w i n t er 2 013 â€˘ VO LU M E 6 N U M B ER 4
Infection prevention in outpatient oncology Multidrug-resistant Tuberculosis Facility emergency preparedness
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A closer lookâ€”Antibiotic resistance and the microbiome By Marilyn Hanchett
Infection prevention in outpatient oncology settings
By Dr. Alice Guh, Dr. Lisa Richardson, and Angela Dunbar
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Celebrating APIC’s first 40 years and looking forward
The infection preventionist of tomorrow
CBIC: Using the building blocks placed by someone before
By Patricia Grant, 2013 APIC President By Katrina Crist, APIC CEO
By Craig Gilliam, 2013 CBIC President
PREVENTION IN ACTION
My Bugaboo: Multidrug-resistant Tuberculosis
Ready, set, implement! An innovative nurse-driven Foley catheter protocol to prevent CAUTI
Facility emergency preparedness starts at home
Collaboration in infection prevention: Infusion nurses and infection preventionists
Centralized sterile processing in ambulatory facilities
Today’s infection prevention challenges in long-term care: Are we ready to manage them?
By Dr. Irena Kenneley
By Brooke Buras By Steve Hilley
By Mary McGoldrick
By Jody Church and Martha Young
By Vicky Uhland
CIC Profile: Stephanie Tismer—Years of infection prevention experience and knowledge, now validated
Briefs to keep you in-the-know • Infection Prevention and You: APIC’s consumer campaign makes waves • Competency Advancement Assistance (CAA) program recipients announced
Capitol Comments: The National Action Plan to Prevent HAIs five years later—Measuring progress and mapping out the future
Global Insight: Egypt’s Professional Diploma in Infection Control (PDIC): A success story
Heroes of Infection Prevention
By Lisa Tomlinson and Nancy Hailpern
By Dr. Ossama Rasslan
By Michele Parisi
34 w w w.apic.org | 7
Celebrating APIC’s first 40 years and looking forward
By Patricia S. Grant, RN, BSN, MS, CIC APIC 2013 PRESIDENT
“As infection preventionists, we challenge ourselves to know when to lead astutely, bravely follow, and how to seek and listen to our multitude of internal and external customers.”
Having the honor to serve as APIC’s 2013 president cannot be easily
placed into words. The APIC membership has sanctioned leadership through exercising the power to vote resulting in an incisive Board of Directors, supported by the exceptional content expertise of our volunteer committee/chapter systems, and our dedicated/astute professional headquarters staff. Being true to the definition, purpose, mission, and expectations of APIC president has been surreal, yet bluntly palpable at times in a very positive way. Because APIC can never be about any one individual, to close out this year’s final Prevention Strategist message, I can think of no better way than to thank the pioneers of infection prevention who have made APIC’s existence and survival possible. To enjoy the entire opening 2013 ceremonies for APIC’s 40th Annual Conference in Fort Lauderdale, visit http://apic.org/About-APIC/History/APIC-Conference-Videos. There you’ll see the Difference Makers and the Infection Prevention Leaders representing each decade from the 1970s through 2000s—be sure to follow them in the order they occurred on June 8, 2013, so you, too, can enjoy the flow and excitement of what you help make possible through your infection prevention quest. If you were unable to attend, the wisdom, retrospective, and earth-shattering revelations shared in each section of APIC’s opening ceremonies is worth your undivided attention because it states where we’ve been and where we are clearly going to continue to improve patient safety. Our APIC history serves us well as a roadmap for the future while we heed words of wisdom shared by those during the opening ceremonies. To celebrate our 40 years together, the first 39 APIC presidents are listed below to remind each of us that we must continue to lead and move infection prevention forward within our own daily realities and within our APIC volunteerism. Each of us can manage our time to realize both. As infection preventionists, we challenge ourselves to know when to lead astutely, bravely follow, and how to seek and listen to our multitude of internal and external customers. As I stated in my opening remarks of the APIC 2013 Annual Conference, “We are here today because of those who came before us, their willingness to learn, and their ability to adjust to those experiences. Mostly, we are here because of their perseverance in paying it forward.” Will You? Patricia S. Grant, RN, BSN, MS, CIC APIC 2013 President
1972-73: Patricia Lynch, RN, MBA 1974: Shirley Chewick, RN 1975-76: Carole DeMille, RN 1977: Shirley Bradley 1978: Kathleen DeLuca, RN 1979: Cheryl Cox 1980: Kathy Holl, RN, BSN 1981: Mary Jane Freeburn, RN, CIC 1982: Jean Parret, RN 1983: George Counts, MD 1984: Ronnie Leibowitz, RN, MA, CIC 1985: Robert Sharbaugh, PhD, CIC 1986: Nancy Click, RN, MA, CIC 1987: Lorraine Harkavy, RN, MS, CIC 1988: Elizabeth Bolyard, RN, MPH, CIC
8 | WINTER 2013 | Prevention
1989: Darnell Dingle, MPH, CIC 1990: Elizabeth Horan-Murphy, MT (ASCP), RN, MSN, CIC 1991: Betsy Palmer, RN, MSN, CIC 1992: Vicky Zelenka, RN, CIC 1993: Linda McDonald, RN, MSPH, CIC 1994: Barbara Russell, RN, MPH, CIC, ACRN 1995: Terrie Lee, RN, MS, MPH, CIC 1996: Ava Lancaster, RN, BSN, CIC 1997: Candace Friedman, BS, MT (ASCP), MPH, CIC 1998: Frances Slater Feltovich, RN, BSN, MBA, CIC 1999: Janet Franck, RN, MBA, CIC
2000: Susan Slavish, BSN, MPH, CIC 2001: Judith English, RN, MSN, CIC 2002: Georgia Dash, RN, MS, CIC 2003: Barbara Soule, RN, MPA, CIC 2004: Jeanne Pfeiffer, RN, MPH, CIC 2005: Sue Sebazco, RN, BS, CIC 2006: Kathy Arias, MS, MT, SM, CIC 2007: Denise Murphy, MPH, BSN, RN, CIC 2008: Janet Frain, RN, CIC, CPHQ, CPHRM 2009: Christine Nutty, RN, MSN, CIC 2010: Cathryn Murphy, RN, PhD, CIC 2011: Russell Olmsted, MPH, CIC 2012: Michelle Farber, RN, CIC
Prevention W I N T E R 2 013 • VO L U M E 6 , I S S U E 4
Board of Directors President Patricia S. Grant, RN, BSN, MS, CIC President-Elect Jennie L. Mayfield, BSN, MPH, CIC Treasurer Vickie M. Brown, RN, MPH, CIC Secretary Linda R. Greene, RN, MPS, CIC Immediate Past President Michelle R. Farber, RN, CIC
Directors Barbara DeBaun, RN, MSN, CIC Susan A. Dolan, RN, MS, CIC Donna Giannuzzi, RN, MBA, NEA-BC Linda K. Goss, MSN, APRN, ANP-BC, CIC, COHN-S Carole S. Guinane, RN, MBA Mary Lou Manning, PhD, CRNP, CIC Connie Steed, RN, MSN, CIC Jacie C. Volkman, MPH, CIC, CHEP Sharon R. Williamson, MT(ASCP)SM, CIC Marc-Oliver Wright, MT(ASCP), MS, CIC
Katrina Crist, MBA
Disclaimer Prevention Strategist is published by the Association for Professionals in Infection Control and Epidemiology, Inc. (“APIC”). All rights reserved. Reproduction, transmission, distribution, or copying in whole or in part of the contents without express written permission of APIC is prohibited. For reprint and other requests, please email email@example.com. APIC makes no representations about the accuracy, reliability, completeness, or timeliness of the material or about the results to be obtained from using this publication. You use the material at your own risk. APIC assumes no responsibility for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. Although all advertising material is expected to conform to ethical (medical) standards, inclusion in this publication does not constitute a guarantee or endorsement of the quality or value of such product or of the claims made of it by its manufacturer.
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The infection preventionist of tomorrow
By Katrina Crist, MBA APIC CEO
“To increase your value as an IP, the value of the overall profession, and to ensure relevancy in a newly emerging healthcare landscape, adaptive change starts with each and every one of us at the individual level.”
“Where you come from is not nearly as important as where you are going.” — Unknown. I recently attended the “Hospital of Tomorrow” conference, a leader-
ship forum by U.S. News and World Report where several hundred hospital CEOs came together to discuss the complex business of healthcare transformation in the United States. This begs the question, “What does the IP of Tomorrow look like?” At APIC board meetings, leadership is engaged in strategic thinking on how to increase the value of infection preventionists (IPs). Throughout 2014, we will be asking the membership to provide information through surveys and focus groups and participate in ongoing dialogue to develop and shape strategy for increasing your value within the ever-changing healthcare landscape. The forerunner to increasing value is development of leadership skills and competencies. The IP of Tomorrow will be adept at analyzing data and making compelling arguments to senior administrators on how to drive not only technical change, but more importantly adaptive change that leads to safer care (patient safety), quality care (performance improvement), and more affordable care (sustainable lower cost) all while providing higher levels of customer service (patient satisfaction) and high reliability. Adaptive change requires changing long-standing habits and deeply rooted assumptions. It involves overcoming feelings of loss and sometimes feelings of betrayal of established values and beliefs. Solutions require learning new ways of thinking and developing new relationships and models of collaboration. To increase your value as an IP, the value of the overall profession, and to ensure relevancy in a newly emerging healthcare landscape, adaptive change starts with each and every one of us at the individual level. APIC looks forward to helping guide you through this journey. Sincerely yours,
Katrina Crist, MBA APIC CEO
“The future we predict today is not inevitable. We can influence it, if we know what we want it to be. We can and should be in charge of our own destinies in a time of change.” — Charles Handy, The Age of Unreason.
To learn more, please see the following articles in the American Journal of Infection Control: • Tensions inherent in the evolving role of the infection preventionists. Laurie J. Conway, Victoria H. Raveis, Monika Pogorzelska-Maziarz, May Uchida, Patricia W. Stone, Elaine L. Larson [November 2013 (Vol. 41, Issue 11, Pages 959-964, DOI: 10.1016/j.ajic.2013.04.008)] • Competency in infection prevention: A conceptual approach to guide current and future practice. Denise M. Murphy, Marilyn Hanchett, Russell N. Olmsted, Michelle R. Farber, Terri B. Lee, Janet P. Haas, Stephen A. Streed [May 2012 (Vol. 40, Issue 4, Pages 296-303, DOI: 10.1016/j.ajic.2012.03.002)] 10 | WINTER 2013 | Prevention
Prevention winter 2 013 • volume 6 , issue 4
PUBLISHER Katrina Crist, MBA firstname.lastname@example.org MANAGING EDITOR Janiene Bohannon email@example.com ADVERTISING Brian Agnes firstname.lastname@example.org GRAPHIC DESIGN Emma Law email@example.com PRODUCTION Heather Williams firstname.lastname@example.org
EDITORIAL COMMITTEE George Allen, PhD, CIC, CNOR Megan Crosser, BS, MPH, CIC Charles Edmiston Jr., PhD, CIC Mary L. Fornek, RN, BSN, MBA, CIC Brenda Helms, RN, BSN, MBA/HCM, CIC Linda Jamison, MSN, RN, CIC, CCRC Irena Kenneley, PhD, APRN-BC, CIC Kari L. Love, RN, BS, MSHS, CIC Caroline McDaniel, RN, BSN, MSN May M. Riley, RN, MSN, MPH, ACNP, CCRN, CIC Steven J. Schweon, RN, MPH, MSN, CIC
CONTRIBUTING WRITERS Janiene Bohannon Brooke Buras, Rn, Bsn Jody Church, Rn, Cpnp Katrina Crist, Mba Angela Dunbar, Bs Elizabeth Garman Craig Gilliam, Bsmt, Cic Patricia Grant, Rn, Bsn, Ms, Cic Alice Y. Guh, Md, Mph Nancy Hailpern Marilyn Hanchett, Rn, Ma, Cphq, Cic Steve Hilley, Rn Irena Kenneley, PhD, Aprn-Bc, Cic Mary McGoldrick, Ms, Rn, Crni® Michele Parisi Ossama Rasslan, Md, PhD Lisa C. Richardson, Md, Mph Lisa Tomlinson Vicky Uhland Martha Young, Bs, Ms, Cspdt
Mission APIC’s mission is to create a safer world through prevention of infection. The association’s more than 14,000 members direct infection prevention programs that save lives and improve the bottom line for hospitals and other healthcare facilities. APIC advances its mission through patient safety, implementation science, competencies and certification, advocacy, and data standardization. Visit APIC online at www.apic.org. PUBLISHED DECEMBER 2013 • API-Q0413 • 9090
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Using the building blocks placed by someone before ® The title of my final column as CBIC president speaks volumes as CBIC’s 30th anniversary
By Craig Gilliam, BSMT, CIC 2013 CBIC President
“Coming together is a beginning, keeping together is progress, and working together is success.” — Henry Ford
12 | WINTER 2013 | Prevention
comes to an end. Pat Lynch, the first CBIC president, said it best in 1985 when she explained that “the challenge is there; the certification process is critical in attaining success.” I believe this means the certification process is used to validate practice—not demonstrate knowledge from an examination. As the 2013 president of CBIC, I have been fortunate that recent CBIC presidents Terrie Lee, RN, MS, MPH, CIC, and Barbara Russell, RN, MPH, CIC—who mentored me and prepared our board for future challenges—were visionaries of what we can accomplish. In the beginning of 2013, I envisioned three main objectives to help advance our profession. First I wanted infection preventionists (IPs) to recognize and celebrate the anniversary of certification, promote professionalism within our chapters, and advocate for certification to IPs and epidemiologists beyond our borders. I suggest you look around in your chapter and at national educational meetings to observe the number of the early advocates of certification from the 1980s and 1990s who are still involved and mentoring newer IPs. In October, I attended the 13th meeting of International Federation of Infection Control (IFIC) in Buenos Aires, Argentina. At the meeting, Patti Grant, RN, BSN, MS, CIC, 2013 APIC president, Bruce Gamage, RN, BSN, CIC, 2013 CHICA-Canada president, and I all spoke at sessions on professionalism and certification. Not only did attendees discuss similar solutions and challenges as North American IPs, they also expressed their desire to demonstrate and communicate that healthcare facilities with trained certified professionals will have better patient outcomes. Second, I think it imperative for CBIC and APIC to continue to work together to demonstrate value to its members. APIC is showing IPs a path to improve their competency—and certification is integral to this advancement. CBIC appreciates the strong verbal support at national education forums from recent APIC leaders and presidents on the importance and necessity of IPs becoming certified. The number of new certificants continues to increase and Self Achievement Certification Exam (SARE) numbers are 10 percent higher than the predicted numbers for 2013. The SARE recertification pass rate is 95 percent; I think this reflects the preparation IPs put forth. The CBIC website also tracks the number of current certificants; we are approaching the 6,000 mark at year’s end. Third, adding the personal touch makes a difference. People notice and appreciate when IPs who attain or maintain certification are recognized. Every month when the new certificant list is released, I write a personal note to a random selection of successful individuals. I truly believe this is recognition of the importance of professionalism we strive to achieve. Your efforts are an example for others to follow in making patients safer in all healthcare settings. If I and others are successful in demonstrating the value of professional certification, we will remember the process started with those who have a vision! As Henry Ford once said: “Coming together is a beginning, keeping together is progress, and working together is success.”
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Meet a CIC Stephanie Tismer, RN, CIC Regions Hospital St. Paul, Minnesota
Why did you choose infection prevention as a career?
It was actually by default. I suffered a back injury while working in the surgical intensive care unit. I was given the opportunity to work in quality then infection control. I realized after a couple of weeks on the job that this was what I needed to be doing all along.
How long have you been working in infection prevention?
It has been eight very interesting years.
How many years had you been practicing infection prevention when you started pursuing board certification? I was encouraged to seek board certification after a few years but didn’t really think I could pass the exam. There is always more to learn and understand about the profession. I marveled at the women in my department that studied and passed. My colleagues would continuously encourage me to just do it. I wanted to but always felt short of the energy to make it a reality. How was I going to squeeze one more activity into my life?
What inspired you to pursue board certification in infection prevention and control (CIC)?
It was at the San Antonio conference [APIC 2012 Annual Conference] when I decided I was going to get certified. I wanted the special dessert that was given to the certified folks. As crazy as it sounds, I wanted to be able to attend the special dessert table. I came home and announced I would be taking the exam. I needed to study like the women in my department. I bought the study guide and read through to the last chapter. In order to pass, I made a commitment to use the study guide and review what I didn’t know. I took a two-week vacation and studied for three to four hours in the morning and rewarded myself in the afternoon. I reserved a room at the library. I was not even available to kids by cell phone!
In what ways has your CIC benefitted you?
While studying for the CIC exam I reviewed the entire APIC Text. In doing that I found areas in which our facility could improve. I was able to measure our performance. I had the confidence and ability to find the answers in a pinch. I was better able to further my education around the topics in which I felt weak. It gave me a foundation to understand the APIC model and the desire to further my career.
In what ways has your CIC benefitted your healthcare organization?
It can depend on me for a body of knowledge. I am a member of the team and am expected to make recommendations for preventing infections in all areas. They can rely on me to participate with others to improve patient outcomes. During a CMS or Joint Commission Survey they will be very happy I am there!
Do you have any tips for infection preventionists (IPs) who are pursuing their certification? You are a unique individual. Ask yourself honestly, “What do I need to do to take the exam and pass?” For everyone, the answer will be different. Take the practice test, and don’t look at the answers until you complete the entire section. If you get a question wrong, study that entire chapter—not just the paragraph to answer the question. Set limits with friends and family about when and where you are studying. I found out after my exam was over that my significant other was in the hospital. He didn’t want to have my thoughts go elsewhere. Wow—I guess I effectively communicated about how important CIC certification was to me. w w w.apic.org | 15
Briefs to keep you in-the-know
Infection Prevention and You APIC’s consumer campaign makes waves. By Elizabeth Garman and Janiene Bohannon
You are an rt important pa of infection prevention! Wash your hands water with soap and r or use hand sanitize often. Ask healthcare workers and your visitors to do the same.
Speak up for your care!
Sneeze and cough not into your elbow, your hand. ns Take medicatio as directed.
Healthcare workers will clean their hands before and after they care for you.
ness effort titled “Infection Prevention and You” helps patients, families, and healthcare professionals understand their role in preventing infections. Launched in conjunction with International Infection Prevention Week (IIPW), October 20–26, the centerpiece of the campaign this year was a new website (www.apic.org/infectionpreventionandyou) with content and resources for both patients and healthcare professionals, designed to simply and clearly convey important infection prevention and patient safety information. APIC’s Communications Committee conceived of the idea for the “Infection Prevention and You” campaign after a 2010 discussion about the need for consumers and other healthcare personnel to understand the importance of infection prevention and the profession. Since then, the campaign was created and expanded to include: • The new content-rich website (www.apic. org/infectionpreventionandyou) for both consumers and healthcare professionals who are not infection preventionists (IPs). • A one-of-a-kind infographic poster for patients that was mailed to all members with the fall issue of Prevention Strategist. APIC encourages members to display it in a patient care area of their respective healthcare facilities. The full-size poster includes tips on how consumers can play an active role in infection prevention. • Engagement via Facebook (www.facebook. com/APICInfectionPreventionandYou) and Twitter (http://twitter.com/@APIC). “Like” or “follow” us for a continuous stream of timely (and fun) information you can share with others. Word about the campaign has been quickly spreading. It was featured in a September 30 Wall Street Journal article titled, “Why hospitals want patients to 16 | WINTER 2013 | Prevention
workers Your healthcare gowns, will wear gloves, the right and masks at
if you still Every day, ask need your catheter.
