Mentoring as Quality Improvement in Infection Prevention

By Constance J. Cutler, MS, BS, BSN, RN, CIC, FSHEA, FAPIC

This article originally appeared in the July-August 2025 issue of Healthcare Hygiene magazine.

As an infection preventionist (IP) with many years of experience, I have been both a mentee and a mentor. At this stage in my career, I love mentoring IPs. Although a long, satisfying career is rewarding in itself, I want to help IPs with less experience learn faster by sharing my knowledge, having learned both the easy way and the hard way. Never was this more apparent than during the COVID-19 pandemic, which is not over, with more than 300 people still dying every week in the U.S.

I officially became an independent consultant in 2019, taking short-term assignments that interested me. Most involved my ability to walk into a large medical center as the director and lead infection prevention and control (IPC) teams ranging from five IPs to 11 full-time equivalents. Incidentally, my philosophy is that I do not know it all and never will, but I know from more than 40 years that I’ll be able to figure it out by pulling from previous positions and circumstances.

This was proven in spades when I was hired in January 2021 as an interim director of IPC in a quaternary university-associated medical center in northeastern New Jersey, just outside New York City. The position was supposed to be for three to six months, and I flew back and forth to my home in suburban Chicago every other weekend. This network of hospitals had a newly formed quality improvement leader who was given a role in IPC, with a network infectious diseases physician. The network was starting a hand hygiene committee, and I volunteered to be a co-leader as long as it could be called a task force, since committees never die. In that role, I successfully evaluated the six current electronic hand hygiene systems on the market, convincing my colleagues, information technology, and administrators to select one that allowed person-specific tracking without the concern that “Big Brother is watching.”

When I started there, I had six FTEs in IPC, three experienced ones with nursing backgrounds like myself and two new IPs, a microbiologist and a nurse from a unit with many COVID-19 patients. She was hired because of her assistance and obvious interest in preventing transmission in her 50-year-old unit housing elderly patients, with a poor heating, ventilation, and air conditioning (HVAC) system in its semi-private rooms. Transmission of COVID-19 kept occurring from patients in two rooms at the end of the long hallway where the HVAC was not adequate, so a hole was drilled in the special window covering to assist in providing negative pressure for these rooms. January 2021 was a critical time in the COVID-19 pandemic, which was now almost a year old. My IPs had blank exhausted expressions when I arrived, so the first thing I did was rotate three-day weekends for two of them at a time. None had even had a typical two-day weekend since the pandemic began, and they were spent, physically and emotionally. I also had only a short time to evaluate each before the official end of the fiscal year for their raises, so I immediately started one-on-ones to determine each person’s strengths and weaknesses, and asked them to honestly tell me why they liked or disliked IP. That gave me the ability to assess them in a short period and focus on their needs and desires to learn.

I quickly perceived that the microbiologist felt intimidated by the nurses in the department, even though she knew way more about laboratory work than they ever would. I asked her to teach the nurses a little about Gram-positive and negative bacteria and viruses, helping her realize that nurses usually considered microbiology the worst requirement in nursing school.

Each nurse also had a specialty before becoming an IP, ranging from the emergency department to home health nursing. All those experiences were also drawn upon at this large, complicated hospital with many outpatient areas, subject to IPC surveys by the state and the accrediting agency, which had recently written up several opportunities for improvement in the next six months. Since COVID-19 vaccines were just becoming available for healthcare workers and clinicians, this resulted in fewer panicky phone calls as vaccinations were snapped up before this became a political topic. Units were flexed to house various increasing numbers of COVID-19 patients, ranging from the mostly critically ill ones to those too sick to remain in a long-term care environment or at home. Attention to HVAC was important because it was increasingly being recognized that COVID-19 had an aerosol component, not just during exposure-prone procedures, and utilizing N95s or PAPRs was better than surgical masks to protect vulnerable HCWs and HCPs. I knew at the beginning of COVID-19 that as more science was available, recommendations from the Centers for Disease Control and Prevention (CDC) were just that – recommendation -- and wearing higher-level PPE and using more negative-pressure rooms if available would increase patient safety, preventing transmission to vulnerable patients and staff. I shared that and other topics at our weekly team meetings.

Mentoring led to quality improvement and improved patient and staff safety, while helping my mentees succeed in this wonderful profession.

 

The Conflict with Manufacturer’s Instructions for Use

By Carol Calabrese, RN, BS, CHESP, CIC

This article originally appeared in the July-August 2025 issue of Healthcare Hygiene magazine.

Several years ago, while attending the national APIC conference, I had numerous conversations with fellow attendees related to the frustrations they were dealing with trying to marry the manufacturer’s instructions for use (IFU) for the insurmountable number of medical devices in their facilities and the IFU of the different chemicals used for cleaning and disinfecting. Some stated that they had charts showing the different medical devices and different disinfectants, indicating they had up to 15 different disinfectants being used.

This presents major issues, including time spent to review the chart to select the disinfectant, where to store this multitude of disinfectants, the money to purchase all the disinfectants only to have staff become frustrated and just pull one wipe – and not necessarily the one that the IFU says to use.

