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 + Requirement #2: www.rduvc.com We look forward to seeing you at APIC 2015. Please visit us at Booth 1140. Call 800.475.9040 or e-mail us at info.northamerica@getinge.com. GPO Contracts: Premier, Novation and MedAssets © 2015 Steriliz, Inc. Steriliz is a trademark of Steriliz, LLC. GSA Contract # GS-07F-193BA FSS Contract # V797P-4452b Approved for use in all Federal Government facilities. Getting patients home safe is a tough job. Now, Environmental Services has a powerful partner. PDI, a leader in infection prevention, provides a full suite of products, education and support designed specifically for Environmental Services professionals to help foster collaboration between departments and reduce HAIs. Together, we can get patients home where they belong. ©2015 Professional Disposables International, Inc. All rights reserved. Don’t miss the Delivering the Difference contest winner presentation at APIC Booth 514. Reduce S. aureus Nasal Carriage Without Antibiotics “Our nurses and patients really like the Nozin program and with the cost savings it’s been a true win-win.” -- Brian Kendler, Infection Preventionist, Marshall Medical Center, CA 3 Perioperative Care 3 Same Day Decolonization* 3 Universal ICU Carriage Reduction 3 Eliminate Screen and Isolate Nozin® Nasal Sanitizer® antiseptic combines ethanol with moisturizing emollients and is clinically proven to profoundly reduce nasal colonization in one day.* No antibiotics. No iodine. With a Nozin® program, you can help protect patients and staff against the spread of infection, improve quality of care and reduce infection control costs. Contact us to learn more and for professional samples. Nozin.com 877-669-4648 Think hand sanitizer for your nose.® *Steed L, et al. Reduction of nasal Staphylococcus aureus carriage. American Journal of Infection Control. Vol 42, Issue 8, 2014. ©2015 Global Life Technologies Corp. All rights reserved. Made in USA. Nozin® Nasal Sanitizer ® antiseptic is an OTC topical antiseptic drug and no claim is made that it has an effect on any disease. 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 TM with the Clorox Healthcare 4% CHG Skin Cleansing Kit. Provide patients with everything they need in one kit, and you’ve helped them enormously. And you’ve taken another important step in your SSI prevention strategy. 4 oz. 4% CHG Bottle: Evidenced-based literature shows 4% CHG bottles are equally effective for infection prevention as 2% CHG pre-saturated cloths – when patients receive standardized instructions.1 WAIT. A e yo Ar you co confi n den nfi ent you o r pa pati tien ents tss hav avee fo av follllllow ow wed d your yo ur pre ur reop oper op errat atiivve sk s in cle lean ansi an siing pro oto oco c ls ls?? *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 preoperative skin cleansing.2 Waterproof Instructions Card: Includes large text and visual icons, which studies show are effective for promoting understanding.3 Online Video Instructions: Easy to follow and drive correct product use. 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 ... e dg le e P infect h et Tak all tice ! prac ls ...to tion skil en v e s n r autio prec ion p ard s stand rm ctice ad of ge re to pra dge p the sp another. o I ple to st n lp o giene to he one pers nd hy ha ing from rform n by clea nds cording y ha c ep m giene a lp y to ke e dge g hand h cies to h le p I poli s. ormin act perf facility’s d of germ t cont y siden cility’s ter re to m e sprea fa e care and af ing to my th provid fore rd stop acco om or nds be A new long-term care (LTC) infection prevention skills tool titled “Take the Pledge” 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/ Topic-specific-infection-prevention/Long-term-care. pe y k, an by policies. ge m , mas ’s nds cle d chan gown m blood as a I will: ep my ha my facility y day an fro ) such t myself • Ke rding to thes ever iled. t (PPE ec acco an clo come so equipmen ed to prot cle r be e ne ea • W thes if they protectiv n when I ed. sick. tiz al is ni y. tio r clo be rson d sa ad otec our polic an an staff mem sily spre ear pe r eye pr • W