and Viral Hepatitis. 2011. Available at: www.cdc.
gov/hepatitis/Settings/HealthcareSettings.htm.
4. Centers for Disease Control and Prevention (HICPAC). Guideline
for Isolation Precautions: Preventing Transmission of Infectious
Agents in Healthcare Settings. 2007. Available at: www.cdc.
gov/hicpac/2007IP/2007isolationPrecautions.html.
5. Centers for Disease Control and Prevention (HICPAC). Guidance on Public Reporting of Healthcare-Associated Infections:
Recommendations of the Healthcare Infection Control Practices
Advisory Committee. 2009. Available at: www.cdc.gov/hicpac/
pubReportGuide/publicReportingHAI.html.
Read more about Hepatitis C
in the American Journal of
Infection Control
Outbreak of Hepatitis C among patients admitted to the Department of Gynecology,
Obstetrics, and Oncology, Rorat, Marta et al., American Journal of Infection Control, Volume
42, Issue 1, e7-e10.
Hepatitis C in Cardiac Patients Investigation Leads to Opportunities for Improvement in
Preventing the Transmission of Bloodborne Pathogens, Sturm, Lisa, et al., American Journal
of Infection Control, Volume 39, Issue 5, E205.
Hepatitis C transmission due to contamination of multidose medication vials: Summary of
an outbreak and a call to action, Branch-Elliman, Westyn et al., American Journal of Infection
Control, Volume 41, Issue 1, 92-94.
Evaluation of a universal vs a targeted Hepatitis C virus screening strategy among pregnant
women at the Vienna University Hospital, Diab-Elschahawi, Magda et al., American Journal of
Infection Control, Volume 41, Issue 5, 459-460.
Outbreak of Hepatitis C virus infection associated with narcotics diversion by an Hepatitis C
virus–infected surgical technician, Warner, Amy E. et al., American Journal of Infection Control,
Volume 43, Issue 1, 53-58.
Learn more at the
APIC 2015 Annual
Conference
Attend this special microbiology workshop at
APIC 2015, June 27–29 in Nashville, Tennessee.
Swimming in Alphabet Soup?
KPC, CRE, IgG, IgM:
A Can’t-Miss Opportunity to Review the
Latest in Microbiology!
Monday, June 29, 8–10:30 a.m.
Learning objectives:
• Discuss the human/pathogen interaction, from
exposure to outright infection.
• Interpret microbiology and immunology patient
reports.
• Apply infection control and prevention interventions to real-life situations common in various
healthcare delivery settings.
w w w.apic.org | 53
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WWW.SPECIALPATHOGENSLAB.COM | 877-775-7284
734896_Special.indd 1
54 | Summer
2015 | Prevention
747795_Editorial.indd 1
04/05/15 6:57 PM
5/20/15 7:47 PM
PREVENTION IN ACTION
Hand hygiene hurdles:
How can we
overcome them?
Q&A with Dr. Timothy Landers
F
or most of the last decade, Timothy Landers, PhD, RN, CNP,
CIC, has been focused on effective hand hygiene programs.
Therefore, it makes perfect sense that he would help write the
latest in the series of APIC Implementation Guides, Guide to Hand
Hygiene Programs for Infection Prevention, sponsored by GOJO—a
long-standing Strategic Partner. Dr. Landers, who is an assistant
professor in The Ohio State University College of Nursing and
a Robert Wood Johnson Foundation nurse faculty scholar,
said the guide examines the historical and regulatory context for hand hygiene programs, and also delves into the
latest science. It’s designed as a best-practices primer
for beginning to intermediate infection preventionists (IPs), their clinician colleagues, and
healthcare facility executives.
w w w.apic.org | 55
PREVENTION IN ACTION
Q:
credit: troy Huffman, The Ohio State University
Why do you have an
interest in hand hygiene?
Timothy Landers, PhD, RN, CNP, CIC.
Prevention Strategist chatted
with Dr. Landers recently about
specifics of the new Guide to
Hand Hygiene Programs for
Infection Prevention, and his
thoughts on how hand hygiene
can be improved in every type of
healthcare setting.
Look for the new
Guide to Hand Hygiene
Programs for Infection
Prevention at
www.apic.org/
implementationguides.
56 | Summer 2015 | Prevention
My area of interest is in the prevention of antibiotic-resistant bacteria, so
the more I learned about the importance of
hand hygiene in preventing these types of
bacteria, the more I wanted to focus on it and
develop effective programs. Hand hygiene is
the cornerstone of our infection prevention
activities; so as IPs, it should be the core of
what we’re doing.
Not to brag too much about IPs, but the
work we do to prevent infections makes many
other advancements in healthcare possible.
Clinicians are able to do highly technological, highly invasive, lifesaving procedures
like brain surgery or chemotherapy because
we’re focused on preventing infections that
would otherwise kill people who are having
these procedures.
Q:
What are the key points
that IPs need to know
in order to design
and implement hand hygiene
programs?
This is the most exciting part of hand
hygiene research in general—that is, the
idea of a multimodal program is absolutely
essential. Some of the key components of
a multimodal program are education and
training, providing effective products where
they’re needed, providing cultural and leadership support for hand hygiene efforts and
monitoring, and then linking that back to
education and training. It’s really the synergy of when all those components of hand
hygiene programs are working together effectively that we see the biggest change.
The guide presents what the individual
components of a hand hygiene program
might look like, and also helps IPs think
about how the different modes or interventions could work together. That is the biggest
take-home message.
This guide is unique in that it gives IPs
the tools to adapt national and international
hand hygiene guidelines to their local settings. A majority of hand hygiene activity
depends on a supportive environment and a
culture that places patient safety at the center.
Successful hand hygiene activity also depends
on the selection of products and the monitoring and training that healthcare professionals
receive; there are local variations in all of
those things.
An off-the-shelf program that anyone can
simply take and implement doesn’t exist.
Having a successful hand hygiene program
requires trained, knowledgeable, and experienced IPs to examine their local settings
and study their local cultures—even things
like the humidity and temperature variations
that affect users’ preferences for hand hygiene
products. The guide highlights the important
role IPs have in developing these programs.
