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Fall 2015 • Volume 8 number 3

Thinking
outside
the box
IPs in action
Sherlockian ability and
teamwork uncover the
Blue Bell listeria outbreak
An IP nurse wants to
strike a chord with

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The White House Forum


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Contents
fall 2015
Features

Sherlockian ability and


teamwork uncover the
Blue Bell listeria outbreak

60
By Vicky Uhland

The White House


Forum on Antibiotic
Stewardship
By Mary Lou Manning

63
Share Prevention Strategist articles with others.
Spread Knowledge

Check out the icons next to each article to help you navigate Prevention Strategist easily and identify
articles to share with others in your healthcare organization or beyond. Audiences include:

Infection Prevention Patient Care Environmental Quality and Risk Disaster C-Suite
Colleagues Services Services Management Preparedness

Let the sharing begin!

6 | fall 2015 | Prevention


VOICE
What’s love got to do with it? 8
By Mary Lou Manning, 2015 APIC President
MegaSurvey more than doubles expected return 10
By Katrina Crist, APIC CEO
Looking back, moving forward—The CBIC strategic plan 12
By Kathy McGhie, 2015 CBIC President

DEPARTMENTS
Meet a CIC: April McGrotha, BSN, RN, CIC 15
Briefs to Keep You In-the-Know 18
• Meet the 2015 Heroes of Infection Prevention

24
• Creating bridges between infection prevention and other disciplines
• APIC Awards program
• We’re engaged! (In patient safety)
• Japanese and U.S. collaboration highlighted at APIC 2015
Capitol Comments: IPs—Your message has been heard 26
By Nancy Hailpern and Lisa Tomlinson
Chapter Spotlight: APIC Northeast Ohio 28
Ohio holds first statewide APIC conference
By Gregory Gagliano
APIC Consultant Corner: Meet an APIC Consultant 30
With Mary Bolaños
Infection Prevention Leadership: Leading with the heart— 33
A chief medical officer’s perspective
With William J. Maples

PREVENTION IN ACTION

41
My Bugaboo: Acanthamoeba—Forget the fungus, 37
there are amebas among us!
By Irena Kenneley
Focus on long-term care and behavioral health outbreaks— 41
Identify the pathogen: Coxiella burnetii
By Steven Schweon
CMS revises ASC infection control surveyor worksheet: 43
Critical changes to know
By Phenelle Segal
Preventing hospital-acquired pneumonia (HAP) outside of 45
the ventilator-associated pneumonia bundle
By Joi Fox, Karen Frush, Cynthia Chamness, Jesi Malloy, and Sandi Hyde
An infection preventionist’s guide to evaluating research studies 50
By Timothy Landers and Monika Pogorzelska-Maziarz
Striking a chord with children to save lives 53
By Terri Embry
What you don’t know can hurt you: A collaborative effort to prepare 55
and provide care for patients with really scary diseases

55
By Sharon Ward-Fore
IPs fighting Ebola: One goal around the world 57
By Jill Holdsworth and the APIC Emergency Preparedness Committee

w w w.apic.org | 7
PRESIDENT’S MESSAGE

What’s love Prevention


In answer to Tina Turner’s famous song lyric, “what’s love got to do with it,”
love and relationships just might be the secret to keeping patients safe from
got to do infection and achieving healthcare quality. This epiphany—or flash of sudden
clarity—occurred to me as the result of two pivotal moments experienced
with it? during the APIC 2015 Annual Conference in Nashville. Fa l l 2 015 • VO L U M E 8 , I S S U E 3

Relationships Board of Directors


President
During the opening plenary, Preparing globally, acting locally: Applying Mary Lou Manning, PhD, CRNP, CIC,
infection prevention lessons learned from the Ebola crisis, each of the four FAAN, FNAP
panelists highlighted that infection preventionists (IPs) are a trusted source President-Elect
Susan A. Dolan, RN, MS, CIC
of information, and emphasized the vital importance for IPs to develop
Treasurer
relationships within and outside of their own organizations with people they Marc-Oliver Wright, MT(ASCP), MS, CIC
may not regularly interact with—before a crisis occurs. However, it was Dr. Secretary
Michael Bell, deputy director, Division of Healthcare Quality Promotion, Connie J. Steed, RN, MSN, CIC
Centers for Disease Control and Prevention, who connected the dots when Immediate Past President
Jennie L. Mayfield, BSN, MPH, CIC
he said, “You can’t be a trusted voice the first time you meet someone; you
can’t be a trusted voice if they don’t know who you are and why you are saying
Directors
what you are saying.” He also made clear that for IPs to be “useful advisors,”
Joseph A. Bosco, III, MD
they must learn the true realities of a situation and provide information that
Kim Boynton-Delahanty, RN, BSN, PHN,
makes sense. There was ‘aha’ moment number one. IPs may possess a wealth MBA/HCM, CIC
of knowledge and treasure chest of unique skills, but to be effective requires Gail Fraine, RN, MMHC, BSN, CIC
being fully present and establishing trusting relationships. Deborah G. Friberg, MBA, FACHE
By Mary Lou Brenda Grant, RN, BSN, MPH, CIC, CHES
Manning, Love
Janet Haas, RN, PhD, CIC
PhD, CRNP, CIC, The second ‘aha’ moment occurred the same day during the Science to Karen K. Hoffmann, RN, MS, CIC, FSHEA
FAAN, FNAP Practice Awards ceremony. I have long admired the work of Dr. Sanjay Saint, Linda McKinley, RN, BSN, MPH, CIC
APIC 2015 PRESIDENT a professor of Internal Medicine at the University of Michigan. This day he Ann Marie Pettis, RN, BSN, CIC
received APIC’s Distinguished Scientist Award for his significant contribu- Katherine S. Ward, RN, BSN, MPH, CIC
tion to infection prevention science and for exemplifying infection preven- Kathy Ware, RN, BSN, CIC
tion leadership within the scientific community. Dr. Saint is well-schooled
in quality improvement, so it was of no surprise when he called upon the EX OFFICIO
work of Dr. Avedis Donabedian, father of healthcare quality, to frame his Katrina Crist, MBA, CAE
remarks. Dr. Donabedian spent his career helping organizations understand
“He concluded the systems and processes necessary to improve quality outcomes in caregiv- Disclaimer
by saying, ing. However, in the end, it was not the systems where he placed his greatest Prevention Strategist is published by
the Association for Professionals in
‘My profound emphasis. In 2000, one month before his death, Dr. Donabedian was asked, Infection Control and Epidemiology,
“What is the secret of quality?” To which he replied: Inc. (“APIC”). All rights reserved.
simplicity to Systems awareness and systems design are important for health professionals, Reproduction, transmission,
improving but they are not enough. They are enabling mechanisms only. Ultimately,
distribution, or copying in whole
or in part of the contents without
quality, the secret of quality is love. You have to love your patient, you have to love express written permission of
APIC is prohibited. For reprint
enhancing your profession. If you have love, you can then work backward to monitor and other requests, please email
and improve the system.1 editor@apic.org. APIC makes no
safety, and Poetically, Dr. Saint echoed Dr. Donabedian’s teachings as applied to representations about the accuracy,
reliability, completeness, or timeliness
preventing infection prevention. He emphasized that what’s important (in our work) of the material or about the results to
is kindness, compassion, and connectedness. He concluded by saying, “My be obtained from using this publication.
infection You use the material at your own risk.
profound simplicity to improving quality, enhancing safety, and preventing
is love.’” infection is love.” From this highly respected physician scientist, the Love
APIC assumes no responsibility for
any injury and/or damage to persons
or property as a matter of products
Message came without warning. It was magnificent! liability, negligence or otherwise,
I was struck by the power of these combined messages. Perhaps the moti- or from any use or operation of any
vation that must underlie any effort at healthcare quality and infection methods, products, instructions,
or ideas contained in the material
prevention must start from a foundation of love (of patient, of profession), herein. Because of rapid advances in
and build upon trusting relationships. the medical sciences, in particular,
independent verification of diagnoses
To answer Tina Turner’s famous song lyric, “What’s love got to do with and drug dosages should be made.
it?” Everything! Although all advertising material
is expected to conform to ethical
Love to all, (medical) standards, inclusion in
Reference this publication does not constitute
a guarantee or endorsement of the
1. Mullan F. A founder of qual- quality or value of such product
ity assessment encounters or of the claims made of it by its
a troubled system firsthand. manufacturer.
Health Affairs 2001;20:137-41. Mary Lou Manning, PhD, CRNP, CIC, FAAN, FNAP

8 | fall 2015 | Prevention


Use of common antibiotics
such as cephalosporins and
ƅXRURTXLQRORQHVKDVEHHQ
strongly associated with
&GLIƄFLOH-associated diarrhea.1

Are you spending time and resources treating &GLIƄFLOH disease when
you could be preventing it?
Accurate diagnosis of respiratory disease is critical to avoid inappropriate antibiotics, limit drug
costs, and reduce the threat of antibiotic resistance and &GLIƄFLOH-associated diarrhea.2

&RQWDFW\RXUODERUDWRU\WRƄQGRXWLI\RXUKRVSLWDOKDVDOUHDG\DGRSWHGWKHVHUDSLGGLDJQRVWLFWRROV

Alere BinaxNOW® S. pneumoniae C. DIFF QUIK


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A diagnosis of/HJLRQHOOD or Rule out &GLIƄFLOH with
6SQHXPRQLDH can have a major VHQVLWLYLW\HTXDOWR3&54
impact on the cost of care including Detect DFWLYHWR[LQSURGXFWLRQ
50% reduction in duration of IV to guide appropriate treatment
antibiotics and 35% decrease in decisions, bed placement, and
length of stay.3 reduce antibiotic overuse.

To learn more contact your local Alere Account Executive or call 1.877.441.7440
References:
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/LP:6%DXGRXLQ69*HRUJH5&+LOO$7-DPLHVRQ&/H-,HWDO%76JXLGHOLQHVIRUWKHPDQDJHPHQWRIFRPPXQLW\DFTXLUHGSQHXPRQLDLQDGXOWVXSGDWH7KRUD[
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&DUUDWDO½-*DUFLD9LGDO&2UWHJD/)HUQDQGH]6DEH1&OHPHQWH0$OEHUR*/RSH]0&DVWHOOVDJXH;'RUFD-9HUGDJXHU50DUWLQH]0RQWDXWL-0DQUHVD)*XGLRO)(IIHFW
 RID6WHS&ULWLFDO3DWKZD\WR5HGXFH'XUDWLRQRI,QWUDYHQRXV$QWLELRWLF7KHUDS\DQG/HQJWKRI6WD\LQ&RPPXQLW\$FTXLUHG3QHXPRQLD$UFK,QWHUQ0HG  
'XEEHUNH(+DQ=%RER/+LQN7/DZUHQFH%&RRSHU6+RSSH%DXHU-%XUQKDP&'XQQH:0-U,PSDFWRI&OLQLFDO6\PSWRPVRQWKH,QWHUSUHWDWLRQRI'LDJQRVWLF$VVD\VIRU
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© 2015 Alere. All rights reserved. The Alere Logo, Alere, BinaxNow and Knowing now matters are trademarks of the Alere group of companies. C. DIFF QUIK CHEK COMPLETE is a
trademark of TECHLAB, INC. under license. 10002382-01 08/15
CEO’S MESSAGE

MegaSurvey We did it! Many were skeptical and told us it was unrealistic to Prevention
hope for a high return, especially with such a long survey. But,
more than once more, APIC members rose to the challenge and exceeded Fa l l 2 015 • VO L U M E 8 , I S S U E 3
expectations.
doubles Research experts told us to expect a 15 percent return. APIC
PUBLISHER
Katrina Crist, MBA, CAE
kcrist@apic.org
expected return more than doubled that with a 31 percent return (4,062 out of MANAGING EDITOR
12,900). Furthering credibility is the high volume of returns, Janiene Bohannon, MS
jbohannon@apic.org
a higher predictive value than the percentage. We are told that
ASSISTANT EDITORS
5,000 returns out of 200,000 would be a highly respectful sample. Elizabeth Garman
Thank you to the 4,062 infection preventionists (IPs) who com- Julie Blechman, MPH
pleted the MegaSurvey—you are the stars! You made it happen, PROJECT MANAGER
Heather Williams
and your contributions will play a significant role in shaping the hwilliams@naylor.com
desired future for IPs. We will send you a complimentary copy of ADVERTISING
Brian Agnes
the compensation report by the end of this year. bagnes@naylor.com
Industry Insights, the independent research firm APIC is work- GRAPHIC DESIGN
ing with, is now sorting and analyzing the data. Our plan is to Dan Proudley
produce three to four reports that will provide benchmarking
EDITORIAL PANEL
data on IP demographics, organizational structure, competen- George Allen, PhD, CIC, CNOR
cies and certification, and compensation. These reports will be Kristine Chafin, RN, MBA, CIC
Megan Crosser, BS, MPH, CIC
By Katrina Crist, made available for purchase along with an online version that Mary L. Fornek, RN, BSN, MBA, CIC
MBA, CAE, APIC CEO will provide for more customized reports. The APIC Research Brenda Helms, RN, BSN, MBA/HCM, CIC
Linda Jamison, MSN, RN, CIC, CCRC
Committee will publish an executive summary in the American Irena Kenneley, PhD, APRN-BC, CIC
Journal of Infection Control in 2016. Kari L. Love, RN, BS, MSHS, CIC
May M. Riley, RN, MSN, MPH,
We are excited about the potential the MegaSurvey data has to ACNP, CCRN, CIC
shed light on the current landscape of the IP workforce and infec- Steven J. Schweon, RN, MPH, MSN, CIC,
HEM, FSHEA
tion prevention and control programs. Members of Congress have
“Thank you to the already expressed interest in seeing data specific to their states. CONTRIBUTING WRITERS
4,062 infection We have also received several requests to have access to the APIC Julie Blechman, MPH
Mary Bolaños, RN, MPH, CIC, CLNC
preventionists MegaSurvey instrument to potentially be utilized by other societies Cynthia Chamness,

(IPs) who to conduct workforce surveys, including two international requests. RN, CPPS, CPHQ, CPHRM
Katrina Crist, MBA, CAE
We look forward to using this data in many ways to better Terri Embry, RN, BS
completed the understand and showcase the critical role IPs play in preventing Joi Fox, RN, CIC
MegaSurvey—you infections and keeping patients safe.
Karen Frush, MD
Gregory Gagliano, RN, BSN, CIC
are the stars!” Nancy Hailpern
Jill Holdsworth, MS, CIC, EMT-B
Sincerely yours, Sandi Hyde, MSPS
Irena Kenneley, PhD, APRN-BC, CIC
Timothy Landers, PhD, RN, CNP, CIC
Jesi Malloy, MSHS
Mary Lou Manning, PhD,
CRNP, CIC, FAAN, FNAP
Katrina Crist, MBA, CAE William J. Maples, MD
APIC CEO Kathy McGhie, RN, BScN, CIC
April McGrotha, BSN, RN, CIC
Michele Parisi
Monika Pogorzelska-Maziarz, PhD, MPH
Steven J. Schweon, RN, MPH, MSN,
CIC, HEM, FSHEA
Phenelle Segal, RN, CIC
Lisa Tomlinson
Vicky Uhland
“Shoot for THE moon, Sharon Ward-Fore, MT(ASCP), MS, CIC

even if you miss Mission


APIC’s mission is to create a safer world
you’ll land among through prevention of infection. The
association’s more than 15,000 members
the stars!” direct infection prevention programs that
save lives and improve the bottom line for
—Author unknown hospitals and other healthcare facilities.
APIC advances its mission through
patient safety, implementation science,
competencies and certification, advocacy,
and data standardization. Visit APIC online
at www.apic.org.
Published september 2015 • API-Q0315• 1062

10 | fall 2015 | Prevention


Learn how Bard® can help.
Celebrating Excellence

Looking
back, moving
forward—
The CBIC
strategic plan
®

The focus of my columns this year has been on change. I provided updates on the new content
outline that forms the basic structure for the certification examination and on changes to the
eligibility requirements that better reflect our changing profession and practice settings. These
changes have been aligned with key goal areas in the Certification Board of Infection Control
and Epidemiology (CBIC) strategic plan.
In 2011, the CBIC Board of Directors initiated a strategic planning process to reassess our
mission and identify a strategic direction with the goal of having a complete three-year plan
by the beginning of 2012. This plan is available on our website for your review and will con-
tinue to guide us through to the end of 2015. To access the plan, visit www.cbic.org/about-cbic/
By Kathy McGhie, cbic-2012-2015-strategic-plan.
RN, BScN, CIC The key goal areas identified were:
2015 CBIC PRESIDENT 1. Certification, recertification, testing, and research
2. Partner and regulatory relationships
3. Marketing, communications, and publications
4. Recruitment, retention, and community
5. Governance and management
Other changes resulting from this plan have been improved communication to candidates and
certificants through more consistent messaging and a growing social media presence. To assist
us with this goal, we’ve added a full-time marketing coordinator to our staff. Over the past three
years, the senior staff and leadership of CBIC, APIC, and Infection Prevention and Control (IPAC)
Canada have held an Organizational Summit on Certification where we meet to discuss issues
pertaining to certification and how we can work together to establish value and further promote
the credential. We’ve improved our Candidate Handbook, developed certification preparation
workshops, and identified consistent and meaningful ways to recognize our certificants, such as
co-hosting with APIC the CIC® reception at APIC annual conferences, sharing CIC® profiles
from Prevention Strategist on our website, and celebrating successes by posting the names of
new and recertified certificants.
By far, the biggest change has been our decision to partner with a new testing company, result-
ing in a complete revamp of our certification examination development process and test delivery
platform. We’ve expanded opportunities to participate in the certification process through the
identification and use of non-board member subject matter experts in the test development
process, and through participation on marketing and certification workshop subcommittees.
Internally, we’ve focused on building a strong board of directors that is representative, inclusive,
and engaged. Board development, succession planning, and self-assessment have become regular
components of our work.
“The farther This fall, CBIC will once again embark on a new strategic planning process that will guide us
backward you forward over the next few years. This process relies on input from you. Please consider participat-
can look, the ing if you are contacted by phone or by email. The strategic planning process is critical to our
continued growth as it enables us to determine where we’re going, how we’re going to get there,
farther forward and to know over time whether we’ve been successful.
you can see.” This is an exciting time in CBIC’s history, and I’m very proud of what we’ve accomplished in
— Winston Churchill four short years. I look forward to imagining the future and continuing the journey.