What are healthcareassociated infections?
ction Who are infe ts? preventionis the bad germs and
devices Catheters or other your in will be placed skin body after your cleaning. receives proper
ask doctors, ‘Have you washed your hands?’” The story, which appeared in the Journal’s Informed Patient column, includes a quote from Carol McLay, DrPH, RN, CIC, chair of APIC’s Communications Committee, who helped design the campaign. “We’ve been focusing on intensive interventions to improve hand hygiene among healthcare workers for decades, yet we’ve really shown very little progress,” says McLay in the article. “We are trying to empower patients and families to speak up and understand their role.” Furthermore, the campaign was featured
If your room looks it dirty, ask to have cleaned.
. injection practices Ask about safe Needle, One Remember: One Time. Syringe, only One
to find detective skills you safe. nists use their things to keep Infection preventio is doing the right make sure everyone
APIC’s new multiyear education and aware-
Surgical site infections
along When germs travel in your bladder or kidney. cause an infection
lungs. Infection of the
in for Professionals Association and Epidemiology Infection Control
happens after An infection that the body where part of surgery in the place. the surgery took
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any equipment that is used on you will be clean.
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and Clean your hands make sure everyone too. around you does
surgery, If you are having shower ask if you should soap ng with a germ-killi ahead of time.
on the CDC’s Safe Healthcare blog via a post authored by Vicki Allen, MSN, RN, CIC, APIC Communications Committee member. APIC members and more than 30 association partners helped spread the message about “Infection Prevention and You” throughout IIPW with live events, social media messages, photo-sharing, and more. APIC headquarters staff, Henry the Hand® Champion Handwasher, and APIC Washington, “We received Prevention Strategist today. DC Metro Chapter Membership Chair Kissa We LOVE the poster! Thanks to any and M. Robinson, RN, BSN, all who thought of it! LOVE IT!” joined together to pass —Susan Kraska, RN, CIC, Memorial Hospital out hand sanitizer and of South Bend, South Bend, Indiana “Infection Prevention and You” posters in front of the Foggy Bottom metro stop next to the
APIC staff members express their enthusiasm for infection prevention with Henry the Hand. Left to right, back row: Monti Bush, Jacqueline Manson, Katrina Crist, Yolanda Tillery, Kathryn Hitchcock. Front row: Bach Truong, Christina James, Elizabeth Garman, Janiene Bohannon, and Lynn Schneider.
“I REALLY like the new resources on the website! The infographic is concise but thorough. I had already printed one from the website, but I was thrilled to get the big one in my [issue of] Prevention Strategist. I have it proudly displayed on my door! ...Thanks for all of the hard work that you all and your teams put into this resource!” —Tiffany Horsley, RN, BSN, CIC, Coffeyville Regional Medical Center, Coffeyville, Kansas
We thank the 2013 APIC Communications Committee for its ongoing support and volunteerism in enhancing and furthering infection prevention communication initiatives. Chair: Carol McLay, DrPH, RN, CIC Lexington, Kentucky
George Washington University Hospital in Washington, DC. APIC will continue to expand its “Infection Prevention and You” campaign to educate both patients/consumers and healthcare professionals. We encourage members to spread the word about the new site (www.apic.org/infectionpreventionandyou) to help engage everyone in infection prevention. If you still haven’t visited the new site, here’s a run-down of what you will find: The consumer tab provides tips, tools, and links to reputable sources of information to promote infection prevention in every setting: healthcare facilities, at work, at school, on vacation, at home, and even in locker rooms. The healthcare professionals tab is designed for healthcare workers who are not trained IPs, which provides basic information on how to keep patients safe regardless of their roles within healthcare organizations. With the continued help of the Communications Committee, APIC
also continues to improve and expand its Consumer section of the main site— www.apic.org/patientsafety. This section of the site was specifically created to house resources for IPs to use in their educational efforts. Here, members can find: • A new flier that explains isolation precautions (Materials for Healthcare Facilities section) • I nfection prevention brochures, PowerPoint presentations, posters, and fliers to display in acute care, home care, long-term care, and ambulatory/outpatient settings (Materials for Healthcare Facilities section) • Links to reputable consumer-focused resources on a variety of infection prevention topics (Additional Patient Safety Resources page) • A rchived monthly email alerts for consumers on everything from antibiotics to vaccines continued on page 18
Vice-Chair: Elizabeth Monsees, RN, MSN, MBA, CIC Children’s Mercy Hospitals and Clinics Kansas City, Missouri Vicki Allen, MSN, RN, CIC CaroMont Health Huntersville, North Carolina Laura Buford, RN, BSN, CIC St. David’s HealthCare Austin, Texas Deb Patterson Burdsall MSN, RN-BC, CIC Lutheran Life Communities Arlington Heights, Illinois Nicole Gualandi, RN, MS/MPH, CIC Centers for Disease Control and Prevention Atlanta, Georgia Crystal Heishman, BSN, RN, CIC, ONC University of Louisville Healthcare Louisville, Kentucky Sharon Jacobs, RN, MS, CIC Bridgeville, Pennsylvania Irena L. Kenneley, PhD, APRN-BC, CIC Frances Payne Bolton School of Nursing Cleveland, Ohio Nancy Szilagyi, LPN, CIC Capital Health Trenton, New Jersey Kim Whisman, RN, BSN Hospice of the Bluegrass Lexington, Kentucky
APIC members Robert L. Geist, MPH, CIC, epidemiologist, Kansas Department of Health and Environment (KDHE) Healthcare-Associated Infections Program; Tiffany Horsley, RN, BSN, CIC, infection prevention nurse, Coffeyville Regional Medical Center; and Joseph M. Scaletta, MPH, RN, CIC, director, KDHE Healthcare-Associated Infections Program, pose in front of the “Infection Prevention and You” poster during International Infection Prevention Week.
Maria Whitaker, MT, CIC Cortland Regional Medical Center Cortland, New York
w w w.apic.org | 17
Briefs to keep you in-the-know “We [California Department of Public Health] are currently in the process of redesigning our entire HAI Program website and are creating an ‘HAI Education and Prevention Library’ on a new ‘Me and My Family’ webpage. We would be thrilled to feature APIC’s infographic, which we believe provides the right information to the public in an accessible and visually appealing format. Thank you for letting us use it for this purpose!” —Lanette Corona, California Department of Public Health, Richmond, California
Competency Advancement Assistance (CAA) program recipients announced To help infection preventionists (IPs) bet-
ter manage costs associated with obtaining the CIC® credential, APIC has continued the Competency Advancement Assistance program (CAA) for 2013-2014, which is designed to support this critical component of competency advancement. Last year, APIC provided financial assistance to more than 80 individuals for costs related to either initial certification or recertification.
Staff members at Charlotte Endoscopy Surgery Center demonstrated their support for “Infection Prevention and You” by wearing black polka-dot ribbons on the right side of their chests to encourage everyone to commit to hand hygiene. The black dots indicate the “the invasion of bacteria” and the white background represents “the purity of sterility.”
continued from page 17 “It’s unfortunate but true that one in 20 patients will develop an infection as a result of their healthcare. As patient safety advocates, APIC wants to empower patients, families, and healthcare professionals to speak up and take action to prevent infections,” said McLay. So, what’s in store for the campaign? APIC and the Communications Committee hope to offer more infographic posters for other healthcare settings and obtain feedback from members on ways we can help make their jobs easier. Thanks to the hard work of APIC members, the word is spreading to others, but we still have more work to do. Elizabeth Garman is APIC senior director of Communications. Janiene Bohannon is APIC associate director of Communications and managing editor of Prevention Strategist. 18 | WINTER 2013 | Prevention
2013 Partners We thank our 2013 Association Partners for their support in spreading the message about the importance of infection prevention. Accreditation Association for Ambulatory Health Care (AAAHC) American Academy of Urgent Care Medicine (AAUCM) American Cancer Society Cancer Action Network American Society for Healthcare Engineering (ASHE) American Society of Ophthalmic Registered Nurses (ASORN) Associação Paulista de Epidemologia e Controle de Infecção Relacionada à Assistência à Saúde (APECIH) Association of periOperative Registered Nurses (AORN) California Department of Public Health (CDPH) Healthcare-Associated Infections Program Centers for Disease Control and Prevention (CDC) Center for Disease Dynamics, Economics & Policy (CDDEP) Certification Board of Infection Control and Epidemiology (CBIC) Children’s HeartLink Coffee Regional Medical Center (CRMC) Colorado Department of Public Health and Environment Community and Hospital Infection Control Association (CHICA) Connecticut Center for Patient Safety (CTCPS)
Det Norske Veritas Germanischer Lloyd (DNV GL Healthcare) Georgia Hospital Association (GHA)/Georgia Hospital Engagement Network (HEN) Healthcare Laundry Accreditation Council Henry the Hand—Champion Handwasher Infusion Nurses Society (INS) Institute for Healthcare Improvement (IHI) Le Bonheur Children’s Hospital MedStar Health Methodist Le Bonheur Healthcare National Foundation for Infectious Diseases (NFID) National Patient Safety Foundation (NPSF) National Resource for Infection Control (NRIC) Organization for Safety, Asepsis and Prevention (OSAP) Safe Injection Practices Coalition (SIPC) Society for Healthcare Epidemiology of America (SHEA) Society of Gastroenterology Nurses & Associates, Inc. (SGNA) St. Jude Children’s Research Hospital The Joint Commission Think About It Colorado Webber Training, Inc.
We are pleased to announce the 2013 CAA
Debra Summers (Franklin, TN) Donna C. McDaniel (Ronan, MT) Heidi LePard (Great Falls, MT) Debra Spavone (Newnan, GA) Amanda Guspiel (Minneapolis, MN) Victoria Mieth (Phoenix, AZ) Scarlett Rivera (Valdosta, GA) Laura Kehler (Garden City, MI) Katelyn Harms (Madison, WI) Susan Oâ€™Connor-Wright (Sandy, UT) Maura K Kivlin RN, BSN (Scranton, PA) Kathleen Pitts (Rochester, NY) Ann P. North (Florence, SC) Heidi Leeper (Rensselaer, IN) Sue Ann B. Avin (Florence, SC) Valerie Lambiase (Salt Lake City, UT) Pamela Webb (Great Falls, MT) Karen C. Ray (Bel Air, MD) Erin Minnerath (Fort Harrison, MT) Kisha Wilkinson (Philadelphia, PA)
Kathryn Larsen (Miles City, MT) Debra Graem (Fort Worth, TX) Rhonda K. Reed (South Bend, IN) Kelley Tobey (Knoxville, TN) Lauri Holmes (White House, TN) Deborah Paul-Cheadle (Wyoming, MI) Sheri Bishop (Fayetteville, AR) Mary Kowatch (Sebastopol, CA) Karen K. Pitman (Olympia, WA) Tersa Bonifant (Portales, NM) Sarah E. Partain (Tigard, OR) Elaine Flowers (Mount Vernon, OH) Paula Simplot (Ottumwa, IA) Karel A. Curtis (Williamsburg, VA) Teresa Barnett (Temple, TX) Mary Post (Lake Oswego, OR) Maribeth Blethen Coluni (Blacksburg, VA) Cheri Bell (West Bend, WI) Sonia Rodriguez (Milwaukee, WI) Ranay Storms (Knoxville, AR) Sheila S. Newman (Troy, AL) Cindy Barloga (Highlands, NC)
Teal Jeffers (Metter, GA) Perri Brooks-Correll (Dalton, GA) Angela Howell (Watsonville, CA) Brittain Avery Wood (Morrisville, NC) Sherry Brace (Saint Petersburg, FL) Joyce E. Weaver (Bucyrus, OH) Kayera Kashmiri (Tampa, FL) Michael Grow (Williamsport, IN) Sandra Neola (South Russell, OH) Lee Ann Angelini (Clearwater, FL) Catriona MacBean-Mann (Saint Paul, MN) Stacia Brown (Tacoma, WA) Amy Michelle Gray (Corinth, MS) Jennifer VanderZee (Cedar Rapids, IA) Paola Beatriz Acuna (Lima, Peru) Rebecca Bartles (Colorado Springs, CO) Elizabeth Coe (Corbin, KY) Michelle Raab (Branson, MO) Donna Sears (Attleboro, MA) Thank you to APICâ€™s Strategic Partnersâ€”the sole sponsors of the CAA program.
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The National Action Plan to Prevent HAIs five years later—
Measuring progress and mapping out the future BY NANCY HAILPERN AND LISA TOMLINSON
September 25–26, 2013, just days before
“If you can’t explain it simply, you don’t understand it well enough.” —Albert Einstein
“Because federal law links the targets and metrics of the HAI Action Plan to Medicare payment, updates to the HAI Action Plan are a good indicator of the direction federal agencies may move when developing regulations.” 22 | WINTER 2013 | Prevention
the federal government shutdown, the U.S. Department of Health and Human Services (HHS) convened its “Road Map to Eliminate HAI: 2013 Action Plan Conference” to assess progress made in reaching the initial five-year targets and metrics of the plan and to discuss setting new targets. As you likely recall, the Federal HAI Action Plan originated out of a 2008 report by the U.S. Government Accountability Office (GAO) that recommended better consistency and compatibility of data across HHS agencies and prioritization of recommendations, followed by a Congressional hearing that highlighted the report’s recommendations. Although HAI data collection and the best way to approach it can be complex, the goal was somewhat simple: to take all the data the federal government collects related to HAIs and provide a simple dashboard of our nation’s progress, and to coordinate around HAI elimination. The first step in developing a National HAI Action Plan was for HHS to convene a steering committee consisting of a variety of agencies within HHS, as well as the U.S. Departments of Labor, Defense, and Veterans Affairs, to coordinate and maximize the efficiency of HAI prevention efforts across the federal government. The first phase of the HAI Action Plan focused on acute care hospitals and determined fiveyear prevention targets for process and outcome metrics in acute care. In order to better understand how the various federal agencies were doing as a whole on reduction of HAIs, it was necessary to come up with federal targets and metrics that drew on the existing data collection methods of the various
federal agencies, specifically the Centers for Disease Control and Prevention (CDC), the Centers for Medicare & Medicaid Services (CMS), and the Agency for Healthcare Research and Quality (AHRQ). The outcome metrics include data drawn from a variety of sources, although APIC has advocated moving away from using administrative data when presenting HAI data. In fact, a presenter from the CDC pointed out that AHRQ Healthcare Cost and Utilization Project (HCUP) data includes both hospital and community onset Clostridium difficile infection (CDI) and reflects an overall trend in burden, while the CDC’s National Healthcare Safety Network (NHSN) is specific to hospital-onset CDI based on laboratory identification and is intended to reflect trends in hospital performance. Measuring Progress Toward HAI Action Plan Outcome Goals
The plan included process measures as well, including Surgical Care Improvement Project (SCIP) measures related to infection, but many of those measures (SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4) have seen compliance of more than 90 percent in the most recent HAI Action Plan. In addition, SCIP-Inf-6, Appropriate Hair Removal, was suspended in 2012 due to topped-out status. As we review progress on the National HAI Action Plan as reported at the September 2013 HHS stakeholder meeting, we see that targets are likely to be met in some areas but others will need more focused attention. Review of this information also allows for identification of opportunities
“Although HAI data collection and the best way to approach it can be complex, the goal was somewhat simple: to take all the data the federal government collects related to HAIs and provide a simple dashboard of our nation’s progress, and to coordinate around HAI elimination.” for improvement in reducing HAIs. One of the CDC presenters outlined the following opportunities for improvement based on where we are to date: CLABSI
• Explore best practices for CLABSI prevention outside the ICU. • Conduct research to assess the current proportion of CLABSIs that are not preventable. CAUTI
• Reduce catheter use. • Widely implement best practices for catheter insertion. • Increase focus on catheter maintenance. • Provide education on appropriateness of diagnostic testing (urine cultures).
• Implement updated recommendations for SSI prevention from upcoming HICPAC guideline. • Collaborate with external partners to produce procedure-specific recommendations for surveillance and prevention. MRSA
• E xpand MRSA prevention efforts to healthcare-associated community onset cases. Clostridium difficile
• Improve antimicrobial use in inpatient settings. • Improve environmental decontamination. In addition to updating the acute care metrics, future iterations of the plan will
Central Line-Associated Bloodstream Infections (CLABSI)
Invasive MRSA infections (population)
Surgical Site Infections (SSI)
Hospital-Onset Clostridium difficile infections
Hospital-Onset MRSA bacteremia
further refine targets and metrics for areas added to the plan as parts of Phase 2, focused on HAI prevention in ambulatory surgical centers and end-stage renal disease facilities, and influenza vaccination of healthcare personnel; and Phase 3, focused on HAI prevention in long-term care facilities. With all of the attention focused on targets and metrics, how does this impact the day-today work of infection preventionists? Because federal law links the targets and metrics of the HAI Action Plan to Medicare payment, updates to the HAI Action Plan are a good indicator of the direction federal agencies may move when developing regulations. Nancy Hailpern is APIC director of Regulatory Affairs, and Lisa Tomlinson is APIC senior director of Government Affairs.
Description of Target
Update at sept. 13 HHS Meeting
50% reduction in ICU and ward-located patients
44% reduction (SIR = .56)
50% reduction in incidence of healthcare-associated invasive MRSA infections
25% reduction in SSIs following SCIP-like procedures on admission or readmission
20% reduction* (SIR =.80)
30% reduction in facility-wide inpatient healthcare facility-onset Clostridium difficile LabID Events
2% reduction (SIR = .98)
25% reduction in facility-wide inpatient healthcare facility-onset MRSA blood LabID Events
3% reduction (SIR = .97)
Catheter-Associated Urinary Tract Infections (CAUTI)
25% reduction in ICU and ward-located patients
2% increase (SIR =1.02)
Clostridium difficile (hospitalizations)
30% reduction in hospitalizations with C. diff
Note: Information based on federal agency presentations at National Action Plan to Prevent HAIs meeting on September 25–26, 2013. *Estimate based on preliminary 2012 data when noted in the presentation. **Projection for 2013.