Q:
What is the future of hand
hygiene in healthcare
settings? What do you
see as the major scientific issues
related to hand hygiene that still
need to be addressed?
Practical questions need to be answered,
like what are the best practice recommendations around glove use and hand hygiene?
Work also needs to be done on designing
well-tolerated hand hygiene products that are
effective against the full range of pathogens
in our healthcare settings. This is something
industry is working on, but I think more
needs to be done there.
Understanding behavioral aspects of hand
hygiene is important, as well as what can be
done as the healthcare system evolves. With
the emphasis on being efficient and having
good patient safety and patient outcomes,
how can we leverage that interest to really
encourage hand hygiene?
Work should be done to pinpoint the
most effective monitoring strategies, including feedback on the best formats and ways
to deliver monitoring results. The role of
the patient in hand hygiene is an important
area that has been overlooked and needs to
be addressed. We haven’t really developed
recommendations or products for patients
to be able to perform hand hygiene in
healthcare settings.
In our guide, we’ve outlined a best-practices approach, and we discuss advancements
in products, culture, behavioral change, and
monitoring. Essentially, the guide is meant
to help IPs be on the lookout for these things
as they emerge. However, it doesn’t necessarily make recommendations about one
thing over another, except for what’s based
on solid science.
Q:
Based on your work, what
do we know about hand
hygiene and glove use?
More work must be done in this area.
The interesting facet of hand hygiene and
glove use is that, in general, we think about
hand hygiene protecting patients from the
transmission of these dangerous organisms
or pathogens, and we tend to think about
glove use as protecting ourselves as healthcare
workers. Thus, there is an intrinsic motivation for glove use and extrinsic motivation
to perform hand hygiene.
Others have called for the glove use guidelines to be based on more solid evidence. I
believe we’ll see more evidence on this topic
in the next two to three years.
Q:
What are some of the
explanations for variations in
hand hygiene compliance?
Compliance varies by discipline. Training
and background sometimes emphasizes the
importance of hand hygiene in different
ways. We also may see levels and frequency
of hand hygiene differing depending on levels
of interaction with patients. Unfortunately,
infection prevention and control measures
don’t have as much of an immediate effect on
a patient as giving the wrong drug or using
the wrong surgical technique. So in infection
prevention, the outcome is somewhat distant
from the intervention.
It’s important for IPs to be aware of the
various ways different professionals respond
to infection prevention initiatives, and how
interventions need to be based on empirical,
validated data. Leadership also must make
a commitment to a hand hygiene program.
Leadership sets an example and provides
resources for integrating multimodal hand
hygiene programs.
Throughout the guide, we present ways
to facilitate cultural change and overcome
hand hygiene compliance variations. Three
unique ways include:
1.Positive deviance. This includes novel
ways of managing change.
2.Frontline ownership. This involves getting direct caregivers to commit to hand
hygiene as their core metrics.
3.Writing a business case. This includes
learning how to converse with corporate leaders about the economics of a
well-functioning hand hygiene program.
For instance, it could mean doing chief
executive rounding to get executive buy-in.
Overall, the guide reinforces the importance of highly skilled IPs. It takes knowledgeable and engaged IPs to recognize the
needs of different audiences and develop
hand hygiene strategies and approaches for
different groups.
Q:
hat does successful hand
W
hygiene implementation
look like?
Successful hand hygiene programs need
to be multimodal, coordinated, adequately
resourced, and be an institutional priority
that are led by highly skilled and engaged IPs
who are able to adapt the program specifically
for their environment.
Q:
It seems like we’ve known
about hand hygiene for
so long, but there are
still issues. What barriers remain
in implementing hand hygiene
programs?
In the non-infection prevention world, an
idea exists that hand hygiene is a simple act.
But it’s really a complex act that has deep
motivations. We need to understand that
hand hygiene is complex but is worth doing
to keep patients safe.
Read more about hand
hygiene in the American
Journal of Infection Control
Impact of sink location on hand hygiene compliance for Clostridium difficile infection, Zellmer,
Caroline et al., American Journal of Infection Control, Volume 43, Issue 4, 387-389.
Sustained increase in resident meal time hand hygiene through an interdisciplinary intervention engaging long-term care facility residents and staff, O’Donnell, Marguerite et al.,
American Journal of Infection Control, Volume 43, Issue 2, 162-164.
Impact of the first hand sanitizing relay world record on compliance with hand hygiene in a
hospital, Seto, Wing Hong et al., American Journal of Infection Control, Volume 43, Issue 3, 295-297.
A multifactorial action plan improves hand hygiene adherence and significantly reduces
central line-associated bloodstream infections, Johnson, Linda et al., American Journal of
Infection Control, Volume 42, Issue 11, 1146-1151.
Comparison of hand hygiene monitoring using the 5 Moments for Hand Hygiene method
versus a wash in-wash out method, Sunkesula, Venkata C.K. et al., American Journal of Infection
Control, Volume 43, Issue 1, 16-19.
Face touching: A frequent habit that has implications for hand hygiene, Kwok, Yen Lee Angela
et al., American Journal of Infection Control, Volume 43, Issue 2, 112-114.
See one, do one, teach one: Hand hygiene attitudes among medical students, interns, and
faculty, Polacco, Marc A. et al., American Journal of Infection Control, Volume 43, Issue 2, 159-161.
Impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional
hand hygiene approach in 3 cities in Brazil, Medeiros, Eduardo A. et al., American Journal of
Infection Control, Volume 43, Issue 1, 10-15.