12 | fall 2015 | Prevention


What do you do for
hand hygiene compliance
at point of care?

“ If you don’t make it [hand hygiene


products] convenient right there at
that second, no one is going to go
around the corner and wash their
hands. It must be available in the
flow of what the employee is doing.

– WILLIAM PARKS, MD
Chief Medical Officer at Memorial

Hermann The Woodlands

Point of Care refers to the moments when healthcare


workers are in contact with patients and are at the highest
risk of spreading infections.

Increase hand hygiene compliance, improve HCAHPS


scores, and reduce HAIs (healthcare associated infections)
with these Symmetry Point of Care items:

50 ml Suction Cups*
Over-bed tables, Computers on wheels *Suction Cups
550 ml Suction Cups* contain Ion Pure, an
Bedside tables, Nurse stations,NICUs antimicrobial agent
550 ml Wire Brackets approved by the
Dietary carts, Phlebotomist carts, FDA, EPA, and NSF.
Bedside commodes
Lanyards
Healthcare workers

“ Many HAIs [healthcare-associated infections] are transmitted by


health care personnel, and hand hygiene is a primary means to


reduce these infections.

– HEALTH RESEARCH & EDUCATIONAL TRUST


affiliate of the American Hospital Association

www.symmetryhandhygiene.com

w w w.apic.org | 13
CIC PROFILE

Meet a CIC
April McGrotha, BSN, RN, CIC
Infection Preventionist
Tallahassee Memorial HealthCare
Tallahassee, Florida

Q. What inspired you to


become an infection
preventionist (IP)?

I was on alternate duty, assisting in a


matter, devoting the extra time to continued
learning is so much more fulfilling. With so
many advances in technology and education
at my fingertips, I want to learn everything
I can to improve patient safety. The more I
few projects and observing hand hygiene understand, the more patients I can protect;
for the infection prevention department. this is the best reason I can think of to get
Simultaneously, an RN in infection preven- certified.
tion was preparing for retirement, which
would create an open position. I loved doing
the research and breaking down how infec-
tions occurred—risk analysis really sparked
an interest within me. Even before I became
a nurse, I was an advocate for infection
prevention.
Q. How did you prepare
for the CIC exam?
What helped?

I utilized all of my resources. I read the


APIC Text, AAMI, AORN, APIC Ready
Reference for Microbes, APIC Certification

Q. How long have you


been an IP?

I assisted with a few projects


and completed observation of hand hygiene
Study Guide, infection prevention manuals,
etc. I went on social media and connected with
others who were seeking certification or who
were already successful with certification in
infection prevention. I would click on a page
and isolation compliance while on alternate that had a question and receive an answer, but
duty. I transferred to the infection preven- more importantly, I benefited from thought
tion department on February 7, 2013, and processes of other IPs around the world.
became certified on March 13, 2015. I recently attended NHSN training at the
Centers for Disease Control and Prevention
in Atlanta. The training was great, but I also

“I think of certification as a
step toward my goal—not
Q. Why is maintaining
board certification
in infection
prevention and
control (CIC)
had conversations with others around the
world struggling with similar issues in infec-
tion prevention or who had already dissected
the problems we were having. I also visited a
couple of great facilities that were facing chal-
the end of my path but the
important to you? lenges we all face. This helped me understand
beginning of a new journey!” I have always felt it’s important to do that challenges were universal, and effective
whatever I am doing with all of my heart communication makes a difference in improv-
and soul—doing tasks I am delegated com- ing quality! I connected, via LinkedIn and
pletely! If I am passionate about the subject other social networks, to some of the greatest

w w w.apic.org | 15
infection prevention minds working toward a
common goal—increased patient safety. The
bottom line is we all want the same thing: to
provide the best possible care in the most effi-
cient way. The forums are great for topics that
to do what it takes and learn what you need
to know to be the best—it will open doors.
CIC has opened doors for me. Q.  an you please
C
share some study
tips for others who
wish to maintain
or pursue their CIC
are shared globally, from bundles to LEAN
processes. Networking really does make all
the difference! Q.  what ways has
In
your CIC benefited
Tallahassee
Memorial Hospital?
The organization promotes certification of
designation?
Dig in with both feet and hands, really
try to understand why an infection occurs,
and you will be well on your way. Get APIC
study guides, the current APIC manuals,

Q. In what ways has


your CIC
benefited you?

My certification has validated everything I


colleagues. When the infection prevention
department has registered nurses certified in
infection prevention and control, it shows a
culture of growth and continued education of
experts in their field. In the healthcare world,
and the other resources mentioned above.
Go online; the Internet is a great place to
network and study how different people
practice infection prevention. A lot of times
I find that we are all working on similar
have learned and worked toward during the education is highly valued, and as things issues and just need to communicate effec-
last two years. The more I learn, the more change—especially technology—the culture tively to solve the problem. Don’t be afraid
I want to understand and educate others. must change with it. When someone takes to step out of your comfort zone and ask lots
When I offer education to patients, families, the next step and gets certified, the orga- of questions, practice active listening, and
or friends, I can say that I am a registered nization functions better. You have people allow others to question you. One thing I
nurse certified in infection prevention and qualified to make strong decisions about have learned from my strenuous preparation
control. When you have those credentials infection prevention, which improves our for the exam is that I don’t know everything,
at the end of your name, it means so much ultimate goal of patient safety. Our organiza- but I do know that there is an answer, and
more. People look to you for expertise. You tion’s vision is: “Leading our community to I am responsible for finding the answer!
are no longer just working in infection pre- be the healthiest in the nation.” Certification I think of certification as a step toward
vention, you are a certified IP. It also helps alone doesn’t ensure this, but it is a step in my goal—not the end of my path but the
professionally when you prove you are willing the right direction. beginning of a new journey!

16 | fall 2015 | Prevention


753640_Ivera.indd 1 6/19/15 4:37 PM
Daily Patient Bathing

Don’t just cleanse…


HIBICLENS®
HIBICLENS, a 4% chlorhexidine gluconate solution, delivers high levels of protection from
pathogens.1,2 Patient bathing helps stimulate circulation, promotes range of motion, and improves
patient comfort levels.3 SHEA and IDSA recommend routine bathing of patients with antiseptics such
as HIBICLENS to reduce the risk of infections.4
In recovery, patients have bigger battles to win than fighting hospital-acquired infections. By using
HIBICLENS as part of the daily bathing routine, you can deliver the power of 4% CHG with a product
that is gentle enough for everyday use.5
References: 1. Climo MW, et. al. Crit Care Med. 2009 Jun; 37(6):1858-65. 2. Rupp ME. Infect Control Hosp Epidemiol 2012;33(11). 3. Caroline Bunker Rosdahl.
Textbook of Basic Nursing 2007. 4. Calfee, David MD, et. al. Strategies to Prevent Transmission of MRSA in Acute Care Hospitals. Infection Control and Hospital
Epidemiology. October 2008, Vol. 29, Supplement 1, Page S - 73. 5. Data on file. Mölnlycke Health Care. Study R05-0225.

Hibiclens, the Hibiclens logo and Mölnlycke are registered trademarks of Mölnlycke Heath Care AB.
Distributed by Mölnlycke Health Care US, LLC, Norcross, Georgia 30092.
© 2013 Mölnlycke Health Care AB. All rights reserved. 1.800.843.8497.
Briefs to keep you in-the-know

Meet the
2015 Heroes of Infection Prevention
PROFILES BY MICHELE PARISI

E
ach year, APIC presents Heroes of Infection Prevention awards to members who have developed and applied innovative infec-
tion prevention programs. Heroes and their programs represent some of the best practices in infection prevention. Since the
inception of the award in 2006, nearly 100 individuals and groups have been recognized for their exceptional work in reducing
healthcare-associated infections.
In 2015, APIC presented six Heroes awards; three are featured in this issue of Prevention Strategist, and the next three will be featured
in the winter issue. For more information on the award, visit www.apic.org/heroes.

Terry Burger, MBA, BSN, NE-BC, CIC


Lehigh Valley Health Network
Allentown, Pennsylvania

Fighting flu through creativity and compassion

Terry Burger and her Lehigh Valley Health “Immunizations are an important part of
Network (LVHN) colleagues are champions infection control, and removing barriers to
in the fight against influenza. Through their vaccination is critical to achieving success,”
creativity and leadership, more than 125,000 Burger said. “This program enables us to
“The novel vaccination people have been vaccinated in their com- reach populations who wouldn’t be vacci-
program has been munity since 1999. nated because of cost or access. Participants
hugely successful, Burger leads a 35-person multidisci- can receive vaccinations at no cost from
plinary task force at LVHN that coordinates the comfort of their own car.” The drive-
attracting more annual distribution of free flu vaccinations through program also has served as a real-
participants each year, to the community. In the early years of the word test for a mass-distribution model that
including hard-to-reach program, older and frail people—along could be used in the event of a pandemic
populations such as with parents and their young children— or bioterrorism requiring mass vaccination
stood in long lines waiting to receive the or prophylaxis.
people without health shot. In 2005, Burger and her task force Each year, Burger and her team intro-
insurance or a primary transformed the program into a two-day duce improvements to their program, such as
care physician, and low- drive-through event held in a large park- hand warmers for volunteers and the ability
income families.” ing lot. The novel vaccination program has for people to book an appointment window.
been hugely successful, attracting more par- After 17 years, Burger has valuable perspec-
ticipants each year, including hard-to-reach tive on how to make large-scale immuniza-
populations such as people without health tion programs successful.
insurance or a primary care physician, and “Go visit someone else’s program, and
low-income families. In 2014, 900 LVNH start small,” she said. “Just keep thinking
employee volunteers vaccinated more than that failure is not an option, and build on
14,000 people. your successes.”

18 | fall 2015 | Prevention


Catherine Fonnie, RN, SECHN, DSO
Rokupa Government Hospital
Freetown, Sierra Leone

Taking control of a frightening outbreak

Catherine Fonnie demonstrated exemplary “I realized that I have the ability to break the train staff on the delivery of effective, safe
initiative, leadership, and resourcefulness to chain of transmission. I focused on eliminating patient care.
help her hospital battle the 2014 Ebola epi- fear and finding the way forward.” “Ms. Fonnie worked tirelessly and self-
demic in Sierra Leone. Fonnie’s dedication Working in a highly stressful and resource- lessly to bring about improvements in infec-
reduced the spread of this frightening disease poor situation, Fonnie determined that staff tion prevention and control practices,” said
among patients and healthcare workers, and training was paramount to controlling the Dr. Lousie Berry, a member of the WHO-led
established a foundation of infection preven- outbreak within her hospital. To reduce team. “She stepped up immediately to pro-
tion standards for her hospital moving forward. cross-contamination between patients and vide mentorship to staff and real empathy
As part of a World Health Organization nosocomial acquisition of the virus, she for her patients.”
(WHO)-led infection prevention and control helped train 60 healthcare and cleaning Fonnie’s efforts improved the standard
team, Fonnie took on the role of infection staff in the donning and doffing of lifesav- of patient care at her hospital going for-
prevention lead, emphasizing measures to ing personal protective equipment, as well ward and enabled nursing staff to carry out
prevent cross-contamination, daily checklist as the importance of maintaining adequate their work in a much more controlled, safe
implementation, and regular evaluation. supplies and disinfectants. She also lever- environment. Fonnie now plans to share
“Losing several of my colleagues during the aged knowledge she had acquired during her training program with local hospitals,
Ebola outbreak really enhanced my interest in prior infectious outbreaks and from a three- schools, universities, marketplaces, churches,
infection prevention and control,” said Fonnie. day infection prevention training course to and mosques.

Mercy Joseph, RN, BSC, CIC


King Fahd Medical City
Riyadh, Saudi Arabia

Building an effective infection prevention


and control department
Mercy Joseph —in partnership with a single “I lost my father to a healthcare-associ- Other infection rates reached zero for more
physician—spearheaded creation of the infec- ated infection, and this experience moti- than six months.
tion prevention and control (IPC) department vated me to commit myself to infection The King Fahd IPC department success-
at King Fahd Medical City. Her initiative and prevention and control,” said Joseph. “I fully applied its learnings to control a Middle
determination resulted in a robust and effec- strongly believe it is one of the backbones East Respiratory Syndrome Coronavirus
tive department that has significantly reduced of the hospital.” (MERS-CoV) outbreak among the hospital’s
the incidence of life-threatening infections Joseph focused next on implementing patients and staff. Joseph worked intensively
among hospital patients and staff. bundles to reduce device-related infections, with staff from other disciplines to ensure the
A nurse who has maintained her certi- including central line-associated blood- necessary IPC resources and measures were in
fication in infection prevention and con- stream infection (CLABSI) and catheter- place, and intensified education around hand
trol (CIC®) since 2006, Joseph’s first step associated urinary tract infection (CAUTI). hygiene and personal protective equipment.
in establishing an IPC department at the She engaged multidisciplinary teams, “Mercy Joseph’s personal effort and
1,100-bed tertiary care center was recruiting emphasizing consistency and communi- involvement in the MERS outbreak was
nurses to join her as infection prevention- cation to overcome resource limitations. tremendous,” said Mahmoud Mukahal, RN,
ists (IPs). Joseph began by providing basic Over time, Joseph and her staff reduced BSc, MScQSHM, CIC, chairman of the
infection prevention training, successfully CLABSI rates from 8.3 per 1,000 device King Fahd Medical City IPC department.
enlisting eight qualified nurses to assist in days to 1.7 per 1,000 days, and CAUTI “She is one of the most dedicated and highly
the IPC department. from 5.5 per 1,000 days to 1 per 1,000 days. skilled professionals I know.”

w w w.apic.org | 19
Briefs to keep you in-the-know

Creating bridges between infection


prevention and other disciplines
APIC’s 2015–2016 Heroes Implementation Research Scholars

A
PIC’s Heroes Implementation Research Scholar Award Program provides career development opportunities for highly quali-
fied individuals to plan, implement, and develop a written report for a research project demonstrating value and implications
for infection prevention and quality efforts across clinical settings.
Applications are evaluated based on the proposed project’s potential to advance implementation science, an APIC strategic
priority. Additionally, the strength of the proposed methodology and the proposal’s ability to bridge infection prevention efforts across
clinical disciplines toward helping to advance the infection preventionist’s role were taken into consideration.
Please read on to learn about the research projects of the 2015-2016 scholars. Both scholars will submit their end-of-project written
reports to the American Journal of Infection Control for publication consideration.
The Heroes Implementation Research Scholar Award Program is made possible by an unrestricted educational grant from BD, a long-
standing APIC Strategic Partner.
Visit www.apic.org/About-APIC/Awards/Implementation-Research-Scholar-Award to learn more.