Abbreviations: EIP/ABC is the CDC’s Emerging Infections Program Antibacterial Core Surveillance program. NHSN is the CDC’s National Healthcare Safety Network. SIR is Standardized Infection Ratio, which is observed number of HAIs/predicted number of HAIs. HCUP is AHRQ’s Healthcare Cost and Utilization Project, an all-payer inpatient care database that uses an ICD-9 code for Clostridium difficile. w w w.apic.org | 23
Egypt’s Professional Diploma in Infection Control (PDIC): A success story Until 2003, there was no structured infec-
BY OSSAMA RASSLAN, MD, PhD
“More than 70 percent of the graduates are now working as infection control doctors/ infection control team leaders, and infection control nurses in different healthcare facilities in Egypt and other Arab countries.” 24 | WINTER 2013 | Prevention
tion control program in Egypt, neither at the national level nor at the peripheral facility level. There were only some individual efforts and isolated trials in some healthcare facilities. Early in 2003, the Ministry of Health (MOH), World Health Organization (WHO), Eastern Mediterranean Regional Office (EMRO), and other relevant governmental and nongovernmental healthcare authorities and organizations established an infection control program. Education in infection prevention and control was targeted as one of the main objectives of the infection control program. The MOH in conjunction with the APIC Egypt chapter (formerly the Egyptian Society for Infection Control [ESIC]) developed short-term infection control Training of Trainers (ToT) courses. These courses were conducted in one of two forms: a oneweek per month course over a six-month period with the three-week gap during each month used for practical on-the-job training in the field, and a one-day per week course for a six-m onth period, with field assignments and projects throughout the course, followed by the awarding of a training certificate after sitting for written, oral, and practical exams. After four years of the certified training, APIC Egypt and the Arab Institute for Continuing Professional Development (AICPD) decided that if qualified professionals are to take over infection prevention and control activities in Egypt, as well as the EMRO region, it was important to have a more comprehensive training program. Thus, the idea for the Professional
Diploma in Infection Prevention and Control (PDIC) was born. PDIC curriculum
The PDIC aims to provide candidates with sufficient knowledge, skills, and attitudes that are essential for leading and managing infection prevention and control programs in various healthcare organizations. The program is organized into two main phases. The first phase covers the basic principles and general measures for prevention and control of healthcareassociated infections (HAIs). The second phase focuses on the applied practices and advanced issues for prevention and control of HAIs. The two phases are conducted as nine learning modules:
1. Basic Principles and Practices for Prevention and Control of HAIs 2. Support Services and Environmental Infection Prevention and Control Measures 3. Infection Prevention and Control Aspects of Occupational Health Programs 4. Basics of Healthcare-Associated Infection Epidemiology and Surveillance 5. B asics of Infection Prevention and Control Program Management 6. Infection Prevention and Control Strategies in Core Healthcare Units 7. Infectious Disease Process and Antimicrobial Stewardship 8. Specific Infection Prevention and Control Measures 9. Patient Safety Issues and Quality Improvement
The main teaching and training sources are listed in the references section at the end of the article.
The program was delivered as part-time training over a 16-month period. The workload equals 22 credit hours, fulfilling the following activities: face-to-face instruction and interactive discussion, field visits and hands-on training, and independent self-study comprising of assignments and project work. Candidates are graduates of medical and nursing schools who have successfully completed the pre-registration house officer year. Enrollment in the program is open three times a year: in January, May, and September. Expert instructors deliver different methods of learning in the form of formal didactic lectures, practical sessions, interactive workshops, and structured, supervised field training. Program administrators evaluate participants using different methods including final summative written exams, objective structured practical exams (OSPEs), periodical written assignments, and final project presentations. All program participants must maintain and update a logbook in which they document their participation in formal teaching sessions and field work activities. A number of factors are taken into consideration when evaluating the program including participant and instructor feedback, peer-review, annual reporting, and external assessment. Participants
To date, 777 participants have joined 16 classes; comprising two classes in 2007/2008, two in 2008/2009, three in 2009/2010, three in 2010/2011, three in 2011/2012, and three in 2012/2013. Participants in 12 classes have graduated. The other four are ongoing. Nationalities: PDIC participants were from nine different Arab countries. About 90 percent were Egyptian. Other participants were from Sudan, Yemen, Iraq, Syria, Libya, Palestine, Saudi Arabia, and Kuwait. Some candidates (mainly from Iraq) were funded by EMRO/WHO, and Palestinian candidates were sponsored by the Arab Medical Union (AMU). Affiliations: Candidates were affiliated with a variety of healthcare organizations and authorities in different Arab countries including MOH, teaching hospitals, health
insurance hospitals, charity hospitals, private hospitals, academic institutions, and university hospitals, in addition to some independent participants. Field work
Expert instructors deliver different methods of learning in the form of formal didactic lectures, practical sessions, interactive workshops, and structured, supervised field training.
Practical field training included a wide variety of essential topics such as hand hygiene, personal protective equipment (PPE), disinfection and sterilization, support services (e.g., laundry, kitchen, air conditioning, ventilation systems, water services, and maintenance), and unit specific measures (e.g., dialysis unit, ICU, NICU, burn unit, endoscopy unit). Many general or specialized tertiary hospitals belonging to the MOH, a university, or teaching hospitals have been included in the practical training sessions. Participation depends on the relevance of studentsâ€™ specialty to the training topic, how well they are equipped, and the presence of expert trainers within the facilities. Each of the two PDIC phases (basic and advanced) include seven to eight daytime supervised practical training sessions. Participants were divided into groups of 10â€“12 people, each under supervision of an experienced trainer. Each training session was conducted by a specialty expert with relevant experience in the specialty, under the supervision of a faculty staff member (a professor or senior infection prevention and control consultant). w w w.apic.org | 25
Participants of each PDIC class are divided (at the beginning of the course) into groups of five. While under supervision, students agreed to conduct a field project throughout the course and to present their findings, conclusion, and recommendations at the end of the project as a prerequisite for taking the final exam. Students targeted a variety of topics for conducting field projects, including: • Situation analysis and benchmarking among different facilities • Surveillance studies in different settings • Intervention studies in some critical care units • Outbreak investigation (e.g., MRSA, VRSA, food poisoning) • Developing and implementing an infection prevention and control program, and measuring its impact • Developing an education program Output and influence
“Infection prevention and control is an essential element in providing high-quality healthcare in achieving accreditation in healthcare facilities. Knowledge, education, and training are the cornerstones in proper implementation of an infection prevention and control program.” 26 | WINTER 2013 | Prevention
More than 70 percent of the graduates are now working as infection control doctors/ infection control team leaders, and infection control nurses in different healthcare facilities in Egypt and other Arab countries. Consequently, about 15 percent of the secondary and tertiary care hospitals in different healthcare authorities in Egypt are currently employing PDIC graduates—and the number is increasing. A number of graduates are now working as consultants and advisory board members in large governmental and non-governmental hospitals. A group of graduates is also working as strategic planners and infection prevention and control directors at the central level of the MOH, specialized medical centers, teaching hospitals, and Institutes Authority in Egypt. Some of the graduates are university staff members in schools of medicine in Cairo, Ain Shams, Alexandria, and Misr International universities and are currently responsible for running infection prevention and control courses and master degree programs. Research
Many infection preventionists (IPs) are now research-minded. A multidisciplinary
research movement is currently underway in important aspects and core functions of HAIs and infection prevention and control such as bloodborne pathogens, antimicrobial resistance, antimicrobial stewardship, hand hygiene, isolation precautions, surveillance issues, and others. Many PDIC graduates have published original research articles in different infectious diseases and infection prevention disciplines in local, regional, and international peer-reviewed journals in the last few years. Recognition
PDIC has been recognized locally by the Egyptian Medical Syndicate (EMS), and graduates are listed as infection control specialists in the EMS registry. PDIC has also been recognized by the Egyptian Board for Medical Specialties. PDIC degree holders who join the Egyptian Board for Medical Specialties receive a one-year period deducted from the mandatory three years for the Egyptian Board for Infection Control. The PDIC was also recognized by EMRO/WHO and AMU. Both organizations have specific scholarships and grants to cover the PDIC course fees for candidates from some of their member states (e.g., Palestine and Iraq). EMRO/WHO signed a memorandum of understanding to support PDIC by providing infection prevention and control experts, meeting rooms, and some small grants. PDIC was also endorsed by the International Federation for Infection Control (IFIC). Progress
Basic PDIC courses were conducted in Libya (two courses in 2008-2009) and in Syria (one course in 2009-2010) in cooperation with EMRO/WHO. In the fall of 2013, a PDIC course was launched in Khartoum-Sudan at the Sudan Branch of the Arab Institute for Continuing Professional Development (AICPD), in cooperation with the Sudan Medical Union. PDIC is currently undergoing an accreditation process by the International Board for Certified Trainers through the Egyptian Supreme Council for Universities
TOP LEFT. Participants received practical on-the-job training in many fields including dentistry. ABOVE. Practical field training included a wide variety of essential topics such as hand hygiene, PPE, disinfection and sterilization, support services, and unit specific measures.
To date, 777 graduates have received their Professional Diploma in Infection Prevention and Control (PDIC).
in Egypt and is expecting recognition for accreditation soon. Webber Training will soon post an Arabic version for the PDIC course presentations to its website. PDIC has future plans to: • Extend to other medical and paramedical specialties, namely dentists and pharmacists • Develop specialized courses for laboratory technicians and veterinarians • E stablish a consultation center (from PDIC staff and graduates) to prepare healthcare facilities for accreditation in infection control areas • Extend to other countries in the region and to develop an e-learning module of PDIC for distant learning in remote countries in the region
Ossama Rasslan, Md, Phd, delivers a speech during a pdic graduation ceremony.
Infection prevention and control is an essential element in providing high-quality healthcare in achieving accreditation in healthcare facilities. Knowledge, education, and training are the cornerstones in proper implementation of an infection prevention and control program. Certification in infection prevention and control is a key professional standard for any IP. A well-organized and structured infection prevention educational program in an appropriately equipped training center under supervision of well-trained educators is one of the main pillars of success in practicing infection prevention. Hands-on sessions, log books, practical assignments, and field projects should be the core elements in conducting an infection
prevention educational program to facilitate translating knowledge into practice. Baseline assessment should be the starting point in tailoring a successful infection prevention educational program, and key concepts should involve teaching basic knowledge and helping others understand how to do the most with limited resources using their existing systems. Ossama Rasslan, MD, PhD, is president of the APIC Egypt chapter and chair of the PDIC Scientific Council in Cairo, Egypt.
w w w.apic.org | 27
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prevention in action
My Bugaboo: Multidrug-resistant Tuberculosis A microbiological overview of MDR-TB. BY IRENA KENNELEY, PHD, APRN-BC, CIC
Greetings fellow infection preventionists! The science of infectious diseases involves hundreds of bacteria, viruses, fungi, and protozoa. The amount of informa-
tion available on 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 multidrug-resistant Tuberculosis (MDR-TB). The intention is to convey succinct information to busy IPs for common etiologic agents of healthcare-associated infections. Please feel free to contact me with questions, suggestions, and comments at email@example.com. Under a high magnification of 15549x, this colorized SEM depicted some of the ultrastructural details seen in the cell wall configuration of a number of Gram-positive Mycobacterium tuberculosis bacteria. Photo courtesy CDC/Dr. Ray Butler; Janice Haney Carr.
w w w.apic.org | 29
PREVENTION IN ACTION
uberculosis (TB) is one of the world’s deadliest infectious diseases. The World Health Organization (WHO) estimates that at least one third of the world’s population is infected with TB. In 2011, TB caused approximately 1.4 million deaths worldwide. TB is the leading cause of death for people infected with the human immunodeficiency virus (HIV).1
Bacteria within the genus Mycobacterium are rod-shaped organisms that are resistant to decolorization in the staining process. Because of this property, they are known as “acidfast bacteria” (also known as acid-fast bacilli). The cell wall of the TB bacterium is composed mainly of lipids, which in turn is responsible for many of the commonly known characteristics of this organism. These characteristics include not only acid-fastness, but resistance to disinfectants and detergents (hence the need for tuberculocidals), slow growth in the laboratory, and resistance to common antibacterial products.2 Most Mycobacteria grow slowly, and the isolation of M. tuberculosis, M. avium-intracellulare, and M. kansasii can require three to eight weeks of incubation. Other human pathogens of this genus include: M. leprae (leprosy), M. fortuitum, M. chelonae, and M. abscessus among others.2 Mycobacterium tuberculosis
M. tuberculosis is an intracellular pathogen that can cause lifelong infection. The organism is acquired through the airborne route via inhaled droplets. Infection of the lungs is the most common course of TB disease, estimated to be 70 to 80 percent of all cases. Overall, only 5 to 10 percent of people exposed to TB progress from infection to 30 | WINTER 2013 | Prevention
disease. The risk of progression is much higher in the immunosuppressed.1, 2 Definitions • M ultidrug-resist ant TB (MDR-TB): strains resistant
to the most effective antiTB drugs (isoniazid and rifampin).1 See Table 1 for more information about the medications used to treat TB.
• E xtensively Drug-resistant TB (XDR-TB): strains that have
developed resistance not only to isoniazid and rifampin but are also resistant to any of the second-line anti-TB drugs. These resistant strains of TB do not respond to the standard six-month treatment with first-line anti-TB drugs and can take two or more years to treat with drugs that are less potent, more toxic, and much more expensive (see Table 1).1
In 2013, the WHO published key findings in TB surveillance. Essentially, resistant TB strains are widespread and occur in virtually all countries. By March 2013, 84 countries had reported at least one case of XDR-TB. WHO estimates that there were 500,000 new cases of MDR-TB in 2011. Of these, 60 percent of cases occurred in Brazil, China, India, the Russian Federation, and South Africa (the so-called “BRICS” countries).1 A total of 9,945 TB cases were reported in the United States in 2012, or 3.2 cases per 100,000 persons. According to the CDC, the percentage of MDR-TB cases decreased slightly from 1.6 percent (127 cases) in 2011 to 1.1 percent (83 cases) in 2012.1 Treatment and drug update
Figure 1 illustrates medications currently used to treat TB and the drug’s mode of action. TB
disease is treated with a multiple drug regimen administered by directly observed therapy (DOT) for six to nine months (usually isoniazid, rifampin, ethambutol, and pyrazinamide for two months, followed by isoniazid and rifampin for an addition four months) if the TB strain is not MDR-TB. If it is MDR-TB, the treatment is more difficult, requiring four to six drugs for 18 to 24 months; the case should be managed by an expert in MDR-TB. The American Thoracic Society (ATS), Centers for Disease Control and Prevention (CDC), and Infectious Disease Society of America (IDSA) have published guidelines on TB treatment.5 The drug, known generically as bedaquiline (brand name Sirturo), is the first new type of TB drug to be approved by the U.S. Food and Drug Administration in more than 40 years. The initial recommendations were issued in December 2012 for treatment of MDR-TB as part of combination therapy in adults over the age of 18 with TB infections of the lung.
Table 1: First and second line of treatment of TB and new TB drugs in development First-Line TB Treatment Drugs
Second-Line TB Treatment Drugs
New TB Drugs in Development Nitroimidazoles*
EMB or E
amikacin (AMK) kanamycin (KM)
INH or H
capreomycin viomycin enviomycin
PZA or Z
ciprofloxacin (CIP) levofloxacin moxifloxacin (MXF)
RMP or R
Terizidone *Nitroimidazoles: novel, complex mechanisms of action: inhibit cell wall synthesis AND inhibit cell respiration. **NIAID has supported the development of two compounds denoted by asterisks (*) above.3
However, in October 2013 the CDC (TB Elimination branch) issued recommendations for treatment beyond the original narrow group of adults to children, pregnant women, and those with diabetes and HIV infection. However, further study is required before routine use of bedaquiline can be recommended in these populations. Reported side effects include hepatotoxicity, renal impairment, and cardiac toxicity.9
Figure 1: Multidrug-Resistant Tuberculosis (MDR-TB) and possible effective treatments
All healthcare settings need an infection control program designed to ensure the following: 1. Prompt detection of infectious patients 2. Airborne precautions 3. Treatment of people who have suspected or confirmed TB disease In order to be effective, the primary emphasis of the TB infection-control program should be on achieving these three goals. Policies and procedures for TB control should be developed, reviewed periodically, and evaluated for effectiveness to determine the actions necessary to minimize the risk for transmission of M. tuberculosis in all healthcare settings. Overview of TB infection prevention and control measures
The TB infection-control program should be based on a three-level hierarchy of control measures and include6: 1. Administrative controls 2. Environmental controls 3. Use of respiratory protective equipment Infection prevention and control ad minist rat ive
Figure 1: MDR-TB occurs when a Mycobacterium tuberculosis strain is resistant to isoniazid and rifampin, two of the most powerful first-line drugs. To cure MDR-TB, healthcare providers must turn to a combination of second-line drugs, several of which are shown here. Second-line drugs may have more side effects, the treatment may last much longer, and the cost may be up to 100 times more than first-line therapy. MDR-TB strains can also grow resistant to second-line drugs, further complicating treatment.4 ILLUSTRATION CREDIT: NATIONAL INSTITUTE OF ALLERGY AND INFECTIOUS DISEASES (NIAID). ILLUSTRATOR: KRISTA TOWNSEND.
controls include the following activities: • A ssigning responsibility for TB infection-control in the setting • Conducting a TB risk assessment of the setting • Developing and instituting a written TB infection-control plan to ensure prompt detection, airborne precautions, and treatment of persons who have suspected or confirmed TB disease • Ensuring the timely availability of recommended laboratory processing, testing, and reporting of results to the ordering physician • Implementing effective work practices for the management
of patients with suspected or confirmed TB disease • Ensuring proper cleaning and sterilization or disinfection of potentially contaminated equipment (e.g., bronchoscopes, endoscopes) • Training and educating healthcare personnel (HCP) regarding TB, with specific focus on prevention, transmission, and symptoms • S creening and evaluating HCP who are at risk for TB disease or who might be exposed to M. tuberculosis • A pplying epidemiologicbased prevention principles, including the use of settingrelated infection control data
• Using appropriate signage advising respiratory hygiene and cough etiquette • Coordinating efforts with the local or state health department The environmental controls listed below are used to prevent transmission and reduce the concentration of infectious droplet nuclei in ambient air: • P rimary environmental controls restrict the source of infection by using local exhaust ventilation (e.g., hoods, tents, or booths) and dilute and remove contaminated air by using general ventilation. • S econdary environmental controls control the airflow to prevent contamination of air w w w.apic.org | 31
PREVENTION IN ACTION
2013 TB diagnosis update Rapid diagnosis and treatment of TB is a major breakthrough to prevent further infections. In July 2013, the U.S. Food and Drug Administration (FDA) allowed marketing of the Xpert MTB/RIF Assay, the first FDAreviewed test that can simultaneously detect bacteria that cause tuberculosis (TB) and determine if the bacteria contain genetic markers that makes them resistant to rifampin, a first-line drug in the treatment of TB. The new test is less complex to perform than other previous FDA-cleared tests for the detection of TB bacteria. Test results, including the detection of TB bacteria and whether the bacteria are drug resistant, are available in approximately two hours. Traditional methods to detect multidrug-resistant TB usually require one to three months.8
in areas adjacent to the source (airborne infection isolation [all] rooms).
32 | WINTER 2013 | Prevention 638106_Nanosonics.indd 1
• C lean the air by using high efficiency particulate air (HEPA) filtration,
or ultraviolet germicidal irradiation. Use of respiratory protection equipment can further reduce risk for exposure of HCP to infectious droplet nuclei that have been expelled into the air from a patient with infectious TB disease. The following measures can be taken to reduce the risk for exposure: • Implementing a respiratory protection program; N95 respirator training and use • Training HCP on respiratory protection • Training patients on respiratory hygiene and cough etiquette procedures Transmissibility of TB appears to decline rapidly after adequate treatment is started; how quickly this occurs
varies from patient to patient. Patients can be considered noninfectious when they meet all of the following criteria: 1. They have been receiving adequate treatment for two weeks or longer. 2. Their symptoms have improved (e.g., they are coughing less and no longer have a fever). 3. They have THREE consecutive negative sputum smears from sputum collected in eightto 24-hour intervals (at least one being an early morning specimen).6 Infection prevention and diagnostic testing
The Mantoux tuberculin skin test (TST) is the standard method of determining whether a person is infected with Mycobacterium
18/04/13 6:09 AM
tuberculosis. Reliable administration and reading of the TST requires standardization of procedures, training, supervision, and practice. Results can be obtained 48 to 72 hours after inoculation, previous vaccination with the BCG vaccine can cause false positive results.7 Interferon-Gamma Release Assays (IGRAs) are whole-blood tests that can aid in diagnosing Mycobacterium tuberculosis infection. They do not help differentiate latent tuberculosis infection (LTBI) from tuberculosis disease. Two IGRAs that have been approved by the U.S. Food and Drug Administration (FDA) are commercially available in the U.S. Advantages include: 1) results within 24 hours; and 2) prior BCG (Bacille CalmetteGuérin) vaccination does not cause a false-positive IGRA test result. 1. QuantiFERON®-TB Gold In-Tube test (QFT-GIT); 2. T-SPOT®.TB test (T-Spot) The CDC recommends using one test or the other, but not both on the same patient.7 Summary
MDR-TB most commonly develops in the course of TB treatment regimens. Resistance occurs when a physician prescribes inappropriate treatment or patients miss doses or fail to complete their treatment. MDR tuberculosis is an airborne pathogen, so persons with active, pulmonary tuberculosis caused by a multidrug-resistant strain can transmit the disease by coughing. Advancements and FDA approval of diagnostic testing has aided the identification and treatment of MDR-TB within hours rather than months, a major infection prevention development.