Systematic qualitative literature review of health care workers’ compliance with hand
hygiene guidelines, Smiddy, Maura P. et al., American Journal of Infection Control, Volume 43,
Issue 3, 269-27.
w w w.apic.org | 57
Lessons
learned:
Questions and concerns
regarding safety of
endoscopes and validity of
manufacturer guidance
R
eports of carbapenem-resistant Enterobacteriaceae (CRE)
infections related to endoscopic retrograde cholangiopancreatography (ERCP) duodenoscopes raised concerns among infec-
tion prevention experts, federal agencies, and the public. In February 2015, Ronald
Reagan UCLA Medical Center notified 179 patients who underwent ERCP that
they may have been exposed to CRE from contaminated duodenoscopes. Ronald
Reagan UCLA Medical Center reported that only patients who underwent ERCP
procedures from October 3, 2014, to January 28, 2015, were at risk of CRE infection as a result of these procedures. UCLA Medical
Center noted that it processed the scopes according
to the standards stipulated by the manufacturer. As
MEET THE EXPERTS
James Davis,
of February 23, a total of seven UCLA patients were
infected and two died.
Among infection preventionists, this incident has
raised many questions about appropriate cleaning
and disinfection of endoscopes, surveillance culturing process of endoscopes, and the validity of
manufacturer guidance. Here, we present common
questions that have arisen about these issues and
answers from experts.
58 | Summer 2015 | Prevention
Centers for Disease Control
and Prevention (CDC)
Division of Healthcare Quality Promotion
Atlanta, Georgia
MSN, RN, CCRN, CIC, HEM
Senior Infection
Prevention Analyst
ECRI Institute Headquarters
Plymouth Meeting, Pennsylvania
James Davis represented APIC as part of the
working group that helped develop the CDC’s
duodenoscope surveillance protocol.
Answers from experts
Q:
How did the FDA
approve the sale
of endoscopes that are not
properly validated to be
reused without the risk of
infection when manufacturer
guidance is followed?
Frank Myers: Press reports have
stated that some of the ERCP
scopes linked to some of the
outbreaks were not approved
by the FDA in the configuration used. Manufacturers are
allowed to make small changes to a design
that does not significantly change the function or cleaning of the device. In this case, the
company in 2010 felt the changes were not
significant enough to warrant a new 510(k)
approval. The FDA has since become aware
of the changes and requested a new 510(k)
application be submitted. Both the FDA and
the manufacturer have supported using the
scope in the interim despite not having 510(k)
approval. Other scopes linked to outbreaks
have been approved by the FDA. Because
of this, the FDA has reached out to APIC
and others to give input on new validation
approaches for these scopes.
Citation: www.fda.gov/NewsEvents/Newsroom/
PressAnnouncements/ucm437804.htm.
Frank Myers,
MA, CIC
Infection Preventionist III
Infection Prevention
Clinical EPI
UC San Diego Health System
San Diego, California
Frank Myers represents APIC’s Practice
Guidance Committee and is APIC liaison to the
Association for the Advancement of Medical
Instrumentation.
w w w.apic.org | 59
PHOTO COURTESY: Dartmouth-Hitchcock/Mark Washburn
Q:
Does the cleaning and disinfection
issue apply to just ERCP endoscopes
or to other items with a similar
elevator channel structure such as endoscopic
ultrasound scopes (EUS)?
CDC: All endoscopes should undergo
appropriate reprocessing in accordance
with the manufacturers’ instructions.
Given the complex design of duodenoscopes, special attention should be paid to the cleaning and
disinfection of the elevator mechanism located at
the distal tip of the duodenoscope and to ensuring
complete drying of all the channels and the elevator
mechanism. Training and oversight of individuals
performing endoscope cleaning and disinfection is
an essential component of successful reprocessing.
Clusters related to transmission of bacteria from
EUS have not been reported to CDC; however, since
these scopes have similar design features to duodenoscopes, similar challenges for transmission might
also exist with these endoscopes. CDC’s interim
surveillance protocol (www.cdc.gov/hai/organisms/
cre/cre-duodenoscope-surveillance-protocol.html) is
primarily intended for duodenoscopes; however,
the measures outlined in the protocol could also be
applied to these devices.
Frank Myers: While the FDA and
other organizations’ guidance have
focused on the ERCP scope, many
institutions have begun to look at and
speak about “elevator scopes” as being
problematic. This grouping includes both ERCP
and EUS. Since “elevator scopes” share a number
of similar characteristics, it is being proactive to
also look at processes and cleaning issues around
these scopes. The American Gastroenterological
Association (AGA) Center for GI Innovation and
Technology convened a meeting, “Getting to Zero,”
in March with experts in gastroenterology, epidemiology, and infectious disease; the endoscope manufacturers Fuji and Pentax; and representatives from
the U.S. Food and Drug Administration (FDA),
CDC, and ECRI Institute to discuss how to prevent
these infections and recommended “treating all elevator-channel endoscopes the same, including both
FNA echoendoscopes (EUS) and duodenoscopes.”
There has been one outbreak linked to EUS, suggesting their design may not be different enough to
prevent the issues seen with ERCP scopes.
Citation: www.prnewswire.com/news-releases/how-to-stop-duodenoscope-infections-300054158.html.
60 | Summer 2015 | Prevention
Q:
If a facility is considering sending their ERCP
endoscope(s) out for ethylene oxide (ETO) gas
sterilization, what things do infection preventionists and
administrators need to consider and plan for?
James Davis: Infection preventionists and administrators need to consider
and plan for:
1. The tracking and management of scopes leaving and returning to the
medical facility.
2. Performing due diligence related to cost and quality for companies that
perform such work (consider the use of a due diligence checklist).
3. Knowing who is responsible if a scope is damaged during transport or reprocessing,
how it will be replaced, and whether or not loaner equipment is available until a
replacement is purchased will be important to know up front.
4. R
eviewing the contract for assignment of liability related to lapses in reprocessing/
sterilization by the contractor.
5.Knowing who provides the transport containers and how sterility is maintained
during transport.
6. Conducting a FMEA [failure mode and effects analysis] prior to initiating the
system change.
7. S imulating the process in-situ. (The best laid plans may need to change once the
process is simulated where the work happens.)
8. Contacting the endoscope manufacturer regarding warranty issues related to off-IFU
[instructions for use] reprocessing, and whether or not the manufacturer support will
change if using ETO.
Q:
ETO gas sterilization is known to degrade medical equipment after
multiple exposures. Is any data available regarding how many times
ERCP endoscopes may be treated with ETO before they degrade?
