Prevention Strategist—Fall 2018

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Implementation Science Features from APIC Annual Conferences Reducing the incidence of surgical site infections SNAP: A hand hygiene campaign

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FALL 2018


Features from APIC Annual Conferences: Life before antibiotics? The era may be coming back Nursing homes lag in infection prevention activities, but the numbers are improving Stay in your lane: New algorithm helps IPs prioritize a variety of scenarios and requests Implementation science offers tools to bring evidence-based practices to your facility By Sandy Smith and Vicky Uhland


From cowboys to collaborators: Building a partnership between IPC and the ED By Beth Wallace


How do you clean this thing? Making a place for IPs in the purchasing process By Meagan Garibay

6 | FALL 2018 | Prevention


Making the pitch to executive row—Part 1: Put together the proposal By William Ward, Jr.


epiLinks: Social media surveillance for infection preventionists By Cody Haag, Angela Vassallo, and Daniel Field


SNAP: A hand hygiene campaign that improves compliance and fosters a just culture By Christine Rose and Lee Anne Siegmund


Reducing the incidence of surgical site infections through evidence-based practice: A success story By Julie Woodruff, Gayla Tripp, Maryann Reese, and Sharon Hohler


VOICE No policing involved

By Janet Haas, 2018 APIC President


Congratulations for increasing your influence!


Certification: Going global


By Katrina Crist, APIC CEO

By Joann Andrews, 2018 CBIC President

DEPARTMENTS Briefs to keep you in-the-know



• APIC 2018 Heroes of Infection Prevention, Part 1 • Congratulations to the 2018 APIC Fellows • PGC Practice Corner: Point-of-use cleaning • Research in infection prevention and control • Protect Your Patients infographic

Meet an MPH


Capitol Comments: The evolution of infection control regulations


Infection Prevention Leadership: New Jersey chapter award winner


A conversation with Alex Sunderman By Rich Capparell, Nancy Hailpern, and Lisa Tomlinson Q&A with Christine Young-Ruckriegel


PREVENTION IN ACTION Celebrate International Infection Prevention Week


My Bugaboo—Update on CRE: carbapenem-resistant Enterobacteriaceae


From data to decisions—Interpreting uncertainty: Is the difference real?


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


By Julie Blechman and Sophie Harcleroad

By Irena Kenneley

By Christina Bronson-Lowe and Daniel Bronson-Lowe

By Steven Schweon and Julie Wright

68 w w | 7


No policing involved


“When IPs bring knowledge and analytic skills to the table as colleagues, we can improve care rather than policing potentially broken processes.”

GREETINGS AND HAPPY FALL! Take a walk to enjoy the blue skies, colorful

leaves, and crisp air. I hope those of you who attended APIC’s Annual Conference over the summer got at least one new idea to implement at your facility; and I know that most of us have a few ideas for improvements at any given moment. This issue of Prevention Strategist focuses on implementation science—implementing is what we already do, often without realizing there is a science behind it! Educating ourselves about the science can make us more effective on behalf of patients, our colleagues, and our facilities. Implementation comes down to “why” and “how.” I am not referring to infection preventionists (IPs) telling staff the rationale for our requirements (although that is important, too). Rather, I’m referring to how we need to understand why care providers are not using best practices. This means getting feedback from front-line providers and listening to what the barriers are. Next comes collaboration to determine how to implement best practices within the clinicians’ workflow. IPs have the reputation of being the police for hand-washing and cleanliness. I was recently chatting with some people, including a medical resident, while waiting in line for an event. He immediately brought up the police metaphor upon hearing that I was an IP. I get it—holding colleagues accountable is part of our role…but it’s a pretty “old school” and negative image. I’d much rather be described as a sleuth who helped solve a problem! Implementation science helps us get there. Dissecting care processes down to each element of work flow to identify exactly where there’s a gap is the first step to a good intervention. And you might be surprised by what you learn! I once had a unit with increasing numbers of neurosurgery patients and increased catheterassociated urinary tract infection (CAUTI) rates. My first IP thought was to re-educate, until we asked the nurses. It turned out that the frequency and documentation for neuro checks was so extensive that they could not get to basic care of Foley catheters. They knew what to do, they just needed the time to do it. In that case, decreasing CAUTI depended on improving the process for neuro checks! The physicians changed the protocol to include only what was essential. This was a win for us as a team and resulted in fewer CAUTIs for patients…no policing involved! When IPs bring knowledge and analytic skills to the table as colleagues, we can improve care rather than policing potentially broken processes. That’s good for patients, good for the clinical teams, and can make our role as IPs particularly rewarding. If you’ve used implementation science successfully—please share your experience with the rest of us! It’s easy to share on IP Talk, or write it up as an abstract for APIC’s Annual Conference next year.

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

8 | FALL 2018 | Prevention

Prevention FA L L 2 018 • VO L U M E 11 I S S U E 3

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

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

EX OFFICIO Katrina Crist, MBA, CAE

DISCLAIMER Prevention Strategist is published by the Association for Professionals in Infection Control and Epidemiology, Inc. (“APIC”). All rights reserved. Reproduction, transmission, distribution, or copying in whole or in part of the contents without express written permission of APIC is prohibited. For reprint and other requests, please email 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.


Congratulations for increasing your influence!


APIC CONDUCTED A STUDY earlier this year to gain an understanding of

how C-level hospital executives view the role of the infection preventionist (IP). Several key findings were exciting to see, especially these two: • More than four in five respondents (86 percent) agree that the IP plays a critical role in improving patient health and safety at their institution. • More than two in three respondents (69 percent) believe that in the past two years, the influence of the IP has increased on issues related to healthcare-associated infections (HAIs). APIC’s Board of Directors will be discussing the results of the C-Suite survey at its September meeting, and we look forward to sharing more of the data with you, along with how we intend to use it moving forward. As part of APIC’s ongoing efforts to increase the influence of IPs, I shared in my last column that APIC will be holding a national consensus conference in November to foster meaningful engagement and actionable recommendations among key stakeholders on The Role of the Infection Preventionist in a Transformed Healthcare System: Meeting Healthcare Needs in the 21st Century. Invited attendees will examine and reach consensus on recommendations that address four themes: 1) The enhanced role of the IP; 2) Evaluate the current state of the IP’s education and preparation; 3) Advance strategies that support the IP’s practice across the continuum of care; and 4) Outline the value proposition to enhance the IP’s role. The future-oriented recommendations will be published in the American Journal of Infection Control (AJIC). Another strategic program that not only speaks to the heart of increasing IPs influence, but showcasing it, is the APIC Program of Distinction ( This program evaluates infection prevention and control (IPC) programs against a set of criteria that APIC developed and recognizes facilities for their excellence in meeting these high standards. We are receiving a great deal of interest, and facilities are starting to move through the application process. We encourage you to purchase a set of the standards and start evaluating your program against them and striving to achieve the criteria and standards that the leaders in IPC established as worthy of distinguished recognition by APIC. APIC will continue to develop programs and strategic initiatives with the goal of continuing to increase the overall value of IPs and increase visibility both within your healthcare facilities and externally. Influence is key—your ability to influence others and decisions is working and will continue to grow!

Prevention FA L L 2 018 • VO L U M E 11 I S S U E 3

PUBLISHER Katrina Crist, MBA, CAE MANAGING EDITOR Rickey Dana CONTRIBUTING EDITORS Julie Blechman, MPH, CHES Elizabeth Garman, CAE Elizabeth Nishiura PROJECT MANAGER Russell Underwood ADVERTISING Brian Agnes GRAPHIC DESIGN BK Publication Design

EDITORIAL PANEL Timothy Bowers, MS, CIC, CPHQ, FAPIC Gary Carter, MPH, CIC, CIH, REHS, DAAS Kristine Chafin, MBA, RN, CIC Edina Fredell, MPH, CIC, MT(ASCP) Ruth Freshman, 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 Julie Blechman, MPH, CHES Elizabeth Garman, CAE 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 PUBLISHED SEPTEMBER 2018 API-Q0318 • 8608

Katrina Crist, MBA, CAE

10 | FALL 2018 | Prevention

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 for free educational resources and evidence-based products to help you stop bloodstream infections before they start.

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Certification: Going global


“I feel privileged and humbled to learn from IPs who are making a difference in their facilities.”

AS I RETURN from the infection preven-

tion conferences of IPAC Canada in the beautiful mountains of BanffAlberta, Canada, and APIC in scenic Minneapolis, I am extremely impressed with the emphasis placed on certification. It is always exciting for the Certification Board of Infection Control and Epidemiology (CBIC) Board of Directors to interact with the many infection preventionists (IPs) who visit us at the booth. At both conferences, the heightened interest in certification was palpable. The value placed upon certification is certainly evident when visiting with groups and individuals at APIC and IPAC Canada. It was exciting to learn of APIC’s strategic initiative “Certification: The Defining Difference.” This new initiative clearly demonstrates that APIC recognizes, as CBIC does, that certification and improved patient care are clearly linked. We thank the many of you who participated in CBIC’s survey in May addressing the value of certification. Stay tuned for the results of this study later in the year. Annual conferences are always a time of renewal. I’m invigorated by the new research, new technology, and new industry partners that will assist us to decrease healthcare-associated infections (HAIs). There were impressive success stories of novel products and approaches to address recurrent long-standing infection prevention and control challenges. I feel privileged and humbled to learn from IPs who are making a difference in their facilities. Some of these IPs are relatively new to the field, but this next generation is looking at old problems with fresh approaches. It is thrilling to think of the momentum that arises from conferences that will transform into initiatives as IPs return home. Are you aware that the initial certification in infection prevention and control (CIC®) examination is available in Canadian French? CBIC is happy to offer this version to IPAC Canada candidates and others who are fluent in Canadian French. Please notify the CBIC office if you have any questions. Our international partners expressed a strong interest in certification at the CBIC booth. The CIC is becoming the gold standard to assure competency and improved patient safety internationally. Did you know that individuals holding the CIC designation at the APIC conference represented 39 countries? We found many IPs hoping to increase certification in their countries in an effort to provide better outcomes and safer care for their patients. The drive for certification was clearly evident in these international partners. In particular, conference attendees represented Australia, Jordan, Saudi Arabia, Thailand, and Taiwan. An impressively large group had journeyed all the way from Japan. Can you imagine traveling 40 hours to arrive at APIC? This is one of the stories of dedication that was shared with us. I hope that I got to meet you at one of the conferences this year. Your stories of success abound in your novel thinking and problem solving, your increased professionalism, and in your improved ability to prevent infections for patients. The CBIC Board of Directors thanks you for your efforts to bring certification to your facility. I celebrate with those of you who proudly wear the CIC credential and use the designation in your correspondence. You are our heroes of certification. Congratulations to all of you who are certified and the best to all who will be sitting for their initial or recertification in 2018!

Joann Andrews, DNP, RN, CIC 12 | FALL 2018 | Prevention

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Meet the 2018 Heroes of Infection Prevention VISIT THE HEROES of Infection Prevention web page,,

to read full profiles and inspirational stories from the heroes.

Containing an outbreak through preparation and collaboration • Patsy Stinchfield, MS, RN, CNP, CIC • Adriene Thornton, RN, MA, CIC • Julie LeBlanc, MPH, CIC • Wendy Berg, BSN, RN, CIC • Jennifer Boe, BSN, RN, PHN, CIC • Joseph Kruland, MPH, CIC • Martina Korinek, MPH, CIC Children’s Hospital and Clinics of Minnesota Minneapolis, Minnesota THE INFECTION PREVENTION and con-

trol (IPC) team at Children’s Hospital and Clinics of Minnesota effectively employed their experience and relationships to rapidly contain the largest state measles outbreak in 30 years. “Unfortunately, we’re experienced in measles outbreaks,” said Patsy Stinchfield, senior director of IPC. “But it helped us be prepared.” When Children’s identified the first measles case in April 2017, established IPC processes and systems gave the team a head start on containment. These included an “empty and ready” spreadsheet to track individual patient details, an electronic medical record that generated reports detailing potential in-hospital exposures, and the knowledge that Children’s staff was MMR-vaccinated. “You don’t want to be building the plane and flying it at the same time,” Stinchfield said. “The clock is ticking.”

14 | FALL 2018 | Prevention

The organization mobilized by using the Hospital Incident Command System (HICS). “We designated a single process of communication and emphasized that HICS only works if everyone follows it,” Stinchfield said. IPC team member Adriene Thornton highlighted the importance of strong, cross-hospital relationships in an outbreak. “Make friends and keep them. You’ve got to have good relationships in order to mobilize people quickly,” she said. The Children’s IT department established a phone bank for exposed patients, and the IPC team recruited other nurses

to make exposure calls while facilities converted emergency department rooms for airborne isolation. The Children’s team also helped contain the outbreak statewide by partnering with the Minnesota Department of Health to assist with at-home patient management and shared information about their interventions in statewide clinicians’ conference calls. Ultimately, the Children’s IPC team helped end the measles transmission within five months and a total of 75 cases, while also improving patient management and fostering IPC relationships statewide.

Improving antimicrobial stewardship nationwide through untiring leadership • Marc Meyer, BPharm, RPh, CIC, FAPIC Southwest Memorial Hospital Cortez, Colorado MARC MEYER HAS tirelessly lever-

aged his infection prevention and pharmacy expertise to become a recognized leader and advocate for antimicrobial stewardship (AMS), driving improvements in his small critical-access facility, his community, and nationwide. A pharmacist by training, Meyer assumed responsibility for his 25-bed hospital’s infection control department in 1995. “I saw an ideal marriage between clinical pharmacy and infection prevention,” Meyer said. “These departments really need to work together, especially in small hospitals.” Meyer quickly recognized the importance of using data to mobilize infection prevention improvements. He also instituted a collaborative, education-based guideline-development process that “works every time.” Southwest Memorial credits Meyer and his department for a 60

percent decline in surgical site infections and a 30 percent decline in multidrug-resistant organisms. But Meyer knew that hospitalbased efforts alone would not preserve antimicrobial efficacy. As a member of the Colorado Hospital Association’s AMS collaborative, he works with 26 hospitals statewide to improve stewardship. He also conducts outreach to community dentists, medical clinics, and long-term care facilities. Meyer designed a urinary tract infection (UTI) stewardship program for a long-term care chain that resulted in a two-day decrease in therapy days as well as a 27 percent reduction in UTIs. “Medical directors in the centers were skeptical and guidelines often weren’t enough to convince them,” Meyer said. “One-on-one discussions and training really made a difference.” Extending his advocacy and leadership even further, Meyer has helped the Centers for Disease Control and Prevention (CDC) and the National Quality Forum develop ASM guidance documents. Arjun

Srinivasan, MD, the CDC’s associate director for healthcare associated infection prevention programs said, “Marc’s rare combination of infection control and pharmacy expertise, along with many years of service in a critical access hospital, make him an invaluable resource to us.” “Rural health is truly different,” Meyer said. “I’m proud to be a leader for these facilities.”

The importance of leadership support for infection prevention and control APIC AND SHEA teamed up to author op-eds that highlight the need for institutional support from hospital leadership for infection prevention and control and antimicrobial stewardship programs, calling on health system leaders to maximize the effectiveness of these programs by aligning them and funding them adequately.

Read them here:

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Process improvements and culture change drive C. diff decrease • Harsha Dave, RN, BSN, BSMT(ASCP), CIC • Jan Olivas, MBA, RN, CPHRM, CPPS • Lisa Schaffer, RN, CIC MountainView Hospital Las Vegas, Nevada


Quality departments at MountainView Hospital combined evidence-based process improvements with an emphasis on front-line collaboration to significantly enhance safety for their patients. In early 2015, the team “de-engineered” the healthcare-associated infections (HAIs) their facility was reporting to identify specific improvement opportunities. Leveraging their varied medical technology, quality, and nursing backgrounds, Harsha Dave, Jan Olivas, and Lisa Schaffer then created processes to reduce HAIs across the board, with an emphasis on Clostridium difficile (C. diff). “C. diff was even lower hanging fruit than some of the other HAIs because

16 | FALL 2018 | Prevention

of the inappropriate testing we identified,” Olivas said. Using evidence-based guidelines, the team developed a C. diff testing algorithm designed to prevent unnecessary and duplicative testing. The algorithm was disseminated to all healthcare workers in the facility; medical staff leadership’s support for the project and appropriate testing was clear. Other process improvements included ongoing education about C. diff (including appropriate testing) at all levels, antibiotic deescalation, and emphasis on proper environmental cleaning. Dave, Olivas, and Schaffer greatly enhanced adoption of these

improvements through a relentless focus on collaboration and communication. “Infection prevention doesn’t live behind a desk. It lives on the units and at the bedside,” Dave said. “We are on the units educating, communicating, and breaking down barriers.” The team also empowered “mini infection preventionists” on every unit. The appropriateness of C. diff testing at MountainView has greatly improved. The facility’s C. diff rate dropped from a standardized infection ratio (SIR) of 1.78 in 2015 to 0.56 in mid-2016. “We found those passionate people who were truly interested to be patient advocates and engaged them to help us change the culture and the outcome,” Schaffer said.

