Infection Prevention and Advocacy: A Conversation About Appropriations and Policies to Enhance the Profession
This article originally appeared in the December 2023 issue of Healthcare Hygiene magazine.
Jill Holdsworth, MS, CIC, FAPIC, NREMT, CRCST, manager of infection prevention at Emory University Hospital Midtown, and Rich Capparell, director of legislative affairs for the Association for Professionals in Infection Control and Epidemiology (APIC), discuss the importance of infection preventionists (IPs) advocating for their profession on Capitol Hill.
Jill Holdsworth: When we talk about advocacy for infection prevention, I don’t think many IPs know what that means or what the hot topics are. Can you give us a taste of what is most important right now?
Rich Capparell: Currently, Congress is struggling to come to an agreement on FY 2024 funding. The House of Representatives and Senate are very far apart, as House measures are looking to make heavy cuts to non-defense spending. APIC has been focused on preserving funding for key infection prevention and control programs, such as the National Healthcare Safety Network (NHSN) and the Antimicrobial Resistance Surveillance Initiative (ARSI). Additionally, we are working with coalition partners to incentivize individuals to enter the infectious disease fields through the Bio-Preparedness Workforce Pilot Program. Although appropriations are important, APIC is also educating lawmakers about policies that will make patients safer. As we know, there are millions of healthcare-associated infections in nursing homes each year and government reports continue to highlight the need for stronger infection prevention and control programs. To see better outcomes, APIC is pushing Congress to require full-time infection preventionists in nursing homes and for these facilities to provide greater HAI data transparency. Finally, APIC is working with a wide array of partners to help support the antibiotic pipeline. To do this we are supporting the PASTEUR Act, which would establish a subscription-style program to provide federal contracts for a reliable supply of critically needed novel antimicrobials and not rely on the volume of sales like most other drugs on the market.
RC: You recently participated in the APIC Board of Directors Lobby Day. Can you share your experiences with Congressional staff (in-person vs virtual)?
JH: Last year, the APIC board of directors met virtually with the congressional staff, which was my first experience with APIC doing this type of work. It gave me the chance to educate myself more on topics most important to infection prevention on a higher level and being able to speak to it and really feel like I was making a difference for all of us and our patients by telling our congressional offices about these items. This fall, we were able to visit the offices in person, which gave us the chance to have a more in-depth conversation about the topics that was really engaging with the staff members. Each APIC board member had an APIC staff member with them and we presented the topics of interest, answered questions and had also done our homework on who we were meeting with, so we also knew what was important to them. This experience was incredible for me personally, allowing me to continue advocating for what is important in our profession, but also what our patients need most.
JH: I know most IPs are going to think they don’t have time for advocacy with everything else we have on our plates. What are some of the things, big and small in terms of time commitment, that IPs can do to make an impact?
RC: There are many ways for APIC members to get involved choose their level of engagement! The easiest way to stay engaged is via the APIC Action eList. This simple action can educate members on key activities and ways they can get involved in the future. For members interested in contacting legislators that aren’t sure what to say, I recommend the APIC Action Center. This resource has pre-written messages on key issues, that take less than a minute to send. Members looking to get more involved can volunteer to be their chapter’s legislative representatives or they can work with staff to start scheduling a virtual meeting with policymakers. Advocacy at any level helps get our message out, so we appreciate all levels of engagement!
RC: As follow-up to your question, what issue did you find most rewarding to talk about?
JH: I have to say I was surprised that it was easiest for me and most engaging to speak to the nursing home staffing ratios, even though that isn’t the setting I work in. This is something we should all be advocating for, as it does impact us all! I was able to speak to scenarios where I have tried to reach “the IP” at these facilities to communicate results, or receive results, and I couldn’t find anyone (or I got someone different each time I asked). The continuum of care is a very real struggle we will continue to deal with until we can ensure appropriate staffing in all facilities where infection prevention resources are needed.
Supplemental Disinfection Technology Use in Long Term-Care Facilities: How, When and Why
By Amanda Sivek, PhD, a-IPC
This article originally appeared in the November 2023 issue of Healthcare Hygiene magazine.
Editor’s note: This article is a summary of “UV Light and Hydrogen Peroxide Vapor Disinfection in LTC Settings: What You Need to Know” co-presented at the 2023 Kairos Education Conference & Exhibit with James Davis, manager of infection prevention and control services at ECRI.
Before the COVID pandemic, the Centers for Disease Control and Prevention CDC) estimated that 1 million to 3 million residents of long-term care facilities experienced a serious infection every year. Infection prevention and control (IP&C) practices can help vulnerable residents avoid getting infections from healthcare workers, other residents, and visitors. Environmental IP&C practices address cleaning and disinfection of environmental surfaces within residents’ rooms and day/common rooms.
At ECRI, we receive many questions from our members about supplemental disinfection technologies like ultraviolet (UV) light and hydrogen peroxide vapor (HPV) devices that are used in a variety of healthcare settings. Let’s discuss how UV light and HPV disinfection work, when these technologies could be used in long term care, and considerations for safely using UV and HPV devices in long term care facilities, such as assisted living facilities, nursing homes, and skilled nursing facilities.
How does UV light and HPV disinfection work?
UV-C light (200-280 nm) and UV-B light (280-315 nm) damage DNA/RNA to prohibit replication of microorganisms, ultimately killing them. UV-C light does not occur naturally on the Earth and is a known carcinogen. UV light disinfection effectiveness depends on the target surface’s distance from the UV light source, shadowing of the surface, and soil load on the target surface. UV light devices used in long term care facilities include UV room disinfection devices, air disinfection devices, UV mobile device disinfection boxes, handheld UV wands and UV phone boxes.
HPV decontamination devices use highly concentrated chemical sterilants to create a pure gas form of hydrogen peroxide that fills an enclosed, unoccupied space. HPV can decontaminate porous and nonporous surfaces within the treated space. A type of HPV decontamination device used in long term care facilities is a portable device with five components: a controller that initiates and tracks HPV device cycles; a dehumidifier that maintains the relative humidity within range to sustain HPV; a vaporizer that creates and disperses HPV with a measured amount of hydrogen peroxide; an aerator unit that breaks down HPV into water vapor and oxygen after the hydrogen peroxide contact time; and at least one hydrogen peroxide sensor that measures HPV concentration within an enclosed area and around sealed outer doors.
When could UV and HPV devices be used in long-term care facilities?
UV and HPV are supplemental disinfection modalities. They can be used after manual cleaning and disinfection methods are performed as shown in the following schematic:
Before using a supplemental disinfection method in a long-term care facility, the first step is to vacate the resident’s room, day room, or resident common area. It is imperative for staff and residents to avoid exposure to UV light and HPV. UV-C light is a carcinogen. Hydrogen peroxide vapor may cause asphyxiation in enclosed areas; other effects from inhalation may include gas embolism, unconsciousness, and respiratory arrest. Bottom line: Stay out of the room when supplemental disinfection devices are in use.
Typical UV Room Device Workflow
After vacating the room, the typical workflow for using a UV room disinfection device is to manually clean and disinfect surfaces within the space, following product IFUs. Next, the room is prepared by placing any safety sensors and the UV device within the room in the designated spots per facility protocol. Finally, the user selects the appropriate cycle, leaves the room, and initiates the disinfection cycle. After the 10- to 40-minute cycle completes, the user reenters the room and moves the device to the resident’s bathroom, another spot in the day/common room, or removes the device from the room.
Typical HPV Device Workflow
Before using a HPV decontamination device in a vacant, enclosed room, users must perform manual cleaning, disinfection, and drying of surfaces within the room, following product IFUs. Next, users should follow the HPV device IFU, which generally indicate to place the portable device in the room; seal HVAC vents, cover smoke detectors, and open cabinets/drawers in the room; place at least one chemical and biological indicator in the room; exit the room; seal all doors to the room using tape; and place a hazard sign at the sealed room doors.
Once the room is prepared, the user initiates a HPV cycle on the device controller and uses the handheld hydrogen peroxide sensor to verify that there is no HPV leakage around the outer doors. Several hours later after the HPV cycle completes, the user returns, unseals the room doors and cracks one door open. They hold the handheld hydrogen peroxide sensor within the room to verify that the chemical concentration is less than one part per million prior to room entry. Once verified, they unseal HVAC vents, uncover smoke detectors, and close cabinets/drawers within the room. Finally, the user documents the results of chemical and biological monitoring. If needed, the user responds to failed chemical and biological indicators per facility protocol.
Why use UV and HPV devices in long-term care facilities?
Supplemental disinfection technologies should only be used safely. Facilities should provide written protocols for each room that UV and HPV devices will be used, a list of any sensitive equipment that must be removed from the rooms, user training on the protocols, personal protective equipment that users should wear, and how users should respond to accidental UV and HPV exposure.
Amanda Sivek, PhD, a-IPC, is principal project engineer II, device evaluation, at ECRI.