James Davis: The scope
manufacturer will need to
provide that answer based
on validation and testing.
One should also contact the
manufacturer regarding warranty issues
related to off-IFU reprocessing.
Q:
What turnaround
time should facilities
who move to ETO
gas sterilization expect (e.g.,
transportation, sterilization,
and aeration time)?
Frank Myers: I agree with
James’ comments. I would add
that some institutions switching to ETO have reported significant losses in the number
of scopes because of degradation. If your
institution is considering ETO sterilization,
it would seem prudent to query institutions
that have or are using ETO sterilization on
scope models that your institution will be
sterilizing. Asking about their experiences
with ETO sterilization, including attrition
rate, will allow your institution to plan for
all the issues around ETO sterilization.
James Davis: Refer to the
answer of question three.
Simulation/FMEA of the process will be the only real way to
answer the question given the
variability of distance transported, facility
processes, and contractor load and lead time.
Q:
Should facilities that chose
to perform surveillance
cultures on endoscopes
perform these cultures on all
endoscopes or just ERCP endoscopes?
CDC: In the United States, bacterial transmission associated with
endoscopes for which no obvious
reprocessing breaches were identified have
thus far been linked to only duodenoscopes.
In light of this, CDC developed an interim
protocol specifically for duodenoscopes that
can serve as a guide for facilities considering cultures of duodenoscopes to assess the
adequacy of their duodenoscope reprocessing.
Although there is no requirement to perform
duodenoscope cultures, some facilities have
elected to perform regular surveillance cultures as part of their response to the issue. This
is not a replacement for ongoing training and
oversight to ensure that cleaning and disinfection steps are performed correctly; however, it
does provide facilities considering duodenoscope cultures with a consistent starting point
for a protocol that can be adapted for use.
Some groups outside the United States have
recommended routinely performing surveillance cultures of other types of endoscopes,
in addition to duodenoscopes. However, the
benefit of this approach is not known.
Q:
Is it recommended that facilities
test each endoscope or a random
sample of endoscopes? If the
latter, what is the recommended interval?
CDC: Facilities choosing to perform
surveillance cultures of duodenoscopes should consider obtaining
post-reprocessing cultures of each duodenoscope
that is in service. However, the optimal frequency
of surveillance cultures has not been determined
and could range from after each duodenoscope
use (after reprocessing) to interval sampling, e.g.,
monthly or after every 60 procedures for each
duodenoscope. International guidelines have
recommended intervals ranging from every four
weeks to annually.
Q:
Is the surveillance culturing process recommended by CDC validated
such that it assures endoscopes that are surveillance cultured
cannot transmit infection?
CDC: CDC’s interim surveillance protocol represents one
possible approach to culturing
of duodenoscopes and has not yet been
validated, i.e., the sensitivity, specificity
and limits on quantitation or detection
are not established for all organisms. As
such, a negative culture result should not
completely exclude the possibility of a contaminated duodenoscope. In the event of
a suspected outbreak linked to duodenoscopes, negative surveillance cultures alone
should not be used to exclude duodenoscopes as a source of cross-contamination.
Q:
Who should perform
the processing,
culture, and
identification of resultant bacteria
from the samples collected?
James Davis: The CDC has provided an interim protocol to help
guide facilities. Validation of a culture method is possible; however, to
say that the validation of the culture
method will eliminate the risk of infection from
a fomite is improbable. One must consider false
results/negatives and an individual laboratorian’s performance of the task. Each facility
that will be performing screening will need
to design a system that validates their own lab
processes and performance.
Frank Myers: No, the CDC has
stated explicitly that the sensitivity of
this culturing method is not known,
meaning false negatives are a distinct
possibility. Unpublished reports have
stated that some scopes implicated epidemiologically in outbreaks have cultured negative using
this method.
Citation: www.cdc.gov/hai/settings/lab/lab-duodenoscopesampling.html
CDC: Samples should be
processed by personnel with
microbiological understanding
of culturing principles and identification of
common environmental and clinical bacteria.
Facilities should use discretion in determining
personnel best qualified and trained for these
activities. A multi-disciplinary team should be
brought together to decide the best approach for
the individual facility. The facility can consider
using an external laboratory for the laboratory
protocol (e.g., academic environmental microbiology laboratory associated with the hospital
or private contract laboratory, etc.) if necessary.
James Davis: Culturing methodology should not deviate from
the standards currently used by a
facility/industry. If a facility does
not conduct environmental or
fomite-based cultures, consider consultation
with an environmental hygienist or an experienced contractor. As for who should culture,
if facility-based, the laboratorians (culturing
is what they do). If non-facility, confirm the
contract stipulates the competency and training
the culturing staff receives.
Learn more at the
APIC 2015 Annual
Conference
Attend these scope and CRErelated sessions at APIC 2015,
June 27–29 in Nashville,
Tennessee.
• 3006—Preventing the Next
Hospital Outbreak of CarbapenemResistant Enterobacteriaceae (CRE).
• 3101—Swimming in Alphabet
Soup? KPC, CRE, IgG, IgM: A Can’t
Miss Opportunity to Review the
Latest in Microbiology!
• 2306—Reprocessing Endoscopes
in Ambulatory Care Settings: What,
When, Why, and Where?
• 2306—The Evidence behind New
Guidelines for Reprocessing Flexible
Endoscopes.
w w w.apic.org | 61
Q:
Do facilities need to quarantine the endoscopes until results are known? If
not, what should the recall process be for endoscopes that culture positive
but have already been used on a patient?
CDC: Facilities could consider holding duodenoscopes out of use while surveillance
culture results are pending, especially if surveillance cultures are performed after each
use. For facilities that choose to not quarantine duodenoscopes, and a high-concern
organism (as defined in CDC’s Interim Duodenoscope Surveillance Protocol) is detected through
surveillance cultures, the duodenoscope should be taken out of use until remedial actions are taken and
cultures no longer detect presence of the organism. The decision to notify exposed patients should be
made in consultation with appropriate facility staff, including infection prevention staff and hospital
epidemiologists, and public health authorities. Patient notification should generally target all patients
who underwent a procedure with the contaminated duodenoscope since the time of the last known
negative duodenoscope culture. Facilities should routinely document the specific endoscope used for
each patient to facilitate the identification of exposed patients in the event of a patient notification.