es, and s and pe ea or ent cle id uipm resident s that can with the glov dy flu and eq a ts rm and bo rfaces r if I think k with ge siden elbow th re t’s ro my ha ocedures in my ep su rviso o are sic siden s or wi hing • Ke my supe clean in pr wh room e a re theter coug t ts ll te av I will ter certa : or no en le will Te g iva I sid pr • y ca zin ng ter es—I so I do le in ep re snee and af s, includi r and af h a urinar ids all tim gloves • Ke her peop te ie zes by es at polic fore I en ter I touc or body flu ask, and to ot germs. d snee practic ion. af an m d Be n d , of io e oo hs • an nt sam my coug s inject inject fore a gown any bl ll: amou r safe th every resident. evention e. • Be r I touch ter I wear body fluid ter, I wi ying the ve ev rm d wa te d pl • Co per sle I perfo needle wi only that fection pr ents, an nds • Af re and af blood, an soap and water, ap ring or up sure that fo to ha cove and n for tional in aff, resid • Be h germs, nds with , running ufacturer seconds ringe di lin pe ake st • M a new sy t’s insu ted on ad tions to of germs. an 20 touc sh my ha th clean the m r at least use e residen be star ecau spread d by nds wi n I wa ese pr e th the s to Whe et my ha mmende orously fo rs • Us ent need explain th prevent vig finge • W uct reco er d lp th sid ill an he w re l ter ,I prod nds toge e hands can If a l towe g wa tions they b ha of th th runnin sposable per towe er, I will: precau milies so ucate pa • Ru surfaces fa s wi an di sanitiz able d ed all their y hand using a cle e dispos ed hand d an te use th as s nse m a til rstan • Ri my hand ucet with alcohol-b e hand rs un y fa unde appropri s with palm of on • Dr off the d finge to nd an e s ha rn e g e d are s • Tu clean my uct to th y hand aff, s that ousand I ple about th od her st s of m er nI Th germ lp ot rs Whe ply the pr s togeth l surface with fections. -resistant will he othe biotics. ions in iotic • Ap my hand t over al e and infect e. b those e antib uc anti rious to treat es f hygien nd hygien • Ru the prod dry th se o t nd of d b ha ha e ne le ge sult • Ru hands ar ck on my tice good peop tics desig direct re of ac ba io a my ns ’ viral e feed milies pr Millio nt to antib ch year as , not dents com fa ta ctions I wel nts, and resis die ea e resi ent l infe fine. ople cteria reside feels ea and m ep th of pe ns. at ba io person ng naus sistant to ke nd equip read of r. infect that: work to tre . en a di e dge a ly inclu flu ed wh iotic-re rstand I ple onment op the sp to anoth unde tibiotics on a cold or not need e effects, and antib escribe rms I ge pr e , st ng with • An ctions lik generally rm and sid fections properly r a lo ated envir to help e person fo in e in s fe to t ha ar in e s as ntam surface ecting n n rtant ibers ns, ye n caus tibiotic be co impo clea s from o prescr may can live on and disinf proper • An iotics ca ic reactio that it is ean rg tib s with ning tand the en I use ok cl e germs germ • An rhea, alle derstand . tibiotic Clea at lo m rs wh eded I un to an diar ces th hands. So hers sick. s. I unde dations fected: ly ne ives ions. tics. surfa is tru my infect e antibio s alternat mmen e germ and ot d disin I know n get on tibiotic e me ove thes rers’ reco clean an e soil d us to discus an bl ak ca an si an m t m n re en e vi that ay k if actu and ca ne to help e manuf environm remov It’s ok sidents. ents to as to • t time th ent’s llow be do pmen and re for resid s must and will fo the resid d equi s okay ep s ll germ ces an sident. • It’ to ke step t to ki a re icals n surfa pmen chem ill clea using it on s d equi r 1: I w rface ces an nt. Step and afte ing su t surfa a reside re clean ec at nf befo th ill disi using it on ilies r fam of germs. r 2: I w ed: Step and afte d thei ad re Sign nts an the spre befo t reside n to lps preven : explai he d in g Date d re I will uipment ahe y eq b d an g e’s logo lezadtion . pni ega thor lo g o iz e ur to mdd yo y ’s C u s Ar fa c il it u o y in 20 | Summer 2015 1| Prevention 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. THE NEXT GENERATION EXTERNAL CATHETER CHANGING THE LANDSCAPE ReliaFit reduces the risk of CAUTIs associated with indwelling catheters1 • Noninvasive design1 ReliaFit offers a superior alternative to condom catheters • Unique design for superior leak prevention2 • Protects sensitive skin1 • One size fits all1 Contact your sales consultant, call 877.433.7626, or visit ReliaFitDevice.com to learn more about ReliaFit References: 1. Urinary Output Monitoring and Management in Accute Care: Clinical Pathway for CMS 1533 Compliance and Positive Economic Impact of Compliance (white paper). http://mensliberty.com/health-professionals-reduce-uti-withmens-liberty/. Accessed May 16, 2013. 