The Importance of Infection Prevention Expertise: Why Google Can't Replace a Professional
By Melissa Travis, MSN, RN, CIC, FAPIC
This article originally appeared in the December 2024 issue of Healthcare Hygiene magazine.
Several years ago, I shared a story that still resonates with me today, especially after living through a global health crisis. The pandemic exposed a glaring gap in infection prevention knowledge and underscored the need for true expertise to guide preventive measures. Healthcare facilities faced unprecedented challenges with managing the spread of a novel virus while also maintaining their current infection prevention practices.
Infection preventionists (IPs) were on the front lines, rapidly developing and implementing protocols to protect both patients and healthcare workers while trying to keep their current program from deteriorating. Without the expertise of IPs, many healthcare facilities would have been ill-equipped to manage the complex infection control challenges presented by COVID-19. This leads to my story about a surprising moment when I was told I could be replaced — by Google.
Let me start by saying that I appreciate the value of Google as much as anyone. However, the notion that one could "Google" their way through infection prevention still makes me cringe. Allow me to set the stage. I was preparing to leave a previous role after serving as the IP for about five years. I was working with my supervisor, a senior leader, to create a transition plan for managing the infection prevention program until a new specialist could be hired. That’s when this educated leader casually told me that, for anything she didn’t understand, she could simply “Google it.” Even now, I remember that moment with disbelief. She had no idea what she didn’t know, and it worried me deeply about the future of the infection prevention program at that facility. Unfortunately, this misconception is not unique; I’ve heard similar comments from other leaders who underestimated the expertise required to manage an infection prevention program effectively.
Like many specialized fields in healthcare, Infection prevention takes years of training and hands-on experience to master. Most IPs begin with a basic knowledge base in an adjacent field such as nursing or microbiology but grow considerably over the first couple of years, eventually achieving certification through rigorous testing. Developing the skills to be an effective IP requires extensive training and mentorship. After nearly two decades as an IP, the idea that my experience could be replaced by a search engine seems, frankly, absurd. While search engines are valuable, infection prevention demands expertise built over time through education and experience, not a quick online search. Not to mention the time and effort it takes to build a credible reputation so that you can influence other highly educated professionals. The role requires significant emotional intelligence and the ability to inspire trust.
Infection prevention is not just about implementing protocols and writing policies; it’s about collaborating with healthcare providers, patients, and families, often in challenging and high-stakes environments. An IP must navigate complex interpersonal dynamics, advocate for best practices, and sometimes challenge longstanding habits and beliefs to promote safe, evidence-based care. Infection prevention is far more complex than simply promoting hand hygiene and covering your cough. While those are important infection prevention measures, it also encompasses research, policy development, influencing behavior, fostering relationships, planning skills, teaching new principles, alleviating fears, and ensuring compliance.
Infection preventionists are also skilled in analyzing and interpreting data, which is essential in identifying patterns, detecting outbreaks early, and reducing infection rates. The effectiveness of infection prevention efforts relies on a deep understanding of epidemiology and an ability to analyze infection data critically. This data-driven approach helps IPs implement targeted strategies and measure their impact, refining interventions to optimize outcomes. The idea that such work could be replaced by a search engine overlooks the nuance and context-specific strategies that a trained IP brings to infection prevention and control.
Moreover, infection preventionists have the skills to translate the surveillance data into actionable interventions and education for healthcare providers. Their role includes continuous training for healthcare workers on infection prevention and control practices such as proper hand hygiene, sterilization, and the correct use of personal protective equipment (PPE) all while staying current with the latest research and regulatory standards. IPs are subject to continuous learning and adaptation as laws, regulations, standards, and best practices evolve. Google may provide information on these topics, but it cannot substitute for the role of IPs in connecting the dots in real-time settings.
In summary, infection prevention is a multifaceted discipline requiring far more than basic online knowledge. From managing outbreaks to fostering a culture of safety, infection preventionists play an irreplaceable role in healthcare. While it may be challenging to quantify the worth of an experienced IP, the research has shown the staggering costs of healthcare-associated infections that these professionals help mitigate. These numbers make a compelling case for the critical role of IPs. Replacing their expertise with search engine results not only underestimates the complexity of their work but also poses risks to patient safety and quality of care. Healthcare leaders must recognize and invest in skilled IPs, ensuring they are valued as integral parts of healthcare teams. After all, the cost of inadequate infection prevention extends beyond finances—it impacts lives.
So, the next time you or a loved one enters a healthcare facility, consider this: would you rather have a seasoned IP or a search engine safeguarding you against infection?
Melissa Travis, MSN, RN, CIC, FAPIC, is the principal of IP&C Consulting, LLC and may be reached through her website: www.ipandcconsulting.com
Bugs Gone Wild
By Teri Hulett, RN, BSN, CIC, FAPIC
This article originally appeared in the November 2024 issue of Healthcare Hygiene magazine.
We’ve all heard about antibiotic stewardship (ABS). It’s been a buzzword within the healthcare world for decades. The Centers for Disease Control and Prevention (CDC) identifies ABS as a core strategy to combat antimicrobial resistance (AMR) by optimizing antibiotic use. In this article, we will review best practices to reduce AMR by preventing bugs from going wild and developing resistance which leads to suboptimal patient outcomes
.Antibiotic stewardship was first discussed in 1996. The Society for Healthcare Epidemiology of America (SHEA) published seminal stewardship guidelines in 1997 for the prevention of antimicrobial resistance (AMR). These guidelines provided criteria for infection control programs to focus on appropriate antibiotic selection, appropriate antibiotic dosing, and prescribing for the appropriate duration of time. Effective, robust antibiotic stewardship requires a multi-disciplinary team approach that includes the infection preventionist (IP). The role of the physician and pharmacist is to review providers’ prescribing practices and provide timely audit and feedback. The role of the IP and nurse on the ABS team is to take the lead on diagnostic testing with respect to chart review for clinical indication for the ordered test and reviewing the culture and sensitivity report for any resistant organisms, communicating with the provider to ensure they review lab results in a timely manner, and for those on IV antibiotics, moving from IV to PO once the patient meets the criteria.
The CDC moved forward next with developing the Core Elements of Antibiotic Stewardship with setting-specific guidelines; Core Elements of Hospital Antibiotic Stewardship Programs:2019, Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals, Core Elements of Outpatient Antibiotic Stewardship, Core Elements of Antibiotic Stewardship for Nursing Homes, and Core Elements of Antibiotic Stewardship Programs in Resource-Limited Settings: National and Hospital Levels. The core elements provided a formalized structure for the work moving forward.
Universal core element interventions included, as noted above, appropriate antibiotic selection, appropriate antibiotic dosing, and appropriate antibiotic duration. Chart review identified new challenges; in some cases, antibiotics were ordered without a culture being obtained, which made it impossible to ensure the appropriate antibiotic was prescribed for the appropriate organism – checking for the bug/drug match. The next challenge identified was that often cultures were being ordered in an attempt to identify if a patient was admitted to a facility with an active infection, the best example of this is the patient presenting to the emergency department (ED) and as part of the admission orders, a urinalysis (UA) and/or urine culture (UC) are ordered. The risk in this situation is for the patient who presents without any clinical indication for a urinary tract infection (UTI) but the lab results identify dirty urine and the provider inappropriately treats the patient with an antibiotic for a UTI, which is identified as a diagnostic error.
This led to a focus on diagnostic stewardship identified in a 2017 Journal of the American Medical Association article Diagnostic Stewardship-Leveraging the Laboratory to Improve Antimicrobial Use. The article states the decision to order a test should be “guided by clinical evaluation, recognition of a clinical syndrome, and estimation of the pre-test likelihood of the condition for which the test is obtained.” Benefits of diagnostic stewardship are improved clinical care, fewer false-positive test results and less overdiagnosis – increased accurate diagnostic results which allow for appropriate antibiotic prescribing and decreased antibiotic exposure which decreases the risk for AMR.