Irena Kenneley, PhD, APRN-BC, CIC, is assistant professor at Case Western Reserve University, Frances Payne Bolton School of Nursing in Cleveland, Ohio. References 1. WHO March 2013. Multidrug-resistant tuberculosis (MDR-TB). Site accessed October 6, 2013: www.who.int/tb/challenges/mdr/en/. 2. Strelkauskas A. (2009). Microbiology: A Clinical Approach. ISBN-10: 0815365144 | ISBN-13: 978- 0815365143. 3. CDC (2012). Treatment of Tuberculosis (2003). Site accessed October 6, 2013: www.cdc.gov/ tb/publications/slidesets/Treatment_Guidelines/2003/default.htm. 4. National Institutes of Allergy and Infectious Disease (2007). Scientific Illustrations of Drug-Resistant TB: Multidrug-Resistant TB (MDR-TB) and Possible Effective Treatments. Site Accessed October 6 2013: www.niaid. nih.gov/topics/tuberculosis/Understanding/ WhatIsTB/ScientificIllustrations/pages/multidrugresistantillustration.aspx. 5. CDC, American Thoracic Society and Infectious Disease Society of America (2011). Recommendations for use of an isoniazidrifapentine regimen with direct observation to treat latent Mycobacterium tuberculosis infection. MMWR Morb Mortal Wkly Rep. 2011 Dec 9;60(48):1650–3. 6. CDC. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR 2005; 54(No. RR-17). Site Accessed October 6, 2013: www.cdc.gov/ tb/publications/factsheets/prevention/ichcs. htm. 7. CDC (2010). Updated Guidelines for Using Interferon Gamma Release Assays to Detect Mycobacterium tuberculosis Infection-United States, 2010. MMWR; June 25, 2010 / 59(RR05);125. Site Accessed October 6, 2013: www. cdc.gov/mmwr/preview/mmwrhtml/rr5905a1. htm?s_cid=rr5905a1_e. 8. Food and Drug Administration (2013). FDA permits marketing of first U.S. test labeled for simultaneous detection of tuberculosis bacteria and resistance to the antibiotic rifampin. U.S. Food and Drug Administration, released July 25, 2013. Site Accessed October 6, 2013: www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm362602.htm. 9. CDC (2013). Provisional CDC Guidelines for the Use and Safety Monitoring of Bedaquiline Fumarate (Sirturo) for the Treatment of Multidrug-Resistant Tuberculosis. MMWR Division of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC. Recommendations and Reports October 25, 2013 / 62(rr09);1-12. Site accessed October 26, 2013: www.cdc. gov/mmwr/preview/mmwrhtml/rr6209a1. htm?s_cid=rr6209a1_e.
w w w.apic.org 10/10/13| 33 10:06 AM
PREVENTION IN ACTION
Ready, set, implement! Guided by the principles of implementation science, a team of nurses develops an innovative nurse-driven Foley catheter protocol to prevent CAUTI. By Brooke Buras, RN, BSN
fter reading the fall 2012 edition of Prevention Strategist, some ambitious and eager nurses were inspired to develop an innovative, nursedriven Foley catheter protocol at North Oaks Medical Center, a 330-bed, acute care facility in Hammond, Louisiana. The focus of an article on a patient-centered approach to preventing catheter-associated urinary tract infections (CAUTIs) captured the nurses’ interest. Ultimately, a CAUTI
Reduction Team was established at North Oaks as part of the facility’s participation in the Centers for Medicare and Medicaid Services Partnership for Patients Campaign.
With infection prevention leading the team and a nursing representative from each major patient care area as members, the team decided that developing a nurse-driven Foley catheter removal protocol would be the best strategy to decrease device days and prevent infections. Prompt removal of the Foley catheter remains a core preventative measure, as recommended by the Centers for Disease Control and Prevention (CDC).1 Getting started
Members of the CAUTI team provide individualized education to ensure all questions and/or concerns are addressed. LEFT TO RIGHT: CAUTI team member Jessica Purvis and staff nurse Nicole Milazzo. 34 | WINTER 2013 | Prevention
After three months of research, multidisciplinary collaboration, partnering with the medical staff, and several revisions, an evidenced-based, nurse-driven Foley catheter removal and postFoley catheter removal protocol was approved by the Medical Executive Committee for use at North Oaks Medical Center (Fig. 1 and 2). A nurse now has the autonomy, as granted by the medical staff, to remove a Foley catheter, barring specific criteria outlined in the protocol. Additionally, the nurse can perform one straight
catheterization if the patient has not voided within the determined timeframe. This places North Oaks in the small percentage of U.S. hospitals that use evidenced-based practice to monitor Foley catheter duration and/or discontinuation to help prevent CAUTIs.2, 3 As the team leader of the CAUTI team, I label the two protocols “mutts” because they were devised using multiple resources, including the publications Prevention Strategist, American Journal of Infection Control, and Journal of Nursing Care Quality; guidance from eQ Health Solutions and the Institute for Healthcare Improvement; and input from North Oaks’ own nurses and physicians. I alluded to Neil Armstrong’s famous quote, “This is one small step for man, one giant leap for mankind,” when informing team members, nursing leadership, and staff of the Medical Executive Committee’s decision to approve the protocol. The protocol is a triumph for North Oaks because it facilitates nurse empowerment by granting
After a team meeting, some members of the CAUTI team show their team spirit. LEFT TO RIGHT: Brooke Buras, Tammy Murphy, Edna Scott, Melissa Fisher, Jessica Purvis, and Amanda Hecker.
autonomy and represents true multidisciplinary collaboration to incorporate evidence and research into practice. In addition, it helps the hospital prevent healthcare-associated infections (HAIs) and reach the ultimate goal of providing patients with the best care possible. Implementation
Using the quality improvement methodology of rapid-cycle change (introduced to the team by the Partnership for Patients Campaign) and implementation science, the team was able to expedite change that yielded reliable results. Rapidcycle methodology uses the traditional Plan-Do-Study-Act (PDSA) cycle to facilitate rapid improvement. PDSA guided the team to test interventions on small scales. If the intervention provided favorable results,
then the change was applied to a larger population.4 Directly applying the PDSA cycle, the two nurse-driven protocols were first introduced to the hospital’s three surgery units. Within a month, those units’ device days decreased significantly. The next month it was rolled out to the remaining seven nursing units. Implementation of the two nurse-driven protocols proved to be a challenge for the CAUTI team. Developing the protocols and obtaining approval for utilization was the easy part. Educating the nursing staff on the appropriate use of the protocols and helping them feel comfortable having the autonomy to employ them continues to be the most challenging aspect for the CAUTI reduction team. Implementation science guided the team, as it accomplished the monumental task of
properly putting the protocols into action. Implementation science is an action-oriented model, as well as a clinical and a social specialty, and provides an operational framework for the systematic uptake of this evidence-based intervention into healthcare practice.5 It includes the four “Es”: engage, educate, execute, and evaluate. Engage
During the whirlwind of tasks and responsibilities in a shiftlong tornado, it is challenging to adjust nursing priorities. Infection preventionists and administrative personnel alike often wonder: “What else can be done to engage employees so they will give an issue the attention it requires?” The answer to that question is very simple. Engagement should come from an internal
source in a patient care area. It’s vital to have a competent, determined team to lead by example. Those informal leaders on the units will facilitate a sustained, meaningful change. Engagement was accomplished by obtaining a crew of high performers who were well-respected by their peers. Real-life stories about how a CAUTI affected a patient’s life were shared with the crew, followed by practical suggestions to decrease infections. Teamwork flourished thereafter, dramatically increasing the frequency of desired results. Consequently, the critical part of this step is to successfully engage the team members. Once members of the team realize the vital nature of the subject matter, they will act as role models in delivering excellent care, and peers will follow suit. w w w.apic.org | 35
PREVENTION IN ACTION
FOLEY CATHETER REMOVAL PROTOCOL:
To be addressed daily on all patients with Foley catheters
Does the patient have an indwelling Foley that has been in longer than 24 hours?
• • •
Continue to assess daily. Document reason for continuing Foley catheter.
Does the patient meet criteria to justify continuing the Foley? See chart A.
Continue to assess daily. Document reason for continuing Foley catheter.
• • • •
Does the patient meet criteria for removal, when applicable? See chart B.
Continue to assess daily. Document reason for continuing Foley catheter.
Chart A Criteria for Continuing Foley Catheter
Known or suspected urinary tract obstruction Neurogenic bladder dysfunction Recent urologic surgery, bladder injury, pelvic surgery, or recent surgery involving structures contiguous with the bladder or urinary tract, after pelvic surgery (e.g., GYN, colorectal) Other post surgical procedure—with an order stating do not remove Foley Urinary incontinence in the patient with Stage III or Stage IV pressure ulcers on the trunk, perineal wounds, necrotizing infections Need for accurate measurement of urinary output in a critically ill patient, patient undergoing aggressive diuresis, or presence of renal impairment (unless patient is able to cooperate with strict output monitoring—can use a bed pan or commode) Gross hematuria in patients with potential clots (for irrigation) Epidural catheter still in place Palliative care for terminally ill Foley placed within 24 hours
Chart B Criteria for Removal by RN (when applicable)
Patient is awake, alert, and oriented or is at baseline mental capacity. Verbally expresses no trouble voiding before the catheter was placed or return to baseline urinary status (i.e., incontinent before Foley was placed) • If surgical procedure, patient able to comfortably use a bed pan/commode which will not interfere with intent of procedure • Order for strict output monitoring is discontinued, or the patient is able to cooperate with strict output monitoring • Epidural catheter is removed Note: A physician order is required for discontinuing Foley in patients who have had a recent urologic surgery, bladder injury, pelvic surgery, and/or recent surgery involving structures contiguous with the bladder or urinary tract.
Yes RN may remove Foley—before 7 a.m. is most optimal time . Removal Reason: Per protocol. Follow post-catheter removal protocol.
Some nurses know the appropriate indications for and timeframe to maintain a Foley catheter, but is this common knowledge among all nurses? Healthcare reform has placed increasing strain on America’s bedside caregivers, increasing patient-to-nurse ratios and pressure related to performance-based reimbursement. All nurses should realize that their actions (and omissions) could impact patient mortality. With those issues in mind, the CAUTI team decided to carry out a massive educational agenda to ensure that everyone was aware of CAUTI prevention. Initially, team members attended each nursing unit staff meeting to promote CAUTI awareness. Additionally, they attended conferences to explain the newly approved nursedriven protocols. They also provided individualized education for each day and night shift to ensure all questions were 36 | WINTER 2013 | Prevention
addressed and to discuss realtime scenarios. Every unit knew its CAUTI team representative
and what actions to take if there was confusion when exercising protocols.
POST-CATHETER REMOVAL PROTOCOL:
Has the patient voided within 6 hours after removing the Foley?
For all patients when a Foley catheter is removed
Does the patient appear comfortable and doesn’t express a desire to void?
See chart A.
Has the patient voided within 4 hours after straight catheterization?
Yes Continue to monitor patient comfort and for retention.
Execution occurs when evidenced-based interventions are converted into practice. The CDC recommends using a combination of core prevention strategies.1 One of these methods includes leaving a catheter in place for short periods of time (with regard to medical necessity, as opposed to nursing convenience) to minimize infection risks.1 The nurse-driven Foley catheter removal protocol allows nurses to determine the need for the Foley catheter on a daily basis and remove it promptly when it is no longer necessary. Furthermore, the
Continue to monitor patient comfort and for retention.
Chart A Do a bladder scan.
If bladder scan volume is <400 ml and the patient is comfortable and does not express a desire to void, encourage oral fluid intake (unless contraindicated) and repeat bladder scan in 2 hours. If bladder scan volume is 400-600 ml the RN will first ensure position of the patient allows comfortable voiding if applicable (standing, sitting up). Reassess in 2 hours. If the patient is not able to void, perform a straight catheterization. See 2 bullets below. If bladder scan volume is >600 ml, perform a straight catheterization. • Document bladder scan volume in the Intake/Output Flowsheet under group: Urine Assessment. • If straight cath performed, document volume in the Intake/ Output Flowsheet under group: Urine Assessment. Document patient tolerance as a Progress Note, Service: Nursing. *A bladder scan should be done for any of the following: patient is uncomfortable at anytime, whether voiding or not, patient has an urge to void but is unable to do so, patient is incontinent at any time (that is not baseline).
Call to action
Regular updates on progress facilitated and sustained team engagement. LEFT TO RIGHT: CAUTI team members Brooke Buras, Tammy Murphy, Edna Scott, Melissa Fisher, Jessica Purvis, and Amanda Hecker.
Engaging bedside caregivers, increasing CAUTI awareness, executing evidenced-based interventions, and continuously evaluating progress—along with using rapid-cycle methodology—resulted in a massive culture change at North Oaks Medical Center. In summary, here are five tips that will be useful in implementing a nurse-driven Foley protocol: Seek team members who are highly engaged to act as role models for delivering excellent care. Determine a framework/model to guide implementation. Rapid-cycle methodology and implementation science can be applied to many HAI prevention strategies.5 Ensure that communication with team members and healthcare workers is clear and concise. When expectations are well defined, courses of action are easy to follow. Provide multiple opportunities for education. Visit staff meetings and individual shifts, and employ passive education strategies (e.g., poster boards and computer-based learning) to allow individuals to learn at their own pace. Have a mechanism for staff to provide feedback and follow up on a routine basis. Education should be ongoing and resources should be available if staff has questions and/or concerns along the way.
1 2 3 4 5
Real patient scenarios are discussed to enhance applicable knowledge of the nursedriven Foley removal protocols. LEFT TO RIGHT: CAUTI team members Amanda Hecker, Jessica Purvis, Melissa Fisher, and Edna Scott. Brooke Buras is seated.
criteria for continuing use of a Foley catheter outlined in the protocol serves as a guide for appropriate placement. The basics of preventing CAUTIs were reinforced—inserting catheters using aseptic technique and proper maintenance of the urinary catheter.1 Also, the team used a Foley catheter securement device, which the CDC also considers a core prevention strategy.1 Catheter securement is important to prevent catheters from exerting excessive force on the bladder neck or urethra, causing inflammation.6, 7 Evaluate
The team chose infection rates as an outcome measure because the CDC provides
standardized, scientifically rigorous definitions. The nurse-driven Foley catheter removal protocols were first implemented in February 2013, and within months North Oak’s CAUTI infection rates plummeted. The hospital’s 2013 CAUTI rate is projected to fall close to the National Healthcare Safety Network’s (NHSN) 10th percentile, with the ultimate goal of zero infections. Surgical Care Improvement Project statistics and Partnership for Patients comparative data are also evaluated to determine progress and are shared with the team and other administrators on a monthly basis. After the nurse-driven protocols were
implemented, the CAUTI team served as a resource to the staff and accepted positive and negative feedback. Future team goals relate to continuously evaluating current processes, as well as validating that staff are inserting catheters aseptically and monitoring duration and/or discontinuation of Foley catheters. Brooke Buras, RN, BSN, is an infection prevention surveillance nurse at North Oaks Health System in Hammond, Louisiana. References 1. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, and HICPAC. Guideline for Prevention of Catheter-associated Urinary Tract Infections 2009. Available at: www.cdc.gov/ hicpac/cauti/001_cauti.html. Accessed July 1, 2013.
2. Krein SL, Kowalski CP, Hofer, TP, Saint, S. Preventing Hospital-Acquired Infections: A National Survey of Practices Reported by U.S. Hospitals in 2005 and 2009. Journal of General Internal Medicine 2012; 27: 773-779. 3. Saint S, Kowalski CP, Kaufman SR, Hofer TP, Kauffman CA, Olmsted RN, Forman J, Banaszak-Holl J, Krein SL. Preventing hospitalacquired urinary tract infection in the United States: a national study. Clinical Infectious Diseases 2008; 46: 243-250. 4. Brown P, Hare D. Rapid cycle improvement: Controlling change. The Journal. 2002; 98: 2-3. Available at: www.ashp.org/DocLibrary/ Policy/QII/Rapid-Cycle.aspx. Accessed July 1, 2013. 5. Saint S, Howell JD, Krein SL. Implementation Science: How to Jumpstart Infection Prevention. Infection Control and Hospital Epidemiology 2010; 31(Suppl 1): S14-S17. 6. Wound, Ostomy and Continence Nurses Society. Indwelling Urinary Catheter securement: Best practice for clinicians.2012. Available at: www.faet.org/docs/IndwellingUrinaryCatheterSecurement.pdf. Accessed July 1, 2013. 7. Oman KS, Flynn MB, Fink, R, Schraeder N, Hulett T, Keech T, Wald H. Nurse-directed interventions to reduce catheter-associated urinary tract infections. American Journal of Infection Control 2012; 40: 548-553.
w w w.apic.org | 37
Association for Professionals in Infection Control and Epidemiology
PREVENTION IN ACTION
Facility emergency preparedness starts at home BY STEVE HILLEY, RN
hen it comes to infection prevention, don’t overlook the basics. Emergency preparedness doesn’t start at the healthcare facility; it starts at home. While every healthcare facility needs an emergency preparedness plan, the plan is not complete if healthcare administrators overlook the personal safety and security of each employee and their families. It sounds obvious, but facility staff must be prepared at home because emergency preparedness plans require employees to come into the facility during disasters. It’s vital to assist colleagues in preparing for disasters—more specifically, preparing staff for an event where they feel comfortable leaving their family safe and secure at home. Without that sense of comfort, staff may not come into the healthcare facility to assist in community response during an emergency or disaster.
Staff show off their 10-gallon bins/totes used to build their own home emergency preparedness kits.
You’ve heard it before—emergencies can strike anytime, anywhere. Without warning, your community can be left without power, water, sanitation, and communications. Being prepared for disasters takes time and resources. The most basic element of preparedness starts with a home emergency preparedness kit.
miles from Denver and 150 miles from Grand Junction, resources can be scarce—especially during a disaster. When internal or external disasters occur, healthcare facilities in rural communities must be self-sustaining for at least 96 hours. After YVMC conducted an informal study on home emergency preparedness among employees, it concluded
Although many Yampa Valley Medical Center (YVMC) staff members have attended workshops that stress the importance of having an emergency preparedness kit at home, it previously didn’t have any data about how many employees actually created a home kit. Because YVMC is situated in Northwest Colorado, approximately 150
that only about 5 percent of the staff had an adequate personal emergency preparedness kit at home or in their car. Thus, part of YVMC’s emergency preparedness plan included assisting its employees with their personal emergency preparedness. To prepare its staff, YVMC started with a basic one-day employee safety fair in 2000. w w w.apic.org | 41
PREVENTION IN ACTION
LEFT: Glenn Sommerfeld and Steve Hilley assemble a personal home emergency preparedness kit. RIGHT: Staff during the YVMC Safety Fair, where employees are rewarded with first aid kits, small emergency preparedness kits, and other gifts of appreciation.