Q:
Significant caution must be
observed when performing
surveillance cultures to
prevent contamination. What type of
room or location should be used for
duodenoscope sampling?
CDC: Duodenoscopes should be
sampled on a clean surface away
from traffic, obvious airflow (e.g.,
vents), and potential contamination with
water. A sectioned-off area of a reprocessing
room or a separate room can be designated for
duodenoscope sampling.
Q:
Q:
Is there any work being done
with the manufacturers to
change the design of ERCP
endoscopes so that they can be adequately
cleaned and disinfected?
James Davis: I am unaware of any
design revisions being proposed.
However, a company may want to investigate such an option. A scope design
that would perform the same ERCP as
the traditional elevator channel type scope and has
been designed with reprocessing ease in mind, would
likely provide that company with a sales edge over the
competition.
What future standards regarding endoscope cleaning do you expect we will see?
James Davis: Healthcare is a hands-on
business, always relying on humans who
need to perform tasks in order for the system to function. ERCP scopes combined
with the CRE organism have shown a
potential weakness in high level disinfection/cleaning
methods. However, where there is weakness there are
opportunities for improvement.
1.Human factors/ergonomics: As is the case with
most instruments used by proceduralists, the
instrument is designed around the procedure. The
reprocessing of said equipment will vary in level
of difficulty as the complexity of the instrument
increases. The ERCP scope has been designed to do
a very specific job within the human body; it has
been designed to not only perform the procedure,
but aide the proceduralist in completing the tasks
related to the procedure. One may ask if the ERCP
scope design has prioritized reprocessing at the same
level as procedural performance. Industry may want
to look at future design and address all of the needs
62 | Summer 2015 | Prevention
of all of the users who come in contact with the
device. If industry does not answer the call, in my
opinion, there should be standards set forth that
ensure human factors and ergonomics are addressed
for each stage of the device’s use.
2.Certification/licensure of reprocessing/sterilization staff: Medical devices that are reprocessed
range in complexity from a simple pair of hemostats
to the ERCP-type duodenoscopes being discussed.
Each device type is processed in a certain way by a
certain method. Due to the complexity and exactness of the tasks reprocessing staff must perform,
several states have proposed bills that would make
certification or licensure a requirement. Currently,
I am unaware of a federal proposal for certifying or
licensure; however, the combination of ERCP and
CRE has proven to be a warning of what is possible. I would expect to see more state—and perhaps
federal—legislation introduced that would require
formal validation of competency that sets standards
for reprocessing staff.
Read more about
endoscopes in the
American Journal of
Infection Control
Aldehyde-resistant mycobacteria
bacteria associated with the use of
endoscope reprocessing systems,
Fisher, Christopher W. et al., American
Journal of Infection Control, Volume 40,
Issue 9, 880-882.
Establishing a clinically relevant bioburden benchmark: A quality indicator for adequate reprocessing and
storage of flexible gastrointestinal
endoscopes, Alfa, Michelle J. et al.,
American Journal of Infection Control,
Volume 40, Issue 3, 233-236.
An Outbreak of Carbapenemresistant Klebsiella pneumoniae Infections Associated
with Endoscopic Retrograde
Cholangiopancreatography (ERCP)
Procedures at a Hospital, Sanderson,
Roger et al., American Journal of Infection
Control, Volume 38, Issue 5, e141.
Validation of adenosine triphosphate
to audit manual cleaning of flexible
endoscope channels, Alfa, Michelle
J. et al., American Journal of Infection
Control, Volume 41, Issue 3, 245-248.
Early identification and control of
carbapenemase-producing Klebsiella
pneumoniae, originating from contaminated endoscopic equipment,
Alrabaa, Sally F. et al., American Journal
of Infection Control, Volume 41, Issue 6,
562-564.
Note from the editor: APIC thanks
Mary C. Virgallito, RN, MSN, CIC,
APIC Public Policy Committee
member, and Susan A. Dolan, RN,
MS, CIC, APIC president-elect and
senior advisor to APIC’s Public
Policy Committee, for developing
the questions for this article.
Additional CRE and scope resources
Visit APIC’s CRE webpage (www.apic.org/Resources/Topic-specific-infection-prevention/CRE) for resources and guidance from CDC and others on preventing
infections associated with duodenoscopes. Here is a small sampling of what you’ll find on this page:
Government resources
Centers for Disease Control and Prevention
resources
• Interim Duodenoscope Surveillance Protocol
• Interim Duodenoscope Sampling Method
• Interim Duodenoscope Culture Method
• Stop Infections from Lethal CRE Germs Now (Vital
Signs report)
• Guidance for control of Carbapenem-resistant
Enterobacteriaceae (CRE)
• Tracking CRE
• Management of multidrug-resistant organisms in
healthcare settings
• Laboratory protocol for detection of carbapenemresistant or carbapenemase-producing Klebsiella
spp. and E. coli from rectal swabs
U.S. Food and Drug Administration resources
• FDA releases final guidance on reprocessing of
reusable medical devices, issued 3/12/2015
741284_GOJO.indd 1
• Reprocessing Medical Devices in Health Care
Settings: Validation Methods and Labeling, issued
3/12/2015
• Safety communication, issued 2/19/2015
•Olympus validates new reprocessing instructions
for model TJF-Q180V duodenoscopes, issued
3/26/15 Agency for Healthcare Research and Quality
resources
• Carbapenem-resistant Enterobacteriaceae (CRE)
control and prevention toolkit
Other resources
• ECRI Institute recommends culturing duodenoscopes as a key step to reducing CRE infections—
ECRI Institute, March 3, 2015
• How to stop duodenoscope infections—American
Gastroenterological Association, March 23, 2015
•Superbug reveals challenges with high level disinfection—The Joint Commission Quick Safety
advisory, March 2015 APIC CRE reporting map
• Summary of state CRE reporting requirements—
APIC Government Affairs resource
APIC communications
resources
• Key talking points for infection preventionists to
ensure effective reprocessing of ERCP duodenoscopes to reduce the risk of infection
• The APIC and Society for Healthcare Epidemiology
of America (SHEA) press release
• ERCP procedures and duodenoscopes frequently
asked questions for consumers
w5/13/15
w w.apic.org
11:30 AM | 63
Measles
in the U.S.