Congratulations to the 2018 APIC Fellows THE APIC FELLOWS PROGRAM recognizes exemplary APIC members with status as a Fellow of the Association for

Professionals in Infection Control and Epidemiology (FAPIC). Fellow of APIC status is a distinction of honor for infection preventionists who are not only advanced practitioners of infection prevention practice, but also leaders within the field. Congratulations to the 2018 APIC Fellows. Learn more: Marsha Barnden, RNC, MSN, CIC, FAPIC Ruth Belflower, MPH, RN, CIC, FAPIC Mary Bellush, RN, MSN, CIC, FAPIC Nathaniel Bravo, RN, BSN, MS, CIC, FAPIC Angela Dickson, MN, BSN, RN, CIC, LSSBB, FAPIC Salah Fouad, MBCHB, MS, CIC, FAPIC Angela Gabasan, MSN, RN, CIC, FAPIC Bobbiejean Garcia, MPH, CIC, FAPIC Barbara Goss-Bottorff, MPH, MSN, RN, CNS, CIC, FAPIC Jessica Hayashi, MS, BSN, RN, CIC, CPHQ, FACHE, FAPIC Sally Hess, MPH, CIC, FAPIC Lisa Hines, MACPR, BS, RN, CIC, FAPIC Kim Horn, RN, BS, MPH, CIC, FAPIC Nancy Johnson, RN, MSN, PHN, CIC, FAPIC Debra Johnson, MPH, BSN, RN, OCN, CIC, FAPIC Christine Kettunen, PhD, MSN, RN, CIC, FAPIC Jill Lindmair-Snell, MSN, RN, CIC, FAPIC Michelle Macaluso, RN, MN, CIC, FAPIC Alexandra Madison, BA, BS, MPH, CIC, FAPIC Sonia Miller, EdD/CI, MSN, BSN, RN, CIC, FAPIC Cathryn Murphy, PhD, RN, BPhoto, MPH, CICP-E, CIC, FAPIC Janet Nau Franck, MBA, BSN, CIC, FAPIC Jeanne Pfeiffer, DNP, MPH, RN, CIC, FAAN, FAPIC Mary Pool, RN, BSN, MS, CIC, FAPIC, FAPIC Mona Shah, MPH, CIC, FAPIC Faith Skeete, MSN, RN, CIC, FAPIC Claudia Skinner, DNP, RN, CIC, CCRN-K, NE-BC, FAPIC Justin Smyer, MBA, MPH, MLS(ASCP)CM, CIC, FAPIC Rachael Snyders, MPH, BSN, RN, CIC, FAPIC, FAPIC Richard Vogel, BS, MS, CIC, FAPIC Cynthia Zips, MPH, SM(ASCP)M, HACP, CPHQ, CIC, FAPIC

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PGC Practice Corner

THE APIC PRACTICE GUIDANCE COMMITTEE (PGC), as part of its charge, routinely reviews and comments on guidelines, standards, and

draft documents that relate to infection prevention. The PGC Practice Corner is intended to update members on relevant issues.

The Importance of point-of-use cleaning POINT-OF-USE CLEANING IS receiving

increased attention as a culprit in the fight to limit equipment contamination and eliminate healthcare-associated infections (HAIs). Infection preventionists (IPs) working with sterile processors, and other healthcare workers who require multipatient use items, need to highlight this critical step. According to the Centers for Disease Control and Prevention (CDC) in the Guideline for Disinfection and Sterilization in Healthcare Facilities, medical equipment and instruments/devices must be cleaned in order to prevent patientto-patient transmission of infectious agents.1 According to multiple Association for the Advancement of Medical Instrumentation (AAMI) standards, point-of-use cleaning is a vital step to processing instruments via high-level disinfection or sterilization. We must also clean and maintain the equipment according to the manufacturers’ instructions, which can prove challenging at times.

Cleaning, including the removal of biofilm, is important as any remaining residual proteinacous material on the instrument/device reduces the effectiveness of the disinfection and sterilization processes. Equipment and devices should also be handled in a manner that will prevent healthcare staff and environmental contact with potentially infectious material. Point-of-use cleaning is the removal of bioburden or foreign material as soon as use of the item is completed, and is performed on critical, semicritical, and noncritical items or equipment at the point of use before leaving the room. This includes critical items such as surgical instruments; semi-critical items such as flexible endoscopes or endocavitary probes; and non-critical general-use items such as commodes, intravenous pumps, ventilators, and other patientcare equipment. Specific to surgical instruments, endoscopes, and endocavitary probes, point-of-use cleaning includes the removal of gross blood

or body fluids and the application of a detergent solution. This step is completed prior to transporting the instruments from the operating or procedural suite.

Take-away notes • Point-of-use cleaning is a vital step; • Utilize detergent or enzymatic solution to perform point-of-use cleaning; • Perform point-of-use cleaning prior to leaving the room and prior to transport; • Handle equipment and devices carefully to prevent transmission to self or environment; and • Follow manufacturer’s instructions for use for both device/equipment and solutions. Reference 1. Centers for Disease Control and Prevention. (2008). Guideline for Disinfection and Sterilization in Healthcare Facilities (2008). Retrieved from Disinfection and Sterilization:

NEW: Protect Your Patients Infographic Poster KEEPING PATIENTS SAFE from infection is everyone’s responsibility. From nurses to doctors, environmental services

to the OR, everyone needs to know the top ways to prevent infections. APIC developed a new infographic poster for IPs to share with their facilities. Download and print your free copy of the Protect Your Patients infographic poster at

A special thanks to APIC's Communications Committee for their help in developing this resource.

18 | FALL 2018 | Prevention

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“The MPH course work in epidemiology, biostatistics, infectious diseases, and more, are all skills used on a daily basis as an IP.”

Describe your path to getting your MPH degree.

In what ways has your MPH degree benefitted you and your facility?

I received my bachelor’s degree in microbiology from the University of Rochester in 2013 but was still unsure about my future career path. However, I knew I was interested in infectious diseases. My advisor told me about the MPH degree and the opportunities with infectious diseases at health departments and hospitals. The University of Pittsburgh Graduate School of Public Health offered an MPH degree in infectious diseases and microbiology, which I thought was the perfect fit for me.

The MPH course work in epidemiology, biostatistics, infectious diseases, and more, are all skills used on a daily basis as an IP. A successful IP needs to know about the diseases we are trying to prevent, the proper study methods to investigate, and the statistical analysis to show effective outcomes. MPH IPs have the foundational knowledge of these investigative skills which are advancing the field of infection prevention.

What inspired you to become an infection preventionist (IP)?

As IPs, we often have to work out operational issues or investigate the root cause of infections. As a graduate student, Dr. Muto would tell me to “keep asking ‘why?’” Eventually, you will get to the answer, which can often be “It is the way we’ve always done it.” That creates an opportunity for you to get everyone on the same page about exploring evidence-based procedural changes that prevent infections.

The Pitt MPH program offers practicum experiences to students, which is a 200-hour program where students work and interact with public health groups to gain real-world experiences. I reached out to the infection prevention and control (IPC) group at UPMC Presbyterian for potential opportunities and was welcomed into the group by Dr. Carlene Muto. Dr. Muto had me helping with central line audits on the units and data compilation. Her compassion and enthusiasm for infection prevention was contagious. I was excited to come work with the department every day!

How long have you been an IP? I started as an IP in December 2014 after successfully defending my thesis on CLABSI prevention. I have since progressed to a senior IP after receiving my CIC.

What is the best advice you have ever received?

How do you see the MPH degree changing the IP field? APIC’s MegaSurvey highlighted that there is an emerging generation of new IPs. Many of these IPs, like myself, are MPH graduates entering the field of IPC with multidisciplinary training of various backgrounds in public health. I hope to see the continued collaboration of research and practice in IPC as we progress in our careers which will advance our field and keep our patients safe. w w | 21


The evolution of infection control regulations “It’s not enough to be busy, so are the ants. The question is, what are we busy about?” –Henry David Thoreau


The last two decades have seen an increasing focus on healthcare quality improvement, including continuing efforts to reduce or eliminate healthcare-associated infections (HAIs). Many healthcare facilities, quality improvement organizations, and federal agencies developed guidelines, measures, targets, and studies. These included the National Quality Forum (NQF) “Never Events” and other measures, the Government Accountability Office (GAO) reports on HAIs in hospitals and ambulatory surgical centers, Centers for Disease Control and Prevention’s (CDC) guidelines, and the National Action Plan for the Elimination of HAIs, a joint effort by multiple government agencies with input from many nongovernmental stakeholders, including APIC. In addition, more than 30 states enacted HAI reporting laws between 2003 and 2011. The first legislative effort to connect Medicare reimbursement to infection prevention and control (IPC) was the Centers for Medicare & Medicaid Services (CMS) Hospital-Acquired Conditions/Present on Admission (HAC/POA) Indicators, mandated under the Deficit Reduction Act of 2005. Although not all HACs were HAIs, certain HAIs, including catheter-associated urinary tract infections (CAUTIs), vascular catheter-associated infections, and certain surgical site infections (SSIs) were among the HACs. The policy prohibited Medicare reimbursement for treatment of HACs that were not present on admission. Congressional passage of the Patient Protection and Affordable Care Act of 2010 incorporated many healthcare quality improvement efforts by creating programs that tied Medicare reimbursement


Payment-based regulations

to quality improvement, including quality reporting programs for multiple care settings, value-based purchasing (VBP), HAC reduction, and hospital readmissions reduction programs. These programs initiated incremental implementation of measures impacting all settings and stages of the healthcare system. All measures were reported to CMS—some via coding data and some via the CDC’s National Healthcare Safety Network (NHSN)—and were used by CMS for Medicare payment determination and public reporting. By 2018, 42 measures have been approved for the Hospital Inpatient Quality Reporting Program, including five NHSN HAI measures, as well as influenza

vaccination measures pertaining to healthcare personnel and patients. The HAI measures are also used for Medicare payment determination in the VBP and HAC reduction programs. NHSN measures are also included in quality reporting programs for long-term acute care, hospital outpatient, PPS-exempt cancer hospitals, ambulatory surgery centers, end-stage renal disease facilities, inpatient rehabilitation facilities, and inpatient psychiatric facilities.

Conditions of participation and coverage Before the implementation of these quality improvement programs, Medicare developed Conditions of Participation (CoPs) for w w | 23

CAPITOL COMMENTS hospitals to ensure that facilities meet certain minimum requirements to qualify for participation in the Medicare program. The first CoPs were published in 1966 with the initiation of Medicare, but infection control was not elevated to a separate condition until 1986. Except for technical corrections, the IPC condition has not changed since then, although accrediting organization standards have evolved. Insufficient or nonexistent federal regulation of IPC in long-term care (LTC), home health, ambulatory care, and other care settings led CMS to re-evaluate Medicare CoPs for all care settings. In 2015, CMS published proposed rules to update CoPs for home health agencies and LTC settings, and in 2016, the agency published proposed updates to hospital and critical access hospital (CAH) CoPs. A common factor in all of the proposals was an increase in infection control requirements, including: • Requirement that facilities have an IPC program, under the direction of an infection preventionist (IP). • The IP be included in the Quality Assessment and Assurance Committee. • The IP must provide IPC education and training to the rest of the facility staff. • [In LTC and hospital/CAH CoP proposals] that the IPC program include an antibiotic stewardship program. APIC has applauded the inclusion of infection control as a fully equal condition and set to work to develop training for IPs to be able to meet the requirements. To date, APIC’s LTC course has provided training to over 1,600 health professionals via 48 courses in 13 states, providing over 52,000 hours of continuing education.

Current regulatory landscape The 2016 election brought in a new administration focused on reduction of regulatory burden on business. After a series of executive orders directing federal agencies to submit reorganization plans and opportunities to repeal regulations, and publication of an American Hospital Association report on regulatory overload on healthcare providers, CMS Administrator Seema Verma 24 | FALL 2018 | Prevention

launched the “Patients over Paperwork” initiative, including the “Meaningful Measures” plan to reduce unnecessary cost and burden, increase efficiencies, and improve beneficiary experience by evaluating and streamlining regulations. The agency is seeking to identify the highest priority areas to improve the core quality of care issues that the agency determines are most vital to improving patient outcomes. The Fiscal Year 2019 CMS proposed rules updating Medicare payment programs for acute care and long-term acute care hospitals, cancer hospitals, inpatient rehabilitation facilities, and inpatient psychiatric facilities demonstrated CMS’s commitment to the Meaningful Measures Initiative. CMS reviewed each measure according to eight factors to determine which measures should be removed from which programs, and redefined the VBP, HAC Reduction, and Hospital Readmissions Reduction Programs to minimize overlap in the final rules. CMS removed 39 of the 42 measures in the Hospital Quality Reporting Program, either because they were retained in other payment programs, did not correspond to improved outcomes, or CMS determined that the cost or burden of implementing the measure exceeded its benefit. The NHSN HAI measures (central line-associated bloodstream infection, CAUTI, MRSA, C. difficile, and SSIs for colon surgeries and abdominal hysterectomies) were removed from the Hospital IQR program and retained in the HAC Reduction Program.

Although CMS proposed to remove these measures from the VBP program, the final rule did not finalize this proposal, so for the time being, these measures are also retained in VBP. In addition, the NHSN MRSA and ventilator-associated events measures have been removed from the Inpatient Rehabilitation Facilities Quality Reporting Program, and the NHSN healthcare personnel influenza vaccination measure has been removed from the Inpatient Psychiatric Facility Quality Reporting Program. The final rules updating the LTC and Home Health CoPs were published in 2016 and 2017, respectively, under the previous administration. However, the hospital/ CAH CoP revisions have been stalled at CMS since 2016. APIC has always supported efforts to streamline IPC measures and requirements to ensure that they are actionable and lead to improved patient safety and outcomes. APIC has applauded CMS for its systematic review of measures under the Meaningful Measures Program in the interest of reducing the cost and burden of quality measures on healthcare facilities. However, the cost and burden of measures should not outweigh the need for CMS requirements to reflect current evidence-based healthcare practices. It is imperative that CMS update the hospital/CAH CoPs to be consistent with new requirements in LTC and home health settings, and to be up to date with current standards of care by publishing the final rule revising the hospital/CAH CoPs.

APPLY NOW: JUDENE BARTLEY ADVOCACY IN ACTION SCHOLARSHIP THE JUDENE BARTLEY Advocacy in Action Scholarship is calling for applications. This award was established by the Society for Healthcare Epidemiology of America (SHEA) and APIC to help nurture rising leaders in infection prevention and healthcare epidemiology. Awardees receive a scholarship of $1,500 to attend a conference or course dedicated to developing their advocacy skillset. Interested applicants need to submit the following to • Curriculum vitae; • Statement of 700 words or less on the importance of advocacy; and • Letter of reference from an APIC or SHEA member. Applications are due Wednesday, October 31.










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A conversation with Christine Young-Ruckriegel, RN, MSN, MPA, CIC

Recipient of the 2017 Chapter Excellence Award in Clinical and Professional Practice from the APIC Northern New Jersey chapter. Christine is a registered nurse with a critical care background and has practiced as an infection preventionist (IP) for 15 years. In 2013, Christine created a unique role as the IP hired directly in perioperative services, where she learned the intricacies of the service line, worked alongside staff for best practices in the operating room theater, reviewed sterilization and disinfection procedures, and recommended evidenced-based practices to the perioperative team, anesthesiologists, and surgeons for the prevention of surgical site infections. Christine has worked in the acute care setting and as a consultant in the ambulatory area. She is currently the infection prevention manager at Atlantic Health System's Morristown Medical Center in Morristown, New Jersey.

How did you get involved in your local APIC chapter? I became involved in my local APIC chapter through the monthly meetings. I recall at my first meeting, I was enthralled listening to all the aspects IPs were involved in. I found the information presented at the committee meetings helpful to a new IP. As time progressed, I became more experienced in my knowledge, and this inspired me to join other groups within the Northern New Jersey chapter of APIC. I was mentored by a group of dedicated and experienced IPs in ambulatory consulting to become a consultant with healthcare facilities needing assistance for their infection prevention and control (IPC) programs. This group was also committed to providing education to organizations across the state of New Jersey for best practices for infection prevention in the ambulatory setting. These IPs were focused on keeping patients safe and infection free. They freely shared their knowledge and were outstanding guides to the consultant role.

How has your experience within APIC translated to your work as an IP? If I am having a difficult time figuring a problem, I turn to the APIC Text, I go on the listserv, and I’m able to collaborate with other IPs in the state. I have supportive members and resources always at my

fingertips. Recently, I was able to do a small presentation about the history and the role of the IP. There are not many of us, but together this organization has played an important role in shaping healthcare and in preventing harm. I’m proud to belong to the mission.

The chapter award you received was based on your work on the NHSN Worksheets ( — What are some challenges you faced while working on these infection worksheets? I would first like to recognize the great people who spearheaded this project (see the names at the end of this article). Our goal was to make a one-sheet guide for the NHSN definitions. Secondly, we knew these worksheets would need to aid both experienced and non-experienced IPs. Individually, we all brought different expertise to the project. Some typed, others read the definitions, and we all collaborated very well with each other. One of our biggest challenges was taking the time out of our schedules to get together. We had the support from the board of directors of our APIC chapter. Through this support we were able to pilot the tool to other IPs. We surveyed them to ensure the worksheets were concise and corresponded to w w | 29

INFECTION PREVENTION LEADERSHIP the NHSN definitions. This is an example of why your professional organization is so important—You have the ability to progress further toward your goals.

What is your leadership style? If I had to name or select just one style, it would be democratic. Over time, I’ve learned that I function in a relational manner to get done what I want to accomplish. So much of an IP’s work relates to modifying behaviors to protect staff, patients, and visitors. In order to process projects, I review data. The next important steps are to assess the issues. I prefer to walk around and speak to staff members who are doing the actual work. It’s important to me to build coalitions to achieve organizational goals. The next important skillset to have is a rapport with leaders within the organization. Making recommendations to guide the organization to be successful starts first by building authentic relationships. People need to identify that your only agenda is about doing the right thing. In my current position as the nurse manager to a team of IPs, collaborating with my team to achieve a set of goals really inspires me. We huddle every morning to review what is going on in each area and what information we want to focus on to prevent healthcare-associated infections or any hot topics. I care about their experience as an IP. This year, I asked the team to render the self-assessment tool based upon the APIC Competency Model. I want to ensure I collaborate on expanding the skillset within their role.