Development, Psychometric, and


Pilot Testing of Standard Precautions
Safety Climate and Observation Tools
Amanda Hessels, PhD, MPH, RN, CIC, CPHQ, School of Nursing, Columbia University, NY


There is a significant and longstanding gap naïve populations and the HCPs who care for and SP adherence. The two tools are the
between recommended and actual practice them. This study will begin to address these Standard Precautions Observation Tool
of standard precautions (SP). There is also gaps by developing and testing such tools. (SPOT) and the Survey on Patient Safety
a knowledge gap in our understanding of This study aims to generate actionable & Standard Precautions (SPSSP). The SPOT
SP adherence, as there is no standard tool knowledge that may be applied across set- is designed to measure HCP-observed adher-
to monitor observed adherence and conse- tings by identifying individual and organiza- ence to components of standard precautions
quently no objective data on which health- tional barriers and facilitators that impede or in hospital settings and is adapted from
care professionals (HCPs), administrators, facilitate the uptake of evidence-based recom- the psychometrically sound World Health
and policy makers can inform their actions. mendations for SP behaviors by HCPs. The Organization Hand Hygiene Observation
Moreover, the correlation between observed objectives of this study are to: (1) develop and Tool and the Centers for Disease Control
and reported SP adherence using psycho- test two well-constructed tools that quantify and Prevention guidelines. The SPSSP is
metrically validated tools that account for observed and reported adherence to SP, and designed to measure HCP perceptions of
the features of the safety climate remains (2) test the relationship among these measures patient safety climate in the hospital unit
unknown. This proposed implementation of adherence and patient safety climate factors on which they work, reported adherence
science study is particularly important and in HCP in hospital settings. to SP practices, and factors that influence
increasingly urgent in context of the juxta- This study is designed to psychometri- that adherence and is adapted from Agency
position of two decades of studies identify- cally evaluate two tools by pilot and field for Healthcare Research and Quality and
ing poor adherence to SP and the increasing testing a SP observation tool and conduct- Standard Precaution and Safety Climate
burden of antimicrobial resistant organisms ing test-retest reliability testing of a survey Surveys (R.R.M. Gershon), all of which have
and global spread of emerging diseases to tool that measures perceived safety climate acceptable psychometric properties.

20 | fall 2015 | Prevention


Use of Personal Protective Equipment:
Ensuring Safety (UPPEES) Study
JaHyun Kang, PhD, MPH, RN, CIC, School of Nursing, University of Pittsburgh, PA


The recent Ebola outbreak reminds us that for HCP with the best practices for patient and (3) create a clear and standardized
the appropriate use of personal protective care and maximum ease and comfort. protocol so HCP can confidently use PPE
equipment (PPE) is very important to pro- Therefore, the goals of the UPPEES study not only at each level of isolation precau-
tect healthcare professionals (HCP) as well are: (1) to ensure safety for both HCP and tions, but also for educational purposes.
as patients. However, very little is known patients by providing a standardized best This study features two separate observa-
about how HCP actually don and doff protocol for the optimal use of PPE at the tions (clinical observation at the UPMC
PPE in practice. Because some PPE (e.g., different levels of isolation precautions Presbyterian hospital and simulation
face shield, goggles, foot cover, head cover, that reflect frontline HCP experience in observation at the University of Pittsburgh
hazmat suit, and powered air-purifying res- clinical settings, and (2) to optimize an Peter M. Winter Institute for Simulation,
pirator) are not commonly used in clinical educational intervention across professional Education, and Research [WISER] cen-
practice, most HCP require extensive train- health schools so the next generation of HCP ter) of HCP PPE use, which feature (1)
ing and administrative support (e.g., the pro- achieve sufficient PPE competency to keep the use of fluorescent markers (as a mea-
vision of specific PPE) in order to use these themselves and their patients safe. surement tool), and (2) hierarchical task
PPE correctly. Additionally, because dif- To achieve these goals, this study aims analysis (HTA). The UPPEES study is
ferent types of PPE provide different levels to (1) describe the knowledge, attitudes, expected to contribute to pursuing APIC’s
of protection and risk, HCP need to know and practices of HCP on the use of PPE, mission to “create a safer world through
these differences to use the PPE properly. (2) assess the performance of HCP regard- prevention of infection,” by providing a
Since more PPE is not always better, it is ing PPE procedures and identify potential highly standardized protocol for optimal
challenging to balance the best protection breaches in and barriers to PPE compliance, PPE use.

Some of the

APIC Awards
2015 Heroes
of Infection
Prevention

program pictured at the


42nd Annual
Conference
in Nashville,
Every year the APIC Nominating and Awards
Tennessee.
Committee (NAC) recognizes the commitment and
achievements of infection preventionists world-
wide. APIC’s awards and recognition programs
are designed to spotlight the profession’s most
distinguished and accomplished clinicians. Help
NAC identify these very deserving members by
nominating them for one of the following awards:
• Carole DeMille Achievement Award
• President’s Distinguished Service Award in Credibility, distinction, and prestige are just Apply now for award and recognition programs
honor of Pat Lynch three of the benefits to being an APIC Award that spotlight the profession’s most distinguished
• Healthcare Administrator Award recipient. Some award recipients also receive and accomplished clinicians! Take the time to submit
• Heroes of Infection Prevention a complimentary registration to the Annual a nomination on behalf of a deserving colleague,
• Chapter Excellence Award Conference (includes hotel accommodations team, or local group before October 31, 2015. Visit
• Chapter Leadership Award and round-trip airfare).  www.apic.org/Awards to learn more.

w w w.apic.org | 21
Briefs to keep you in-the-know

We’re engaged! (In patient safety)


BY JULIE BLECHMAN, MPH

Infection prevention is everyone’s job. Each All three slogans will be available safety? APIC created two online
of us has an important role to play in keep- in multiple layouts and sizes so pledges (for healthcare pro-
ing patients safe from infection. During the you can use whichever is most fessionals and patients and
third week of October, infection prevention- suitable for your facility. We families) as a public display
ists (IPs) take time out of their already busy encourage you to place these of advocacy for infection
schedules to celebrate International Infection materials in patient admis- prevention. Healthcare
Prevention Week (IIPW) to raise awareness of sion packets, patient rooms, professionals are asked to
the role infection prevention plays in improv- on tissue boxes, and even on sign a pledge and promise
ing patient safety. Mark your calendars now the bathroom mirror. We hope to set an example for their
for IIPW, October 18–24, 2015! the new materials will be helpful colleagues by taking the right
This year, APIC wants to help patients in your efforts to encourage patients steps to prevent infections to keep
and care providers talk to each other about to speak up with questions or concerns. We patients safe. We invite you to sign the pledge
infection prevention. Promoting engagement would love your feedback on how useful they and share it through social media with your
between patients, visitors, and healthcare pro- were to you. For example, how did you use colleagues, friends, and family. Help us make
fessionals around infection prevention is the the materials? Did they help patients feel the pledge go viral!
2015 theme. Because hand hygiene is one more at ease asking if hand hygiene had been What germ are you? Lighten up your day
of the most direct ways to begin a conversa- performed? Was staff more open to questions by taking our quiz to find out what germ
tion about infection prevention, the APIC from patients? What are your challenges in best matches your personality. Brighten a
Communications Committee and staff have encouraging patients to speak up? We will colleague’s day with an infection prevention
created some simple slogans and materials use your feedback to develop more resources eCard to thank them for washing their hands
on this topic to help get the dialog started. in the coming year. (for the 100th time). Just like the number of
APIC members and others may purchase or Infection prevention starts with me. Do flu vaccines available, there is no shortage
download artwork to print a variety of stickers you pledge to protect your patients and your- of fun, interactive activities from APIC this
and fliers with the following three messages: self from infections and foster a culture of year. Do you know the ABC’s of antibiot-
• Clean hands stop germs. Ask us if ics? Take our 10-question quiz to prove it,
we washed. then host a little friendly competition with
• Clean hands stop germs. Ask how you your friends and colleagues! We hope your
can help. Facebook page lights up with comments,
• Clean hands stop germs. Ask if you likes, and shares when you post your score!
have questions. Explore the updated Infection
Prevention and You websites. The APIC
Communications Committee works dili-
gently throughout the year to update these
pages with new information and tools you
can use for both consumer and healthcare
professional audiences. Check out the free
resources at www.apic.org/IPandYou.
How do you celebrate IIPW? We want
to hear from you! Connect with us on social
media. Like us on Facebook (facebook.com/
APICInfectionPreventionandYou) and follow us
on Twitter (twitter.com/APIC) for the most
up-to-date news and IIPW activities. Tag us
in the pictures of your facility celebrations,
CleanHandsCampa
ign_8.5x11_AskHel
p_final.indd 1 and post your IIPW activities to IP Talk to
9/1/2015 2:14:46
PM
join the conversation. Or, feel free to email
me directly at jblechman@apic.org.

Julie Blechman, MPH, is the APIC communications


associate and a hand-washing enthusiast.
CleanHandsCampaign_TissueBox_8.75x1.75_AskWashed.indd 1 9/1/2015 3:27:48 PM

22 | fall 2015 | Prevention


Briefs to keep you in-the-know

Japanese and U.S. collaboration highlighted at APIC 2015


While at the 42nd Annual Conference in Nashville, APIC lead-
ers and International Committee members from the Japanese
Society for Infection Prevention and Control (JSIPC) met to
discuss infection prevention challenges and opportunities for
continued collaboration between the two organizations. JSIPC
leaders have been attending the APIC Annual Conference
since 2004 to help foster communication and coordination.
Several APIC presidents and board members have partici-
pated in JSIPC’s conferences. “We were honored to be able to
Photo courtesy Toshihiro Mitsuda, MD, PhD, CICD.

attend the conference,” said former APIC President Russell


Olmsted, MPH, CIC, and current APIC President Mary
Lou Manning, PhD, CRNP, CIC, FAAN, FNAP. “The col-
laboration and networking with our colleagues in Japan has
been extremely beneficial for both organizations, with learn-
ing and insights that members of APIC and JSIPC have been
able to share to improve care of patients on both sides of the
Pacific. We could not be more pleased that this collaboration
has continued.”
APIC annual conferences have enjoyed a high level of atten-
APIC leadership and JSIPC International Committee members. Back row: Yuji Morisawa, MD, dance from many countries, including Japan, where this year more
PhD; Toshihiro Mitsuda, MD, PhD, CICD; Hanako Misao, RN, PHN, RNM, PhD; Keita Morikane, than 30 infection preventionists and physician epidemiologists
MD, PhD; Yoko Tsukamoto, RN, CID, CRNI, PhD; and Kei Kasahara, MD, PhD. were able to make APIC 2015 an overwhelming success.

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24 | fall 2015 | Prevention


760099_Cleanis.indd 1 8/19/15 11:32 PM
CAPITOL COMMENTS

IPs: Your message has been heard


BY NANCY HAILPERN and LISA TOMLINSON

When Congress passed the Affordable Care could be used in real time to improve IPC
Act in 2010, the inclusion of healthcare- programs in hospitals and other healthcare
“Don’t let the noise of associated infections (HAIs) in Centers settings.
others’ opinions drown out for Medicare & Medicaid Services (CMS)
quality measures was seen as an opportu-
However, there was concern that pro-
visions tying Medicare reimbursement to
your own inner voice.” nity to elevate the focus on infection pre- quality improvement would result in mis-
vention and to advocate for more resources leading reporting to prevent reductions in
–Steve Jobs for infection prevention and control (IPC) Medicare payments. The CDC’s Healthcare
programs. The requirement that HAIs be Infection Control Practices Advisory
reported through the Centers for Disease Committee (HICPAC) addressed this issue
Control and Prevention’s (CDC) National in a 2013 report identifying strategies for
Healthcare Safety Network (NHSN) was surveillance, prevention, and control of
preferred by infection preventionists (IPs) HAIs, and assessing the challenges associ-
because it would ensure the use of accu- ated with using HAI surveillance data for
rate, standardized, and actionable data that external quality reporting, including the

26 | fall 2015 | Prevention


unintended consequences of clinician veto and • Surveillance definitions:
clinical adjudication panels.1 – Purpose: Identify trends within a popula- “It may also
Now that quality reporting and pay-for-perfor- tion for prevention and research be helpful to
mance programs have gone into effect, the initial – Components: Limited predetermined data
concerns have proven to be true. As Value-Based elements remind physicians
Purchasing (VBP), Hospital-Acquired Condition • Clinical diagnoses: and hospital
(HAC) Reduction, and Hospital Readmission – Purpose: Identify disease in, and treatment administrators that
Reduction programs have resulted in substantial needs for, individual patients federal law and
penalties for some facilities, some clinicians and – Components: All diagnostic information
administrators have undertaken to reinterpret regulations require
HAI rates by using different definitions than It may also be helpful to remind physicians reporting HAIs
those required by NHSN protocols. IPs, as the and hospital administrators that federal law and into NHSN in
primary NHSN users in many facilities, have regulations require reporting HAIs into NHSN strict adherence to
borne the brunt of these disputes by trying to in strict adherence to NHSN protocols, and
be true to NHSN definitions but are receiving long-term unintended consequences of noncom- NHSN protocols,
pressure from other clinicians to use different pliance could be severe. NHSN has the right to and long-term
definitions in order to reduce HAI rates. revoke the enrollment of facilities that know- unintended
Fortunately, IPs have spoken out and the fed- ingly violate NHSN protocols. If enrollment is consequences of
eral government is responding. By listening to IPs revoked, those facilities will be unable to meet
who have written or called the NHSN help desk CMS quality reporting requirements and will noncompliance
and raised issues and asked questions at APIC’s incur Medicare penalties for failure to comply. could be severe.”
Annual Conference and NHSN training sessions, If IPs or other NHSN users are unable to
CDC staff have learned about the challenges IPs reconcile differences within their facilities, the
face in their facilities. Troubling reports received U.S. Department of Health and Human Services
about HAI reporting include: (HHS) Office of the Inspector General (OIG)
• Decisions to report to the NHSN being made is tasked with protecting the integrity of HHS
by personnel who may not be aware of CDC’s programs, including Medicare. Facility staff
protocols, definitions, and criteria, or who may who become aware of intentional devia-
choose to disregard them; tions from NHSN reporting protocols are
• Facilities using review processes to overrule encouraged to contact the OIG hotline at
the decision of an IP to report an infection 1-800-HHS-TIPS (1-800-447-8477) or
to NHSN; https://oig.hhs.gov.
• Clinicians departing from standard diag- NHSN is used by CDC, state health depart-
nostic practices to avoid reporting infections ments, hospitals, and other healthcare facilities
to NHSN, which can raise patient safety for HAI surveillance. CMS chose to require
concerns. reporting into this established system when
When IPs are faced with disputes about NHSN developing HAI reporting requirements. CDC,
definitions, it may be helpful to remind colleagues CMS, state governments, healthcare providers,
that the definitions you follow are not for clini- and consumers all agree the primary goal is
cal diagnosis, but rather for preventing HAIs. always to keep patients safe. The best way to
Although clinical and surveillance definitions do eliminate HAIs is to know where they are and to
not always agree, according to the CDC, “surveil- implement successful strategies to prevent them.
lance determinations always ‘trump’ in epidemio- This can only be accomplished when all pro-
logic surveillance.” It is important that IPs know viders use standardized definitions to identify
the NHSN definitions, consistently apply them, and monitor HAIs and apply prevention efforts
and are able to articulate the differences in clinical across the continuum of care. Federal agencies
and surveillance definitions with the entire clinical rely on IPs as stewards of HAI surveillance. Reference
team and to management when necessary. In a 1. Talbot TR, Bratzler DW, Carrico RM, et al.
Public reporting of health care-associated
March 2014 NHSN training presentation, CDC Nancy Hailpern is APIC director of Regulatory surveillance data: recommendations From
staff summarized the difference between surveil- Affairs, and Lisa Tomlinson is APIC vice president of the Healthcare Infection Control Practices
Advisory Committee. Ann Intern Med.
lance definitions and clinical diagnoses as follows: Government Affairs and Practice Guidance. 2013;159:631-635.

w w w.apic.org | 27
Chapter Spotlight: APIC Northeast Ohio

Ohio holds first statewide


APIC conference
By Gregory Gagliano, RN, BSN, CIC

“The bridge we started


in Ohio could be linked
with other bridges across
the nation to form a
strong and significant
advancement while
we navigate the ever-
challenging road to
patient safety.”