Photo courtesy: CDC/Amanda Mills.
Discussions with public health representatives
64 | Summer 2015 | Prevention
LEFT: This image depicts a young boy who was receiving an injection in his right
lateral thigh muscle. This is known as an intramuscular injection, and in this case,
was delivering the requisite vaccination appropriate for his age group.
T
he United States declared measles eliminated in 2000. But less than 15 years later, U.S.
public health officials have seen cases of measles skyrocket, with a total of 23 measles
outbreaks in 2014 resulting in 668 measles cases reported from 27 states. The Centers for
Disease Control and Prevention (CDC) noted that this is the greatest number of measles cases since
measles elimination was documented nearly 15 years ago. The 2014 case count is in stark contrast
to the case count of 2013, when the U.S. reported only 58 measles cases.1
Public health officials are still grappling with increasing cases of measles in 2015. From
January 1 to May 29, 2015, 173 cases of measles have been reported from 21 states and the
District of Columbia—72 percent of these cases were linked to a large multistate outbreak
associated with an amusement park in California.1 The measles case count continues to grow.
Prevention Strategist had the opportunity to interview public health officials and departments
that have been contending with measles in their regions.
MEET THE panel
Demian
Christiansen,
DSc, MPH
Cook County
Department of Public Health
Dr. Christiansen is interim director of
Communicable Disease Control for the Cook
County Department of Public Health in Forest
Park, Illinois.
Chicago
Department of
Public Health
Tammy Sylvester, RN, BSN
Maricopa County Department
of Public Health
Sylvester is communicable disease nursing supervisor in the Office of
Epidemiology, Disease Control Division of the
Maricopa County Department of Public Health
in Phoenix, Arizona.
Q:
Measles was declared eliminated in the U.S. in
2000. Was that a premature declaration?
Chicago Department of Public Health: Endemic
transmission of measles in the U.S. ended in 2000.
However, since measles remains prevalent in other parts of the world
where MMR [measles, mumps, rubella] vaccine isn’t readily available,
imported cases still continue. We live in a global community, and many
places around the world lack access to the measles vaccine; therefore,
there is a continued risk of imported cases of vaccine-preventable illness.
Demian Christiansen, DSc, MPH: With the recent outbreak associated with a California theme park that has resulted
in at least 159 cases across 18 states, it certainly makes sense
to ask this question. This declaration meant that sustained
transmission ended in the United States, but we always expected to see
imported cases, which seems likely to have sparked the recent multistate outbreak. In fact, in the five years prior to our most recent daycare
outbreak this past February, travel history for all measles cases had
perfect positive predictive value. Unfortunately, this is no longer the case.
Tammy Sylvester, RN, BSN: Yes, the U.S. did achieve
measles eliminations in 2000. McLean defined measles elimination “as interruption of year-round endemic measles transmission.”2 From 2002 through 2007, measles cases in the U.S.
averaged 60 reported cases per year.1 Not until 2014 did the U.S. reach
an all-time high more than 600 reported cases.1
w w w.apic.org | 65
Q:
How has public health
played a role in recent
measles outbreaks?
Chicago Department of
Public Health: Public health
plays a major role in disease surveillance
and control. This includes provider education, contract tracing, and laboratory testing
of specimens. It is important for public health
departments to maintain a high level of communication with local healthcare providers to
ensure they have the resources necessary to
educate their patients on the importance of
vaccines, recognize and diagnose illnesses,
report infected individuals to public health,
and follow the proper post-exposure infection
control protocols.
Demian Christiansen, DSc,
MPH: Measles is one of the most
highly contagious diseases known,
and we are seeing what happens
when just a small number of people are not
vaccinated against this disease. To contain the
spread, each of us has a role, whether it is identifying cases and investigating them as quickly
as possible, identifying exposed individuals
and notifying them, educating parents of well
children to abide by recommended immunization schedules—all of these are required to
control outbreaks and prevent further spread.
It takes all of us, working in concert.
Tammy Sylvester, RN, BSN:
Measles is spread in communities that are missing herd immunity. Herd immunity is when groups
of people are vaccinated to protect the herd
from rapid disease spread. In the cases of
reported measles, “the majority of people
who got measles were unvaccinated.”1 In fact
“an unvaccinated child is 35 times more likely
to contract measles as compared to a vaccinated child.”3 Public health has issued multiple
campaigns about herd immunity, the impact of
disease, and the need to vaccinate on the local,
state, national, and international level. Much
work was done in every city to notify the public
and providers about the outbreak, as well as
to provide algorithms and contact information
for consultation on suspected cases. Public
health provided fliers for healthcare facilities
that warn of the outbreak and to tell individuals
with rash not to enter a healthcare facility or
waiting room. FAQs were issued to clinicians
to give information about the outbreak.
66 | Summer 2015 | Prevention
public health have taken a more active role in educating
Q:Sthehould
public about the importance of vaccines 10–15 years ago
when there was an increase in the anti-vaccine movement?
Chicago Department
of Public Health:
Public health has always promoted
vaccines as a means to prevent the
transmission of vaccine preventable
illness. Parents want to do what’s right
for their children; however, there have
been certain instances where misinformation influenced their decision not to
vaccinate. One of the best ways for the
public to increase its understanding of
the benefits and safety of vaccines is to
make sure healthcare providers have
the information they need to educate
their patients. Numerous studies have
shown that a healthcare provider recommendation for a vaccine increases
the likelihood of a patient accepting the
vaccine. Public health has and continues to partner with healthcare provider
organizations (e.g., American Academy
of Pediatrics, American Academy of
Family Physicians, American Nurses
Association) to make educational
opportunities and materials available
to their members. We know that the
MMR vaccine is safe and effective, so
public health officials are committed
to educating the public directly and
through healthcare providers about the
importance of vaccines and ensuring
that residents have the opportunity to
get the vaccines for themselves and
their children.