What precipitated the issue? It was that the Centers for Disease Control and Prevention (CDC) reported to the Food and Drug Administration (FDA) that there were several outbreaks of multidrug-resistant Carbapenem-resistant Enterobacteriaceae (CRE) at several large medical centers.

A very serious and reasonable concern, right? But the issue is complicated for several reasons.

The reports of CRE were related to semi-critical devices – duodenoscopes -- which are very intricate devices which makes cleaning and high-level disinfection (HDL) difficult.

The FDA is responsible for ensuring that manufacturers of medical devices provide instructions for cleaning and disinfecting or sterilization within their labeling. While the Environmental Protection Agency (EPA) is responsible for approving the labeling that the manufacturers of the different chemicals develop for cleaning and disinfecting of the environment and medical devices, chemicals used as a high-level disinfectant or sterilant fall under the FDA for approval.

[Click on this button to access the list of medical devices to which the FDA regulations apply: https://www.raps.org/news-and-articles/news-articles/2017/6/fda-unveils-list-of-reusable-devices-requiring-new]

Of note, this FDA list did not contain many of the medical devices that are routinely used at the bedside, as it came after the 21st Century Cures Act (section 3059) was passed which requires FDA to identify and publish a list of reusable device types that are required to include such instructions for use and validation data regarding cleaning, disinfection and sterilization in 510(k) notifications.

Additionally, the Association for the Advancement of Medical Instrumentation (AAMI) publications ANSI/AAMI ST98:2022, and ANSI/AAMI ST91:2021 provide standards that pertain to medical devices that meet the critical criteria. See: https://array.aami.org/content/news/joint-commission-provides-guidance-meeting-infection-control-standards

Regulatory Focus, a news and peer-reviewed content organization reported on June 8, 2017 that the FDA released a list of reusable devices requiring new validation data. Subsequent to the CDC report, in around 2017 The Joint Commission (TJC) added to the standards that IFUs must be adhered to because there was a 72 percent rate of non-compliance with Standard IC.02.02.01.

After the implementation of TJC Standard IC.20.02.01, EP2 has continued to be the top standard out of compliance in 2017 and again was in the top 10 for 2020. In my IP mind, this is understandable, as there are numerous medical devices used throughout healthcare, hospitals, ambulatory surgery, long-term care, home health, hospice and others.

Medical devices to be sold in the United States they must go through rigorous approval process by the FDA to receive a 510K and/or pre-market approval. It has been reported that the FDA regulates more than 190,000 distinct devices. The FDA classification process is rigorous yet not perfect. Granted, many of these are surgical instruments which require sterilization. But I ask, is it not reasonable to consider that for non-critical medical devices the number of disinfectants used for cleaning/disinfecting non-critical medical devices could be streamlined from 15 to just two or three?

Many medical devices used have been available for a considerable length of time and IFUs for cleaning and disinfecting may not have been available. It takes a great deal of valuable time to contact the right person at a company to obtain insights as to what should be done to clean and disinfect a device if the IFUs are missing or incomplete.

According to the Spaulding classification, medical devices are divided into three categories:

- Critical: requires sterilization

- Semi-critical: requires high-level disinfection

- Non-critical: requires low to intermediate level disinfection

These classifications were created more than 65 years ago. While the FDA uses Spaulding, they use the additional categories below which are based on risk to the consumer.

Title 21, Chp I, Subchapter H of eCFR system Code of Federal Regulations has 16 parts addressing medical devices (See: https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H). Per Part 860, devices are in one of the following categories:

Class I: medical devices are considered low risk; example – elastic bandage

Class II : medical devices considered moderate risk example - stethoscope

Class III: medical devices that are considered high risk – example – silicone gel-filled breast prosthesis

Per the FDA, device classification is based upon its intended use and although there are seven primary categories of disinfectant chemistries that can be used for low-level cleaning/disinfecting. Iodophors and alcohols are not routinely used to clean/disinfect, and the FDA does not instruct device manufacturers to test all of the disinfectants currently approved by the EPA to identify which disinfectant (s) would be best suited to that medical device. (See: https://www.fda.gov/medical-devices/reprocessing-reusable-medical-devices/what-are-reusable-medical-devices and https://www.congress.gov/crs-product/R47374)

The FDA’s document, “Reprocessing Medical Devices in Health Care Settings: Validation Methods and Labeling, Guidance for Industry and Food and Drug Administration Staff,” was issued on March 17, 2025. It superseded the previous guidance from 1996.

The FDA has six criteria for reprocessing instructions:

Labeling should reflect the intended use of the device
Reprocessing instructions for reusable devices should advise users to thoroughly clean the device
Reprocessing instructions should indicate the appropriate microbicidal process for the device
Reprocessing instructions should be technically feasible and include only device and accessories that are legally marketed
Reprocessing instructions should be comprehensive
Reprocessing instructions should be understandable
(Source: Reprocessing Medical Devices in Healthcare settings: Validation Methods and Labeling Guidance for Industry and Food and Drug Administration Staff, 2017)

One of the issues that I believe has contributed to the problem is that in Section X, FDA Review of Reprocessing Instructions and Documentation of Reprocessing Method Validation in Submissions, (page 28) it states that all cleaning, disinfection and sterilization methods should be validated and reprocessing instructions included in the labeling when the FDA reviews premarket submissions yet, as noted above, there is no guidance regarding testing each of the disinfectant categories. In addition, AAMI provides guidance for the reprocessing of reusable medical devices that predominantly come under the categories of semi-critical and critical devices -- thus lending to greater confusion and conflict.

