SPRING 2018 â€˘ VOLUME 11 NUMBER 1
New Insights Unintended effects: Sepsis protocol and healthcare facility-onset Clostridium difficile infection Creating a dream team: How frontline collaboration reduced healthcare-associated infections APIC 2018 sneak peek
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Unintended effects: Sepsis protocol and healthcare facilityonset Clostridium difficile infection By Robert Hiensch
Creating a dream team: How frontline collaboration reduced healthcare-associated infections By Claudia Skinner, Lilian Ablir, Todd Bloom, Stacie Lomibao, and Regina Sy-Santos
4 | SPRING 2018 | Prevention
VOICE Take a fresh look
New initiatives and 2017 scorecard
By Janet Haas, 2018 APIC President By Katrina Crist, APIC CEO
Choices, chances, changes
By Joann Andrews, 2018 CBIC President
DEPARTMENTS Briefs to keep you in-the-know • Meet the 2018 APIC Board of Directors • AHRQ toolkit helps reduce SSIs • APIC founding member recognized as distinguished alumna • PGC Practice Corner
APIC Consultant Corner: Conducting customized training
Capitol Comments: The APIC advocacy triad and the role of a CLR
Infection Prevention Leadership
Q&A with James Marx
By Rich Capparell, Nancy Hailpern, and Lisa Tomlinson A conversation with Sharon Parrillo
PREVENTION IN ACTION My Bugaboo: Hepatitis A outbreak!
From data to decisions: Measures of validity
Focus on long-term care and behavioral health outbreaks: Identify the pathogen!
Vanderbilt receives inaugural APIC Program of Distinction award
The Proficient Practitioner Bridge: A new self-assessment in professional development for IPs
Making the business case: Useful financial analysis tools
APIC 2018 sneak peek: Conversations with plenary speakers Alicia Cole and Jessica Green, PhD
By Irena Kenneley
By Daniel Bronson-Lowe and Christina Bronson-Lowe
By Steven Schweon
By Melanie Padgett Powers
By Corrianne Billings By William Ward, Jr.
By Rickey Elaine Dana
50 w w w.apic.org | 5
Take a fresh look
BY JANET HAAS, PhD, RN, CIC, FSHEA, FAPIC, 2018 APIC PRESIDENT
“A great thing about being an APIC member is the network of colleagues who are striving to make a safer world through prevention of infection— like you!”
SPRING IS HERE, inspiring us with nature’s renewal. Thus, it’s fitting that
this issue of Prevention Strategist is focused on the theme of new insights. In a brilliant example of taking a fresh look at a problem, college student Samir Lakhani saw mothers in Cambodia washing infants with laundry soap, while leftover soap from hotels was being discarded. His “Aha!” moment led to an initiative that reclaims, disinfects, and recycles soap; this project provides jobs for 35 local women, while distributing soap and hygiene education to children and rural villagers.1 New insights don’t come from repeatedly doing the same things the same way. The trick is to figure out how to get a fresh perspective. Here are some ideas: • Find new insight about a challenging situation. Often our colleagues providing direct care have a different perspective on infection prevention than we do. In my facility, we instituted weekly root-cause analysis rounds, where we go to each unit to which healthcare-associated infections (HAIs) were attributed. Caregivers discuss the challenges to preventing infections in each situation, then we brainstorm solutions together and make changes based on the care team’s suggestions. In weeks with no HAIs, we bring “Confections for No Infections” to each unit. Sharing the good news with our teams reinforces the great work they are doing. No one tires of being praised for preventing infections—and who doesn’t like chocolate kisses? • Phone a friend! A great thing about being an APIC member is the network of colleagues who are striving to make a safer world through prevention of infection—like you! Reach out to your colleagues through your local chapter, via the APIC Listserv, or by emailing someone whose work you have seen. We work better when we work together, and APIC members are, in my experience, very willing to give advice and share ideas when asked. • Expand your horizons—do something new. Maybe you could learn about new diagnostics or be an observer in the operating room (OR). Many of our roles now include project management and change leadership, so learning about those skills may be helpful to you. My goal for this spring is to meet the environmental services workers who clean the ORs at night. I want to see what they do and why, and thank them for doing this crucial work. We all have something on our “to do” list that we just have not gotten to—why not do it now? • Find some ways to make your day better. Spring is a great time to get outside—have a picnic lunch, add some outside components to your exercise regime, or just take a walk in the park. Research in human factors shows that we are more effective when we give ourselves a chance to renew our energy and have balance in our lives.2 In other words, working through lunch and staying late every day is not doing anyone a favor. So take time to enjoy the daffodils; it may make you a better infection preventionist!
Janet Haas, PhD, RN, CIC, FSHEA, FAPIC References 1. Marusic K. Meet the 23-year-old who’s saving lives with bars of used hotel soap. MTV News. November 2015. http://www.mtv.com/news/2371839/eco-soap-bank-samir-lakhani/. Accessed November 2017. 2. Schwartz T, McCarthy C. Manage your energy, not your time. Harvard Business Review. October 2007. https://hbr.org/2007/10/manage-your-energy-not-your-time. Accessed November 2017.
6 | SPRING 2018 | Prevention
Prevention SSPPRRIIN NG G 22017 018 •• VO VOLLUUM MEE 10 11, IISSSSU UEE 11
BOARD OF DIRECTORS President Janet Haas, PhD, RN, CIC, FSHEA, FAPIC President-Elect Karen Hoffmann, RN, MS, CIC, FSHEA, FAPIC Treasurer Sharon Williamson, MT(ASCP)SM, CIC, FAPIC Secretary Ann Marie Pettis, RN, BSN, CIC, FAPIC Immediate Past President Linda Greene, RN, MPS, CIC, FAPIC
DIRECTORS Dale Bratzler, DO, MPH, MACOI, FIDSA Tania Bubb, PhD, RN, CIC, FAPIC Thomas Button, RN, BSN, NE-BC, CIC, FAPIC Linda Dickey, RN, MPH, CIC, FAPIC Beth Duffy, MBA Annemarie Flood, RN, BSN, MPH, CIC, FAPIC Pat Metcalf Jackson, RN, MA, CIC, FAPIC Irena Kenneley, PhD, RN, CNE, CIC, FAPIC Lela Luper, RN, BS, CIC, FAPIC Carol McLay, DrPH, MPH, RN, CIC, FAPIC Barbara Smith, RN, BSN, MPA, CIC, FAPIC
EX OFFICIO Katrina Crist, MBA, CAE
DISCLAIMER Prevention Strategist is published by the Association for Professionals in Infection Control and Epidemiology, Inc. (“APIC”). All rights reserved. Reproduction, transmission, distribution, or copying in whole or in part of the contents without express written permission of APIC is prohibited. For reprint and other requests, please email email@example.com. APIC makes no representations about the accuracy, reliability, completeness, or timeliness of the material or about the results to be obtained from using this publication. You use the material at your own risk. APIC assumes no responsibility for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. Although all advertising material is expected to conform to ethical (medical) standards, inclusion in this publication does not constitute a guarantee or endorsement of the quality or value of such product or of the claims made of it by its manufacturer.
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New initiatives and 2017 scorecard
BY KATRINA CRIST, MBA, CAE, APIC CEO
THE FIVE STRATEGIC priorities in APIC’s Strategic Plan 2020—patient
safety, implementation science, competencies and certification, advocacy, and data standardization—are an important measure of APIC’s success. The 2017 scorecard provides a snapshot of key metrics. We are making great progress, with a high probability of meeting, or exceeding, 10 out of 12 targets by 2020. In 2018, APIC will also focus on the following new initiatives: • Map the desired future of the infection preventionist (IP) – a consensus conference will be held in the fall, leading to a published paper. • Redefine the IP role in antibiotic stewardship programs. • Publish a joint paper with the Society for Healthcare Epidemiology of America (SHEA) and the Society for Infectious Diseases Pharmacists (SIDP) that highlights the synergy between antimicrobial stewardship and infection prevention. • Advocate for state legislatures to require certification in infection prevention. • Launch a member communications campaign on the advocacy efforts for certification in infection prevention to be required by regulators. • Field a survey to C-Suite/healthcare executives on perceptions of the IP role. • Conduct market research on long-term care, outpatient clinics, and critical access hospital settings. • Launch a joint APIC/SHEA leadership development program. 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, as well as an executive summary of strategy and programs.
2017 Cumulative Total
Change from Last Year
1,000,000 consumer interactions
60 organizational communications
100 courses and published resources*
1,000 advanced practice designation
450 participants in research training
3,000 subscribers to advocacy update
5,000 clicks on regulatory resources
3,000 clicks on public policy agenda
40 organizations supporting NHSN
3,700 members take action*
*Noncumulative n/a = Initiative topped out Green = High probability of achieving 2020 target Red = Low probability of achieving 2020 target
8 | SPRING 2018 | Prevention
Prevention S P R I N G 2 018 • VO L U M E 11 I S S U E 1
PUBLISHER Katrina Crist, MBA, CAE firstname.lastname@example.org MANAGING EDITOR Rickey Dana email@example.com CONTRIBUTING EDITORS Julie Blechman, MPH, CHES Elizabeth Garman Elizabeth Nishiura PROJECT MANAGER Russell Underwood firstname.lastname@example.org ADVERTISING Brian Agnes email@example.com GRAPHIC DESIGN Dan Proudley
EDITORIAL PANEL Timothy Bowers, MS, CIC, CPHQ, FAPIC Gary Carter, MPH, CIC, CIH, REHS, DAAS Kristine Chafin, MBA, RN, CIC Edina Fredell, MPH, CIC, MT(ASCP) Ruth Freshman, BSN, RN, CIC Kathryn Galvin, MS, MLS(ASCP)CM, CIC Meagan Garibay, RN, BSN, CIC Jessica Hayashi, MS, RN, CIC, CPHQ, FACHE Adrienne Pinto, MSN, RN, CIC Alexander Sundermann, MPH, CIC Christine Young-Ruckriegel, RN, MSN, MPA, CIC
CONTRIBUTING WRITERS Doug Allen Julie Blechman, MPH, CHES Darlene Carey,MSN, RN, NE-BC, CIC, FAPIC Elizabeth Garman Silvia Quevedo, CAE
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 MARCH 2018 • API-Q0118 • 4822
Antimicrobial. Pro-patient. As your trusted partner in protecting patients, we share your goal of sustaining zero bloodstream infections. And we want to do everything in our power to help you achieve it. Visit 3M.com/IVProtectPS for free educational resources and evidence-based products to help you stop bloodstream infections before they start.
©3M 2018. All rights reserved. 3M and “3M Science. Applied to Life.”, are trademarks of 3M Company.
Choices, chances, changes AS WINTER ENDS and spring begins, David Bowie’s iconic “ch-ch-changes” chorus comes to mind.
BY JOANN ANDREWS, DNP, RN, CIC, 2018 CBIC PRESIDENT
“CBIC is celebrating the 35th anniversary of the CIC in 2018. We would like to celebrate this achievement with you all year long.”
Can you hear it? Yes, I am a child of rock and roll, but it’s also quite natural to think of new changes and new beginnings in the springtime. You probably have challenges and changes ahead of you this year, both at home and in your professional life. And speaking of change, the Certification Board of Infection Control and Epidemiology (CBIC®) continues to seek out new opportunities for growth and improvement. In 2018, CBIC is entirely rebuilding our website to provide better service for our certificants and candidates. CBIC listens! We have used your feedback and are looking at ways to improve navigation through the website. The application process will be simplified, and we will provide you all the information needed to achieve certification. We hope to roll out the new website later in the year and will be looking for feedback when it is released. Another exciting change is already in place. As of January 1, CBIC is including a free practice exam with every purchase of the initial certification in infection control (CIC®) exam. In a 2017 study, 51 percent of participants expressed that practice exams were the most helpful resource when studying for the initial certification examination (CIC Funding Assessment Findings conducted by the National Association of County and City Health Officials). This offer will be running until June 30, 2018. Please share this information at your chapter meetings and in your newsletters so that colleagues can take advantage of this opportunity while it lasts. I am also thrilled to mention that CBIC is preparing a study to address the value of certification for patients, facilities, and individual infection preventionists. The goal is to provide quantitative results to leadership and decision makers, and to ultimately build a business case for certification. Stay tuned for further details! Have you set your sights on taking the CIC exam? I encourage you to accept my challenge to become certified this year. There are many different ways to receive help and support in your quest for certification. The CBIC website is the first stop; then check out our social media campaigns on Facebook. Our partners, APIC and IPAC Canada, provide excellent education and resources to round out your skills and can often provide financial assistance. Whether you are sitting for the initial CIC exam or the online recertification exam, “Start Early, Finish Early” should be your motto. We look forward to celebrating your success with you! Speaking of celebrating...I’m happy to announce that CBIC is celebrating the 35th anniversary of the CIC in 2018. We would like to celebrate this achievement with you all year long. CBIC has an active social media platform and further details about the 35th anniversary celebration will be posted regularly. I want to thank everyone who has held the CIC designation over the years, and I applaud your accomplishments. If you’re not yet certified, I challenge you to make this the year you stretch yourself and take that next step. I am so excited to serve as your 2018 CBIC president. I look forward to meeting you in person at conferences and electronically meeting you in other venues. Remember, in our lives we all have choices, chances, and changes. You must make a choice to take a chance, or your life will never change. The best to you –
Joann Andrews, DNP, RN, CIC
10 | SPRING 2018 | Prevention
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BRIEFS TO KEEP YOU IN-THE-KNOW
Meet the 2018 APIC Board of Directors APIC IS GOVERNED by an elected board of directors composed of four
officers, the immediate past president, and nine to 12 directors. The executive committee includes the president, who serves as chair, the president-elect, the immediate past president, the treasurer, the secretary, and one at-large board member. The chief executive officer serves as a nonvoting, ex officio member of the board of directors and the executive committee.
• The board is responsible for positioning the association to best serve APIC members, as well as maintaining the focus and vision to improve the practice and management of infection prevention. • The board establishes policy; directs the activities of the elected officials, committees, and chief executive officer; oversees APIC’s finances; and charters chapters.
Janet Haas, PhD, RN, CIC, FSHEA, FAPIC
Karen Hoffmann, RN, MS, CIC, FSHEA, FAPIC
Director of Epidemiology Lenox Hill Hospital New York, New York Dr. Haas is the director of epidemiology at Lenox Hill Hospital in New York, New York. She previously served as director of Infection Prevention and Control at Westchester Medical Center and as an assistant professor of medicine at New York Medical College. Dr. Haas has served as the chair of the APIC Professional Development Committee, as a member of the APIC Research Committee, and as a member of the New York State Department of Health Healthcare-Associated Infections Technical Advisory Work Group. She authored the Hand Hygiene chapter of the APIC Text, as well as several peer-reviewed publications in the field of infection prevention and control. Dr. Haas also serves as an associate editor of the American Journal of Infection Control. Her research interests include hand hygiene, environmental disinfection, and infection prevention informatics. Dr. Haas earned her Bachelor of Science in nursing from the Sage College of Albany, New York; Master of Science in epidemiology from the University at Albany; and doctorate in nursing from Columbia University. She has been certified in infection prevention and control (CIC®) since 1999.