Resources to help build a home emergency preparedness kit
• www.ready.gov/be-informed • www.ready.gov/make-a-plan • www.ready.gov/build-a-kit • www.ready.gov/get-involved • For monthly preparedness text messages, text PREPARE to 43362 (4FEMA) to receive preparedness tips (message/data rates apply). • To order publications, call 800-BE-READY, 888-SE-LISTO, and TTY 800-462-7585.
The goal of the fair is to help educate and equip staff to be trained members of the community—not victims. YVMC recruits vendors from the community to assist with training and education needs. For example, YVMC has organized the sheriff’s office to advise on firearms safety, the fire department to train on fire extinguisher use, local bike shops to teach bike safety, public health partners to educate about emergency preparedness, the dangers of texting/drinking and driving, and more. During its safety fairs, YVMC rewards employees with
first aid kits, small emergency preparedness kits, and other gifts of appreciation. The Federal Emergency Management Agency (FEMA) declared September 2013 as Emergency Preparedness Month. In honor of Emergency Preparedness Month, the focused goal of this year’s safety fair was to assist staff in building their own home emergency preparedness kits. YVMC invited vendors from all over the county to educate staff on emergency preparedness, influenza, fire extinguisher use, interpretation services, clear text/review of internal emergency codes, N95 respirator fit-testing, biohazard waste disposal, MRI safety, as well as topics covered from previous years (e.g., effects of drinking and driving, and firearm safety). This year, when an employee signed in to the fair, he/she received a 10-gallon tote with lid. Y VMC chose this size because of its portability for
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both the car and at home. After receiving their tote, they proceeded into the conference rooms where the vendors were set up. Each vendor give a brief five- to 10-minute presentation. After each presentation, they give out one small component for the home preparedness kit. The items of this year’s kit included a fire starter, bottles of water, matches in a waterproof container, a whistle, nylon rope, an emergency blanket, paper towels, toilet paper, and a small mirror. It’s important to note that this event was not intended to produce a complete emergency preparedness kit; it was intended to assist staff in starting to build their kits. Y VMC encouraged all the staff to complete their kits and included a list of other items needed for the kit. To continue engagement after the event, YVMC held a contest for the best completed home emergency preparedness kit. Employees could send in a photo of their finished kits and whoever had the best kit was awarded a prize. This year’s safety fair was a huge success. The staff truly enjoyed the hands-on interaction with the vendors and building their own kits. YVMC strives to prepare its staff for disasters and emergencies. Because of YVMC’s physical location, it can be limited in its access to resources; thus, the concept of “self-help” is considered paramount. Steve Hilley, RN, is emergency preparedness coordinator/infection preventionist for Yampa Valley Medical Center in Steamboat Spring, Colorado. He is also chair of the APIC Emergency Preparedness Committee.
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PREVENTION IN ACTION
Collaboration in infection prevention Infusion nurses and infection preventionists. BY MARY MCGOLDRICK, MS, RN, CRNI ®
nfusion nurses and infection preventionists (IPs) both share a mutual goal of preventing patient infections in all care settings and in all patient populations; however, the role of the IP is much broader in its scope and requires a more extensive body of knowledge to prevent a broader spectrum of patient infections (e.g., catheter-associated urinary tract infections [CAUTI], surgical site infections [SSIs], central line-associated bloodstream infections, ventilator-associated pneumonia). The infusion nurse’s role is typically much narrower in focus and limited to preventing infections associated with the insertion, use, and management of a myriad of intravascular devices. This article will focus on the role of the infusion nurse and the IP, and how they can work together in a collegial, collaborative manner to achieve their mutual goal of preventing patient infections. CRNIs® and CICs®: Partners in preventing infections
Infusion Nurses Certification Corporation Chair Mary McGoldrick, MS, RN, CRNI® 44 | WINTER 2013 | Prevention
Just like not all IPs are CICs, not all infusion nurses are CRNIs (Certified Registered Nurse Infusion)… unfortunately. Certification, like the CRNI and CIC designation, is an earned credential that demonstrates an individual’s specialized knowledge, skills, and experience and is awarded by a third-party, nongovernmental entity, such as the Infusion Nurses Certification Corporation (INCC) for the CRNI and the Certification Board of Infection Control and Epidemiology (CBIC), for the CIC. The CRNI is the only nationally recognized
and accredited certification in infusion nursing. Like the CIC, certification candidates receive their CRNI credential only after meeting strict eligibility criteria and successfully completing a 150-question standardized exam that is based on the following eight core areas: 1) Technology and Clinical Applications; 2) Fluid and Electrolyte Therapy; 3) Pharmacology; 4) Infection Prevention; 5) Antineoplastic/ Biological Therapy; 6) Parenteral Nutrition; 7) Special Populations; and 8) Transfusion Therapy. Note that one of the core areas on the CRNI exam is infection prevention, which overlaps with the body of knowledge and focus of that of an IP.
Incorporating standards into practice
IPs and infusion nurses know that patient care practices are to be based on evidence-based guidelines to reduce the risk of vascular access device-associated infections. Evidencebased guidelines include the Centers for Disease Control and Prevention’s (CDC) 2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections 1 (both INS and APIC collaborated with the CDC on its development), as well as the Infusion Nurses Society’s (INS) Infusion Nursing Standards of Practice (Fig. 1).2 APIC also has a position paper on safe injection, infusion, and medication vial practices in healthcare, which provides practice guidance.3 INS’ Infusion Nursing Standards of Practice provides the framework that guides clinical practice in infusion nursing and is applicable in all care settings and addresses all patient populations. In the latest edition of the Infusion Nursing Standards of Practice, the practice criteria are supported by the latest available research and ranked by the strength of the body of evidence. The ranking
“The knowledge and research in the field of preventing infections in patients with intravascular infections is growing and will continue to evolve.”
FIGURE 1: Infusion Nursing Standards of Practice.
system identifies the level of evidence and research that supports each of the practice criteria. The rankings range from Level I, which includes metaanalyses, systematic literature reviews, and guidelines based on randomized controlled trials, to Level V, which includes clinical articles, consensus reports, and generally accepted practices. As both IPs and infusion nurses strive to prevent infections and meet the infusion needs of their patients, the Infusion Nursing Standards of Practice can be an invaluable guide for decision making and developing a patient-centered plan of care.
Infusion nursing and IPs
Infusion nursing has become a highly specialized practice, with procedures ranging from inserting a peripherally inserted central catheter in a healthcare facility to teaching a patient and his or her caregiver how to set up and self-administer parenteral nutrition in the home setting. The infusion nurse can assist the IP in preventing vascular access device-associated infections by: 1. Providing consultation and serving as a resource person (in collaboration with the IP) on patient care practices; 2. Providing educational programs that include both
didactic and interactive components for those staff who insert and maintain peripheral and central venous catheters; 3. Participating in competenceassessment activities; 4. Allowing the IP to focus limited infection prevention and control resources on other priority-directed surveillance activities; 5. Writing, reviewing, and/or approving infusion-related policies and procedures; and 6. Offering input in analysis of patient surveillance data collected, and as needed, actionplanning activities. Infusion nurses and IPs have successfully collaborated in specific clinical scenarios (e.g., validating effective vascular access device insertion practices, selecting skin antisepsis products). This collaborative effort is supported by the CDC’s 2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections, as it states: “to improve patient outcomes and to reduce healthcare costs, there is considerable interest…in reducing the incidence of these infections. This effort should be multidisciplinary, involving healthcare professionals who order the insertion and removal of CVCs, those personnel who insert and maintain intravascular catheters, infection control
personnel… and those who allocate resources… Specialized ‘IV teams’ have shown unequivocal effectiveness in reducing the incidence of CRBSI [catheterrelated bloodstream infections], associated complications, and costs.”1 The knowledge and research in the field of preventing infections in patients with intravascular infections is growing and will continue to evolve as we collect and publish research and outcome data, which ultimately affects patient care practices and outcomes. It is together, in collaboration with infusion nurses and IPs, that we can truly meet our mutual goal of zero patient infections! Mary McGoldrick, MS, RN, CRNI®, is chair, Infusion Nurses Certification Corporation, in Norwood, Massachusetts. References 1. Centers for Disease Control and Prevention. 2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections. www.cdc.gov/ hicpac/bsi/bsi-guidelines-2011.html. Accessed September 24, 2013. 2. Infusion Nurses Society. (January/February 2011). Infusion Nursing Standards of Practice. Journal of Infusion Nursing, 34(suppl. 1S). www. ins1.org/i4a/pages/index.cfm?pageid=3310. 3. Dolan, S., Felizardo, G., Barnes, S., Cox, T., Patrick, M., Ward, K., et al., (2010). APIC position paper: Safe injection, infusion, and medication vial practices in health care. American Journal of Infection Control. 38:167-72. http://apic. org/Professional-Practice/Practice-Resources/ Position-Statements. Accessed September 24, 2013.
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PREVENTION IN ACTION
Centralized sterile processing in ambulatory facilities Recommendations and resources to implement a safe, economic, and efficient centralized sterile processing program. BY JODY CHURCH, RN, CPNP, AND MARTHA YOUNG, BS, MS, CSPDT
he Association for the Advancement of Medical Instrumentation (AAMI) recommends that “Whenever possible, centralized processing (i.e., decontamination, preparation, packaging, and sterilization processing in one department) is encouraged and preferred over replicating this function in multiple areas for both safety and cost-effectiveness” (Section 3.1).1 It’s important to understand the best way to design a centralized sterile processing area suitable for ambulatory care settings and to offer ideas for workflow practices, equipment, personal protective equipment (PPE), and transport of contaminated and sterilized instruments. The key is using resources with evidence-based, recommended practices from AAMI and others to ensure safe and effective processing of reusable medical devices in both ambulatory care and ambulatory surgery centers (ASCs). Sterile processing area design
When setting up a sterile processing area, consider the following questions: • Is your site an office setting or ASC? • W hat types of procedures will be done? • W hat type of instruments will be processed? • W hat will the instrument volume/workload be like?
The answers to these questions will guide you on how to customize sterile processing for your particular site. A success story from the field
Northeast Valley Health Corporation (NEVHC) is a Joint Commission accredited ambulatory health center with 13 licensed sites in multiple locations. In the past, reusable
instruments used for invasive procedures were processed at six separate sites. All procedures such as ingrown toenail removal, IUD insertion/removal, LEEP, colposcopy, and dental extractions are done in exam rooms, not operating rooms. In 2011, The Joint Commission (TJC) released findings related to sterile processing, which illuminated pitfalls in the NEVHC system. A number of weaknesses
helped drive the change to a centralized program: staff didn’t have up-to-date sterile processing training; there was a lack of supervision at each site; and the busy clinical setting was not optimal for correct processing to be performed. Organizations may resist change and put up barriers to implementing a new system. To facilitate the transition to the new program, NEVHC created an action plan and timeline and engaged key stakeholders in the sterile processing program to help nurture buy-in from resistant staff. Finally, NEVHC emphasized the safety and economic benefits of centralization to justify the change. They communicated that the centralization would: • A llow for consistent processing personnel • Facilitate updated and ongoing training for staff • Improve quality assurance practices w w w.apic.org | 47
PREVENTION IN ACTION
FIGURE 2: Wrapping/packaging and sterilizer stations at an ambulatory care center.
FIGURE 1: Receiving, cleaning, milking, and drying stations at an ambulatory care center.
• E nhance ability for monitoring and supervision of staff • Free up staff at local health centers The new process did accomplish all of the aforementioned goals. It is possible to implement a safe, economic, and efficient centralized sterile processing program. Just keep in mind some important points. Resources
To avoid taking risks in processing reusable medical devices, ambulatory facilities must follow recommended practices and standards. TJC National Patient Safety Goal (NPSG) 07.05.01 advises developing policies and procedures based on evidencebased guidelines to prevent surgical site infections.2 Healthcare organizations should follow evidence-based guidelines and recommended practices published by AAMI, the Association of periOperative Registered Nurses (AORN), and 48 | WINTER 2013 | Prevention
the Centers for Disease Control and Prevention (CDC).1, 3, 4 The CDC’s 2011 Infection Prevention Guide & Checklist for Outpatient Settings is also very helpful.5, 6 In addition, the manufacturer’s instructions for use (IFU) need to be available and followed. To obtain updated manufacturer’s IFU for instruments, cleaning equipment, disinfectants, cleaning solutions, packaging, and sterilization equipment, check corporate websites. The ECRI Institute listed inadequate reprocessing of flexible endoscopes and instruments for patient use as hazard No. 8 on its “Top Ten Technology Hazards for 2013.” 7 To improve processing of reusable endoscopes and instruments, ECRI advises that a facility should have adequate space and equipment, and trained staff, instructional materials (e.g., IFU), resources (e.g., A AMI ST79), and
sufficient instruments to meet demand and allow adequate time for processing.7 Now is the time to collect data and ask for additional resources to ensure improvement of the processing of reusable medical devices in your facility. AAMI ST79 states that all staff who perform sterilization processing activities should be certified within two years (Section 4).1 The Certification Board for Sterile Processing and Distribution, Inc. (www.sterileprocessing.org), and the International Association of Healthcare Central Service Materiel Management (www.iahcsmm.org) can provide additional information on certification. Workflow practices
Instrument flow in the processing area should be unidirectional with clear transitions between each process. Ambulatory facilities need stations for:
• Soiled receiving to one side of sink(s) • Washing (at least one sink) • R insing (an additional/second sink) • Milking/lubrication • Drying • Wrapping/packaging • Sterilization Figure 1 shows an example of receiving, cleaning, milking, and drying stations at an ambulatory care center, and Figure 2 shows an example of wrapping/ packaging and sterilizer stations at an ambulatory care center. Summary of recommended practices Options for workflow practices
AAMI ST79 discusses the setup of the processing area. Section 188.8.131.52 states, “Ideally, the area in which instruments and other devices are decontaminated should be physically separated from all other processing areas and from areas in which clean or sterile patient care procedures
“AAMI ST79 states that all staff who perform sterilization processing activities should be certified within two years (Section 4).1 The Certification Board for Sterile Processing and Distribution, Inc., and the International Association of Healthcare Central Service Materiel Management can provide additional information on certification.”
FIGURE 3: Bagged instruments that have been placed into a puncture-resistant, leak-proof, closable container, labeled as biohazard.
are carried out.”1 For ASCs, the only option is physical separation of decontamination and clean areas. Because of limited space, this may be a challenge for an ambulatory care center. TJC is concerned about droplet contamination and ventilation.8 Ambulatory facilities could have the option of placing a Plexiglas divider next to the sink to ensure that splashes, splatters, or droplets from the decontamination area do not enter the cleaning area. AAMI ST79 Section 184.108.40.206 also states that in ambulatory clinics and dental or medical offices, a procedural barrier separation could be adequate “provided that work practices prevent splashing, the production of aerosols, and the contamination of clean items and work surfaces, and provided that work practices promote the changing of PPE [personal protective equipment] when personnel leave the decontamination area and enter clean areas.”1 First, clean the medical devices; next,
change PPE to package and sterilize the devices. AAMI ST79 Section 220.127.116.11 states that decontamination should preferably have a threesection sink; but if not, there should be an adequate number of sinks to accommodate concurrent soaking, washing, and rinsing.1 Ideally, sinks should be 36 inches from the floor, eight to 10 inches deep, and wide and long enough to allow a tray or container basket of instruments to be placed flat for pretreatment or manual cleaning.1 Sink inserts are available to create two sinks in one area or to place next to one sink to create another sink.9 AAMI ST79 Section 7.5.4 states to use treated water (e.g., deionized, distilled, or reverse osmosis) as the final rinse to prevent staining of instruments and recontamination from tap water.1 Equipment
Readily available hand hygiene dispensers (A AMI Section
18.104.22.168), installed emergency eyewash/shower devices (Section 22.214.171.124, 3.3.8), and a variety of brushes and other cleaning implements (Section 3.4, 126.96.36.199) are also needed in the area.1 Make sure the sterilizers are appropriately sized to accommodate your facility’s packaging types and instruments. Plan ahead so there will be enough sterilizer volume to meet instrument turnaround demands. Personnel protective equipment (PPE)
Section 4.5.2 of AAMI ST79 stipulates that the following PPE should be worn while cleaning instruments: • Fluid-resistant masks to protect from splash and splatter • Goggles or full-length face shields to protect eyes against liquid splashes, microorganisms, and chemicals (in addition to the masks) • Liquid-resistant covering with sleeves to protect from splash
Key points for ambulatory facilities
1. Follow the latest recommended practices when writing policies and procedures in order to establish stateof-the-art sterile processing.
2. Follow the most up-todate IFU to ensure instruments are being effectively processed.
3. Collect data to support
your requests for additional resources (e.g., space, equipment, instrumentation, trained staff, and educational material). Resources are the key to improving patient outcomes. Patients are depending on you.