2. Lucas LM, Iseler J, Gale L. Evaluation of a new, novel male external urinary management device. Poster presented at: Cleveland Clinic’s Spring 2013 WOC Nursing Symposium; April 12, 2013; Cleveland, OH. 529 th #1 o o B Visit PIC 2015 at A n More! ar to Le ReliaFit® is a trademark of Ferndale IP, Inc. ©2013 Eloquest Healthcare®, Inc 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! Infection 10 Control Sink 'HVLJQHGVSHFLÀFDOO\ ' tto minimize splashing and reduce the spread of infectious disease. o ADA Compliant Offset drain position keeps water from splashing directly into drain and aerosolizing contents of the trap. Oversized backsplash has coved edges and helps to keep water FRQWDLQHGDQGÁRZLQJ toward drain. Sloped rear basin wall minimizes splashing of water stream and FUHDWHVFLUFXLWRXVÁRZ to drain. Aquasurf® solid surface color options: Sandstone Bone Red Coral Black Granite White Granite Grey Granite Glacier White Nocturnal Blue Sea Green Now we're even easier to specify! 800.428.4065 |ZZZZLOORXJKE\LQGFRP 30 | Summer 2015 746794_Willoughby.indd 1 | Prevention © 2015 Willoughby Industries Inc. » ,QIRUPDWLRQVKHHWDQG5(9,7ÀOHVDUHDYDLODEOHDWZLOORXJKE\LQGFRP 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. 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Our mission at Xenex is to eliminate the pathogens that cause infections affecting the health and lives of millions of patients and their families by providing the only Full Peer reviewed patient outcomes: 53% reduction in C. diff infection rates.1 57% reduction in MRSA infection rates.2 100% elimination of VRE in isolation rooms.3 SpectrumTM Pulsed Xenon UV Disinfection Robot. 1. Levin J, et al., Cooley Dickinson in AJIC 2013, 41:746-748. 2. Simmons S, et al., Cone Health System in JIP 2013. 3. Stibich M, et al., M.D. Anderson Cancer Center in ICHE 2011, 32:286-288. xenex.com | 888 340 7832 | @XenexDisinfect 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 741111_Sage.indd 1 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 SANITIZE | SEPARATE | SUBSTITUTE | SWAB Introducing a Comprehensive Approach to Environmental Cleaning Environmental cleaning programs are routinely compromised by a variety of issues. From a lack of monitoring to microfiber damaged by improper laundering, these problems can contribute to the spread of infection. Which puts patients at greater risk. That’s why we developed our MicroVantage 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 clean with confidence. Take a closer look at APIC’s Annual Conference, Exhibit 630. Aramark’s wash formulation meets EPA requirements for laundry sanitizing and provides a 99.9% reduction of the following organisms during the wash cycle: Pseudomonas aeruginosa, Klebsiella pneumoniae, Staphylococcus aureus and Methicillin-resistant Staphylococcus aureus (MRSA). Sanitized products are only provided to customers of Aramark who require and request their products be processed as containing bloodborne pathogens. 1 © 2015 Aramark. All rights reserved 800-ARAMARK (272-6275) 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 PREVENTING LEGIONNAIRES’ DISEASE TAKES A TEAM. JOIN THE LEGIONELLA EXPERTS® t Legionella and waterborne pathogens testing t Water safety plans t Risk assessments and outbreak response t Construction and design review t Training and seminars VISIT 37 H 10 T O O B Accredited and CDC-ELITE certified for Legionella testing. 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 BEDPAN WASHER MEIKO............................................ 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