Infection Prevention Consultant, Centers for Medicare & Medicaid Services Clinical Instructor, University of North Carolina School of Medicine Chapel Hill, North Carolina Karen Hoffman is an infection prevention consultant in the Survey and Certification Group for the Centers for Medicare & Medicaid Services. Ms. Hoffman has been a clinical instructor in the Division of Infectious Diseases at the University of North Carolina’s School of Medicine in Chapel Hill since 1988. She has specialized in infection prevention and control for more than 30 years, beginning at Detroit Medical Center, then at the University of Virginia hospitals. Prior to joining the Centers for Medicare & Medicaid Services, Karen spent 23 years as the associate director for the North Carolina Statewide Program for Infection Control and Epidemiology (SPICE).
12 | SPRING 2018 | Prevention
IMMEDIATE PAST PRESIDENT
Sharon Williamson, MT(ASCP)SM, CIC, FAPIC Infection Prevention Director Texas Health Resources Arlington, Texas
Ann Marie Pettis, RN, BSN, CIC, FAPIC Director of Infection Prevention University of Rochester Medical Center Rochester, New York
Linda Greene, RN, MPS, CIC, FAPIC Manager of Infection Prevention University of Rochester Highland Hospital Rochester, New York
Tania Bubb, PhD, RN, CIC, FAPIC Director of Infection Prevention Mount Sinai Hospital New York, New York
Thomas Button, RN, BSN, NE-BC, CIC, FAPIC Director of Infection Prevention and Control Children’s Mercy Hospital Kansas City, Missouri
Linda Dickey, RN, MPH, CIC, FAPIC Senior Director of Quality, Patient Safety and Infection Prevention University of California Irvine Health Orange, California
Annemarie Flood, RN, BSN, MPH, CIC, FAPIC Manager of Infection Prevention City of Hope Duarte, California
Pat Metcalf Jackson, RN, MA, CIC, FAPIC Director of Infection Prevention and Control Children’s Medical Center Dallas, Texas
Irena Kenneley, PhD, RN, CNE, CIC, FAPIC Associate Professor Frances Payne Bolton School of Nursing, Case Western Reserve University Cleveland, Ohio
w w w.apic.org | 13
BRIEFS TO KEEP YOU IN-THE-KNOW DIRECTORS continued
Lela Luper, RN, BS, CIC, FAPIC Infection Control Manager Chickasaw Nation Department of Health Ada, Oklahoma
Carol McLay, DrPH, MPH, RN, CIC, FAPIC Chief Executive Officer Infection Control International Louisville, Kentucky
Dale Bratzler, DO, MPH, MACOI, FIDSA Edith Kinney Gaylord Presidential Professor, University of Oklahoma Colleges of Medicine and Public Health
Barbara Smith, RN, BSN, MPA, CIC, FAPIC Nurse Epidemiologist Mount Sinai St. Luke’s/Mount Sinai West Hospitals New York, New York
Beth Duffy, MBA Chief Operating Officer Einstein Medical Center Montgomery East Norriton, Pennsylvania
Katrina Crist, MBA, CAE Chief Executive Officer, APIC Serves as a nonvoting member of the board.
Chief Quality Officer, OU Physicians Oklahoma City, Oklahoma
AHRQ toolkit helps reduce SSIs THE AGENCY FOR HEALTHCARE RESEARCH AND QUALITY (AHRQ) new Toolkit to Promote Safe Surgery helps
hospitals reduce surgical site infections (SSIs). Based on the experiences of frontline providers in approximately 200 hospitals that participated in a national implementation project and successfully reduced SSIs, the toolkit was adapted from AHRQ’s Comprehensive Unit-based Safety Program (CUSP) for the surgical setting. These strategies can help prevent infections that may occur with surgical procedures including colorectal surgeries and hysterectomies, two areas tracked by the Centers for Medicare & Medicaid Services. Visit www.ahrq.gov/haisurgery to download the toolkit. 14 | SPRING 2018 | Prevention
APIC founding member recognized as distinguished alumna ELIZABETH “BETSY” BACHHUBER SIMONS, RN, has
been recognized as a distinguished alumna of Marquette University. She will be honored in April by Marquette’s College of Nursing with the Distinguished Alumna of the Year Award. Betsy is one of APIC’s founding members and received the Carole DeMille Award, APIC’s most distinguished award, in 1985.
BRIEFS TO KEEP YOU IN-THE-KNOW
PGC Practice Corner
THE APIC PRACTICE GUIDANCE COMMITTEE (PGC), as part of its charge, routinely reviews and comments on guidelines, standards, and draft docu-
ments that relate to infection prevention. The PGC Practice Corner is intended to update members on relevant issues.
Expert guidance for the discontinuance of contact precautions In light of the need for discontinuation criteria for contact precautions (CP) as an infection prevention strategy, the Society for Healthcare Epidemiology of America (SHEA) has created expert guidance (EG) to address when and under what circumstances acute care hospitals may discontinue CP for individual patients. The SHEA Expert Guidance: Duration of Contact Precautions for Acute Care Settings is designed to assist qualified professionals in determining the appropriate duration of CP and potential practice changes to consider for the infection prevention program. Focusing on methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), multidrugresistant Enterobacteriaceae (MDR-E), and Clostridium difficile infection (CDI), the SHEA document provides recommendations addressing the duration of CP, along with pertinent rationales. The EG assists infection prevention professionals in reviewing current practices and helps them navigate through potential practice changes within healthcare institutions. The recommendations are listed here, and the full document can be accessed via http://www.shea-online.org/index.php/practice-resources.
Overall Recommendations for MRSA and VRE: 1. Establish a policy for discontinuation of CP. 2. Obtain negative screening cultures to guide decisions about discontinuation of CP. 3. Extend CP for certain populations from last positive culture, prior to assessing for CP discontinuation. 4. Consider the alternative approach of not using CP, if facility endemic rates of MRSA and VRE infections are low. Overall Recommendations for MDR-E: 1. Establish a policy for discontinuation of CP. 2. Maintain CP for MDR-E for the duration of the index hospital stay after initial detection. 3. Consider discontinuation of CP on a case-by-case basis (criteria-based). 4. Maintain CP indefinitely for extensive drug-resistant Enterobacteriaceae. Overall Recommendations for CDI: 1. Maintain CP for at least 48 hours after diarrhea resolution. 2. Extend CP through the duration of hospitalization for elevated rates of CDI. 3. There is insufficient evidence for CP use when patient is readmitted to the hospital.
w13/02/18 w w.apic.org 11:04 PM | 15
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APIC CONSULTANT CORNER
Conducting customized training Q&A WITH JAMES MARX, PhD, RN, CIC, FAPIC
DR. JAMES MARX is an infection preventionist consultant working with small and large
skilled nursing facilities, as well as community and large-system acute care hospitals. He is a coauthor of several APIC implementation guides (C. difficile; MRSA in California; and Hand Hygiene), as well as an APIC surveillance paper. Dr. Marx is also certified as a registered nurse executive.
hat type of customized W training have you done on behalf of an individual facility or health system?
A: “Good training programs begin with an honest selfassessment of the individual IP’s skills and knowledge, as well as an assessment of the facility program.”
I have worked with large national health systems, smaller regional systems, and privately owned facilities. The most common training request is facility assessment training within a larger system. Often these facilities are the best performers in the system, and their practices can be shared with others. I have also developed and delivered standardized infection prevention and control (IPC) program site-lead training and education.
What work was completed for the facility/health system prior to the training?
Infection preventionist (IP) professional development is often requested, and I like participants to do a self-assessment using the APIC Roadmap for the Novice IP with the goal of achieving certification in infection prevention and control (CIC®). For those IPs who are certified, I encourage further formal education such as a bachelor’s or master’s degree. I also encourage certified IPs to publish their work. Begin with something small, like an abstract at a national or regional meeting.
Finally, for those who are already certified and proficient, I encourage IPs to look at the criteria for the APIC Fellow program.
hat has been the focus or W emphasis of such trainings, and who are the audience members?
Good training programs begin with an honest self-assessment of the individual IP’s skills and knowledge, as well as an assessment of the facility program. I have used the tools provided by APIC and the Centers for Disease Control and Prevention (CDC) to do these assessments. They allow the participant to come to the training prepared to address areas of improvement. In addition to IPs, I have had quality professionals, nursing directors, educators, surveyors, and administrators attend the training.
Which facilities or systems would benefit most from this type of work?
Hospitals and nursing homes with 5 to 15 facilities are easier to assess and coordinate change. The logistics and costs of training typically work best for this size group. Larger systems usually require more people to participate, which may slow down decision-making. In addition, group w w w.apic.org | 17
APIC CONSULTANT CORNER “Certification is one of the most recognized methods to demonstrate competency. Be sure to evaluate the credibility of the certifying organization.”
training may be more cumbersome to coordinate. For smaller systems, the IP may need to travel to training offered by APIC or regional collaboratives.
What makes nursing home infection prevention different?
First, it involves a resident population with multiple comorbidities. Nursing home IPs will need to complete an infection risk assessment of their resident and staff population. Second, healthcare is delivered in a social setting, where residents and staff are encouraged to interact with each other. This can promote the transmission of infections such as scabies, norovirus, and influenza. And third, a nursing home resident depends on caregivers to provide help with bathing, dressing, eating, ambulating, and going to the bathroom. The majority of direct care is delivered by nurse’s aides rather than by licensed nurses. In addition, staff turnover is a problem. In 2012, the median turnover rate for all nursing home staff was 43.9 percent. RNs had a median turnover rate of 50 percent. Nursing assistants had the largest median turnover at 51.5 percent, and LPNs/LVNs had the lowest at 36.4 percent. High turnover requires more frequent retraining and supervision.
Should nursing home IPs get CIC certification?
Yes! Certification is one of the most recognized methods to demonstrate competency. Be sure to evaluate the credibility of the certifying organization. For example, the Certification Board of Infection Control (CBIC) is accredited by the National Commission for Certifying Agencies (NCCA). NCCA provides an impartial, third-party validation that recognizes national and international credentialing industry standards for development, implementation, and maintenance of certification programs.
What kind of training does CMS require of nursing home IPs?
The Centers for Medicare & Medicaid Services (CMS) did not specify the type of training required in the Mega-Rule. New IPs should evaluate the quality of the education being provided based on the topics covered, and the credentials of those who develop and provide the training. Look for someone who has a CIC credential and experience in long-term care (LTC).
What is in the future?
It is likely that CMS will require nursing homes to report infection rates through the CDC’s National Safety Healthcare Network (NHSH). IPs will need additional training to accomplish this.
What is your advice on getting started?
Join your local APIC chapter and network with the fellow IPs. Attend educational programs on infection prevention; many are offered by APIC chapters, regional collaboratives, nursing home associations, CDC’s state healthcare-associated infection programs, and CMS Quality Improvement Organizations. Plan to attend a comprehensive infection prevention course like EPI® for long-term care (EPI for LTC). APIC’s EPI for LTC combines the EPI 101 and 102 courses into a certificate program specifically designed by, and for, those working in LTC, and covers the basic principles of infection prevention. Participants are given a certificate of completion.
What are some specific tools or resources you would recommend?
Use the APIC Roadmap for the Novice Infection Preventionist. Take the IP Competency Self-Assessment; you can download it from the APIC website.
Dr. Marx recommends the following IPC program assessment tools: Acute care hospitals: https://www.cdc.gov/infectioncontrol/pdf/icar/hospital.pdf LTC facilities: https://www.cdc.gov/infectioncontrol/pdf/icar/ltcf.pdf Outpatient settings: https://www.cdc.gov/infectioncontrol/pdf/icar/outpatient.pdf Hemodialysis facilities: https://www.cdc.gov/infectioncontrol/pdf/icar/dialysis.pdf
18 | SPRING 2018 | Prevention
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The APIC advocacy triad and the role of a CLR BY RICH CAPPARELL, NANCY HAILPERN, AND LISA TOMLINSON
APIC CHAPTERS ARE the backbone of advocacy efforts. Through our
chapters, APIC is able to effectively communicate with members, receive feedback about potential policies, and track regulatory and legislative trends in the states. This free flow of information would not be possible without chapter legislative representatives (CLRs). These key volunteers are the primary conduit for sharing regulatory
and legislative updates with chapters, as well as a great source of information for APIC to learn about its members. The focus of CLRs continues to evolve along with the everchanging role of infection preventionists (IPs). Once focused primarily on state and local legislative issues, the importance of this chapter leadership position has greatly increased. Government policy w w w.apic.org | 21
CAPITOL COMMENTS is changing so fast that APIC relies on a triad consisting of chapters, the Public Policy Committee (PPC), and staff to analyze policies, provide input to policymakers, and keep APIC’s 15,000+ members up to date (see Figure 1). APIC also deploys that same triad to make sure that legislation and regulation are evidence-based, implementable, and capable of driving infection prevention and control.
Figure 1. The APIC Advocacy Triad
Public Policy Committee The PPC provides clinical expertise to: • analyze proposed government actions that will impact the work of IPs or the practice of infection prevention, and develop an appropriate APIC response that will encourage continuing education of policymakers about healthcare-associated infections and antimicrobial resistance; • spot government policy trends in order to anticipate and prepare for implementation of new evidence-based practices to improve patient safety; and • provide guidance to policymakers on regulatory measures to ensure accuracy and standardization of data for use in surveillance, prevention, and treatment of infections, as well as safe care settings for patients and healthcare personnel.
APIC Staff The role of APIC staff is to: • maintain contact with federal policymakers and agencies to keep track of new or proposed actions;
APIC Policy Influence
Public Policy Committee
• act as liaisons between policymakers and IPs; and • work with PPC members to draft comments to Congress and federal agencies on pending government actions.
CLRs As noted, CLRs are essential to the advocacy triad. They serve as information conduits, policy liaisons, and the eyes and ears
RESOURCES FOR CLRS TO KEEP MEMBERS INFORMED Action eList – The Voice for Infection Prevention (VIP) Action eList is a free member benefit that provides the most up-to-date legislative and regulatory information. Subscribe by going to www.apic.org/imavip. MyAPIC CLR Community – As an APIC member, you have access to MyAPIC communities. CLRs have a community dedicated to discussing legislative trends, breaking news, and other information you can use to update your chapter. Take a moment to locate the CLR community at http://community.apic.org/home. VIP Advocacy Toolkit – Originally compiled by CLRs from the Greater St. Louis chapter, the toolkit provides helpful instructions and tips for chapters that want to plan a lobby day at their state capital. The VIP Advocacy Toolkit is located at http://cqrcengage.com/apic/toolkit.
PUBLIC POLICY WEBPAGES What’s New – The APIC Public Policy webpage has a “What’s New” section dedicated to providing members with the latest breaking news. Learn more at http://cqrcengage.com/apic/Whatsnew. Regulations – This webpage can help you navigate what regulations are being considered and APIC’s response to proposed rules. Visit http://cqrcengage.com/apic/regulations for more information. Federal and State Legislation – These webpages provide updates on legislation that is currently being considered at the federal and state level, as well as APIC responses and positions on legislation. Go to the Public Policy homepage at http://cqrcengage.com/apic/home to learn more.