ECRI Supplemental Disinfection Technology Resources:
Evaluation Background: UV Room Disinfection Devices
Evaluation Background: Countertop UV Disinfection Devices
Technology Briefing: Hydrogen Peroxide Vapor Room Decontamination Devices
Hydrogen Peroxide Room Disinfection for Preventing Healthcare-associated Infections
Dry Hydrogen Peroxide Disinfection Systems for Reducing Healthcare-associated Infections
Hasty Deployment of UV Disinfection Devices Can Reduce Effectiveness and Increase Exposure Risks(Hazard #6—Top 10 Health Technology Hazards for 2021)
Avoiding Misuse of UVC Room Disinfection Technology
Considerations for Clinical Use of Countertop UV Disinfection Devices
Technology Briefing: Chemical Fog Room Disinfection Devices
Technology Briefing: Electrostatically Augmented Disinfectant Spray Devices
Technology Briefing: Far-UVC Disinfection Devices
Technology Briefing: Filtration and Germicidal UV Light for HVAC Applications
Technology Briefing: Handheld UV Disinfection Devices
Technology Briefing: Permanent Environmental UV Disinfection Fixtures
Technology Briefing: Portable Air Cleaners and UV Air Purifiers
Technology Briefing: Upper-Air UV Disinfection Devices
Technology Briefing: UV Mobile Device Disinfection Boxes
Technology Briefing: UV Phone Disinfection Boxes
Technology Briefing: UV Room Disinfection Devices
Technology Briefing: UV Shoe Sole Disinfection Devices
July 1: What is the Significance in Infection Prevention?
By Jill E. Holdsworth, MS, CIC, FAPIC, NREMT, CRCST
This article originally appeared in the September 2023 issue of Healthcare Hygiene magazine.
Every year, July 1 comes around and, if you work in healthcare, you either love it or you dread it. Why? A new class of residents and fellows start in our facilities, and the trained, experienced physician trainees leave. There will always be those who feel July 1 means more medical errors and mistakes with less-experienced trainees; however, I have learned to take a different perspective—this is an incredibly exciting time where we can catch this new class when they first come in, teach them good habits right out of the gate so they will teach other residents that come after them correctly, thus creating a cascade effect of proper technique and practice. July 1 should be viewed as a significant opportunity in all areas of healthcare -- especially infection prevention!
It’s easier to dread July 1 than to see the silver lining, but why not try? Having new, bright minds ready to soak up every ounce of training and knowledge they can is such a powerful time. Residents want to do the right thing and they absolutely want to be taught correctly. When asked, many senior residents will tell you they were taught certain skills by the resident prior to them—thus the need to ensure all residents and fellows are taught basic infection prevention skills and knowledge correctly. How does this fit in with infection prevention? There are many ways infection preventionists (IPs) can impact how residents are learning, and thus help prevent infections.
One of my favorite memories of working with our teaching Head & Neck surgical team is when a resident came up to me before a case started in the operating room (OR) and held up a chemical indicator from a surgical drill tray that he had opened to prepare for the case and said, “I am not comfortable with how this indicator turned. I am going to send it back to the sterile processing department (SPD).” This was an incredible moment for our entire team and showed that we had come full circle in what we had talked about, learned and now were able to put it into action to keep our patients safe. But how did we get here?
You must put the time in as an IP — “Go to the Gemba,” as they say. This means to go where the work is done. When it comes to surgical teams, this may look different than your typical rounding with your nursing units, checking for isolation compliance and hand hygiene. To educate surgical teams, you first must understand their workflow, and to do this you must live it. I am the first to admit that this is not easy, and it means getting up very early and spending a lot of time with the team simply observing and learning. The first step is always spending time with the teams you are working with, getting to know their work, their barriers, and their work. When you gain their trust, they will learn from you as much as you learn from them.
When does the surgical team round? Who does the rounding? Who does the surgical prep in the OR? What is the resident’s role in the OR? Who marks the patients for clipping in pre-op? Do residents see the patients in pre-op? These questions will get you started with where you can make an impact with surgical site infection (SSI) protocols with your surgical team. In the past, we have surveyed a service line’s residents at the beginning of the year for general knowledge in skin-prep application techniques such as dry time, application time, as well as sterile processing practices such as checking blue wrap for holes, verifying sterility on chemical indicators, and asking questions about who taught them this information in the past. We spent the next year of their training teaching and emphasizing proper technique and protocols and then we surveyed them again at the end of the year and saw a significant difference in overall attitude and knowledge toward infection prevention processes.
When I spent time educating the surgical residents, I followed up on observing their cases alongside them, being in pre-op with them and tagging along during surgical rounds in the morning. Essentially, I became part of their team too. As an IP, we can either be a teammate or an auditor. I guarantee you that a teammate will get father every time. When I observe cases and attend surgical rounds, I don’t bring a clipboard or even a notebook. I put my hands up and let them know I am here to learn, listen and observe.
Teaching services also will have education sessions during their week—find when these sessions are and put yourself on the schedule. You can emphasize the educational topics you need to cover, show pictures of things you saw during rounds, ask questions about how you can help them, etc. When you become part of the solution, you become a teammate, and everyone begins working together. Everyone in the operating room should know how to check for sterility of instruments, perform an appropriate skin prep, and check an instrument wrap for a hole. When we partner with our physician trainees who may be doing these tasks, we can ensure not only that they are doing these tasks correctly and understand the importance, but that they pass down the correct information to the next class of trainees.
Jill E. Holdsworth, MS, CIC, FAPIC, NREMT, CRCST, is manager of the Infection Prevention Department at Emory University Hospital Midtown in Atlanta.
Rationing Rather Than Omitting Care: A Nursing Expert Addresses an Alarming Trend
By Kelly M. Pyrek
This article originally appeared in the August 2023 issue of Healthcare Hygiene magazine.
In the February 2023 and April 2023 issues of Healthcare Hygiene magazine, we examined the impact of missed nursing care on patient safety as well as infection prevention and control. In this column, we feature a conversation with nursing expert Kasia Bail, PhD, a professor of gerontological nursing at the University of Canberra in Australia, about the tough choices nurses make during every shift.
HHM: What do you believe has been the impetus for the recent number of papers on missing care?
Kasia Bail: Given the time that it takes to establish research and publish it, I suspect that the surge in numbers has more to do with the prevalence of the issue and the momentum that science gains when there’s a phenomenon that justifies examination. Developing and examining evidence is slow and happens incrementally and has been building for the last 20 years.
HHM: Did COVID perhaps bring this issue to the forefront? And how might COVID have exacerbated an already problematic trend of missed nursing care?
KB: This has certainly been the case and there are publications to support it (See: https://qualitysafety.bmj.com/content/30/8/639.abstract). I would argue that “missed nursing care” isn’t a new problem so much as it is a labeling of an ongoing issue. Nursing will always, and has always, rationed care in different ways. I think we need to involve the public in choosing what it wants nursing to ration. For example, my older nursing peers will often make jokes about how they used their time during shifts to make sure none of the pillowcase openings were facing the door, and to line up the wheels on the bed. Anecdotally, this was clinically and theoretically practical, to make sure the sand didn’t get into the pillowcases and the beds could be wheeled into the operating theatre promptly – various hang-ups from the Crimean War, perhaps. There is no evidence that I’m aware of, but one can assume nurses were choosing to use their time on these activities, rather than perhaps talking with patients or supporting family relationships or performing hygiene practices, which might have a stronger evidence base and cultural support now. Pillowcases and trolley wheels might sound like facetious examples, but the point being that the activities that nurses spend time on have always required prioritization; care has always been rationed. These days, if a nurse must choose between brushing someone’s teeth, administering a life-saving antibiotic on time, and admitting a new patient onto the ward so that a new bed can be created in the emergency department, it is logical that the teeth brushing will be the lowest priority. That doesn’t mean a nurse chooses not to do it but chooses not to do it right now and may choose to delay it within her shift or to hand it over to the next nurse. In the “Failure to Maintain” article I referred to, this kind of nurse decision making as “in-hospital triage.” I am a strong advocate for a “nurse interrupted” button in new digital information systems. Nurses work in multi-tasking, interrupted manners, yet many of the workflows being developed don’t recognize this and try to tie the nurse to the computer to complete her documentation. Nurses need to be able to make these decisions about immediate prioritization and be supported in delaying or postponing care but still communicating their need, to create a functional work environment that recognizes the reality of care rationing. Similarly, we need better data to help us make these decisions, and to support resourcing. For example, we often don’t have any clear measurable and comparable indicators about patient load – whether patients are self-caring and independent with showers or need bed sponges and two-hour wound dressings. Nurses are the flex of any hospital system, and we rely on their decision making within patient allocations and ward allocations to ensure care continues to be delivered. But that is rarely acknowledged in hospital governance systems, and minimal research. I recommend a key measure is the introduction of International Functional Standard – currently in use in rehabilitation hospitals only – to be included in acute-care hospitals for ICF (International Classification of Functioning, Disability and Health). This would still be a crude measure, but it would provide some indication of workload. There are many in use across the world, but many are resource intensive and require nurses to do more work to identify how much work they must do, which is ironic.