The positive outcomes of diagnostic stewardship has led the CDC to release recently the Core Elements of Hospital Diagnostic Excellence Assessment Tool Priority Examples and Core Elements of Hospital Diagnostic Excellence Assessment Tool Additional Examples. The CDC advises hospitals to “set aside resources for a diagnostic excellence team and committee; to track and report any incorrect diagnoses; to involve patients in care decisions and to put protocols in place to ensure the right diagnostic tests are ordered, interpreted, communicated and acted upon.” This supports the need to commit necessary resources to this work. While at a conference on antimicrobial resistance this month, there was an IP attendee from a foreign country who shared that she just received approval for a full-time nurse whose job will be to take the lead on this work.
It’s time we as infection preventionists start developing a business case for the same thing here in the United States. Reducing patient harm, improving patient outcomes and preserving a decreasing resource in our antibiotic armamentarium as more and more antibiotics develop resistance is key to maintaining effective antibiotics in our tool box of treatments in the future.
Teri Hulett, RN, BSN, CIC, FAPIC, has been in nursing for 44 years. Her experience includes 27 years as a bedside nurse with her area of specialty being neonatal ICU. She transitioned from the bedside to infection prevention in 2006. Over her tenure as an IP, she has served in multiple leadership roles at the local level to include president of the APIC Mile High Colorado Chapter, and at the national level as chair of the APIC Education Committee. She has been involved in multiple projects and initiatives at the local, regional, and national level, and has co-authored multiple articles published in peer-reviewed journals. Infection prevention and control areas of focus include antimicrobial and diagnostic stewardship to include co-leading a two-year statewide antibiotic stewardship collaborative for Colorado in 2016. She continues to partner with and mentor colleagues in antimicrobial stewardship across the continuum of care.
Going with the Flow: AAMI ST108:2023 and What to Know
By Hillary Hei, MPH, CIC, LSSGB, FAPIC
This article originally appeared in the October 2024 issue of Healthcare Hygiene magazine.
The transition from AAMI TIR34:2024 to AAMI ST108:2023 is an evolution in water quality standards for the processing of medical devices, shifting from advisory best practices to enforceable standards. This new standard is a comprehensive approach to ensure water quality and steam purity with proper design, monitoring, testing, and maintenance. Here is a summary of the key changes and requirements in AAMI ST108 for healthcare:
Multidisciplinary Water Management Team
One of the most significant changes is the requirement for healthcare facilities to establish a multidisciplinary team responsible for water quality and the water management program. The team can be comprised of internal or external partners and should have representatives of the following disciplines, including but not limited to senior organizational leadership, facilities engineering, infection prevention and control, medical device processing, clinical engineering, surgical suite/procedure room personnel, and water treatment. This team is responsible for developing, implementing, and documenting all parts of the Water Management Program. This multidisciplinary team of diverse roles ensures a comprehensive approach to water management and ultimately ensuring patient safety.
Categories of Water Quality and Criteria
AAMI ST108 expanded the categories of water quality for medical device processing to include:
Utility Water: This is water from the tap that may require further treatment. It's used for flushing, washing, and initial rinsing of medical devices.
Critical Water: Extensively treated water to ensure the removal of microorganisms, inorganic, and organic materials. It's used for final rinse or steam generation.
Steam: Water heated to vapor phase, used for sterilization of medical devices.
The standard also lists water quality parameters for all three categories, including pH, alkalinity, bacteria, endotoxin, and ionic contaminants.
Water System Design
AAMI ST108 places strong emphasis on proper water system design. The system should be appropriate for the specific needs of the facility, with proper installation, operation, and performance evaluations as necessary components. An expert in water treatment and knowledge of local feedwater conditions is essential for planning the configuration of the water system. Facilities may need to further treat municipal feed water to produce utility water, including particulate filtration and some form of softening. The goal of treating utility water is to prevent scale formation and ensure adequate pH levels for compatibility with cleaning agents. To produce critical water, required water systems can include reverse osmosis (RO), deionization (DI), electrodeionization (EDI), and distillation. These systems are used to extensively treat the water to remove all microorganisms, inorganic, and organic contaminants. Lastly, the standard emphasizes a validation plan of the installed water system, including creating and conducting operational protocols.
Ongoing Water Monitoring and Maintenance
AAM ST108 introduces more stringent testing and monitoring requirements to maintain the integrity of the water treatment system. Table 4 in ST108 is a guideline for monitoring requirements, while Table 5 provides a minimum frequency of testing. The primary accountable party for monitoring water quality is the facility’s engineering/water maintenance personnel, but sterile processing staff should be aware of water quality monitoring and its implications when testing does not meet certain thresholds. Contaminated water used in processing instruments can contribute to corrosion, staining, and elevated risk of microbial transmission. To prevent these adverse effects, frequent monitoring and continuous quality improvement ensures that water quality is maintained and does not deteriorate over time. Lastly, this standard emphasizes the need for maintenance protocols during emergency circumstances, such as extended service interruptions or boil water advisories.
Considerations for Healthcare Facilities
The adoption and implementation of AAMI ST108 is a vital step toward improving efficacy and efficiency of water used in medical device processing and ultimately ensuring patient safety. Considerations for Infection Preventionists include partnering with facilities to understand current water treatment systems and the maintenance of these systems. Laboratory testing can assess the current quality of water used for processing, and regular audits and monitoring can assist in continuous improvement. Existing water management plans will need to be amended to incorporate new or revised policies and procedures, and all relevant personnel will need to be educated. Lastly, facilities may need to invest in infrastructure, such as upgrading or installing new water treatment systems. Failure to implement proper water systems may result in risk of non-compliance with Joint Commission standards, inability to perform surgery dues to failed sterilization tests, or patient health risks due to improperly sterilized or malfunctioning equipment.
In conclusion, AAMI ST108:2023 provides a significant advancement in water quality standards for medical device processing. Infection preventionists and other key stakeholders must familiarize themselves with these new standards and take proactive steps to ensure compliance, which may involve significant updates to existing water treatment systems and processes.
Hillary Hei, MPH, CIC, LSSG,B FAPIC, is a senior infection preventionist with ECRI, an independent, nonprofit organization improving the safety, quality, and cost-effectiveness of care across all health care settings worldwide. ECRI infection preventionists provide insights on topics of interest in infection prevention and control, environmental services, and sterile processing services to help advance worker and patient safety.
Reference: ANSI/AAMI ST108:2023. Water for the processing of medical devices. AAMI, Arlington, VA. 2023.
Risk Assessment in Infection Control: Do We Need a Standard?
By Linda Goss, DNP, BS, APRN, ANP-BC, COHN-S, CIC, FAPIC
This article originally appeared in the September 2024 issue of Healthcare Hygiene magazine.
Assessing risk in infection control is second nature; determining which format and numerical rating system to use is not always as clear. A quick search of the Centers for Disease Control and Prevention (CDC) website will reveal guidance and/or templates for assessing risk in healthcare construction, occupational health and safety, water safety and tuberculosis.
While the goal is clear -- risk should be assessed -- the process contains gaps and variability. A similar challenge is discussed in a publication titled Risk Analysis in Healthcare Organizations: Methodological Framework and Critical Variables, where the authors describe concerns in the approach to risk assessment in the field of risk management in healthcare. Staff in healthcare facilities are tasked with determining risk using a high low format however as the authors note they too could benefit from definitions and perhaps a revised or totally new design.
The infection preventionist (IP) designs the infection prevention and control program based on the results of the facility risk assessment which includes the following:
Geographic location and the community and population served by the facility
The various care, services and treatment provided at the facility
Local, state and/or federal requirements
The results of the risk assessment should be used to guide the infection prevention program, including surveillance and prevention activities as well as to develop goals. The emphasis on this process for prioritizing the next fiscal year activities would seemingly be better served with a more rigorous design. The choice between numerical ratings of 1-3 or 1-65 or 1-14 is generally left up to the facility to decide on as well as the method of totaling the number assigned to the risk e.g., adding or multiplying the totals. While the rating implies a quantitative analysis it is typically developed in a qualitative manner due mainly to the subjectivity in the scoring process. How reliable is the prioritization of infection control activities when the scale variability is so evident.