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PREVENTION IN ACTION
Access peer-reviewed articles on sterile processing in the American Journal of Infection Control A multi-site field study evaluating the effectiveness of manual cleaning of flexible endoscopes with an ATP detection system, Marco Bommarito, Grace A. Thornhill, Dan J. Morse [June 2013 (Vol. 41, Issue 6, Supplement, Page S24, DOI: 10.1016/j.ajic.2013.03.049)]
Validation of adenosine triphosphate to audit manual cleaning of flexible endoscope channels, Michelle J. Alfa, Iram Fatima, Nancy Olson [March 2013 (volume 41 issue 3 Pages 245-248 DOI: 10.1016/j. ajic.2012.03.018)] The role of biofilms in reprocessing medical devices, Charles G. Roberts [May 2013 (volume 41 issue 5 Pages S77-S80 DOI: 10.1016/j. ajic.2012.12.008)] Disinfection and sterilization: An overview, William A. Rutala, David J. Weber [May 2013 (volume 41 issue 5 Pages S2-S5 DOI: 10.1016/j. ajic.2012.11.005)] High-level disinfection, sterilization, and antisepsis: Current issues in reprocessing medical and surgical instruments, Rose Seavey [May 2013 (volume 41 issue 5 Pages S111-S117 DOI: 10.1016/j.ajic.2012.09.030)] New developments in reprocessing semicritical items, William A. Rutala, David J. Weber [May 2013 (volume 41 issue 5 Pages S60-S66 DOI: 10.1016/j. ajic.2012.09.028)] The adenosine triphosphate test is a rapid and reliable audit tool to assess manual cleaning adequacy of flexible endoscope channels, Michelle J. Alfa, Iram Fatima, Nancy Olson [March 2013 (volume 41 issue 3 Pages 249-253 DOI: 10.1016/j.ajic.2012.03.015)] Comparison of adenosine triphosphate, microbiological load, and residual protein as indicators for assessing the cleanliness of flexible gastrointestinal endoscopes, Ryo Fushimi, Masaki Takashina, Hideki Yoshikawa, Hiroyoshi Kobayashi, Takashi Okubo, Seizoh Nakata, Mitsuo Kaku [February 2013 (volume 41 issue 2 Pages 161-164 DOI: 10.1016/j. ajic.2012.02.030)] Development and validation of rapid use scope test strips to determine the efficacy of manual cleaning for flexible endoscope channels, Michelle J. Alfa, Nancy Olson, Pat DeGagné, Patricia J. Simner [November 2012 (volume 40 issue 9 Pages 860-865 DOI: 10.1016/j.ajic.2011.10.006)] In vitro evaluation of cleaning efficacy of detergents recommended for use on dental instruments, Gordon W.G. Smith, June McNeil, Gordon Ramage, Andrew J. Smith [November 2012 (volume 40 issue 9 Pages e255-e259 DOI: 10.1016/j.ajic.2012.05.009)]
50 | WINTER 2013 | Prevention
“To facilitate the transition to the new program, NEVHC created an action plan and timeline and engaged key stakeholders in the sterile processing program to help nurture buy-in from resistant staff.” and splatter (change if the covering gets wet or soiled) • Liquid-resistant shoe coverings to protect shoes if there is a potential for shoes becoming contaminated and/or soaked with blood or other bodily fluids • General purpose heavy duty, waterproof, long and cuffed gloves to prevent punctures, contact with microorganisms, and decrease cross-contamination.1, 4 Instrument transport
Establish a plan for preparing contaminated instruments at the outlying clinical sites to transport to the centralized sterile processing area. One choice is to train staff at the point of use to don PPE and remove gross soil using a disposable sponge moistened with water. Instruments can then be air dried and double red bagged. See the following recommended practices for further details. Figure 3 shows bagged instruments that have been placed into a puncture-resistant, leak-proof, closable container, labeled as biohazard. These “transport bins” have a reversible label that is used to identify the destination of the instruments. An inventory sheet quantifying the number of sets and/or individual instruments should be placed on the outside of the bin under the label. If your facility has an existing courier service, this can be
used to transport contaminated instruments from clinics to the centralized sterile processing area. Depending on travel distance and courier routes, this method may require increased instrument inventory to ensure acceptable turnaround time. Sterilized instruments should be transported back to the outlying sites by the same courier method. Recommended practices
Instruments should be precleaned at the point of use as described in recommendation IV and V of the AORN Recommended Practices for Cleaning and Care of Surgical Instruments and Powered Equipment.10 A AMI ST79 states that if decontamination of the instruments will not occur immediately, the instruments must be kept moist to prevent the formation of biofilm (Section 6.3).1 Options for keeping instruments moist include placing a towel soaked with water (not saline) over the instruments or using an instrument spray designed for pretreatment.1 Contaminated instruments need to be contained and readily identifiable by everyone who handles them, per AAMI ST79, Section 6.2.1 It is not necessary to double red bag instruments before placing them into the containment devices if you have a hazardous material label.
Per AAMI ST79: • Store sterilized instruments in a clean, dry area in a controlled environment (Section 8.9.2). • Shelf life is event-related (Section 8.9.3). • Rotate storage of stock by “first in, first out” (Section 8.9.3). • Inspect all packages for damage before transporting, storing, or using (Section 8.10.1). • Label packages with a control date for stock rotation and a statement such as “Contents sterile unless package is opened or damaged. Please check before using” (Section 10.3.3). 1
Available at: www.cdc.gov/hicpac/pubs. html. 5. Centers for Disease Control and Prevention (CDC). Guideline to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care, July 2011. Available at: www. cdc.gov/HAI/pdfs/guidelines/standatds-ofambulatory-care-7-2011.pdf. 6. Centers for Disease Control and Prevention (CDC). Infection Prevention Checklists for Outpatient Settings: Minimum Expectations
for Safe Care. Available at: www.cdc.gov/ HAI/pdfs/guidelines/ambulatory-carechecklist-07-2011.pdf. 7. ECRI. Health Devices: Top 10 Health Technology Hazards for 2012. Available at: www.ecri. org/Documents/Secure/Health_Devices_ Top_10_Hazards_2012.pdf. 8. Eiland, John E, Surveyor, The Joint Commission. Joint Commission presentation at IAHCSMM annual meeting in May 2013. Presentation available on flash drive pro-
vided to attendees. Martha Young attended the presentation. 9. Pure Processing. Accessed July 9, 2013 at: www.pure-processingcom. 10. R ecommended Practices for Cleaning and Care of Surgical Instruments and Powered Equipment. Perioperative Standards and Recommended Practices. Denver, CO: AORN, 2013. www.aorn.org.
A centralized sterile processing program can ensure a safe, economic, and efficient system to sterilize reusable medical devices. Ambulatory settings can customize a program that meets their individual facility’s needs. Jody Church, RN, CPNP, is infection control coordinator of Northeast Valley Health Corporation in San Fernando, California. Martha Young, BS, MS, CSPDT, is president of Martha L. Young, LLC, in Woodbury, Minnesota. References 1. Association for the Advancement of Medical Instrumentation. Comprehensive guide to steam sterilization and sterility assurance in health care facilities, ANSI/AAMI ST79:2010 & A1:2010 & A2:2011 & A3:2012 (Consolidated Text). Arlington, VA.www.aami.org. 2. The Joint Commission. National Patient Safety Goals, NPSG.07.05.01. Hospital Accreditation Standards (HAS), 2013. Available at: www.jointcommisssion.org/ standards_information/npsgs.aspx. 3. AORN. Recommended practices for sterilization. Perioperative Standards and Recommended Practices. Denver, CO: AORN, 2013. www.aorn.org. 4. Centers for Disease Control and Prevention (CDC). Guideline for Disinfection and Sterilization in Healthcare Facilities. 2008.
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3M Infection Prevention Solutions for the OR
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Clearly at the cutting edge. In clean wounds (219 patients total) there was a signiﬁcant difference in wound contamination. Contamination occurred in 9.1% of the patients draped with Ioban drapes compared with 16.2% of the patients without drapes (P<0.05).*
Wound Contamination* 50 40 30 20 10
3M™ Ioban™ 2 Antimicrobial Incise Drapes *Dewan PA, Van Rij AM, Robinson RG, et al. The use of an iodophor-impregnated plastic incise drape in abdominal surgery--a controlled clinical trial. Aust N Z J Surg. 1987;57(11):859- 863. Poster presented at: 19th Annual Scientiﬁc Meeting of the Society for Healthcare Epidemiology of America (SHEA), March 19-22, 2009, San Diego, Calif.
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PREVENTION IN ACTION
Today’s infection prevention challenges in long-term care Are we ready to manage them? BY VICKY UHL AND
t’s no secret that the number of people entering long-term care facilities (LTCFs) is growing every day, and with that burgeoning population comes increased instances of LTCF-associated infections. And yet, notes Irena Kenneley, PhD, APRN-BC, CIC, there is a lack of adequately trained personnel and resources to prevent those infections.
Learn more about the new Infection Preventionist’s Guide to Long-Term Care at www.apic.org/store.
Kenneley, who is an assistant professor at Case Western Reserve University, is one of eight authors of APIC’s new book, Infection Preventionist’s Guide to Long-Term Care. This comprehensive resource examines infection prevention practice in the larger scope of long-term care (LTC) trends, initiatives, and regulations. The new book, which is available at www.apic.org/store, discusses how to develop infection prevention programs in response to integration of LTCFs within the larger healthcare community, addressing issues such as frequent resident movement in and out of facilities and the use of laboratory, pharmaceutical, and other types of consultants. There is also a strong focus on interdisciplinary collaboration, a lengthy chapter on emergency and disaster preparedness, and an accompanying CD-ROM with tools and resources. In preparation for the launch of the book, Kenneley; coauthor Deb Burdsall, MSN,
RN-BC, CIC, corporate infection preventionist, Lutheran Life Communities; and lead author Steven J. Schweon, RN, MPH, MSN, CIC, HEM, an infection prevention consultant, discussed a series of questions on LTC infection prevention.
What do you think the biggest infection prevention and control challenge is in long-term care?
Burdsall: The increased complexcare needs of the people living and staying in the LTC continuum. Older adults used to come into LTC when they still were ambulatory and could care for themselves, but now they are staying in their own homes for a longer period of time. The days of “rest homes” are gone. Now, people enter LTC with significant physical, psychological, social, and spiritual needs. w w w.apic.org | 53
PREVENTION IN ACTION
Increased physical needs mean more dependence on caregivers, more exposure to antibiotics, and a history of invasive procedures—all of which have been shown to increase the chance that LTC residents are colonized with multidrug-resistant organisms (MDROs). Kenneley: The vast majority of LTCF infection preventionists (IPs) have multiple responsibilities and work part-time on infection prevention regardless of the bed size or acuity of the residents in their facility. Additionally, less than 10 percent of the current IPs in LTCFs have any specific infection prevention and control training—such as a Certification in Infection Control (CIC)—compared to more than 95 percent of acutecare IPs in some states. Other issues include limited staff resources, high staff turnover, funding difficulties, and limited information technology access and infrastructure to support infection prevention and control activities.
What needs to be done to improve/ expand infection surveillance and reporting in nursing homes?
Schweon: First, the facility can make a voluntary decision to upgrade its infection prevention program and promote resident safety by expanding its surveillance program. The other alternative is to have a regulatory or legislative mandate requiring selected, targeted surveillance 54 | WINTER 2013 | Prevention
such as central line-associated bloodstream infections or total house surveillance. Secondly, public reporting of surveillance needs to be regulatory driven. For example, a legislative mandate is required for LTCFs to report surveillance findings. In my home state of Pennsylvania, LTCFs must perform total house surveillance, and infections meeting the Pennsylvania LTC surveillance definitions must be electronically reported. Kenneley: There are two major areas that must be addressed:
1. Standardized surveillance definitions. In October 2012, a Society
for Healthcare Epidemiology of America (SHEA)/Centers for Disease Control and Prevention (CDC) position paper was published that updated the 1991 surveillance definitions specifically for LTCFs. It is imperative that all LTCFs use the same infection definitions so reported data is meaningful, baseline statistics can be compiled, and comparisons can be made.
2. Implementation of infection prevention best practices. The
CDC developed a standardized assessment tool that, among other things, measures the extent of best-practice implementation in LTCFs within six categories.
How does a rapidly aging population— and one that increasingly needs LTC services—impact infection prevention practice? Are IPs ready to face these new challenges?
Schweon: Residents of all ages with complex medical needs were once kept in the hospital for management; today, they may be discharged to LTC, possibly with MDROs such as ESBLs (extended spectrum beta-lactamase) or CRE (carbapenem-resistant Enterobacteriaceae), where the goal is to maintain or improve their ability to function as independently as possible, for as long as possible. Some residents may also have advance directives or expressed wishes to limit a diagnostic workup and treatment in the event of an infection such as pneumonia. IPs can be prepared to meet these challenges by: • Having a basic and hopefully an advanced understanding of infection prevention and implementing best practices • Having awareness of the residents’ health status • Having policies and procedures that are evidencebased and that are being implemented • Being visible in the facility and developing collegial relationships with all disciplines • A ssisting with staff education and training • Being a role model; IPs are continually watched to see whether they perform hand hygiene, take the influenza vaccine, etc. • Realizing that what may work in a hospital may not work in LTC; for instance, you can’t keep a resident with a MDRO in his or her room for the next 10 years • Accepting that there may be human capital, bed space, and equipment limitations compared to acute care
Kenneley: The geriatric population has many unique aspects that contribute to the severity and frequency of infections, including limited physiologic reserves, defects in host defenses, higher rates of chronic diseases, poorer responses to antimicrobial therapy, increased frequencies of therapeutic toxicity (secondary to increased rates of liver and renal failure), and complications from invasive diagnostic procedures. Symptoms of infection may be vague or atypical compared to younger populations. There is also the additional risk of infection from exposure to MDROs, delays in diagnosis and therapy, and complications from treatments. The U.S. Department of Health and Human Services’ Long-Term Care chapter of the National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination, published in 2012, compiles current statistical data and information and provides a chapter specifically on infection prevention and control in LTCFs, offering a roadmap to decrease HAIs that IPs can follow.
What do you think the top infection surveillance priority is/should be in long-term care?
Bu rdsa ll: We need to make it clear that diagnostic definitions of infection focus on the individual, which is important, but surveillance definitions focus on identifying patterns within
a group so interventions can be put into place. The MDS 3.0 definitions are based upon a mixture of diagnosis and criteria that need to be brought into line with the currently revised CDC/SHEA/Stone, et al. definitions. Everyone also needs to get on the same page for surveillance so we can all compare apples to apples.
What do you think are the most urgent education and training needs for LTC staff? Is this information readily available? Does our process of educating LTC staff need to change and if so, how?
Kenneley: There are three crucial areas in which IPs need to educate LTCF staff: hand hygiene, urinary tract infections (UTIs), and environmental controls. Evaluation of educational programs must be done to assess whether a training event was successful, and evaluation of staff practices such as observation of hand hygiene compliance also needs to be documented and a part of the educational process. For IPs who are not trained or are part-time, this information may not be readily available. National standardization of regulatory guidelines for IPs working in LTCFs needs to take place so that IPs are able to properly educate LTC staff. Some states have stricter regulatory guidelines for IP training and education than others. This will change when surveillance data are reported and the results made public.
How can nurses and IPs better collaborate to improve infection prevention in U.S. nursing homes? What makes up an effective team approach in long-term care?
Burdsall: An interdisciplinary team includes the person who needs care and his or her family and significant others, the nursing department, therapy department, culinary and dining services, life enrichment/activities, environmental services, plant operations, materials management, and maintenance. As an example, take a person who needs to be placed on isolation precautions for an infection with an MDRO. Everyone on the team needs to know how they should approach the person and the environment to prevent the spread of microorganisms to others and to the surrounding environment.
What can IPs do to help meet the increasingly complex medical needs of residents in skilled LTCFs?
Schweon: It’s mission critical to have IPs who like (or love) their job. The program will fail if infection prevention is viewed as a mundane chore or task. IPs must also have an awareness and understanding of: • The changes that occur in the immune, respiratory, urinary, gastrointestinal, and circulatory system during aging • Polypharmacy that may lead to drug interactions
“...less than 10 percent of the current IPs in LTCFs have any specific infection prevention and control training—such as a Certification in Infection Control (CIC)—compared to more than 95 percent of acute-care IPs in some states.”
—Irena Kenneley, PhD, APRN-BC, CIC
• Medications that impact the immune system • M alnutrition/failure to thrive’s impact upon the body • Functional impairments that may impair assessment and performance of activities of daily living • A ltered ability to metabolize medications • Limited physiological reserves • Slower response to treatment • Blunted immune response to infection
Do you think current clinical management strategies for MDROs in nursing homes are adequate? Is there anything else we should be doing?
Kenneley: A major opportunity for improvement lies in the full implementation of antimicrobial stewardship programs. Antibiotic stewardship is recognized as a national challenge in LTCFs. In effective LTCF antimicrobial stewardship programs, the medical director shares personalized reports with prescribers detailing antibiotic usage and infection rates for the LTCF’s residents compared with peer facilities. Several LTCFs have
also indicated that there is a challenge in educating the nursing staff regarding definitions for infections that require treatment, as many prescribers report ordering antibiotics at the request of nursing staff based on positive microbiology culture results alone.
There have been disease outbreaks in LTCFs due to unsafe injection practices, especially related to blood glucose testing and insulin administration. Are we doing enough to protect residents? Why is this issue so problematic?
Schweon: Unsafe practices have become problematic in acute/LTC/ ambulatory care due to inadequate disinfection of multiple-patient-use glucose testing equipment such as glucometers; and failure to follow basic safe-injection practices during medication preparation and administration, which leads to contamination and infection. In my view, the IP must target zero infections and adverse events. Realistically, we will never achieve this when working w w w.apic.org | 55
PREVENTION IN ACTION
“We need to advocate a nimble approach to infection prevention that focuses on the individual first. The LTC IP needs to understand LTC, the resident and patient populations, what types of interventions are helpful, and what types of interventions have been shown to be harmful.” —Deb Burdsall, MSN, RN-BC, CIC with residents who are biologically/chemically/physiologically complex; however, we need a target for our implementations. To say “only one resident” had pneumonia this month diminishes the significance of that infection on the resident.
Only a few states currently require public reporting of infections by nursing homes. What needs to happen to include more facilities in this process?
Schweon: Currently, there is no national mandate or legislative requirement for public reporting of all LTCFs. However, in 2012,
the CDC’s National Healthcare Safety Network (NHSN) released a voluntary LTC component. This secure, Internet-based surveillance system uses a standardized and precise approach for tracking healthcare-associated infections. The LTC component (www.cdc.gov/nhsn/LTC) includes the recently released “Revisiting McGeer” LTC surveillance UTI and C. difficile standardized epidemiological definitions. Additionally, MDRO activity and preventative process measures can be monitored. LTCFs now have the capability of benchmarking their data against other organizations. The National Action Plan to Prevent Healthcare-Associated Infections in Long-Term Care Facilities has a goal of 5
percent of certified nursing homes enrolling in NHSN over the next five years. In my view, for facilities that have a strong commitment to resident safety and preventing infection, joining and actively participating in the LTC component may lead to improved resident outcomes and decreased expenditures related to infectious diseases.
What needs to be done to better prepare IPs to work in LTC settings?
Burdsall: Basic training in infection prevention strategies, such as APIC’s infection prevention training programs. This
training shows a person how to look at infection prevention in the context of a more global view of how LTC fits into the healthcare continuum. We need to advocate a nimble approach to infection prevention that focuses on the individual first. The IP needs to understand LTC, the resident and patient populations, what types of interventions are helpful, and what types of interventions have been shown to be harmful. This takes consistent review of the current evidence. Our understanding of what we thought were effective strategies 10 years ago has changed significantly. Vicky Uhland is a medical writer for Prevention Strategist.