What is your advice for new IPs looking to further their skills as an IP and as a leader? It’s important to come out of your comfort zone. Push yourself to try something new. This will translate to your personal and professional growth. It might be by offering to give a presentation on an IPC topic at your local senior care center or joining a committee of interest in your local chapter with people you don’t know. All new situations feel uncomfortable at first, however, by pushing yourself, new experiences add to your value both as an IP and as a leader. 30 | FALL 2018 | Prevention

Have you acquired any new skills or learned something new during your time on the Prevention Strategist editorial panel? I enjoy acquiring new knowledge and having the forum to share ideas. My time on the Prevention Strategist editorial panel has provided me with both. The meetings are well run and the format for reviewing the articles is simple. The best experience—if there is something you wish to have more information on, the editor looks for ideas for future publications, so you have the opportunity to make suggestions. I’ve been able to learn more on subjects of interest simply by asking. How exciting! Being a part of the panel, I’ve been able to hear what the interests are from IPs around the country. This is one of the best groups I’ve belonged to. I’ve learned how your experiences can be shared through writing and reading this publication. My next professional goal is to write a piece for this magazine.

Can you suggest any books or resources to help IPs enhance their leadership and infection prevention skills? In other words, what has helped you along the way? Tough question for someone who loves to read. To learn about infection prevention, subscribe to the APIC Text Online; it is a great resource! Additionally, the APIC website has provided excellent material. In addition, once you join APIC, you have access to the American Journal of Infection Control. Here are a few of the leadership and infection prevention materials I’ve enjoyed: 1. Crucial Conversations 2. Harvard Business Review 3. How to Talk so People Listen — Connecting in Today’s Workplace

4. John C. Maxwell 5. Leading Quietly by John L. Badaracco Jr. 6. Nursing Economics (journal) 7. Leadership the Eleanor Roosevelt Way by Robin Gerber 8. Bennet & Brachman’s Hospital Infections by William R. Jarvis 9. NPR-National Public Radio – It’s important to know what is going on outside your world. 10. Health Affairs (journal)

What else is important? I have two thoughts here: First, we have multi-generational groups in the workforce. We need to recognize this and adjust how we deliver our message regarding IPC. What might have worked in the past to deliver our message may need revision. New generations want to have more of a voice and be part of the educational process through surveys on their phone, videos, or tabletop exercises. We must use the technology to our advantage as well. Second, as IPs we need to be open to new ideas. We risk stagnation if we don’t encourage novice team members the opportunity to provide input and feedback. Statistics regarding the age range of IPs suggests we need to nurture more IPs into the field to continue our work. Organizations might consider modifying current work systems to encourage older IPs to stay on in a modified capacity to guide newer IPs. These members are needed for their intellectual capital to support those in new roles. We as leaders need to reach out to our colleges to provide internships to educate others about the field and what it is we do to encourage new members to the field.

• Bhavna Desai, BS, MT(ASCP), CIC • Vicki DeChirico, MSN, RN, CIC • Karen Tomlin, BS, MT(ASCP), CIC • Jennifer Pruden, RN, BSN, CIC • Joan Mayo, MS, MBA, RN, CIC • Maryellen Marek, MLT, ASCP, MS, BSN CIC • Amanda Hessels, RN, PhD, MSN, MPH, CIC, CPHQ

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Celebrate International Infection Prevention Week BY JULIE BLECHMAN, MPH, CHES, AND SOPHIE HARCLEROAD

HOW TO CELEBRATE IIPW! 1. Use the hashtag #IIPW in your tweets, share API’s tweets, and make sure to follow @APIC. 2. Join the Twitter chat (#IIPWChat) and spread the message of infection prevention. 3. Update your facility’s screen savers to the IIPW button! 4. Test your infection prevention knowledge with APIC’s quizzes! 5. Download and share APIC’s new “Protect Your Patients” infographic. For more ideas, download APIC’s IIPW Toolkit:


nternational Infection Prevention Week (IIPW) is a weeklong celebration for infection preventionists (IPs) to raise awareness of the role infection prevention and control plays in improving patient safety. IIPW takes place October 14-20, and this year’s theme is “Protecting Patients Everywhere.” Infection prevention is everybody’s business, and IPs can empower healthcare professionals, patients, and families to stop the spread of germs. This week is a time for patients, families, and healthcare professionals to better understand the role they play in preventing infections. It is critical that these core patient support groups understand the implications that infections can have, and that they take steps to avoid infection. IIPW was established in 1986, and since then, APIC has worked with many organizations, such as the Centers for Disease Control and Prevention (CDC), to promote safer healthcare practices. IIPW has advanced into a global initiative

that has been instrumental in providing important infection prevention information to healthcare professionals, academics, administrators, legislators, and consumers. IIPW is an important reminder that it is everyone’s job to help prevent infection. Making infection prevention and control education a top priority allows for the spread of information from IPs to the public. IPs and healthcare professionals face a myriad of infection prevention challenges: it’s important that we all work

together to stop the spread of germs both inside and outside healthcare facilities. BE SOCIAL WITH APIC

Raising awareness for IIPW is easy with technology. In an age where posting, tweeting, and sharing are main forms of communication, there are quick and simple ways to share information with your followers, friends, and family. Like APIC on Facebook ( APICInfectionPreventionandYou) and follow APIC on Twitter ( for the most up-to-date infection prevention and control information. Share APIC’s ready-made social media posts to join the #infectionprevention conversation. HAVE FUN AND INVOLVE YOUR COMMUNITY

Infection prevention is a serious issue, but there are great ways to engage the community w w | 33

PREVENTION IN ACTION while also having fun online. Visit www. Online quizzes and word searches are a great way to spread the IIPW spirit with people of all ages. From screensavers to selfie frames, APIC has got you covered. Don’t forget to tag APIC in your IIPW celebration pictures. ACCESS HELPFUL IIPW RESOURCES

On the IIPW website, there are resources, infographics, and toolkits available free for download. Looking for

something to brighten up your office? These helpful infographics give patients information regarding their care, such as speaking up for their care, learning about infections, and asking about vaccinations. The IIPW toolkit page includes easy ways for you to advocate and promote IIPW, the materials to give infection prevention special visibility, and the best opportunities for conversations about why infection prevention matters. Explore these resources and incorporate them into your IIPW celebration and activities.


Healthcare professionals, patients, and families should pledge to keep everyone safe from the spread of infection. Sign the pledge and commit to prevent infections, protect your patients, and encourage others to do the same! The pledge includes getting appropriate vaccines, thoroughly washing hands, and practicing clean habits that reduce the risk of infection. If everyone takes responsibility for the care of patients, all aspects of care will improve. JOIN THE #IIPW TWITTER CHAT

APIC will host a Twitter Chat on Tuesday, October 16 at 12 p.m. ET to discuss how healthcare providers, patients, and others can prevent infections. Questions will focus on “Protecting Patients Everywhere.” Follow @APIC on Twitter (www.twitter. com/apic) and use the hashtag (#IIPWChat) to join the conversation. Whichever way you choose to celebrate IIPW, you are spreading knowledge and preventing infections! Working together and using all available resources, we can all work to help stop the spread of infection. By joining your friends, family members, and healthcare colleagues in celebrating IIPW, you are raising awareness of the role infection prevention and control plays to improve patient safety, because we’ll all be patients one day.

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| Prevention

APIC'S NEWEST INFOGRAPHIC POSTER Download and print your free copy of the Protect Your Patients infographic poster at All materials from the Infection Prevention and You website are print-ready and free.

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Update on CRE— carbapenem-resistant Enterobacteriaceae BY IRENA KENNELEY, PhD, RN, CNE, CIC, FAPIC

GREETINGS FELLOW INFECTION PREVENTIONISTS! The science of infectious diseases involves hundreds of bacteria, viruses, fungi, and protozoa. The amount of information available about microbial organisms poses a special problem to infection preventionists (IPs). Obviously, the impact of microbial disease cannot be overstated. Traditionally, the teaching of microbiology has been based mostly on memorization of facts (the “bug parade”). Too much information makes it difficult to tease out what is important and directly applicable to practice. This quarter’s My Bugaboo column features information about the emergence of resistance in the human pathogens in the tribe Enterobacteriaceae, specifically carbapenem-resistant gram-negative bacilli. The intention is to convey succinct information to busy IPs for common etiologic agents of healthcare-associated infections (HAIs). Please feel free to contact the author with questions, suggestions, and comments at



36 | FALL 2018 | Prevention

The Enterobacteriaceae are a group of gram-negative bacilli that are common etiologic agents of infections isolated from both healthcare patients as well as those in the community. According to the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network, the most common organisms causing HAIs are Klebsiella species, Escherichia coli, and Enterobacter species. Resistance to the beta-lactam antimicrobials by these gram-negative bacilli has been recognized for years. Carbapenem resistance has been relatively uncommon in the United States with an uptick in frequency within the past ten years.1 Between 2001 and 2011, resistance to the carbapenems increased from about one percent to four percent, with the highest percentages among the

Carbapenemase Classification Carbapenemase Enzyme Source/Name

Carbapenemase Enzyme Abbreviation


Klebsiella pneumoniae


• Most common CRE in the USA • KPC transported in plasmids

Oxacillinase 48


• Occurs mainly in Acinetobacter species

New Delhi metal-beta-lactamase


• Described in New Delhi in 2009

Verona integron-encoded metallo-beta-lactamase


• Evenly distributed in Europe, North and South America, and Far East • Mainly in Pseudomonas aeruginosa; rarely in Enterobacteriaceae

Imipenemase-type metallo-beta-lactamase-producing


• Described in Japan in 1990s in Enterobacteriaceae, Pseudomonas, and Acinetobacter species

Klebsiella species, which increased from about two percent to ten percent.1,2 The antibiotic class known as the carbapenems have a broad spectrum of activity against gram-negative bacteria (including the Enterobacteriaceae) and gram-positive bacteria. Carbapenems are also active against extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae and are considered to be a reliable treatment for patients with multidrug-resistant infections.1,2 The enzyme known as carbapenemase produced by gram-negative bacilli confers resistance to the carbapenems. The carbapenemases are named after the specific genotype of the carbapenemase enzyme produced. Specific carbapenemases are listed in the table above.3 SIGNIFICANCE AND RISK FACTORS

Clinical carbapenem-resistant Enterobacteriaceae (CRE) infections can have a mortality rate as high as 50 percent.2 There is also the potential for a CRE epidemic through person-to-person transmission. Non-resistant Enterobacteriaceae that are exposed to CRE can acquire the genes for cabapenemase resistance by a horizontal transfer of resistance genes through the plasmidmediated process known as conjugation. Significantly, these plasmids contribute to the spread of multidrug-resistant organisms because they can be easily transferred between bacteria within the same species or between different species.3,4 The majority of CRE patients are

asymptomatic, but they are colonized and can serve as a source of transmission to other patients. EPIDEMIOLOGY

The most commonly identified organism worldwide to possess genes coding for the enzyme carbapenemase is Klebsiella pneumoniae carbapenemase (KPC).2,5,6 The carbapenemase enzyme was first described in 2001 in the U.S. from a patient culture in North Carolina. In 2015, the UCLA Ronald Reagan Medical Center reported two patients died and five others were infected with carbapenemase-producing CRE (CP-CRE). There were 179 additional patients potentially exposed to the organism from a contaminated endoscope used to treat pancreaticobiliary disease at the hospital. In 2017, the CDC reported a CRE strain of Klebsiella pneumoniae was isolated from a patient in Nevada who died of sepsis. (The patient acquired the infection in a hospital in India.) Antibiotic susceptibility testing of this isolate indicated pan-resistance as all 26 antibiotics were resistant. Other carbapenemases have been described in hospitalized patients in the U.S. including NDM, VIM, IMP, and OXA-48. The significance is that these non-KPC carbapenemases have previously been identified in patients who had received healthcare outside of the U.S. The prevalence of CRE remains low for most European countries; however, the countries with the highest prevalence

rates of carbapenem-resistant bloodstream infections caused by carbapenemresistant Klebsiella pneumoniae in the world have been identified as Romania (31 percent), Italy (34 percent), and Greece (67 percent). Regions of the world with high reported levels of CRE are countries in the eastern and southern Mediterranean regions, the Indian subcontinent, and Southeast Asia.6 The current literature reveals evidence that the prevalence of CRE organisms remains relatively uncommon in many parts of the U.S.2 Aggressive infection prevention and control action now has the potential to slow the emergence of these organisms. THE IP’S ROLE IN PREVENTING THE DEVELOPMENT OF FURTHER RESISTANCE

CRE can be prevented. For example, a hospital in New York recently reduced CRE by more than 50 percent by implementing the CDC’s recommended practices.3 Another striking example was reported by Israel, where CRE infection rates were reduced in all 27 of its hospitals by more than 70 percent in one year by implementing recommended isolation of CRE patients as well as cohorting of staff in a national, coordinated infection prevention and control program.7 The recommendations in the CDC’s CRE Toolkit have also been successfully used in many settings, such as longterm acute care hospitals and long-term care facilities, to control the spread of these organisms. w w | 37



Carbapenem-resistant Enterobacteriaceae at a low prevalence tertiary care center: Patient-level risk factors and implications for an infection prevention strategy. Doll M, Masroor N, Major Y, et al. Am J Infect Control 2017; 45(11): 1286-1288. Development of a risk prediction model of carbapenem-resistant Enterobacteriaceae colonization among patients in intensive care units. Song JY, Sook J. Am J Infect Control 2018; (not yet assigned to volume).

38 | FALL 2018 | Prevention


Carbapenem-Resistant Enterobacteriaceae Surveillance to Detect Transmission, Wisconsin Division of Public Health. Borlaug G, Gundlach K, Valley A, et al Am J Infect Control 2016;45(6): S147.

CRE Risk Factors. Risk factors include contact with a person infected with CRE, contact with a contaminated instrument (such as an endoscope), those who have received multiple antibiotics and/or have been treated outside of U.S. hospitals, and clinicians who work in institutions that use many different antibiotics.

Surveillance • Recognize patients in your facility who have CRE 1. Request immediate alerts when the lab identifies CRE. 2. A lert the receiving facility when a patient with CRE transfers out, and develop a process for being informed when a

patient with CRE transfers into your facility. • Protect your patients from CRE 1. Follow contact precautions and strict hand hygiene when treating patients with CRE. 2. Dedicate rooms, staff, and equipment to patients with CRE (cohorting). 3. Adhere to an antibiotic stewardship program. 4. Remove medical devices such as catheters and ventilators as soon as possible.

of CRE positive patients have resulted in significant declines in CRE rates.1,2,5 References

4. Queenan AM, Bush K. Carbapenemases: the versatile β-lactamases. Clin Microbiol Rev. 2007;20(3)440-458. Accessed July 2018.

1. Centers for Disease Control and Prevention. Facility Guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE). 2015. hai/organisms/cre/cre-toolkit/index.html. Accessed June 2018.

5. Burton N, Aguirre D, Leung S, et al. PCR-based active surveillance carbapenem-resistant Klebsiella pneumoniae (KPC) colonization with rapid initiation of contact isolation achieved significant reduction in KPC colonization prevalence of ICUs of a NYC medical center. Program and abstracts of ID Week. 2012; abstract 686. Accessed May 2018.

2. Chae S, Yaffee AQ, Wenk MK, et al. Notes from the field: Investigation of Carbapenemase-Producing CarbepenemResistant Enterobacteriaceae among patients at a community hospital — Kentucky, 2016. MMWR Morbidity and Mortality Weekly. 2018;66(5152);1410. http:// Accessed June 2018.

6. European Centre for Disease Prevention and Control. Rise of carbapenem-resistant Enterobacteriaceae: A threat to health in Europe. European Centre for Disease Prevention and Control. 2018. Accessed June 2018.

3. Murray PR, Rosenthal KS, Pfaller MA. Medical Microbiology, 7th Ed. Philadelphia, PA: Elsevier, Saunders; 2013.

7. Schwaber MJ, Lev B, Israeli A, et al. Israel CarbapenemResistant Enterobacteriaceae Working Group. Clin Infect Dis. 2011;52(7)848-855.


The following major items have been updated in CRE 2015 Toolkit since 20121: 1. The CDC modified the CRE surveillance definition. 2. The two intervention tiers have been replaced by a single tier. Not all interventions might be applicable in all settings or situations. Information is provided about situations in which specific interventions might be most important. 3. Further discussion has been added on the use of Contact Precautions in post-acute settings. 4. Information on regional interventions has been removed in order to target this document specifically to facilities. Coordinated regional approaches to prevent infections with multidrugresistant organisms remain important; additional information on these approaches will be made available in other documents. 5. Inter-facility communication has been added to the interventions. LABORATORY TESTING

The laboratory should have immediate alert notification in place when CRE is identified to report to appropriate clinical and infection prevention staff to ensure timely implementation of infection control measures. This includes on-site and off-site clinical laboratories.1 Polymerase chain reaction (PCR) testing of isolates involves demonstrating the organism’s resistance to multiple antibiotics, including carbapenem. The results of PCR are conclusive and real-time analyses available. Active surveillance and rapid isolation 925969_USHIO.indd 1

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Interpreting uncertainty: Is the difference real? BY CHRISTINA BRONSON-LOWE, PhD, CCC-SLP, CLD, AND DANIEL BRONSON-LOWE, PhD, CIC, FAPIC


What is “real”? Three meanings used when data guide decisions are: “not due to random chance,” “truly due to the proposed explanation,” and “meaningful.”

Statistical tests assess if the data was “not due to random chance” by treating it as samples of populations. Data points in Figure 1 are samples from the population


Welcome to the 10th installment in a series examining statistical concepts relevant to infection prevention. This article discusses how to decide whether differences in data are real.