Today, there are thousands of non-critical medical devices in more than 100 different categories in an average hospital that require low to intermediate level cleaning and disinfection. (Exact numbers were not able to be identified.) Cleaning and disinfecting of reusable medical devices is performed by many healthcare professionals, including EVS technicians, nurses, certified nursing assistants (CNAs), radiology staff, occupational and physical therapy staff, and others. Technology has advanced over the past 30 years, and some non-critical medical devices are complex medical devices that require more time for cleaning and disinfecting and may require that a healthcare worker have more advanced training to perform the task.

The FDA does recognize that many medical devices are older and “may not be consistent with state-of-the-art science and therefore may not ensure that devices is clean, disinfected, or sterile.”

Incremental steps to address the cleaning and disinfecting concerns started as early as 2013, according to Carling, et al. (2013) who indicated that standardization should be studied to support the use of a single EPA-approved agent for cleaning and disinfection of common patient care items. (Source: Carling, P, Improving Healthcare Environmental Cleaning and Disinfection: Current and Evolving Issues, Infection Control and Hospital Epi, May 2013, Vol. 34, No. 5.) However, it took almost another 10 years before the topic was addressed again.

In 2022 the FDA released additional information highlighting the importance of device design and composition of the materials used in the manufacturing of new products. (See: https://www.fda.gov/medical-devices/reprocessing-reusable-medical-devices/working-together-improve-reusable-medical-device-reprocessing) Around the same time, APIC conducted a focus group related to this issue and shared feedback at the 2023 National APIC conference. The association then conducted a survey of infection preventionists to gain further insight as to the issues with which IPs are confronted.

In 2023, TJC released its Guide to Reprocessing Reusable Medical Devices. Chapter 1 of this document focuses on the Spaulding classification system, single-use devices, and manufacturer instructions. Chapter 2 addresses high-level disinfection of semi-critical devices and chapter 3 addresses Sterilization. The authors review what they have called a hierarchical approach to cleaning, disinfection and sterilization. In essence, this document addresses what principles and practices must be followed to review and develop policies and procedures within the healthcare organization; however, I wasn’t able to evaluate the impact on this guidance to ease the conflict over IFU.

In May 2025, APIC announced that it sent a letter to TJC asking the agency to modernize the compliance with IFU evaluated during the survey process. APIC recommended that TJC:

Differentiate between simple non-compliance with policies/stated practices and situations in which facilities have conducted risk assessments and determined that alternative cleaning, disinfection, and/or sterilization method is appropriate.
Reassign IFU findings from the “Infection Prevention and Control” chapter to “Environment of Care” or “Leadership” to better reflect responsibility and workflow.
(Source: https://apic.org/modernizing-medical-device-instructions-for-use-ifus/)

Taking things one step further, maybe it is time to revise the Spaulding classification or to consider changing the risk levels to the concept proposed by Kremer, et al. (See: https://www.journalofhospitalinfection.com/action/showPdf?pii=S0195-6701%2823%2900393-6)

Some hospitals have been proactive by implementing policies and procedures that state a new medical device will not be approved for purchase unless the disinfectant they use for low- to intermediate-level disinfection is approved or a risk analysis can be performed. (Contact the author for an example.)

Addressing the conflict will require more than TJC to “modernize compliance.” It will take a village of the FDA, AAMI, APIC, EPA, CDC, device manufacturers as well as disinfectant manufactures to come to the table for in-depth conversations as to the issues and possible resolutions.

The time for action now. Let’s not wait another decade to resolve this.

Carol Calabrese, RN, BS, CHESP, CIC, is an independent consultant and principal of Calabrese Consulting Services, LLC.

Additional references:

https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-860

https://www.beckershospitalreview.com/quality/fda-publishes-list-of-reusable-medical-devices-with-greatest-infection-risk/

The Mycelium Network and Infection Prevention: What Can We Learn?
By Linda Goss, DNP, BS, APRN-BC, CIC, COHN-S, FAPIC

This article originally appeared in the May-June 2025 issue of Healthcare Hygiene magazine.

Recently I had the opportunity to snowshoe in the beautiful mountains outside of Bend. Ore. This was an experience I will not soon forget due to the beauty of mountains and the fatigue of my muscles! Our guide, Dylan Kalnbach of Wanderlust Tours, gave us the million-dollar view of Mt. Bachelor and the Three Sisters while expertly describing one of nature’s fascinating communication systems known as the mycelium network. The mycelium network is often referred to as nature’s “wood wide web,” consisting of a vast underground fungal network that connects plants and trees through their root systems. I was impressed by Dylan’s knowledge and his ability to share expert knowledge in a relatable way but also struck by the parallels of this network and the network of infection preventionists (IPs). The parallels could provide a nature-made model for infection prevention collaboration.