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1. Ohl, M., et al. (2011). Hospital privacy curtains are frequently and rapidly contaminated with potentially pathogenic bacteria. Am J Infect Control. 2012 Dec; 40(10):904-6. 2. Neely AN, Maley MP, “Survival of enterococci and staphylococci on hospital fabrics and plastic.” J Clin Microbiol 2000; 38:724-726. * 100% polyester and 100% cotton. Soft surface claim has been registered by the Federal EPA and may not be available in all 50 states. Please check with your sales representative for updates in your state. © 2013 Clorox Professional Products Company. NI-22353
A closer lookâ€”
60 | WINTER 2013 | Prevention
—Antibiotic resistance and the microbiome BY MARILYN HANCHETT, RN, MA, CPHQ, CIC
he current analysis of the human microbiome is providing a more comprehensive understanding of the diverse types of bacteria that not only exist in various anatomical locations (e.g., skin, oral cavity, nasopharynx, groin, axilla), but whose presence is essential to health. Caroline McDaniel, RN, BSN, MSN, provided an overview of the microbiome in the fall 2013 Prevention Strategist article titled, “The Human Microbiome Project: What’s in it for IPs?” Foremost among these is the intestinal tract, where the normal flora, often called the microbiota, are the most dense and diverse than any other location. Recent studies have estimated that over 40,000 bacterial species, primarily anaerobes, are part of the natural biodiversity of the gut ecosystem.1 In fact, the variety and complexity of the gut microbiota is now described as a “virtual organ” or emerging body system.2 In addition, bacterial diversity changes along the gastrointestinal tract; high levels are reported in the oral cavity and intestines but are low in the stomach.3 Research conducted during the past 10 years consistently reports that homeostasis within the intestinal microbiota is essential for health. Disruptions
may occur from diet, surgery, alcohol abuse, and medications—especially antibiotics. No matter what the trigger, impaired bacterial function,
referred to as dysbiosis, has been associated with inflammatory bowel conditions, insulin resistance, diabetes, and obesity. In many cases it remains unclear if w w w.apic.org | 61
the changes in intestinal microbiome are a symptom of the disease or a contributing factor.4 Due to the wide variation in microbiota among individuals, no single bacterial species can serve as a marker of disease.3 Other factors are thought to contribute to bacterial homeostasis in the gut. Environmental, immunological, hormonal, and genetic variables have been investigated. While much remains unknown, it is clear that maintenance of the microbiota is a far more complex process that previously believed.5 The emerging science of metagenomics or environmental gene sequencing holds great promise for a deeper understating of gut ecology. The intestinal microbiota has been almost impossible to analyze using traditional laboratory approaches such as culture and strain typing, as less than 1 percent of intestinal bacteria have been successfully cultured.6 PCRbased approaches eliminate the need for culture, but they can only detect previously identified genes when compared to the metagenome that now lists more than 5 million non-redundant genes. The field of metagenomics uses this vast pool of information to produce a more complete description of all types of human microbiota, as well as reduce the previous risk of underreporting the size and nature of microbial communities.7 The environmental resistome
The first step in understanding antibiotic resistance is recognition of the environment as a natural reservoir. A growing number of studies suggest that human health may not only be 62 | WINTER 2013 | Prevention
determined by individual genetics, but also by the genes of the trillions of microorganisms that exist on and within the human body.8 Antibiotic resistance is now viewed as an ancient process. New technologies have revealed the presence of antibiotic resistance in the environment, suggesting a co-evolution between antibiotic and antibiotic resistance that occurs as a natural event. The environmental microbiota, even in antibioticfree conditions, possesses a large and diverse number of antibiotic resistant genes—some of which resemble the genes of pathogenic microbes.9 This global environmental combination of susceptible and resistant bacteria comprises a worldwide resistome. The contemporary resistome is under increasing selective pressure from human activities—especially agriculture—that may accelerate resistance and gene transfer. Changes in the environment then impact the clinical resistome. For example, evidence now suggests links between aminoglycoside and vancomycin resistance enzymes and the environment.10 Today’s commercial production and widespread use of both natural and synthetic antibiotics intensifies the pressure on both environmental and clinical resistomes. For this reason, scientists have used the beta lactamases for modeling as they represent the most widespread mechanism of resistance among pathogenic bacteria worldwide.11 Early testing has been promising. For example, in one of the first metagenomic studies on antibiotic resistance in the human intestinal microbiome, researchers identified 10 novel
beta lactamase families that reflected only 35–61 percent of known genes.12 Antibiotic resistance and new research
Antibiotic resistance is a serious and growing threat to the prevention and containment of communicable diseases worldwide. According to the most recent data, antibiotic resistance in the United States causes an estimated $20 billion a year in excess healthcare costs, $35 million in other societal costs, and more than 8 million additional acute care inpatient days.13 In the United States, a growing list of resistant pathogens includes not only the long-recognized MRSA and vancomycin-resistant Enterococci, but also cases of H1N1 influenza, carbapenemresistant Enterobacteriaceae, Klebsiella pneumoniae, TB, and gonorrhea.13 Antibiotic resistance develops in one of two basic ways. A bacterium can undergo spontaneous genetic mutation. It can also receive genetically coded resistance via plasmids or transposons from other bacteria that already contain this genetic information. However, bacteria can also receive resistance genes from viruses, as well as via direct exposure to DNA in the environment. These processes can occur at varying times, increasing the number and types of antibiotics that they can resist. Once resistance is acquired, it may be transferred vertically, through bacterial replication, or horizontally, via contact between bacteria without any type of reproduction. The density of intestinal bacteria, especially during disease progression, increases the risk of
horizontal transfers of antibiotic resistant genes within the microbiota. Due to the probability of genetic exchange during disease, the intestinal microbiota may represent the largest reservoir for resistance.12 Previous antibiotic susceptibility studies, attempting to analyze this lateral transfer mechanism, have relied on Escherichia coli. However the use of metagenomic sequencing has, as in the study of beta lactamases, now identified resistant genes previously unknown and not recognized using E. coli cultures.14 New research is also examining the role of bacteriophages (also known as phages). Phages are viruses that attack bacteria. The community of phages is referred to as a phageome. The rapid increase in antibiotic resistance since the 1990s has focused renewed attention on phage-based research. Recent research in animal models has attempted to analyze the role of phages in the spread of antibiotic resistance. In one study, phages were studied as a potential reservoir for bacterial adaptation. In this study, antibiotic treatment led to enrichment of phageencoded genes. This research demonstrated that phages from treated laboratory mice lead to increased resistance in aerobically cultured naĂŻve microbiota.15 More research is needed to fully understand the role of the phageome in antibiotic resistance. Another area of investigation focuses on biochemical alteration of the intestinal epithelium. Disruption of normal epithelial permeability and mucous integrity can impact the microbiota. For example, one project has examined carbohydrate
metabolism. Laboratory analysis has shown that antibiotic impact on intestinal microbiota changed mucosal carbohydrate availability in ways that supported the growth of S. typhimurium and Clostridium difficile.16 Other studies have looked for relationships between medication use, especially antibiotics and proton pump inhibitors, and Clostridium difficile. Research in these areas is ongoing. Microbiota and obesity
Obesity is rarely a consequence of only nutritional imbalance. It is a complex problem linked to both metabolic and immunologic functions.17 The intestinal microbiota are increasingly recognized as part of the connection between genes, environmental factors, and the immune system. Specifically, emerging research shows a link not only between gut microbiota and obesity, but also with insulin resistance and type 2 diabetes. Although a causal relationship is not yet absolutely described in the literature, experts are increasingly looking at the association of gut microbes, a high fat/high sugar diet, and excessive weight gain. While studies are ongoing, the number of potentially confounding variablesâ€”including factors such as antibiotic use, previous dietary habits, meal frequency, and physical activityâ€”makes conclusive investigation challenging.17 Manipulating the microbiota
As more is learned about the intestinal microbiome and its impact on overall health, various strategies have been proposed to restore or maintain gut homeostasis. Foremost among these future strategies is the
judicious use of antibiotics. In addition, the future may yield new pharmacological treatments, immunomodulatory vaccines, and nutritionally based therapies. Targeted modification of microbial communities may be accomplished through deployment of antibiotics (to remove or suppress undesirable segments of the microbiota), and/or administration of pre- and probiotics. A better understanding of the development of gut microbiota early in life may yield new opportunities to prevent or manage adult disease. More information about nutritional components is needed to understand and manage endotoxinemic and inflammatory responses in the gut, especially related to lipid and fructose intake. However, all proposed methods of manipulation are based on varying approaches to human host-microbiota co-regulation of intestinal homeostasis.18 Marilyn Hanchett, RN, MA, CPHQ, CIC, is APIC senior director of Professional Practice.
References 1. Frank DN, Pace NR. Gastrointestinal microbiology in the metagenomics era. Curr Opin Gastroenterol, 2008. Jan; 24 (1): 4-10. 2. Evans JM, Morris LS, Marchesi JR. The gut microbiome: the role of a virtual organ in the endocrinology of the host. J Endocrinol 2913 Aug; 218 (3): R37-47. 3. Luke KU, Clemente JC, Rideout JR, Gevers D, Caporaso JG, Knight R. The interpersonal and interpersonal diversity of human-associated microbiota in key body sites. J Allergy Clin Immuno. 02012 May; 129 (5):1204 -1208. 4. Blumbert R, Powrie F. Microbiota, disease and back to health: a metastable journey. Sci Transl Med. 2012; 4:137rv7. 5. Dave M, Higgins PD, Middha S, Rioux KP. The human gut microbiome: current knowledge, challenges and future directions. Transl Res. 2012 Oct; 160 (4): 246-57. 6. Konkel, L. The environment within: exploring the role of the gut microbiome in health and disease. Environ Health Perspect. 2013 September; 121 (9): A276-A281. 7. Pehrsson EC, Forsberg KJ, Gibson MK, Ahmadi S, Dantas G. Novel resistance functions uncovered using functional metagenomic investigations of resistance reservoirs. Front Microbiol 2013; 4:145. 8. Konkel, L. The environment within: exploring the role of the gut microbiome in health and disease. Environ Health Perspect. 2013 September; 121 (9): A276-A281. 9. Aminov RI. The role of antibiotic and antibiotic resistance in nature. Environ Microbiol 2009 Dec; 11 (12): 2970-88. 10. Perry JA, Wright GD. The antibiotic resistance mobilome: searching for the link between environment and clinic. Front Microbiol 2013 May 30; 4:138. 11. Galan JC, Gonzalez-Candelas F, Rolain JM, Canton R. Antibiotics as selectors and accelerators of diversity in the mechanisms of resistance: from the resistome to genetic plasticity in the B-lactamases world. Front Microbiol 2013 Feb 8; 4:9. 12. Sommer MO, Church GM, Dantas G. The human microbiome harbors a diverse reservoir of antibiotic resistance genes. Virulence. 2010 July-Aug; 1 (4): 299-303. 13. CDC. Antimicrobial resistance posing growing health threat. Press release: April 7, 2011. www. cdc.gov. 14. Penders J, Stobberingh EE, Savelkoul PH, Wolffs PF. The human microbiome as a reservoir of antimicrobial resistance. Front Microbiol 2013 April 17; 4:87. 15. Modi SR, Lee HH, Spina CS, Collins JJ. Antibiotic treatment expands the resistance reservoir and ecological network of the phage metagenome. Nature 2013 July 11; 499 (7457): 21922. 16. Ng KM, Ferreyra JA, Higginbottom SK, Lynch JB, Kashyap PC, Gopinath S et al. Microbiotaliertaed sugars facilitate post-antibiotic expansion of enteric pathogens. Nature 2013 Sept 1: 10. 17. Giovanni M, Gambino R, Cassader M. Obesity, diabetes and gut microbiota. Diabetes Care 2010 Oct; 33 (10): 2277-2284. 18. Burcelin R, Serino M, Chabo C, Garidou L, Pomie C, Courtney M et al. Metagenome and metabolism: the tissue microbiota hypothesis. Diabetes Ober Matab 2013 Sept 15; Suppl 3: 61-70.
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in outpatient oncology settings
CDC offers tools to fight back against infections among cancer patients. BY ALICE Y. GUH, MD, MPH, LISA C. RICHARDSON, MD, MPH, AND ANGEL A DUNBAR, BS
espite advances in oncology care, infections remain a major cause of morbidity and mortality among cancer patients.1-3 Several factors predispose cancer patients to developing infections, including immunosuppression from their underlying cancer and chemotherapy treatment. Frequent contact with healthcare settings may expose them to other patients with transmissible infections. Patients with cancer often require the placement of long-term intravascular devices, such as implanted ports, to provide ease with chemotherapy infusion. However, these devices can provide direct portal-of-entry for microorganisms to enter the bloodstream if they are not appropriately disinfected prior to access. Thus, careful attention to proper infection prevention practices is essential to the care of cancer patients to minimize their risks for infectious complications. In recent decades, the vast majority of oncology services have shifted from inpatient to outpatient settings. Each year nearly 650,000 patients with cancer receive outpatient chemotherapy.4 However, not all outpatient facilities maintain regular access to infection prevention expertise or have dedicated infection prevention policies for patient protection.
Furthermore, unlike acute care hospitals, there is limited federal and state regulatory oversight of many outpatient settings, including outpatient oncology facilities. As a result, many outpatient facilities are not routinely inspected for infection prevention practices. Breaches in basic infection prevention practices have resulted in a number of outbreaks
www.preventcancerinfections.org 1. What? PREPARE: Watch Out for Fever! When?
blood cell count is likely to be the lowest since this is when you’re most at risk for infection (also called nadir). • Keep a working thermometer in a convenient location and know how to use it. • Keep your doctor’s phone numbers with you at all times. Make sure you know what number to call when their office is open and closed. • If you have to go to the emergency room, it's important that you tell the person checking you
You should take your temperature any time you feel warm, flushed, chilled or not well. If you get a temperature of 100.4°F (38°C) or higher for more than one hour, or a one-time temperature of 101° F or higher, call your doctor immediately, even if it is the middle of the night. DO NOT wait until the office re-opens before you call. You should also: • Find out from your doctor when your white
in that you are a cancer patient undergoing chemotherapy. If you have a fever, you might have an infection. This is a life threatening condition, and you should be seen in a short amount of time.
• If you develop a fever during your chemotherapy treatment it is a medical emergency. • Fever may be the only sign that you have an infection, and an infection during chemotherapy can be life threatening.
2. What? PREVENT: Clean Your Hands! When?
Keeping your hands clean is important in preventing infections. This should include you, all members of your household, your doctors, nurses and anyone that comes around you. Don't be afraid to ask people to clean their hands. If soap and water are not available, it's o.k. to use an alcohol-based hand sanitizer.
Clean your hands: • Before, during, and after cooking food • Before you eat • After going to the bathroom • After changing diapers or helping a child to use the bathroom • After blowing your nose, coughing, or sneezing • After touching your pet or cleaning up after your pet • After touching trash
• Before and after treating a cut or wound or caring for your catheter, port or other access device
• Many diseases and conditions are spread by not cleaning your hands. • Cleaning your hands is EXTREMELY important during chemotherapy treatment because your body can’t fight off infections like it used to.
3. What? PROTECT: Know the Signs and Symptoms of an Infection! When?
During your chemotherapy treatment, your body will not be able to fight off infections like it used to. Call your doctor immediately if you notice any of the following signs and symptoms of an infection: • Fever (this is sometimes the only sign of an infection) • Chills and sweats • Change in cough or new cough • Sore throat or new mouth sore • Shortness of breath
• • • • • • • • • • •
Nasal congestion Stiff neck Burning or pain with urination Unusual vaginal discharge or irritation Increased urination Redness, soreness, or swelling in any area, including surgical wounds and ports Diarrhea Vomiting Pain in the abdomen or rectum New onset of pain Changes in skin, urination, or mental status
Find out from your doctor when your white blood cell count is likely to be the lowest since this is when you’re most at risk for infection. This usually occurs between 7 and 12 days after you finish each chemotherapy dose—and will possibly last up to one week.
• When your counts are low, take even the slightest sign or symptom of an infection as serious and call your doctor immediately. • Infection during chemotherapy can be very serious, and can lead to hospitalization or death.
Write the number(s) to call in an emergency here:
Doctor’s daytime number: ________________________________ Doctor’s after-hours number: ________________________________
Emergency Number Card 1. Treat a fever as an emergency. 2. Call your doctor immediately if you develop a fever. 3. If you have to go to the emergency room, tell them right away that you are undergoing chemotherapy treatment. Doctor’s daytime number:___________________________ Doctor’s after-hours number:_________________________ FEVER: TEMPERATURE OF 100.4°F (38°C) OR HIGHER FOR MORE THAN ONE HOUR OR A ONE-TIME TEMPERATURE OF 101° F OR HIGHER.
Cut out the emergency number card. Fill in your doctor’s information. Carry this card with you at all times.
The Three Steps Brochure was created for cancer patients and caregivers to help increase awareness about the importance of infection prevention. Image COURTESY cdc/www.preventcancerinfections.org.
w w w.apic.org | 65
involving outpatient oncology settings. For example, in a Nebraska oncology clinic, syringe reuse to access saline bags shared among multiple patients led to the transmission of hepatitis C virus to at least 99 cancer patients, resulting in one of the largest healthcare-associated outbreaks of viral hepatitis.5 Similar lapses in injection safety (e.g., reusing single-dose vials on multiple patients, storing prefilled saline flush syringes for later use) have also been implicated in outbreaks of bacterial bloodstream infections among cancer patients.6-8 Other identified lapses have included poor hand hygiene, suboptimal disinfection of injection caps (e.g., needleless connectors) prior to accessing central lines, and inadequate environmental conditions for chemotherapy preparation. To help combat this public health challenge, CDC launched its Preventing Infections in Cancer Patients campaign in October 2011. This public health program offers healthcare providers, patients, and families a set of user-friendly resources designed to help reduce the risk of life-threatening infections during a cancer patient’s treatment. Each of these tools is described in more detail in the following sections. Basic Infection Control and Prevention for Outpatient Oncology Settings (BICAPP)
The BICAPP (www.cdc.gov/hai/pdfs/guide-
lines/basic-infection-control-preventionplan-2011.pdf) can be used by any outpatient
oncology facility to standardize and improve infection prevention practices. The document is based on the CDC’s evidence-based guidelines as well as relevant guidelines from professional societies and is tailored for quick implementation in outpatient oncology facilities. It includes key policies and procedures that will ensure a facility meets or exceeds minimal expectations of patient safety. The main components of the plan include the following: Education and training. All facility staff
should receive appropriate education and training in infection prevention during orientation as well as annually and any time policies change. Competency evaluations of facility staff should be regularly conducted to 66 | WINTER 2013 | Prevention
storage and handling; and 5) safe handling and cleaning/disinfection of potentially contaminated equipment or surfaces in the patient environment. Procedures for each component of Standard Precautions are detailed in the BICAPP. For example, as part of respiratory hygiene, triaging of patients upon entry to the facility should be performed, especially during periods of increased community respiratory virus activity, to prevent spread of respiratory infections among clinic patients. Safe injection practices that are relevant to oncology facilities include appropriate preparation and handling of saline and heparin syringes for flushing central lines. Transmission-based BICAPP can be used by any outpatient oncology facility to standardize and improve infection prevention practices. Image COURTESY the cdc.
assess adherence to recommended infection prevention practices. At Your Fingertips: A list of names of designated personnel and their specific roles and tasks and contact information that can be tailored to your facility is provided as an appendix. Surveillance and reporting. Routine
surveillance of infections (e.g., bloodstream infections) and process measures related to infection prevention practices (e.g., hand hygiene) should be conducted for outbreak detection and improvement of healthcare practices. Facility staff should also be aware of and adhere to local, state, and federal requirements for reportable diseases and outbreak reporting. At Your Fingertips: The BICAPP contains an appendix where a facility can insert a list of reportable disease/conditions specific to their state and the appropriate contact information for their local and state health authorities. Standard Precautions. All facility staff
should adhere to Standard Precautions, which include: 1) hand hygiene; 2) use of personal protective equipment (e.g., gloves, gowns, facemasks) depending on the anticipated exposures; 3) respiratory hygiene and cough etiquette; 4) safe injection practices, including appropriate medication
Implementation of additional precautions, such as Contact Precautions, Droplet Precautions, and Airborne Precautions, may be warranted in certain situations and should be applied based on a patient’s history and symptoms. Central venous catheters. When accessing
a patient’s central line for infusions and blood draws, all facility staff should use
OUT OF SIGHT, OUT OF MIND...
NOT THIS TIME!
One of the most dangerous side effects of chemotherapy cannot be seen? That’s right, a low white blood cell count, or neutropenia, puts cancer patients at a higher risk for getting an infection. An infection in people with cancer is an emergency. Be prepared, and remember the following three things during chemotherapy: 1. Treat a fever as an emergency, and call your doctor right away if you develop a fever. 2. Find out from your doctor when your white blood cell count will be the lowest because this is when you are most at risk for infection. 3. If you have to go to the emergency room, it’s important that you tell the person checking you in that you have cancer and are receiving chemotherapy. If you have an infection you should not sit in the waiting room for a long time. Infections can get very serious in a short amount of time.
Learn more at: www.cdc.gov/ cancer/preventinfections
National Center for Chronic Disease Prevention and Health Promotion Division of Cancer Prevention and Control
Made possible by a CDC Foundation partnership with Amgen
The Out of Sight, Out of Mind poster alerts both providers and consumers that patients undergoing chemotherapy are at a higher risk of developing infections. Image COURTESY cdc/www.preventcancerinfections.org.