The International Organization for Standardization (ISO) relies on the expertise of members from around the world to develop and provide consensus on standards for management, technology and manufacturing. The standards provide structure and rigor designed to reduce variability and the stakeholders are explicitly challenged in the process of standard development to play a role in the outcome. Globally, organizations rely on ISO standards to do business as they know there is a high degree of reliability in the standard development process.
Membership in ISO is comprised of countries all over the world with the U.S. representation from the American Standards National Institute (ANSI). Founded in 1918, ANSI coordinates the voluntary consensus standards in the United States. They don’t write the standards, rather they oversee standards and how they are or aren’t conformed to in the United States. This may seem far removed from Infection Control however looking further into standard development will eventually lead to the American Society for Testing Materials or ASTM International.
This may seem familiar to most when during the height of the COVID-19 pandemic in 2020, ASTM opened their standards library for free so that IPs and others could closely examine the testing requirements related to personal protective equipment (PPE). Familiarity with ASTM in infection control is most closely associated with masks and their ability to protect the healthcare worker. While most of us in infection control were aware of the level of the masks for protection against splashes or sprays, there may not have been an awareness of the specification for materials performance or testing process as outlined in F2100. When PPE was in peak demand, there were many who were attempting to discern the “real” from the “fake” and the open standards allowed for greater insight to assist in that process. Furthermore, ASTM International published a whitepaper in February 2021 to discuss the state of infection control PPE standards and the development of a global collaboration platform. The platform, to be led by ASTM, was to address PPE challenges going forward with respect to standardization. Additionally, ASTM International joined with the National Institute for Occupational Safety and Health Administration (NIOSH) to develop F3502.21, a new standard addressing barrier face coverings.
These standards are applicable and followed by infection control as they directly impact healthcare workers and patients along with those from the Occupational Health and Safety Administration (OSHA) and the Association for the Advancement Instrumentation (AAMI). However, when it is time to review and/or develop the risk assessment that will guide the program into the future there is a lack of standardization. Some decisions around risk assessment may even fall to the level of using a word document or a spreadsheet to facilitate portability when surveyors ask for a copy. Additionally, collaboration of all stakeholders is a must for the risk assessment however again there is subjectivity and potential bias in assigning risk when the manager of an intensive care unit (ICU) assigns the rating on the potentially critical nature of the patient.
While this may be correct it does imply that every time a risk assessment is reviewed by the manager or the IP, the rating will always be higher in an intensive care unit (ICU) than on a medical surgical unit. The ICU may have made significant progress on healthcare-acquired infection (HAI) initiatives like catheter-associated urinary tract infections (CAUTIs); however, they will always have a higher numerical rating. The higher rating may or may not be necessary as the mandated reporting of certain HAI’s will take precedence over any rating as there isn’t a standard for approaching the risk. The next step after the rating or scoring is to assign priority to the highest rated risks. This is usually subjective in that the decision is made by the facility leaders, infection control and/or the infection control committee members. The decision is sometimes made by taking the top 10 or the top 15 highest-rated risks though this too could be adjusted.
In conclusion, the facility risk assessment is a necessary requirement, the components of the risk assessment are generally standardized however the process for assigning risk to the categories is not. Infection preventionists work tirelessly to implement guidelines, follow instructions for use (IFU) and design processes around regulatory requirements and best practice. However, when it is time to do the annual risk assessment the lack of a standard rating process can lead to unnecessary variability and potentially overinflated or underinflated priorities.
Ultrasound Technologies and IP&C: Balancing Appropriate Disinfection, Workflow and Manufacturer Recommendations
By Daniel Merton, BS, RDMS, FAIUM, FSDMS
This article originally appeared in the June 2024 issue of Healthcare Hygiene magazine.
The use of diagnostic ultrasound imaging is rapidly growing in conventional settings, such as radiology and cardiology, as well as for a wide range of point of care ultrasound (POCUS) applications. The use of nonionizing radiation allows ultrasound to be used on the most vulnerable of tissues such as the fetal brain, and structures in the eye, and permits its use when and where other imaging modalities cannot. While the clinical value of ultrasound imaging is well known, use of the modality can also present the potential for patient harm, most notably cross contamination leading to infection.
Regardless of whether it’s a premium cart-based scanner used in a maternal-fetal medicine setting, a handheld wireless probe used for a quick assessment of a patient’s lungs in the emergency department, or a portable scanner used to guide vascular access in the ICU, safe use of ultrasound devices demands appropriate and effective reprocessing. Ultrasound professionals (e.g., sonographers, echocardiographers) are expected to be familiar with the processes used to clean and disinfect the equipment they use, but many “new users’” of POCUS may not recognize the importance and particulars of properly reprocessing ultrasound devices – especially transducers (AKA probes). Some recent advances, such as touchscreens and sealed user interfaces, facilitate reprocessing, while others, such as probes that wirelessly connect to a smartphone for data display, pose additional infection prevention concerns, particularly if a clinician uses their personal smart device for POCUS applications.
Dr. Earle Spaulding, a microbiologist at Temple University in Philadelphia, classified reusable medical devices as critical, semi-critical, and non-critical based on the potential risk of patient infections from their use, and defined the required level of disinfection to minimize risk.1 Spaulding also classified levels of germicidal effectiveness as low-level disinfection (LLD), high level disinfection (HLD) and sterilization. Several organizations and professional societies including the American Institute of Ultrasound in Medicine (AIUM), Society of Diagnostic Medical Sonography (SDMS), and ECRI have published guidelines and recommendations pertaining to reprocessing ultrasound devices based on the Spaulding scheme.2-4 When applied to ultrasound probes, the Spaulding categories are noncritical (e.g., transducers that only contact intact skin), semi-critical (e.g., probes that come in contact with mucosal surfaces and probes used to scan near open wounds), and critical (e.g., probes used in sterile body cavities such as laparoscopic ultrasound probes, intracardiac echocardiography (ICE) catheter probes and robotic “drop-in” probes). More detailed information can be found in the references below.
Vendors of ultrasound equipment are required to validate reprocessing products and processes for their scanners and probes as part of the FDA 510(k) clearance requirements.5 Device Instructions for Use (IFU) include information regarding the approved cleaning and disinfection products and recommended procedures. The lists of approved products can be quite extensive, are frequently updated as new products become available, and it can sometimes be challenging to identify an approved product to use on a given transducer. The need to use vendor approved products can be particularly onerous for facilities that have ultrasound equipment from multiple vendors and their inventory includes many types of probes. Vendors base their recommendations on the intended clinical application of the probe – for example a probe used to perform abdominal or obstetric sonograms, and considered a non-critical device typically requires cleaning and LLD, which can be performed using a vendor-approved disinfectant wipe. However, a probe used to perform an endovaginal gynecologic ultrasound exam requires cleaning and HLD, which is more labor intensive and time consuming than LLD.
Note that the Spaulding system calls for sterilization of semi-critical devices such as endovaginal ultrasound probes, but HLD is commonly used as a chemical sterilant because most probes cannot undergo heat sterilization. Vendor approved products have been verified to be both biologically effective and not detrimental to device surfaces. Thus, it is important for users to follow a vendor’s reprocessing recommendations or risk ineffective disinfection, damage to the probe and possibly voiding the warranty. While vendors provide recommendations, it remains the responsibility of the user to choose appropriate cleaning and disinfection products based on the exam performed and facility policies.