Photo courtesy Gregory Gagliano, RN, BSN, CIC.


Raising the bar on patient safety by build- attendees on their products and services. In
ing the bridge of communication between addition to infection preventionists (IPs)
healthcare workers and construction pro- and construction professionals, professionals
fessionals was the focus at the first Ohio from occupational health, environmental
statewide APIC conference, held April 17, health and safety, quality, corporate compli-
2015, in Akron, Ohio. It all started with a ance, environmental services, and nursing
sponsorship proposal from two of our own attended the conference, giving us a wide
APIC Northeast Ohio (NEO) members, audience representing multiple disciplines.
Mike Bohan and Aaron Wright.
The idea was proposed in October 2014, Well-rounded program
and on April 17, 2015, members from all five appealed to all audiences
Ohio chapters and some from neighboring Speakers represented hospitals and con-
states, as well as more than 150 area con- struction equally. They emphasized the
struction professionals and many vendors, importance of ensuring the highest level of
came together for the first statewide Ohio patient safety and requiring all construc-
APIC conference. tion-related professionals to successfully
There were 330 registered attendees and complete an accredited Construction ICRA
31 vendors demonstrating and educating Best Practices Training Program prior to

28 | fall 2015 | Prevention


performing work at a healthcare facility. We Conference to take place in the fall of 2016. the idea to the table at your next APIC chap-
ended the program with a panel discussion Rotating the location will allow some, who ter meeting and tell our story. Then make
with all speakers on stage to answer questions. were not able to travel for the day, to attend a few calls to ICRA leads in your area and
There were so many questions we barely had closer to their homes. present the idea. The bridge we started in
time to get them all answered. We are grateful to our sponsor, IKORCC, Ohio could be linked with other bridges
Participants also enjoyed great food, raf- and to all the healthcare and construction- across the nation to form a strong and sig-
fle prizes, and networking opportunities. related professionals and vendors who nificant advancement while we navigate the
Nurses received continuing education units, attended. By working together we took the ever-challenging road to patient safety.
and others from varied professions received opportunity to raise the bar on patient safety!
engineering education credits. We sincerely hope that this was the first Gregory Gagliano, RN, BSN, CIC, is an infection
Since the conference, we have received of many statewide APIC conferences and preventionist at Cleveland Clinic and president of
numerous requests for the presentations encourage others to follow our lead. Bring APIC Northeast Ohio.
and videos, countless compliments on the
speakers, topic, food, and vendors, as well
as excitement and anticipation for the next
event of its kind. We have already begun
planning the next statewide Ohio APIC

WILLOUGHBY WICS SERIES


W
Ohio APIC Conference
topics and speakers Infection
Best Practice Construction
Control
Sink
in a Healthcare Environment
Andrew Streifel, University of Minnesota

Environment of Care:
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746794_Willoughby.indd 1 w w w.apic.org 29PM


12/05/15 |3:15
APIC CONSULTANT CORNER

Meet an APIC Consultant


Mary Bolaños, RN, MPH, CIC, CLNC

Prevention Strategist (PS): Tell PS: You have a successful independent


us about yourself and your work consulting business of your own.
as an infection prevention and What made you want to work for APIC
control consultant for APIC Consulting?
Consulting Services. MB: APIC Consulting has a reputation for
Mary Bolaños, RN, MPH, CIC, CLNC hiring experienced infection preventionists
(MB): As a consultant, I have more than 39 (IPs) who are “the cream of the crop” nation-
“The most important years of experience in nursing, with 34 of wide. I was interested in an assignment that
those years working in infection prevention would be able to match my skill set with
role I performed was the and control. In addition, I have worked as a a position that was flexible given my own
political communication private consultant for multiple organizations personal time commitments. I also wanted
between the surveyors, since 1981 to educate others in the infection to utilize my many years of experience in the
administration, and prevention and control arena. My credentials care and safety of patients through infection
include a Master’s degree of Public Health prevention and control implementation.
management, and from the University of Washington, CIC®
drilling the messages certification since 1997, and national certifi- PS: For more than eight months, you
down to the staff cation since 2002 as a legal nurse consultant. were working as a temporary IP for
I am bilingual in English and Spanish, which APIC Consulting Services. What was
levels throughout your role as a consultant?
is very useful in healthcare settings.
all departments in My previous experience includes working MB: This particular assignment focused
the hospitals.” as an independent infection prevention con- on the response and correction of infection
sultant for an acute care hospital that owned prevention and control non-compliance cita-
more than 16 ambulatory care centers, assist- tions in a large acute care trauma facility
ing the ambulatory care centers to prepare for the Centers for Medicare & Medicaid
for their upcoming Joint Commission Services (CMS) and The Joint Commission.
accreditation surveys. I worked in the greater I worked with a team of infection prevention
Los Angeles area in the early ‘80s during consultants, as well as the facility infection
the beginning of the AIDS epidemic, and prevention staff and executive director over
moved to Washington State in 1985 during Quality Assurance, Risk Management, and
the secondary wave of the AIDS epidemic Infection Prevention. In this role, I assisted
to specialize in HIV/AIDS assessment. in the implementation of initiating surveys
I also managed the infection control/ in the departments noted to be in non-
employee health programs at multiple hos- compliance, education for all staff in those
pitals over many years. In addition, I worked departments, and coordination of informa-
with the Washington State Department tion between the medical staff, nursing staff,
of Social and Health Services in 1994 as and other ancillary department managers
the nurse consultant advisor, infection and staff. Policies were updated and/or
control coordinator, in the Office of Risk rewritten, including a risk assessment and
Management, Employee Services Division infection prevention and control program
to manage the statewide infection control plan. At one point, the temporary infection
program for the 15 agency institutions. prevention director stepped down, and I was

30 | fall 2015 | Prevention


asked to fill that role for approximately six That is where my many years in infection
weeks to transition the newly hired infection prevention management and bilingual skills
prevention director into that position. were an asset and enabled me to be successful
“The main challenge
in assisting the infection prevention team to was to educate other
PS: Can you explain what a temporary IP meet the goal from administration to correct departments on how
role is? the identified non-compliance issues. The critical the infection
MB: The role focuses on filling the needs result was that we laid the groundwork for a
of the infection prevention department for successful, well-rounded infection prevention
prevention program
a given period of time. This role may be department that would be able to continue to is to the success of
expanded once the consultant is actually move forward with the growth of the organiza- the organization.”
onsite. Because facility management does tion, and ensure the safety and quality of care
not have hands-on experience with infec- for the patient population served.
tion prevention and control, I have found
that many times they are unclear about the PS: What were some of the challenges?
role(s) that need to be filled. The temporary MB: The main challenge was to educate
IP needs to complete an assessment of the other departments on how critical the infec-
situation, be frank about what is possible tion prevention program is to the success of
to accomplish in the designated amount of the organization. It was difficult to get buy-in
time, and be realistic about the skill match from staff on the concept that the infection
between the infection prevention consultant prevention program is hospital-wide, and
and the needs of the facility. therefore there is a level of accountability
for all staff. In addition, administration was
PS: As a temporary IP consultant, unaware of what a complete infection preven-
what type of work did you perform tion program entailed.
for the client?
MB: I checked in with the infection preven- PS: What type of client do you think
tion staff daily to review surveillance results. would benefit from a TEMPORARY
I attended all management-level meetings at consultant IP?
the Command Center to be apprised of the MB: A client that would benefit is one that
progress of responses to CMS and TJC, as well is open to having experienced IPs take the reins
as to be able to respond to the non-compliance and provide leadership to assist the organization
issues via written and verbal reports. I made in expanding and complementing the infec-
infection prevention rounds of the depart- tion prevention program. This would help the
ments that had been identified as infection organization to meet standards and educate
prevention non-compliant and completed lit- staff on current infection prevention program
erature reviews to prepare departmental and criteria advocated by APIC, the Centers for
hospital-wide surveys to address employees’ Disease Control and Prevention, accrediting
infection prevention re-education of CMS and bodies, state health departments, the World
TJC requirements. A special software program Health Organization, and regulatory agencies.
was used to input the data from the surveys. The client could be an individual practitioner
Reports and analysis of the data were main- or part of a large organization.
tained and reviewed on a weekly basis by the Infection prevention continues to expand
infection prevention department to measure into all of the healthcare fields. Regulatory
outcomes of success and identify problem areas agencies are raising awareness of its impor-
for correction. This information was shared tance through accreditation and licens-
with repeated surveys completed by CMS and ing surveys. The public is more educated
TJC over the eight-month period. through the media and their own healthcare
The most important role I performed was experiences. Consumers, including our fam-
the political communication between the sur- ilies and coworkers, expect to be protected
veyors, administration, and management, and in all healthcare environments. I am proud
drilling the messages down to the staff levels to participate in that mission as an infection
throughout all departments in the hospitals. prevention consultant.

w w w.apic.org | 31
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INFECTION PREVENTION LEADERSHIP

William J. Maples,
MD, receives the
2015 APIC Healthcare

Leading
Administrator Award
at the 42nd APIC
Annual Conference.

with the
heart

Photo courtesy Solares Photography.


A chief medical
officer’s perspective

a Q&A with William J. Maples, MD

William J. Maples, MD, has always been a


passionate advocate for patient safety. Prior Q. What are some leadership
lessons you can share from your
work and management experiences
describe how two people looking at the same
object may see completely different things.]
to his current role as chief medical officer for
Professional Research Consultants and exec- in infection prevention?
utive director of the Institute for Healthcare
Excellence in Ponte Vedra Beach, Florida,
Know your “true north” and be certain it
is congruent with your institution’s mission, Q. How does one lead in times of
high pressure or crisis?
he was the chief quality officer and senior vision, and goals. Know what is negotiable You have to pause frequently to ask
vice president at Mission Health System in and what is non-negotiable. Communicate whether your leadership reflects your own
Asheville, North Carolina. It was for his again and again the “why” of an initiative/ internal compass—your true north—and
work at Mission Health that he was awarded program and connect to the mission/vision/ the true north of the organization. Check
the 2015 Healthcare Administrator Award goals. Understand the cone-in-the-box phe- frequently with the team to make sure there
at APIC’s 42nd Annual Conference in nomena to develop an understanding of how is a common understanding of the work
Nashville, Tennessee. two individuals may look at the same situation at hand, and harvest differences of opin-
Throughout his tenure at Mission (2010- very differently. Develop relationship-based ion. Transparently share the situation with
2015), Dr. Maples instilled a safety culture communication skills to build trust. Finally, stakeholders. Harvest the strengths of your
and championed infection prevention and model behavior—promises made are prom- team, trust their contributions, and validate
control, engaging consistently with infec- ises kept. their work. Take responsibility for wins and
tion prevention teams, pushing for process losses in the journey, and share transparently.
improvements to protect patients, and ensur- [ Editor’s note: For those who may not
ing that senior leadership appreciated the
value of infection prevention.
be familiar, the cone-in-the-box analogy
imagines that there is a cone inside a closed Q. Communication and
transparency are two essential
tools for leaders. How do you deal
Prevention Strategist recently chatted with box. There are two peepholes: one on top, and
Dr. Maples about his leadership philosophy one on the side. An individual who looks in with these challenges?
and the skills he sees as essential for one to the top sees a circle; the one who looks in the Share all information unless there are det-
become an effective and authentic leader. side hole sees a triangle. The analogy is used to rimental consequences where harm would

w w w.apic.org | 33
INFECTION PREVENTION LEADERSHIP

“Harvest the strengths of your team, trust Dr. Maples’ top 10 leadership pearls
their contributions, and validate their work.
Take responsibility for wins and losses in
the journey, and share transparently.” 1 Always keep your vision.
Never lose sight of your vision. Never compromise
your vision. Persevere your vision.

2 Connect “why are we doing this” with your


daily work and vision.
outweigh good (there are not too many of these situations, but each
situation needs to be evaluated). Communicate in every possible
form and as many times as possible. Understand that there often
3 Believe in the skills and talents of your team.

will be misperceptions of what is communicated (i.e., keeping your


mind, eyes, and ears open to the cone-in-the-box phenomena). 4 B
 uild trust with open communication.
(This one could be number one.)

Q. How do leaders create an environment where


people can learn from their mistakes?
5 Provide resources for your team.

Embrace Just Culture principles. This requires setting


guidelines, expectations, and rules and assessing if a situation 6 Hold each other accountable.
Accountability takes perseverance.
occurred due to a misunderstanding, different interpretation,
or system failure, in which case you coach and do not blame.
At the same time, authentic accountability is necessary, and
7 Weave humility into everyday work.
We all come to the table with something different.

8
consequences for reckless behavior need to be incorporated into Have fun with your team.
the culture. No matter how hard it gets or what crisis comes, have fun.

9 Validate each other.

Q. Do you have any other leadership advice?


Build trust; communicate; appreciate diversity; listen,
Take time and validate who is working across from you and
who is working next to you.
listen, and listen more; know your true north (and remain true to
that); embrace frequent, open, authentic, and transparent commu-
nication; and always understand the likelihood of misinterpretation
10 Pace yourself.
Don’t get too far ahead of your team, or you will
start to look like the enemy.
of information and the cone-in-the-box phenomena.

34 | fall 2015 | Prevention


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PREVENTION IN ACTION

My bugaboo

Acanthamoeba
Forget the fungus, there
are amebas among us!
A microbiological overview of Acanthamoeba
BY IRENA KENNELEY, PhD, APRN-BC, CIC

Greetings, fellow
infection preventionists!
The science of infectious diseases
involves hundreds of bacteria, viruses, fungi,
and protozoa. The amount of information
available about microbial organisms poses
a special problem to infection prevention-
ists (IPs). Obviously, the impact of microbial
disease cannot be overstated. Traditionally,
the teaching of microbiology has been based
mostly on memorization of facts (the “bug
parade”). Too much information makes it
difficult to tease out what is important and
directly applicable to practice. This quarter’s
My Bugaboo column features information
about the human pathogen Acanthamoeba.
The intention is to convey succinct informa-
tion to busy IPs for common etiologic agents
of healthcare-associated infections.
Please feel free to contact me with
questions, suggestions, and comments at
irena@case.edu.

Visitors to the Roman Baths complex in Bath,


England, can see the baths and museum but
cannot enter the water.

w w w.apic.org | 37
Photo courtesy David Iliff via Wikimedia Commons.
PREVENTION IN ACTION

Acanthamoeba is known as a ubiquitous “The ameba that causes this condition is common in freshwater
free-living ameba. It has been isolated from and soil and is also found in seawater, hot tubs, and in contact
soil, tap water, freshwater lakes and rivers,
swimming pools and hot tubs, cooling tow-
lens solution. It can also travel via airborne dust. The infection
ers, sewage systems, and heating/ventila- causes severe eye pain and destruction of the corneal epithelium.”
tion/air conditioning (HVAC) systems.1 The
ameba is found worldwide in both water
and soil. Most people have been or will be and occasionally the lungs and uro- Clinical significance and epidemiology
exposed to this ameba during their lifetime, genital epithelia. Those at higher risk AK predominantly affects healthy per-
but few become infected. There are three are people with traumatic eye injuries, sons who wear contact lenses. An estimated
clinical diseases caused by Acanthamoeba: contact lens wearers, AIDS patients, and 85 percent of U.S. cases occur in contact
1. Acanthamoeba keratitis (AK): A local those with a compromised immune sys- lens wearers (including wearers who follow
infection of the eye that usually occurs tem exposed to contaminated water. recommended contact lens-care practices).2
in healthy persons and can result in per- 3. Disseminated infection: A widespread As of May 24, 2007, a total of 138 patients
manent visual impairment or blindness.1 infection that can affect the skin, sinuses, with onset of symptoms on or after January
2. Granulomatous Amebic Encephalitis lungs, and other organs independently 1, 2005, and positive Acanthamoeba cul-
(GAE): This is a serious infection of the or in combination. It is also more com- tures from corneal specimens had been
brain and spinal cord. The portal of mon in persons with a compromised reported to the Centers for Disease Control
entry is broken skin, the conjunctiva, immune system. and Prevention (CDC) by public health

Figure 1. Acanthamoeba life cycle.