HHM: Is the current focus on healthcare professional burnout and nurse exodus from the field peri- and post-pandemic perhaps shedding more light on the issue of missed nursing care?
KB: The professional burnout has been an ongoing issue, but not really addressed, hence the ongoing issues. The pandemic brought the underlying issues to the fore at a time when even the best health systems in the world are stretched. The National Health Service (NHS) reaching its 75th birthday has been highlighted about the conflation of expectations and health management strategies (See: https://www.theguardian.com/books/2023/jun/17/fighting-for-life-by-isabel-hardman-our-nhs-by-andrew-seaton-review-the-nhs-at-75). The intersection between burnout and missed nursing care, and the factors that can ameliorate them, is a key area for research and intervention. The new attempt at Magnet rollout in Europe attests to this. (See: https://www.magnet4europe.eu/ and https://www.magnet4europe.eu/blog-page/four-questions-to-walter-sermeus)
HHM: Is the average nurse even aware of the concept of Cascade iatrogenesis? Is it a concept that should be included in nursing education?
KB: That’s a good question. Certainly, all the undergraduates in my university course would be exposed to this concept; however, university degrees are often contested with so many specialty areas vying for space. I suspect that as a complex issue it is perhaps not well covered (it would be a great research project for an honors or PhD student). Many health organizations don’t understand it well; all over the world we are trying to get the right balance of risk assessment (sometimes called comprehensive assessment), and then providing ameliorating or risk-modifying interventions. However, these are in addition to whatever the admitting diagnosis is (for hospitals, or other health services similarly). I would argue that cascade iatrogenesis is less the issue, than the ability of the staff to provide comprehensive care. In other research I’ve done it’s shown that nurses are under such pressure to complete the assessments – that is what is audited – but what care they provide to respond to that assessment is harder to audit. And so, there’s a perverse incentive, based on how clinical governance ends up working, that emphasizes the assessment and its documentation rather than the delivery of care. The reason this is an issue in relation to cascade iatrogenesis is that health services struggle to get the right balance to support staff to make decisions about patients that may be deteriorating. Missing someone’s cup of tea is a justifiable decision when it means making sure someone else’s antibiotic is administered on time. But when multiple cups of tea get missed, and then dehydration occurs, and then that isn’t assessed or identified and responded to, then the risk profile for that patient goes up. But arguably a large issue as to why cascade iatrogenesis may be occurring is less about what is taught, as what is translated into practice, and what is sustained based on the work environments. We also need to promote that the higher risk of complications means the need for higher prophylaxis. That sounds logical – when the risk for deep vein thrombosis is higher, there are protocols for clexane or heparin; when the risk for infection is higher, then there are protocols for antibiotic cover. However, with many of the competing nursing issues – confused patients, long wound dressings, complex medication regimes – there aren’t protocols to increase the prophylaxis, because the increased prophylaxis is increased nursing care. We have no clear way to “increase the nursing dose.” We rely on clever and articular shift managers, on ward managers communicating their needs to hospital administrators, or reviews of workload models, sometimes in conjunction with nursing unions. So, I would reiterate – we need to promote that higher risk of complications means the need for higher prophylaxis, and nursing care needs to be recognized and recommended as prophylaxis.
HHM: Do most nurses struggle with their decision to omit care, or is it more of an unconscious occurrence?
KB: This is a difficult question to answer. The old adage about “applying the oxygen mask to yourself before helping others” must be considered. Self-preservation is a natural response under threat – the increased pressure during covid that has intensified the front-line responses as well as public awareness of these tensions. Yes, nurses struggle with any decisions to omit care, but significantly, I would argue for the language of “rationing” rather than “omitting care.” All healthcare gets rationed, all health services make decisions about what they can and can’t provide, who’s within and who’s outside the boundaries of care, which medications make it to the subsidized list, which services are provided to which areas, which rural area gets the next diagnostic scanning machine (X-ray, MRI, CT, PET). But the difference with nurses is that it’s very direct, it is within the four walls of the ward that the decisions are made, which is all the more reason that the emotional labor of those nurses making the decisions must be considered. Research shows that many nurses leave roles when they are dissatisfied with the quality of care they are able to provide. But equally, yes, nurses will unconsciously omit care. There is research that highlights that some rationing of care can become habitual – that nurses may be used to being busy and get used to using the most streamlined approach they have developed to save them in times of duress. I believe patient teeth-brushing has been habitually sacrificed, and the evidence seems to back this, as one of the most commonly rationed nursing tasks. But my hospital used to have backup toothbrushes and toothpastes but no longer does; we hardly seem to have any kidney dishes and most of the patients are bedbound so without a kidney dish it’s hard to help them brush their teeth in bed. And not all wards stock the mouth buds, which quite frankly are fine for a quick mouth refresh for a dying patient but not particularly useful if someone needs a vigorous toothbrushing. So, if there isn’t the environmental nudge toward this good practice then it can reinforce this habitual de-prioritization. Will the after-hours shift coordinator prioritize delivery of a toothbrush at 9pm? I doubt it (I’m happy to be corrected!), but they would an antibiotic, so that helps you see what practices get enabled and prioritized systemwide. I think that increasingly missed nursing care is also being taught in the nursing curricula, particularly given the increasing science supporting and investigating the phenomena. I think the bigger issue is the shock that people experience about nurses having to ration their care. There will always be a finite number of resources. Health is no different to other areas of the economy, but arguably is dealing with the conflating issues of ageing populations, which means an increased volume of the population with complex illnesses that require ongoing treatment (rather than dying from their conditions); as well as increased expectations about health and medical care due to increased technology and specialization in responding to conditions, as well as increased transparency in terms of clinical governance. These do great things to support quality care, but they also put additional pressure on those settings to deliver. Nurses will always be the face of many of these health interactions, and in hospital settings in particular, the tensions between who receives the resource – in this case, nursing time -- is more visible.
HHM: In your study, were the nurses working as general floor/unit nurses or were they specifically tasked with infection control-related duties? Did this make any difference in their behavior?
KB: Seven of the 11 interviewees were directly in infection control nursing roles. The other four had varied roles which are specified. Further research, including quantitative research which seeks to differentiate different types of nurses and their value of infection control practices, would be interesting. I think this article highlights, however, that staffing needs to be controlled for the questions of “Do higher proportions of RNs affect the value placed on infection control? Or does a higher proportion of RNs reduce the incidence of missed nursing care?” Missed nursing care research is very hard to do prospectively however, hence the dearth of research in this arena.
HHM: Is missed care attributable to a gap in knowledge or a gap in practice, or both, and should this be a wake-up call that training and education need improvement?
KB: I think that is an oversimplification of complex issues, which is all too common in the interpretation of nursing work. I would encourage a review of the sections in our paper on the “whole of hospital” approach on pages 4-5. These nurses talked about how they needed to be able to talk convincingly to get the support of accountants to make appropriate purchases. The nurses also talked about there being excellent policies in place, but not enough nurses to make the policies deliverable. These are issues beyond teaching undergraduate nurses, or a gap in translating their learnings into practice – it’s a wake-up call that all layers of hospital administrators need to better understand and respect infection control nursing work, collect local data, and respond meaningfully.
HHM: Is it simply a matter of resourcing and staffing, to address missed nursing care in infection control-related practices, or is it also a behavioral issue/human factors engineering-related issue?
KB: It’s absolutely both. We know from the magnet hospital research, which has continued to be supported through decades of research (and increasing continental reach, with the European Magnet Hospital program in mid-delivery) that hospitals with good work environments have better outcomes. We know that the ingredients of these healthy work environments include resourcing and staffing as well as sound clinical governance and trusting and effective relationships between nurses, managers and other health professionals.
HHM: You make a very key statement in your paper when you observe “There are many situations of clinical care delivery that have not had robust research conducted to support the practice, despite widespread expert recommendations." This is a very big reason why many nurses in the U.S. believe they can skip some infection prevention-related practices, so how can this be addressed by health systems?
KB: Great question. Healthcare is always delivered in a state of uncertainty – evidence is continually being developed and refined, and some elements of care will always have a more theoretical principled approach and will not be able to develop a gold standard prospective clinical trial to “prove” an association or demonstrate the ‘best’ way. There’s an interesting article on the World Health Organization’s 5 Moments of Hand Hygiene highlighting the impracticality of this “protocol” which doesn’t have an evidence base. That doesn’t mean it doesn’t work – it is a very sound theoretical approach, and as an adoptable system has likely increased the hand hygiene practices and therefore infection rates. (See: https://qualitysafety.bmj.com/content/31/4/322 and https://www.sciencedirect.com/science/article/pii/S0195670123000725) Clinicians are accustomed to working in very messy settings where the group norms determine the practices, as well as making their own clinical decisions – that’s what they are paid to do, as registered health professionals. This is why some data and monitoring, as well as healthy working relationships, are crucial to be able to assess and interpret practices in an ongoing manner. Again, the magnet hospital approach supports this transparency and openness to practice development and change. (See: https://www.nursingworld.org/organizational-programs/magnet/magnet-model/ and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4431919/)
HHM: This is also a key observation from your paper: "Activities are prioritized in relation to the perceived impact of non-performance" -- are nurses taking it upon themselves to reject evidence-based practice because they think there is negligible impact on patients? Isn't this a potential undoing of any patient safety-first nursing care?