Unfortunately, reprocessing recommendations from different sources are not always consistent, which can lead to uncertainty and inconsistency in reprocessing. For example, the 2021 Intersocietal Position Statement titled “Disinfection of Ultrasound Transducers Used for Percutaneous Procedures” indicates ultrasound probes that are covered by a sterile sheath and used in percutaneous interventional procedures, such as biopsies and vascular access guidance, require cleaning and LLD between use.6 This updated recommendation has been embraced by some users, such as vascular access (VA) teams who perform numerous ultrasound guided VA procedures every day. The previous recommendation of HLD for these devices was time and labor intensive, which adversely impacted workflow. However, this change has not been universally accepted and adopted. Some guidelines indicate that probes used for percutaneous interventional procedure guidance are semi-critical devices, and therefore require cleaning followed by HLD. Furthermore, the IFU may not address this specific clinical scenario, leaving it up to the user to determine an appropriate level of disinfection.
So, what should users do when faced with conflicting recommendations from vendors, professional guidelines, and their own facility’s reprocessing policies? Users should work closely with their facility’s infection prevention specialists to identify disinfection products and procedures that:
Are effective and provide the desired level of disinfection (e.g., LLD, HLD or sterilization)
Are approved for use by the probe vendor. Providers who have devices from multiple vendors must ensure compatibility of the disinfectant with each probe;
Minimize workflow disruptions
When considering a new disinfectant that is not listed in the device’s IFU, users should contact the vendor to see if the product is approved, but just has not been added to their device’s IFU. Many vendors also maintain on their website an updated list of validated cleaning and disinfection products for their systems and probes, which should be reviewed. Any deviations from the vendor’s recommendations should be documented in the IP&C policy document with an appropriate rationale.
In addition to reprocessing the transducer between each patient, the same must be done for the ultrasound scanner and accessories such as keyboards and gel bottles, as these also have the potential to harbor contaminants that could cause infection in patients or care givers. As the use of ultrasound continues to expand in many healthcare sectors, appropriate reprocessing of ultrasound devices is critical to ensure the safety of this increasingly important imaging modality.
Daniel A. Merton, BS, RDMS, FSDMS, FAIUM, is the ultrasound specialist and a principal project officer at ECRI.
References:
Rutala WA, Weber DJ. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 Update: May 2019. Available: Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 (cdc.gov) Accessed 5/15/2024.
AIUM Official Statement: Guidelines for Cleaning and Preparing External‐ and Internal‐Use Ultrasound Transducers and Equipment Between Patients as Well as Safe Handling and Use of Ultrasound Coupling Gel, Journal of Ultrasound in Medicine, 10.1002/jum.16167, 42, 7, (E13-E22), (2023). Available: Guidelines for Cleaning and Preparing External- and Internal-Use Ultrasound Transducers and Equipment Between Patients as Well as Safe Handling and Use of Ultrasound Coupling Gel (aium.org). Accessed 5/24/2024
Sonographer best practices for infection prevention and control: Reprocessing the Ultrasound Transducer. Available: pdf (sdms.org)
Cleaning and disinfecting diagnostic ultrasound transducers: our recommendations. Health Devices 2018 Jul 25. Available Cleaning and Disinfecting Diagnostic Ultrasound Transducers: Our Recommendations (ecri.org). Accessed 5/24/2024.
Marketing Clearance of Diagnostic Ultrasound Systems and Transducers: Guidance for Industry and Food and Drug Administration Staff. February 2023. Available: Marketing Clearance of Diagnostic Ultrasound Systems and Transducers | FDA Accessed 5/22/2024
Disinfection of Ultrasound Transducers Used for Percutaneous Procedures. Intersocietal Position Statement Disinfection of Ultrasound Transducers Used for Percutaneous Procedures - 2021 - Journal of Ultrasound in Medicine - Wiley Online Library Accessed 5/20/2024.
Considering Health Equity in Infection Prevention and Control Against Contagious Respiratory Viruses for Multigenerational Households in the Post-COVID-19 Era
By Shanina Knighton, PhD, RN, CIC
This article originally appeared in the May 2024 issue of Healthcare Hygiene magazine.
It is established that race, ethnicity, and socioeconomic status (SES) are associated with the incidence or infections of communicable illnesses and or death. Lower access to healthcare, greater exposures through employment, housing situation1 and a lack of education and understanding how to navigate life before, during and after exposure are contributing factors. However, a factor often overlooked that is intersectional with these challenges is infection prevention and control education for overcrowded households or multigenerational households (MGHs).
Overall, it is estimated that 20 percent of the U.S. population lives in a MGHs2,3 which is defined as households that include two or more adult generations, or grandparents and grandchildren younger than 25 living under one roof. Black American and Latino families are more likely to live as part of a multigenerational household than others. In 2016, compared to 16 percent of Whites, Black families were estimated to have 26 percent of people dwell in multigenerational households and Latino families 27 percent.2 Dense housing is often driven by economic pressures such as recent unemployment or lack of alternatives for caregiving.4 Additionally, cultural norms and a sense of shared familial responsibilities for taking care of the young and the old in the family may contribute to these trends.4,5
Individuals living in community-dwelling, low-income MGHs are likely one of the more difficult undeserved and vulnerable populations to reach. For individuals living in multigenerational housing, particularly infants and older adults and those with underlying health conditions, these challenges lead to a disproportionate risk for exposure to communicable respiratory viruses and once exposed, these individuals suffer the most severe consequences of these viruses.6 MGHs are more likely to have family members with varying viewpoints (e.g., vaccine hesitancy) in the current era of COVID-fatigue and science mistrust that can influence the outcomes of the home.
Unlike congregate living such as assisted living, nursing homes and group homes, multigenerational and overcrowded households do not have organizational advocates or practical informational resources applicable to their living situation. Furthermore, in congregate living settings standardized education and policies are put in place such as regular hand hygiene practice, support with cleaning of linens, environmental cleaning and safe food and medication handling. Thus, alternative, and innovative approaches to support infection prevention and control education for MGHs are critical to maintain interest and promote adherence to fundamental strategies that prevent the transmission of germs that lead to viruses such as influenza and SARS-CoV-2.
Infection prevention and control utilizing audience-specific messaging and educational resources especially for lower-income MGHs can be effective when tailored to address influential factors such as age, learning styles, and where people get their trust information from. For example, older adults may traditionally watch the news whereas teenagers and young adults may get their information from social media sources.
Oftentimes, when education is provided to patients upon discharge, the information provided takes into account directions for the patient, but rarely addresses infection prevention and control for where they live, work and play to not only protect themselves from complications and illness but to also protect their families.
Standardized education for households will vary, but it is important that as infection prevention and control move into community settings we start to connect the ‘why’ behind the ‘why’ for people. For example, explaining why family members should clean the handles to the fridge, light switches, doorknobs etc. that is commonly used by all and especially when someone in the home has a known illness. Furthermore, it is also producing a prevention plan that can minimize waiting too late to seek out care. Below, while there are many topics that can be discussed, I provide some areas that the public health community should focus on for improving the missing gap of multigenerational household infection prevention and control education.
MGHs Need Education About How:
To make an emergency response list of doctor information include phone #, put it in an accessible place like the refrigerator, and alert others where it is. Call the doctor if you or your household member(s) is getting sicker.
Track your symptoms and have someone track your symptoms: take their temperature several times a day, record readings, and note when new symptoms occur.
To not wait to be seen if you have life threatening symptoms such as chest pain or pressure that does not go away, confusion or cannot be woken up, shortness of breath, trouble breathing, feeling “off” bluish lips, fingers, feet, or face. Call 9-1-1 and seek emergency care.
Prevent spreading viruses from you to your loved ones vice versa.
Avoid touching face, especially after handling items touched by sick household members. Contagious respiratory viruses transfer by eyes mouth and nose droplets.
Hand Hygiene: Everyone in the home should wash hands often and correctly (20 to 25 seconds). Remember drying is just as important as washing. Clean your hands before and after touching your face and any items touched your or sick person.