Life cycle image and information courtesy of DPDx/CDC.

38 | FALL 2015 | Prevention


Table 1. Amebic Encephalitis.

Primary Amebic Meningoencephalitis (PAM) Granulomatous Amebic Encephalitis (GAE)

Causative organism Naegleria fowleri Acanthamoeba

Common mode of Vehicle (exposure while swimming in water) Direct contact


transmission

Virulence factors Invasiveness Invasiveness

Culture/diagnosis Examination of cerebrospinal fluid; Examination of cerebrospinal fluid;


brain imaging; biopsy brain imaging; biopsy

Prevention Avoid fresh warm water –

Treatment Amphotericin B; mostly ineffective Surgical excision of granulomas; ketoconazole,


mostly ineffective corneal transplant

authorities and ophthalmologists from central nervous system, death occurs a few “In the mid-1980s, 24
35 states and Puerto Rico.1 Based on an weeks after onset of neurological symptoms.3 cases of Acanthamoeba
analysis of cases reported to the CDC dur-
ing 1985-1987, the incidence of AK in the Risk factors keratitis were reported
United States has been estimated at one to Those at increased risk for infection to the CDC, 20 of which
two cases per million contact lens users.1 include persons who: were users of contact
An estimated 30 million persons in the • Improperly store, handle, or disinfect their lenses. Since then,
United States wear soft contact lenses.2 lenses (e.g., by using tap water or home-
made solutions for cleaning) more than 100 cases
Background • Swim, use hot tubs, or shower while wear- have been reported.”
In the mid-1980s, 24 cases of AK were ing lenses
reported to the CDC, 20 of which were users • Come in contact with contaminated water
of contact lenses. Since then, more than 100 • Have minor damage to their corneas or
cases have been reported. The ameba that have previous corneal trauma
causes this condition is common in fresh-
water and soil and is also found in seawater, Infection prevention and control
hot tubs, and in contact lens solution. It can The primary way to prevent AK is through
also travel via airborne dust. The infection appropriate use and handling of contact
causes severe eye pain and destruction of the lenses. Unfortunately at this time, it is
corneal epithelium. Some patients have been unclear what steps one can take to prevent
successfully treated with ketoconazole or GAE and disseminated infection, both of
miconazole, but others have required corneal which are very rare.
transplants. Contamination of the water by
Photo courtesy of Dan B. Jones, MD/CDC.

this ameba is responsible for the closing of


the historic baths in Bath, England, where a
girl contracted and died from GAE.1,4
Amebae that live in the soil include
the opportunistic human pathogens
Acanthamoeba and Naegleri, both associated
with meningoencephalitis. Naegleria fowleri
is usually seen in swimmers where the ame-
bae enter nasal passages and proceed to the
meninges. Acanthamoeba polyphaga causes Figure 2. Slit lamp photo; broad
ulceration of eyes or skin. If it invades the illumination. AK, early stage of infection.

w w w.apic.org | 39
PREVENTION IN ACTION

Reporting
After the 2007 outbreak of AK, the CDC cre-
Additional resources
ated a team of investigators for reporting of AK Treatment recommendations from The Medical Letter
cases so that risk factors could be described. The • Granulomatous Amebic Encephalitis (GAE)
team also included other federal, state, and local www.cdc.gov/parasites/acanthamoeba/resources/amebic_meningoencephalitis.pdf
public health partners; partner ophthalmology • Acanthamoeba keratitis 
centers and laboratories; academic institutions www.cdc.gov/parasites/acanthamoeba/resources/acanthamoeba_keratitis.pdf
around the country; and professional academies
of eye care providers.1 Fact Sheets
• Acanthamoeba keratitis Fact Sheet [Health Professionals]
Irena Kenneley, PhD, APRN-
 w ww.cdc.gov/parasites/acanthamoeba/health_professionals/acanthamoeba_
BC, CIC, is associate professor at
keratitis_hcp.html
Case Western Reserve University,
• CDC, Acanthamoeba keratitis Prevention and Control
Frances Payne Bolton School of
www.cdc.gov/parasites/acanthamoeba/prevention.html
Nursing in Cleveland, Ohio.
• CDC, Acanthamoeba keratitis Epidemiology and Risk Factors
www.cdc.gov/parasites/acanthamoeba/epi.html
References
1. Centers for Disease Control and Prevention. Mortality and Morbidity
• CDC, Vision Health (Including information about common eye disorders)
Weekly Review (MMWR) Acanthamoeba Keratitis—Multiple States, www.cdc.gov/visionhealth
2005-2007; May 26, 2007:56(Dispatch);1-3. Available at www.cdc.
gov/mmwr/preview/mmwrhtml/mm56d526a1.htm.
• American Academy of Ophthalmology, Proper Care of Contact Lenses
2. U.S. Environmental Protection Agency. Do you wear contact lenses? www.geteyesmart.org/eyesmart/glasses-contacts-lasik/contact-lens-care.cfm
There’s something you should know. Available at www.epa.gov/ • FDA, Consumer Update: Mom, Can I Get Contact Lenses, Please?
waterscience/acanthamoeba.
www.fda.gov/ForConsumers/ConsumerUpdates/ucm318020.htm
3. Cowan MJ (2013). Microbiology Fundamentals/A Clinical Approach.
Infectious Diseases Affecting the Nervous System; pp 460-489. • FDA, Contact Lens Care, Demonstration Video
McGraw-Hill: New York, NY. www.accessdata.fda.gov/videos/cdrh/contactlens.wmv
4. Acanthamoeba life cycle: www.cdc.gov/parasites/acanthamoeba/
biology.html.

40 | FALL 2015 | Prevention


763603_Editorial.indd 1 8/28/15 6:54 PM
PREVENTION IN ACTION

Focus on long-term care and behavioral health outbreaks

Identify the pathogen:

Coxiella
burnetii

PHOTO COURTESY National Institute of Allergy and Infectious Diseases (NIAID).


By Steven J. Schweon, RN, MPH, MSN, CIC, HEM, FSHEA

Produced by the National Institute of Allergy and Infectious Diseases


(NIAID), this scanning electron micrograph (SEM) of a dry-fractured
Vero cell revealed its contents and the ultrastructural details at the
site of an opened vacuole, inside of which you can see numerous
Coxiella burnetii bacteria undergoing rapid replication.

H
ospital outbreaks are reported more often in the medical literature than occurrences in the
long-term care (LTC) or behavioral health setting. By studying and learning from outbreaks
in the LTC or behavioral health setting, the infection preventionist (IP) will glean additional
knowledge and apply this information to hopefully prevent future infections, and infection clusters, in
their facility. This quarterly column will assist the IP in heightening awareness of appropriate interven-
tions to preventing an outbreak.

Koene et al. report an outbreak of atypi- Influenza and Legionella were ruled out from Throat swabs and sputum specimens were
cal pneumonia that occurred in inpatients, this investigation. A total of 45 persons were polymerase chain reaction (PCR) positive
staff, and visitors, in a long-term psychiatric considered suspect cases, with 28 persons for Coxiella burnetii, a Gram-negative bac-
institution housing 127 patients.1 This type having confirmed disease. terium. This pathogen is responsible for Q
of pneumonia is not caused by the traditional Based on your education and training, you fever, a zoonosis, which is an infection that
pathogens that are responsible for typical suspect the following pathogen for being the is transmissible from animals to humans,
pneumonia. Sources of atypical pneumonia illness source: and humans to animals. Q fever, first rec-
infection include bacteria, viruses, fungi, and 1. Streptococcus pneumoniae ognized as a human disease in 1935, was
protozoa. Initially, three residents developed 2. Staphylococcus aureus associated with workers who butcher ani-
symptoms of high fever, headache, cough, 3. Mycobacterium tuberculosis mals. The “Q” stands for “query,” due to
and chills, resulting in hospitalization. 4. Coxiella burnetii the causative organism being unknown

w w w.apic.org | 41
PREVENTION IN ACTION

at the time.2 This organism is primarily fever. It was speculated that windborne “Coxiella burnetii is
found in sheep, goats, and cattle who are spread may be responsible for causing responsible for Q fever,
usually asymptomatic when infected. A high illness at the institution.
bacterial load of Coxiella burnetii is found Animal cultures were obtained from rab- a zoonosis, which is an
in the birth products of infected animals bits at the psychiatric institution, the sheep infection that is transmissible
within the amniotic fluid and placenta.1 The and lambs on the premises, and the flock from animals to humans, and
organism is transmitted to humans through of sheep living near the institution. Positive humans to animals.”
contaminated dust and aerosols containing Coxiella burnetii samples were found in the
dried placental material, birth fluids, and sheep and the abandoned lamb living on
infected animal excreta,3 with a one-to-six the institution grounds. Investigators con- Treatment should not be withheld while
week incubation period.1 About 50 percent cluded that the mother rejecting the lamb awaiting laboratory test results or an initial
of those who become infected develop clini- led to intensive and frequent patient con- negative test finding.4 There is no prophy-
cal illness.1 Fatal infections are rare. tact with the adopted animal. Additionally, laxis after a known exposure.
An epidemiological investigation was transmission may have occurred through In the United States, Q fever cases are
initiated to determine the infection source inhaling dust from the manure or most frequently reported from Western and
and to prevent additional transmission. Two birth products. Plains states, where ranching and cattle
main hypotheses were developed: Coxiella burnetii is a very hardy organism rearing are common. There may be an
• A flock of six sheep lived in a meadow and resistant to heat, drying, and many increased disease incidence in other areas,
on the premises. Five lambs were born types of disinfectants. Besides inhalation, where sheep, goat, and cattle ranching are
prior to the outbreak and were consid- additional means of transmission include locally practiced.2 In 2014, there were 168
ered the most likely source. One lamb tick bites, ingesting unpasteurized dairy reported cases in the United States, but
was abandoned by its mother, and products, and human-to-human transmis- the infection is not reportable in all states.5
was taken into the institution where sion.3 Humans are very susceptible to the To prevent future transmission, the
the residents bottle-fed and cuddled disease, and very few organisms are required authors recommended having a height-
the animal. The ill patients could have to cause illness. This organism has been ened awareness with the health risks of
become infected by inhaling contami- developed for use in biological warfare. lambing sheep and reducing personnel
nated aerosols after close contact with the Q fever can cause acute or chronic illness. contact. Institutions maintaining flocks
pregnant or newborn animals. Most infected persons go on to recover; oth- of sheep should take hygienic measures dur-
• A large flock of sheep lived in a large ers may develop more complicated infected ing the delivery of sheep and handling their
meadow directly near the institution’s infections and develop pneumonia, myo- birth products.
entrance. Two shepherds were ill with Q carditis, hepatitis, and central nervous sys-
tem complications, including meningitis. Steven J. Schweon, RN,
Infection during pregnancy may result in MPH, MSN, CIC, HEM,
Take-home messages for the a miscarriage or pre-term delivery. Chronic FSHEA, is an infection
behavioral health and LTC IP: Q fever may appear as endocarditis, aortic prevention consultant with
1. Have a heightened awareness of the aneurysms, and infections of the bone, liver, a specialized interest in
dangers of animal birth products and and reproductive organs. acute care/long-term care/
limit patient and staff exposure. While most patients completely recover, behavioral health/ambulatory care infection
a post Q fever fatigue syndrome has been challenges, including outbreaks.
2. Use only pasteurized dairy products. reported in 10 to 25 percent of patients,
References
resulting in chronic fatigue, night sweats,
3. A Q fever vaccine is available in severe headaches, photophobia, myalgia, 1. Koene RP, Schimmer B, Rensen H, et al. A Q fever outbreak
in a psychiatric care institution in The Netherlands. Epidemiol.
Australia but is not commercially mood changes, and difficulty sleeping.4 Infect. 2011; 139:13-18.
available in the United States. The wide variety of symptoms may ini- 2. Centers for Disease Control and Prevention. Q fever statistics
tially make diagnosis difficult. Diagnostic and epidemiology. 2013. Available at: www.cdc.gov/qfever/
4. Use standard precautions when stats/index.html. Accessed July 4, 2015.
antibody tests may initially be negative. A
caring for ill individuals.
sample of whole blood can be polymerase 3. Centers for Disease Control and Prevention. Q fever. 2013.
Available at: www.cdc.gov/qfever/. Accessed July 4, 2015.
5. The CDC offers Q fever patient chain reaction tested. A recent travel his-
tory to an agricultural area where infected 4. Centers for Disease Control and Prevention. Q fever symptoms,
education information at diagnosis, and treatment. 2013. Available at: www.cdc.gov/
www.bt.cdc.gov/agent/qfever/clini- livestock were present will assist with the qfever/symptoms/index.html. Accessed July 4, 2015.

cians/patient.asp. diagnosis. Doxycycline is the first line treat- 5. Centers for Disease Control and Prevention. Morbidity and Mortal-
ment for all adults and children with severe ity Weekly Report. Notifiable diseases and mortality tables. Avail-
able at: www.cdc.gov/mmwr/preview/mmwrhtml/mm6425md.
illness and should be initiated immediately.4 htm?s_cid=mm6425md_e. Accessed July 4, 2015.

42 | FALL 2015 | Prevention


PREVENTION IN ACTION

CMS revises ASC infection


control surveyor worksheet:
Critical changes to know
BY PHENELLE SEGAL, RN, CIC

O
n June 26, 2015, the Centers for Medicare & Medicaid Services (CMS) released an update
to the Ambulatory Surgical Center (ASC) Infection Control Surveyor Worksheet (ICSW),
which is used by federal and state surveyors to determine infection control Conditions for
Coverage (CfC) compliance. This worksheet has been used since 2009 and was last revised in 2012.

CMS has released this update for the pur- that these changes are “effective immedi- Several changes, some of them in-depth,
pose of bringing the worksheet into align- ately.” Recent issues relating to improper have been made in a number of clinical
ment with current accepted standards of disinfection of duodenoscopes, ongoing categories. The updates will require review
practice and recently released guidance. issues with safe injection practices, areas and re-education of staff directly involved
Improving the clarity of questions is an of confusion such as artificial nails in the in patient care, as well as staff who are
additional goal. direct care setting, and other breaches responsible for infection prevention
While CMS states this is an “advanced may be, in part, what prompted CMS and control.
update” with a final copy to be “published to make these changes to the existing The changes relate to Part 2 of the
at a later date,” the memorandum stipulates survey worksheet. worksheet—Infection Control Related
Practices—and include the following
significant revisions:

1 A separate column with instructions


for surveyor’s notes has been added
to the worksheet.

2 “Unable to observe” has been added


to the response categories.

3 A n instruction for increased docu-


ment and policy/procedure review
has been added, particularly if a
practice is not observed.

4

Hand hygiene section now includes
the following:
• “Readily accessible, in appropriate
location” when referring to prod-
uct availability such as soap, water,
and alcohol-based hand rub.

w w w.apic.org | 43
PREVENTION IN ACTION

• “Personnel providing direct patient care • Bags of intravenous solutions are • A detailed and in-depth subsection on
do not wear artificial fingernails and/or used for only one patient (and not as immediate-use steam sterilization (IUSS).
extenders when having direct contact a source of flush solution for multiple • A detailed addition for sterilizer monitoring
with patients.” patients). with chemical and biological indicators.
• The following practice, while stated

5

Several updates to “injection practices,”
including the following:
• Statement addressing reporting of
as voluntary, has not appeared in prior
versions of the worksheet: “The ASC
has voluntarily adopted a policy that
7 A minor update to environmental infection
control: “Environmental surfaces in patient
care areas are cleaned and disinfected, using
“unsafe medicine practices” to the medications labeled for multi-dose use an EPA-registered disinfectant on a regular
state’s public health authority if sur- for multiple patients are nevertheless basis (e.g., daily), when spills occur, and when
veyor evidence suggests breaches. only used for one patient.” surfaces are visibly contaminated.”
• Syringes are used for only one patient • Multi-dose vials used for more than


(this includes manufactured prefilled
syringes).
• A lcohol cleaning of the rubber sep-
one patient must be stored appropri-
ately and do not enter the “immediate
patient care area; and if they enter the
8 A comprehensive update of “point of care
devices,” which added in several steps.

tum before entering a multi-dose vial area, they must be dedicated as single Phenelle Segal is a consultant with
has been an area of confusion on an use and discarded immediately after.” APIC Consulting Services, Inc.
ongoing basis. The change stipulates
that “the rubber septum on a medica-
tion, whether unopened or previously
accessed, vial is disinfected with alco-
6

The section on sterilization has several
additions, including the following:
• Pre-cleaning and disinfection refer Reference
hol prior to piercing.” to processes “specified by manufac- 1. Centers for Medicare & Medicaid Services. Advanced Copy – Update to
• “Beyond use date” has been added turer’s instructions, or if the manu- Ambulatory Surgical Center (ASC) Infection Control Surveyor Worksheet
(ICSW). Available at: www.cms.gov/Medicare/Provider-Enrollment-
to the practice of labeling pre-drawn facturer does not provide instructions, and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-
medications. evidence-based guidelines.” Cert-Letter-15-43.pdf. Accessed July19, 2015.