22 | SPRING 2018 | Prevention
“The focus of CLRs continues to evolve along with the ever-changing role of infection preventionists (IPs). Once focused primarily on state and local legislative issues, the importance of this chapter leadership position has greatly increased.” of APIC in local matters. The main role of CLRs is to be a link between the PPC, APIC staff, and local chapters. CLRs have the critical task of relaying APIC communications with policymakers and APIC members across the country. Each quarter, APIC staff provides slides to assist CLRs in providing regular updates to their chapters. CLRs serve as primary liaisons between IPs and state policymakers. CLRs help staff monitor infection-related legislative activity in their states, provide this information to chapter members, and, in collaboration with APIC staff, determine what level of advocacy is needed on the legislation. For most legislation, CLRs and staff will monitor the bill; however, IPs in the state may need to contact their legislators to advocate for action on some measures. On these occasions, APIC staff will assist CLRs in crafting an appropriate response, and then rely on CLRs to encourage their chapter members to send the prewritten messages to their elected representatives.
Conversely, CLRs are an important resource to help APIC staff understand the thoughts and concerns of members or local officials. CLRs are the on-the-ground eyes and ears of the public policy team. They have firsthand access to what members say about potential, or implemented, policies and regulations when they are discussed at their chapter meetings. Additionally, CLRs may be among the first to hear about legislation that is being considered. This news can be from other organizations they work with, chapter members, or colleagues at their healthcare facility. Information provided to CLRs is very valuable, as they are APIC’s best way to hear about what is happening on a local level with members or policies. Through the combined clinical expertise of IPs (represented by the PPC), the unified voices of APIC chapters (represented by the CLRs), and the public policy experience of the APIC staff, APIC has gone from being just another healthcare professional organization to being a partner to policymakers who seek information regarding infection prevention efforts. As our teamwork increases, so does our influence. Members interested in learning more about the role of CLRs can watch a short video about the role at www.apic.org/clr_video.
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INFECTION PREVENTION LEADERSHIP
A conversation with
BSN, RN, CIC
SHARON PARRILLO is the assistant director
of infection prevention at Robert Wood Johnson University Hospital Somerset. She is a recipient of a 2017 Chapter Leader Award and past president of the Northern NJ Chapter, which received the 2017 Chapter Excellence Award in Clinical and Professional Practice (Large). Sharon started her infection prevention career in corrections in 2004 and moved to acute care in 2009, becoming board certified in 2010.
“Having a large group of professionals to network with is helpful in times when the answers are not exactly black and white. I have enjoyed learning from colleagues with different leadership styles than my own, and incorporating new ideas when the opportunities arise.”
How did you get involved in your local APIC chapter? When I made the transition to acute care in 2009, I was fortunate to work under the leadership of someone who was very active in our local APIC chapter. She made attending meetings a priority. I started attending meetings regularly in 2010 and decided to join the board in 2013 as treasurer.
What are some challenges you have faced as a chapter leader?
tense moments. It’s pushing forward when you want to give up, and encouraging others along in their journey.
What is your leadership style? I believe, the majority of the time, I am a transformational leader; it is inherent to the nature of our work. In order to achieve quality organizational goals, we motivate others to do more than they feel is possible. I’ve learned the “why” is so critically important to gaining buy-in for new initiatives. When people know why they must do something, it makes change easier to swallow and compliance increases. I’ve also learned to loosen my grip on how initiatives are rolled out. We set goals and we educate on best practices, but does it really matter how we get there? Each department has its own internal culture, and what works for one area may not work for everyone. Allow staff to be a part of the design and they will own the outcomes.
One of the challenges is keeping the balance. Work and home life pull me in many directions, especially with a 19-month-old little boy at home. I’ve learned to set priorities within the chapter, schedule, and tackle them. It’s unreasonable to think you will be able to fix or change everything during your leadership tenure with your local APIC chapter. Choose one thing and go for it; set up the team for success to tackle the next item on the list when you hand over the reins the following year.
How has your experience within APIC translated to your work as an IP?
What does leadership mean to you?
What were the defining moments of your career?
Leadership means listening, problemsolving, and educating. It means being flexible and available for consultation in
My involvement in the APIC Northern NJ Chapter has been very beneficial to my work as an infection preventionist (IP). Having a large group of professionals to network with is helpful in times when the answers are not exactly black and white. I have enjoyed learning from colleagues with different leadership styles than my own, and incorporating new ideas when the opportunities arise.
Two moments initially come to mind: a local measles outbreak in 2013 and Ebola w w w.apic.org | 25
INFECTION PREVENTION LEADERSHIP preparation in 2014; both nearly broke me. It is amazing what we are able to accomplish while food- and sleep-deprived. The most defining moment of my career is how I actually ended up in this field. I initially interviewed for a corrections staff nurse position back in 2004, and, after my interview, the director began introducing me to everyone as the new infection control nurse.
I had told her I didn’t have any experience in that specialty, and she said, “Don’t worry, you’ll figure it out.” The rest is history.
“Jump right in! Attend your local chapter meetings and ask how you can get involved. Board members will be more than happy to help guide you. Speak to individuals who have held leadership roles in the past to get an inside scoop on what to expect.”
Who has helped you along the leadership journey? I am very fortunate in my career to have worked alongside many strong leaders. Two stand out immediately: Pat Lafaro
and Amanda Hessels. Their mentorship has strengthened and encouraged me more times than I can count, and I am thankful for the opportunity to know them.
Do you have any advice for other chapter officers on boosting chapter participation?
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Do you have any advice for an IP looking to get involved as a chapter leader? Jump right in! Attend your local chapter meetings and ask how you can get involved. Board members will be more than happy to help guide you. Speak to individuals who have held leadership roles in the past to get an inside scoop on what to expect. Sometimes it’s simply saying “yes” when a nominating committee representative calls to ask if you would consider running for a leadership position. The individuals currently in those roles are not superhuman; you too can do this!
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26 | SPRING 12018 890647_TRSA.indd
Meeting attendance remains a challenge for many of us. We currently have 185 active chapter members; however, average attendance at meetings is approximately 25 to 35. As the profession evolves and practitioners are asked to “do more with less,” it is difficult to dedicate time for chapter meetings. In 2018, our chapter will be experimenting with what we are calling “the traveling show.” Meetings will be held at various locations throughout the region in hopes of boosting attendance. We are also hosting an evening meeting for the first time this year.
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PREVENTION IN ACTION
Hepatitis A outbreak!
A microbiological overview of the
hepatitis A virus BY IRENA KENNELEY, PhD, RN, CNE, CIC, FAPIC
GREETINGS FELLOW INFECTION PREVENTIONISTS! THE SCIENCE OF INFECTIOUS DISEASES involves hundreds of bacteria, viruses, fungi, and protozoa. The amount of information available about microbial organisms poses a special problem to infection preventionists (IPs). Obviously, the impact of microbial disease cannot be overstated. However, the teaching of microbiology has traditionally 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 issue’s My Bugaboo column features information about the hepatitis A virus (HAV). The intention is to convey succinct information to busy IPs about this common cause of healthcare-associated infections. Please feel free to contact the author with questions, suggestions, and comments at firstname.lastname@example.org. OVERVIEW
The digestive tract is one of the major portals of entry for many infectious organisms. HAV causes an acute inflammatory disease of the liver. It is an RNA virus and belongs to the Picornaviridae family. Formerly known as “infectious hepatitis,” its transmission often involves an infected food handler, but some outbreaks have been traced to daycare centers or transmitted through contaminated food or water. There 28 | SPRING 2018 | Prevention
is no treatment for HAV other than supportive therapy, such as prolonged rest, and relieving the symptoms. Maintaining high standards of personal hygiene—especially handwashing—and removal of the source of contamination are essential to prevent the spread of hepatitis A.1,2 EPIDEMIOLOGY
In the United States, approximately 700,000 people are diagnosed with HAV, an
acute viral disease.1 Like hepatitis B and C, HAV goes through the five stages characteristic of viral infections: the incubation period, the prodromal phase (the person is infectious but does not know they are infected), the acute period of possible jaundice and dark urine, and the decline period, which leads to the convalescent phase.1 Interestingly, children are a principal reservoir of HAV because their infections are usually asymptomatic. HAV can be transmitted by raw or undercooked shellfish such as clams and oysters. It can also spread from person to person through ingestion of contaminated food or water, as well as oral contact with objects (including hands) contaminated
by the feces of an HAV-infected person. Transmission occurs easily among sexual contacts, close household contacts, and those who share needles. RECENT OUTBREAK
In August 2017, a public health emergency was declared in the United States after an outbreak of HAV spread across five states: California, Michigan, Utah, Arizona, and Colorado. To date, more than 1,200 people have been infected, more than 800 have been hospitalized, and at least 40 people have died in this outbreak. Originally spreading among the homeless population and people who share needles, infections are now
affecting individuals of every background. Of the 644 people with confirmed HAV cases in California, one-third were neither homeless nor users of illicit drugs. In mid-September, after 12 homeless people died in San Diego, the public health department tried to stop transmission by using a bleach-based disinfectant to wash the streets contaminated with feces.3 Free HAV vaccines were offered, and portable handwashing stations were set up. Unfortunately, these efforts did not stop the spread of HAV.2–4 ACUTE HEPATITIS
The incubation period is about 14 to 28 days. In the prodromal phase, initial
“In August 2017, a public health emergency was declared in the United States after an outbreak of HAV spread across five states...To date, more than 1,200 people have been infected, more than 800 have been hospitalized, and at least 40 people have died in this outbreak.” w w w.apic.org | 29
PREVENTION IN ACTION
“If a healthcare worker or anyone else is exposed to HAV, immune globulin (IG) can be used as postexposure prophylaxis, or HAV vaccination can be used if IG is not available.”
symptoms in older children and adults include anorexia, nausea, vomiting, and low-grade fever because the primary site of viral replication takes place in the gastrointestinal tract. As the virus spreads to the liver, upper-right quadrant discomfort is common. The acute period occurs 4 to 10 days after the onset of the prodromal phase and is characterized by pronounced jaundice, dark urine, and pale stools. The period of slow decline of the virus is the next stage, followed by convalescence, which can take 2 to 3 months; relapses occur in approximately 20 percent of cases. Long-term immunity to HAV occurs after recovery.1,2 DIAGNOSIS
A positive serology test for the presence of antibody to HAV (anti-HAV) is needed to confirm the diagnosis. Anti-HAV immunoglobulin M (IgM) antibody is detectable in the serum from 2 weeks before the onset of symptoms, to approximately 6 months afterward. The presence of IgM anti-HAV usually indicates current or recent infection, but it does not tell us whether immunity is the result of infection or the vaccination. Remember, acute hepatitis A is a nationally notifiable disease. INFECTION PREVENTION
We IPs know that the best way to prevent further transmission of infections is through vaccination. More than 90,000 people have received the HAV vaccine since the beginning of the 2017 outbreak. The HAV vaccine is a 30 | SPRING 2018 | Prevention
series of two inoculations that offers nearly 100 percent protection.2 Prevention efforts should be aimed at vaccination, observation of standard precautions, and proper handwashing.1,2 All confirmed or suspected cases should be reported to the local health department within 12 hours (reporting rules vary from state to state).2 Promotion of vaccination for those exposed to HAV and anyone in a risk group also will help to stop transmission. The Centers for Disease Control and Prevention recommend screening patients at risk for HAV infection.2,4 At-risk patients include the following: • men who have sex with men; • persons with a history of substance abuse; • persons currently homeless or in transient living; • correctional facility inmates; • persons with underlying liver disease (e.g., cirrhosis, hepatitis B or C). If a healthcare worker or anyone else is exposed to HAV, immune globulin (IG) can be used as postexposure prophylaxis, or HAV vaccination can be used if IG is not available.2 In conclusion, many viral infections can be prevented by infection prevention measures (which vary depending on the transmission mode of a given agent). Important measures include handwashing, appropriate food preparation and water treatment, avoidance of contact with sick people, and safe-sex practices. Irena Kenneley, PhD, RN, CNE, CIC, FAPIC, is a professor at Case Western Reserve University, Frances Payne Bolton School of Nursing in Cleveland, Ohio. She serves on the APIC Board of Directors and is a past member of the Prevention Strategist editorial panel. References 1. Pommerville JC. Fundamentals of Microbiology, 11th ed. Burlington, MA: Jones and Bartlett Learning; 2018. 2. Nelson NP. Infectious diseases related to travel: Hepatitis A. In: CDC Yellow Book 2018: Health Information for International Travel. Atlanta, GA: Centers for Disease Control and Prevention; 2017. https:// wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseasesrelated-to-travel/hepatitis-a. Accessed December 2017. 3.
K ennedy M. San Diego washing streets with bleach to combat hepatitis A outbreak. National Public Radio. September 2017. https://www. npr.org/sections/thetwo-way/2017/09/13/550674476/sandiego-washing-streets-with-bleach-to-combat-hepatitisa-outbreak. Accessed December 2017.
4. Michigan Department of Health and Human Services. MDHHS Hepatitis A guidance: Hospital emergency departments. November 2017. http:// www.michigan.gov/documents/mdhhs/Hepatitis_A_Outbreak_ Emergency_Dept_Poster_11x17-final_606068_7.pdf. Accessed December 2017. Additional resource Viral Hepatitis Patient Education Resources. https://www.cdc.gov/ hepatitis/hav/patienteduhav.htm#cdc.
PREVENTION IN ACTION
FROM DATA TO DECISIONS
s e r u s a e M y t i d i l a v f o @ISTOCK.COM/OEZ
BY DANIEL BRONSON-LOWE, PhD, CIC, FAPIC, AND CHRISTINA BRONSON-LOWE, PhD, CCC-SLP, CLD
WELCOME TO THE eighth installment in a series examining statistical concepts relevant to the field of infection prevention. This article continues the discussion from the last two issues around the roles that ratios can play in making data more useful.
he first positive rapid influenza test in the middle of the off-season didn’t draw much attention. However, when two more positive results were reported the next day—from long-term inpatients, no less—the questions started coming. At the top of the infection preventionist’s list was a deceptively simple-sounding one: How good is the influenza test that is being used? w w w.apic.org | 31
PREVENTION IN ACTION
Figure 1. HAI Lab Test Results
Figure 2. Lab Test Interpretation for 100% Sensitivity
Figure 3. Lab Test Interpretation for 100% Specificity
32 | SPRING 2018 | Prevention
This question splits into several others. Fortunately, there are established proportions used to answer them. • Sensitivity: If someone has the disease, what is the likelihood the test will be positive? • Specificity: If someone does not have the disease, what is the likelihood the test will be negative? • Positive predictive value (PPV): If the test result is positive, what is the likelihood that the person truly has the disease? • Negative predictive value (NPV): If the test result is negative, what is the likelihood that the person truly does not have the disease? SENSITIVITY AND SPECIFICITY
Let’s begin with sensitivity and specificity. These are characteristics of the test or tool being used to determine whether someone has a given disease or outcome. They describe aspects of the test’s validity, establishing how well it measures what it’s supposed to measure. To see how they work, imagine we have developed a new lab test to quickly identify patients with healthcare-associated infections (HAIs). The test result is a score between 0 and 6 (Figure 1). There is just one problem. If someone has an HAI, they will have a score greater than 2. If they do not have an HAI, that person will have a score less than 4. Therefore, between scores 2 and 4, it’s unclear whether an HAI is present. We must decide how to handle those scores. If we set the cutoff score for a positive result at 2, then we’ll classify any score of 2 or greater as an HAI. Our test will then successfully identify every HAI because all HAIs have a score of 2 or greater. The test will therefore have 100% sensitivity. However, because some non-HAI patients also have test results greater than 2, using this cutoff will generate some false-positive results (Figure 2). On the other hand, if we set the cutoff score for a positive result at 4, then we’ll only classify scores of 4 or greater as HAIs. Note that we haven’t changed the physical analysis our test is using, only the way we interpret its results. With this new cutoff, we’ll lose some sensitivity because we’ll miss some HAIs—any with a score less than 4—but now the test will have 100% specificity. It will only read positive if we are absolutely certain the patient has an HAI (Figure 3). If we now imagine moving the cutoff line back and forth between scores of 2 and 4, it becomes clear that the test can never be 100% sensitive and 100% specific for the same cutoff. A test might get close to achieving that if the gray overlapping area is narrow, but any shift toward a given end of the gray area increases one measure while decreasing the other (Figure 1).