KB: I think that is an extreme interpretation, regarding “rejecting evidence-based practice.” The point of evidence-based practice is for the clinician to make interpretations of the evidence, and apply them in relation to the current situation, and their knowledge of the patient. I often tell my students to imagine they have one hand on the patient, one hand on their pile of textbooks and journals, and they themselves are the body in the middle with the eyes and ears to interpret the situation and try to make the best possible decision. I would argue that nurses work with a never-ending litany of contextually imagined yellow and red flags of possible future, potentially likely and actual and immediate threats to patient safety on a minute-by-minute basis. They manage this through “cognitive stacking” – continually re-prioritizing their mental list of tasks and worries as their shifts progress (See: https://journals.lww.com/jonajournal/Abstract/2005/07000/Understanding_the_Cognitive_Work_of_Nursing_in_the.4.aspx). It is exhausting, exacting and delicate work. They use their knowledge of their patients, biology, pathophysiology, pharmacology, hospital systems, hospital policies, hospital personalities and time and other resources to make these decisions on a minute-by-minute basis. An activity that will alleviate an immediate and actual threat to safety (and, of course, patient comfort) may need to take priority to a possible threat with a lower likelihood of risk outcome. It is a never-ending and constantly adapting risk matrix that the nurse conducts without much support. It has been argued that nurses would benefit from “clinical supervision” – the approach that psychologists use to reflect on the complexities of their role in working patients and use a mentor to help reflect on decision making and allow space for growth and adaptation. This is being taken up in a number of jurisdictions. This reflective practice would offer an opportunity to review practices and policies with a peer. Arguably this used to often happen in handovers, however handovers are now often done by tape recorder or at the bedside and/or with the computer, potentially limiting the reflecting learning space that they provided. In the style of magazine questionnaires, I have compiled some examples of the kinds of impossible decisions nurses deal with on a minute-by-minute basis:
You have 10 minutes left in your shift. Do you:
Check whether Mary’s pain relief has worked or if she needs another 5mg of endone.
Check the emergency trolley and make sure all equipment is present and sterile if appropriate in case of a life-threatening code next shift.
Go home early. You’ve already done two hours unpaid overtime this week.
You are interrupted mid-task. Do you:
Continue your task of educating Mr. Aliia regarding his colostomy bag, including infection control practices and emotional support for coming to terms with his new body
Stop your current task, and attend to Mavis the patient in the next room who you have been told is nauseous and about to vomit
Depends on whether you like Mr. Aliia or Mavis better
You are set up to do a catheter insertion on Maria. You realize you may have touched the tip of the sterile catheter with your sterile glove but you’re not sure. Do you:
Stop the procedure, and set it all up again, because the risk of infection is present and you would like to save Maria from that risk
Continue the procedure, because you’re not certain you did touch it so the risk is small, and also because Maria is confused with delirium and also doesn’t speak English as a first language, so you think you would do more harm by lengthening the procedure, and also because relieving her distended bladder with the catheter may ease her delirium, which is a higher and more immediate risk than the risk of infection
Call out to see if another nurse can help you make the decision
Reference: Bail K, et al. Missed infection control care and healthcare-associated infections: A qualitative study. Collegian. Vol. 28, Issue 4. Pages 393-399. August 2021.
Navigating the Environmental Protection Agency’s Lists of Disinfectants
By Katherine Lunt, MPH, MBA, CIC, HEM
This article originally appeared in the July 2023 issue of Healthcare Hygiene magazine.
In healthcare, cleaning and disinfection are extremely important to prevent the spread of infections. Cleaning is the physical removal of visible dirt, blood, body fluids, and other foreign material from objects and surfaces and must be performed prior to disinfection. Disinfection is the process of destroying microorganisms, such as bacteria, viruses, and fungi. There are three levels to categorize disinfectants: low-level, intermediate-level, and high-level disinfectants.
High-level disinfectants are intended to be used for critical and semi-critical medical devices and instruments; high-level disinfectants are regulated exclusively by the Food and Drug Administration (FDA) and are not intended to be used on environmental surfaces. Intermediate-level disinfectants are intended to be used on some semi-critical items and non-critical items. Low-level disinfectants, such as environmental surface chemical disinfectants, are intended to be used on noncritical items. Intermediate-level and low-level disinfectants are regulated by the Environmental Protection Agency (EPA) and have EPA registration numbers.
The Environmental Protection Agency (EPA) and Chemical Disinfectants
There are several types of disinfection methods used in healthcare. The most common method of environmental disinfection is chemical disinfection. Chemical disinfection is a process that uses chemicals to destroy microorganisms. Some common chemical disinfectants for environmental surface disinfection used in healthcare include alcohols, quaternary ammonium compounds, phenolics, and sodium hypochlorite (i.e., bleach). In the United States, the EPA regulates pesticides, including chemical disinfectants, used in healthcare to ensure they are safe and effective. An EPA-registered chemical disinfectant has been evaluated by the agency and certifies that the disinfectant is effective against the pathogens specified on the disinfectant’s label. Appendix A outlines the lists of antimicrobial products registered by the EPA.
The EPA requires laboratory potency testing for products to support product label claims. Chemical disinfectants labeled as “hospital disinfectant” have passed potency testing for activity against three representative organisms: Staphylococcus aureus, Pseudomonas aeruginosa, and Salmonella cholera suis. Hospital disinfectants that demonstrate potency against mycobacteria may include “tuberculocidal” on the label as well and are considered an intermediate-level disinfectant. A chemical disinfectant labeled as a hospital disinfectant without a tuberculocidal claim is considered a low-level disinfectant.
Selecting a Disinfectant on an EPA-Registered Disinfectant List
Chemical disinfectants are often marketed and sold under different brands and product names. To find out more information about a specific chemical disinfectant, locate the EPA-registration number on the product label. The EPA-registration number is listed on the product as EPA Reg. No. and is followed by two or three sets of numbers on the label. Search the EPA-registration number in the specific EPA-Registered Disinfectant List of the pathogen you are trying to kill exactly as the number appears on the label. If the disinfectant is EPA-certified, it will populate on the list and include the following information:
The Registration number is listed on the product. This is to help you identify the product on the EPA disinfectant lists.The Active Ingredient/s is the ingredient in the disinfectant that destroys the pathogen.
The Product Name is the common name of the product.
The Company is the manufacturer of the disinfectant.
The Contact Time in Minutes (“dwell time” or “wet time”) is the amount of time that the surface must remain wet for the disinfectant to work effectively.
The Formulation Type denotes whether the disinfectant is ready-to-use or requires a dilution for safe use.
The Surface Types describes the type of surfaces that this disinfectant can be used on. For example, many disinfectants can only be used on hard, nonporous surfaces, which would include most high-touch surfaces.
The Use Sites (Hospital, Institutional, Residential) are the settings where the product is intended to be used.
If there is not an EPA-registered disinfectant list available for a specific multidrug resistant organism (MDRO), search for a product claim against the organism or bacteria itself. To is important to highlight that MDRO denotes that the organism is resistant to treatment, not disinfection. MDROs are still susceptible to disinfection. Occasionally, a disinfectant will include kill claims against a specific MDRO. If the chemical disinfectant is effective against a drug-resistant form of the organism, it is effective against all forms of the organism.
Always follow the information on the product’s label and adhere to the instructions for use (IFU), personal protection equipment (PPE) requirements, and contact time to ensure maximum efficacy of the chemical disinfectant.