         


    

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44 | FALL 2015 | Prevention


758714_Healthmark.indd 1 13/08/15 2:04 am
PREVENTION IN ACTION

Preventing hospital-acquired
pneumonia (HAP) outside
of the ventilator-associated
pneumonia bundle
BY Joi Fox, RN, CIC; Karen Frush, MD; Cynthia Chamness, RN, CPPS, CPHQ, CPHRM;
Jesi Malloy, MSHS; AND Sandi Hyde, MSPS

A
2014 study published in the New England Journal of Medicine identified hospital-acquired
pneumonia (HAP) and surgical site infections as the most common healthcare-associated infec-
tions (HAIs), both accounting for 22 percent of infections in hospitalized patients.1 The authors
of the study noted that as device- and procedure-related infections decrease, healthcare personnel should
work to expand surveillance and prevention activities to focus on other HAIs, including pneumonia.
LifePoint Health, Inc., was ready for this challenge.

LifePoint Health was selected as one of critical access hospital that did not admit “Collecting and sharing
26 Hospital Engagement Networks (HENs) ventilated patients. Therefore, we were faced
by the Centers for Medicare & Medicaid with the option of disenrolling the hospital
outcome and process
Services (CMS) in 2010, and hospitals in from the collaborative or reviewing data in measurement data with
all HENs were challenged to reduce spe- an attempt to identify patients who were at front-line staff at each
cific types of harm to patients. The analyses risk for developing HAP that was not associ- hospital is a key component
upon which this publication is based were ated with a ventilator.
performed under Contract Number HHSM- LifePoint Health Support Center person-
for success.”
500-2012-00014C Partnership for Patients, nel reviewed the Centers for Disease Control
sponsored by CMS. The LifePoint HEN and Prevention (CDC) guidelines on pneu-
targeted HAP as a harm and launched an monia prevention and identified two distinct
improvement collaborative that consisted patient populations to target (other than
of 12 of the company’s hospitals. Initially, ventilated patients)—post-op patients and
the LifePoint HEN instructed the 12 par- patients receiving tube feedings. The critical
ticipating hospitals to work on preventing access hospital admitted patients from both
pneumonia by implementing the ventilator- of these populations, so we then reviewed
associated pneumonia (VAP) bundle in their the guidelines for items specific to these two
intensive care units. But a problem arose that groups and developed safe practice bundles
was unexpected. One of the facilities was a based on those items.

w w w.apic.org | 45
PREVENTION IN ACTION

Components of the HAP bundles Tube-fed patient bundle collaborative (Collaborative B) was launched
The safe practice bundles for both • Maintain the head of the bed at 30 to with four hospitals from Collaborative A and
post-op patients and tube-fed patients 45 degrees. 21 additional hospitals. Finally, a third group
are shown here. • Verify the placement of the feeding tube of hospitals (Collaborative C) was launched
prior to starting each feed. in July of 2014.
Post-operative patient bundle • Check residuals prior to starting each feed- Collaboratives B and C hospitals received
• Maintain head of bed at 30 to 45 ing; if the residual is greater than 200 cc the same information as those in enrolled in
degrees, especially while the patient is or other ordered limits, hold the feeding Collaborative A, but content was delivered
recovering from anesthesia or while at and contact the physician for additional through one teaching webinar followed by
risk for aspiration. orders. three monthly small group coaching calls.
• Provide mouth care at least twice daily. • Provide mouth care to the patient at least Four to five similarly sized facilities made
• Assess the oral membranes and notify twice daily with an antiseptic. up each small group, allowing each hospi-
the physician of any breaks in the • Administer peptic ulcer prophylaxis, tal to share ideas and concerns. This was
membranes. unless contraindicated. different from Collaborative A where we
• Instruct the patient how to use an incen- • Assess the oral membranes and notify the conducted one-on-one coaching calls with
tive spirometer at least once per hour. physician of any breaks in the membranes. the teams from each hospital. Collaborative
• Encourage the patient to turn, cough, • Assess the patient’s immunization status C was delivered using the same format as
and deep breathe at least once hourly. and administer influenza and pneumonia Collaborative B, although the time between
• Ambulate the patient as soon as medi- vaccines, as appropriate. the small group coaching calls was com-
cally possible. pressed to once every three weeks.
• Educate the patient and/or family on As the initial improvement collaborative Feedback received from the collaborative
preventing HAP. (Collaborative A) progressed, we introduced teams indicated the small group coaching
• Assess the patient’s immunization status the HAP bundles to all participating hos- calls were more effective in providing useful
and administer influenza and pneumo- pitals for implementation in September information, and team performance dem-
nia vaccines as appropriate. of 2012. In June 2013, a second HAP onstrated that the compressed timeframe

Graph 1. Performance of LifePoint Health for hospital-acquired pneumonia reduction, January 2010–March 2015; all facilities.

46 | FALL 2015 | Prevention


between coaching calls was optimal for task 54 percent reduction in non-VAP, hospital-
completion. Sharing between the teams acquired pneumonias following comple- “Throughout the
allowed everyone to understand they were tion of their six-month collaborative, while collaboratives, we
all facing similar challenges and barriers. Collaboratives B and C hospitals have expe-
During the calls, the hospitals collected rienced a 43 percent and 33 percent reduc-
discovered common
nuggets of information they took back and tion, respectfully, following a four-month inconsistencies in practice
implemented into their own processes. The program each. and challenges in multiple
teams also identified barriers encountered
Things we learned
areas including mouth care,
by other teams and used that information
to navigate around similar issues at their Throughout the collaboratives, we
use of incentive spirometry,
own facilities. discovered common inconsistencies in early ambulation, and
practice and challenges in multiple areas identifying other patient
Measurement including mouth care, use of incentive populations at risk
LifePoint collected HAP data for the com- spirometry, early ambulation, and iden-
pany’s 57 hospitals between the first quarter tifying other patient populations at risk
for aspiration.”
of 2010 and the first quarter of 2015. Graph for aspiration.
1 shows the cumulative performance for While most post-op patients are capa- The incentive spirometer has been avail-
HAP reduction by all LifePoint hospitals ble of performing activities of daily liv- able as a tool for preventing pneumonia for
and demonstrates the reduction of HAP ing independently, they often lacked the many years, but it was noted during the
starting with the launch of Collaborative A tools to clean their teeth and mouth cavity collaboratives that use of the device was
in September 2012, and continuing through adequately. During the admission assess- suboptimal. One hospital’s observations
Collaborative C. A trend of sustained and ment, several hospital teams discovered determined that the nursing staff did not
consistent reduction since the introduction that once the nurse determined the patient possess a good understanding of the physi-
of the HAP bundles is evident. was independent with activities of daily ology behind using the device and lacked
LifePoint has experienced a 54 percent living, he or she often failed to ensure the the knowledge to adequately instruct the
reduction of HAP across the company since patient had the tools needed for mouth care. patient on proper use. In response, the hos-
the completion of both collaboratives. Table Additional education has been provided to pital’s respiratory therapy department con-
1 shows a 19 percent reduction in HAP for the nursing staff to ensure the patient pos- ducted training sessions for the nursing staff,
all LifePoint Health facilities following the sesses the necessary tools to complete the increasing their ability to instruct the patient
first collaborative, progressing to a 40 per- task. Independent patients are educated to on proper use of the incentive spirometer.
cent reduction following the second collab- perform oral care at least twice daily. The While conducting a point prevalence
orative, and finally a 54 percent reduction hospitals also require documentation of oral study, another hospital discovered that
at the completion of the third collaborative. care in the patient’s medical record each although patients had been instructed on
Collaborative A hospitals have experienced a time this activity is completed. the proper use of the incentive spirometer,

LifePoint average before collaboratives began 2.162

LifePoint average after Collaborative A (before Collaborative B) 1.758 -19%

LifePoint average after Collaboratives A and B (before Collaborative C) 1.298 -40%

LifePoint average after Collaboratives A, B, and C 1.004 -54%

Collaborative A average before collaborative 2.715


-54%
Collaborative A after collaborative 1.237

Collaborative B average before collaborative 2.105


-43%
Collaborative B after collaborative 1.198

Collaborative C average before collaborative 1.678


-33%
Collaborative C after collaborative 1.121

Table 1. Reduction in infection rates reported as number of infections/1,000 patient days with percentage of change from
pre-collaborative to post-collaborative timeframe.

w w w.apic.org | 47
PREVENTION IN ACTION

are shared with the front-line staff members identifying patients at high risk for aspira-
“Monitoring and measuring to encourage ongoing improvement. tion. As a company, LifePoint is now devel-
compliance with bundle Work from Collaboratives A and B oping an aspiration risk-assessment screening
elements are methods used revealed a need to expand the tube feeding process within the electronic medical record
bundle for HAP reduction to include other for use across the enterprise.
to assess the success of the
patients at risk for aspiration. A screening Collecting and sharing outcome and pro-
collaborative.” tool has been introduced to assess patients cess measurement data with front-line staff at
for risk of aspiration, especially high-risk each hospital is a key component for success.
the device was sometimes left out of reach, populations such as stroke patients and As previously mentioned, point prevalence
resulting in patients being unable to use the patients with dysphgia due to other causes. studies are conducted weekly while process
instrument at the appropriate times. The col- As we rolled out our third HAP cohort, changes are implemented, and the result-
laborative team arranged education for nurs- hospitals were encouraged to initiate a ing data is presented to participating units.
ing and respiratory staff members to make screening process for aspiration risk for all This allows the healthcare team to evaluate
sure that the incentive spirometer remained patients. Examples of screening tools were the effectiveness of those process changes
within reach of patients at all times. As an provided in the HAP Prevention Toolbox for on patient outcomes. The information is
element of their weekly point prevalence Collaborative C hospitals. These tools were shared through various information streams
study, the team continues to assess for this used to aid the hospitals in development of such as staff meetings, committee meetings,
practice and tracks improvement. The results a nursing bedside screening tool to assist in newsletters, and quality improvement com-
munication boards.
Monitoring and measuring compliance
Read more about with bundle elements are methods used to
assess the success of the collaborative. The
hospital-acquired pneumonia improvement teams measure compliance
in the American Journal of with all (cumulative) bundle elements and
Infection Control also drill down to assess compliance with
each individual element of the bundle. This
Effectiveness of a multidimensional approach to reduce ventilator-associated pneumo- allows the team and staff members to see
nia in pediatric intensive care units of 5 developing countries: International Nosocomial exactly where problems exist. An example
Infection Control Consortium findings, Rosenthal, Victor D. et al., American Journal of Infection of identified non-compliance is in the area
Control, Volume 40, Issue 6, 497-501. of mouth care for post-op patients discussed
earlier in the article. Teams were able to
Effectiveness of oral hygiene interventions against oral and oropharyngeal reservoirs of quickly identify areas in need of future focus
aerobic and facultatively anaerobic gram-negative bacilli, Lam, Otto L.T. et al., American and began to develop an action plan to close
Journal of Infection Control, Volume 40, Issue 2, 175-182. the gaps.
While we recognize there are additional
Risk factors and mortality of patients with nosocomial carbapenem-resistant Acinetobacter opportunities for improvement, we cel-
baumannii pneumonia, Zheng, Yu-long et al., American Journal of Infection Control, Volume ebrate our successes and the lives saved by
41, Issue 7, e59-e63. our talented and dedicated LifePoint Health
hospital teams and collaborative facilitators
Prospective study of colonization and infection because of Pseudomonas aeruginosa in at the LifePoint Health Support Center.
mechanically ventilated patients at a neonatal intensive care unit in China, Hu, Hong-bo
et al., American Journal of Infection Control, Volume 38, Issue 9, 746-750. Joi Fox, RN, CIC, is director, Infection Prevention,
at LifePoint Health, Inc., in Brentwood, Tennessee.
Community-acquired versus nosocomial Legionella pneumonia: Lessons learned from
an epidemiologic investigation, Cunha, Burke A. et al., American Journal of Infection Control, References
Volume 39, Issue 10, 901-903. 1. Magill SS, Edwards JR, Bamberg W, et al. Multistate Point-
Prevalence Survey of Health Care–Associated Infections. N Engl
J Med 2014;370:1198-120. www.nejm.org/doi/full/10.1056/
Seasonal variation of respiratory pathogen colonization in asymptomatic health care NEJMoa1306801. Accessed March 27, 2014.
professionals: A single-center, cross-sectional, 2-season observational study, Hassoun, 2. Centers for Disease Control and Epidemiology (CDC), Press Release
Ali et al., American Journal of Infection Control, Volume 43, Issue 8, 865-870. – Despite Progress, Ongoing Efforts Needed to Combat Infections
Impacting Hospital Patients. Centers for Disease Control and
Epidemiology (CDC) website. 2014. Available at: www.cdc.gov/
Risk factors for hospital-acquired pneumonia outside the intensive care unit: A case- media/releases/2014/p0326-hospital-patients.html. Accessed
March 27, 2014.
control study, Sopena, Nieves et al., American Journal of Infection Control, Volume 42,
3. National and State Healthcare Associated Infections Progress
Issue 1, 38-42. Report. Centers for Disease Control and Epidemiology website.
2014. Available at: www.cdc.gov/HAI/pdfs/progress-report/hai-
progress-report.pdf. Accessed March 27, 2014.

48 | FALL 2015 | Prevention


PREVENTION IN ACTION

Methods Discussion Assessment

Introduction Results
Evaluation Impact

An infection preventionist’s
guide to evaluating
research studies
BY TIMOTHY LANDERS, PhD, RN, CNP, CIC, AND MONIKA POGORZELSKA-MAZIARZ, PhD, MPH

E
valuating research studies and incorporating the results of research findings into the practice
of infection prevention and control are core competencies for the infection preventionist (IP).1
Understanding how research is conducted and identifying the key components of how the results
of a study are presented can help IPs ground their daily work in evidence-based practice and apply the most
current findings to the prevention of infection.

50 | FALL 2015 | Prevention


In this article, we review the main compo-
nents of a research paper and some key ques-
“Another key element to consider when evaluating the validity
tions that are useful when evaluating such a and reliability of a research paper is the types of measures
paper. Understanding the basic structure of used, and their appropriateness for the underlying variables.”
a research article is a first step in the critical
review process.
How to evaluate for validity, Variables and measures
IMRAD: Introduction, Methods, reliability, applicability Variables are observations made or data
Results, and Discussion Study design and methods collected. Independent variables are risk
The results of research studies are pre- In broad terms, data from a research factors or other descriptors of the study
sented in a standard format including an study can be qualitative or quantitative. participants. Dependent variables are the
introduction, a description of the methods, Qualitative data includes narrative descrip- outcomes associated with the independent
the results, and a discussion (IMRAD). tions of phenomena and themes or summa- variables. In essence, the outcome depends
The introduction to a research paper ries of experiences collected from groups of on the independent variables; thus, it is
provides an overview of the topic and the people through focus groups, observations, called the dependent variable.
importance of the problem to be studied. or interviews. Quantitative data is collected For a study to be valid, it is important
A well-done introduction addresses what is through precise measurement of different that the dependent variables actually relate
known in the field, gaps in current knowl- variables and is presented as numbers, to the outcome of interest. Dependent
edge, and then describes the purpose of the counts, and statistics. variables can be process measures or out-
study. The methods section includes infor- Understanding the study design, or come measures. For example, a process
mation on how the study was designed and how the data was collected, is important measure might be the number of patient-
conducted, and how data was collected, to evaluating the validity and reliability of days of urinary catheter utilization while
measured, and compared. The results sec- a study. Research studies can be prospec- an outcome measure might be the number
tion presents the specific data collected and tive or retrospective. Prospective studies of catheter-associated infections.
provides the results of statistical comparisons. present an idea or hypothesis to be tested Another key element to consider when
The discussion and conclusion summarize the looking forward. Retrospective studies use evaluating the validity and reliability of a
main results in order to provide an overview previously collected data looking backward research paper is the types of measures used
of how the findings are similar or different to identify trends and make comparisons and their appropriateness for the underlying
from other studies, discuss any study limita- between groups. The topic of the research, variables. Data may be collected on several
tions, and provide applications of the find- access to the patient population, frequency scales and this can impact the validity and
ings in terms of practice and future research. of the outcome, and other factors impact reliability of the study. Nominal, ordinal,
The discussion compares results of the study whether a prospective or retrospective study interval, and ratio data describe the scale
to observations made from previous studies is most appropriate. of the data, and variables can be collected
including similarities of the results to other
studies as well as important differences of
Validity • Were the results of the study obtained using sound scientific methods?
the results to previous findings. The discus-
sion section also addresses the purpose and • What factors impact the accuracy of the study?
outcome of the study and any implications
• Some study characteristics to consider when evaluating the validity of a
for practice.
quantitative study include: random selection/assignment of study partici-
After IMRAD: Evaluate and assess pants, inclusion/exclusion criteria used, appropriateness of statistical tests.