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n infection preventionist (IP) comparing hand hygiene compliance (HHC) on two intensive care units (ICUs) observes each for three days, finding mean compliance of 54% on Unit A and 86% on Unit B (Figure 1). Is that difference real? of all measurements that could have been observed (for instance, on different days). The null hypothesis states that samples from Units A and B are drawn from one

population (Figure 2): There is no “real difference” between units. The alternative hypothesis states that they derive from distinct populations (Figure 3): The observed difference reflects a real difference (Sidebar 1). Statistical tests ask, “If the null hypothesis were true, what would be the chance of observing a difference at least this large?” They provide a test statistic and a p-value (a proportion between 0 and 1). A high p-value means that a difference at least as large as what was observed is likely if the null hypothesis is true. A low p-value means that a difference at least that large is unlikely per the null hypothesis. What p-values are high or low? The common cut-off of 0.05 means that we reject the null hypothesis if there is no more than a 5% chance that it could have produced the observed difference. We choose this cut-off represented as (α) before data analysis, depending upon our purpose. In an exploratory study, we might set α higher, because our goal is to identify differences for more rigorous future investigation. We don’t want to risk failing to find a difference that actually exists (a false negative). The

Figure 1

Figure 2

Figure 3

SIDEBAR 1 THE SIMPLEST ALTERNATIVE hypotheses are non-directional or two-sided: X “differs from Y” or “is associated with Y.” Often, however, we suspect a particular difference: “ICUs have HHC greater than emergency departments (EDs)” or “Experience (in years) is positively associated with HHC.” These hypotheses are directional or one-sided. The corresponding null hypotheses absorb the other possible direction of difference: “ICUs have HHC less than or equal to EDs” or “Experience is not associated or is negatively associated with HHC.” The hypothesis including “equal,” “no difference,” or “no association” is always the null hypothesis. We care whether hypotheses are directional because statistical tests can be directional too, and using the right test yields a better answer.

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FROM DATA TO DECISIONS trade-off is greater risk of a false positive (concluding that there is a difference when there really isn’t). We use lower α when we’re less willing to risk false positives — trading off greater risk of false negatives (Sidebar 2 and Synonym Alert.) • If p > α, the risk of a false positive is too high. We conclude there is no difference. • If p ≤ α, the risk of a false positive is acceptable. We conclude a statistically significant difference exists. Our example’s IP doesn’t have resources to waste pursuing a false positive, so she selects α = 0.05. Statistical testing yields p < 0.0001 — a less than 0.01% chance that the observed difference would have occurred per the null hypothesis. She concludes that the difference is statistically significant, then considers our other meanings of “real.” Is the difference really between units (the proposed explanation)? Her statistics discredit the null hypothesis but can’t prove her alternative hypothesis. Were her data biased? For instance, if she observed Unit A at shift change and Unit B mid-shift, the difference might actually be due to

SYNONYM ALERT False positive: falsely rejecting the null hypothesis, α error, Type I error. False negative: incorrectly failing to reject the null hypothesis, b error, type II error.

SIDEBAR 2 time-varying demand on staff attention. This is an example of selection bias — selecting data unrepresentative of the population. The IP considered bias before data collection and believes she has avoided the most obvious sources. However, she wonders about confounding variables — things she didn’t measure that could influence both her independent variable (unit) and her dependent variable (HHC). What if more senior staff prefer Unit B and have higher mean HHC? In that case, the “real difference” would depend upon staff, not unit. Finally, is this difference clinically significant — does it meaningfully affect patient care? The IP decides that a difference in mean HHC of 32% between units is clinically important1 and begins planning how she’ll rule out confounding variables and discover what Unit B is doing right. Contact us with questions or comments at Christina Bronson-Lowe, PhD, CCC-SLP, CLD, is a speech-language pathologist with experience in hospitals, inpatient and outpatient rehabilitation, SNFs, and home health care. Daniel Bronson-Lowe, PhD, CIC, FAPIC, has been an infection preventionist, infectious disease epidemiologist, and statistics lecturer. He has been an instructor for APIC’s “Basic Statistics for Infection Preventionists” Virtual Learning

EACH TEST’S P-VALUE applies only to that test. If a study with only one test has p ≤ 0.05, using α = 0.05 means a 5% or smaller chance of a false positive. But what if the study includes two tests (e.g., unit differences on both HHC and staff years of experience)? Ten tests? Millions, as is common in genome-wide association studies? The probability of a false positive over an entire study (experiment-wide α, αEXP) depends upon per-test α (αTEST) and the number of tests n: αEXP = 1 – (1 – αTEST) n. Using α TEST = 0.05 for two or ten tests leads respectively to αEXP = 9.75% or 40.13%. It takes only 90 comparisons to reach αEXP = 99%. Rigorous studies describe how they maintained αEXP ≤ 0.05: basically, a more conservative (lower) αTEST than 0.05. For details, search for “multiple comparison correction” or “Bonferroni adjustment” plus the type of study.

Lab and is a senior clinical manager with Baxter Healthcare Corporation. 1. In a real study, a criterion for clinical significance would, like α, be chosen during study design. Additional Resources Aron A & Aron EN. (1997). Statistics for the behavioral and social sciences: A brief course. Upper Saddle River, NJ: Prentice-Hall. Potts A. (2014). Chapter 13: Use of Statistics in Infection Prevention. In: Grota P, et al. (Eds.). APIC Text Online. APIC.

CONCEPT QUIZ QUESTIONS REFER TO Ethington T, Newsome S, Waugh J, Lee LD. (2018). Cleaning the air with ultraviolet germicidal irradiation lessened contact infections in a long-term acute care hospital. AJIC 46(5): 482-6. You can take the quiz without reading the article.

Question 1


The authors state, “[S]ignificance level α was set at 0.05; therefore, any P value ≤ 0.05 was statistically significant.” Their six tests had p-values of 0.035, 0.00, 0.001, 0.001, and two unspecified. Of those given, how many are statistically significant per their standard?

1. All. Some authors report only p-values that met their significance criterion, but reporting all p-values is preferable so readers can judge how far the test was from significance.

Question 2 (Sidebar 2) No correction of α for multiple tests is described. Why is this problematic? Which p-value they claimed to be significant most concerns you?

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2. They did not differentiate between αEXP and α TEST. With six tests and α TEST = 0.05, they had αEXP = 1 – (1 – 0.05)6 = 0.265, meaning a 26.5% risk of false positive results across the study. We know α TEST needed to be more conservative (lower), so we are most suspicious of the highest value (0.035).


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


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 settings, 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.

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peare and Ahn report on the case of Mrs. N.F., a 57-year-old female nursing home resident who was admitted to an acute care hospital.1 While hospitalized, the nursing staff detected a parasitosis, with treatment consisting of 0.2 percent permethrin lotion being administered four times over a two-day period. Based on your knowledge and experience, you suspect the following pathogen: 1. Demodex canis 2. Borrelia burgdorferi 3. Pediculus humanus capitis 4. Babesia microti The resident’s condition, known as pediculosis or head lice, is caused by the parasitic insect Pediculus humanus capitis. In addition, one percent permethrin was administered, with the nursing staff noticing minimal effect on the killing of the patient’s head lice, after the treatment. The staff determined the head lice were resistant to permethrin and changed the treatment to an herbal head lice lotion. This topical agent was applied to her scalp, from the roots to the tips. Afterward, dead and immobilized lice were recovered. A second treatment was applied two days later, and no additional head lice were observed upon examination. Upon further investigation at the infested facility, pediculosis had been detected at the resident’s nursing home during the previous 12 months, with residents receiving various topical preparations, including permethrin and benzyl benzoate.1 Two weeks after the hospital pediculosis diagnosis, 20 residents of the nursing home were examined for possible infestation, with five residents (25 percent) having active signs. Four residents were topically treated with an herbal lotion, with some requiring additional treatments. The fifth resident declined the topical agent but accepted treatment with oral ivermectin. All the

residents subsequently had no evidence of live lice or eggs. One member of the nursing staff reported her 13-year-old daughter, who was a frequent visitor to the nursing home, also had long-standing pediculosis and required three topical treatments for complete eradication. The authors noted the importance of contact tracing to assist with identifying the index case.1 WHO IS AT RISK?

Head lice are found worldwide, with infestation most common among children and household members of infested children in the United States, although an exact number of cases is not available.2 Head lice are transmitted by direct head-to-head contact with an infested individual. Personal cleanliness or hygiene is not a factor for becoming infested. Transmission by contact with the infested person’s clothing such as hats, scarves, coats, or personal items, including combs, brushes, or towels is uncommon. 2 Head lice do not transmit diseases. Head lice have three stages or life cycles: the nit, nymph, and adult. Head lice and their eggs, also known as nits, are found on the scalp, especially behind the ears and the back of the neck.2 Head lice have claws at the end of their six legs which allow for securement to the hair. Nits also become cemented firmly and can be difficult to remove. The head lice diagnosis is confirmed by finding a live nymph or adult louse on the scalp or hair; nits can be confused with dandruff, hair spray droplet, and dirt particles.2 INFESTATION

Signs and symptoms of a head lice infestation include: • Sensation of something moving in the hair; • Itching due to the bites resulting with an allergic reaction; • Difficulty sleeping due to the head lice being more active in the dark; and • Sores, due to scratching, which can become infected.

The Centers for Disease Control and Prevention (CDC) recommends, in addition to standard precautions, the use of contact precautions until 24 hours after effective treatment when caring for patients with pediculosis infestation.3 When a person has been diagnosed with an infestation, all household members and close contacts should also be examined.4 These contacts should be treated only when live lice are discovered. Finding only nits is not enough for a diagnosis; the examiner must observe a live louse for a diagnosis to be made. Head lice are wingless insects that move by crawling; they cannot hop or fly. The CDC recommends the following steps to help prevent the spread of lice infestations.5 • Avoid head-to-head contact. • Children should be taught to not share personal items such as combs, brushes, and hats. • Personal items that have come in contact with an infested individual should be soaked in very hot water (at least 130° F) for 5-10 minutes. • Bed linens and recently used hats, clothes, and towels should be machine washed on hot and a high-heat drying cycle. Items that cannot be machine washed should be placed in a sealed plastic bag for two weeks. • Vacuum carpets and furniture where the infested person sat or laid. Head lice survive less than 1-2 days after they fall off a person and are unable to feed. Nits (head lice eggs) generally die within a week away from their human host and cannot hatch at a temperature lower than that of the human scalp. According to the CDC, Pediculus humanus capitis is not a reportable condition; however, some public health departments do require it to be reported if it is associated with an outbreak.6,7 TREATMENT

There are several options available for treatment of head lice infestations. The pharmacologic treatment of head lice can be achieved with over-the-counter (OTC) medications or with prescription medications from a healthcare provider.8 w w | 47

PREVENTION IN ACTION The two OTC medications available are Permethrin 1% and Pyrethrin/ Piperonly Butoxide. These two pediculicides have been proven to be effective, safe, and inexpensive means for eradicating head lice.8 Both medications have a neurotoxic action on the louse, which will result in paralysis, or physical asphyxiation which occludes the respiratory spiracles of the louse.9 Most medications will kill the live lice, but will not kill the unhatched egg which is why a second treatment is needed 7-10 days after the first treatment.10 Persons allergic to chrysanthemums or ragweed should avoid using Pyrethrin shampoos since they are derived from natural extracts from the chrysanthemum.4 Resistance to these OTC medications have been reported in the U.S., but often the treatment failure can be attributed to the following:10 • Misdiagnosis (no active infestation). • Inadequate or incomplete treatment. • New infestation or reinfestation. • Lack of ovicidal or residual killing properties of the product. If there is failure of treatment or proven resistance to the OTC medications, patients should seek care from their medical provider.10 There are several prescription options available for the treatment of Pediculus humanus capitis which include Malathion lotion (0.5%), Benzyl alcohol lotion (5%),

Spinosad topical suspension (0.9%), and Ivermectin lotion (0.5%). The instructions for use on these medications should be read and carefully followed. A non-pharmaceutical treatment option, which may be appealing to some patients who wish to avoid chemicals, is a technique called “wet combing.”9 This technique involves using a finetooth comb on wet hair moistened with a lubricant to facilitate the process. The hair is then systematically combed through from the hair root to the tip to remove all live lice and nits. This can be a tedious and labor-intensive process depending on the length and thickness of the hair. It is recommended that the combing be done every 3 days for 2 weeks, although combing for up to 24 days may increase treatment success. Home remedies with occlusive products such as petroleum jelly, olive oil, butter, or mayonnaise have not been studied sufficiently to determine if they can be a reliable treatment option.9 Products such as essential oils or herbal treatments are sometimes used by patients for treatment of head lice.9 Since these products are not regulated by the FDA, the efficacy and safety cannot be guaranteed and therefore should not be recommended.10 Steven J. 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. Julie Wright, RN, MSN is an infection preventionist with a specialized interest in pediatrics. References 1. Speare R, Ahn S. Eradicating head lice in a nursing home. Aust Fam Physician. 1999;28:915-918. 2. Centers for Disease Control and Prevention. Parasites. Frequently asked questions. https://www.cdc. gov/parasites/lice/head/gen_info/faqs.html. Accessed June 2018. 3. Centers for Disease Control and Prevention. Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings, 2007. https://www. Accessed April 2018. 4. Centers for Disease Control and Prevention. Parasites. Head lice information for parents. https://www.cdc. gov/parasites/lice/head/parents.html. Accessed June 2018. 5. Centers for Disease Control and Prevention. Parasites. Prevention and Control. Accessed June 2018. 6. Oklahoma State Health Department-head lice. https://,_Prevention,_ Preparedness/Acute_Disease_Service/Disease_ Information/Head_Lice.html. Accessed June 2018. 7. Ohio Department of Health-Pediculosis. http://www. Accessed April 2018. 8. Centers for Disease Control and Prevention. Parasites. Treatment. treatment.html. Accessed June 2018. 9. Gunning K, Pippitt K, Kiraly B, and Sayler M. (2012). Pediculosis and scabies: A treatment update. Am Fam Physician, 86(6), 535-541. 10. Frankowski BL, Bocchini JA. Council on School Health and Committee on Infectious Diseases. (2010). Clinical report- head lice. Pediatrics 2010.126(2), 392-403.

TAKE-HOME MESSAGES 1. Signs and symptoms of a communicable condition should be promptly reported to the receiving or referring healthcare organization. 2. Using a head lice comb is very effective with removing head lice and nits. It should be performed every 3 days for 2 weeks in case the nits should hatch. The nit comb should be cleaned after use, per manufacturer’s instructions. A regular, typical comb may not be effective due to its wide “teeth” and inability to grasp the hair shaft. 3. A magnifying glass may be helpful while examining the scalp for possible infestation. 4. The patient’s belongings such as personal items and clothing should be placed in a sealed plastic bag and given to family. The items should be taken home and machine washed on hot and a high-heat drying cycle. 5. When transporting a patient with head lice who has not been sufficiently treated, use the appropriate personal protective equipment, per facility policy, to prevent the spread of the lice. Consider placing a head covering over the infested individual. Receiving units should be informed of the patient’s status of treatment and any precautions required. 6. Determine if pediculosis outbreaks are a reportable infestation to the health department in your facility’s state of licensure.

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Features from APIC Annual Conferences BY SANDY SMITH AND VICKY UHLAND



At an APIC 2017 session, “Crashing into the Pre-Antibiotic Era,” Wava Truscott, PhD, MBA, BS, cited a World Health Organization (WHO)/Centers for Disease Control and Prevention (CDC) study that anticipated a staggering number of deaths throughout the world by 2050. In North America, some 371,000 will die each year due to antibiotic-resistant illnesses. In Asia and Africa, those numbers top 4 million on each continent. “That’s not even looking at new bacteria that is coming,” Truscott said. “Put all that together and we’re coming to a perfect storm, unfortunately.” That perfect storm has many elements, including a lack of development of new antibiotics. Truscott cited figures that showed in 1980-1984, 16 new antibiotics were introduced. In 2008-2012, there were two. Compounding that issue: Drugs like vancomycin and erythromycin had about 40 years of efficacy before the first cases of resistance appeared. These days, antibiotics may have a year before drug resistance develops. “If you can imagine, you are now developing a pharmaceutical that will cost between $800 million and $1.7 billion, and it will be good for about a year,” Truscott said. “You can understand why we have less and less of those antibiotics being invented.” To personalize the numbers, Truscott featured a number of people who had common illnesses, like a cough or strep throat. A drug-resistant bacterium changed their 50 | FALL 2018 | Prevention


ashion trends come back around. So why not medicine? We are on the cusp of a throwback era that mimics life before antibiotics. While a good debate may occur over whether some fashion trends need to come around again, returning to an era where antibiotics are practically unavailable—or at least ineffective—will have dire results.

lives dramatically, with some losing all of their limbs. One lost her life. The prime directive of animals is survival, Truscott said. The secondary directive is for progeny to survive. Bacteria are no different and have evolved as other microorganisms have taken over their niches. “No wonder they have developed resistance.” In the perfect drug-resistant environment, in seven hours, a surviving pathogen can produce more than 2 million bacteria. She looked at the ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species), which the CDC says

“Drugs like vancomycin and erythromycin had about 40 years of efficacy before the first cases of resistance appeared. These days, antibiotics may have a year before drug resistance develops.” “represent the new pathogen. They have not only the antibiotic resistance, but new aggressiveness. That’s important.” There are many reasons for the rise in antibiotic resistance, including over-prescribing

and patients not following the instructions. Lapses in infection prevention processes and poor hygiene also compound the issue. Overuse of antibiotics in livestock and aqua farming, and the rise of fertilizers are equally problematic, she said. Animals in the United States consume about twice as many antibiotics as humans, and 97 percent of medically important antibiotics are sold over the counter. She cited her work with turkeys, where an entire flock can be wiped out in 72 hours. Still, about one in five resistant infections are caused by resistant bacteria from food and animals, she said.