Table 1. Test Result versus Actual Disease Status
In real life, even if a test had 100% sensitivity or specificity, that wouldn’t necessarily make it a good test. To understand why, let’s examine how those values are calculated. Table 1 shows the logical framework underlying the math in the following equations. You may find it helpful to use this table and Figures 2 and 3 to track where the numbers for each equation are taken from and how they relate to each other. Recall that sensitivity answers the question “If someone has the disease, what is the likelihood the test will be positive?” That means we need to know what proportion of the time the test is positive when disease is present: Number of True Positive Results Sensitivity = × 100% Number of Individuals with Disease To be 100% sensitive, the test must correctly identify all patients with the disease. Note, however, that false-positive results aren’t included in this formula. That means that sensitivity isn’t impacted by the presence of those errors; therefore, a test that gives a positive result every time it is used will have a sensitivity of 100%. That doesn’t mean it’s a useful test. Specificity addresses the question “If someone does not have the disease, what is the likelihood the test will be negative?” It uses the proportion of the time the test is negative when disease is not present:
Number of TrueNegative Results Specificity = × 100% Number of Individuals without Disease To achieve 100% specificity, the test must correctly identify all patients who are disease-free. This time, false-negative results aren’t part of the calculation and therefore have no impact. Consequently, it is possible for a test to have a specificity of 100% if all it does is give a negative result every time it is used.
“To achieve 100% specificity, the test must correctly identify all patients who are diseasefree. This time, falsenegative results aren’t part of the calculation and therefore have no impact.”
PPV AND NPV
Now that we’ve covered two characteristics of the test itself, let’s go over two measures that describe how accurate the test results are: PPV and NPV. PPV is the proportion of positive test results that are real and answers the question, “If the test result is positive, what is the likelihood that the person truly has the disease?” In other words, if a patient has a positive result, how worried should he or she be? Number of True Positive Results PPV = × 100% Number of Individuals with Positive Results To achieve a PPV of 100%, every positive test result must be accurate; it must be someone who actually has the disease. The catch with PPV is that it doesn’t take into consideration the total number of people w w w.apic.org | 33
PREVENTION IN ACTION
who have disease. It’s possible for a test to only identify a few of the total diseased individuals as positive and still end up with a PPV of 100% as long as it doesn’t generate any false positive results. NPV works similarly, providing the proportion of negative test results that are real and answering the question “If the test result is negative, what is the likelihood that the person is really free of disease?” If a patient has a negative test result, how reassured should they be? Number of TrueNegative Results NPV = × 100% Number of Individuals with Negative Results To achieve an NPV of 100%, every negative test result must be a true negative. The total number of people without disease doesn’t play a role in this equation; therefore, a test can achieve an NPV of 100% while accurately identifying only a portion of the disease-free individuals. It requires only that there be no false-negative results; false-positive results don’t matter here.
Let’s take an example of a rapid influenza test with a technical write-up that reads as follows: • Sensitivity: 80% • Specificity: 91% • PPV: 85% • NPV: 87% This translates to: • Sensitivity: If a person has influenza, the test result will be positive 80% of the time. • Specificity: If a person does not have influenza, the test result will be negative 91% of the time. • PPV: If the test result is positive, the patient will actually have influenza 85% of the time. • NPV: If the test result is negative, the patient will truly not have influenza 87% of the time. With that in mind, let’s also say that the technical write-up includes a disclaimer that the documented PPV and NPV are only accurate if the test is used during influenza season. Why might that be the case? As it turns out, while sensitivity and specificity won’t change based on the time of year—they
are characteristics of the test itself and the test isn’t changing—PPV and NPV are impacted by the prevalence of the disease in the population being tested. That means that during the off-season, when influenza is scarce, this flu test could have very different values for PPV and NPV, like so: • PPV = 8% • NPV = 99% This happens because the more disease there is to find, the more likely it is that a positive result will be accurate. Figure 4 depicts the prevalence of influenza over time in an example community in the northern hemisphere, with very little disease present in the summer and a spike in the winter. Now imagine that the two circles in that figure are dartboards. Every time our rapid influenza test is positive during the off-season, we throw a dart at the dartboard on the left. If we hit that very small red bull’s-eye, then our positive result is a true positive. If we hit the white area, the result is a false positive. The reason the bull’s-eye is so small is that there is very little real influenza to find. The result is that our PPV is very small because most
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of the time we get a positive result it is going to be a false positive. When we use the same influenza test during the peak of the flu season, however, we get to use the dartboard on the right. The bull’s-eye is now much larger because there is so much more influenza present in the community that a positive result is much more likely to be real. Thus, our PPV is much higher. NPV works in reverse (Figure 5). Every time we get a negative result during the off-season, we throw a dart at the left target, and, if we hit the blue bull’s-eye, then the result is a true negative. If there is very little disease in the community, then almost every negative result will be a true negative. In the middle of flu season, however, when a larger proportion of the population actually has the disease, the chance of a false negative increases and the bull’s-eye shrinks a bit.
Figure 4. Variability of Positive Predictive Value
No test is perfect. Use these measures to better understand tests’ strengths and limitations during test selection and interpretation. For example, if the risks associated with a missed diagnosis are significant, it is vital to identify patients with positive results, even if that means having some false positives; therefore, you should look for a test with high sensitivity. Alternately, if a false-positive result can have serious detrimental effects, such as stigmatizing patients or leading them to believe they don’t have long to survive, then it may more important to find a test with high specificity and PPV. If you have any questions or comments, please feel free to contact the authors at IPandEpi@gmail.com. Daniel Bronson-Lowe, PhD, CIC, FAPIC, has been an infection preventionist, an infectious disease epidemiologist, and a statistics lecturer. He has been an instructor for APIC’s “Basic Statistics for Infection Preventionists” Virtual Learning Lab and is a senior clinical manager with Baxter Healthcare Corporation. Christina Bronson-Lowe, PhD, CCC-SLP, CLD, is a speech-language pathologist who has worked in hospitals, inpatient and outpatient rehabilitation, skilled nursing facilities, and home health care. Additional resources Potts, A. Use of statistics in infection prevention. In: Grota P, et al., editors. APIC text online. APIC; 2014.
Figure 5. Variability of Negative Predictive Value
“NPV works in reverse (Figure 5). Every time we get a negative result during the off-season, we throw a dart at the left target, and if we hit the blue bull’s-eye, then the result is a true negative.”
Potts, A. Use of statistics in infection prevention. In: PogorzelskaMaziarz M, editor. Fundamental statistics & epidemiology in infection prevention. Washington, D.C.: APIC; 2016. p. 18-53.
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PREVENTION IN ACTION
Focus on long-term care and behavioral health outbreaks:
Identify the pathogen! BY STEVEN SCHWEON, RN, MPH, MSN, CIC, HEM, FSHEA, FAPIC
HOSPITAL OUTBREAKS ARE reported more often in the medical literature than occurrences in the long-term care (LTC) or behavioral health setting. By studying and learning from outbreaks in the LTC/behavioral health setting, infection preventionists (IPs) will glean additional knowledge and apply this information to, hopefully, prevent future infections and infection clusters in their facility. This quarterly column will assist the IP with heightening awareness of appropriate interventions for preventing an outbreak.
“Pneumococcal transmission occurs person-to-person by direct contact with respiratory secretions such as saliva or mucus. Adults may be colonized with this organism and subsequently develop the disease.”
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uroki and colleagues relate that in April 2013, a local Japanese hospital alerted them that an unusually large number of nursing home residents, all 80 years of age or older, had been admitted to the hospital with acute respiratory symptoms.1 At this nursing home resided 31 residents with physical disabilities and cognitive impairments. Most were women, at least 80 years of age, and bedridden. Drawing from your experience and education, would you suspect the pathogen of interest to be: • Influenza, • Vibrio cholerae, • Streptococcus pneumoniae, or • Bacillus anthracis? A pneumonia diagnosis was given based on acute respiratory symptoms coupled with evidence of a new infiltrate on the chest x-ray. Streptococcus pneumoniae pneumonia was diagnosed if the organism, also known as the pneumococcus, was isolated from the sputum or if the rapid urinary antigen test was positive. Influenza-like illness (ILI) was defined as an episode of respiratory symptoms with a sudden fever. Ten residents (32 percent attack rate) had pneumonia, and they all required hospitalization. One case resulted in death. Five of these residents had positive Streptococcus
pneumoniae sputum cultures, and two had positive rapid urinary antigen tests. Eight of the 10 residents with pneumonia were tested for influenza; all were negative. There were also 16 ILI cases [combined pneumoniaILI] (84 percent attack rate); one resident had a positive Streptococcus pneumoniae nasopharyngeal swab. Six of the 28 staff members developed ILI, but none developed pneumonia. All six gram-positive isolates (five from the sputum and one from the nasopharyngeal swab) demonstrated identical pulsed-field gel electrophoresis patterns. The isolates were susceptible to penicillins, cephalosporins, carbapenems, and vancomycin. Twenty-seven of the residents (87 percent) had been vaccinated with the influenza vaccine, but only two of them (7 percent of those vaccinated) had received the 23-valent pneumococcal polysaccharide vaccine (PPSV23).
U.S. CENTERS FOR DISEASE CONTROL AND PREVENTION/JAMES ARCHER
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PREVENTION IN ACTION
The Society for Post-Acute and Long-Term Care Medicine offers an algorithm to assist with pneumococcal vaccine decision-making.
CSF = cerebrospinal fluid HIV = human immunodeficiency virus PCV13 = pneumococcal conjugate vaccine PPSV23 = 23-valent pneumococcal polysaccharide vaccine
None of the residents who developed pneumonia had received PPSV23. In Japan, there was no national recommendation for PPSV23 vaccination at the time. The authors believed that dysphagia, impaired immunity, and crowded living conditions contributed to the outbreak. In their concluding commentary, the investigative team strongly advocated for an “effective vaccination program for adults, and particularly for extremely elderly people.”1 EPIDEMIOLOGY
“Vaccination is the optimal approach for preventing pneumococcal disease.” 40 | SPRING 2018 | Prevention
Pneumococcal disease—an infection caused by the S. pneumoniae bacterium— causes pneumonia, meningitis, and bacteremia. About 1 million adults get pneumonia, with a 5 to 7 percent mortality rate.2 Persons with S. pneumoniae pneumonia may develop a high fever, chills, cough, shortness of breath, chest pain, stiff neck, disorientation, and sensitivity to light.2 Sequelae include hearing loss, seizures, blindness, paralysis, and heart problems. Pneumococcal disease kills between 20
percent and 25 percent of persons over the age of 65 who become ill.2 Pneumococcal transmission occurs from person to person by direct contact with respiratory secretions such as saliva or mucus.3 Adults may be colonized with this organism and subsequently develop the disease. Standard precautions are used when caring for persons with pneumococcal disease.4 The Centers for Disease Control and Prevention (CDC) note that adults 65 years of age or older are at increased risk for pneumococcal disease.3 Some adults between the ages of 19 and 64 years are also at increased risk for pneumococcal disease, including those: • with chronic illnesses (chronic heart, liver, kidney, or lung disease [including chronic obstructive lung disease, emphysema, and asthma]; diabetes; or alcoholism). • with conditions that weaken the immune system (HIV/AIDS, cancer, or damaged/ absent spleen).
• with cochlear implants or a cerebrospinal fluid leak (escape of the fluid that surrounds the brain and spinal cord). • who smoke cigarettes. VACCINATION
Vaccination is the optimal approach for preventing pneumococcal disease. Two types of vaccines are available: the PPSV23 and the pneumococcal conjugate vaccine (PCV13). The CDC provides specific recommendations regarding which types of vaccine should be offered to nursing home residents, and when to offer them.5 The Centers for Medicare & Medicaid Services requires each nursing home resident be offered the appropriate pneumococcal vaccine. 6,7 Patients of all ages are required to receive Vaccine Information Statements prior to vaccination.8 Both types of pneumococcal vaccine should be maintained in a proper refrigerator for storing medications, not a “dormitory style” unit.9 Penicillin and its derivatives are effective for treating pneumococcal infections when used against susceptible isolates.10 However, penicillin resistance has been increasing. Pneumococcus has been reported to be resistant to one or more antibiotics in three out of every 10 cases.11 Alternative antibiotics may have to be administered. Steven Schweon, RN, MPH, MSN, CIC, HEM, FSHEA, FAPIC, is an infection prevention consultant with a specialized interest in acute care/ long-term care/behavioral health/ambulatory care infection challenges, including outbreaks.
3. The Centers for Disease Control and Prevention. Pneumococcal disease. Risk factors and transmission. https://www.cdc.gov/ pneumococcal/about/risk-transmission.html. Accessed November 2017. 4. Siegel JD, Rhinehart E, Jackson M, et al. 2007 Guidelines for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/ pdf/guidelines/isolation-guidelines.pdf. Accessed November 2017. 5. Centers for Disease Control and Prevention. Immunization schedules. Recommended immunization schedule for adults aged 19 years or older, by vaccine and age group. https://www.cdc.gov/ vaccines/schedules/hcp/imz/adult.html. Accessed February 2018. 6. Centers for Medicare & Medicaid Services. Pub. 100-07 State Operations Provider Certification. March 2017. https:// www.cms.gov/Regulations-and-Guidance/Guidance/ Transmittals/2017Downloads/R168SOMA.pdf. Accessed January 2018. 7. The Society for Post-Acute and Long-Term Care Medicine. Pneumococcal vaccination guidance. 2016. https://paltc.org/ publications/pneumococcal-vaccination-guidance. Accessed November 2017. 8. Immunization Action Coalition. You must give your patients current Vaccine Information Statements (VISs) - It’s federal law! http:// www.immunize.org/catg.d/p2027.pdf. Accessed November 2017. 9. Immunization Action Coalition. Storage and handling. Vaccine storage units. http://www.immunize.org/askexperts/storagehandling.asp. Accessed November 2017. 10. Nieves Prado CA. Pneumococcal infections (Streptococcus pneumoniae) medication. Medscape. Pneumococcal infections medication. https://emedicine.medscape.com/article/225811medication#2. Accessed February 2018. 11. Centers for Disease Control and Prevention. Pneumococcal disease. Diagnosis and treatment. https://www.cdc.gov/pneumococcal/ about/diagnosis-treatment.html. Accessed November 2017.
“Patients of all ages are required to receive Vaccine Information Statements prior to vaccination.”