Understanding the Mycelium Network

Mycelium plays a critical role in forest ecosystems. It forms symbiotic relationships with plant roots, known as mycorrhizae, through which nutrients are exchanged. Plants provide the fungi with carbohydrates, and in return, the fungi supply minerals and water from the soil.1 Moreover, the network allows for interplant communication. Through mycelial connections, trees can share resources or send chemical yield signs about invading pests or disease.2 IPs also share inter-network communication. While we are not literally or physically grounded in our practice we are grounded in our knowledge circle. This knowledge circle usually consists of two to three colleagues with whom a close collaborative relationship has been formed. This relationship comes with a certain level of trust in that they have earned your respect, and you embrace and endorse their recommendations. I have a network like this that I tap into regularly; however, this may not be true for everyone. Observation of practices has demonstrated situations of not choosing to “phone a friend” or research a topic for more information rather than simply handing the issue off to leadership.

Changing the Dynamic

Professional communication among IPs internally and externally has its challenges. A survey on infection prevention knowledge sharing conducted by the Society for Healthcare Epidemiology of America (SHEA) noted recognizing important information and managing knowledge should take precedence over rapid implementation of precaution measures for emerging infectious diseases.3 The survey was performed after an outbreak of Ebola virus disease and found that strategies to share knowledge largely does not exist in epidemiology literature. Respondents indicated obstacles to knowledge sharing was frequent and useful feedback after training of healthcare workers in their institution suggests this is the place to start for improvement. This was applicable to routine and outbreak situations. Most hospitals surveyed were found to be open to sharing tools; however, this was rarely the source for developed materials. One explanation for this was poor density of knowledge sharing networks among IPs. How can this be improved? A parallel with the forest and infection prevention may be the key. The preservation and recognition of institutional knowledge. The intricate network of communication amongst the trees in the forest serves as an elder led communication system. When the “older” yet experienced tree is harvested, that knowledge is lost to the network. The same principal exists amongst IP professionals in that a new IP may be hired when the existing program has been without a leader. The IP is left to find institutional resources on their own as the only subject matter expert or rely on other members of the department. Some IPs are hired as the sole practitioner to start a program or revive an existing program and left to reinvent the proverbial wheel or start from scratch. So where did the institutional knowledge go and how can we preserve it?

Talk Story and Improve Communication

In Hawai’i a common phrase that can be heard is “talk story.” This model of communication is rooted as a cultural practice referring to the sharing of stories and experiences with the intent of developing connections, community and sharing of wisdom. This oral preservation of knowledge is a way of life and includes Hawaiian values like aloha (love and compassion), ‘ohana (family), kuleana (responsibility) and ‘lke (sharing of wisdom).4 Paul Cook advocated for implementation of talking story beyond current indigenous settings by suggesting use of talking story in “wider cultural contexts to co-create relational knowledge.”5 His comparison of Western Research Methodologies (WRM) to Indigenous Research Methodologies (IRM) includes case studies of surf clans with experienced and inexperienced surfers. In other words, what is lived versus what is about to be lived vary vastly. He suggested implementing IRM into WRM to preserve the institutional knowledge base. This principle supports commonalities between the mycelium network and infection prevention and encourages the preservation of knowledge.

The mycelium network is fundamental to ecosystem health and serves as a model of communication. Talk Story provides a cultural foundation for preservation of knowledge and communication and collaboration. IPs are adept at sharing knowledge however there are lessons to be learned from both the mycelium network and the Hawaiian culture to preserve the institutional knowledge of the “elder trees” to improve communication and collaboration. First is the management of that knowledge and second is the sharing of that knowledge. Preservation of the world wide web of IPC knowledge by engaging in a few minutes of Talking Story can go a long way in the profession of infection prevention.

Linda Goss, DNP, BS, APRN-BC, CIC, COHN-S, FAPIC, is a doctorally prepared adult nurse practitioner who is board certified in infection prevention and occupational health nursing. She is an infection prevention consultant and coordinator and an employee health nurse practitioner. She is a fellow of APIC and volunteers with CBIC after serving on the board of directors and as the 2020 CBIC president. She enjoys tackling marathons which gives her plenty of time to discover the parallels between the outdoors and infection prevention.

References:

Smith SE and Read DJ. (2008). Mycorrhizal Symbiosis (3rd ed.). Academic Press.

Simard SW, et al. Net Transfer of Carbon Between Tree Species with Shared Ectomycorrhizal Fungi. Nature, vol. 388, no. 6642, 1997, pp. 579–582. https://doi.org/10.1038/41557.

Morgan DJ, et al. Knowledge Sharing in Infection Prevention in Routine and Outbreak Situations: A Survey of the Society for Healthcare Epidemiology of America Research Network. Antimicrobial Resistance & Infection Control, vol. 6, no. 1, 2017, p. 10. https://aricjournal.biomedcentral.com/articles/10.1186/s13756-017-0237-5.

Our Values. HULI PAC, https://www.hulihi.com/hawaiian-values.

Cook P. Talk-Story: Performing an Indigenous Research Methodology With Hesitant Non-Indigenous Participants to Learn Previously Silenced Knowledge. Int J Qual Methods, vol. 22, 2023, pp. 1–11. SAGE Publications, https://doi.org/10.1177/16094069231213711.

 

When to Hire an Infection Prevention Consultant: A Guide for Healthcare Leaders and Product Developers

By Melissa Travis, MSN, RN, CIC, FAPIC

This article originally appeared in the March-April 2025 issue of Healthcare Hygiene magazine.