“It’s a quandary,” she said. “Some antibiotics are important to prevent the rampant loss of food animals. There will be less meat, and more contaminated meat can reach the kitchen. It’s not an easy answer.” She cited some progress in antibiotic stewardship and patient instructions. The U.S. Food and Drug Administration (FDA) and the CDC are working together on the GAIN Act, which would put new antibiotics for specific infections on a 9-month fast track. The plan also would extend the patent by five years. GAIN covers drugs designed to treat 21 multiantibiotic/drug-resistant bacteria.

It’s not just new drugs; modifications to current antibiotics also are being explored. Faster identification of bacteria is also needed; the FDA has recently approved a faster testing method for sepsis. Phage therapy, a method that was shelved when antibiotics were first introduced, is getting a new look. “When man is faced with bad situations, they become inventive,” Truscott said. She closed with a picture of a sun over a tree. “Is the sun setting as we face these austere CDC and WHO predictions? Or is it dawning on a new age of innovation? I think that depends on the perspective.”



ew data show that more than 1.3 million Americans are living in nursing homes. Those residents have between 1 million and 3 million infections annually; one out of every three nursing home patients has a multidrug-resistant organism (MDRO) infection.

What’s more, research shows that antibiotics account for about 40 percent of all medications administered in nursing homes. And as many as 79 percent of nursing home residents receive antibiotics at least once a year. Data like that show the need for sessions like what was presented at the APIC 2018 Annual Conference in Minneapolis in June: Changing Landscape of [infection prevention and control] IPC in Nursing Homes. A trio of speakers from Columbia University School of Nursing presented their research on baseline characteristics of infection control processes and antibiotic stewardship in nursing homes, and national- and state-level policies aimed at reducing healthcare-associated infections (HAIs). Mansi Agarwal, PhD, MPH, discussed a Columbia survey of 990 nursing homes nationwide conducted from 2013-14. The nursing homes had an average bed size of 119, with 82 percent occupancy. Seventy percent were for-profit facilities. Survey questions focused on infection prevention program characteristics, respondents’ demographics and training,

nursing home staffing and turnover, and policies on antibiotic stewardship. Nearly 35 percent of the respondents had received infection control citations, Agarwal said. Only 32 percent of the nursing homes had an IPC collaborative. And there was a 40 percent turnover rate of infection preventionists (IPs), administrators, and other key IPC personnel in the past three years. Only 40 to 50 percent of the nursing homes had five of the seven antibiotic stewardship policies, and those were more likely to be present when the facility had a trained IP. Overall, training was lacking for infection prevention, Agarwal said. Richard Dorritie, RN, followed with a discussion of a Columbia survey of state HAI plans. Researchers analyzed Centers for Disease Control and Prevention and state department health websites. “Data extracted included existence of HAI collaboratives, voluntary or mandatory HAI reporting mechanisms, and quantity of specific HAI training materials,” he said. The survey found that 39 percent of the states identified nursing homes as a target

area for HAI reduction. In 2012, Dorritie said only 23 states had the same goal. Almost all (94 percent) states included nursing homes in their HAI plans. But those initiatives most often included HAI advisory councils rather than training for long-term care (LTC), he said. In fact, only 57 percent of states offered nursing home-specific IPC training, Dorritie said. That training was made up mostly of books or printed materials (78 percent). Sixty-four percent of training focus was devoted to antibiotic stewardship; 10 percent to C. difficile; 8 percent to hand hygiene; 8 percent to MDROs; 7 percent to environmental cleaning; 3 percent to CAUTIs; and 0 percent to CLABSI. “Nearly every state identifies nursing homes as an area of effort, but less than half have a collaborative that includes nursing homes,” Dorritie said. Training materials specific to nursing homes are infrequent but could be easily shared through electronic links, he noted. Ashley Chastain, MPH DrPH(c), said according to the Infection Surveillance in Nursing Homes survey, 3,269, or about 20.8 percent, of all nursing homes nationwide w w | 51



“Research shows that antibiotics account for about 40 percent of all medications administered in nursing homes. And as many as 79 percent of nursing home residents receive antibiotics at least once a year.” are currently enrolled in the National Healthcare Safety Network (NHSN). In 2017, the Columbia research team conducted a qualitative study with staff from 14 nursing homes across the country. The research team did confidential interviews with three staff members from each nursing home, who had an average of 18 years working in LTC. Chastain said participants described a number of benefits of NHSN reporting, including helping them compare infection rates with different facilities around the

state, responding to potential outbreaks appropriately, and increasing staff awareness of infection prevention. Barriers included lack of an IPC champion, the fact that NSHN enrollment and reporting may take time, and that staff are in short supply in LTC settings. Chastain also discussed her research team’s new Study of Infection Management and Palliative Care at End-of-Life (SIMP-EL). The study is currently recruiting nursing homes, and 510 surveys were completed between November 2017 and March 2018.

Goals of the study include: • Describing the integration of infection management and palliative care, including environmental scans of state policies and Quality Innovation Network-Quality Improvement Organization (QIN-QIO) activities. • Examining factors associated with antibiotic use in nursing home residents, and analyzing factors associated with transfer due to infections, using quantitative analyses of Medicare files, surveys, and other data. Chastain said preliminary findings include: • A quarter of nursing homes reported high turnover in critical staff roles. Almost 20 percent had three or more administrators in the previous three years; 24 percent had the same level of IP exits, and 26 percent reported the same statistics for their directors of nursing. • The person in charge of infection prevention spent an average of 12 hours (out of 40) per week on IPC activities. • Almost 44 percent of people in charge of nursing home IPC had no infection prevention training. • 27.6 percent of facilities were enrolled in NHSN. Columbia’s nursing home data is expected to be particularly relevant in November 2019, when phase three of the CMS Final Rule will be implemented. “We’re not sure how that will affect nursing homes,” Chastain said.



onsider the following scenarios:

You receive a phone call from your pediatric facility’s child life manager. She’s planned an event with carnival games, clowns, and food for pediatric inpatients. Parents and siblings are also invited. She asks you about infection-risk exclusion criteria for patients.

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You receive a phone call from an operating room (OR) staff nurse who says she’s seeing fruit flies in the OR. She wants to know what to do. You receive a phone call from the obstetrician manager, who says the majority of her labor and delivery patients are not being vaccinated for Tdap during their pregnancy. She asks you to implement a vaccine program. Your hospital has a new OR manager. He notices the staff are wearing jewelry,

nail polish, and t-shirts, and they have uncovered hair when they’re in restricted areas. He believes the OR dress code policy is outdated and these issues are not being properly addressed, making it unclear what staff should wear. He wants you to write a new dress code policy for the OR staff. What should you do? Are these situations within your job description? Should you handle them directly, consult

someone else, or refer them to another person entirely? Three infection preventionists (IPs) from BJC Healthcare in the St. Louis area designed a framework called “Stay in Your Lane” to answer scenarios and questions like this. Patti Kieffer, RN, BSN, CIC, FAPIC; Carole Leone, RN, MSN, CIC, FAPIC; and Rachael Snyders, MPH, BSN, RN, CIC, got the idea for the framework during the FDA’s recent investigation of heater-cooler devices and their likely contamination with Mycobacterium chimaera during manufacturing. At one point, Kieffer said, “Our medical director said: ‘Ladies, stay in your lane’” regarding specific aspects of the investigation. But what does “stay in your lane” actually mean when it comes to infection prevention? During a session at APIC 2018, Kieffer and her co-workers said the Stay in Your Lane framework is designed to help IPs use an objective approach for prioritizing topics, issues, and projects that are presented to them. They went on to explain the Stay in Your Lane framework and asked audience members how they would apply the framework to specific scenarios like the ones mentioned above. “Quite frankly, we made this up,” Kieffer said with a laugh. “So, we want to know how it works for you.” DEFINING THE SCOPE

The Stay in Your Lane framework begins with the question in the chart in next column: Kieffer said the framework is designed to address gray areas, ambiguous questions,

“Questions to ask as you work through the framework include: What are your resources? What is the risk of doing nothing? What do you see, hear, and feel? Is the request part of your written job responsibilities or IPC plan?”

DOES A REQUEST PRESENT A REAL/PERCEIVED INFECTION RISK TO PATIENTS? IF THE ANSWER IS YES, DOES THE ISSUE FALL INTO YOUR INFECTION PREVENTION PLAN OR ROLES AND RESPONSIBILITIES? IF NO, REFER IT TO SOMEONE ELSE. IF YES, THE NEXT QUESTION IS “ARE CONTROL MEASURES WITHIN YOUR SCOPE?” IF NO, CONSULT WITH OTHERS. IF YES, THEN YOU WOULD INVESTIGATE AND MANAGE THE ISSUE. and tough issues. Snyders added with a laugh, “We hope this framework makes you feel so supported and empowered that you will go back and tell your coworkers you are not going to do their work anymore.” Kieffer said the framework isn’t applicable to emergency situations, including The Joint Commission or Centers for Medicare & Medicaid Services visits, or situations where all hands need to be on deck. It also may not be effective for reporting and data requests. “If you are the only person with access to data, even if it isn’t infection prevention-related, you may need to get the data. But if it’s not your data, let it go and let others take ownership of their data,” Snyders said. The framework may also not be relevant for people with dual roles or responsibilities like occupational health, budgeting, and management of personnel, and it may not be applicable to supply-chain requests. Kieffer said key concepts related to the Stay in Your Lane framework include: Your responses may vary depending on the size of

your facility and how many IPs you have; you shouldn’t rely solely on past experience and training; and you need to understand that you may have to work outside of your comfort zone. Questions to ask as you work through the framework include: What are your resources? What is the risk of doing nothing? What do you see, hear, and feel? Is the request part of your written job responsibilities or IPC plan? FRAMEWORK DO’s AND DON’Ts

“The framework isn’t going to solve your problems or fix the culture at your facility,” Snyders said. “But it does help you determine how invested you may need to be in an issue, and provides guidance on decision-making and your own commitment to an issue.” The bottom line is, “If everyone is used to the IP doing everything, they will not get used to ‘staying in your lane’ overnight,” Snyders said. Therefore, instituting the framework may take some effort and repetition. She suggested starting out by testing the framework on supportive colleagues. Snyders also offered the following dos and don’ts for applying the framework: Do: • Evaluate whether you have the bandwidth to help with the request. • Ask if priorities can be shifted or tradeoffs made. • Show a willingness to pitch in if there are small ways you can contribute to the project. • Be honest; give reasons for saying no. • Practice saying “no” out loud and eventually it will become easier. Don’t: • Use a harsh tone. • Use a hesitant tone or be overly polite. Strive for a steady and clear “no.” • Hold back the real reason you’re saying “no.” “You are not the sole person responsible for preventing infections and promoting patient safety in your facility,” Kieffer said. “At the core, an IP should function as a subject-matter expert. The ideal state is to work as a consultant. Act as if you’re mentoring a new IP—what would you tell them to do?” w w | 53





t’s been estimated that it takes 17 years for research to make it into practice, said Heather Gilmartin, PhD, NP, CIC, FAPIC, during the session Implementation Science for IPs, at APIC’s Annual Conference.

That’s why the new field of implementation science is so important, said Gilmartin, an investigator and nurse scientist with the Seattle-Denver Center for Innovation, Department of Veterans Affairs. Implementation science, otherwise known as dissemination and implementation (D&I), is designed to bridge the evidence-to-practice gap and bring best practices to the bedside, Gilmartin said. Examples include hand hygiene practices and delivering flu vaccines to people who need it the most. Of course, she said, infection preventionists (IPs) have been doing this all along. In fact, D&I skills are addressed in the APIC Competency Model. But all IPs know there

54 | FALL 2018 | Prevention

are issues with bridging the evidence-topractice gap. Amanda Hessels, PhD, MPH, RN, CIC, CPHQ, FAPIC, Columbia University/Hackensack Meridian Health, addressed the how-to’s of D&I. Evidence-based practice is a method to deal with the uncertainty inherent in healthcare practice. “Call me Pollyanna, but I would like to think all practice is based on evidence,” she said as the audience laughed. First, IPs need to find evidence through academic, health-sciences, and hospitallibrary resources. They can also consult internal evidence like outcomes management, performance improvements and quality projects, and in-house clinical experts.

“You are the expert in internal evidence where you work,” Hessels said. External evidence includes research, evidence-based theory, expert panels, and opinion leaders. These are divided into primary versus secondary sources. One of the best ways to determine the quality of evidence is to evaluate the study design through the hierarchy of evidence. For infection prevention and control, Hessels said evidence comes from the middle levels of the hierarchy, including observational studies. “The challenge is to rapidly apply this new evidence to practice,” Hessels said. This can be accomplished by the Consolidated Framework for Implementation Research

(CFIR), which helps IPs identify and problem-solve common research ideas. Hessels and Gilmartin listed five major “buckets” that affect implementation of those ideas: 1. Characteristics of the intervention. This includes the intervention source, evidence strength and quality, relative advantage, adaptability, trialability, complexity, design quality, and cost. 2. Inner setting. This includes structural characteristics of your facility, networks and communication, culture, and the implementation climate. 3. Outer setting. This includes patient needs and resources, the robustness of your networks, peer pressure to implement a program, and external policy and incentives like guidelines and reporting. 4. Individuals involved. This includes people with knowledge and beliefs about intervention, helpers, and hinderers within your organization, people’s stages of change, identification with the organization, and personal attributes (e.g., implementation exhaustion).

5. Implementation process. This includes planning, engaging appropriate staff who will help you carry a program to the finish line, executing the plan, and reflecting on and evaluating the plan and outcomes. Gilmartin said the challenges of D&I work are that it takes time, leadership needs to be involved, reinvention and adaptation will be needed, and you will need help carrying the torch. It also requires the ability to simplify an intervention so that you can engage someone with only a 30-second conversation. Finally, you need the humility and vulnerability to say to your peers that you need help, she said. Hessels closed with the promises of D&I work. First of all, she said, it contributes to our nation’s goals to improve healthcare. Secondly, a systematic approach helps IPs deal with the unique social and cultural components of their organization. And finally, there’s the opportunity to communicate lessons learned to the larger community.

READ MORE ABOUT PROTECTING PATIENTS IN THE AMERICAN JOURNAL OF INFECTION CONTROL The Project Protect Infection Prevention Fellowship: A model for advancing infection prevention competency, quality improvement, and patient safety. Reisinger J, Wojcik A, Jenkins I, et al. Am J Infect Control 2017;45(8): 876-882. What do visitors know and how do they feel about contact precautions? Seibert G, Ewers T, Barker AK, et al. Am J Infect Control 2018;45(1): 115-117. Applying human factors and ergonomics to the misuse of nonsterile clinical gloves in acute care. Wilson J, Bak A, Loveday H. Am J Infect Control 2018;45(7): 779-786.

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Building a partnership between IPC and the ED BY BETH WALLACE, MPH, CIC, FAPIC


roviding patient care in the emergency department (ED) is hard. Every conceivable complaint and patient acuity level can arrive at any moment. Ensuring proper infection prevention and control (IPC) in the ED is also hard.

During the 2018 APIC Annual Conference, Jennifer Boe, BSN, RN, PHN, CIC, Renee Sanders, RN, MSN, and Robert Sicoli, MD, shared the experience of Children’s Hospitals and Clinics of Minnesota in building a relationship between IPC and the ED. As an infection preventionist (IP), I have witnessed the difficulty of implementing IPC practices in the ED setting. The Children’s team defined the conflict perfectly. From the IP perspective of staff in the ED: • Have a cavalier attitude about exposures to infectious diseases — “I’ve already BEEN exposed to everything!” • Don’t believe in personal protective equipment (PPE) use • Don’t perform hand hygiene • Insert an indwelling urinary catheter in all patients • Don’t believe the rules apply to them • Have a bad track record with flu shot compliance • Avoid IP colleagues From the ED perspective of IP staff: • Have unrealistic expectations, and don’t understand the life-saving work that is being performed in the ED — “we can’t be bothered with PPE during a resuscitation” • Only want to talk about hand hygiene 56 | FALL 2018 | Prevention

• Don’t understand the differences between inpatient units and the ED • In general, “just don’t get it!” A series of challenges beginning with a 2012 pertussis outbreak forced the ED and IP staff to interact and move away from the above outlined conflict and perceptions. With more than 4,000 cases of pertussis in the community resulting in nearly 300 possible exposures in the ED, Children’s administration urged the two departments to come to the table and mutually ensure Children’s EDs were prepared. These meetings led to actions ensuring they were ready to appropriately identify, isolate, minimize exposures, and respond to exposures after the fact. As a result of these meetings, IPs and ED patient care supervisors began rounding together. This helped the IPC staff recognize some of the unique issues the ED was dealing with and helped the ED staff see that IPC staff are interested in more than just hand hygiene. PPE utilization by ED staff is a big IPC concern, but through the IPC/ED rounding process, IPs realized that ED staff were using three carts to have PPE on hand for the entire ED. These carts were mobile, and the intent was to put them where needed. However, three stations for PPE was not adequate, particularly in the setting of a community outbreak of an illness requiring isolation precautions.