Additional resource The Society for Post-Acute and Long-Term Care Medicine. https:// paltc.org.
READ MORE ABOUT PNEUMOCOCCAL PNEUMONIA IN THE AMERICAN JOURNAL OF INFECTION CONTROL
References 1. Kuroki T, Ishida M, Suzuki M, et al. Outbreak of Streptococcus pneumoniae serotype 3 pneumonia in extremely elderly people in a nursing home unit Kanagawa, Japan, 2013. J Am Geriatr Soc 2014;62(6):1196-1197. 2. National Foundation for Infectious Diseases. Pneumococcal disease. http://www.adultvaccination.org/pneumococcal. Accessed November 2017.
Risk factors for hospital-acquired pneumonia outside the intensive care unit: A casecontrol study. Sopena N, Heras E, Casas I, et al., American Journal of Infection Control, Volume 42, Issue 1, 38–42.
TAKE-HOME MESSAGE Invasive pneumococcal disease (an infection of a normally sterile body site, e.g., meningitis or bacteremia) is reportable to your local health department. Partner with your clinical laboratory to ensure that the health department is notified. Whenever an outbreak, or possible outbreak, occurs, your local health department or other infectious disease experts can provide invaluable guidance on operational, management, and control issues.
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PREVENTION IN ACTION
Vanderbilt receives inaugural APIC
Program of Distinction award BY MELANIE PADGETT POWERS
“The Program of Distinction confers a designation of excellence to acute care facilities for IPC programs that meet a set of high-level standards established by leaders of APIC. The new program also aims to assist facilities in maintaining an increased level of readiness with standards developed for infection prevention teams by experienced infection preventionists.”
hen patients and their families walk through the Vanderbilt University Medical Center in Nashville, Tennessee, they can easily spot “quality boards” that highlight updated, easy-to-undestand metrics about infection prevention and control (IPC). Each department—and the hospital as a whole—has embraced transparency when it comes to infection prevention efforts. Back in 2009, when the neonatal intensive care unit (NICU) posted the first quality board, it was controversial among some staff, said Tom Talbot, MD, MPH, Vanderbilt’s chief hospital epidemiologist. NICU staff updated the board daily to show how long the unit had gone without a central line-associated bloodstream infection (CLABSI). “When they hit a hundred days without an event, we could go to everyone else and say, ‘Here is a unit with extremely vulnerable patients, yet look what they were able to accomplish. If we can make gains in that population, we can do it anywhere,’” Talbot said. Now, every unit in the hospital maintains a transparent quality board, and staff at all levels are enthusiastic about the IPC program. Vanderbilt’s dedication and ability to create a hospital-wide culture committed to infection prevention has earned it APIC’s first Program of Distinction recognition. The Program of Distinction confers a designation of excellence to acute care facilities for
IPC programs that meet a set of high-level standards established by leaders of APIC. The new program also aims to assist facilities in maintaining an increased level of readiness with standards developed for infection prevention teams by experienced infection preventionists (IPs). “It shines a light on our program and really shines a light on our partners...all the people who make up the entire infection control family,” said Vicki Brinsko, MSN, RN, CIC, FAPIC, Vanderbilt’s director of infection prevention. “It’s not just the people that have IP after their name.” Brinsko pointed to all the frontline staff, including techs, assistants, and nurses, as well as those who work in facilities management and environmental health and safety. “It’s every single frontline nurse that’s taking care of the patients, and washing their hands, and scrubbing the hub, and keeping the Foley bag off the floor, and doing all those things that we are ingraining in them. It’s working.” w w w.apic.org | 43
PREVENTION IN ACTION
THE APPLICATION PROCESS
“By earning the Program of Distinction designation, Vanderbilt can use the program’s logo in its marketing and communications outreach, promoting its exceptional quality control to the public and partners.”
Applying for the Program of Distinction starts with an online self-assessment (https://programofdistinction.org) to see if a hospital is ready to apply. Next is the online application process, followed by an onsite assessment by a team of IPC experts. The online self-assessment was easy to understand and complete, Brinsko said. The application itself was straightforward and allowed her to upload policies, forms, and data to a HIPAA-compliant site without the need to mail anything. It did take some prep time to gather the documents that showed how Vanderbilt was meeting the standards. The next step was to prepare for the visit by the IPC expert team. “We prepared for the surveyors by lining up infection prevention partners and groups they thought the surveyors would like to interview,” Brinsko said, “but most of the frontline staff didn’t know the reviewers were coming.” Vanderbilt didn’t change any IPC processes to prepare for the survey. Hospitals should not create systems solely to meet application requirements, Talbot said. Instead, “just continue to build your program and work on your priorities, and as you do that and bring in best practices, you’ll be cultivating that application.” THE ASSESSMENT
The surveyors started their days by reviewing documents, and then meeting with various staff members. But most of their time was spent visiting individual units, speaking directly with frontline staff who didn’t know they were coming. Unprompted, time and time again, staff members led the surveyors over to the quality boards to point out the unit’s successes. The surveyors observed staff washing their hands as they entered and exited rooms, and they visited Vanderbilt’s offsite sterilization facility. They praised areas that were working well. “They were impressed with a couple of our processes, our flow diagrams, and our flowcharts,” Brinsko said. “They took a couple of samples with them of things that we were doing that were pretty innovative and they had not seen at other places.” For example, Vanderbilt received high marks on its infection control risk assessment.
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At the end of an assessment, staff list what they think were the key drivers to different infections, such as CLABSI, catheter-associated urinary tract infections, and surgical site infections. The assessment color-codes processes by green, yellow, and red—green for systems that are working well, yellow for those that have just started, and red for those that still need to be implemented. At the end of each day, the surveyors met with the IPC department to ask questions and provide feedback. Talbot said it was rewarding and educational to have surveyors who truly understood infection prevention, unlike with a more general hospital review program. The surveyors spotted a few areas for improvement, pointing them out to the staff. “They would find things and see things that we’d miss because we look at it every day,” Talbot said. THE REWARD
By earning the Program of Distinction designation, Vanderbilt can use the program’s logo in its marketing and communications outreach, promoting its exceptional quality control to the public and partners. The IPC department is also touting the designation internally to reaffirm to all staff that they are moving in the right direction. “This wouldn’t have been done with just the IP team we have,” Talbot said. “Sometimes you get in the weeds so much and you don’t see the change and the impact, so to have this third-party expertise come in and [confer to us this designation], it’s an honor. And we want our team to know that.” As a teaching hospital and one of the larger hospitals in Tennessee, Vanderbilt was already accustomed to working with other hospitals in the South, as well as the state hospital association and department of health. “I think it [Program of Distinction award] allows our hospital to be a beacon, if you will, of good practice, best practices, in the way that all hospitals aspire to be, for preventing patient harm and preventing infections on a day-to-day basis and making sure that this is filtering down to the frontline,” Brinsko said. Melanie Padgett Powers is a medical writer based in the Washington, D.C., metropolitan area.
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PREVENTION IN ACTION
The Proficient Practitioner Bridge:
A new self-assessment in professional development for IPs BY CORRIANNE BILLINGS, BS, BSN, RN, CIC
HAVE YOU EVER thought to yourself, “Now that I have become certified, or recertified, in infection prevention and control [CIC®], how do I grow as an infection preventionist (IP)?” Are you a proficient or advanced IP wondering where to go next on your professional development journey? Are you interested in becoming an APIC Fellow but don’t know where to start? Read on for some exciting information about a new APIC resource designed to provide you with a professional development plan tailored for you.
“The PPB is novel in its offering, being the first online, interactive professional development tool for APIC members, and hosted in APIC’s new learning management system.”
hortly after the publication of the APIC Competency Model (see Figure 1), a group of APIC volunteers assembled to carry forward this foundational document. Forming what would eventually become the APIC Professional Development Committee, the group focused on providing APIC members with essential resources for progressing through their career.1 The first of these resources, the APIC Competency Self-Assessment, appeared in Prevention Strategist shortly thereafter.2 This document merged both the Certification Board of Infection Control and Epidemiology (CBIC®) competency domains, and the future-oriented domains of the APIC Competency Model. The Competency Self-Assessment prompted users to evaluate how they anticipate practicing within these future-oriented domains in the next three to five years, and what knowledge and skills they will require to meet their goals. Flash forward to the present day, where, after establishing the APIC Fellows program and updating the APIC Professional and Practice Standards, the APIC Professional Development Committee is ready to announce the release of the Proficient Practitioner Bridge (PPB).3 This resource
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“builds the bridge” for the proficient IP to progress to the advanced career stage—helping the IP to build the professional background and experience to reach the advanced career stage, and ultimately guiding the IP through the requirements of application for the APIC Fellow credential.
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PREVENTION IN ACTION
Table 1. APIC professional development resources through career stages.
* See Fellow criteria requirements
Novice Roadmap for the Infection Preventionist
Competency Self-Assessment Proficient Practitioner Bridge
Professional and Practice Standards valuable resource throughout career span
“One important thing to remember as you use the PPB is that, while each of the self-assessment responses has a point value, there are no incorrect answers.”
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Using the future-oriented domains of the Competency Model, the PPB defines the subdomains and provides a rating scale established from interpretation of the IP experience of that subdomain. These definitions are based on the Competency Model, but the concepts have been expanded and modernized for accuracy in an everchanging healthcare environment. For consistency, this five-tiered rating scale mirrors the rating scale in the previous Competency Self-Assessment and follows the Competency Model career stages. The four future-oriented domains of the Competency Model were selected as the basis of the PPB because they build on the core competencies located in the center of the Competency Model and established by CBIC.4 Together, the Competency Self-Assessment and PPB allow the IP to evaluate the competencies and expectations of infection prevention practice. The real value of the tool is that where previous assessments required participants to develop their own plan, the PPB provides suggestions for professional development activities. Curated from APIC resources and other sources, these proposed plan items provide tangible next steps for IPs to work through on their professional development journey. Examples of activities include resource documents, independent studies, APIC webinars and courses, scholarly articles, advanced degrees, and volunteer opportunities. Additionally, the suggested activities for those who self-assess at a high level are directly related to the APIC Fellow criteria, providing a path for the IP to navigate. The PPB is novel in its offering, being the first online, interactive professional development tool for APIC members, and hosted in APIC’s new learning management system. The tool offers a self-assessment with personalized output, including a score that ranks the IP within the APIC Competency Model career states. The PPB comprises four separate self-assessments—one for each Competency Model future-oriented domain—to allow flexibility in selfassessment timing and provide focused feedback on
the IP’s strengths and opportunities for improvement within each domain. Thus, the PPB is in line with the APIC Competency Model as it both specifies that the domains should be connected and that the IP will progress through career states within the domains at different rates. Figure 2 presents a sample of one of the subdomains of the Infection Prevention and Control domain. One important thing to remember as you use the PPB is that, while each of the self-assessment responses has a point value, there are no incorrect answers. In addition to a point scale that provides an initial sense of proficiency, a results report will be available for download after each assessment; these reports offer an analysis of your responses, including the suggested activities for professional growth. The PPB is an exciting addition to APIC’s growing family of resources dedicated to professional development, and we hope you will take the opportunity to utilize this tool. Who knows, it may lead you to becoming an APIC Fellow! To find the PPB, and additional development resources for IPs, visit https://apic.org/Professional-Practice/roadmap. If you have questions, please contact Hannah Andrews, associate director of eLearning, at email@example.com. Corrianne Billings, BS, BSN, RN, CIC, is the manager of infection prevention, surveillance, and data analytics with Mission Health System, in Asheville, North Carolina. Corrianne recently completed her term as chair of the APIC Professional Development Committee, which she has been a member of since 2013. References 1. Murphy DM, Hanchett M, Olmsted RN, et al. Competency in infection prevention: a conceptual approach to guide current and future practice. Am J Infect Control 2012;40(4):296-303. 2. Hanchett M. Self-assessment to advance IP competency. Prev Strateg 2013;6(4):62-67. 3. Bubb TN, Billings C, Berriel-Cass D, et al. APIC professional and practice standards. Am J Infect Control 2016;44(7):745-749. 4. Henman L, Corrigan R, Carrico R, et al. Identifying changes in the role of the infection preventionist through the 2014 practice analysis study conducted by the Certification Board of Infection Control and Epidemiology, Inc. Am J Infect Control 2015;43(7):664-668.
Figure 2. A subdomain from the APIC Competency Model.
Domain 2: Infection Prevention and Control Subdomain 1: Epidemiology and surveillance
How would you rate your epidemiology and surveillance knowledge and skills?
Epidemiology is the study of the frequency, distribution, cause, and control of disease in populations, while surveillance is a comprehensive method of measuring outcomes and related processes of care, analyzing the data, and providing information to members of the healthcare team to assist in improving those outcomes. Together, they form the basis of infection prevention analysis and workflow.
I can apply nationally recognized surveillance and/or outbreak definitions relevant to my practice setting, reporting if applicable, but I am not confident in analyzing my data or benchmarking.
• The infection Preventionist’s Guide to the Lab • APIC Text Vol. 1, Ch. 10-12 ° General Principles of Epidemiology ° Surveillance ° Outbreak Investigations • EPI 101 at APIC’s Infection Prevention Academy • NHSN Patient Safety Manual • NHSN Training Modules for HAI Surveillance • Webinar: McGeer’s definitions (Long-Term Care) • APIC-HICPAC Home Health Infection Definitions • Recommended practices for surveillance: Association for Professionals in Infection Control and Epidemiology (APIC), Inc. Lee, Terrie B. et al; American Journal of Infection Control, Volume 35, Issue 7, 427-440.
I am confident in conducting surveillance applying pertinent definitions and able to use proper benchmarks, but I am not able to use fundamental statistics and/or data tools to detect clusters and outbreaks.
• APIC Text Vol. 1, Ch 13-14 ° Use of Statistics in Infection Prevention ° Process Control Charts • Online course: Basics of Statistics for Infection Preventionists • Fundamental Statistics and Epidemiology in Infection Prevention • NHSN Analysis Training Modules • NHSN Guide to the SIR • CDC Epidemiologic Case Studies
I can interpret surveillance results and detect clusters/ outbreaks by using fundamental statistics and simple data tools.
• Online course: Effectively Using Data • NHSN Data Analysis and Statistics Tools ° HAI Data and Statistics ° Patient Safety Analysis Resources
I can appropriately select and use more complex statistics to display data and detect clusters/outbreaks and create an action plan based on my data analysis. Additionally, I can perform surveillance outside my practice setting.
• APIC Text Vol. 1, Ch. 15-18 ° Risk-Adjusted Comparisons ° Quality Concepts ° Performance Measures ° Patient Safety • College/university biostatistics course/certificate program • Advanced degree (master’s, doctorate, etc.) • Volunteer on APIC Practice Guidance Committee
I am confident in my ability to improve outcomes through a combination of an advanced understanding of epidemiology principles and statistics; data analysis; using complex display tools to communicate my data; and using literature searches to benchmark and confidently set infection rate thresholds upon which to react.
• Author a peer-reviewed publication on a topic related to epidemiology and surveillance • Complete an oral presentation on the state, regional, or national level on epidemiology and surveillance • Contribute to the development of a APIC resource (course, APIC book, or APIC implementation guide) on surveillance and epidemiology
The infection preventionist combines an understanding of epidemiology and surveillance to proactively approach setting infection reduction targets and establish thresholds upon which he or she may need to react. To do this, the IP must be able to apply and expand surveillance principles; use complex data display tools (control charts, affinity diagrams, scatter plots); conduct basic cluster/ epidemic investigations; interpret results using statistics, rates, and ratios; and know what benchmarks to use for his/her program.