Appendix A – Antimicrobial Products Registered with EPA for Claims Against Common Pathogens
List A: Antimicrobial Products Registered with the EPA as Sterilizers
List B: Antimicrobial Products Registered with EPA for Claims Against Mycobacterium tuberculosis (TB)
List C: EPA’s Registered Antimicrobial Products Effective Against Human HIV-1 Virus
List D: EPA’s Registered Antimicrobial Products Effective Against Human HIV-1 and Hepatitis B Virus
List E: EPA’s Registered Antimicrobial Products Effective Against Mycobacterium tuberculosis, Human HIV-1, and Hepatitis B Virus
List F: EPA’s Registered Antimicrobial Products Effective Against Hepatitis C Virus
List G: Antimicrobial Products Registered with EPA for Claims Against Norovirus (Feline calicivirus)
List H: EPA's Registered Antimicrobial Products Effective Against Methicillin-Resistant Staphylococcus aureus (MRSA) and/or Vancomycin-Resistant Enterococcus faecalis or faecium (VRE)
List J: EPA’s Registered Antimicrobial Products for Medical Waste Treatment
List K: Antimicrobial Products Registered with EPA for Claims Against Clostridium difficile Spores
List L: Disinfectants for Use Against Ebola Virus
List M: Registered Antimicrobial Products with Label Claims for Avian Influenza
List N: Disinfectants for Use Against SARS-CoV-2
List O: Disinfectants for Use Against Rabbit Hemorrhagic Disease Virus (RHDV2)
List P: Antimicrobial Products Registered with EPA for Claims Against Candida Auris
List Q: Disinfectants for Emerging Viral Pathogens (EVPs)
Katherine Lunt, MPH, MBA, CIC, HEM, is an infection preventionist with ECRI.
References:
CDC. 2019. Background E. Environmental Surfaces. https://www.cdc.gov/infectioncontrol/guidelines/environmental/background/services.html.
CDC. 2016. Chemical Disinfectants. https://www.cdc.gov/infectioncontrol/guidelines/disinfection/disinfection-methods/chemical.html.
CDC. 2016. Cleaning. https://www.cdc.gov/infectioncontrol/guidelines/disinfection/cleaning.html.
CDC. 2016. Guideline for Disinfection and Sterilization in Healthcare Facilities (2008), Tables and Figure: Table 1. https://www.cdc.gov/infectioncontrol/guidelines/disinfection/tables/table1.html
Environmental Protection Agency (EPA). 2022. Selected EPA-Registered Disinfectants. https://www.epa.gov/pesticide-registration/selected-epa-registered-disinfectants
WHO. 2018. Table 3.3.3, Spaulding Classification of Equipment Decontamination. In: Global Guidelines for the Prevention of Surgical Site Infection. https://www.ncbi.nlm.nih.gov/books/NBK536426/table/ch3.tab7/
Biofilms and Healthcare
By David W. Koenig, PhD
This article originally appeared in the June 2023 issue of Healthcare Hygiene magazine.
Healthcare facilities -- such as hospitals, nursing homes and outpatient facilities -- are opportunistic locations for acquiring secondary infections unrelated to a patient's primary condition. Healthcare-acquired infections (HAIs) are a primary concern for healthcare providers, administrators, and governments worldwide due to the reduced quality of healthcare and the considerable associated socioeconomic costs resulting from extended hospital stays for infection treatment.
Some of the most common HAI types occur during the use of indwelling medical devices, such as a catheter, endotracheal tube, feeding tube or prosthesis. According to the Centers for Disease Control and Prevention (CDC), the most common underlying cause of infections related to in-dwelling medical devices is the ability of microorganisms to adhere to the surface of devices and form biofilms. Biofilms are often associated with tissue infections such as chronic wounds, skin infections, endocarditis, chronic otitis media and cystic fibrosis.
Biofilms are a gathering of microbes that colonize various surfaces. Many biofilms are beneficial. The beneficial human microbiome consists of diverse biofilms on the skin, teeth and mucosa of the gut, nasal, and reproductive organs; however, if a biofilm contains pathogens, these biofilms can become a severe concern for healthcare facilities, leading to HAIs.
The aspect of most concern is increased resistance to antimicrobials and antibiotic therapy; because of this concern's broad acceptance that the most effective way to reduce the incidence of medical device-related infections is to prevent primary microbial adhesion and subsequent biofilm formation.
Biofilms produce an extracellular polymeric substance (EPS) that protects the microbes in the biofilm. EPS interferes with the penetration of antibiotics or antimicrobials through biofilm. EPS interference is compounded by the cells in the biofilm having an altered physiology that further protects those cells from any antimicrobial that might penetrate the biofilm. Biofilms also provide the microbes with an environment that allows cell-cell communication and quorum sensing and enhances the transfer of genetic elements and resistance genes. Indeed, biofilm bacteria can transform into a persistent state that mimics a spore. Ultimately, biofilms increase the prevalence of antibiotic-resistant microbes and the risk of transmission to the caretaker and patient.
Healthcare environmental biofilms can act as reservoirs for the transmission of pathogens. Biofilms are commonly associated with surfaces that remain wet; however, a biofilm cover surface does not necessarily have to appear watery to the eye for a biofilm to persist. Recently, dry surface biofilms have been receiving extensive study. Dry surface biofilms form an exterior veneer while the surface is wet and then dry when the moisture dissipates. Biofilm EPS plays a critical role in the persistence of a dry biofilm allowing the retention of enough water for sustained survival. Biofilm "hot spots" can include drains, sinks, plumbing connections, areas of toilets that remain wet and not cleaned with mechanical action, bathrooms, sink traps, air filtration mediums, window ledges and seals, air conditioning systems, fabrics, and carpets and rugs. Dry surface biofilms grow on various surfaces, such as blood pressure cuffs, intravenous poles, door handles, touch screens, and cell phones. Dispersion of cells from biofilms can perpetuate microbial resistance, recurrence, and transmission of dangerous pathogens in the healthcare environment.
The types of microbes associated with biofilms are very diverse. The most common bacteria associated with hospital device-related infections is Staphylococcus epidermidis. Other hospital biofilm bacteria are methicillin-resistant Staphylococcus aureus (MRSA), Viridans Streptococci, Enterococcus faecalis, Vancomycin-resistant Enterococci (VRE), Escherichia coli, Pseudomonas aeruginosa, Acinetobacter baumannii, Proteus mirabilis, and Klebsiella pneumoniae. Recently, the fungi Candida auris has emerged as a critical biofilm-associated pathogen. Other medically associated fungi that form biofilms are Aspergillus, Cryptococcus, Trichosporon, Coccidioides, and Pneumocystis— furthermore, human viruses and bacteriophages present in biofilms.
Control of biofilms is complex. For device-related biofilms, various prevention strategies are initiated. One process is to impregnate the device with leachable antimicrobials such as silver. Another is to coat the surface with anti-adherents that interfere with the initial attachment of the microbe to the surface, interfering with the 1st step of biofilm formation. There is also the possibility of imprinting micro-patterns on surfaces that inhibit biofilm formation. These tactics have allowed various levels of protection from biofilm formation on devices. Removing biofilms from animate surfaces commonly involves mechanical methods such as water jets and sonic disruption, widely found in dental cleaning.
Prevention and removal of biofilms on inanimate environmental surfaces are just as challenging. The biofilm is often on a surface that is hard to reach or in a dead leg within a water system. Cleaned and disinfected surfaces contiguous to the contaminated area can be readily re-contaminated by biofilm dispersion leading to a transmission hot spot. A strategy to help reduce surface recontamination is to employ a persistent antimicrobial. For example, copper-containing materials, such as bed rails, have prevented biofilm formation. Using a residual disinfectant may also be an excellent option to reduce the recontamination of a surface.
Biofilms are inherently resistant to chemical disinfectants; therefore, mechanical and chemical methods are usually employed to treat environmental biofilms effectively. Mechanical methods may include abrasive scrubbing, high-power sprays and jets, and sonic cleaning, to name a few. Strong oxidants such as peracetic acid are good candidates for treating biofilms, although insufficient evidence exists to distinguish between product performance and biofilms. Recently, there has been a trend for disinfectant manufacturers to evaluate disinfectant performance against biofilms. Additionally, if the biofilm matrix or dead biofilm cells remain on a surface after cleaning, biofilms will form faster than surfaces free of the contaminating material. Removal of the biofilm matrix after disruption on surfaces points out the importance of removing biofilm debris as a prophylactic for future biofilm control.
Healthcare biofilm control is a cornerstone in reducing antimicrobial resistance and making a significant dent in HAIs. Everyone involved in cleaning must better understand and grasp the types of disinfectants required to control healthcare biofilms. Therefore, more effort is needed in all these knowledge areas to help healthcare practitioners and caregivers develop efficient tactics to identify, prevent, and remove biofilms.
David W Koenig, PhD, is principal of DKMicrobios LLC, founded in 2022 to provide consulting microbiology and skin biology services for R&D, technology discovery, product development, R&D strategy and portfolio assessment, IP landscaping, technical writing, and EPA submissions. Koenig has 35-plus years of experience in the life sciences (microbiology and skin biology) with government labs (NASA), private industry R&D, and academia. He also is a member of the advisory board for the Environmental Services Optimization Playbook (EvSOP).
References:
Aillón-García P, Parga-Landa B, et al. Effectiveness of copper as a preventive tool in healthcare facilities. A systematic review. Am J Infect Control. 2023.
Alonso VPP, Gonçalves MPM, et al. Dry surface biofilms in the food processing industry: An overview on surface characteristics, adhesion and biofilm formation, detection of biofilms, and dry sanitization methods. Comprehensive Reviews in Food Science and Food Safety, 22(1), pp.688-713. 2023.