Due to rounding, IPC/ED leadership were able to identify the need for greater PPE availability, and successfully advocated for one PPE wall unit for every two rooms in the ED. COMPLIANCE WITH PPE IMPROVES WHEN IT’S EASIER TO COMPLY

In 2013, a large measles outbreak brought ED and IPC together again. After some exposures occurring in the EDs because of patients waiting in the lobby, the Children’s IPC team made recommendations for transmission-based precautions readily available in the triage documentation area of the electronic medical record. This helped staff identify and isolate potential cases to minimize exposures. During 2014, the United States, and the world, faced an unprecedented outbreak of Ebola virus. ED staff recognized that they would not be prepared to handle an Ebola case without an IP. IPs recognized that they could not adequately prepare the hospital without the ED—the most likely first point of contact with a patient. Recognizing their mutual need, and the fact that the Ebola event increased visibility of both departments, the Children’s IPC and ED teams collaborated to leverage the crisis. The collaboration of the departments with administrative support led to physically changing the ED through expeditious


construction to ensure optimal patient flow in a contained negative-pressure area. In the wake of Ebola, and with their new appreciation of each other, Children’s did not stop their IPC/ED partnership. Building on the importance of rapid identification and isolation of easily transmissible infections, Children’s added a new role to the triage process—a pivot nurse. The pivot nurse serves a key role in the ED and sees patients prior to the traditional triage. From the ED perspective, this allows identification of life-threatening conditions upon arrival to prioritize the truly critical patient care need. Because of the flourishing relationship, IPs were able to get involved with this new role and leverage it as well. Pivot nurses perform the travel screening and have received training to recognize potentially infectious conditions. This resulted in patients being placed in transmission-based precautions within moments of arrival to the ED. When measles returned to the community in 2016, the pivot role allowed the ED to rapidly identify and isolate two patients based on the rash and information gleaned practically upon arrival. The success of the pivot role in identification and isolation is evident in that the two measles patients who had a combined three visits to Children’s ED resulted in 41 exposures compared to an outpatient setting where these two patients led to 450 people exposed.

As Ebola and measles began to wane, infection prevention staff noticed that ED staff were drifting away from proper PPE use. Taking advantage of the collegial relationships established, IPC and ED leadership worked together to establish transmission-based precautions specific to the ED. For patients requiring contact and droplet precautions—those with respiratory illness—isolation precautions were modified only in the ED to make complying with transmission-based precautions easier for ED staff. Gowns and eye protection are only required in the ED for patients with copious secretions or when performing an activity likely to generate a splash or a spray. Hand hygiene, masks, and gloves are expected for all patients requiring the combined contact and droplet precautions. Measles was back in the community in 2017, but this proved to be the culmination of the IPC/ED relationship. The mutual trust and shared perspective helped speed the collaboration, and the team developed updated versions of a measles screening tool as the epidemiology of the outbreak evolved. ED staff took ownership as they realized that their IPC efforts could play a large role in curbing the outbreak and letting them return to their normal ED routine. IPC checked in with ED leadership daily which allowed resolution of issues quickly and easily. A dedicated phone

line—“the ED bat phone”—helped the ED reach out to IPC just as conveniently and easily. Children’s staff shared their key learnings/helpful hints for other IPs looking to turn their ED cowboys into collaborators: • Recognize the challenges of implementing IPC in the ED: o Significant traffic o Shared spaces, even in the face of isolation precautions o Variable acuity and rapid turnover with a need to prioritize saving lives • Pick the right time and location to discuss IP concerns. Times and places should be convenient to ED staff. • Hear out ED staff when they make suggestions to solve ED IP issues. They know their department best and know what will work in their unique setting. • Build the relationship and find common ground. With fortitude, patience, time, and relationship-building, IPs can help develop their ED staff from cowboys to collaborative IPC professionals who just happen to work in the ED. Beth Wallace, MPH, CIC, has been an infection preventionist since 2006, and been board certified in infection prevention and control since 2008. She is the senior director of system infection prevention and epidemiology for Beaumont Health in southeast Michigan. Beth is also a member of APIC’s Communications Committee. w w | 57



Making a place for IPs in the purchasing process BY MEAGAN GARIBAY, RN, BSN, CIC


ne Tuesday, my infection prevention partner and I were doing rounds in the emergency department (ED). When we went into one of the storage rooms to check the storage of supplies, we found on one of the shelves a product we had never seen or heard about before: a small video laryngoscope. We took our discovery to the ED manager and director and started asking questions. They knew what the product was, what it did, and how to use it, but our most important question went unanswered: How do you clean it? That chance discovery and conversation led to a solid month’s worth of work for our infection prevention and control (IPC) team. It also led to major inconveniences for our ED and anesthesia doctors and residents; in the beginning, we did not know exactly how to safely clean and disinfect the device, and, therefore, we could not confirm that the device was being safely cleaned and disinfected between patient uses. In this situation of uncertainty, our ED director did the only thing he knew would protect our patients—he sequestered the device and prohibited its use.

be vague or ambiguous. Similarly, the differences between critical, semi-critical, and noncritical devices can be poorly understood by most of those outside of our profession.

If not for the vigilance of infection preventionists (IPs), many caregivers might just give a medical device a quick wipe with a “disinfecting” product between patients and consider the device to be safe to use. In general, the differences among the terms “cleaning,” “disinfecting,” and “sterilizing” are misunderstood by most people outside of the IPC profession. These words are often used interchangeably by our coworkers who do not know the nuanced meanings of the terms. They are also sometimes used interchangeably by manufacturers and vendors, especially if the companies are new to, or not well established in, the healthcare industry (in general, major companies in the business tend to use these terms appropriately). As a result, manufacturer instructions can 58 | FALL 2018 | Prevention



Furthermore, the people who bring products into a facility may not know the capabilities of the facility to properly reprocess them. Steam sterilization, gas plasma,

automated high-level disinfection, manual high-level disinfection—these are all capabilities that need to be assessed and matched with the manufacturer’s cleaning recommendations before the product is purchased. Failure to do so can lead to costly mistakes: the purchase of a product we can’t use because we can’t clean it, the use of a product we think we cleaned but did not clean effectively, or the cleaning of a product in an improper way that greatly shortens its life. STOPPING “BACK DOOR” PURCHASES

When departments “sneak” products through the back door (i.e., without going through the purchasing committee), the risk for infection transmission can rise. However, when we involve as many people as possible in the process of product purchasing, we can emphasize that individual departments (which have individual budgets) must not go rogue with product implementation, so that we can avoid problems such as having

to sequester equipment until we can figure out how to use it safely. Prioritizing infection prevention in purchasing is a challenge because, as always, there are many competing interests at play. Healthcare workers want the latest and greatest equipment—or, at minimum, they want something that works reliably in the way it’s supposed to work. Department leaders want to provide a good and safe working environment, and may be concerned with patient satisfaction scores, hospital rates of healthcare-associated infections, and limiting lengths of stay. If a product can deliver in any one of these areas, somebody is going to say they need it and they need it now! Convincing people that it is worth waiting for the products committee to review the product in question is paramount. Acquisition may be delayed while a product goes through the approval process, but patience is rewarded because the product will be vetted to the best of the committee’s ability, which should lead to fewer hiccups down the road.

THE NEED FOR A COMMITTEE So, how do we avoid making costly mistakes? The formation of an interdisciplinary committee that oversees the purchasing of products within the facility is one of the best ways to regulate the inflow of products into the organization. The products committee at our organization is composed of the following: • Staff from materials management, infection prevention, and education; • A representative from each unit within the hospital (medical-surgical, critical care, surgery, sterile processing, and so on); and • A representative from our clinics. We meet every other week, or once a month, depending on how many requests for products have been received, and every committee member has a role: • The director of materials management is the committee chair. He receives most of the requests for products and is responsible for taking the requests further up the supply chain to see whether the facility will purchase them after they have been approved by the committee. • As the IPC representatives, my partner and I anticipate reprocessing issues if the device is reusable. We also assess staff safety issues from an occupational health standpoint and patient issues from a cross-contamination standpoint. • A member of the education staff assesses the education plan. • The unit representatives are valuable because they can foresee potential problems with the actual implementation or use of the product and can give us feedback on whether the product is actually needed or offers improvement over current products. We also invite the requester of the product to come to the meeting to lobby for the product and why it is necessary.

For the committee to be successful in its vetting process, all departments and disciplines must agree to send every product they’re considering to the committee. You will have to generally educate people that a committee exists and also intervene on the spot when you have individual incidents of “back door” purchasing. We have found that on-the-spot education is especially relevant in the surgical department, where we had several incidents of vendors promoting a new product directly to surgeons so that they would use it in their next cases. When vendors bring in new implantable products, such as mesh, it can be a huge problem. Some of those products may be considered biological and, therefore, must be tracked a certain way within the facility. Fortunately, our operating room manager (who sits on the committee) has ensured that all vendors and all physicians submit products to the committee before using them. THE IP’S ROLE

Formation of a products committee is a prudent idea for so many reasons, but the committee absolutely needs an IP to participate. By sharing our knowledge and expertise, we can help ensure that the facility has the ability to sustain the use of new products through safe use and adequate cleaning and disinfection. We can use our expertise to decode sales language for our coworkers, especially when vendors use buzzwords that relate to infection control—IPs are uniquely qualified to look at information presented and determine whether the research about a product backs up the vendor’s infection control claims. We can also help to determine if a reusable versus a disposable product is more effective from an IPC standpoint, or which type may be safer to use. And, of course, we are the ones who will ask one of the most important questions about any purchase: How do you clean this thing? Meagan Garibay, RN, BSN, CIC, is an IP at Comanche County Memorial Hospital, a 283-bed non-profit hospital in southwestern Oklahoma. She has been a registered nurse since 2009, with a background in medical-surgical/oncology and NICU nursing. She has been working as an IP since 2015. w w | 59



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


A proposal generally consists of five parts: 1. The executive summary; 2. Description; 3. Benefits to be derived; 4. Financial analysis; and 5. The implementation plans. In all sections, aim to be concise and clear, as decision makers are often short of time. Remember that the audience for the proposal may not be subject matter experts in your field, so it is best to avoid the use of highly technical or clinical language. Also, keep in mind that reviewers always have questions. The best proposals and business plans anticipate those questions and answer them as part of the narrative. Among the questions to be anticipated are the following: • Does the proposal represent good science? • Can the organization afford not to proceed? • Does the initiative support new market opportunities? 60 | FALL 2018 | Prevention

• Does it fill a service gap? • How does it fit with the goals of the organization’s strategic plan? THE EXECUTIVE SUMMARY

The executive summary is a brief and engaging description of the initiative’s basic “who, what, where, when, why, and how” elements that journalists use when writing a news story. This summary should be no more than two pages long. It can incorporate “bullet features” interspersed with a concisely written narrative. The goal is to paint a bold, compelling picture that encourages the reviewer to delve deeper into the details. DESCRIPTION

The description section explains the proposal in detail. Start by describing the problem that the initiative will address. For example, if the goal is to reduce the incidence of patientto-patient transmission of infections, explain how such infections occur and their consequences for the organization and its patients.

Next, describe what will be done to achieve the objective. This might involve listing any processes that will be modified or eliminated, new procedures, new equipment or building renovations, staffing changes, and so on. This description can include photographs, f low diagrams, schematic drawings, and other illustrations to make the proposal easier for the reader to understand. When writing the description, it is the time to expand upon the “who, what, when, where, why, and how” questions that you touched upon in the executive summary. Who will benefit from the initiative and who will provide the services? What services will be provided and where will they be located? When will services be offered (e.g., 24/7/365, only in certain months, on demand)? The “why” and “how” questions may be the most important to gaining approval. Answers to “why” questions explain the value of the initiative to all concerned parties. Why should scarce resources be devoted to this project? Why choose this initiative and

overcome potential skepticism on the part of reviewers and enhance their receptivity to the proposal. BENEFITS-TO-BE-DERIVED

The benefits-to-be-derived section is a detailed explanation of the clinical, operational, and financial benefits. The clinical benefits should be described first because they go to the heart of the organization’s purpose— patient care. Anticipated reductions in length of stay, improved outcomes, fewer infections, and so on should be described comprehensively. A review of the clinical literature can be helpful in describing the benefits, but local results are often more convincing than those reported in national studies. Results from New England, for example, may not be obtainable in the Pacific Northwest. Retrospective chart reviews often provide the best data because they are hospital-specific. A short, prospective in-house trial can also provide useful data. A proposal that speculates on the improvement to be derived from the addition of staff can sometimes be

modeled using overtime to simulate the staff addition without actually hiring anyone. Similarly, vendors may temporarily provide equipment to support an in-house demonstration trial. Operational benefits such as improved staff productivity, faster response times, or reduced employee turnover should be described in as much detail as possible. Flow diagrams and the like are useful in comparing before and after, and for illustrating the improvements to be achieved. Finally, the financial effects—changes to volume, revenues, expenses, and profits—should be described in broad terms. For example, this section can be used to highlight a variety of tangible and intangible financial benefits to be derived, such as the following: • Cost-efficiency and/or costreduction possibilities • Revenue enhancements associated with increased patient volume • Increased throughput in the surgical and emergency departments • Improved cash flow associated with increased revenue


not a different project? Why should the investment be made now? This is where you want your passion for the proposal to be on display. While decisions are best made using hard data, the soft side of the process should not be overlooked or minimized. Anecdotes involving real cases and real patients (with appropriate masking of identities) give a sense of intimacy and urgency to the decision process. Instead of simply talking about infection control, describe the difficulties a grandmother faced when, five days into her hospital stay, she developed a methicillin-resistant Staphylococcus aureus infection, or tell the story of how a Clostridium difficile infection affected a little boy; People tend to relate to stories about people more than just numbers on a page. A description of the “how” (the operational aspects) of an initiative helps decision makers become more comfortable with the proposal, particularly if cutting-edge technologies are involved. For example, explaining how a technology-based system can increase hand hygiene compliance can

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• Reduced malpractice claims because fewer infections and other untoward events occur • Higher satisfaction scores among patients and their families • Improved staff satisfaction scores, resulting in decreased turnover • A better organizational reputation that can enhance recruitment and patient volume • Improved market share Specific details will be provided in the financial analysis section, so the narrative here should focus on the overall financial impact. Descriptive language, such as “The initiative provides a $2.4 million improvement in bottom-line results,” will both get the reader’s attention and provide a natural transition to the financial analysis that will accompany the proposal. Clinical literature is of little relevance when predicting the revenue and cost implications of an initiative. It is preferable to work collaboratively with staff in the finance department to determine the real, institution-specific impact. As a bonus, you can emphasize in your proposal that the finance department has already verified the numbers. This “seal of approval” may help eliminate any skepticism. FINANCIAL ANALYSIS

The financial analysis section presents the marginal profit-and-loss statement,

benefit/cost analysis, breakeven analysis, comparative expense or revenue analyses, and other formal financial analyses. It should include detailed information on the cost of any new equipment or technologies, installation and construction costs, licensure fees, and other expenses. Exercise caution when predicting expenses such as equipment costs. Despite vendor claims to the contrary, virtually nothing can be just plugged into existing systems. It is always best to consult the engineering department to understand how much infrastructure (HVAC, electrical, etc.) modifications will cost. Often, when deciding whether to pursue an opportunity, decision makers focus on its return on investment (ROI). The ROI should be calculated in this section and also noted in the executive summary. Simply stated, ROI is a method of examining the value (the return) derived from an investment. Examples include the interest earned on a bank account, profits derived from a rental property, or profits from a new program. The formula is as follows: ROI = Average Return Average Investment The average return is the average annual profit. For an investment in a piece of equipment or technology, the average investment is half of the total

investment. This is because the technology is assumed to be worth 100% of its purchase price on its first day in service and 0% on its last day, and an average of those two values is 50%. If the investment does not involve equipment or technology (for example, a new work process that reduces infections), the average investment is the average annual cost of the new process. Consider the following example. Grandiose General Hospital is considering a new technology costing $970,000. The technology has a five-year life span and is expected to generate $986,600 of new net revenue in its first year. This revenue will grow each year thereafter. The associated annual operating costs are $600,000 for salaries and fringe benefits, $50,000 for a maintenance contract and $194,000 for depreciation. The cost of operating supplies will be $136,000 in the first year and will grow slowly over time. Table 1 details the annual operating results as well as the five-year averages. As seen in the table, the annual profit is quite small in the first year ($6,600), but it grows significantly over the following four years. The average annual profit over the five-year life is $219,000. The ROI is calculated by dividing the $219,000 of average annual profit by the $485,000 of average investment ($970,000 ÷ 2). The result is a return


Year 1

Year 2

Year 3

Year 4

Year 5

Annual Average

Net patient revenue







Salaries and benefits







Operating supplies







Maintenance contract














Total operating expense













Profit or (loss)

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Year 1

Year 2

Year 3

Year 4

Year 5

Annual Average

Net patient revenue







Salaries and benefits







Operating supplies







Total operating expense







Profit or (loss)







on investment of 45.2%. This is an asset acquisition ROI. The calculation would be a bit different if no new equipment or technology were involved. Assume that Grandiose General Hospital achieved the financial results depicted in Table 2 without investing in new technology. Compared with the previous example, the average annual profit rises to $463,000 because the depreciation expense and the maintenance contract associated with the technology are eliminated. In this case, the ROI is calculated by dividing the $463,000 of average annual profit by the $741,600 of average operating cost (the “investment” in this instance is the staff and expenses). The ROI is 62.4%. This is an operating ROI—the return is based on the new way of operating and not an asset acquisition. IMPLEMENTATION PLAN

An implementation plan at the end of the proposal serves two purposes: It lays out a clear path to achieving the desired results (the benefits described previously

in the proposal), and it provides a subliminal boost to the proposal by sending a “We’re so sure you will want to approve this” message to the reviewers. The plan begins with a clearly identified outcome. Avoid vague goals like “reduce patient-to-patient infections.” Instead, include measurability, as shown in the goal in Figure 1. In this way, progress can be tracked and adjusted as necessary. After the goal is set, document the measurable subordinate objectives that will lead to achieving the overall goal. All of the actions needed to achieve objectives should be identified in detail and assigned deadlines. Qualified individuals should be assigned to these tasks and held accountable for their achievement. Appropriate amounts of resources— not too much and not too little—need to be assigned. This balance may be the most critical element of the proposal. While the initiative should not waste valuable and potentially scarce resources, the implementation will fail if insufficient resources are provided. If,

for example, a position is to be staffed 24/7/365, it requires approximately five full-time equivalents (FTEs). Assigning only four FTEs will result in failure. The same issue applies to the resource of time. Deadlines should be aggressive but realistic. Some actions take specific amounts of time, and the schedule for them cannot be shortened. Once the business proposal is finished, your focus will shift to the presentation. Part 2 of this series will address the “how to” of presenting the proposal. Read it in the winter issue of Prevention Strategist. 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.