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PREVENTION IN ACTION
business case Part 2: Useful financial analysis tools BY WILLIAM WARD, JR., MBA ©iStock.com/Yok46233042
INFECTION PREVENTIONISTS (IPs) are often asked to provide a business justification for their proposals. This can be a challenge if the IP
lacks the business knowledge to articulate the financial benefits of their initiative that will convince decision makers. Part 1 of this article described the general business model that drives hospital financial performance and how improvements in infection control can result in positive “bottom-line” results. This article is a “how to” for the financial analysis tools that IPs can use to make the business case for initiatives that reduce the incidence of infections. Feel free to contact the author with questions or comments at firstname.lastname@example.org.
ow sad would it be to work tirelessly to develop a smart initiative to reduce infections, only to see it rejected because the case was not properly articulated with sound, convincing financial analysis to support it? The need for a compelling business case cannot be minimized. Three forms of decision support analysis can be used to supplement the clinical and operational description of an initiative: marginal analysis (including a marginal profit-and-loss statement), benefit/cost analysis, and breakeven analysis. MARGINAL ANALYSIS
As the term implies, marginal analysis looks at marginal or incremental changes in revenue, cost, or profits—in other words, any changes that are solely associated with, and driven by, whatever is being examined, and not attributed to the ongoing operation of the business. Consider a new procedure that requires the addition of two nurses to the existing staff of 20 people. Marginal analysis would only consider the marginal or incremental cost for the two added nurses, not the total budget for all staff. In a similar way, if this procedure were billable, the 50 | SPRING 2018 | Prevention
marginal analysis of its revenue would only consider the revenue generated by this sole procedure on its own. If whatever is being examined has both revenue and cost, a marginal profit-and-loss (P&L) statement looks at both cost and revenue at the same time and calculates a third value: the profit or loss. In preparing a marginal P&L, it is best to prepare a multiyear (three- to five-year) analysis because some initiatives take time to fully develop. They lose money in the early months, or years, before volume and revenue grow sufficiently to cover operating costs and generate a profit. A multiyear analysis
is the best way to deal with situations like this. Consider the following example of such an opportunity. A new procedure is priced at $1,500. The collection rate is expected to be 75%. Demand for this new procedure is anticipated to be 800 units in the first year, growing by 200 units each year thereafter, until reaching a capacity limit of 1,600 units. The procedure will be offered in rented space at a local medical office building. Annual rent is $20,000. Salaries are estimated to be $100,000 a year for the director and $50,000 each for eight full-time
equivalents of procedure techs. Fringe benefits amount to 20% of the salary cost. Each procedure consumes $400 of medical supplies. Office and other supplies needed to run the business amount to $8,000 per month. The marginal P&L analysis of this opportunity (Table 1) shows a loss of $136,000 in the first year. The initiative is still losing money at the end of the second year ($127,000), but then turns the corner and, by the end of five years, it has accumulated profits of $770,000. This is an opportunity that, lacking information to the contrary, should be pursued. If only the first year’s performance were considered, most decision makers would reject the opportunity. For this reason, it makes sense to complete a multiyear analysis spanning five fiscal years and demonstrating an upward performance trend. As shown in Table 1, the volume grows each year until capacity is reached in year five. As a result, revenue grows as well, doubling from the first year’s $1.2 million of gross revenue to $2.4 million in year five. But gross revenue must be reduced to reflect what is actually collected—the net revenue. The latter is calculated by multiplying the gross revenue by the collection rate of 75%.
The result is net revenue of $900,000 in year one that grows to $1.8 million in year five. The finance department can advise the appropriate collection rate to use. The next element in the P&L is marginal variable cost. In this example, there is only one item—medical supplies. This cost grows each year in lockstep with the volume. The marginal fixed costs include salaries, fringe benefits, office and other supplies, and rent. These costs do not grow as the volume increases. The combination of marginal fixed and variable costs amounts to $1,036,000. When subtracted from the $900,000 of marginal net revenue, a loss of $136,000 results. Again, if the analysis stopped at this point, the opportunity would likely be rejected. But when the financial performance is drawn out over five years, the opportunity “works” financially—it begins to show a marginal annual profit in the second year (although not enough to cover losses from year one), and years three and beyond are very profitable. The analysis concludes with a summary column displaying the total marginal net revenue for the five years, along with the associated marginal costs and the five-year total profit.
While marginal analysis can be used to support an initiative, benefit/cost analysis is particularly useful for examining proposals involving investments in technology, equipment, and facilities. It develops a ratio of the benefit derived from the investment to the cost of the investment. Generally, a ratio greater than 1.000 means the investment should be pursued, whereas a ratio less than 1.000 means it should be rejected. Decision makers are usually indifferent to a ratio of 1.000 exactly. The higher the ratio, the better the opportunity. The ratio (sometimes called a profitability ratio) can be used to select the best investment from among several competing options. The following investment opportunity demonstrates the use of benefit/cost analysis to support decision-making. A new technology will reduce cost and allow additional admissions at the local hospital. The price of the technology is $4 million, with $3.5 million of that amount paid at the time of purchase and the remaining $500,000 one year later. Installation cost is $500,000. The technology will reduce operating cost by $400,000 a year. A newer instrument will replace this technology in
Table 1. Marginal Profit-and-Loss Analysis Year 1
Marginal Revenue Units of Volume Marginal Gross Revenue Collection Rate Marginal Net Revenue
Salary - Program Director
Medical Supplies Marginal Fixed Costs
Marginal Variable Costs
Salaries - 8 Techs
Office & Other Supplies
Total Total Marginal Cost Marginal Profit - Annual
Marginal Profit - Cumulative
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PREVENTION IN ACTION
Table 2. Benefit/Cost Analysis Investment Present Value Year
Present Value Factors
Investment Present Value
Benefit Present Value Revenue Increases
Present Value Factors
Benefit Present Value
Net Present Value
six years. The first-year maintenance contract for the technology is included in the purchase price. In subsequent years, maintenance will cost $125,000 per year. The finance department has estimated that the additional admissions have net revenue of $450,000 in the first year, increasing by $100,000 each year thereafter. Finance has also indicated that future cash flows should be discounted at 2%. Because the assumption is that the technology will be replaced after six years, the analysis is done over a six-year period. First, the cost associated with the equipment, its installation (the cost of plugging it into hospital systems like HVAC, electrical, and so on), construction costs (for physical construction of space to accommodate the equipment), and other costs (licensure, legal, certificate of need costs, and so on) are identified. Since this will be a six-year analysis, the monetary values for each of the four categories are listed for each of the six years. In most cases, these costs will be incurred 52 | SPRING 2018 | Prevention
“Because the assumption is that the technology will be replaced after six years, the analysis is done for a six-year period.” in the first year, but the construction may occasionally precede the equipment acquisition. Sometimes, as seen in Table 2, the payment for the technology may be spread over two or more years to soften the impact on the organization’s cash flow. A similar six-year time frame is used to collect the financial information for revenue increases, revenue decreases, expense decreases, and expense increases. In this case, there is a projected revenue increase of $450,000 in the first year. The revenue increase then grows by $100,000 in each subsequent year. There is no decrease in revenue. A cost reduction of $400,000 is achieved in each year. Lastly, the cost of
the annual maintenance contract is entered for years two through six in the Expense Increases column. The third column from the right displays the investment cost and the benefit for each year, as well as the six-year totals. At this point, however, the analysis is not complete. In its more sophisticated application, the analysis is prepared using the present value of future flows of funds. As noted earlier, the finance department indicated that future cash flows for this example should be discounted at a rate of 2%. The rate is applied by using present value factors for 2%, which can be found online by searching for a “present value table.” In other words, the value of money to be received in the future (e.g., $1.125 million in year five) is discounted by a present value factor (0.906 for year five) to estimate its current or present value ($1,019,250). As a result, this approach to the analysis is said to involve present valuation, which uses present value factors to discount the future funds.
Once the discounts on the future funds are calculated by multiplying the present value factors for 2%, the present values of both the investment ($4,490,000) and the benefit ($5,551,325) can be compared. The result, as shown in Table 2, is a net present value, the arithmetic difference between the two, of $1,061,325. Present values are further explained later in this article. The benefit/cost ratio, the present value of the benefit divided by the present value of the investment (the cost), is 1.236. Since this ratio is above the 1.000 decision point, this investment has exceeded the 1.000 hurdle and should be pursued, at least from a financial standpoint. In fact, the ratio indicates that the opportunity surpasses the way the organization is currently invested by 23.6% (1.236 – 1.000). But why discount future funds? Clearly, the total benefit of $5,975,000 easily exceeds the $4,500,000 investment. Why is this extra step necessary? The reason is that the value of money changes over time. Consider the person who could have $10,000 today or $10,000 a year from now. The obvious choice is to take the $10,000 today because, if invested properly, it could be worth more in a year’s time. But what if that person was given the choice of having either $9,400 today or $10,000 in a year? Which is better? The answer depends on how the $9,400 could be invested. If the person invested at an interest rate of 2%, it would be worth $9,588 at the end of a year, and waiting for the $10,000 would be the better choice. If the money were invested at 7%, it would be worth $10,058; therefore, the best choice would be to take the $9,400. Comparisons like this are simple and straightforward. However, in the business
Table 3. Five-Year Cash Flow Options Year
world, the flows of money are often spread over multiple years with different monetary amounts. What if, instead of receiving $10,000 in a year and then nothing for the next four years, the person received varying amounts each year that totaled $11,500 at the end of a five-year period? Would that be better than the one-time payment of $10,000? Table 3 displays three cash flow scenarios over a five-year stretch of time. Which one is the best choice? What about the person who is considering these options versus having $9,200 cash in hand today? Some might prefer Option A because of its accelerating cash flow. Others may prefer Option B because the first year brings in significantly more cash than Option A. Still others may prefer bringing in all of the cash as soon as possible—Option C. But rather than making a subjective decision, it is possible to look at these options objectively using the present value of the flows of cash and comparing them to the cash-in-hand ($9,200) option. Once again, using the present value factors for 2%, the flows can be discounted, as shown in Table 4.
When the flows are discounted using the present value factors for 2%, the three future flows of cash yield present values of $10,702, $10,869, and $9,800. The best option is Option B because it has the highest present value. As the table demonstrates, each year’s cash flow is multiplied by the present value factors for 2% for each of the five years. The first step in accomplishing the present valuation of future monies is to select the proper discount factors. Generally, this involves determining the organization’s rate of return (or “hurdle rate”) that an investment must exceed in order for it to be pursued. Some organizations use the average return on their investment portfolio, assuming they will use those funds to make the acquisition. Others use the interest rate they will have to pay if funds are borrowed to make the acquisition. Some use a required rate of return, whereas still others use a blended rate that takes into account the interest rate on borrowed money, current earnings on investments, overall financial return on company assets, and so on. Whatever the methodology
Table 4. Present Value of Future Flows of Cash Over Five Years Option A
Annual Cash Flow
Present Value Factors
Annual Cash Flow
Present Value Factors
Annual Cash Flow
Present Value Factors
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for calculating rates, only the finance department can advise what rate to use. Never guess. Because the benefit/cost ratio is based on assumptions about volume, revenue, cost, and other factors, caution must be exercised when the ratio is hovering just above or below 1,000. A favorable ratio of 1.012 could turn unfavorable fairly quickly if a revenue growth assumption is off by just a fraction. For this reason, some organizations hold that favorability begins with a ratio of 1.050 or higher. In this way, they are adjusting for the sensitivity of the underlying assumptions. The number of years included in the benefit/cost analysis is equal to the life of the investment. A piece of technology that will be in use productively for eight years should be analyzed over an eight-year period. If it’s only to be in use for three years, then use three years. If the lifespan is unknown, the default is to five years.
Table 5. Breakeven Point Calculation Annual Volume
Variable Operating Costs Procedure Costs Marginal Profit
Fixed Operating Costs
Salaries Fringe Benefits Office and Other Supplies Total Fixed Operating Costs
A third type of analysis that can be helpful in making a sound business case is breakeven analysis. This analysis identifies the amount of volume needed to achieve financial breakeven—the point at which there is neither a profit nor a loss. The breakeven point is calculated by dividing the fixed operating costs of the initiative by the marginal profit per unit, which is the difference between the net revenue per unit and the variable cost per unit. For example, let us suppose that a facility has the opportunity to offer a new procedure that is expected to generate net revenue of $1,125 each time the procedure is done. The procedure will be offered in space that is currently unused and available. Salaries for staff dedicated to this procedure are estimated to be $500,000 a year, plus fringe benefits equaling 20% of salaries (i.e., $100,000 per year). These are considered fixed costs. Each procedure consumes $400 of medical supplies (the variable cost). Office and other fixed supplies amount to $8,000 per month. Volume is expected to be 1,500 units per year. As seen in Table 5, the calculation is fairly straightforward. The marginal profit per procedure (the net revenue for each minus the variable cost for each) is divided into the total marginal fixed cost associated with this initiative ($696,000). The result, 960, is the number of procedures that will exactly cover those fixed costs. This means that at 960 units of volume, there will be zero profit and zero loss. If another unit of volume is achieved, a profit of $725 will result. If one unit fewer than 960 is achieved, there will be a loss of $725. Three data points must be considered to make a prudent decision about whether to proceed with the initiative. The breakeven point must be less than both the demand for the procedures and the organization’s capacity to perform them. If demand is only 900 procedures, the breakeven point of 960 will never be achieved. Even if the demand is for several thousand, breakeven will never be achieved at a facility whose capacity is only 750. As the proposal moves through the review process, questions may arise over the ability to achieve the level of volume underlying the proposal—the 1,500 units. How comfortable is the manager that the estimate will stand the test of time? A quick breakeven analysis can give some comfort despite the uncertainty. A breakeven point of 960 units represents less than 65% of the proposal’s volume estimate.
Total Operating Cost
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Profit or Loss
Net Revenue per Procedure
Variable Operating Cost per Procedure
Marginal Profit per Procedure
Total Fixed Operating Costs Marginal Profit per Procedure Breakeven Point
How comfortable is the manager that 65% of the proposed volume will be achieved? Knowing the proposal need only achieve 65% of the estimated volume to be successful, a decision maker may feel confident enough to move the proposal forward even though there is some question about the underlying 1,500-unit estimate. PARTING THOUGHT
Merely articulating the clinical and operational aspects of an infection prevention initiative is no longer enough. IPs must go further and use standard financial analysis tools to make the business case for their initiatives. Using the tools requires forethought and an understanding of financial principles, but once the analysis is completed, it can be paired with a compelling narrative to drive a favorable business decision and improve the quality of care. William (Bill) Ward, Jr., MBA, is an associate professor of health finance and management at the Johns Hopkins Bloomberg School of Public Health, and an associate professor of nursing at the Johns Hopkins University School of Nursing. He is the former director of the Master of Health Administration Degree Program and the Sommer Scholars Public Health Leadership Program. Prior to joining academia, he was a senior healthcare operations and finance executive.