Barnes M, Feit C, et al. Antimicrobial polymer modifications to reduce microbial bioburden on endotracheal tubes and ventilator-associated pneumonia. Acta biomaterialia. 91, pp.220-234. 2019.
Brandwein M, Steinberg D, et al. Microbial biofilms and the human skin microbiome. NPJ biofilms and microbiomes, 2(1), p.3. 2016.
Dancer SJ. How Do Biofilms Affect Surface Cleaning in Hospitals? Hygiene. 2(3), pp.132-135. 2022.
De Vos WM. Microbial biofilms and the human intestinal microbiome. NPJ biofilms and microbiomes. 1(1), pp.1-3. 2015.
Fanning S and Mitchell AP. Fungal biofilms. PLoS Pathogens. 8(4), p.e1002585. 2012.
Ferrer MD and Mira A. Oral biofilm architecture at the microbial scale. Trends in microbiology. 24(4), pp.246-248. 2016.
Gu H, Lee SW, et al. Magnetically driven active topography for long-term biofilm control. Nature Communications. 11(1), p.2211. 2020.
Harper DR, Parracho HM, et al. Bacteriophages and biofilms. Antibiotics. 3(3), pp.270-284. 2014.
Horton MV and Nett JE. Candida auris infection and biofilm formation: going beyond the surface. Current clinical microbiology reports. 7, pp.51-56. 2020.
Ikner LA, Rabe AB and Gerba CP. Residual Sanitization of Three Human Respiratory Viruses on a Hard, Non-Porous Surface. bioRxiv, pp.2023-03. 2023.
Iseppi R, Sabia C, et al. Virulence factors, drug resistance and biofilm formation in Pseudomonas species isolated from healthcare water systems. Current Microbiology. 77, pp.1737-1745. 2020.
Jorge P, Magalhães AP. Antimicrobial resistance in three ways: healthcare crisis, major concepts, and the relevance of biofilms. FEMS Microbiology Ecology. 95(8), p.fiz115. 2019.
Mazaheri T, Ripolles-Avila C and Rodríguez-Jerez JJ. Elimination of mature Listeria monocytogenes biofilms formed on preconditioned and non-preconditioned surfaces after the application of cleaning treatments and their cell regeneration. LWT, 173, p.114316. 2023.
Mazaheritehrani E, Sala A, et al. 2014. Human pathogenic viruses are retained in and released by Candida albicans biofilm in vitro. Virus research. 179, pp.153-160.
Moore G, Stevenson D, et al. Biofilm formation in an experimental water distribution system: the contamination of non-touch sensor taps and the implication for healthcare. Biofouling. 31(9-10), pp.677-687. 2015.
Nkemngong CA, Voorn MG, et al. A rapid model for developing dry surface biofilms of Staphylococcus aureus and Pseudomonas aeruginosa for in vitro disinfectant efficacy testing. Antimicrobial Resistance & Infection Control, 9(1), pp.1-9. 2020.
Richardson M and Rautemaa-Richardson R. Exposure to Aspergillus in home and healthcare facilities' water environments: focus on biofilms. Microorganisms. 7(1), p.7. 2019.
Saleem Z, Godman B, et al. Point prevalence surveys of health-care-associated infections: a systematic review. Pathogens and global health. 113(4), pp.191-205. 2019.
Tahir S, Chowdhury D, et al. Transmission of Staphylococcus aureus from dry surface biofilm (DSB) via different types of gloves. Infect Control Hosp Epidemiol. 40(1), pp.60-64. 2019.
Vadyvaloo V and Otto M. Molecular genetics of Staphylococcus epidermidis biofilms on indwelling medical devices. The International Journal of artificial organs. 28(11), pp.1069-1078. 2005.
Yin W, Xu S, et al. Ways to control harmful biofilms: prevention, inhibition, and eradication. Critical reviews in microbiology. 47(1), pp.57-78. 2021.
Zhen X, Lundborg CS, et al. Economic burden of antibiotic resistance in ESKAPE organisms: a systematic review. Antimicrobial Resistance & Infection Control. 8, pp.1-23. 2019.
Infection Prevention and Surgeon Collaboration: The Secret Sauce to Working Together
By Jill E. Holdsworth, MS, CIC, FAPIC, NREMT, CRCST
This article originally appeared in the May 2023 issue of Healthcare Hygiene magazine.
Preventing surgical site infections (SSIs) can seems very daunting to infection preventionists (IPs) and one of the hardest parts of forming an interdisciplinary team can be finding an engaged surgeon champion who wants to make changes globally for all service lines. Where do you start with surgeon engagement? How do you involve physicians in general to partner for success? I have found a multi-factorial approach is the best way to go when working on any type of healthcare-acquired infection (HAI), but it is even more important when tackling SSIs.
Finding Common Ground: I have heard physicians say that finding something that we both find important to connect with is the key to starting a partnership. In other words, “What’s in it for me?” Most physicians have a to-do list that the infection prevention department can help them with, but they don’t know where to start. Once you begin a partnership with SSI work, you can start to learn what they have on their minds, form action plans and get to work. One personal tip—work on things that are service line specific with your surgeon champions, so the tasks are personalized and feel very tailored to their needs.
Rounding Together: How often do you round with your surgical teams? I have one warning for you—you will need to wake up very early. The rewards far outweigh the lack of sleep. When I started rounding with our ENT/head and neck surgical team, I first had to walk in with my hands in the air and tell them I am honestly here to learn from them, not to audit. As IPs, it’s very hard to round anywhere or with anyone and not be viewed as the “auditor” or “surveyor.” I made it a habit to not bring a notebook or anything to write on to prove I was there to simply observe, learn and see what they did each morning. To be honest, this took some time before we all built trust with each other, but when this happened, the results were more than we could have asked for. They started calling me when they found issues, they invited us to their resident education sessions to discuss certain topics like skin prep, hand hygiene, scope processes, etc. We even found common ground in the operating room, where we improved the pre-op clipping process with our head and neck surgeries, skin prep and understanding how to check sterile indicators in instrumentation—all because the IP team put away their clipboards and were humble enough to learn and observe FIRST and put building relationships first.
Our SSI champion as well as head and neck surgeon, Dr. Brian Boyce, says, “Collaborating with our infection prevention team has been critical to the success in reducing post-operative surgical infections in our patients. Our infection prevention team brings a unique perspective to the entire perioperative process that enabled us to identify and mitigate risk factors for SSI.”
Involving the Residents: As mentioned above, residents can be your most influential asset when learning about the opportunities and challenges or barriers in various aspects of prevention infections.
Surgical Instruments: Show the surgeon. Have you ever gone through the surgical set with the surgeon? Give it a try. Going through each set, inspecting the instrumentation in each set together as a team and using this as a quality tool for the surgical team, infection prevention department and sterile processing department can help everyone. This is something we did with our ENT resident team and surgical attending, which also let us know we needed to do additional education on how to look for holes in wrappers and how to verify sterilization from the chemical indicator in the tray. For facilities who have residents, you may find they are taught by the resident prior to them, and prior to them, and so on. If you can teach them right the first time, they will start teaching those who follow in their footsteps correctly. Start asking yourself the question, how do my residents get education on an annual or routine basis on all infection prevention items? Once you learn this answer, insert yourself into that process.
In summary, surgeons will become interested in what the infection prevention department is doing when they see there is something that interests them, that IP is invested in them and/or their program or that IP shows them how beneficial and inclusive the programs are for their practice. Gaining trust, building relationships, and putting in the effort up front is key to a successful partnership between infection prevention and our surgeon partners.
Jill E. Holdsworth, MS, CIC, FAPIC, NREMT, CRCST, is manager of the Infection Prevention Department at Emory University Hospital Midtown in Atlanta, and is currently co-chair of the AAMI PB70 Committee.
Applying Infection Prevention to Endoscope Evaluations
By Margaret Miller, BS, MT(ASCP)M, CIC, FAPIC; Mairead Smith; and Amanda Sivek, PhD
This article originally appeared in the April 2023 issue of Healthcare Hygiene magazine.
Endoscopy is a valuable diagnostic and therapeutic tool for many clinical specialties, but the technology presents a particular challenge to infection prevention. Long, flexible endoscopes with internal working channels or intricate mechanical elevator mechanisms can harbor contaminants and microorganisms despite best efforts to clean and disinfect them.
Reprocessing can include hundreds of individual steps. The steps are broadly grouped into "point of use" pre-cleaning, leak testing, inspection, manual cleaning (brushing), high-level disinfection or sterilization, rinsing, drying, and finally, storage. Improper handling and storage practices at any point can re-contaminate previously disinfected scopes, heightening the risk of patient infections.
Often, these critical tasks are performed by healthcare workers (HCWs) with limited time, resources, and tools working in cramped spaces with poor ergonomics. Although FDA and experts have repeatedly emphasized the need to adhere closely to a manufacturer’s reprocessing instructions, gaps and variations in practices are common.