3 key concepts • Control for other extraneous factors that can affect the variables of
The standardized IMRAD format allows interest (confounding).
readers to become oriented quickly to a
research paper. In addition, the abstract of
the paper, included in the published article, Reliability • Are the findings repeatable? If the study were repeated using the same
briefly summarizes the methods, main find- methods in a similar patient population, is it likely that it would yield the
ings, and conclusions of the study. same results?
Once the reader is oriented to the research
paper, it becomes easier to keep in mind
Applicability • Are the results of the study appropriate to your particular setting/practice?
three important concepts that help to eval-
uate and assess the relative importance of • Does the study address an important topic in infection prevention practice?
the research results: validity, reliability, and
applicability (see Table 1). Table 1. Key concepts in evaluating research papers.

w w w.apic.org | 51
PREVENTION IN ACTION

“The goal of statistical analysis


is to determine whether Additional resources
differences observed between • Herzig CT (2014). Research Study Design in Grota, P (Ed.) APIC Text of Infection Control and
groups are due to random Epidemiology. Available at http://text.apic.org.
variation or a true difference.” • Pogorzelska-Maziarz M (2014). Qualitative Research Methods in Grota, P (Ed.) APIC Text of
Infection Control and Epidemiology. Available at http://text.apic.org.
• Manning ML, Davis J (2012). Journal club: A venue to advance evidence-based infection
prevention practice. American Journal of Infection Control, 40 (7), 667-669.
using different scales. For example, tempera-
ture may be collected as a nominal measure • American Journal of Infection Control Journal Club series. Available at www.ajicjournal.org.
(“normal” or “abnormal”), as an ordinal • British Medical Journal How to read a paper series. Available at
measure in which different categories can be www.bmj.com/about-bmj/resources-readers/publications/how-read-paper.
ranked (“hypothermia,” “normal,” “elevated,”
and “high”), in an interval scale (less than
35.6°C, 35.6–38.0°C, greater than 38.0°C),
or as an absolute number (degrees C). confidence intervals that are reported in context of the study. For example, a study
A consideration of how the research study the paper. on the use of an educational intervention to
analyzed the data collected is another impor- improve hand hygiene might measure hand
tant component of evaluating the validity How can the study change practice? hygiene compliance in a group receiving the
and reliability of the study being presented. A commonly missed aspect of critiquing intervention (experimental) compared to a
Different statistical methods are used research studies is understanding how the group that did not receive the intervention
depending on the scale of the dependent results of this study can impact practice and (control). Evaluating the applicability of this
and independent variables. The statistical the relevance of the findings to a particular study requires background knowledge of the
methods selected should be appropriate to setting. After evaluating validity and reli- efficacy of hand hygiene and the impact of
the type of data collected. Quantitative, sta- ability, an important next step is to consider hand hygiene on overall infection rates.
tistical comparisons measure the differences how the results of the research study could The relevance of the study population
in dependent variables between groups. be used to change practice. should be compared to a specific setting and
The goal of statistical analysis is to deter- In order to assess the applicability of a institution. For example, the intervention
mine whether differences observed between study, the outcomes of interest should be and design of a study on universal contact
groups are due to random variation or a considered in relationship to the desired isolation conducted in an intensive care set-
true difference. To identify this, look for clinical outcome. This requires thoughtful ting may not be practical or relevant in a
measures of precision such as a p-value or comparisons and an understanding of the long-term care setting.
Being able to evaluate and critique
research studies in order to inform practice
is an important competency for the IP. The
best way to become better at reading and
critiquing research studies is to practice and
share thoughts with colleagues.

Timothy Landers, PhD, RN, CNP, CIC, is an


assistant professor at The Ohio State University
College of Nursing in Columbus, Ohio. Monika
Pogorzelska-Maziarz, PhD, MPH, is an assis-
tant professor at Thomas Jefferson University in
Philadelphia, Pennsylvania.

Learn more about the APIC Research


Committee at www.apic.org/About-APIC/
Committees/Research-Committee.

Reference
1. Murphy D, Hanchett M, Olmsted RN, et al. Competency in infec-
tion prevention: A conceptual approach to guide current and
future practice. American Journal of Infection Control 2012, 40(4),
296–303. doi:10.1016/j.ajic.2012.03.002.

52 | FALL
763228_UV.indd 1 2015 | Prevention 8/21/15 12:30 AM
PREVENTION IN ACTION

St rikin g a
chord with children
to save lives
BY Terri Embry, RN, BS

A
ccording to the Centers for Disease Control and Prevention (CDC), more than
two million children under the age of five die each year from diarrheal diseases
and pneumonia, making them the top two killers of young children around
the world.1 This is a staggering statistic. Many germs are becoming resistant to
antibiotics and that can lead to grave consequences, especially for children and
those with compromised immune systems. Now more than ever, we need to ensure that basic
hand hygiene practices are taught, learned, and performed properly.
Realizing that we live in an era of aware of people engaged in hand hygiene
YouTube videos, which quickly reach practices. For example, in restrooms and
young viewers, I began looking for a way elsewhere throughout my daily routine, I
to educate children using this new for- realized that there were two things miss-
mat. The idea led me to explore the world ing as I observed people quickly rinsing
of creative education and took me far their hands or, at best, giving their hands a
beyond the commonly taught practice of cursory rub under water—the missing ele-
teaching a child to simply sing the birth- ments were technique and timing. In addi-
day song twice while washing one’s tion to what I noticed about hand washing
hands. The process ultimately led practices, I realized that everywhere I
me to write a song for children that looked, I saw people routinely touching
focused on the instructional aspects surfaces and then using their hands to eat
of hand-washing. without first washing, and I noticed them
For several weeks, I mulled the touching their faces after touching poten-
idea of composing a song to teach tially contaminated items and surfaces.
proper hand hygiene to children. Based on what I observed, and because
During that time, I became more I had been reviewing the World Health

w w w.apic.org | 53
PREVENTION IN ACTION

Organization’s (WHO) steps was very rewarding and exciting them to be potentially helpful and feasi-
to properly perform hand to be in the studio, watching and ble. It is important to be patient with the
hygiene, I realized a massive listening, as something that had process. The graphic art and the video
need for awareness.2 It was been nothing more than an idea production took a couple of months to
then that the words to Happy less than six months prior to that finalize. Since the song and video were
Hands, Oh Happy Hands© began to roll morning became a tangible reality. not part of my full-time job, it took lon-
around in my mind until, one day, I just The next phase of development was to ger to produce.
started writing them down as if I were introduce Happy Hands, Oh Happy Hands I believe that Happy Hands, Oh Happy
writing a poem. to the public. I needed a graphic designer Hands has the potential to help children
Now that I had a concept and the words to create images to convey the meaning around the world learn the most basic
were beginning to form, I recognized that and purpose of the song. Fortunately, I and accessible way to help defend against
the character of the song must be very needed to look no further than to my very the threat of germs that are ever-present
intuitive and catchy. I also wanted to pro- own fiancée, Richard Drummond, for that in our surroundings. And, while it is
duce a video version of the song so it could assistance. I envisioned a slideshow illustrat- important that people learn early in life
be easily accessed online. Happy Hands, Oh ing the steps to proper hand washing with to become aware of the threats that await
Happy Hands was quickly developing in a a cartoon image of germs dropping off of a them, I believe that it is equally impor-
way that seemed to fit that bill, perfectly. child’s hands being washed over a sink. The tant that they understand that good
Once I had the lyrics, I sought the help final slide would show that no more germs hand hygiene habits can help to protect
of Marc Lawson, a professional composer, were present on the hands. My intent was themselves and those around them, espe-
to assist me with the structure and the to simply help children visualize the fact cially those with compromised immune
style of the song, while maintaining the that there are any number of germs on their systems.
message I wanted to convey. To appeal to hands at any given time, and that it is very
children, we focused on making it upbeat important that they learn, and remember, Terri Embry, RN, BS, is
and fun. Lawson guided me through a how to wash their hands properly. Once, director of Specialty
creative new world, and when I heard the graphic art was complete, and the song & Clinical Programs at
the musical score for the first time, I was and video were ready to be released to the Home Solutions Infusion
amazed! I immediately knew that our general public. Services in Atlanta, Georgia.
ideas and efforts had blended into a col- My advice to anyone who has an idea,
References
laborative product that would meet all of even if it falls outside of their comfort
1. Centers for Disease Control and Prevention. Show Me the
the criteria. zone, is to be confident in recognizing Science-Why Wash Your Hands? www.cdc.gov/handwashing/
We finessed the lyrics, auditioned and their own skills, knowledge, and experi- why-handwashing.html. Accessed October 20, 2014.
hired professional singers, selected a pro- ence. Then, nurture the idea and seek 2. World Health Organization. Hand Hygiene Why, How and When
Brochure. www.who.int/gpsc/5may/tools/training_education/
ducer, and chose a recording studio. It to develop these ideas when one believes en. Accessed October 24, 2014.

To view the video, visit


tinyurl.com/HappyHands2015.

Happy Hands, Oh Happy Hands


Happy Hands, oh Happy Hands.
Soap and water, that’s the plan.
First my palms, both one and two.
And now my fingers, I’ ll show you.
Front and back, and in between.
Scrub those germs that can’t be seen.
Both my thumbs are waiting too.
I’ ll wash both sides before I’m through.
Happy Hands, oh Happy Hands.
Soap and water, that’s the plan.
Rinse with water, dry them too.
Now Happy Hands are here for you!

Figure 1. Cover art for Happy Hands, Oh Happy Hands.

54 | FALL 2015 | Prevention


PREVENTION IN ACTION

Photo courtesy Sharon Ward-Fore.

What you
don’t know
can hurt you
A collaborative effort to prepare
and provide care for patients
with really scary diseases

BY Sharon Ward-Fore, MT(ASCP), MS, CIC

I
n our world of global travel, news is not the only thing that travels fast. Diseases that we have only
seen portrayed in movies like Contagion have crossed the oceans and landed on our shores. As health-
care institutions, we need to think about how to prepare to handle the “next big thing,” whether it’s
Ebola Virus Disease (Ebola) or something else. This article is about how our institution—Northwestern
Memorial Healthcare in Chicago, Illinois—began to prepare for the arrival of Ebola patients.

w w w.apic.org | 55
PREVENTION IN ACTION

“Staff safety is The healthcare epidemiology and infection pre- Patient screening/housing

critical. As healthcare vention (HEIP) and emergency management (EM) Patients considered “persons under investiga-
departments began by refining the plan already in tion” brought to the ED will be screened for
providers, we tend to place for decontamination from hazardous material signs, symptoms, and recent travel. Based on this
think of the patient’s (HAZMAT) exposure. The HAZMAT model assessment, they will be held in the ED until the
needs first. We had laid the foundation for three areas we knew we staff can don the necessary PPE. An emergency
to train the staff to would need to tailor to a biological versus chemical response telephone cascade will be activated, and
exposure: appropriate personal protective equip- the process to isolate the patient will begin. A
remember that their ment (PPE), a training program, and a location to contact list of volunteer responders that may be
safety comes first, screen and house potential patients. needed beyond the ED staff will begin to be
especially with Ebola.” called. Others will be notified as necessary.
Personal protective equipment It took five months to achieve a program that
The emergency department (ED) regularly trained the necessary number of staff to be able
trains putting on (donning) and taking off (doff- to respond to this biological threat. Some of the
ing) PPE for chemical HAZMAT exposures. lessons learned are:
Unfortunately, Ebola is a biological hazard and • Staff safety is critical. As healthcare providers,
needs to be approached from a completely different we tend to think of the patient’s needs first.
mindset—slowly and carefully. The Ebola PPE is We had to train the staff to remember that
very similar to the HAZMAT PPE. It consists of a their safety comes first, especially with Ebola.
one-piece zip front Tyvek suit, over boots, powered This level of PPE takes some time to don and
air purifying respirator (PAPR) with a shrouded doff, so they could not rush in to care for the
hood, and double gloves. Unlike HAZMAT where patient until they were appropriately protected.
you can wash off the contamination, Ebola PPE There was a lot of discussion around this issue,
requires meticulous attention to safely remove it. which we addressed by training to don more
quickly, and having a staff member always par-
Training program tially donned and at the ready, in case a patient
With guidance from the Centers for Disease needed something.
Control and Prevention (CDC) website to deter- • The training process was long and arduous due
mine the type of PPE to use, HEIP and EM began to the lack of sufficient quantity of available
the process of determining the sequence for PPE PPE. It was either back ordered or the recom-
donning and doffing. Once that was completed, mendations were constantly changing. Plan
HEIP and EM began to prioritize who should be to maintain a sufficient supply of PPE. We
trained as first receivers. The HAZMAT users recommend you prepare for the worst—you
in the ED were deemed the first group to begin can always de-escalate if needed.
training. It was thought they would be the most • Staff turnover or insufficient available staff
comfortable with the Ebola PPE because it closely makes this a difficult level of training to main-
resembles the HAZMAT PPE, and the likelihood tain. Train and retrain a core group of first
of a patient presenting to the ED, either as a walk- responders who can be the experts.
in or from the airport, was relatively high. • Build a program that can be reviewed at least
Two people from HEIP and EM were consid- annually, similar to HAZMAT training. The
ered “super-users” because of their expertise in program needs to be hands-on to maintain the
donning and doffing Ebola PPE. They began the level of expertise necessary to keep patients and
process of training the HAZMAT team. Each staff safe.
super-user would train no more than two staff at The planning and training for Ebola can be
a time, carefully watching them don and doff the applied to any biological threat. The PPE might
PPE, with critical attention paid to doffing. Staff change, but preparing for the worst lets you eas-
had to complete two successful doffings without ily de-escalate. Whether it’s Ebola, MERS-CoV,
contaminating themselves before they were con- SARS, or something we don’t even know about
sidered trained to care for an Ebola patient. Once yet, keep this high level of training going so you’ll
the ED HAZMAT staff was trained, with the help always be ready.
of our Academy Learning Center, we rolled out
the training program to a wider group of volunteer Sharon Ward-Fore, MT(ASCP), MS, CIC, is an infection
responders including nurses, doctors, and necessary preventionist, Healthcare Epidemiology and Infection
support staff. The Academy Learning Center is a Prevention at Northwestern Memorial Healthcare in
formalized education center within our institution. Chicago, Illinois.

56 | FALL 2015 | Prevention


PREVENTION IN ACTION

IPs fighting Ebola:


One goal around
the world
BY Jill Holdsworth, MS, CIC, EMT-B, and The APIC Emergency Preparedness Committee

I
nfection preventionists (IPs) around the world felt the burden of the 2014 Ebola outbreak in West Africa
and continue to spend time preparing, educating, practicing, and planning for what may never occur at
their facilities. When the crisis hit, many aspects of identification, protection, and treatment had yet to
be defined, leaving infection prevention teams to determine, in the moment, what was best for their facility
and organization. Though we all were reaching for the same goal, we got there in different ways. Below,
members of the APIC Emergency Preparedness Committee share their experiences.