PREVENTION IN ACTION
APIC 2018 Sneak Peek
Conversations with plenary speakers Alicia Cole and Jessica Green, PhD INTERVIEWS BY RICKEY ELAINE DANA
PIC 2018, which takes place June 13–15 in Minneapolis, promises to offer a robust learning experience with more than 100 educational sessions and workshops led by experts from around the globe. A highlight is always the plenary sessions, which provide new perspectives on common infection prevention issues. This year’s plenary keynote speakers are sure to add a new dimension to your thinking. Prevention Strategist recently spoke with Alicia Cole and Jessica Green, PhD, who offered a sneak peek of what they plan to cover during their presentations.
APIC 2018 sneak peek with Alicia Cole Alicia Cole —actress, health educator, and patient advocate—will be the opening
speaker at APIC 2018. In 2006, what was supposed to be a 2-day hospital stay for her rapidly descended into a two-month battle to save her life from the ravages of severe sepsis and necrotizing fasciitis. Since then, she has fought for system-wide improvement by serving on the California Department of Public Health (CDPH) HealthcareAssociated Infection Advisory Committee, and by currently serving a four-year term on the Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria (PACCARB). Her incredible healthcare odyssey is a 10-year case study of the state of healthcare, healthcare-associated infections (HAIs), and patient safety.
CAN YOU GIVE US A PREVIEW OF WHAT YOU WILL BE SHARING DURING YOUR TALK AT APIC’S ANNUAL CONFERENCE?
I’m very excited to be at this year’s APIC conference! The work being done by your membership is so crucial. I think the most important thing I can share is my story and my experience. I hope I might inspire those whose life’s work is preventing infections and who know how to do it better than anyone in the facility to “take the lead.” Now more than ever, patients need you!
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PREVENTION IN ACTION
“It shook me to my core to learn that more than two million other patients in the United States had suffered from an agonizing HAI that year, just like me. Even more sobering was learning that more than 100,000 of them would not survive.”
OU GOT INTO THIS Y FIELD BECAUSE OF YOUR EXPERIENCE AS A PATIENT; CAN YOU WALK US THROUGH YOUR JOURNEY?
I consider myself a sort of “accidental advocate.” It wasn’t something that I planned or even knew existed. On my bedridden days, I couldn’t sit up at the computer, so on a whim, I ordered a “talkto-type” program and, lying there with a headset, began blogging and using social media to share my road to recovery with others. I taught myself how to use editing software and began making videos to document the struggles of affected patients. In just a few months, the Myspace group I created for survivors and families touched by hospital infections and medical errors grew to more than 2,500 people. Suddenly, established healthcare organizations from across the country began calling to ask about my “organization”! The defining moment came when I received a call from the Consumers Union Safe Patient Project inviting me as one of their “Power 50” advocates to attend a patient safety summit and advocates training. It changed my life! I learned about advocacy, healthcare policy, and infections 101. I left there knowing that this was my new calling.
WHAT DID YOU LEARN EARLY ON THAT SURPRISED YOU?
Initially, the sheer numbers and the magnitude of HAIs. I had no idea. In my ignorance, I just assumed that infections only happened to people who did not keep their cuts and scrapes clean. It shook me to my core to learn that more than two million other patients in the United States had suffered from an agonizing HAI that year, just like me. Even more sobering was learning that more than 100,000 of them would not survive. The more I learned, the more I also became filled with great anger and disappointment. (Only one in four providers washes their hands between patients!?) Then, my hospital was cited by the local health department for not reporting my infection to them as mandated by law—a fact I find all the more appalling given that one of those months was spent in intensive care, fighting for my life!
IN YOUR OPINION, WHAT DO YOU THINK NEEDS TO BE DONE TO ADDRESS HAIs?
So much can be said on this subject. I think the most urgent and practical needs are those which address HAIs at the bedside and facility-wide levels. Time and again, hospitals across the country have demonstrated that we already have the knowledge to prevent deaths due to hospital infections. I would also like to see the government create an incentive program for infection prevention similar to the Centers for Medicare & Medicaid Services (CMS) Electronic Health Record (EHR) Incentive Programs. These programs provided incentive payments to eligible professionals and hospitals as they adopted, implemented, upgraded, or demonstrated meaningful use of certified EHR technology. To read the interview with Alicia Cole visit
Alicia Cole at the swearing-in for the Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria.
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APIC 2018 sneak peek with Jessica Green, PhD
CAN YOU GIVE A BRIEF DESCRIPTION OF WHAT YOU’LL BE SHARING WITH US AT APIC’S ANNUAL CONFERENCE?
AS A PROFESSOR, HOW DO YOU ENGAGE WITH YOUR STUDENTS TO DRAW OUT THEIR PASSION AND GET THEM EXCITED?
WHAT PROJECT ARE YOU CURRENTLY WORKING ON?
WHAT DO YOU SEEN ON THE HORIZON FOR THE FIELD OF INFECTION PREVENTION AND CONTROL?
WHAT CAN APIC MEMBERS DO TO HELP FACILITATE A HEALTHY MICROBIAL ENVIRONMENT?
AND FINALLY, WHAT EXCITES YOU?
I’ll be sharing new perspectives on indoor environmental quality based on published microbiome research and will touch upon emerging technologies and healthcare environments.
One way to engage students is to actively involve them in research. As an example, I worked with undergraduate students on a project to examine how direct contact among humans might impact the skin microbiome. We used roller derby as our model system and published our research here: https://peerj.com/articles/53/.
Jessica Green, PhD, is an engineer and
ecologist who specializes in biodiversity theory and microbial systems. Jessica uses approaches at the interface of microbiology, ecology, and data science to understand complex ecosystems with trillions of diverse microorganisms interacting with each other, with humans, and with the environment. She has been honored with numerous awards, including a Blaise Pascal International Research Chair, a John Simon Guggenheim Memorial Foundation Fellowship, and a TED Senior Fellowship. Jessica is a professor of biology at the University of Oregon, where she codirects the Biology and Built Environment Center (BioBE), and is external faculty at the Santa Fe Institute.
I am working on a lot of projects at the moment! One project I am working on at the University of Oregon is focused on understanding how daylighting impacts the viability and composition of microbial communities in indoor dust.
My sense is that infection prevention and control is becoming increasingly grounded in microbial ecology. Rather than focusing on individual pathogens, we now have access to technology that allows us to understand how individual pathogens respond to the entire indoor ecosystem.
Advocate for, sponsor, and engage in microbiome research in your facility. The more research and development that takes place in healthcare facilities, the faster we will learn. An example of this type of research can be found here: https://www.nature.com/ articles/ismej2011211.
As an entrepreneur, I’m excited about developing technologies that one day may improve the lives of people and the planet. I also love learning and very much look forward to the APIC conference.
To read more about our keynote speakers and see the education being offered, visit apic.org/AC2018
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Sepsis protocol and
healthcare facility-onset Clostridium difficile infection
BY ROBERT HIENSCH, MD
epsis remains a major cause of increased hospital costs, morbidity, and mortality.1 To improve the early recognition and treatment of sepsis in the emergency department (ED) and inpatient hospital units, a committee of experts and international organizations launched the Surviving Sepsis Campaign (SSC). One of the major initiatives to come out of the SCC guidelines was the development of integrated sepsis care bundles, in which a set of interventions—distilled from evidence-based guidelines—are grouped to provide an impact greater than any single intervention alone.2,3 In addition, the Centers for Medicare & Medicaid Services (CMS) now mandates reporting and adherence to sepsis quality measures as a core quality measure.4 Several studies have demonstrated that improved overall survival and decreased hospital costs are associated with increased adherence to the SSC guidelines, but there’s a lack of published data investigating unintended consequences of the program.3,5,6 w w w.apic.org | 61
“Integrated sepsis care bundles streamline evaluation and treatment, yet our research is a reminder that providers must face the difficult task of balancing delivery of timely sepsis care while mitigating unintended consequences.”
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Based on data that show increased mortality in patients with septic shock in whom antibiotic administration is delayed, the SSC guidelines stipulate that antibiotics should be administered within one hour of the recognition of sepsis onset.7 The stipulation of such an aggressive time frame—especially for a disease process such as sepsis that can be quite nebulous and lacks a gold standard test or event—parallels the former CMS mandate that required antibiotic administration for pneumonia within four hours of presentation to the ED. This rule led ED physicians to overprescribe antibiotics to anyone with potential pneumonia, which resulted in increased discrepancies between admission and discharge diagnoses of pneumonia, increased cases of Clostridium difficile infection due to unnecessary antibiotic use, and no differences in pneumonia mortality rates; the rule was ultimately abandoned by CMS.8 STOP-SEPSIS INITIATIVE In 2012, as part of the Greater New York Hospital Association, Mount Sinai Hospital introduced a sepsis performance improvement program called Strengthening Treatment and Outcomes for Patients with Sepsis (STOP-Sepsis) that was largely inspired by the SSC guidelines. It consists of a multimodality and interdisciplinary approach to recognizing and treating patients with potential sepsis. Paramount to the program is an electronic health record (EHR)-based sepsis screening tool and a sepsis order set bundle for the management of patients with suspected sepsis. The order set facilitates rapid entry of orders for laboratory testing, nursing monitoring stipulations, intravenous fluids, and antibiotics. Certain broad-spectrum antibiotics are made available on the nursing unit for immediate administration without requiring approval from the hospital’s antibiotic stewardship team. STOP-Sepsis appears to have been largely successful in reducing mortality rates due to sepsis.9 Which facet of the program led to improved clinical outcomes is unknown, but we suspect that early and appropriate antibiotics are at least partially contributing. However, the prevalence of healthcare facility-onset C. difficile infection (HCFO
CDI) has also increased in recent years, and the principal, modifiable risk factor for HCFO CDI is broad-spectrum antibiotic use.10 Therefore, we sought to investigate whether the introduction of STOP-Sepsis coincided with both a change in antibiotic usage and a change in HCFO CDI rates. This potential inadvertent impact of sepsis care programs had, to our knowledge, not yet been investigated. ANTIBIOTIC USE AND HFCO CDI We used interrupted time series data, a quasi-experimental design, to investigate the usage patterns of broad-spectrum antibiotics and HCFO CDI rates during three time periods: before, during, and after STOP-Sepsis was introduced in adults admitted to inpatient hospital units with the highest incidence of sepsis. Segmented regression analyses compared outcomes in the three time segments. We found that there were changes in patterns of antibiotic administration that correlated with the various stages of the STOP-Sepsis initiative. Among the most interesting findings was a trend toward increased use of antibiotics during the implementation phase, driven in large part by an increased use of levofloxacin. This trend reflected a change from the period before STOP-Sepsis was introduced, when broad-spectrum antibiotic use was generally decreasing. The increased use appeared to level off once STOP-Sepsis was fully implemented and integrated into the hospital. HFCO CDI rates mostly mirrored antibiotic use, increasing in trend during the implementation phase. The implementation phase reversed a decreasing trend for both antibiotic use and HCFO CDI. Of interest, levofloxacin is not one of the antibiotics typically used for the empiric treatment of sepsis in our hospital, nor is it part of the STOP-Sepsis order set. We speculate that it may have been used as the antibiotic of choice for de-escalation in patients started on broad-spectrum antibiotics for the empiric treatment of sepsis. The Infectious Diseases Society of America (IDSA) did not endorse the SCC guidelines, despite being represented in the working group that drafted the guidelines.11 A chief concern was the difficulty in distinguishing sepsis from noninfectious syndromes, which
could lead to overprescribing of antibiotics. As opposed to other CMS core measure guidelines, sepsis lacks an objective test or event to define the syndrome. Even sepsis experts often disagree about whether patients have sepsis, and more than 40 percent of patients with a working diagnosis of sepsis do not ultimately have the condition.3, 12 Anyone who abstracts charts for sepsis quality review purposes can attest that, even with all the data available, it can be quite difficult to separate cases of sepsis from noninfectious conditions. Inappropriate administration of antibiotics in patients who are not infected, or would not benefit from antibiotics (such as those with viral infections), has negative consequences for the individual patient and hospital populations in general. This riskbenefit ratio becomes all the more skewed as we include patients in the sepsis-screening algorithms who have sepsis but do not have shock or organ dysfunction. In the rush to meet the rigid time frames, broad-spectrum antibiotics will be given more frequently to uninfected patients with syndromes that mirror sepsis. MOVING FORWARD WITH SEPSIS BUNDLES While the increased rates of antibiotic use and HCFO CDI rates during our STOPSepsis implementation were worrisome, we were encouraged to see that these trends seemed to reverse as the program became more widely adopted. The longer-term effects (over several years) are still unknown. Optimistically, it is possible that providers have become more familiar at distinguishing sepsis and are therefore using antibiotics for a more appropriate patient population, as opposed to reflexively prescribing antibiotics to any patient who screened into the STOP-Sepsis program. Alternatively, increased adherence to another recommendation of the SSC guidelines—daily antibiotic reassessment and de-escalation when appropriate—may have become more widespread. Of course, it is also possible that the changes were due to factors unrelated to the sepsis initiative. Integrated sepsis care bundles streamline evaluation and treatment, yet our research is a reminder that providers must face the difficult task of delivering timely sepsis care
while also mitigating unintended consequences. We do not by any means discourage early broad-spectrum antibiotic administration in the septic patient, but further research is required to explore what other effects may come from the implementation of the CMS guidelines. Areas for investigation include the effects on HCFO CDI rates that we have attempted to highlight, as well as potential associations with antimicrobial resistance, laboratory overtesting, and excessive volume administration. We hope that identifying any adverse outcomes will allow the sepsis community to identify changes to further improve a program that has been demonstrated to save lives. Robert Hiensch, MD, is an assistant professor in Medicine, Pulmonary, Critical Care and Sleep Medicine Departments at the Icahn School of Medicine at Mount Sinai. He served as chief fellow during his final year of pulmonary and critical care training, and was awarded the Alvin S. Teirstein, MD, Fellow Award for excellence in clinical practice, teaching, and research. References 1. Gaieski DF, Edwards JM, Kallan MJ, et al. Benchmarking the incidence and mortality of severe sepsis in the United States. Crit Care Med 2013;41:1167-1174. 2. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41:580-637. 3. Mukherjee V, Evans L. Implementation of the Surviving Sepsis Campaign guidelines. Curr Opin Crit Care 2017;23(5):412-416. 4. Rhee C, Kadri SS, Danner RL, et al. Diagnosing sepsis is subjective and highly variable: A survey of intensivists using case vignettes. Crit Care 2016;20:89. 5. Levy MM, Dellinger RP, Townsend SR, et al. The Surviving Sepsis Campaign: Results of an international guideline-based performance improvement program targeting severe sepsis. Intensive Care Med 2010;36(2):222-231. 6. Levy MM, Rhodes A, Phillips GS, et al. Surviving Sepsis Campaign: Association between performance metrics and outcomes in a 7.5-year study. Crit Care Med 2015;43:3-12. 7. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006;34:1589-1596. 8. Klompas, M, Rhee C. The CMS Sepsis Mandate: Right disease, wrong measure. Ann Intern Med 2016;165(7):517-518. 9. Vogel, L. EMR alert cuts sepsis deaths. CMAJ 2014;186(2):E80. 10. Magill SS, Edwards JR, Bamberg W, et al. Multistate pointprevalence survey of healthcare-associated infections. N Engl J Med 2014;370:1198-1208.