In the healthcare industry, the role of an infection preventionist (IP) is crucial for safeguarding patient safety and ensuring regulatory compliance. However, many corporations, healthcare facilities, and product development companies often wonder when it’s the right time to bring in an infection prevention consultant. Here are seven scenarios where hiring an infection prevention expert can significantly benefit your organization or company.

During Vacancies and Onboarding
When an infection preventionist leaves an organization, it creates a significant gap, especially if they were the sole practitioner. To avoid lapses in infection prevention reporting and monitoring, a consultant can step in to provide continuity while the organization searches for a permanent replacement. They can also offer valuable insights and recommendations for the new hire, ensuring a smoother transition. A consultant is particularly helpful during onboarding, especially if they were already assisting during the vacancy. They can ensure that the new IP has all the necessary tools and instructions for success, help them get organized, and support their transition. Additionally, the consultant can help manage the workload while the new employee undergoes orientation and becomes acclimated to the facility.

After an Inspection
Inspections and regulatory visits are stressful for everyone in the organization. This stress is compounded when issues are found, and immediate actions are required. The full-time IP may already be overextended with their daily responsibilities, making it difficult to manage post-inspection corrections effectively. To avoid further disruption, an IP consultant can help prepare a response and implement necessary changes after a regulatory or accreditation visit. They can also collaborate with the existing IP to develop processes that prevent future citations and deficiencies, ensuring continuous compliance.

Developing or Launching a New Medical Device or Product
If your company is developing a new medical device or launching a healthcare-related product, involving an infection preventionist early in the process is essential. Unlike other healthcare professionals, IPs focus exclusively on infection risks and can evaluate your product through a specialized lens. Their expertise ensures that your product aligns with infection prevention protocols, potentially preventing issues that could arise later during product launch or regulatory reviews. Companies that overlook this input often face challenges when infection control considerations are not adequately addressed during development.

Creating or Revising Manufacturer’s Instructions for Use (IFU)
Healthcare facilities are required to follow the manufacturer’s instructions for use (IFU) strictly. However, many companies create technical IFUs that are difficult for frontline healthcare workers to interpret. If the instructions are unclear, healthcare providers may avoid using the product altogether due to fear of non-compliance with regulatory bodies like The Joint Commission or the Centers for Medicare & Medicaid Services (CMS). An infection prevention consultant can help revise or create clear, user-friendly IFUs, ensuring compliance with infection prevention guidelines and reducing the risk of healthcare-associated infections (HAIs).

Expanding into New Markets
When you’re looking to introduce an existing product into new markets—especially in specialized healthcare settings like operating rooms—consulting with an infection prevention expert becomes vital. Each market has unique infection control challenges that must be addressed. An IP consultant can help identify potential risks in these environments and provide guidance on adjustments needed to ensure your product complies with specific infection prevention standards. This proactive approach minimizes the chances of setbacks when entering new healthcare markets.

Educating Your Sales and Executive Staff
Many companies have innovative healthcare products but struggle to bridge the gap between their offerings and infection prevention requirements. Sales teams, in particular, may lack the knowledge to effectively communicate the infection control benefits of their products to healthcare professionals. An infection prevention consultant can educate your staff on the basics of infection control and help them engage confidently with healthcare facilities’ infection prevention teams. This education empowers your sales force to demonstrate the real value of your products in preventing infections.

Managing Outbreak Situations
If your facility is facing an outbreak—especially when managing multiple healthcare locations or if your in-house infection preventionist is inexperienced—bringing in a consultant can provide critical support. Consultants offer guidance on outbreak management, help contain the spread, and ensure compliance with infection control protocols. Additionally, if your facility lacks a dedicated IP due to staff turnover, a consultant can step in temporarily to manage outbreaks and train your team on how to handle future incidents.

In summary, there are several critical situations where an infection prevention consultant can provide essential support. Whether you're filling an IP vacancy, addressing inspection deficiencies, developing a new medical device, refining manufacturer instructions for use, expanding into new markets, training staff, or managing an outbreak, a consultant brings specialized expertise to keep infection prevention a top priority. Engaging a consultant at the right time helps organizations and companies strengthen their infection prevention programs, maintain compliance, and ultimately improve patient and resident safety.

Melissa Travis, MSN, RN, CIC, FAPIC, is the principal of IP&C Consulting, LLC and may be reached through her website: www.ipandcconsulting.com

 

Making the Business Case by Telling Your Story

By Teri Hulett, RN, BSN, CIC, FAPIC

This article originally appeared in the March-April 2025 issue of Healthcare Hygiene magazine.

Infection preventionists (IPs) have forever been expected to do more with less. The legendary motto is that infection prevention is a non-revenue generating department, it has no budget. When requesting additional support, either manpower or equipment (technology or devices), the common response is develop a business case and present it to the board – the target group who can support, approve, and move forward IPs’ requests. Sometimes we forget our audience reaches beyond the executive leaders within our facilities to include those at the bedside. Knowing your audience is key and disseminating the infection prevention and control (IP&C) work to all vested parties is central to obtaining and maintaining buy-in.