Overall implementation goal: Reduce the incidence of patient-to-patient infections by 40% by end of fiscal year 20XX Subordinate Objectives

Necessary Actions

Required Completion Date

Resource Needs

Accountable Individual
















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64 | FALL 2018 | Prevention


n a little more than a decade since their founding, social media networks like Twitter and Facebook have digitally connected 70 percent of Americans, including more than half the population aged 50 years or older.1 Social media platforms (SMPs) allow users to collect and share information with a speed and scale unmatched by any other media type. In a 2011 interview with Terri Gross of the National Public Radio show Fresh Air, Twitter cofounder Biz Stone described his early understanding of Twitter as “rudimentary communication among individuals in real time that allows the many to behave as one,” analogous to “a flock of birds moving around an object in flight” (an image that inspired the Twitter bird logo).2 Since that 2011 interview, SMPs such as Twitter and Facebook have gained about 1.4 billion new users worldwide, with more than 3 billion users expected by 2021.3 The use of social media both offers benefits and poses challenges for infection preventionists (IPs). On the one hand, because SMPs reach a large audience at a low cost, they have been widely adopted by public health officials and infection prevention and control (IPC) educators.4 SMPs are used to communicate critical, timely information during public health crises,5 and nurses and physicians also use them for ongoing education and professional development.6 On the other hand, IPs face certain obstacles when seeking to benefit professionally from social media:4

READ MORE ABOUT SOCIAL MEDIAL AND INFECTION PREVENTION IN THE AMERICAN JOURNAL OF INFECTION CONTROL Journal Club: Social Media as an antimicrobial stewardship tool. Conway LJ, Knighton SC. Am J Infect Control 2017; 45(3): 293-294. Social media as a tool for antimicrobial stewardship. Pisano J, Pettit N, Bartlett A, et al. Am J Infect Control 2016; 44(11): 1231-1236. Zika virus pandemic — analysis of Facebook as a social media health information platform. Sharma M, Yadav K, Yadav N. Am J Infect Control 2017; 45(3): 301-302.

• The scale of information available is overwhelming: Every day, tens of thousands of tweets related to IPC are issued by thousands of experts—the Centers for Disease Control and Prevention (CDC) alone has 68 official Twitter accounts,7 and relevant social media content can be displayed in separate but similar channels of discussion (such as #infectionprevention and #infectioncontrol), increasing the chance that you or your audience may miss critical information. • Information lacks context: Social media discussion is typically about breaking news or research, and the life cycle of information is extremely short. The design of SMPs preferentially exposes users to new information, and social media content may contain misinformation or lack the context given by previously published evidence. • Users may not be meaningfully engaged by social media posts: If experts use social media as a “one-way street” to communicate information, they miss an opportunity to fully engage with the audience’s questions or concerns. These factors limit an IP’s ability to learn and share information on social media. In consideration of these limitations, a collaboration between Clean Sweep Group, Inc. (CSGI) and California APIC (a council of all 12 APIC chapters in California) has developed epiLinks. WHAT IS EPILINKS?

epiLinks is an online dashboard to help IPs navigate and contextualize the latest IPC discussion topics on Twitter. Available at, the dashboard displays infection prevention–related topics from the previous few days of tweets, alongside links to relevant scientific literature and

popular channels of Twitter discussion (i.e., Twitter hashtags). The team behind epiLinks collectively crafts search terms for each subpage and refines the analysis, such as screening out irrelevant terms or phrases like “computer virus infection prevention.” epiLinks is typically updated three times daily and is available for free. There is no registration, and users do not need a social media account to access epiLinks. The dashboard on the homepage ( is generated from search terms related to IPC, such as “infection prevention” and “infection control.” The site also has webpages dedicated to specialties within IPC, such as antibiotic stewardship ( Emergency management pages are created ad hoc during public health events such as a hurricane (Figure 1) or the 2018 Lassa virus outbreak. Additionally, previous emergency management editions of epiLinks are archived and available for reference should similar incidents develop later (; Figure 1A). Data for the dashboard are collected and generated by (1) using the Twitter application programming interface—known as API—to search tweets containing common infection prevention terms for each webpage;8 (2) applying common machinelearning techniques to sort tweets into topics;9 (3) using key terms for each topic to search the CrossRef database for recent scientific literature;10 and (4) updating the dashboard to reflect the latest search results and analysis.11 WHY SHOULD IPS USE EPILINKS?

A quick skim of the epiLinks dashboard gives IPs a high-level understanding of current SMP discourse related to IPC, which is w w | 65


Figure 1. epiLinks Hurricane Harvey special edition (accessed March 29, 2018).

Key: A = epiLinks webpages dedicated to specific aspects of infection prevention; B = current Twitter discussion topics and respective keywords; C = most frequently observed Twitter hashtags per topic; D = example of a popular tweet on a topic (e.g., a tweet with likes/retweets or one that uses a popular hashtag); E = relevant scientific literature for the topic.

helpful for ongoing education and professional development. Additionally, emergency management editions of epiLinks can provide a sentinel for public health events in novel or unconventional scenarios such as pandemics and natural disasters. epiLinks scales your information network

epiLinks aggregates and analyzes content from thousands of messages across multiple channels of similar Twitter discussions to identify discussion topics. A topic model text-mining technique processes thousands of messages, and the user is able to identify high-level themes in the discussion without manually reading all content. The text-mining technique used in epiLinks vastly increases the amount of social media information an IP can engage. For example, when Hurricane Harvey struck the Houston metropolitan area in August 2017, it caused record flooding, which left entire neighborhoods submerged, forced tens of thousands of residents into close-quartered evacuation shelters, and instantly created new disease risks for millions of Texans.12,13 In response, an emergency management edition of epiLinks ( was generated 66 | FALL 2018 | Prevention

by using generic hurricane-related search terms such as “#hurricaneharvey”; “#harvey”; “infections”; and “health.” Among the more than 1,000 publicly sourced tweets included in the epiLinks special edition, the health effects of Zika virus and mold were among the most frequently discussed topics (Figure 1B). epiLinks provides evidence-based context to social media content

epiLinks shows users recent journal articles for each discussion topic identified. Key terms from topics are used to construct CrossRef DOI searches, and results are displayed per topic to provide an evidence-based context for the social media discussion. For example, on the Hurricane Harvey special edition page, a link to the retrospective, cross-sectional study titled “Residential Flood Damage After Hurricane Floyd, Mold, Household Remediation, and Respiratory Health,” is displayed alongside the “mold” topic (Figure 1E). epiLinks helps IPs engage on social media

On epiLinks, the pieces for meaningful social media engagement are laid out on

one screen. For example, during Hurricane Harvey, #harvey, #houston, and #health were the most popular hashtags in moldrelated tweets (Figure 1C). From the dashboard, the IP can see that the public is concerned about mold and is referred to mold-related epidemiology literature. Using popular social media channels of public discussion, the IP can then communicate his or her expert perspective to the public. For example, the IP might infer from the social media discussion that there is a need for masks and bleach in the hurricane’s aftermath. With the public’s concern and a solution identified, the IP can use SMPs to effectively address the public’s concerns. In summary, epiLinks scales up an IP’s information intake during a public health crisis or for ongoing education, provides evidence-based context to social media content, and helps users identify and craft responses to public health concerns. LIMITATIONS OF EPILINKS

epiLinks is subject to many of the same limitations and issues as SMPs themselves. Scale continues to be a problem for epiLinks. An epiLinks dashboard will link together multiple search terms, but any related tweets

that did not contain the selected search terms would not be identified. Furthermore, misinformation, such as tweets from an antivaccination advocate, may be displayed alongside highly credible information from an official CDC account. Users must therefore take the same precautions when viewing epiLinks as they would when using any other SMP. However, future research may improve methods to identify and sift through misinformation. Finally, epiLinks relies solely on Twitter tweets to define current social media topics. Critical information posted on other SMPs, like Facebook, will not be captured by epiLinks; however, public health agencies and experts often post similar messages to multiple platforms. The epiLinks team is currently integrating other SMPs. CONCLUSION

Billions of people worldwide are engaged on SMPs, and IPs can harness social media to enhance the work they do every day. epiLinks was built by APIC members with the goal of providing a simple but powerful tool

to help IPs identify and promote information on social media relevant to their field. Cody Haag is the vice president of research and development for Clean Sweep Group, Inc. (CSGI), where he builds tools and protocols to effectively implement no-touch disinfection technologies. Angela Vassallo, MPH, MS, CIC, FAPIC, is an infection prevention expert who works for Health Services Advisory Group, a quality improvement organization. She has published and speaks on many topics related to infection prevention and is past-president of Greater Los Angeles APIC and California APIC. Daniel Field, RN, CIC, is the director of infection control and employee health at Mission Community Hospital in Los Angeles. He currently serves as the communications chair/webmaster for California APIC and the APIC Tri-Valley chapter. References 1. Sheaerer E, Gottfried J. News use across social media platforms 2017. Pew Research Center. September 2017. Accessed February 2018. 2. National Public Radio. Digital life: Twitter’s Biz Stone on starting a revolution [interview transcript]. February 2011. php?storyId=133775340. Accessed February 2018. 3. Statista, Inc. Number of social media users worldwide from 2010 to 2021 (in billions). https://www.statista.

com/statistics/278414/number-of-worldwide-socialnetwork-users. Accessed February 2018. 4. Moorhead S, Hazlett DE, Harrison L, et al. A new dimension of health care: Systematic review of the uses, benefits, and limitations of social media for health communication. J Med Internet Res 2013;15(4):e85. 5. Merchant R, Elmer S, Lurie N. Integrating social media into emergency-preparedness efforts. N Engl J Med 2011;365:289-291. 6. Conway LJ, Knighton SC. Journal club: Social media as an antimicrobial stewardship tool. Am J Infect Control 2017;45(3):293-294. 7. Centers for Disease Control and Prevention. Social media at CDC. html. Accessed February 2018. 8. Twitter, Inc. Search tweets. en/docs/tweets/search/overview/standard. Accessed February 2018. 9. Grün B, Hornik K. topicmodels: An R package for fitting topic models. J Stat Softw 2011;40(13):1-30. 10. CrossRef. Accessed February 2018. 11. Allaire JJ, McPherson J, Luraschi J, et al. rMarkdown: Dynamic documents for R. [R package software]. 2016. Accessed February 2018. 12. National Weather Service. Major Hurricane Harvey — August 25-29, 2017. harvey. Accessed February 2018. 13. Guarino B. The health dangers from Hurricane Harvey’s floods and Houston’s chemical plants. The Washington Post. September 2017. https://www.washingtonpost. com/news/to-your-health/wp/2017/08/29/the-healthconsequences-to-expect-from-hurricane-harveysfloods. Accessed February 2018.

Cloud-based Software with Mobile App 928220_Smart.indd 1

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n 2016, the surgical site infection (SSI) rate of 1 percent at Saint Francis Medical Center, a tertiary care hospital with more than 300 beds and 19 operating rooms (ORs) in Cape Girardeau, Missouri, was below the estimated national rate of 2 to 5 percent.1 However, the medical center’s new nurse chief operating officer (COO) believed the facility could—and should—do more to substantially lower its incidence of SSIs, as well as the associated morbidity and mortality risks for patients and the financial costs to the medical center. In response to the COO’s challenge, the OR manager and other stakeholders launched an evidence-based initiative to cut the rate of SSIs by at least half. ANALYZING THE PROBLEM OF SSIs

Once the COO made clear that reducing the incidence of SSIs would be a priority for the medical center, we selected apparent cause analysis (ACA) as an appropriate quality improvement methodology to identify problems and corrective actions. Compared with an in-depth, formal root cause analysis, ACA takes less time and requires fewer resources; also, the ACA method allows for staff to be included on an ad hoc basis as their input is needed.2 For example, clinical pharmacists assisted with recommendations regarding antibiotic administration. Beginning in April 2016, the core team of stakeholders for the initiative started analyzing the prior three years of SSIs using an ACA worksheet that was developed in-house. The worksheet guides users to answer five questions about specific cases: 1. What happened? A brief description of the problem is documented. 68 | FALL 2018 | Prevention

2. What normally happens? The standard procedure is outlined. 3. What does the process require? A list of all steps is reviewed. 4. Why did the problem occur? If the initial answer to this “why” question does not find the root cause, investigators ask “why” again. This step is called the “five why” method because you may need to ask “why” multiple times to drill down to the root cause. 5. What actions can we take to avoid the problem in the future? An action plan, including the staff responsible and the completion date, is documented. Around 9,000 surgical procedures are performed annually at St. Francis, and all were evaluated in the ACA process. The surgical services director and her team, in consultation with the OR steering committee—which included key surgeons and anesthesiologists—decided to focus on deep surgical infections because they are the most difficult to treat and bring the

most risk to patients. A deep surgical infection involving implants can be devastating to a patient and costly to the medical center. The OR manager and her team, which included the surgical services quality improvement nurse, performed a literature review to research relevant evidencebased practices, and meetings were held to conduct ACA for all specific events. The staff and physicians involved with the specific patient’s care were invited to these ACA meetings; typically, perioperative nurses, the scrub tech, the anesthesia care provider, and the surgeon attended. Other staff, including pharmacists, representatives of infection control, and any pertinent medical center staff attended when appropriate. As ACA identified the causes of problems and the medical center’s practices were compared with evidence-based guidelines, a plan of action to combat SSIs emerged. To address the medical center’s issues, we have made changes in hygiene compliance


A real-time surgical site infections surveillance mode to monitor surgery classification−specific, hospital-wide surgical site infections in a Chinese tertiary hospital. Du M, Li M, Liu K, et al. Am J Infect Control 2017; 45(4): 430-432.

and environmental services; antimicrobial administration; perioperative support; and post-discharge care. HYGIENE COMPLIANCE AND ENVIRONMENTAL SERVICES

One of the key priorities for our SSI initiative was to reduce the risk of infection transmission from caregivers. To improve hand hygiene compliance, we implemented The Joint Commission’s Targeted Solution Hand Hygiene program, eventually incorporating it into a daily performance management system to monitor critically important practices.3,4 Additionally, the dress code for perioperative staff and surgeons was updated to Association of periOperative Registered Nurses (AORN) standards.5 Changes included requiring staff to cover facial hair and wear snug-fitting, long-sleeve jackets during surgical skin preps. These measures can help prevent contamination of surgical sites, particularly when OR leadership

periodically monitors patient care practices to ensure technique and compliance. Environmental cleaning was also a target for improvement. The entire medical center changed cleaning products from a lower-grade cleaning product to a 0.55 percent sodium hypochlorite (intermediate-level) product effective against bacterial spores, viruses, fungi, and bacteria, including Mycobacterium tuberculosis and Clostridium difficile, and OR and environmental services staff were re-educated in the enhanced cleaning protocol.5 Additional cleaning changes included switching to microfiber mops, which are more effective at removing microorganisms than cotton string mops (95 percent vs 68 percent), and weekend terminal cleaning of the ORs used for call cases.5 Also, members of the medical center staff and cleaning staff in departments other than the OR received education on how to use the hypochlorite product for both terminal and daily cleaning of patient care and ancillary areas.