Masks: Consider masks in the home for everyone to ensure germs are not being transferred between sick and well household members. Sick member should wear a mask. Always wash or sanitize hands first before and after using a mask, never leave a dirty mask sitting around, apply your mask to a clean face, do not take your mask off from the front, only remove ear to ear. Cough and sneeze into your elbow. Do not wear a mask if you think masks is troubling your anxiety, asthma, allergies, or chronic breathing problems, or under the age of 2 years old, but stay isolated. Wash masks daily, however, if possible, consider disposable ones if sick person cannot clean their mask daily.
Physical distance when possible: Limit contact with others as much as possible. Try to minimize your footprint by having a dedicated space if possible. Do not go within six feet of others in the home unless mouth and nose are covered with a mask or cloth. Have others prepare your food and try to eat in your room.
Social Coping and Connecting: For ways to feel socially connected consider interacting and communicating through video chat options on phone or computer video. Consider virtual games. If you share a room with someone you should use the bedroom as the isolated space in the home. Try to avoid contact with items in the room so that you will not have to go inside of the closed in space. Not having the capability to not share space may mean wearing masks at least for the ill person to help with source control. No visitors unless they are essential to getting better, however people at risk of dying from respiratory viruses such as people older than 65 years old, with chronic conditions such as heart disease and diabetes should stay away.
Shared Items: Avoid sharing personal items and spaces as much as possible. Do not share dishes, cups/glasses, silverware, towels, bedding, or electronics (like a cell phone) with the person who is sick. Be sure to wash down contaminated items immediately. If the ill loved one cannot walk, cover eyes, mouth and nose when delivering and removing meals (wash hands before and after).
Multi-user Bathrooms/Shared Surfaces: Try to use a separate bathroom. If not be sure to clean the sinks, doorknobs tables, hard-backed chairs, light switches, remote controls, handles on cabinets and refrigerators, desks, toilets, sinks, computer keyboards and mice, tablets, and more commonly touch areas daily before and after the use of you the sick person and others. If you cannot do it, advise family members to do so. Be sure to wash and or disinfect surfaces daily and allow it to dry. Pay attention to the contact time on the surface cleaners. Some must sit before you wipe them up in order for them to work effectively. This is found on the back of the product.
Fresh Air: Get fresh air into the home as much as possible by opening windows for good airflow. Viral droplets can stay suspended in the air; outside air helps reduce the number of droplets concentrated in the air in closed spaces. Use air exhaust systems, open windows to minimize potential virus droplets in the air especially since bathrooms are smaller areas. If you have a yard, garden, patio, balcony, or porch, spend time there to get outdoors, but stay 6 feet away from anyone who doesn’t live with you.
Trash: Dedicate a lined trash can for the person who is sick. Use gloves when possible. Immediately discard trash with contaminated items such as dirty tissues. Be sure to clean your hands after handling removing items from the person and placing outside the home.
Laundry: There is no need to launder clothing separately however to careful not to fluff clothing into the air. Consider wearing eyes, nose and mouth covering for safety. Be sure to wash your hands before and after handling the clothing items. Try to gather items in bulk so that you are not washing items daily. This helps minimize contact with sick person and their items. Be sure not to touch your face when handling items.
Shanina Knighton, PhD, RN, CIC, is an associate professor at Case Western Reserve University.
References:
1. Coughlin SS, Moore JX, et al. COVID-19 Among African Americans: From Preliminary Epidemiological Surveillance Data to Public Health Action. Am. J. Public Health 110, 1157–1159 (2020).
2. Cohn D, et al. A record 64 million Americans live in multigenerational household s. Pew Res. Cent. 1-8 (2017).
3. Taylor P, Passel J, et al. The Return of the Multi-Generational Family Household. Pew Research (2010).
4. Marquez-Velarde, G. Multigenerational Households: A Descriptive Approach to Distinctive Definitions. Nat. Switz. (2020) doi:10.1007/978-3-030-35079-6_15.
5. Keene JR and Batson CD. Under One Roof: A Review of Research on Intergenerational Co-residence and Multigenerational Households in the United States. Sociol. Compass 4, 642–657 (2010).
6. Abuelgasim E, et al. COVID-19: Unique public health issues facing Black, Asian and minority ethnic communities. Curr. Probl. Cardiol. Vol. 45 Issue 8 August 2020 100621 45, 1–10 (2020).
The Role of Human Factors Engineering in Infection Prevention
By Susan Singh
This article originally appeared in the April 2024 issue of Healthcare Hygiene magazine.
Infection prevention and control (IP&C) leaders are tasked with effectively implementing new surveillance technologies, creating innovative strategies to combat healthcare-associated infections (HAIs), and formulating plans for addressing emerging pathogens. Amidst a widespread shortage of healthcare personnel, IP&C leaders must seek new methods to adjust workload balance, promote long-term adoption and implementation of infection prevention measures, and keep patients, visitors, and staff safe.
Human factors engineering (HFE) is an applied field of study that focuses on creating tools, devices, and systems that address human abilities, limits, and characteristics within an environment. The application of HFE in healthcare can be a key method in reducing the more than one million HAIs that occur each year.1
What is human factors engineering?
HFE is the application of scientific methods to the design and evaluation of people’s knowledge, skills, abilities, and limitations as it applies to the design of tools, machines, systems, tasks, jobs, and their surroundings.
The goal of HFE is to focus on how work is done in situ versus how work is perceived to be done, considering environmental stressors that can create fallible situations for humans. HFE attempts to design systems that prioritize and optimize safety and enhance performance in a complex healthcare environment.
Why is it important to understand healthcare as a system?
When implementing HFE in infection prevention efforts, one must consider healthcare as a complex, multi-layered system. Due to the complexity of healthcare, it’s essential to identify and understand the various components of the system and how they interact. Thus, areas where the system is susceptible to errors and near misses are identified which allows human factors engineers (HFEs) to analyze performance data, arriving at optimized models of testable workflows striving for improved reliability and outcomes.
HFEs also define healthcare as a sociotechnical system, meaning it involves people and technology working together in the same environment.
Because healthcare is a sociotechnical system, workarounds or errors may arise from inadequate design or unintended use of tools. Issues in one area of the system can generate risks elsewhere: a ripple effect. Left unnoticed, ripples within any component of the system or systems have the potential to harm patients, individual workers, teams, or visitors. Understanding healthcare as sociotechnical reveals that human-environmental interactions are intricate and likely run deeper than what may be perceived upon first glance.
An example of HFE and IP&C
Considering that healthcare is a complex sociotechnical system, adverse incidents are not caused by one bad decision or action. Instead, incidents are caused by interactions between the systems component parts: people, tools and technology, tasks and processes, the physical environment, organizational policies, and even things outside the organizational environment.
Let’s look at a hypothetical example of how HFE can be used to investigate an increase in infections.
An outpatient hemodialysis clinic saw an increased incidence of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia amongst their patients. Between January 2023 – May 2023, they identified nine patients with MRSA after they presented to clinic with signs and symptoms of an active infection.
Outbreak investigation uncovered that the dialysis treatment area was not being appropriately cleaned and disinfected by environmental services (EVS) personnel. An Apparent Cause Analysis placed the blame on EVS, citing non-adherence to protocols as the cause of the outbreak. However, HFEs investigated further and uncovered several problems in the overall hemodialysis work system, including how people interact in the clinics environment:
• Post investigation, the HFEs learned about the challenges that the EVS staff faced. EVS are expected to clean the dialysis treatment area after each of the three dialysis shifts. However, the dialysis treatment area is never without patients and staff members.
• Patients wait in the dialysis treatment area instead of the designated waiting room. Staff and patients are also using empty chairs in the treatment area to store their personal belongings (e.g., coats, backpacks, purses, etc.)
• EVS knew how to perform proper cleaning and wanted to keep the area clean and disinfected, but the system didn’t support their workflow.