READ MORE ABOUT SEPSIS IN THE AMERICAN JOURNAL OF INFECTION CONTROL Epidemiology of bloodstream infections caused by methicillin-resistant Staphylococcus aureus at a tertiary care hospital in New York. Yasmin M, El Hage H, Obeid R, et al., American Journal of Infection Control, Volume 44 Issue 1, 41–46. Impact of an electronic sepsis initiative on antibiotic use and healthcare facility–onset Clostridium difficile infection rates. Hiensch R, Poeran J, Saunders-Hao P, et al., American Journal of Infection Control, Volume 45, Issue 10, 1091–1100. Mortality in intensive care: The impact of bacteremia and the utility of systemic inflammatory response syndrome. Brooks D, Smith A, Young D, et al., American Journal of Infection Control, Volume 44, Issue 11, 1291–1295.
READ MORE ABOUT CLOSTRIDIUM DIFFICILE IN THE AMERICAN JOURNAL OF INFECTION CONTROL Hospital Clostridium difficile infection (CDI) incidence as a risk factor for hospital-associated CDI. Miller AC, Polgreen LA, Cavanaugh JE, et al., American Journal of Infection Control, Volume 44, Issue 7, 825–829. Impact of an electronic sepsis initiative on antibiotic use and health care facility–onset Clostridium difficile infection rates. Hiensch R, Poeran J, Saunders-Hao P, et al., American Journal of Infection Control, Volume 45, Issue 10, 1091–1100. Prevalence of Clostridium difficile infection in acute care hospitals, long-term care facilities, and outpatient clinics: Is Clostridium difficile infection underdiagnosed in long-term care facility patients? Krishna A, Pervaiz A, Lephart P, et al., American Journal of Infection Control, Volume 45, Issue 10, 1157–1159.
11. Gilbert D, Kalil A, Klompas M, et al. Infectious Diseases Society of America (IDSA) position statement: Why IDSA did not endorse the Surviving Sepsis Campaign guidelines. Clin Infect Dis 2017. doi: 10.1093/cid/cix997. 12. Klouwenberg PM, Cremer OL, van Vught LA, et al. Likelihood of infection in patients with presumed sepsis at the time of intensive care unit admission: A cohort study. Crit Care 2015;19:319.
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Creating a dream team: How frontline collaboration reduced healthcare-associated infections BY CLAUDIA SKINNER, DNP, RN, CIC, CCRN-K; LILIAN ABLIR, BSN, RN, CIC; TODD BLOOM, BS, CHES; STACIE LOMIBAO, MSN, RN, PCCN; AND REGINA SY-SANTOS, BSN, PHN, RN
The HAI dream team
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hile the annual costs of healthcare-associated infections (HAIs) have surpassed $9.5 billion in the United States alone, the clinician’s impetus to prevent HAIs is to save lives, not money.1 Building an interdisciplinary, shared-governance committee that engages frontline staff is imperative to creating and fostering a culture of safety. HAI reduction has been a strategic goal for St. Jude Medical Center for more than three years. While the hospital had a strong infection prevention department and was seeing some gains, HAI reduction targets were not being met. To reach our goals, we would need to increase collaboration with other disciplines and engage frontline clinicians. The New England Journal of Medicine reported in 2014 that on any given day approximately one out of 25 inpatients acquires one or more HAI.2 The HAI Progress Report, published by the Centers for Disease Control and Prevention (CDC) in 2016, showed significant reduction in nearly all infections; however, as a country, we still have a long way to go to ensure that all patients receive safe, reliable care.3 A robust body of evidence now indicates that HAIs can be significantly reduced. IMPLEMENTATION In our organization, we apply a high-reliability organization (HRO) model for program development, which requires leadership engagement, a culture of safety, and a strong performance improvement structure.4 In July 2015, the high-reliability philosophy was at the forefront of the design of the HAI Committee. The committee meets on a monthly basis and has four subcommittees: Central Line-Associated Bloodstream Infection (CLABSI) Reduction, Catheter-Associated Urinary Tract Infection (CAUTI) Reduction, Clostridium difficile Infection (CDI) Reduction, and Hand Hygiene Improvement. Surgical site infections (SSIs) are outside the scope of this committee because the stakeholders for SSIs are very specialized. The
HAI COMMITTEE STRUCTURE 2nd hour Frontline staff, physician champion – Metrics shared, case review, education sessions
– Managers dismissed – Working meetings & decisions made by frontline staff
– Co-Chaired by CCU RN and RCT – Focus on procedures & VAEs
1st hour All team, leaders
3rd hour CCU Team
Provided by Claudia Skinner, DNP, RN, CIC, CCRN-K
committee is based on the shared governance model, with active frontline staff participation and shared decision-making replacing a hierarchical structure. Each committee and subcommittee is chaired by an infection preventionist (IP). Monthly committee meetings consist of three 1-hour sections (see Figure 1). Department managers, frontline staff, and physician champions attend during the first hour, as IPs present metrics and case reviews of recently identified infections. Participants may receive education related to committee work on topics such as CDI testing methodologies, National Healthcare and Safety Network (NHSN) definitions, or evidence-based practice review and prevention strategies. For the second hour, managers are dismissed and the HAI Committee divides into subcommittee
“Our first priority involved building an infrastructure to support the committee work and promote enthusiasm about projects that traditionally did not attract frontline staff. To ensure meetings were interactive and fun, we incorporated team-building activities.”
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activities. HAI Committee members were asked to commit for a full year for continuity of project work. Hospital executives showed support and engagement through attendance at the first meeting, and by compensating staff for up to four hours a month for focused rounding, completing audits, and HAI Committee meeting attendance. Staff were encouraged to attend meetings on their days off to ensure that census or staffing issues didn’t compromise their ability to attend.
teams for working meetings where decisions are made by the interdisciplinary team members. During the breakout sessions, subcommittees work on evidence-based literature reviews, bundle designs, documentation changes, dashboard development, audit tools, and product/equipment selection. The third hour is reserved for the critical care staff to review infection prevention strategies specific to their unit, including ventilator-associated events. The session is co-chaired by a critical care nurse and respiratory therapist lead. To build out the subcommittees, we recruited frontline staff with an interest in infection prevention and a willingness to commit the time. We looked for staff with good communication skills and the
ability to collaborate well with other departments, such as nursing and environmental services. Each team included a physician champion specializing in infectious disease, nephrology, or gastroenterology. In addition, teams included representatives from frontline nursing and ancillary staff, such as speech therapy, environmental services, vascular access team RNs, and dialysis RNs. Staff were able to choose the subcommittee where they felt their service could have the most impact. Our first priority involved building an infrastructure to support the committee work and promote enthusiasm about projects that traditionally did not attract frontline staff. To ensure meetings were interactive and fun, we incorporated team-building
“To build out the subcommittees, we recruited frontline staff with an interest in infection prevention and a willingness to commit the time.” 66 | SPRING 2018 | Prevention
PROCESS, STRATEGIES, AND TACTICS The community that was built through this process brought together staff with a variety of clinical and nonclinical experiences and a wide range of expertise. Allowing staff to select their subcommittee of interest helped promote active participation. Over time, a healthy competition developed among the reduction teams, which kept team members engaged. The staff were given the opportunity to be innovative in their efforts to reduce HAIs. For instance, the CDI Reduction team members decided to trial placing bouffant head covers over alcohol sanitizer dispensers in patient care rooms where CDI is identified. This visual alerts staff and visitors to wash their hands with soap and water instead of using alcohol hand sanitizer. One of the subcommittees’ tasks was to review a root-cause analysis of past infections and develop strategies for prevention. An example of a robust process improvement strategy is the timely dissemination of newly identified HAIs. When a CAUTI, CLABSI, or CDI is discovered, the root-cause analysis is completed and shared promptly with the unit manager and subcommittee members. This information allows frontline staff to identify gaps, create action plans, and become involved in the prevention of future infections. By following this process, we acknowledge the patient who is harmed and do not merely view the HAI as a number in our metrics. To promote a culture of safety, the IP chair for each committee works with their team members to develop rounding/auditing tools and create an audit dashboard to display the adherence to bundle elements. These tools
drive improvement measures for high reliability. The dashboard metrics are reported to individual patient care units, with the focus on holding each unit and manager accountable. To improve compliance, any barriers to adherence are addressed. In addition, the HAI Committee compares metrics from other health system hospitals to glean best practices from high performers. Members of the CAUTI Reduction Committee visited a sister hospital to go on rounds and view its prevention bundle efforts while learning about its implementation process from frontline staff. A final strategy to keep the HAI Committee energized is recognizing staff and celebrating success when infection rates are reduced. For example, members of the leadership team went on rounds on patient care units to share their appreciation. At the closing meeting of the year, all committee members received an â€œHAI Heroâ€? decorated cookie and were served a special meal by the infection prevention team. These simple efforts highlight the significant work of committee members and keep staff engaged.
FINDINGS Much of the introductory work of the HAI Committee concentrated on researching evidence-based practices to develop bundles for prevention. The results of this focused work created experts in CLABSI, CAUTI, and CDI prevention, along with best practices for hand hygiene. HAI rates began to drop, with a reduction in overall HAIs over the past two years. Because hand hygiene is the most effective way to prevent the spread of infections, a strong hand hygiene campaign was necessary. Strategies developed by the Hand Hygiene Improvement subcommittee influenced our success. For example, to increase hand hygiene awareness and compliance, the subcommittee piloted an electronic hand hygiene surveillance program on the critical care unit. The standardized infection ratios (SIRs) for CDI, CAUTI, and CLABSI were at their highest points one year prior to the launch of the HAI Committee (See Figures 2-4). Those data inspired the call to action to address the rise in HAIs. Over time, through reduction efforts, the units achieved w w w.apic.org | 67
“The standardized infection ratios (SIRs) for CDI, CAUTI, and CLABSI were at their highest points one year prior to the launch of the HAI Committee. Those data inspired the call to action to address the rise in HAIs.” decreases in CLABSI and CDI. To reduce CLABSI, we implemented a new central line kit and bundle and improved the care and maintenance of central line dressings. This comprehensive approach resulted in a hospital-wide CLABSI reduction. Through the efforts of the CDI Reduction Subcommittee, a CDI nursing screening protocol was created, and the testing methodology was changed with approval from medical staff. This change included adding an antigen/toxin test to the previous PCR DNA methodology to capture more active CDIs versus colonization. While we saw a slight drop in CAUTIs during the first six months of our effort, this reduction was not sustained. The barriers we faced reflect the ongoing nationwide struggle to decrease this particular HAI.3 The CAUTI Reduction Subcommittee continues to review intensive assessments to identify potential gaps and other possible prevention strategies. The subcommittee identified that half of the CAUTIs in our neurological population had central fevers that were possibly related to the patients’ neurological deficits rather than a true urinary tract infection. Based on this finding, strategies must be developed to ensure that physicians include appropriate indications prior to ordering a urine culture, as well as changing the electronic medical record (EMR). An additional strategy will focus on appropriate collection of urine cultures and use of regularly scheduled intermittent catheterization instead of indwelling urinary catheters. 68 | SPRING 2018 | Prevention
CHALLENGES In any new program, challenges will occur. Some of those encountered by the HAI Committee included: • Getting participation from night-shift staff in daytime meetings. o We established a set schedule of meetings and sent it out in advance to allow all staff to make arrangements to attend. • Garnering physician buy-in for initiatives such as using CDI testing algorithms or timely removal of indwelling urinary catheters. o We used physician champions to deliver a consistent message about the importance of implementing infection prevention measures. The IP chairs attended medical staff meetings and presented rationales for action plans. • Attaining timely EMR documentation changes to support the infection prevention strategies. Only regional EMR documentation changes were approved; no individual hospital change requests were allowed. o We sought regional health system buy-in for best practices to encourage acceptance.
• Addressing the lack of infection prevention review when products are changed. For example, a change in needleless connectors led to a spike in CLABSIs. o We discussed the issue with executive leadership overseeing the materials management department. This resulted in a structure change that allowed stakeholder participation in decision-making regarding new products. CONCLUSION The prevalence of HAIs makes collaborative infection prevention efforts necessary. The goals of our HAI Committee include keeping staff committed and sustaining project efforts and results through the participation of frontline staff. As hospitals deal with
“The goals of our HAI Committee include keeping staff committed and sustaining project efforts and results through the participation of frontline staff.”
the financial cost of HAIs, it is the patients who bear the direct burden of these preventable harm events. Our interdisciplinary approach to reduce HAIs has not only heightened awareness of prevention strategies, but also created a culture of safety that builds and fosters a safe environment for staff, patients, and loved ones. Claudia Skinner, DNP, RN, CIC, CCRN-K, is a director overseeing an infection prevention program at a midsize community hospital with more than 20 years as a bedside critical care nurse. She is certified in critical care nursing as well as infection control. Lilian Ablir, BSN, RN, CIC, is an infection preventionist. Her responsibilities include facilitating the CLABSI HAI Committee. She has more than 20 years of professional nursing experience, including more than 10 years of experience as an infection control nurse. Todd Bloom, BS, CHES, is an infection prevention coordinator. His primary focus is working with nonclinical areas, including dietary services and environmental services, to ensure that proper infection prevention measures are being followed. He also chairs the Hand Hygiene Committee. Todd received his Bachelor of Health Science in 2006. Stacie Lomibao, MSN, RN, PCCN, is an infection prevention registered nurse. Her background includes more than eight years of experience in the clinical laboratory and three years of experience as a bedside RN on the cardiac/telemetry and step-down units.
Regina Sy-Santos BSN, PHN, RN, is an infection preventionist. She facilitates the CAUTI Team and collaborates with frontline staff and the nephrology (physician) champion to improve outcomes for patients. References 1. Zimlichman E, Henderson D, Tamir O, et al. Health careassociated infections. A meta-anylsis of costs and finacncial impact on the US health care system. JAMA Intern Med. 2013;173(22):2039-2046. 2. Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of healthcare-associated infections. N Engl J Med 2014;370:1198-1208. http://www.nejm.org/doi/full/10.1056/NEJMoa1306801. Accessed October 2017. 3. Centers for Disease Control and Prevention. National and state healthcare-associated infections progress report. 2016. https://www.cdc.gov/hai/surveillance/progress-report/ index.html. Accessed February 2018. 4. Sutcliffe, KM. High reliability organizations (HROs). Best Pract Res Clin Anesthesiol 2011;25(2):133-144.
READ MORE ABOUT PREVENTION OF HEALTHCARE-ASSOCIATED INFECTIONS IN THE AMERICAN JOURNAL OF INFECTION CONTROL Perceived strength of evidence supporting practices to prevent healthcare-associated infection: Results from a national survey of infection prevention personnel. Saint S, Greene MT, Olmsted RN, et al., American Journal of Infection Control, Volume 41, Issue 2, 100–106. The influence of intensive care unit-acquired central line-associated bloodstream infection on inhospital mortality: A single-center risk-adjusted analysis. Wong SW, Gantner D, McGloughlin S, et al., American Journal of Infection Control, Volume 44, Issue 5, 587–592. Risk factors for healthcare-associated infections: From better knowledge to better prevention. Ferreira E, Pina E, Sousa-Uva M, et al., American Journal of Infection Control, Volume 45, Issue 10, e103–e107.
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