Microbiology of surgical site infections in patients with cancer: A 7-year review. Hernaiz-Leonardo JC, Golzarri MF, CornejoJuárez P, et al. Am J Infect Control 2017; 45(7): 761-766. Validation of an electronic tool for flagging surgical site infections based on clinical practice patterns for triaging surveillance: Operational successes and barriers. Pindyck T, Gupta K, Strymish J, et al. Am J Infect Control 2018; 46(2): 186-190. ANTIMICROBIAL ADMINISTRATION

The appropriate use of antimicrobials is, of course, essential to infection prevention and control.1 As part of the SSI initiative, preoperative antibiotic dosing was changed to use a weight-based methodology, as recommended in evidence-based guidelines.1,6,7 All surgeon orders are to be checked by medical center pharmacists, perioperative nurses, and anesthesia providers to ensure that weight-based dosing and the appropriate antibiotics are given. w w | 69


Preoperative nasal screening for methicillin-resistant Staphylococcus aureus (MRSA) was implemented to the surgical specialties of neurosurgery, orthopedics, cardiovascular, and vascular. Preoperative decolonization of MRSA-positive patients includes five days of mupirocin and appropriate preoperative antibiotics, including vancomycin. Additionally, the EPIC electronic medical record was configured so that a pop-up note reminds anesthesia care providers at the appropriate time during long cases to administer another antibiotic dose.1 PERIOPERATIVE PATIENT SUPPORT

Our plan to reduce SSIs includes multiple efforts focused on improving care throughout the perioperative encounter. For example, the practice of patient bathing with chlorohexidine gluconate (CHG), which had already been a preoperative recommendation, has been expanded to include daily CHG bathing for inpatients.1 Furthermore, surgeons now have the option to use additional treatments, such as CHG irrigation (Irrisept) and negative pressure incision therapy (Prevena or wound vac), in patients with traumatic wounds or ruptured viscus, or whose surgical procedure puts them at increased risk of SSIs. The ACA meetings identified a group of patients at increased risk for SSIs: patients with comorbidities such as hypertension, obesity, peripheral vascular disease and congestive heart failure, diabetes mellitus, chronic obstructive pulmonary disease, tobacco usage, and sleep apnea. This finding drove home the fact that these patients need careful monitoring and specialized support during the perioperative period to ensure that they remain normothermic and normoglycemic throughout the perioperative period, and we have implemented ongoing supportive interventions to address these issues.1,6 For example, warming OR rooms when appropriate, and utilizing warm blankets and forced air blankets while continuously monitoring the patient’s core temperature helps keep patients normothermic during the perioperative timeframe. The 2017 Centers for Disease Control and Prevention guidelines for preventing SSIs recommend an “increased fraction 70 | FALL 2018 | Prevention

of inspired oxygen intraoperatively and in the immediate postoperative period following extubation for all patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation.” Our medical center now routinely follows this recommendation.6 During the initiative, general surgeons and OR leadership discussed the need for optimizing nutritional support for patients undergoing elective colon and genitourinary cystectomy-ileal conduit procedures.8 The surgeons began screening these patients during preoperative office visits and prescribed for them the nutrition formula IMPACT Advanced Recovery® (Nestlé), which provides 18 grams of protein and 24 essential nutrients. When patients followed the instructions to drink the supplement twice a day for five days preoperatively and five days postoperatively (as permitted), the SSI rate for this population decreased from 5 percent to 1.5 percent, and there were no readmissions. This nutrition optimization program has been subsequently expanded and is available to all medical center patients at nutritional risk. POST-DISCHARGE CARE

Because patients go home quickly after surgery, educating them and their caregivers on ways to prevent infection is critically important. All patients and their caregivers/family watch a video, “Keep it Clean: Preventing Surgical Site Infections,” before leaving the medical center. Patients discharged to a nursing home or rehabilitation unit have physician orders that include daily baths and linen changes for cleanliness and SSI prevention. CONCLUSION

Initially, the key stakeholders in our SSI initiative were medical center leadership and OR leadership and staff, but, as the project grew, the stakeholders expanded, too. Over time, the project became a medical center-wide initiative, involving all staff and physicians who care for surgical patients. Over a 15-month period, and through the collaborative use of the ACA tool and evidence-based practices, the medical center decreased its deep SSI rate from 1 percent to 0.1 percent (0.3 percent for all SSIs).

Julie Woodruff, RN, MBA, BSN, has been working in the operating room in 1998. She has served as an OR manager and a surgical services director. She recently transitioned into chief nursing office at the Saint Francis Healthcare System in Cape Girardeau, Missouri. Gayla Tripp, RN, MSN, CIC, CPHQ, is the lead infection preventionist at Saint Francis Healthcare System in Cape Girardeau, Missouri. Gayla has over 20 years of nursing experience, including 12 years in infection prevention. Maryann Reese, RN, MHA, DHA, FACHE, is the president and CEO of the Saint Francis Healthcare System in Cape Girardeau, Missouri. She has earned multiple nursing and healthcare degrees including a doctorate in healthcare administration. She has served in various leadership roles throughout her career before joining the Saint Francis Healthcare System in 2015 as the executive vice president and COO. Sharon Hohler, RN, BSN, CNOR, has worked as an OR nurse since 1978 and recently retired as the Orthopaedic Team Coordinator and full-time OR nurse. She plans to continue her second career as a freelance medical writer and PRN Clinical Nurse IV at Saint Francis Healthcare System in Cape Girardeau, Missouri. References 1. Anderson DJ, Podgorny K, Berrios-Torres SI, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hospl Epidemiol. 2014;35(6):605–627. 2. Crandall KM, Stem MB, Almuhanna A, et al. Improving apparent cause analysis reliability: a quality improvement initiative. Pediatr Qual Saf. 2017;2:e025. http://journals. Apparent_Cause Analysis_Reliability_A.7.aspx. Accessed May 2018. 3. The Joint Commission Center for Transforming Healthcare. Targeted Solution Tool for Hand Hygiene. tst_hh.aspx. Accessed May 2018. 4. Centers for Disease Control and Prevention. Clean Hands Count for Healthcare Providers. https://www. Accessed May 2018. 5. Association of PeriOperative Registered Nurses. Guidelines for Perioperative Practice, 2017 ed. Denver, CO; AORN, Inc.; 2017. 6. Berrios-Torres SI, Umscheid CA, Bratzler DW. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. AMA Surg. 2017;152(8):784791. doi:10.1001/jamasurg.2017.0904. 7. Bratzler DW, Dellinger EP, Olsen KM, et al. clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-System Pharm. 2013;70(3):195-283. 8. Fairfield KM, Askari R. Overview of perioperative nutritional support. contents/overview-of-perioperative-nutritionalsupport Accessed May 2018.

Apparent Cause Analysis Worksheet Event Date:


Day of Week:


Patient Initials:




How to complete the “5 Why” questions: 1. What happened? A brief description of the problem is documented. 2. What normally happens? The standard procedure is outlined. 3. What does the process require? A list of all steps is reviewed. 4. Why did the problem occur? If the initial answer to this “why” question does not find the root cause, investigators ask “why” again. This step is called the “five why” method because you may need to ask “why” multiple times to drill down to the root cause. 5. What actions can we take to avoid the problem in the future? An action plan, including the staff responsible and the completion date, is documented.

Using ACA to examine and improve CAUTIs 1. Did the catheter meet HOUDINI criteria? 2. Was the catheter in place upon admission? Was a UA or reflex culture performed? 3. When was the catheter inserted? Was protocol reviewed each shift? 4. When did the patient show s/s of infection? When was specimen collected? Why? Properly obtained? How was it collected? 5. Was the patient transported during hospitalization while catheter in place? 6. Was peri-care performed appropriately? Was a securement device in place

Sample trigger questions for performing an ACA Category

Trigger Questions

Policy/procedure not followed

Are there policies or procedures to describe the process or prevent the event? Was the policy/ procedure followed? Did staff perform as expected? If not, why?

Patient assessment issue

Was the appropriate assessment performed? Was the information documented properly? Was there a RRT called prior to the event?


Were staff properly trained and qualified to perform their duties? Was competency up to date and documented? Did someone perform beyond their scope of practice? Was equipment used that staff were not properly trained to operate? Was the physician properly credentialed?

Communication issue

Were there communication barriers that contributed to this event? Was there a lack of communication between participants? Was the physician notified of a change in the patient’s condition or critical results? Did proper hand-off take place?

Missing/misinterpreted information

Was the misunderstanding (e.g. language barrier, unsafe abbreviation, etc.)? Was the information available, accurate, and complete when needed? Was the information documented? Did staff have access to policies or procedures?

Staffing or personnel issue

How did staffing levels compare to ideal levels? Were float staff or news staff involved? Was the preceptor available and performing duties properly? Were staff rushing to complete a task? Were there other personnel issues (e.g. boredom, substance abuse, fatigue, personal problems, illness, etc.)? Were staff working overtime?


Was equipment available? Did the equipment/device malfunction? Were staff using the equipment/device properly and for its intended use? Were staff properly inserviced on the equipment? Were alarms functioning properly? Were biomed checks up to date? Was rental/ leased equipment involved?

Work environment

Was the physical environment appropriate to support the function it was being used for? Was work performed under adverse conditions (e.g., heat, noise, improper lighting, cramped space, overhead paging, etc.)? Were there safety issues identified, but not addressed at the time that could have contributed to the event? w w | 71

WITH THE BD POWER IN PREVENTION PROGRAM FOR IMPROVED SURGICAL PROCESSES. At BD, we want to help increase patient safety and lower costs by reducing variability in surgical processes. It’s why we’re expanding the BD Power in Prevention program, an evidence-based approach of proven strategies to optimize clinical and financial outcomes, improve patient care, increase surgical efficiency, and decrease the risk of HAIs during hospital stays. Built on the results of more than 28,000 Operating Room (OR) observations at over 1,000 hospitals, the BD program is delivered by clinical and process experts who are ready to help your clinicians identify inconsistent practices, while helping to pinpoint root causes from the Sterile Processing Department through the OR. The goal? Better outcomes through alignment with the evidence-based standards of organizations from AORN to the CDC. Discover the Power in Prevention. Discover the new BD.

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nfection preventionists (IPs) are well aware that hand hygiene helps prevent healthcare-associated infections (HAIs) and supports the safety of patients and healthcare workers (HCWs) alike.1,2 We also understand that HAIs are associated with longer hospitalizations and increased healthcare costs.3 However, despite the clear evidence of the benefits of hand hygiene, compliance with hand hygiene guidelines can be challenging to achieve. Tools such as electronic hand hygiene reminders have value,4,5 but a recent project at our health system demonstrated that open communication among empowered HCWs may be the key to improving hand hygiene compliance. w w | 73


Figure 1. Results of employee survey on “secret code” options (n = 382 votes)


Our project was initiated at a 204bed community hospital within a larger health system in northeastern Ohio. The Cleveland Clinic Health System includes a main campus tertiary care hospital with 1,400 beds and 10 regional hospitals. The lead hospital, Cleveland Clinic Lutheran Hospital, is designated as a Pathway to Excellence hospital and employs approximately 700 HCWs, half of whom are nurses. In 2014, the lead hospital noted a decline in hand hygiene compliance that coincided with a change in the data collection process for the enterprise. Previously, internal auditors had audited hand hygiene data; now, data were analyzed by outside observers who did not work for the health system. This decline in compliance at the lead hospital prompted the formation of a hand hygiene project team, which was tasked with identifying and addressing barriers to compliance. Among the perceived barriers were the fast-paced nature of healthcare, employees’ preoccupation with the next task at hand, having full hands when entering a room, and insufficient awareness among staff of the HAI risks associated with inadequate hand hygiene. 74 | FALL 2018 | Prevention

During a monthly infection prevention meeting, the project team discussed choosing a “secret code” word that personnel could use to remind colleagues to perform hand hygiene. While HCWs understand the importance of hand hygiene, they may be reluctant to speak up if they fear an adversarial response to a well-intended reminder. The team theorized that a code word would promote a just culture because it could be discreetly said in front of patients without drawing attention or causing embarrassment. The team recognized that involving employees from the inception of the campaign would be a key to its success, and so they sent an email inviting employees to submit suggestions for this secret code. Employees from various disciplines submitted eight options (see Figure 1). The winning acronym, chosen through a survey of the staff, was “Scrub Now and Prevent” (SNAP), which was submitted by a nurse working in the integrated care unit. PROJECT IMPLEMENTATION

Once we chose SNAP as our acronym for hand hygiene reminding, we launched the project at the lead hospital

by giving Rice Krispies treats labeled with the SNAP acronym to every healthcare worker. Employees were instructed on the use of SNAP in various ways, such as emails to hospital leaders, posters, flyers, and a brief PowerPoint presentation that was given during an educational day. During the implementation phase, we found two ways that SNAP could be used discreetly in front of patients. A person could quietly snap his or her fingers to provide an audible but nonverbal cue to another worker, or an employee might use SNAP in a conversation by saying something like, “Oh, SNAP, I forgot to tell you something,” or “We will get this done in a SNAP.” Also, when speaking out of earshot of patients, employees might ask each other, “Do you need to SNAP?” The project team sought feedback from healthcare employees regarding their comfort with using this to remind one another about hand hygiene. Based on their comments, SNAP seems to work as we hoped to promote a just culture. For example, an employee in environmental services told us she used SNAP to remind a physician to clean his hands when exiting a patient room.

The physician responded by nodding, thanking her, and promptly using the hand sanitizer. PROJECT EXPANSION

In the months following the rollout of SNAP, leaders held daily conversations with bedside HCWs to assess the progress of the project, and the IP reinforced the use of SNAP during her daily rounding. Use of the word was also promoted during hospital events such as the annual patient safety fair. The project reached a turning point when it was featured during an enterprise quality event a few months after its implementation and drew the attention of key stakeholders. This led to an opportunity for project team members to personally discuss SNAP with the chief executive officer (CEO) for the enterprise, who embraced the concept. With the CEO’s support, we developed a SNAP toolkit, which has been posted on the health system’s intranet as a resource for improving hand hygiene compliance. Furthermore, SNAP has been included in onboarding orientation and the annual mandatory educational core curriculum, and the SNAP tool has been shared at local and national conferences such as the Ohio Hospital Association Quality Summit and the Pathway to Excellence annual conference.

Figure 2. Cleveland Clinic Lutheran Hospital hand hygiene compliance, 2014-16 (n = 400 hand hygiene observations)

“The team theorized that a code word would promote a just culture because it could be discreetly said in front of patients without drawing attention or causing embarrassment.”


Following implementation of SNAP, hand hygiene compliance improved markedly. At Cleveland Clinic Lutheran Hospital, annual compliance rose from 71 percent in 2014 to 95 percent in 2016 (see Figure 2 for a month-by-month comparison), and compliance at the enterprise level increased from 65 percent in 2013 to 93 percent in the second quarter of 2017 (Figure 3). Furthermore, the number of hospital-onset Clostridium difficile (C. diff) infections decreased by 2-3 infections per year during the hand hygiene improvement phase at the lead hospital (Figure 4). While these outcomes associated with SNAP are encouraging, there are limitations to the interpretation of our project results. We do not know whether

! Figure 3. Cleveland Clinic Health System hand hygiene compliance, 2013-17

w w | 75


in our healthcare system. HCWs have identified key places to locate hand sanitizer; hand sanitizer canisters have been labeled with the contact information for reporting empty canisters; and pocket-sized sanitizers are distributed to caregivers working in the behavioral health areas, where alcohol-based sanitizer access is more limited due to population risk factors. Finally, employees in environmental services have been trained to monitor the need for hand sanitizer replacement in those areas they service. SNAP is a simple tool for hand hygiene reminding that may improve compliance and contribute to more collegial and safer care. Our project suggests that SNAP has the potential to limit the spread of infection via hands while, at the same time, promoting a just workplace culture. Figure 4. Hand hygiene compliance and C. diff rates, from 2014 through first quarter of 2017

READ MORE ABOUT HAND HYGIENE CAMPAIGNS IN THE AMERICAN JOURNAL OF INFECTION CONTROL Measuring the Impact of a Caregiver Education and Awareness Campaign on Hand-hygiene in an Adult Critical Care Unit. Dinh TA. Am J Infect Control 2014; 42(6): S76-S77. Saving time and resources: Observational research to support adoption of a hand hygiene promotion campaign. Mackert M, Lazard A, Liang MC, et al. Am J Infect Control 2015; 43(6): 656–658. Pilot study of digital tools to support multimodal hand hygiene in a clinical setting. Thirkell G, Chambers J, Gilbart W, et al. Am J Infect Control 2018; 46(3): 261-265.

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the decline in C. diff infections can be attributed directly to the project, and we cannot determine whether hand hygiene compliance improved solely because of the use of the secret code word. Other aspects of the project may have directly or indirectly led to improved compliance. For example, the attention given to the project within our health system probably made employees more aware of the importance of hand hygiene and its relationship to safe care. Leadership support of this project, from the executive level cascading down to the frontline caregivers, may have also played a significant role in improving compliance. Additionally, compliance data were disseminated monthly, and areas where improvements were needed received detailed reports to facilitate follow up. Finally, compliance may have improved as a result of the monthly visits from a trained observer; workers may have been more attentive to hand hygiene because they knew they were being monitored. CONCLUSION

Since SNAP heightened awareness of hand hygiene, other efforts to support compliance have been implemented

Christine Rose, BSN, CIC, has been an infection preventionist at Cleveland Clinic Lutheran Hospital in Cleveland, Ohio, for nine years. She has 34 years of healthcare experience, mostly as a direct RN caregiver. She is the co-director of the Northeast Ohio APIC chapter and has served on its education committee. Lee Anne Siegmund, PhD, RN, CEP, is a nurse scientist in Nursing Research and Innovation at Cleveland Clinic. She has worked as a registered nurse in public health, home health and hospice, labor and delivery, and cardiac rehabilitation; taught nursing and nutrition at Lorain County Community College; and was assistant professor at Calvin College in Michigan, where she taught clinical exercise physiology. References 1. Ellingson K, Haas JP, Aiello AE, et al. Strategies to prevent healthcare-associated infections through hand hygiene. Infect Control Hosp Epidemiol 2014;35(8):937-960. doi: 10.1086/6771454. 2. Pittet D, Allegranzi B, Boyce J. The World Health Organization guidelines on hand hygiene in health care and their consensus recommendations. Infect Control Hosp Epidemiol 2009;30(7):611-622. doi: 10.1086/600379. 3. Scott RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. Centers for Disease Control and Prevention. 2009. Accessed October 2017. 4. Ellison RT, Barysauskas CM, Rundensteiner EA, et al. A prospective controlled trial of an electronic hand hygiene reminder system. Open Forum Infect Dis 2015;2(4):1-8. doi: 10.1093/ofid/ofv121. 5. Fakhry M, Hanna GB, Anderson O, et al. Effectiveness of an audible reminder on hand hygiene adherence. Am J Infect Control. 2012;40(4):320-323. doi: 10.1016/j. ajic.2011.05.023.

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DISINFECTION APPLIANCES Micro-Scientific Industries, Inc. ������������������������������������������������������������������9 HAND HYGIENE *BD ����������������������������������������������������������������������������������������������������������72 INFECTION CONTROL PRODUCTS Contec Inc ������������������������������������������������������������������������Inside Front Cover Healthmark Industries Co. ����������������������������������������������������������������������� 55 *Medline Healthcare �����������������������������������������������������������������������������������4 TOMI Environmental Solutions, Inc. ����������������������������������������������������������78 INFECTION PREVENTION PRODUCTS & SERVICES umf Corporation ��������������������������������������������������������������������������������������� 45 USHIO America, Inc. �������������������������������������������������������������������������������� 39 IV CARE SOLUTIONS *3M Vascular Care Pathways �������������������������������������������������������������������11

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