• The HFEs learned of an organizational policy to keep patients in the waiting room until called in for treatment.
• It was discovered, as dialysis patients often develop close bonds with their caregivers, staff allowed patients into the treatment area so the patients could socialize with staff as many of them were friends.
• During the systems analysis, the HFEs were able to assess and develop a plan. Rather than focusing only on re-education of EVS staff and their responsibilities, a holistic assessment approach uncovered unforeseen system-level factors that affected practice and resulted in patient harm.
• Without clinical staff providing space and time between treatment shifts, EVS staff were unable to properly clean and disinfect the area and keep a vulnerable constellation of patients safe.
• When the dialysis clinical staff understood the importance of using the waiting room, patients were asked to comply with policy. The rationale was explained to patients and families as to the importance of infection prevention interventions to keep them, the patients, and the staff safe.
• This intervention allowed EVS staff to adequately clean and disinfect the treatment area and provide a safe environment for staff, patients, and visitors. The observations and implementation of human factors principles resulted in a palpable decrease in infections.
How can you apply HFE to your practice?
Remember that healthcare is a complex sociotechnical system that has component parts, and those parts work together.
If you are responsible for addressing opportunities for improvement, consider a human-centered just-culture approach.
If you are asked to be involved in finding a solution, have empathy for workers and include them in the investigation and formulation of potential solutions.
Remember, if blame is considered the answer to a suboptimal outcome, the power to create positive and meaningful safety change evaporates.
Resources:
1. AHRQ. PSNet. Health Care – Associated Infections. Sept. 7, 2019. https://psnet.ahrq.gov/primer/health-care-associated-infections
Are Masks Really Not Working or Do We Need to Focus on Community-level Masking Education Around Proper Handling and Indications for Use?
By Shanina Knighton, PhD, RN, CIC
This article originally appeared in the March 2024 issue of Healthcare Hygiene magazine.
As we reflect on being what some people would describe as being out of the “eye of the storm” as it relates to COVID-19, there are many opinions and reflections about what worked well and what did not. One controversial scientific question that still exists is “are masks effective?” A few scientific reviews, including Cochrane1 suggest the effectiveness of masks were inconclusive, whereas mainstream media outlets shared the message that “masks do not work.”
As an infection preventionist, nurse and scientist, I understand that non-healthcare workers do not always understand how important proper wear and handling of masks are and the risks associated with mishandling and reuse2 of disposable masks. In healthcare, it is established that if masks are mishandled or improperly used, they can increase the risk for infection transmission between patients. For example, in the pre-pandemic era it was standard for surgical masks to be one-time use when needed for precautions and or if you had a patient that required airborne precautions you would be told to use a N-95 mask for just that patient during your shift. These measures helped decrease the risks of transmission. During the pandemic, emergency reuse was emphasized due to limited supplies favoring the opinion that mask reuse provided more of an upside for protection than risks. However, data was scarce in determining that.
As attention turns more to public health and community-level infection prevention and control efforts it intreats the scientific community to pause and ask, “Are we educating and measuring the effectiveness of basic infection prevention and control practices and in this example— mask use and handling including the practical uses that can keep everyday people safe. Furthermore, do we educate the community on the benefits of proper mask use and handling and the potential consequences associated with misuse and mishandling?
Briefly, I summarize some examples of misuse and education tips often overlooked.
Dirty hands taking the mask on and off parallels to a dirty mask. Hand hygiene is the simple most important wat to prevent the spread of germs that lead to infections. During the pandemic people were told to put on masks. However, evaluating if people clean their hands at all, less known correctly before and after putting their masks on should be considered. Mouths and noses expel germs and are also entry for germs. The mask coming in direct contact with the mouth and nose means that people run the risk of unknowingly transmitting germs directly to and from their face by way of the mask.
Dirty cell phones hashtag our third hand links to a dirty mask. Cell phones are seen as the third hand and are shown to be 10 times dirtier 3than a toilet seat. Cell phones create a segue to germs being directly transmitted to the face. Imagine your face, cell phone and mask all coming in contact with each other as you place your phone against your mask while keeping it on or pulling it down to take a call instead of removing it from ear to ear. Cell phones can get contaminated just because we use them for almost everything. People that do bathroom scrolling are at risk given many studies showing the splash effect from sinks4 and toilets5 thus justifying the transmission of some harmful germs. Mobile hygiene and touchscreen hygiene is important to avoiding germs that can travel to or from your “third hand.”
Mishandling and mis-wearing of masks connect to microbes. Treading through the hallways in many walks of life from emergency departments where the highest foot traffic occurs to COVID testing or vaccine clinics many people including healthcare workers could be observed time and time again wearing masks as chin girdles or beneath their nose while some wore them correctly above the bridge of their nose with a snug fit. Incorrect masking wearing means that the protection against particulates is inaccurate compared to what the manufacturer’s protection standards might say. Many factors such as not removing masks from ear to ear, sitting masks on unclean surfaces, wearing disposable masks multiple times because it is not “visibly” dirty and exposure of the mask under certain conditions can alter the effectiveness of how well a mask will protect someone. Education round correct technique and understanding of how to handle and wear masks is needed for community use of masks.
We won’t be masked forever, but we should when it matters. It is not likely people will wear masks while sitting privately in their cars forever. It is also not likely that masking will go away. Geographical areas where transmission is high, working with high-risk populations or being considered a part of a high-risk population warrants consideration for wearing masks according to the Centers for Disease Control and Prevention6. However, based on my expertise there are situations where transmission is at its highest that influences my personal masking habits. While I do not wear masks in every setting, I do wear them on public transportation7 where cleaning practices have slowed, and high air exchange is no longer occurring. I wear masks in old buildings8 where I know the heating, ventilation and air conditioning systems are not up to par. If I am in an elevator9 with strangers, I wear my mask. Unfortunately, you cannot predict when someone will have to cough or sneeze in these types of closed environments therefore, I would rather take my chances on wearing a mask for that short duration of time than coming in contact with droplets that can make me sick. Many agree that wearing masks in healthcare settings should go away, but I disagree. We know that within healthcare settings people are likely to go to facilities because they are sick including a higher likelihood to carry transmissible germs such as respiratory illnesses.
Disposable masks are disposable and do expire.10 It is understandable that resources at certain points during the pandemic were scarce. However, people should be aware that similarly to following directions on a box of food for preparation directions, masks have directions that include country of origin, expiration date and most importantly directions for use including the number of hours that you should wear them. Furthermore, similarly to how technology and food gets recalled, education around ensuring masks are breathable without restriction, how to inspect masks for defects, and proper reporting and discarding if you detect defects is important, yet something rarely considered during evaluation of mask effectiveness.
Notably, many healthcare protocols that are implemented in community settings are derived from healthcare settings as it relates to messaging about hand hygiene and proper mask wearing. While many heard “just wear the mask”— this led to many healthcare professionals observing people mishandle masks. Similar to many Infection Preventionists, we know that emphasis on mask education could have made a difference in COVID-19 outcomes and still can. People’s mistrust and belief that masks do not work can be negated with sharing the risks associated with improper handling, use and by providing education about mask safety.
Shanina Knighton, PhD, RN, CIC, is an associate professor at Case Western Reserve University.
References:
1. Jefferson T, et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst. Rev. (2023) doi:10.1002/14651858.CD006207.pub6.
2. Easwaran V, et al. Examining factors influencing public knowledge and practice of proper face mask usage during the COVID-19 pandemic: a cross-sectional study. PeerJ 12, e16889 (2024).
3. Kõljalg S, et al. High level bacterial contamination of secondary school students’ mobile phones. Germs 7, 73–77 (2017).
4. Fucini G-B, et al. Sinks in patient rooms in ICUs are associated with higher rates of hospital-acquired infection: a retrospective analysis of 552 ICUs. J. Hosp. Infect. 139, 99–105 (2023).