Endoscope Reprocessing in the Real World
Through consultations with medical facilities, ECRI has observed some recurring issues, including:
• Confusion regarding expiration dates on test strips – specifically, the shelf life of sealed, unopened test strips as compared to shelf life after packaging has been opened
• Lack of separation between clean and dirty areas in endoscope reprocessing rooms
• Insufficient HCW education and training, including rationale for essential steps
• Use of brushes not recommended by a manufacturer - for example, a toothbrush
• Too few scopes to meet demand
• Failure to plan to replace scopes at the end of their useful life. Scopes require maintenance to remain functional and intact. Damage may inhibit reprocessing and clinical functionality.
• Failure to routinely clean the scope storage cabinets, and
• Storage of endoscopes in procedure rooms – for convenience, or lack of another appropriate storage area.
In addition, ECRI surveyed HCWs who perform duodenoscope pre-cleaning and manual cleaning about their experience. Three-hundred forty-one HCWs responded. Responses showed that:
• Approximately 8 percent of respondents did not have the required equipment to perform their work
• 12 percent of respondents’ facilities do not have a procedure for situations when manual cleaning is delayed; another 12 percent did not know if their facility had a procedure
• Greater than 50 percent of respondents reported experiencing moderate, significant, or excessive discomfort in each of the following areas: lower back, neck, shoulders, and mid-back
To combat these challenges, ECRI recommends that facilities establish reprocessing protocols and policies for HCWs based on professional association guidelines. This will support a safe environment for HCWs and help reduce the risk of infection for patients. All endoscopes are to be cleaned and high-level disinfected or sterilized according to the manufacturer's instructions for use (IFUs).
Further, HCWs should be trained in standard infection prevention and control practices as well as model-specific cleaning and high-level disinfection processes for each endoscope type. Make the IFUs understandable and accessible to your HCWs by posting checklists, graphics, and other memory aids for helping in times of stress (like high production pressure), and for tasks that are not performed often. And remember that IFUs change as suppliers update their recommendations. Consider having the endoscope manufacturer provide annual training or an onsite update when a new reprocessing technique or accessory is introduced. The goal is to have a safe scope to use for every patient.
Possible Technological Solutions to Consider
Publicized outbreaks of multi-drug resistant organisms, linked to ineffective reprocessing of duodenoscopes over the last decade, have helped to drive technological and practice changes across the endoscope landscape. Beginning in 2015, the U.S. Food and Drug Administration (FDA) required manufacturers to conduct post-market surveillance studies to understand duodenoscope cross-contamination. Since then, major duodenoscope manufacturers have introduced new models with single-use endcaps, intended to improve access to the difficult-to-clean elevator mechanism. Other manufacturers have introduced fully single-use models.
In 2022, FDA recommended that healthcare facilities transition to these newer duodenoscope models. ECRI has found that single-use endoscopes can offer advantages for:
• Patients with compromised immune systems
• Patients with a known infection
• Situations when scope reprocessing is unavailable (for example, after hours)
• Facilities that perform endoscope procedures infrequently
However, the cost of single-use endoscopes may be prohibitive for facilities that perform a high volume of procedures, and in some cases, physicians may need advanced features that are not currently supported by single-use models.
In 2021, FDA similarly recommended that facilities consider the use of single-use bronchoscopes “in situations where there is increased risk of spreading infection.” They further recommended that facilities consider routine sterilization of reusable bronchoscopes when feasible to increase the margin of safety, as compared to high-level disinfection.
Facilities looking to transition to sterilizing endoscopes will need to:
• Verify that validated sterilization methods exist for current endoscope inventory, or transition to models that support sterilization
• Ensure that proper sterilization equipment that conforms to endoscope IFUs is available
• Consider any time, space, or cost challenges associated with moving from a high-level disinfection workflow to a sterilization workflow
Conclusion
Endoscope reprocessing is mission-critical, labor-intensive, meticulous, and often time-sensitive work. Staff may not have access to all the resources they require. Despite when reprocessing guidelines are carefully followed, cross-contamination continues to occur. Reprocessing recommendations and technology continue to evolve. Infection preventionists, clinicians, and healthcare facilities need to make informed decisions about the latest developments to keep progressing towards our joint goal of preventing pathogen transmission from patient-to-patient.
Margaret Miller, BS, MT(ASCP)M, CIC, FAPIC, is an infection preventionist at ECRI.
Mairead Smith is principal project engineer I at ECRI.
Amanda Sivek, PhD, is principal project engineer I at ECRI.
References:
1. Healthcare worker views: duodenoscope reprocessing workflow and ergonomics. Device Evaluation 2021 Jun 9.
2. Sivek AD, Davis J, Tremoulet P, Smith M, Lavanchy C, Sparnon E, Kommala D. Healthcare worker feedback on duodenoscope reprocessing workflow and ergonomics. Am J Infect Control. 2022 Jan 30: S0196-6553(22)00055-4. Doi: 10.1016/j.ajic.2022.01.012. Epub ahead of print. PMID: 35108583.
3. Poor Duodenoscope Reprocessing Ergonomics and Workflows Put Healthcare Workers and Patients at Risk: Hazard #8—2022 Top 10 Health Technology Hazards. Device Evaluation 2022 Jan 12. For members: Top 10 Health Technology Hazards for 2022: Solutions Kit (ecri.org)
Executive brief available at: Top 10 Health Technology Hazards for 2022 Executive Brief (ecri.org)
The Role of Evidence-Based Guidelines and Consensus Documents: What is Required?
By Sylvia Garcia-Houchins, MBA, RN, CIC
This article originally appeared in the March 2023 issue of Healthcare Hygiene magazine.
Healthcare organizations (HCOs) preparing for survey understand they will undoubtedly be asked to reveal which evidence-based guidelines (EBGs) their facility uses. This is a staple of survey, whether conducted by The Joint Commission, the Centers for Medicare and Medicaid Services (CMS) or a state since all require the use of EBGs.
The most accurate way to prepare for and respond to this EBG inquiry during survey is to:
• Identify which EBGs and consensus documents are required vs. those that are optional
• Document and disclose basic processes used for determining required elements
How many EBGs are required?
The Joint Commission does not require a minimum number of EBGs. HCOs that receive CMS deemed status through The Joint Commission can locate required EBGs within program-specific CMS State Operations Manuals. For example, the Ambulatory Surgery Center (ASC) State Operations Manual states, “The infection control and prevention program must include documentation that the ASC has considered, selected and implemented nationally recognized infection control guidelines.”
During an ASC deemed status survey, Joint Commission surveyors complete a form to identify selected guidelines and must confirm a selection or score non-compliance “even if the ASC’s infection control practices comply with generally accepted standards of practice/national guidelines.”
The survey form lists potential guidelines ASCs may select, including:
• The Centers for Disease Control and Prevention’s (CDC) isolation, hand hygiene, environmental, or disinfection and sterilization guidelines
• The Association of periOperative Registered Nurses (AORN) Perioperative Standards and Recommended Practices
• Specialty surgical societies’ guidelines
Each surveyor must indicate at least one infection control-related EBG by name during survey.
During the guideline selection process, while it is critical infection preventionists understand there is no specified number of EBGs to consider, they must demonstrate their facility has reviewed and selected EBGs to implement. Additionally, they must maintain an active and organization-wide infection control program consistent with nationally recognized infection prevention standards.
Which EBGs are required by The Joint Commission and/or CMS?
During every Joint Commission survey, compliance is evaluated with:
• CDC and/or World Health Organization (WHO) 1A, 1B and 1C hand hygiene guidelines (NPSG.07.01.01 EP1)
• CDC isolation guidelines (IC.02.01.01, EP 2 and 3 on standard and transmission-based precautions)
Joint Commission standards and CMS requirements are not prescriptive regarding other EBGs or consensus documents that HCOs must consider or implement. CMS recently clarified this within its interpretive guidance chapters:
• Hospitals have ample recognized evidence-based approaches to select from in order to adhere to nationally recognized guidelines without impeding their ability to otherwise make progress in infection prevention and control.
• ASCs must select one or more sets of guidelines that enable them to address the key functions of an effective infection control program.
Joint Commission standards contain general wording that specifies an HCO should “measure and monitor its infection prevention processes, outcomes and compliance using EBGs or best practices, and consider EBGs when implementing evidence-based practices.”
Are there any other requirements for EBGs?
Joint Commission-accredited HCOs that have considered, selected and implemented nationally recognized infection control guidelines should be considered compliant as long as there are not manufacturer instructions for use (IFUs) or state regulations that otherwise specify compliance with a particular EBG or consensus document.
Joint Commission standards require HCOs comply with state law and regulation and follow manufacturer IFUs as part of a hierarchical method to address infection control-related requirements.