We have been taught that how you develop your business case will be different if in a large system consisting of varied patient settings (inpatient, outpatient, acute versus rehab, etc.) where we present to the C-suite versus a rural facility that includes acute-care and post-acute care settings on the same campus where you may be presenting to administrators. We forget that we need to disseminate results (outcomes) to the unit level – those performing the work to improve patient safety and outcomes. The question I found posing to myself was should the business case really change depending on the size and scope of facility or audience to which you will present?

The goal is to develop a story -- a presentation that tells your work’s story and not only informs your audience but engages and inspires your audience to support the ongoing demands of your work to prevent healthcare-associated infections (HAIs) leading to improved patient outcomes, shortened lengths of stay, and eliminates potential decreased reimbursement because of HAIs. I like to keep it simple, making the data easily digestible.

I discovered infection prevention when the neonatal ICU (NICU) I worked in was dealing with two separate multidrug-resistant organism (MDRO) outbreaks. As a charge nurse, I worked closely with the IP assigned to the NICU. After the outbreaks ended, I was encouraged to apply for the open IP position, which I did, and was subsequently offered the job. Working in a large, regional referral academic medical center on a 50-bed unit that was a revenue generator, then moving to a department that was non-revenue generating was a culture shock. I understood we had no budget, but I knew our work was producing positive outcomes that had to be impactful at some level. I was determined to find a way to tell our story. We were good at producing data, taking raw data and putting it into a graph and sharing at Infection Control Committee (ICC) meetings and disseminating to unit managers on a quarterly basis. What I didn’t know is if the information was getting to the bedside caregivers who were doing the work.

After being in the IP&C department a few years and having multiple units for which I was responsible, I decided to take a deeper look at the data being produced – to look from cumulative perspective. I had been dedicated to four adult ICUs and the NICU. I looked at the data over time – specifically the first three years of my work with these units; I had committed time on the unit to work with staff -- educate on basic IP&C principles including hand hygiene and multiple Agency for Healthcare Research and Quality (AHRQ) bundles developed to prevent infections. I reinforced compliance with the bundles and developed a facility-wide IP&C Champion Committee supported by the director of nursing (DON). This was an opportunity to develop an IP-focused sphere of influence on each unit. The committee structure was mandated by the DON to include a minimum of one champion from each unit/department including nursing, radiology, laboratory, environmental services, pharmacy, etc. It was an opportunity to educate monthly on IP&C practices, at a facility-wide level, the impact each hospital employee has in preventing infections, complications, and unnecessary costs to the patient and facility should a patient develop an HAI. This was an opportunity to share unit-level work being done that resulted in decreased patient harm and improved patient outcomes.

I needed to tell the story in simple terms using an easily digestible format. I outlined each bundle element, the data when I started covering the unit, interventions implemented over the three-year period, the data after three years of focused work, the decreased infections, decreased costs, and percent reduction device-associated infections over time. I put the data into a single PowerPoint slide and provided laminated copies for each unit manager to share at staff meetings and post in key places on the unit. It was an opportunity to acknowledge the staff at the unit level. The same information was shared at the executive level. It was an opportunity for the IP&C department to share with executives that while IP&C is not revenue-generating, it is revenue-saving. Preventing HAIs prevents non-payment for HAIs. We presented device-associated infections and hand hygiene.

Keeping it simple is best -- present data in an easily digestible format (one page is best) that tells the story, whether the IP is there or not. When presenting, remember the executives’ time is in high demand. They need to know why IP&C is important, outcomes recognized because of the IP&C work, and what the IP needs to continue being successful in keeping patients and staff safe.

Teri Hulett, RN, BSN, CIC, FAPIC, is an infection prevention consultant and educator for Infection Prevention Strategies, LLC.

 

What’s That Itch All About?

By Carol Calabrese, RN, BS, CHESP, CIC

This article originally appeared in the January/February 2025 issue of Healthcare Hygiene magazine.

My first exposure to scabies was as a novice infection preventionist. Issues always seem to happen on a Friday at 3 p.m. or just before you go on vacation. As I was in the office trying to clear things off the desk, the phone rang, and it was one of the nursing units asking for me to check out a patient’s skin rash. The patient had been in the hospital for about five days and had come to the hospital from a long-term care facility. This was all new to me, so I was unsure of several things.

What causes purpuric skin conditions in the elderly?

As a person ages, their skin becomes fragile, and an elderly person can develop a skin condition called senile purpura which causes a purple discoloration on the skin.

Assessing the resident’s skin condition is a good starting point as well as reviewing their medications and lab results.

Many residents may be taking multiple medications so it essential to evaluate the medications they are taking and which one (s) if any have itching (pruritus) as a side effect. Antibiotic treatment should be evaluated first and then move onto the other drugs.

There are a wide variety of medications that have itching as a side effect. These include common cardiovascular drugs, metabolic, psychotropic, opioid/analgesics, steroids, chemotherapeutic and other drugs like radiopaque contrast agents have itching as a side effect.

A study conducted at John Hopkin’s between 2013 and 2018 identified through chart review that 9802 patients developed pruritus after drug initiation and more than 1.5 million did not develop any. Females (70 percent) were most likely to have this complication and were between the ages of 50 and 79 years. Forty percent of the patients were black. Heparin caused more of an issue and trimethoprim-sulfamethoxazole and calcium channel blockers were the major drug categories that caused itching.