5. Abney SE, et al. Toilet hygiene—review and research needs. J. Appl. Microbiol. 131, 2705–2714 (2021).
6. CDC. Use and Care of Masks. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-face-coverings.html.
7. FTA. Using Your Safety Management System (SMS) to Mitigate Infectious Disease and Respiratory Hazard Exposure. https://www.transit.dot.gov/regulations-and-programs/safety/using-your-safety-management-system-sms-mitigate-infectious-disease.
8. Burridge HC, et al. The ventilation of buildings and other mitigating measures for COVID-19: a focus on wintertime. Proc. Math. Phys. Eng. Sci. 477, 20200855.
9. Liu S and Deng Z. Transmission and infection risk of COVID-19 when people coughing in an elevator. Build. Environ. 238, 110343 (2023).
10. Health C for D and R. Face Masks, Barrier Face Coverings, Surgical Masks, and Respirators for COVID-19. FDA (2024).
Isolation: Pondering the Issues
By Carol Calabrese, RN, BS, T-CSCT, CHESP, CIC
This article originally appeared in the February 2024 issue of Healthcare Hygiene magazine.
During clinical rotation I vividly recall one of my fellow classmates passing medications and walking directly into a room in which the patient was on isolation precautions.
Practicing good isolation techniques is important. We saw this especially in 2014 with the risk of Ebola in the United States. Everyone was franticly trying to re-educate their staff on donning and doffing technique of personal protective equipment (PPE). After the emergency was over, staff went back to their old bad habits. I have asked myself, are they old habits or did they never receive proper education? Are we doing enough isolation education for all healthcare workers (HCWs)?
How, where and when is education provided to HCWs in your institution? Infection preventionists (IPs) struggle to provide much-needed content during hospital orientation which has gone from an hour to just 15-30 minutes. If it is not provided in general orientation, then where is it provided? It might be in the unit/department’s orientation; and if it is, who has trained the preceptors in these locations? Are competencies performed?
With the emphasis we place on isolation, we may not be evaluating many of the issues related to caring for patients/residents that need to be in isolation.
I’ve seen a wide range of infractions. Staff wearing the gown backwards, leaving a gap in the front; staff walking out of isolation with a specimen, taking it to the nurses station to send through the pneumatic tube system; water pitchers being filled incorrectly, dietary walking out of a contact isolation room with the menu and then faxing it to dietary at the nurses station, a respiratory therapist in full PPE at the doorway of the room typing on the computer at the mobile work station; the whole endoscopy cart in contact precautions and a CNA doing one-to-one care in contact precautions without PPE, to name a few.
The Centers for Disease Control and Prevention (CDC) provides clear guidance for donning and doffing PPE, how to manage linen and to use certain disposable equipment but does not discuss other activities involved in patient care.
When a staff member is doing one-to-one care, the typical expectation is that they are wearing PPE for an eight- to12-hour shift, minus breaks. I wonder how realistic an expectation this is. A thought I have had but never implemented is to provide the HCW with hospital-provided scrubs and a lab coat. The HCW would wear the scrubs while doing one-to-one, don the lab coat when they leave the room for breaks and place it on a hook outside of the patient’s room upon re-entry. Naturally hand hygiene is very important prior to donning and doffing the lab coat.
Staff are encouraged to identify all supplies that need to be taken into the room to provide care, however, issues arise with items coming out.
When I trained, we were taught to have a “buddy” that would assist us. I went into the isolation room to collect a urine specimen. I collected the specimen and labelled it. My buddy is outside of the room with the specimen bag, holding it open for me to place the specimen into it. They then took the specimen to the nursing station to send it to the laboratory. The outside of the specimen bag is not contaminated using this process. This process can and should be applied to other items coming out of an isolation room.
Evaluating how other departments providing care to the patient in Isolation are managing items used to care for that patient is critical. A nurse or CNA can be their buddy.
Does this take some coordination? Absolutely; however, it also aids in reducing the risk of transmission.
Over the past few years, research has demonstrated that pathogens such as C. difficile and other multidrug-resistant organisms (MRDOs) are being found in non-isolation rooms.
Teska and Gauthier (2021) suggest that IPs may need to consider having environmental services (EVS) personnel disinfect the floors of patients on Contact Precautions. The references cited discuss the transmission of pathogens between rooms via the shoes and hands of the HCWs.
With this evidence, IPs may also want to consider adding shoe covers to the necessary PPE worn for contact precautions.
The CDC’s CDI TAP Assessment Tool (2022) is helpful to evaluate what is being done to minimize the risk of transmission of CDI, however, I believe this should be utilized for all MDROs.
Per the CDC’s report, Antibiotic Resistance Threats in the United States, 2019, antimicrobial resistance (AR) report, it states that resistance is growing. Utilizing contact precautions will continue to grow as AR grows in addition to the threat of new and emerging pathogens.
As the draft 2024 transmission-based precautions guidance is released by CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC), it may be time for us to take a deeper look at isolation technique, implementing the use of additional PPE and components to environmental hygiene.
Carol Calabrese, RN, BS, T-CSCT, CHESP, CIC, is an infection prevention consultant with 30-plus years of experience. Her experience includes many settings, acute to industry with leadership background. Connect with Carol on LinkedIn: linkedin.com/in/carol-calabrese-rn-bs-t-csct-chesp-cic-a09bb216 and visit her website at: www.infectionpreventionconsultant.com
Should We Start Thinking More About Patient Hand Hygiene Education in Healthcare?
By Shanina C. Knighton, PhD, RN, CIC
This article originally appeared in the January 2024 issue of Healthcare Hygiene magazine.
For decades now, healthcare-associated infections continue to be an unyielding ongoing patient safety concern affecting millions of people and causing hundreds of thousands of deaths globally each year. The approach to preventing healthcare-acquired infections (HAIs) differ from most patient safety issues as it has many factors associated with infection prevention and control especially for multidrug-resistant organisms (MDROs), antibiotic-resistant organisms and viruses known as “superbugs” that are difficult to prevent and control.
Most innovative strategies to address HAIs focus specifically on antibiotic use, policy, hospital staff practices (e.g., not routinely cleaning hands) and hospital environmental factors (e.g., lack of extensive cleaning between patients). However, an important contributing factor to HAIs has received far less attention and study — the role of patients’ hands as a source of pathogen transmission in healthcare settings. Uncontended, most would argue that hand hygiene is the single most important practice for anyone to prevent the spread of pathogens that lead to HAIs, however there is less agreement on normalizing patient hand hygiene in healthcare settings. Scientific discovery regarding patients’ hand cleanliness and pathogen transmission is relatively new and emerging unlike decades of mounting evidence to support the healthcare worker transmission and hand hygiene.
Motivated from earlier science, healthcare staff hand hygiene has advanced immensely since the decades between the 1960s and the 1990s, confirming the carriage of pathogens on healthcare staff’s hands. Notably, in some of the same studies that recognized the carriage of pathogens on the hands of healthcare staff, results also showed that patients’ hands and bodies also tested positive for pathogens; furthermore, in some cases, patients were found to be the original carrier of these harmful organisms.1-5
Patients can transfer pathogens to their environment and to healthcare staff, and cross-contaminate themselves as germs are not unidirectional. Therefore, they can be transferred in various ways. Documented evidence shows that patients carry one or more MRDOs on their hands,6-9 proximal areas (trunk), and clothing10 thus increasing the risk of contaminating their environment or cross-contaminating themselves. Once admitted to hospitals, patients are at risk of getting or spreading HAIs simply by inadvertently and unknowingly transmitting pathogens from their hands by making contact with their own devices (some indwelling), dressings, surgical wounds, healing and non-healing ulcerations, IV sites, and orifices, including their mouths through making contact with their food.