Demian Christiansen,
DSc, MPH: Public health
must lavish health education
and health literacy with the
same attention and resources it pays to
disease surveillance and control. We
can always do more to educate people
about the importance of vaccinations.
But we have an uphill climb. The stark
reduction in measles cases beginning
in the mid- to late-1960s was, in some
ways, a victim of its own success. In
our recent measles outbreak associated with a daycare, we had several
children with fever and rash illness
who were misdiagnosed. This is not to
lay blame at the feet of those healthcare
providers but rather to point out that
many had never seen a measles case—
because of the past measles vaccination successes. Without their patients
having had a clear link to the California
theme park or travel to an area with
ongoing measles transmission—coupled with a dearth of measles cases
in recent years in suburban Cook
County—it may indeed be difficult for
many healthcare providers to “Think
Measles.” We hope this is changing
now. Our own daycare-associated outbreak of measles along with the larger
multi-state outbreak should have been
a wake-up call.
Beyond that, however, public health
needs to change with changing times.
The Internet, in general, and social
media, in particular, have revolutionized the ways messages are created,
how they are packaged and delivered, and how they are consumed and
assimilated. Public health knows the
message is “Get Vaccinated!” We just
need to find the right way to deliver
that message. We have much to learn
from our marketing brethren! In some
cases, outraged parents delivered
the message their own way—taking
to social media and blogs, angry that
their children, some extremely ill,
may have been exposed to measles
because some chose not to vaccinate.
Many such exposures could have been
easily avoided.
Tammy Sylvester, RN,
BSN: Public health took an
active role in educating the
public about the importance
of vaccines. People were very afraid
of autism because of the false reports
by Andrew Wakefield stating an association between autism and MMR [vaccines]. This was a very difficult barrier
to overcome and not much more could
have been done at the time. Public
health, especially the CDC, worked very
hard to study the claims and were able
to show that no association between the
two existed.
Q:
What did the U.S. do correctly to eliminate measles in the
past and what can we use to do the same now?
Q:
What are the plans to
eradicate measles?
Chicago
Department of
Public Health: Measles remains
prevalent in many parts of the world.
In order to fully eradicate measles,
the vaccine needs to be made available in places where healthcare
systems are underdeveloped or do
not have the means to obtain the
vaccine. Current global efforts to
eradicate polio are nearing success,
and those same core public health
approaches can be applied to eliminating other vaccine-preventable illnesses like measles.
Demian Christiansen,
DSc, MPH: No doubt,
local and state health
departments along with
CDC will bring the multistate measles outbreak under control in short
order, if they haven’t already. But as
everyone knows, we live in an interconnected world. Truly, nothing in
recent memory has demonstrated
this more clearly than the Ebola
Virus Disease epidemic affecting
West Africa. As we have seen, any
disease can be on our doorstep in
a matter of hours. It simply isn’t possible to ignore what is going on elsewhere in the world. Several years
ago, the theme for World TB Day was,
“TB Anywhere is TB Everywhere.”
This certainly applies to measles and
countless other infectious diseases.
For measles to be eradicated, we
need to ensure it is eliminated here
in the U.S.—and everywhere else
around the world. Measles eradication will take a worldwide effort
and political and economic will not
dissimilar from those required to
eradicate smallpox.
Chicago Department
of Public Health: After
the first measles vaccine was licensed
in the 1960s, there was a dramatic
decrease in the number of cases. Prior
to that, there was a very high prevalence
of measles cases in the U.S. Furthermore,
once a second dose of vaccine was recommended in the 1980s, the number of
cases continued to drop even further to
the point that endemic transmission in
the U.S. ended in 2000.
Demian Christiansen, DSc,
MPH: Vaccinate, of course!
We have an excellent, safe, and
effective vaccine to prevent
measles. A single dose of measles vaccine,
usually given as MMR vaccine provides
93 percent protection against measles.
Getting the recommended two doses of
MMR brings that level of protection up to
97 percent. Vaccination against measles
results in lives saved and avoids permanent disability. In 2014, CDC estimated that
among children born during the past 20
years, vaccinations, including MMR vaccine, prevented 21 million hospitalizations
and prevented 732,000 deaths.4 That’s the
equivalent of preventing a child from being
hospitalized every 30 seconds. That’s an
amazing success story.
Q:
Should the MMR vaccine be mandated for children to
start school?
Chicago Department of Public Health: School vaccine requirements contributed to the high levels of vaccine coverage that have
been achieved among school-aged children. They are regulated at the state level
and as a result, vary from state to state. Some states allow individuals to opt out of
the required vaccines if they have a personal belief or religious belief that prohibits
receipt of the vaccine. In Illinois, the MMR vaccine is required for students who attend
daycare centers, preschools, elementary, middle, and high schools, and religious
and medical exemptions are allowed. The MMR vaccine is still required for most
individuals who attend daycare or school and do not have underlying medical conditions that would prevent them from receiving the vaccine. Because there is a small
percentage of individuals who cannot receive the vaccine, it is important for those
who can receive it to do so. This concept of community immunity helps protect those
who are more vulnerable to illness.
Demian Christiansen, DSc, MPH: MMR vaccine is mandated by all
states for children to start school. However, we know that there are gaps
when individuals, or groups of individuals, opt out for religious or philosophical reasons. There are several states looking to tighten requirements
for parents who seek exemptions. The Illinois General Assembly voted on such a bill.
Ultimately, though, everyone must understand that when it comes to vaccinations,
what each individual does affects the group—for better or for worse.