Assess the resident’s lab values. If labs have not been performed recently and the resident has a history of renal, liver, blood disorders as well as psychological, labs may need to be ordered.

There are several lab values that should be checked. These include vitamin D deficiency, iron deficiency, as well as thyroid issues can cause itching. In addition, itching can be caused by liver disease and can mimic Scabies as the itching is more prevalent at night and the palms of hands as well as soles of their feet or limbs. S. aureus is part of the normal skin flora; however, 90 percent of skin lesions with skin inflammation and/or lesions are caused by S. aureus. This is possibly due to mast cell mediation and histamine release.

Individuals with advanced kidney and liver disease may also experience severe itching. (An example is an elevated creatinine or bilirubin).

So, utilizing nursing assessment skills is critical to evaluating the cause of itching prior to saying this is a potential for an outbreak.

Also ask yourself, what is going on in the facility?

If the facility is undergoing renovation, be sure that the infection control risk assessment (ICRA) is being adhered to. Back in the late 1980s, prior to ICRAs, we had a major issue with dust mites in the long-term care facility in which I worked. The facility was undergoing major renovation. Unfortunately, the dermatologist insisted it was Scabies even though skin scrapings were not performed.

Ensure that all the barriers are intact and negative pressure is being maintained. The unit(s) used for negative pressure should have their filters checked and changed if needed to ensure proper functioning. Talk with environmental services (EVS) personnel to confirm cleaning is being performed to minimize dust and plant operations is changing the air filters in the HVAC as needed.

These steps are necessary to be sure you have ruled out other potential causes of itching as the work involved is time-consuming and treatment for Scabies has a neurotoxicity side effect and if treatment isn’t needed then that is a plus.

After a thorough investigation as to other causes of itching has been completed and ruled out, you may move on to developing a working hypothesis to evaluate that this may be an outbreak.

Most of the time, by the time you think you have a problem, Scabies will have had the opportunity to spread. One to two cases should be considered an outbreak, as this is something that normally is not observed. However, outbreaks of Scabies are more common in long-term care facilities and aggregate-living facilities than you might imagine. Scabies outbreaks extend beyond the patients/residents to healthcare personnel, their families and visitors.

In searching for information related to the incidence of Scabies in LTC facilities in the United States, I went to the Centers for Disease Control and Prevention (CDC) website and found that the Scabies page had not been updated since November 2010. Some of the more recent peer-reviewed literature comes out of South Korea and Japan, so my suggestion is that you should contact your state health department.

You may be asking yourself, “Is it time to go into outbreak mode?” You may still be determining if you have a problem and wondering if it is time to kick into an active outbreak mode. Since there are many different things that can cause itching in the elderly, it is important to approach things in an organized manner.

First, a review of Scabies is in order. Scabies is essentially a parasite. It does not cause any type of disease. According to the Control of Communicable Diseases manual, 20th edition, the Sarcoptes scabiei mite can live on humans but cannot reproduce. These mites burrow down into the layers of the skin with papule, vesicles and linear burrows presenting in the webs of the fingers, around wrists, around the waist, under breasts, the abdomen and the buttocks. This is different than what you will observe with shingles. Itching is caused by a histamine reaction to the fecal droppings of the mite. Itching can be very intense, especially at night. The incidence of Scabies is worldwide, and they have been in existence forever.

Transmission occurs through direct skin-to-skin contact. Skin to skin contact needs to be long enough for the mite to leave one body and burrow under the skin of another person. It takes about an hour for this to occur.

Mites need their host (human beings) to survive! For people that have never had Scabies, it may take two to six weeks for symptoms to appear, thus providing ample opportunity for transmission to continue. For those individuals that have previously had Scabies, symptoms can start one to four days after exposure.

In addition to the residents in a long-term care facility being at risk, so are healthcare personnel as well as their household members and the family members/visitors of the resident(s).

When a resident or even a healthcare worker reports itching, don’t dismiss it, assess and start a line listing, which is one type of epidemiologic database and is organized like a spreadsheet with rows and columns. Typically, each row is called a record or observation and represents one person or case of disease, per the CDC. This link [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7171381/pdf/main.pdf] provides a good overview of how to conduct an epidemiologic investigation. Establish the case definition. “Ex. 2 or more cases within a 2 – 6-week period” (see transmission). Keep one line listing for residents and one for healthcare personnel.

The line listing should include the following at a minimum:

- Name/Case ID

- Room number/unit

- Date of onset of symptoms

- Caregivers

- Chart review and assessment of the resident. This will include a review of the medication and any recent lab work. If it is a HCW, do a skin assessment and be sure to include questions about the family, where do adults work, do they work at more than one LTC facility,

- Skin scraping performed, date, by whom and results.

- Treatment

Regarding managing the situation, at first suspicion, I always suggest having a meeting with the facility’s chief nursing officer, director of nursing, administrator and the chief medical officer to provide an overview of the potential situation. Review with them the results of your research related to the patient/resident’s medical history, medications, etc. and explain why you believe that an outbreak is suspected. Be sure to communicate with the ancillary department heads.