Furthermore, patients frequently interact with nurses, doctors, visitors, and other patients, which can also increase risks for getting an HAI. While randomized controlled trials that address decolonization and isolation efforts repeatedly and effectively decreased pathogen transmission outside of the patients’ room and after patients are already infected,11 evidence supports bidirectional relationships between patients’ hand contamination and the contamination for high-touch environmental surfaces.12-15
Surfaces and tools commonly used by staff and patients such as bedside tables,12,16-17 bedrails,18 medical devices,12 or call lights contain MDROs.10,16 Contamination of patients’ personal belongings including cell phones19 and clothing10 also increases their risk of contact with MDROs (20,21). Hence, strategies to prevent growth and colonization of MDROs are needed. Recommendations and conclusions of earlier studies have contended that healthcare staff should clean their hands, but for patients, it was only suggested that patients could be a source of transmission resulting in minimal recommendations for patients to have clean hands.1,5 Accrediting bodies and governing entities acknowledge that patients should have an active role in their care to prevent HAIs; however, patients’ role in infection prevention is still passive. For example, patients are encouraged to ask healthcare staff to clean their hands before providing care, but rarely are educated on cleaning their own hands.
Patient hand hygiene as a quality improvement strategy can help prevent the transmission of pathogens that lead to HAIs while simultaneously promoting patient self-management and patient engagement. Furthermore, providing patients with the opportunity to clean their hands is an underutilized approach that can reduce patients’ hand contamination that can lead to infection. For uncontaminated patients, patient hand hygiene can provide an additional layer of protection for them to prevent predisposition to colonization that leads to HAIs. As viral bacterial and fungal infections increase and we continue to face multi-viral seasons comprised of influenza, SARS-CoV2, respiratory syncytial virus, pneumonia, and others it is timely to update the growing body of literature on the status of patient hand hygiene in hospitals, which can influence how we integrate or implement patient hand hygiene programs in acute care settings and long-term care settings.
Shanina C. Knighton, PhD, RN, CIC, is a nurse-scientist, infection preventionist and an associate professor in the Schools of Nursing and adjunct in biomedical engineering at Case Western Reserve University. Knighton was the Inaugural executive director of APIC’s Center for Research Practice and Innovation where she championed their transformation to advance science and practice. She is known for being able to take infection prevention science and turn it into practical and equitable tools for improvement in various settings. During COVID-19, she provided practical prevention tools and guidelines to community members, small businesses, community organizations and public officials including the state of Ohio, the American Nurses Association, the New York State Board of Education, and others. Her practical tips have appeared in media outlets including local news, Forbes, Fox News, Self magazine, and Modern Woman magazine. In 2022 she was recognized as a Case Western Reserve University Faculty Innovator.
References:
1. Casewell M, Phillips I. Hands as route of transmission for Klebsiella species. Br Med J. 1977 Nov 19;2(6098):1315–7.
2. Casewell MW, Desai N. Survival of multiply resistant Klebsiella aerogenes and other Gram-negative bacilli on fingertips. J Hosp Infect. 1983 Dec 1;4(4):350–60.
3. Gwaltney JM, Moskalski PB, Hendley JO. Hand-to-hand transmission of rhinovirus colds. Ann Intern Med. 1978 Apr;88(4):463–7.
4. Gwaltney JM. Rhinoviruses. Yale J Biol Med. 1975 Mar;48(1):17–45.
5. Sanderson PJ, Weissler S. Recovery of coliforms from the hands of nurses and patients: activities leading to contamination. J Hosp Infect. 1992 Jun;21(2):85–93.
6. Sunkesula VCK, Kundrapu S, Knighton S, Cadnum JL, Donskey CJ. A Randomized Trial to Determine the Impact of an Educational Patient Hand-Hygiene Intervention on Contamination of Hospitalized Patient’s Hands with Healthcare-Associated Pathogens. Infect Control Hosp Epidemiol. 2017 Jan 5;1–3.
7. Cao J, Min L, Lansing B, Foxman B, Mody L. Multidrug-resistant organisms on patients’ hands: A missed opportunity. JAMA Intern Med. 2016 May 1;176(5):705–6.
8. Mody L, Krein SL, Saint SK, Min LC, Montoya A, Lansing B, et al. A Targeted Infection Prevention Intervention in Nursing Home Residents with Indwelling Devices. JAMA Intern Med. 2015 May 1;175(5):714–23.
9. Mody L, Washer LL, Kaye KS, Gibson K, Saint S, Reyes K, et al. Multidrug-resistant Organisms in Hospitals: What Is on Patient Hands and in Their Rooms? Clin Infect Dis Off Publ Infect Dis Soc Am. 2019 Apr 13.
10. Kanwar A, Cadnum JL, Thakur M, Jencson AL, Donskey CJ. Contaminated clothing of methicillin-resistant Staphylococcus aureus (MRSA) carriers is a potential source of transmission. Am J Infect Control [Internet]. 2018 Jun 22 [cited 2018 Oct 14];0(0). Available from: https://www.ajicjournal.org/article/S0196-6553(18)30679-5/abstract
11. Peng HM, Wang LC, Zhai JL, Weng XS, Feng B, Wang W. Effectiveness of preoperative decolonization with nasal povidone iodine in Chinese patients undergoing elective orthopedic surgery: a prospective cross-sectional study. Braz J Med Biol Res [Internet]. 2017 Dec 18 [cited 2018 Oct 14];51(2). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5734184/
12. Pilmis B, Billard-Pomares T, Martin M, Clarempuy C, Lemezo C, Saint-Marc C, et al. Can we explain environmental contamination by particular traits associated with patients? J Hosp Infect [Internet]. 2019 Dec 20 [cited 2020 Jan 9]; Available from: http://www.sciencedirect.com/science/article/pii/S0195670119305328
13. Sethi AK, Al-Nassir WN, Nerandzic MM, Bobulsky GS, Donskey CJ. Persistence of skin contamination and environmental shedding of Clostridium difficile during and after treatment of C. difficile infection. Infect Control Hosp Epidemiol. 2010 Jan;31(1):21–7.
14. Weber DJ, Anderson D, Rutala WA. The role of the surface environment in healthcare-associated infections. Curr Opin Infect Dis. 2013 Aug;26(4):338–44.
15. Cheng VCC, Chau PH, Lee WM, Ho SKY, Lee DWY, So SYC, et al. Hand-touch contact assessment of high-touch and mutual-touch surfaces among healthcare workers, patients, and visitors. J Hosp Infect. 2015 Jul;90(3):220–5.
16. Boyce JM. Environmental contamination makes an important contribution to hospital infection. J Hosp Infect. 2007 Jun;65 Suppl 2:50–4.
17. Dancer SJ. Controlling Hospital-Acquired Infection: Focus on the Role of the Environment and New Technologies for Decontamination. Clin Microbiol Rev. 2014 Oct;27(4):665–90.
18. Hassan M, Gonzalez E, Hitchins V, Ilev I. Detecting bacteria contamination on medical device surfaces using an integrated fiber-optic mid-infrared spectroscopy sensing method. Sens Actuators B Chem. 2016 Aug 1; 231:646–54.
19. Tekerekoǧlu MS, Duman Y, Serindağ A, Cuǧlan SS, Kaysadu H, Tunc E, et al. Do mobile phones of patients, companions and visitors carry multidrug-resistant hospital pathogens? Am J Infect Control. 2011 Jun 1;39(5):379–81.
20. Sunkesula VCK, Kundrapu S, Knighton S, Cadnum JL, Donskey CJ. A Randomized Trial to Determine the Impact of an Educational Patient Hand-Hygiene Intervention on Contamination of Hospitalized Patient’s Hands with Healthcare-Associated Pathogens. Infect Control Hosp Epidemiol. 2017;38(5):595–7.
21. Rai H, Saldana C, Gonzalez-Orta MI, Knighton S, Cadnum JL, Donskey CJ. A pilot study to assess the impact of an educational patient hand hygiene intervention on acquisition of colonization with health care–associated pathogens. Am J Infect Control. 2019 Mar 1;47(3):334–6.