Several states have adopted specific EBGs or consensus documents by incorporating them into healthcare code requirements. It is key HCOs access their specific state requirements as they vary from state to state. For example:
• Illinois: Requires long-term care (LTC), ASCs and hospital settings to adhere to specific CDC guidelines ,
• New Jersey: Provides an exception to the adoption of specific CDC guidelines by LTC if there is sound infection control rationale based upon scientific research or epidemiologic data. Additionally, specific Advancement of Medical Instrumentation (AAMI) and Society of Gastroenterology Nurses and Associates (SGNA) standards are required for central services.
• Texas: Requires ASCs to develop policies and procedures for sterile supplies based on standards, guidelines and recommendations by AORN, Association for Professionals in Infection Control and Epidemiology (APIC), CDC, and if applicable, SGNA.
Infection preventionists may access statutes, codes and regulations by state but should be cautious to ensure they have considered all applicable requirements based on their unique healthcare setting and confirm requirements with the source and/or legal counsel.
Additionally, manufacturer IFUs may direct users to reference EBGs and consensus documents for further information. HCOs must ensure EBGs are used to clarify additional requirements and not to supersede the IFU.
If an EBG is not required, how can infection preventionists assess whether it should be incorporated into their infection control program?
It is essential for infection preventionists to pay careful attention to sources and processes used to develop recommended infection control practices. They should know the difference between an EBG, guidance, consensus documents, position statements and policies, as well as the processes used to develop these documents so they can make educated choices.
• EBGs: Developed to answer questions via a literature search protocol which identifies relevant articles. The evidence in those articles is then abstracted and summarized before a group assesses it and formulates recommendations based on consensus. Before approval and publication, factors assessed include impact, feasibility, and risk and benefits. EBGs should provide references for the user to evaluate relevance and context specifically for their HCO.
• Guidance: Meant to provide instruction on how to address a situation and may include relevant literature. However, guidance documents may not consider unique aspects of each HCO and must be carefully evaluated to determine risk and benefits to HCOs that follow the guidance.
• Consensus documents: Created by a group and represent those individuals’ collective opinions, which may or may not be supported by scientific literature. If a consensus group follows the American National Standards Institute (ANSI) and agrees to its oversight, procedures, approval process and more, their resulting consensus document becomes an American National Standard. ISO standards are an example of consensus documents developed through the consensus of experts from many countries and approved and published by a globally recognized body. Infection preventionists may need to review literature to ensure it supports recommendations made in consensus documents.
• Position statements: Provide viewpoints of a professional organization on a particular topic, as well as background and rationale to support that viewpoint. Infection preventionists may need to do their own literature review to determine if the viewpoint is sound or could be negated by additional information.
• Policies: Represent both how an HCO interprets relevant requirements and how it implements them.
Misinterpreting EBGs, guidance, consensus documents and position statements as requirements and adopting policies of other organizations with differing requirements, especially across state lines, has led to significant misunderstandings regarding Joint Commission and CMS requirements. Such misinterpretations can result in regulatory, financial and resource implications for HCOs Infection Preventionists must clearly articulate to surveyors which EBGs are required within their state or manufacture instructions and which EBGs or other documents have been incorporated by choice.
Which part of an EBG is required by The Joint Commission?
Unless required by Joint Commission standards, regulation or manufacturer instructions, HCOs may choose which segments of EBGs and consensus documents to incorporate into their practices. To help identify the appropriate recommendations to use, HCOs should consider level of recommendation or word choice, for instance:
• CDC (use of rankings): 1A and 1B recommended, 1C required, and II suggested
• AORN (use of a word within context of the guidelines): Should indicates action is recommended; must describes requirements mandated by regulation; may indicates action is permissible within the limits of the guideline; and can indicates possibility and capability.
• Association for the Advancement of Medical Instrumentation (AAMI) (use of verbal terms within documents to distinguish its requirements): Shall and shall not express requirements; should and should not express recommendations; may and may not express permission; can and cannot as statements of possibility or capability; might and might not express possibility; and must signifies external constraints or obligations defined outside the document.
It is important to review rankings and terms provided by authors seek clarity of a perceived requirement from the authoring organization.
Infection preventionists need to clearly understand when, which and what part of EBGs are required before selecting a particular EBG or another document to incorporate into their infection control policies, protocols or processes. They should add recommendations above the basic requirements from EBGs to organizational requirements only if they are based on compelling evidence that the improve safety or quality, are feasible, and cost effective. Requirements based of optional EBGs should never be added if they conflict with routine organizational practices.
An ideal EBG process is one that includes multidisciplinary input and evaluation of EBGs and other documents before they are incorporated into policies. Since leadership is responsible for the development and implementation of organizational policies, there should be a process to ensure leadership agrees with the incorporation of optional EBGs. This helps an HCO avoid being scored for non-compliance during survey and allows it to explain which and what part of EBGs have been incorporated into its infection control program.
Sylvia Garcia-Houchins, MBA, RN, CIC, is director of infection prevention and control for The Joint Commission.
References:
1. The Joint Commission. Clarifying Infection Control Policy Requirements. Perspectives. April 2019.
2. Illinois Administrative Code. Title 77 § 300.696 available at Section 300.696 - Infection Prevention and Control, Ill. Admin. Code tit. 77 § 300.696 | Casetext Search + Citator Accessed February 25, 2023
3. Illinois Administrative Code. Title 77 § 250.105 available at Section 250.105 - Incorporated and Referenced Materials, Ill. Admin. Code tit. 77 § 250.105 | Casetext Search + Citator Accessed February 25, 2023
4. New Jersey Administrative Code. Section § 8:43G-14.1. Available at Section 8:43G-14.1 - Infection control program structural organization, N.J. Admin. Code § 8:43G-14.1 | Casetext Search + Citator Accessed February 25, 2023.
5. Texas Administrative Code. Section 135.11 Available at https://casetext.com/regulation/texas-administrative-code/title-25-health-services/part-1-department-of-state-health-services/chapter-135-ambulatory-surgical-centers/subchapter-a-operating-requirements-for-ambulatory-surgical-centers/section-13511-anesthesia-and-surgical-services Accessed February 25, 2023.
Revised Liquid Barrier Standard Reflects Real-Life Experiences, Needs of End Users
By Jill E. Holdsworth, MS, CIC, FAPIC, NREMT, CRCST
This article originally appeared in the February 2023 issue of Healthcare Hygiene magazine.
The Association for the Advancement of Medical Instrumentation (AAMI) has released an updated version of the American National Standard of personal protective equipment (PPE) in the healthcare environment. This standard, ANSI/AAMI PB70:2022, Liquid barrier performance and classification of protective apparel and drapes intended for use in healthcare facilities, has been revised for the first time since the last release in 2012. Why update now? What has changed? Quite frankly, a lot. As healthcare providers, representatives from professional organizations, and manufacturers, the committee has incorporated a vast amount of knowledge to ensure the standard reflects real-life experiences and needs of end users.
A main driver for the revisions centered on the limited variety of gowns that were listed in the document. The committee members wanted to expand the choices to allow for more specific personal protective equipment (PPE) to be selected for individual tasks and jobs. By expanding the definition of the choices of gowns, as well as updated the labeling requirements to ensure clear labeling of the type of gown you are choosing, the end user will be provided a safer environment for their work.
A new category of surgical gown was introduced, labeled “Surgical Gown-E.” This gown specifically provides extended protection in the critical zones due to the nature of certain procedures and actions that may require a higher level of protection from potentially infectious materials.
Additional explanation of procedure gowns, such as definition protection for open-back gowns, non-protection back gowns, and decontamination gowns were also added to assist the end-user in making an informed choice on what gown to wear during specific tasks.
The decontamination gown for sterile processing professionals is a new category that is of particular interest to those who have ever worked in sterile processing and/or at a decontamination sink. Have you ever taken off your PPE after working several hours in the decontamination area and your scrubs underneath are wet from strike-through? Were you wearing an appropriate gown? One of the bigger questions is—do you know what an appropriate gown for working in the decontamination area is? Now, with the new updates to PB70, this is very clear. Decontamination gowns must be a minimum of an AAMI Level 3; how can end users use this to move forward with the new standards immediately? Until manufacturers begin marketing new gowns with this label, end-users should check their current gowns to be sure they have gowns with this minimum level of protection for their team members.
Future plans and work items for the PB committee include developing a standard for emergency preparedness and PPE practices by gathering data and information from the lessons learned during the COVID-19 pandemic. The group will also focus on updating the current TIR11 (Technical Information Report) document to assist end users with implementing the PB70 document into the daily practices.
Jill E. Holdsworth, MS, CIC, FAPIC, NREMT, CRCST, is manager of the Infection Prevention Department at Emory University Hospital Midtown in Atlanta, and is currently co-chair of the AAMI PB70 Committee.
The author acknowledges Cheron Rojo, BS, FCS, CHL, CIS, CER, CFER, CRCST, co-chair of the AAMI PB70 Committee, for editing assistance with this article.