Be sure to have a dermatologist involved to assess the patients/resident(s) involved and be sure that they perform skin scrapings for confirmation. It will be necessary to determine if you are dealing with (regular) Scabies or Norwegian (crusted) Scabies. Any healthcare personnel with symptoms should be evaluated by the employee health representative and skin scaping performed, as well as providing treatment.

What is the difference? Regular Scabies rash is generally not seen above the neckline and Norwegian Scabies can be seen on the neck and scalp of the individual and looks crusty. The dermatologist can assist with this.

Determine if the outbreak is contained to one unit. To do this, you will need to assess staffing on all the shifts for at least six weeks. Look to see if any healthcare personnel rotated to another unit. Also investigate if the resident(s) had physical therapy or other therapies, participated in activities, or were exposed to healthcare personnel in other departments. If a resident in a long-term care facility experienced a recent hospital admission, be sure to contact the infection preventionist at the hospital and vice versa.

Have a staff meeting to alert all healthcare personnel about what they should be looking for and to notify you as soon as possible of potential new complaints by patients/residents of itching or observing a patient/resident itching. Note: itching is more prevalent during the evening and nighttime. Do not have them ask “are you itching?” as that plants a subjective thought into the person’s mind. Instead, ask the patient/resident to describe what it feels like and if they notice it at certain times.

If a resident(s) has gone to any outside appointments, be sure to notify that office (s) as well once the outbreak has been confirmed.

In good conscience, can you state that the outbreak is isolated to one unit? If yes, you may be able to only treat the residents and staff on that unit. A word of caution, if you do this, you may end up having to retreat.

Once confirmation is established by the dermatologist performing the skin scrapping (s), convene the management team mentioned earlier and add the dermatologist as well as the pharmacy to discuss the action plan. The plan should include how to effectively treat all the patients/residents and staff in a timely manner. Include how staff should treat members of their household.

Another staff meeting should be held to share the plan with the staff. My recommendation is to identify a team of staff on each unit to be designated to apply the treatment to all the patients/residents on that unit. Patients/Residents should be bathed/showered, their body allowed to cool to room temperature prior to the application of the treatment. Clean clothing is to be donned, as well as changing bed linens.

It is also important that you notify your local health department, as their experts can be an excellent resource. Check your state’s reportable disease list, too.

Consult with risk management as to the necessity of sending a letter to the power of attorney or the family member responsible for the patient/resident to notify them of the situation. This should be written by the medical director, chief nursing officer, director of nursing, and infection preventionist.

Facility administration will need to determine if they will cover the cost of treatment for family members of the residents as well as the cost to treat the healthcare workers’ family members.

The medical director, epidemiologist, infection preventionist, dermatologist and the pharmacist should discuss the treatment. Orders will need to be written by the epidemiologist or the medical director for treatment. Once the orders are written, the pharmacy should let infection prevention know how soon they will have the medication available.

Per the CDC, a prescribed scabicide lotion or cream should be used. See: https://www.cdc.gov/parasites/scabies/treatment.html

As noted earlier, a team on each unit should be designated to bathe the residents and apply the prescribed treatment lotion, following the prescriptions instructions for use. Note: You may need morning and afternoon teams based upon the number of patients/residents on each unit. Team members should utilize Contact Precautions, gown and gloves.

Completion of treatment of all patients/residents and staff should be aimed for the same day or at least the next day. This is a huge task, but it can be done.

Contact precautions can be discontinued 24 hours after treatment. https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/type-duration-precautions.html

Since itching can persist for several weeks, daily assessment of the resident’s skin should continue to be sure that no further burrows appear. If they do, re-treatment shall be needed.

Leadership should help to convey the necessity that each HCWs household members be treated is highly recommended with documentation that it was done. HCWs may need to contact their pediatrician if they have very young children.

It is more difficult to be sure that family members or visitors of the residents have been compliant so you will need to identify what process shall be used.

Regarding reporting, as mentioned earlier, be sure to notify your local health department as this may be reportable in your state.

The management process of the outbreak should be reported and documented in the facility’s Infection Prevention and Control Committee as well as adding to the Infection Prevention and Control Risk Assessment and Plan.

Do not be surprised if you have a visit from the state or the ombudsman.

After all impacted patients/residents have been treated and about six weeks have passed without a new case, you should be in the clear.

Carol Calabrese, RN, BS, CHESP, CIC, is an independent consultant and principal of Calabrese Consulting Services, LLC.

References:

Fourzali KM, Yosipovitch G. Management of Itch in the Elderly: A Review. Dermatol Ther (Heidelb). 2019 Dec;9(4):639-653. doi: 10.1007/s13555-019-00326-1. Epub 2019 Sep 23. PMID: 31549284; PMCID: PMC6828892.

DermNet – dermnetnz.org/topics/drug-induced-puritis

Huang A. Pruritus Associated with Commonly Prescribed Medications in a Tertiary Care Center, Medicines (Basel) 2019 Sep; 6 (3):84. Published online Aug. 4, 2019. Doi: 10.3390/medicines6030084

Control of Communicable Disease Manual, 20th Edition. Pages: 550-552.

Centers for Disease Control and Prevention (CDC). https://www.cdc.gov/csels/dsepd/ss1978/lesson2/section1.html