Tammy Sylvester, RN, BSN: It is. The problem is the ease to which
exemptions are facilitated. Some schools are passing rules to only allow
physical exemptions documented by the primary care provider. Others
are allowing religious exemptions if signed by a pastor and requiring
parent to go to corporate district office to pick up exemption forms. The thought is
that when it is more difficult to be exempt than to go get immunized, only the ones
that really need to be exempted will go through the work.
w w w.apic.org | 67
ost parents turn to the Internet for
Q:Mtheir
information. What can be done to
educate this population about the use
of credible websites?
Chicago Department of Public
Health: Healthcare providers and public
health professionals rely on evidence-based guidelines
to educate patients and families about healthcare-related
concerns. Although there are websites that do rely on science-based medicine, many others that are easily accessible do not use these same evidence-based guidelines.
The best thing parents can do if they have questions about
a certain healthcare issue is to contact their provider. Those
who do not have a provider should reach out to their local
public health department, many of which have vaccine
programs for those who are uninsured or underinsured.
Demian Christiansen, DSc, MPH: This
is crucial, and once again, this is an issue of
health education and health literacy, important themes in communicable disease control.
Credibility is key, but for a website to be useful, it must
be well-organized, quick, and it must make technical
information accessible to parents. At the end of the day,
we tend to listen to those we trust; healthcare providers,
especially nurses, have a vital role in providing credible
and trustworthy information to their patients. It starts with
educating ourselves first so we can direct our patients and
the public to the right resources.
Q:
How can infection preventionists assist in
the eradication of measles?
Chicago Department of Public Health: Public
health professionals work closely with infection
control practitioners in healthcare settings to report communicable diseases, identify individuals who were exposed to
infectious patients, and implement protocols that help prevent
transmission when patients with communicable diseases seek
and receive care. These efforts are ongoing to ensure that individuals who are ill receive the proper care, but also that others
in healthcare settings are protected as well.
Demian Christiansen, DSc, MPH: Infection preventionists are the closest partners we have in communicable disease control. Their everyday work is
geared toward preventing the spread of communicable
diseases, which is obviously a goal we share. Together, we work
every day to eradicate diseases. But we cannot do it alone. We
need to continue emphasizing vaccinations and being creative
in the messaging. Debunking myths about lack of vaccine safety
and educating the public with culturally sensitive and linguistically appropriate language is key. Tammy Sylvester, RN, BSN: Quick reporting of
suspect cases (e.g., phone calls to local public health),
protocols in place for rash illnesses, and continued
close working relationships with local public health. It
takes a team, and we all want the same thing: optimal community
and patient outcomes!
Note from the editor: APIC thanks Mary L. Fornek RN, BSN, MBA, CIC, head of Kenrof IC Consulting and Prevention Strategist editorial
panel member, for developing the questions for this article.
References
1. Centers for Disease Control and Prevention (2015). Measles Cases and Outbreaks. Accessed April 24, 2015. Retrieved from: www.cdc.gov/measles/cases-outbreaks.html.
2. McLean, H. (2012). Measles – United States, 2011. CDC Morbidity and Mortality Weekly Report 61(15), 253-257. Retrieved from: www.cdc.gov/mmwr/preview/mmwrhtml/mm6115a1.htm.
3. Vara, C. (2013) Explaining measles outbreaks despite high vaccination status. Shot of Prevention. Retrieved from: shotofprevention.com/2013/09/19/explaining-measles-outbreaks-despite-highvaccination-status.
4. Centers for Disease Control and Prevention (2014). Report shows 20-year US immunization program spares millions of children from diseases. Accessed April 10, 2015. Retrieved from: www.cdc.gov/media/
releases/2014/p0424-immunization-program.html.
Learn more at the APIC
2015 Annual Conference
Attend these measles-related sessions
at APIC 2015, June 27–29 in Nashville,
Tennessee.
• 3402—California Measles Outbreak:
Epidemiology and Public Health
Response, December 2014—April 2015.
• 021—Measles Emergency Response:
Lessons Learned from a Measles
Exposure in an 800-bed Facility.
68 | Summer 2015 | Prevention
Read more about measles
in the American Journal of
Infection Control
Measles in health-care settings, Maltezou, Helena C. et al., American Journal of
Infection Control, Volume 41, Issue 7, 661-663.
Measles investigation: A moving target, Helmecke, Megan R. et al., American
Journal of Infection Control, Volume 42, Issue 8, 911-915.
Impact of a Measles Exposure in an Emergency Department, O’Donnell, Anna
et al., American Journal of Infection Control, Volume 38, Issue 5, e41-e42.
Measles and pertussis outbreaks: An important role for travel clinics, Rapose,
Alwyn, American Journal of Infection Control, Volume 41, Issue 11, 1140.
Measles Outbreak Management at a Minnesota Children’s Hospital in 2011,
LeBlanc, Julie et al., American Journal of Infection Control, Volume 40, Issue 5, e67.
INDEX TO ADVERTISERS
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Clorox Healthcare.....................................................9
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Ivera Medical Corporation.......................................20
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Molnlycke Health Care............................................13
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PDI, Professional Disposables International.............4
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Sage Products, Inc..................................................34
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Virox Technologies Inc............................................14
www.virox.com
DISINFECTION APPLIANCE
Hygie Canada..........................................................18
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70 | Summer
2015 | Prevention
747796_Editorial.indd 1
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GOJO Industries......................................................63
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INFECTION CONTROL PRODUCTS
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Eloquest Healthcare................................................25
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Metrex....................................................................36
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Sanuvox Technologies Inc.......................................31
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INFECTION PREVENTION SOLUTION CONSULTING
Xenex Disinfection Services....................................32
www.xenex.com
LABORATORY SERVICES
Special Pathogens Laboratory................................54
www.specialpathogenslab.com
MEDICAL DEVICES & INSTRUMENTS
Eloquest Healthcare................................................25
www.ReliaFitDevice.com
Ivera Medical Corporation.......................................20
www.curos.com
Retractable Technologies, Inc.................................35
www.vanishpoint.com
NASAL SANITIZER
Global Life Technologies Corp..................................5
www.nozin.com
SKIN & WOUND CARE PRODUCTS
Eloquest Healthcare................................................25
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