EMERGENCY ROOM PERSONNEL
in ever tients f A r pa re mo ce can ay be eets m nm . tha he eye t This is especially true for a cancer patient undergoing chemotherapy who develops a fever. Get the full picture about people with cancer who are receiving chemotherapy. If they have a fever, remember— 1. A fever may be the only sign of infection and should be treated as an emergency. 2. Developing an infection is a life-threatening complication. 3. A minor infection can turn serious fast. Quick action can save a life.
Learn more at: www.cdc.gov/ cancer/preventinfections
National Center for Chronic Disease Prevention and Health Promotion Division of Cancer Prevention and Control
Made possible by a CDC Foundation partnership with Amgen
Intended for healthcare personnel, the Emergency Room Personnel poster increases awareness of the dangers of fevers in cancer patients. Image COURTESY cdc/www.preventcancerinfections.org.
aseptic technique, including scrubbing the access port with an appropriate antiseptic agent. Additional maintenance and access procedures, such as changing catheter site dressing and injection caps, are outlined in the BICAPP for various types of central lines. At Your Fingertips: The appendix provides a list of relevant resources, including the United States Pharmacopeia (USP) Chapter <797> Guidebook to Pharmaceutical Compounding—Sterile Preparations. All oncology facilities that provide on-site chemotherapy preparation should follow USP guidance in consultation with the state pharmacy board. At Your Fingertips: The BICAPP also includes the CDC Infection Prevention Checklist for Outpatient Settings that can be tailored by an outpatient oncology facility to systematically assess personnel adherence to recommended infection prevention practices. Interactive website for cancer patients and caregivers to prevent infections
While the BICAPP is a resource for healthcare providers, the Preventing Infections in
Cancer Patients campaign also created an educational tool for patients and their caregivers that addresses one of the most common and potentially deadly side effects in patients receiving chemotherapy treatments: neutropenia (low white blood cell count). Patients with neutropenia are more susceptible to bacterial infections. Their risk for acquiring a life-threatening infection increases progressively with both the duration and magnitude of neutropenia. The CDC used knowledge gained through formative research to tailor messages and launch a website aimed at helping cancer patients understand their risk for developing a low white blood cell count and steps they can take to lower their risk of infection when they are most vulnerable. Three Steps Toward Preventing Infections During Cancer Treatment (www.preventcancerinfections.org), is an evidence-based tool that assesses a cancer patient’s risk for developing neutropenia during chemotherapy. After the assessment is completed, patients can receive downloadable information about how to help lower their risk for infection and keep themselves healthy while receiving chemotherapy. Educational information is available for everyone even if the assessment is not completed. The CDC hopes this information will lead cancer patients and caregivers to take actions to seek care if they develop this potentially life-threatening condition. For more information, action steps, and tools to help reduce a cancer patient’s risk of developing potentially life-threatening infections during chemotherapy treatment, please visit www.cdc.gov/cancer/preventinfections or www.preventcancerinfections.org. References 1. Kamboj M, Sepkowitz KA. Nosocomial infections in patients with cancer. Lancet Oncol 2009;10:589−597. 2. Maschmeyer G, Haas A. The epidemiology and treatment of infections in cancer patients. Int J Antimicrob Agents 2008;31:193−197. 3. Guinan JL, McGuckin M, Nowell PC. Management of healthcare-associated infections in the oncology patient. Oncology 2003;17:415−420. 4. Halpern MT, Yabroff KR. Prevalence of outpatient cancer treatment in the United States: estimates from the Medical Panel Expenditures Survey (MEPS). Cancer Invest 2008;26:647−651. 5. Macedo de Oliveria A, White KL, Leschinsky DP, Beecham BD, Vogt TM, Moolenaar RL et al. An outbreak of hepatitis C virus infections among outpatients at a hematology/oncology clinic. Ann Intern Med 2005;142:898−902.
At your fingertips: Basic Infection Control and Prevention for Outpatient Oncology Settings (BICAPP) The BICAPP can be used by any outpatient oncology facility to standardize and improve infection prevention practices. • The BICAPP also includes the CDC Infection Prevention Checklist for Outpatient Settings that can be tailored by an outpatient oncology facility to systematically assess personnel adherence to recommended infection prevention practices. • The appendix provides a list of relevant resources, including the United States Pharmacopeia (USP) Chapter <797> Guidebook to Pharmaceutical Compounding— Sterile Preparations. All oncology facilities that provide on-site chemotherapy preparation should follow USP guidance in consultation with the state pharmacy board. • The BICAPP contains an appendix where a facility can insert a list of reportable disease/conditions specific to their state and the appropriate contact information for their local and state health authorities. • A list of names of designated personnel and their specific roles and tasks and contact information that can be tailored to your facility is provided as an appendix.
6. Watson JT, Jones RC, Siston AM, Fernandez JR, Martin K, Beck E, et al. Outbreak of catheter-associated Klebsiella oxytoca and Enterobacter cloacae bloodstream infections in an oncology chemotherapy center. Arch Intern Med 2005;165:2639−643. 7. Abe K, Tobin D’Angelo M, Sunenshine R, Noble-Wang J, Cope J, Jensen B, et al. Outbreak of Burkholderia cepacia bloodstream infection at an outpatient hematology and oncology practice. Infect Control Hosp Epidemiol 2007; 28:1311-1313. 8. Kim MJ, Bancroft E, Lehnkering E, Donlan RM, and Mascola L. Alcaligenes xylosoxidans bloodstream infections in outpatient office. Emerg Infect Dis 2008;14:1046-1052.
Alice Y. Guh, MD, MPH, is with the Centers for Disease Control and Prevention’s Division of Healthcare Quality Promotion in Atlanta, Georgia. Lisa C. Richardson, MD, MPH, is with the Centers for Disease Control and Prevention’s Division of Cancer Prevention and Control in Atlanta, Georgia. Angela Dunbar, BS, is with the CDC Foundation in Atlanta, Georgia. w w w.apic.org | 67
68 | WINTER 2013 | Prevention
Blood on glucose test strip vials1 Two independent laboratory analyses found blood on exterior and interior surfaces of vials in active use in a hospital environment. Of 51 vials tested: 2 tested positive for blood on the exterior 1 tested positive for blood on the interior
Visible blood smear on actual glucose test strip vial collected from clinical setting
Luminol test positive for blood
Positive Teichmann test showing brown crystals, indicating presence of blood
Could this pose a risk to your patients and your clinical staff? Q Are you routinely and consistently inspecting test strip vials for blood? Q In addition to glucose meters, should vials be cleaned? Q
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Is your institution at risk? To learn how Abbott Diabetes Care can help minimize potential risks to your patients and staff, contact us at 1.877.643.2098 or email firstname.lastname@example.org. For In Vitro Diagnostic Use 1. Analysis funded by Abbott Diabetes Care. Fifty-one opened vials of Roche Accu-Chek Comfort Curve test strips being used in two hospitals were obtained and tested for the presence of blood. Of the 51 vials, three vials (5.9%) tested positive for blood by two methods (luminol test and either the phenolphthalein test or Teichmann test). Two of the three vials tested positive for blood on the exterior surface of the vial; one tested positive for blood on the interior surface. Blood detection analysis was performed in April-June 2013 by Microbe Inotech Laboratories, Inc., St. Louis, MO. Data on ﬁle at Microbe Inotech Laboratories. Reports MILB0024A and MILB-0127A. Results show blood contamination from two facilities and are provided for informational purposes only. Contamination at other facilities may vary. 2. As of June 2013 among leading hospital brands of blood glucose test strips (Roche, Nova Biomedical and LifeScan). Source: Manufacturer’s websites.
Precision and related brand marks are trademarks of the Abbott Group of Companies in various jurisdictions. © 2013 Abbott ART25579 Rev A 07/13
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Heroes of Infection Prevention
Meet the 2013 Heroes of Infection Prevention PROFILES BY MICHELE PARISI
ach year, APIC presents Heroes of Infection Prevention awards to members who have developed and applied innovative infection prevention programs. Heroes and their programs represent some of the best practices in infection prevention. Since the inception of the award in 2006, 96 individuals and groups have been recognized for their exceptional work in reducing healthcare-associated infections. Four Heroes are featured in this issue of Prevention Strategist. For more information on the award, visit www.apic.org/heroes.
Improving infection prevention practices worldwide Chandrakant Ruparelia, MD, MPH Jhpiego (an affiliate of Johns Hopkins University) Baltimore, Maryland
Over the past 10 years, Chandrakant
Ruparelia, MD, MPH, has helped improve infection prevention practices in more than 20 resource-challenged countries. Dr. Ruparelia is a senior technical advisor at Jhpiego, an international non-profit health organization affiliated with Johns Hopkins University. He supports the organization’s
mission of enhancing the health and saving the lives of women and families in limitedresource settings by providing governments with technical assistance in infection prevention and control, family planning, HIV/ AIDS, maternal and child health, and other health issues. “The most important thing is to understand each country’s culture and people,” said Dr. Ruparelia. “We never impose ourselves, but instead work hand-in-hand with in-country colleagues. The more the local stakeholders own a program, the more likely it will be sustainable.” Infection prevention program development in every country starts with advocacy for evidence-based guidelines and grassroots level competency-building. In Ethiopia, for example, Dr. Ruparelia coordinated a threeday infection prevention workshop with local thought leaders—including Ethiopian Ministry of Health (MOH) representatives—to gain buy-in for improved practices. Since then, he has worked with the MOH and local medical professionals to develop national infection prevention guidelines and
performance standards, recruit and train more than 20 master trainers, and implement quality improvement approaches. He and in-country colleagues also conducted onsite infection prevention and control training for more than 600 healthcare providers in less than six months. In Tanzania, Dr. Ruparelia developed the technical approach with the Jhpiego Tanzania team for a project to improve quality of infection prevention practice in hospitals and medical schools. So far, he and local colleagues have created national infection prevention and control guidelines, standards, training materials, and site strengthening approaches. Dr. Ruparelia also hopes to establish a Tanzanian APIC chapter and adapt the APIC competency model to low-resource settings. As he tackles infection prevention challenges in widely varying cultures with limited resources, Dr. Ruparelia remains motivated by one thought: “At the end of the day, if I am able to change the practices of even one healthcare provider in a remote area, I’m happy.” w w w.apic.org | 71
Heroes of Infection Prevention
Acting as a powerful voice for infection prevention in India Sanjeev K. Singh, DCH, MD, MPhil Amrita Institute of Medical Sciences Kochi, Kerala, India
Faced with a staggering lack of infec-
tion prevention resources and policies in his native India, Sanjeev Singh, DCH, MD, MPhil, can only be described as “undaunted.” Through relentless focus on collaboration and best practices, Dr. Singh has generated infection prevention practice
and policy improvements benefiting patients and practitioners in his 1,200-bed hospital and across India. As the medical superintendent at the Amrita Institute of Medical Sciences teaching hospital in Southern India, Dr. Singh is a powerful voice for infection prevention. “Our country has 1.2 billion people, but no national infection control policy,” he says. “My mission is to make people see it is important.” Dr. Singh grew his own infection prevention department by demonstrating that good infection-prevention practices improved his hospital’s bottom line. He chairs the hospital’s infection control committee, which meets weekly to review surveillance practices and key issues. Dr. Singh is a role model for infection preventionists who want to affect change beyond their own institutions, spearheading infection prevention and control program and policy creation at district, state, and national levels. He initiated a district-wide infection control certification program and is working closely with two Indian states to
implement standardized infection prevention and control policies. “We can’t tackle all 28 states at once, so we start small,” he said. In October 2012, Dr. Singh coordinated a meeting between representatives from every Indian clinical society, doctors, nurses, and experts from the Centers for Disease Control and Prevention (CDC), and World Health Organization (WHO). The group developed a declaration calling for a national Indian infection prevention and control policy, which they submitted to India’s National Health Ministry. Dr. Singh is also working toward founding APIC’s India chapter and hopes to build India’s infection prevention and control capacity through online and multi-state APIC training. He is enthusiastic about other future projects as well: a national infection prevention and control database and antimicrobial stewardship programs, and an infection prevention journal, to start. “Look outside your institution; let others be enriched by your expertise, and you can create broad, impactful change,” he said.
Dramatically reducing C. difficile with best practices and leadership Azalea Wedig, BS, CIC The Jewish Hospital – Mercy Health Cincinnati, Ohio
When daily surveillance revealed an
increasing rate of Clostridium difficile (C. difficile) at her 200-bed hospital in 2009, Azalea Wedig, BS, CIC, immediately jumped into action. A microbiologist who transitioned to infection prevention after personal experience with 72 | WINTER 2013 | Prevention
a healthcare-associated infection (HAI), Wedig is particularly adept at connecting the science of infection prevention to the people most deeply affected and involved. Wedig’s first step was to form a cross-disciplinary C. difficile performance improvement team. After a thorough review of
Establishing best practices for municipal infectious disease prevention Carolyn Williams, RN City of Portland Portland, Oregon
Carolyn Williams, RN, has spearheaded
“A group of us agreed we needed an ‘on the street’ guide in addition to the well-written APIC chapter on this topic [emergency medical services].”
comprehensive infectious-disease (ID) prevention and education programs that are protecting the health of 7,000 municipal workers in the city of Portland. Williams’ responsibilities encompass the full spectrum of municipal ID prevention, from managing and implementing city-wide immunization and needlestick prevention programs to conducting department risk assessments and evaluating waste-water management systems. Her constituents range from lifeguards and daycare staff to police officers, the latter of whom absorb about 80 percent of her time. “Police officers are a very complex population from an ID standpoint,” she said. “They’re exposed to a lot of people on a daily basis. Bloodborne pathogens are a big risk.” Williams’ primary strategy for protecting her diverse population is education. In 2012, she taught 45 infection prevention classes to almost 1,900 city employees. “I’ve learned that the information has to be understandable and fact based,” she said. “The police
officers, in particular, always want evidence. They say, ‘Show me.’” Motivated by this need as well as her years of experience in nursing and infection prevention, Williams spearheaded the development of the Guide to Infection Prevention in Emergency Medical Services, a free APIC implementation guide now available to emergency medical services (EMS) and public safety personnel nationwide. “A group of us agreed we needed an ‘on the street’ guide in addition to the well-written APIC chapter on this topic,” said Williams, who serves as national chairperson of the EMS/Public Safety Section of APIC. “There wasn’t a lot of evidence-based literature on this topic, but many, many people contributed, and I’m very proud of the result.” Williams is a believer in the power of collaboration among infection prevention professionals. “I’m a one-person office working with limited resources; most municipal nurses are,” she said. “We need to create networks so our populations can benefit from other perspectives.”
literature, data, and existing guidelines, the team agreed to focus on three areas: environmental services, antibiotic stewardship, and standardization of clinical care. They committed to reduce their hospital’s C. difficile incidence rate by 10 percent for the first quarter of 2010. “We didn’t do anything new,” said Wedig. “We didn’t reinvent wheels. We used science, best practices, and teamwork.” Wedig and her team members systematically identified specific environmental, pharmacy, and clinical practice behaviors that were contributing to the hospital’s
C. difficile rates and then worked to change them. Ongoing education and engagement of staff, patients, visitors, and volunteers played a significant role. Within six months, the Jewish Hospital C. difficile rate had dropped from 33.3 per 10,000 patient days to 15.8. By June 2011, the rate had fallen to 3.08—half the statewide incidence rate. “Our hospital succeeded because we worked as a team,” said Wedig. “Infection prevention became everyone’s business. Empowerment and encouragement were key.”
Over the past three years, the team has sustained the lower C. difficile rate through staff education and recognition programs, including an annual hospital-wide infection prevention award. “You have to make everyone in the facility feel like part of the infection prevention team,” said Wedig.
The Heroes program is supported by a grant from BD.
w w w.apic.org | 73
INDEX TO ADVERTISERS CLEANING, DISINFECTION & STERILIZATION Rubbermaid Commercial Products . . . . . . . . . . . . . . 70 www.rubermaidcommercial.com/99 CLEANING, DISINFECTION & STERILIZATION Clorox Healthcare . . . . . . . . . . . . . . . . . . . . . . . . 28, 59 www.cloroxhealthcare.com Ivera Medical Corporation . . . . . . . . . . . . . . . . . . . . 51 www.curos.com JanPak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 www.janpak.com Molnlycke Health Care Inc. . . . . . . . . . . . . . . . . . . . . . 9 www.molnlyckehc.com Steriliz, LLC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 www.steriliz.us Vernacare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 www.vernacare.com Virox Technologies Inc. . . . . . . . . . . . . . . . . . . . . . . . 13 www.viroxaccel.com ENVIRONMENTAL SERVICES & SOLUTIONS JanPak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 www.janpak.com HAND HYGIENE CareFusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 www.carefusion.com/chloraprep JanPak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 www.janpak.com INFECTION PREVENTION PRODUCTS & SERVICES Abbott Diabetes Care . . . . . . . . . . . . . . . . . . . . . . . . 69 www.abbott.com
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Association for Professionals in Infection Control and Epidemiology . . . . . . Outside Back Cover www.apic.org/partners BD Diagnostics . . . . . . . . . . . . . . . . Outside Back Cover www.bd.com/ds/labefficiency Eloquest Healthcare www.mastisol.com . . . . . . . . . . . . . . . . . . . . . . . . . 68 www.ReliaFitDevice.com . . . . . . . . . Inside Back Cover Metrex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 www.Metrex.com/Prevent Nanosonics Limited . . . . . . . . . . . . . . . . . . . . . . . . . 32 www.nanosonics.us PDI, Professional Disposables International . . . . . . . . . . . . . . Inside Front Cover, 19 www.PDIBeTheDifference.com Sanuvox Technologies Inc. . . . . . . . . . . . . . . . . . . . . 20 sBioMed LLC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 www.steriplex.com XSTREAM Infection Control . . . . . . . . . . . . . . . . . . . 11 www.xstreaminfectioncontrol.com INFECTION PREVENTION SOLUTION - CONSULTING 3M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 www.3m.com/Ioban JanPak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 www.janpak.com Xenex Healthcare Services . . . . . . . . . . . . . . . . . . . . 64 www.xenex.com
INFECTION RESISTANT COATING Somay Products, Inc. . . . . . . . . . . . . . . . . . . . . . . . . 56 www.somay.com/steri-shield/steri-shield.html LABORATORY SERVICES Special Pathogens Laboratory . . . . . . . . . . . . . . . . . 42 www.specialpathogenslab.com MANAGING INFECTION RISK DNV Business Assurance . . . . . . . . . . . . . . . . . . . . . . 5 www.dnvcert.com MEDICAL DEVICES & INSTRUMENTS 3M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 wwwgo.3m.com/clippers Association for Professionals in Infection Control and Epidemiology . . . . . . Outside Back Cover www.apic.org/partners Eloquest Healthcare www.mastisol.com . . . . . . . . . . . . . . . . . . . . . . . . . 68 www.ReliaFitDevice.com . . . . . . . . . Inside Back Cover Ivera Medical Corporation . . . . . . . . . . . . . . . . . . . . 50 www.curos.com Retractable Technologies, Inc. . . . . . . . . . . . . . . . . . 43 www.vanishpoint.com SKIN & WOUND CARE PRODUCTS Eloquest Healthcare www.mastisol.com . . . . . . . . . . . . . . . . . . . . . . . . . 68 www.ReliaFitDevice.com . . . . . . . . . Inside Back Cover
07/11/13 4:11 PM
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