Finding safe and reliable personal protective


equipment for Ebola
Sicily, Italy
by Stuart Hitchcock, MSHS, BSN, PhDc

After assuming the role as the IP for a considering its geographical proximity and

photo: Google Maps


22-bed community hospital, I was interested the prevalence of immigrants in the nearby
in identifying what diseases were of regional city of Catania. After conferring with my
concern in order to update the facility’s risk colleagues in the public health sector, it was
assessment. Though bordered on three sides clear they had a solid plan in conjunction
by the Tyrrhenian, Mediterranean, and with the local Ministry of Health. However,
Ionian seas, the island is just 105 miles from there were some unanswered questions as to
the northern coast of Africa. how best to address the situation from inside over bare hands.1 However, before these PPE
During my exploration of regional dis- the facility. Specifically, we needed a solid standards were put in place, the ensemble for
eases endemic to the area, I came across a plan for personal protective equipment (PPE) a contact patient was the ubiquitous yellow
notice that the World Health Organization that was effective and appropriate. gown. As a result, I began to look for selection
(WHO) and Guinea’s National Ministries of The Centers for Disease Control and criteria which ultimately led me to look at the
Health had just reported an Ebola outbreak Prevention (CDC) PPE guidelines worked gowns used in the operating rooms (ORs) and
in March 2014. I was immediately inter- out the nuances concerning neck coverage, evaluate their potential as part of our Ebola
ested in assessing the facility’s level of risk taping of sleeves, and the pulling of sleeves response ensemble.

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PREVENTION IN ACTION

Given the potential bloodborne patho- contained a ranking system broken into four Fortunately, the level of protection offered
gen transmission during surgery, it seemed categories based on their performance and by the surgical gowns was AAMI Level 4,
apparent that the level of protection afforded included the level of protection they offer as which the healthcare collaborative team
by these gowns could be an effective bar- a barrier against liquid penetration. There adopted as the gown component of the
rier against Ebola. The classification sys- are four levels of protection (1–4), moving Ebola response ensemble. This develop-
tem developed by the American National from the least protective (1), to the most ment was followed by staff education and
Standards Institute (ANSI) and the protective (4) as tested against water under team training exercises on the doffing and
Association for the Advancement of Medical pressure and viral penetration. Armed with donning guidance established by the CDC.1
Instrumentation (AAMI) concerning the this information, I needed to determine While the facility has not had a case, the staff
level of barrier protection offered by different how much better protection a Level-4 gown remains vigilant due to its vulnerable geo-
medical apparel were valuable resources. I (the OR gown) provided over a Level-1 graphic location. Meanwhile, as the Ebola
discovered that the ANSI/AAMI standard gown (the yellow contact gown). Through outbreak in West Africa appears to be wind-
PB70:2003 Liquid barrier performance online AAMI training, I learned that Level ing down, on May 13, 2015, an Italian nurse
and classification of protective apparel and 4 performance is only met if the item is who had been working in Sierra Leone tested
drapes intended for use in healthcare facilities totally impervious. positive for Ebola.2

Dealing with inaccurate travel information, keeping


the media away, and Friday afternoon emergencies
Pensacola, Florida
by Lisa Lavoie, MPH, RN, CIC

photo: Google Maps


On a Friday afternoon, I received a call to said he worked on an oil rig off the coast of
let me know we had a suspicious patient in Africa but did not know the exact locations
the emergency department (ED) who was he had been to within Africa. As the IP, I
coding on arrival and bleeding from every had the ED specimen collection equipment
orifice of his body. The patient had expired, brought to the ED, contacted marketing as a passport so we could review the countries
and the room was closed by ED staff pend- heads-up about media coverage, and kept in he visited. In the meantime, we made a list
ing further instruction. The family reported constant contact with the health department, of potentially exposed employees and made
that he had just returned from Africa two who reported that the patient was not on the sure that the ambulance remained out of
weeks ago. While the health department known Traveler List. We tried to contact his service. Once the family returned with the
searched the database to find out whether the employer to determine the exact location of passport, we determined that he was not in
patient was on the Traveler List, I went to the his work, but they were unreachable. We the affected countries and therefore was not
waiting room to talk with the family. They also asked the patient’s family to retrieve his an Ebola risk.

Too many cooks in the kitchen!


Minneapolis, Minnesota
by Tom Michels, RN

A multidisciplinary group was formed CDC recommendations were tailored for


in our ambulatory care site to include acute care sites and didn’t include specific
photo: Google Maps

IPs, administration, employee health and guidance for other facility types. The shear
safety, risk and legal, marketing, infection panic and fear was far worse than we saw
disease, and a few others. The challenge with HIV/AIDS. We struggled to get our
was that there were too many cooks in the electronic medical records to assist with
kitchen, which slowed down our progress. our efforts. We spent large amounts of time and developing educational materials, and
Administration wanted answers faster than practicing donning and doffing personal ensuring protocols, such as waste disposal,
the CDC could publish them. Many of the protective equipment with staff, educating cleaning, and disinfecting, were ready.

58 | FALL 2015 | Prevention


Public health perspectives on Ebola preparedness
Pueblo, Colorado
by Margaret Comstock, RN, MSHCA

The Ebola outbreak initiated a response and assess the level of preparedness among
from local and state public health agen- our hospitals and first-responder partners.
cies to educate and provide guidance to Public health identified several challenges
the public, medical, and first-responder when reaching out and communicating with
community. The Health Alert Network our community partners:
(HAN), the primary method of sharing • Determining the most effective and appro-
information about urgent public health priate way to reach the needs of our first

photo: Google Maps


incidents, was used to push out informa- responders.
tion and guidance about Ebola. Public • Determining the effectiveness of the edu-
health surveyed how prepared our hospi- cation and guidance documents.
tal and community partners were to care • Understanding how best to support the
for a patient with suspect or confirmed medical community in identifying and
Ebola. Survey responses would also help caring for a suspected or confirmed presentations reinforced the importance of
to understand what support our hospital Ebola case. community relationships and the role of
partners identified. • Obtaining feedback from community public health in emergency planning and
The Emergency Preparedness and partners to effectively address their needs. preparedness.
Response Team initiated the Incident
Command System and developed an edu- Finally, keeping our stakeholders (e.g., “Public health surveyed how
cation plan. This plan was designed to City Council, Board of Health) and medical prepared our hospital and
ensure public education, staff education, community informed through educational
community partners were
to care for a patient with
suspect or confirmed Ebola.
Read more about Ebola Survey responses would
preparation, screening, and also help to understand
PPE training in the American what support our hospital
Journal of Infection Control partners identified.”

Nebraska Biocontainment Unit patient discharge and environmental decontamination Conclusion


after Ebola care, Jelden, Katelyn C. et al., American Journal of Infection Control, Volume The Ebola crisis of 2014 required the
43, Issue 3, 203-205. expertise of IPs worldwide in many dif-
ferent capacities. If nothing else, this
Nebraska Biocontainment Unit perspective on disposal of Ebola medical waste, Lowe,
situation has reinforced the need for IPs
John J. et al., American Journal of Infection Control, Volume 42, Issue 12, 1256-1257.
on the team. IPs became leaders in their
Handling Europe’s first Ebola case: Internal hospital communication experience, organizations and the go-to source for
Mosquera, Margarita et al., American Journal of Infection Control, Volume 43, Issue 4, 368-369. what to do next. Though the waters are
calmer now, the IP is ever ready. After all,
Environmental infection control considerations for Ebola, Lowe, John J. et al., American it’s part of the job.
Journal of Infection Control, Volume 43, Issue 7, 747-749.
Jill E. Holdsworth, MS, CIC, EMT-B, is an
Planning and response to Ebola virus disease: An integrated approach, Smith, Philip W. infection control practitioner at Sentara Northern
et al., American Journal of Infection Control, Volume 43, Issue 5, 441-446. Virginia Medical Center and is the chair of
the Emergency Preparedness Committee. The
Ebola virus disease: What clinicians in the United States need to know, Fischer, William Emergency Preparedness Committee provides the
A. et al., American Journal of Infection Control, Volume 43, Issue 8, 788-793. education, tools, and reference materials needed for
preparedness, response, recovery, and mitigation of
disasters and emerging public health threats.

w w w.apic.org | 59
Sherlockian ability and
teamwork uncover the
Blue Bell listeria
outbreak
BY Vicky Uhland

60 | fall 2015 | Prevention


I
n December of 2013, a man with multiple comorbidities was
admitted into Via Christi Health St. Francis Hospital in Wichita,
Kansas, with severe gastrointestinal bleeding. Infection Prevention
and Control Director Kären Bally, RN, BSN, didn’t know it at the
time, but this seemingly routine admission was the beginning of a
complex infection prevention mystery that wasn’t solved until more
than a year later—thanks to Bally and her team’s relentless sleuthing.

A couple of weeks after he was admitted, the Bally and her team—two quality analysts and
patient tested positive for listeria. Over the next two infection prevention coordinators—used all of
year, four more St. Francis patients would also their epidemiological tools to determine where the
be diagnosed with listeria, and three would die. patient contracted listeria. They examined state and
But thanks to countless hours of epidemiological national food recall records. And they investigated
work combined with a Sherlockian ability to deci- any similarities between the two listeria patients.
pher clues, Bally was able to trace the listeria to “The only commonality is that they had tube feed-
Texas-based ice cream manufacturer, Blue Bell ing,” Bally said. “I couldn’t find any connection
Creameries. As a result of her and the rest of the Via between what they consumed in-house.”
Christi infection prevention team’s detective work,
Blue Bell recalled its products nationwide and shut Back-to-back cases
down its operations in April of 2015. Spring ended and summer began with no more
Using information from the Via Christi infection listeria cases. But then two patients who were
prevention team and public health officials in five admitted a day apart in September of 2014 cultured
states, the Centers for Disease Control and Prevention positive for listeria in October.
(CDC) announced in June that the Blue Bell listeria “They didn’t have the same medical history
outbreak actually began in 2010. It affected five peo- or floor history, but I thought, ‘There’s got to be
ple in Texas, Oklahoma, and Arizona prior to the five something here. There’s got to be a match in their
St. Francis patients. All 10 patients were hospitalized, samples,’” Bally said.
and three of the Kansas patients died. She sent their samples to the state lab for a DNA
analysis. “They said the isolates weren’t a genetic
The detective work begins match—not even close,” Bally said. “My bubble
Because listeria has a three- to 70-day incubation deflated when they called and told me that.”
period, Bally knew finding the cause of the infection Then, in January 2015, a fifth patient was diag-
in the man admitted to her hospital in 2013 would nosed with listeria. Bally once again sent the isolate
be tough. She looked at his diet, both in the hospital to the state lab, and it came back a genetic match
and pre-admission, but nothing raised a red flag. She for one of the patients admitted in September. The
did note that the man lived in another county and state sent the isolate to the CDC for confirmation.
wondered if it was simply an isolated case of listeria. Genome sequencing revealed that the two listeria
But about two months later, on March 13, 2014, a samples were a near-perfect match.
second St. Francis patient tested positive for listeria. “That was my ‘aha’ moment,” Bally said.
Bally said this patient, like the previous one, had a She and her team pulled all of the patients’ dietary
significant medical history and multiple comorbidi- records. They looked at CDC and Food and Drug
ties, so he had been in the hospital weeks before his Administration records for listeria outbreaks asso-
listeria diagnosis. He eventually was admitted into ciated with cantaloupe, fresh fruit, lunch meat—you
hospice and died. name it, they investigated it.

w w w.apic.org | 61
“I can’t stress enough “I was on constant phone calls with the took 30 environmental samples but found
local and state health departments,” Bally no isolates for listeria.
how important it is for said. Soon, state representatives started The next step was to test the ice cream
asking about the hospital’s food—spe- itself, which was delivered in 3-ounce cups.
infection preventionists cifically, tuna, dairy, and ice cream. St. “I felt like I went through ice cream cups
to get to know the Francis has in-house food service, so Bally for hours,” Bally remembered. One of the
consulted with the Director of Nutrition cups finally tested positive for listeria and
heads of departments Services Wanda Reinking. matched the strains found in all five patients
“I had already built a rapport with her, and in the Blue Bell manufacturing plant
and the staff of the so I was able to rely on her,” Bally said. “I in Texas.
kitchen, environmental can’t stress enough how important it is for On March 23, the state issued a press
infection preventionists to get to know the release about the listeria outbreak. “Local
services, and the lab. heads of departments and the staff of the and national media blew up,” Bally said. “And
kitchen, environmental services, and the lab. Blue Bell did a recall that same day on all of
It’s so important to You don’t want to go to strangers during a their 3-ounce food service cups.”
get credibility and crisis and say, ‘I need this, this, and this.’ It’s Bally later learned that the FDA found that
so important to get credibility and account- Blue Bell’s Oklahoma plant had listeria in its
accountability with them ability with them before a crisis.” facility since 2013. And in February 2015,
both the Texas and South Carolina health
before a crisis.” “Oh honey, don’t you worry” departments reported listeria in Blue Bell
In early March, during one of her conver- products after routine testing.
sations with Bally, Reinking mentioned that Blue Bell recalled all of its ice cream
the hospital’s ice cream supplier had recently products nationwide on April 20. In late
starting delivering a different brand, due to July, the company announced it would do
a “quality issue” with the Blue Bell ice cream a limited production run at its Alabama
the supplier had previously carried. plant to “test the effectiveness of new
Bally’s ears perked up. “In the food service procedures, facility enhancements, and
world, a quality issue could be that a recipe’s employee training.”
not right or a label’s not right,” she said. “It
didn’t trigger an interest with Reinking, but It takes a team to
it sure did with me.” solve a mystery
Bally got the contact information for the Bally may have made the connection
Blue Bell supplier in Texas and gave him between Blue Bell ice cream and her hospi-
a call. tal’s listeria outbreak, but it took teamwork
“I said, ‘I hear you have a quality issue to unravel the mystery.
and pulled products from our facility,’” she “It was really a collaborative effort between
remembers. “And he said, ‘Oh, honey, don’t infection prevention, dietary services, and
you worry, the FDA is involved. We had a the state and local health departments,” she
product manufacturing problem that’s being said. “I learned from this outbreak that if you
taken care of. You’ll get your ice cream back don’t work as a team and follow procedures,
real soon.’” you run around in circles.”
Noting that she “couldn’t get off the phone The outbreak was also a test of the CDC’s
fast enough” after this revelation, Bally imme- new PulseNet system, which takes teamwork
diately called the state health department. to a whole new level. PulseNet is a national
That was on a Friday. By Monday after- database of bacteria DNA “fingerprints” col-
noon, March 9, the state epidemiologist lected by public health labs. It relies on two
called and said there was enough support- cutting-edge techniques—pulsed-field gel
ing evidence to pull all Blue Bell products electrophoresis (PFGE) and whole genome
across Via Christi’s five hospitals. On Friday, sequencing (WGS). WGS was used to find a
March 13, the state epidemiologist and FDA match between the five Via Christi listeria
representatives invaded the St. Francis isolates and Blue Bell ice cream samples.
kitchen, doing environmental samples of
kitchen surfaces, freezers, drains, and the Vicky Uhland is a medical writer for
ice cream shake machine. Bally said they Prevention Strategist.

62 | fall 2015 | Prevention


Q&A
The White House Forum on

Antibiotic
Stewardship
BY Mary Lou Manning, PhD, CRNP, CIC, FAAN, FNAP

T
he White House Forum on Antibiotic Stewardship marked a major milestone
in the fight against the threat of antibiotic resistance. More than 150 private and
public key stakeholders including hospitals and health systems, clinical and pro-
fessional organizations, food producers and retailers, pharmaceutical companies,
and other leaders in human and animal health convened in this invitation-only
event held on June 2, 2015, in Washington, D.C.1 I was deeply honored to represent
APIC, provide information, and offer examples of how infection preventionists
(IPs) can facilitate antibiotic stewardship efforts as they work across the continuum of patient
care to identify and report trends and outbreaks from antibiotic-resistant infections; support
efforts to improve antibiotic prescribing and stewardship; and implement interventions to guide
the delivery of evidence-based practices to prevent infections.

w w w.apic.org | 63
Q&A The forum followed a series of important steps
that began on September 18, 2014, when the White “IPs are highly skilled
House published the National Strategy for Combating
Antibiotic-Resistant Bacteria and President Obama
professionals with expertise
signed an Executive Order directing the enactment of in teaching, promoting, and
the strategy.2 The President’s Council of Advisors on
Science and Technology also released a related report
implementing evidenced-
with specific recommendations to address antibiotic- based infection prevention
resistance. In March 2015, the Administration released
the National Action Plan for Combating Antibiotic-
practices and therefore should
Resistant Bacteria.3 The National Action Plan outlines be included as key members
Federal activities over the next five years to enhance
domestic and international capacity to prevent and of stewardship teams.”
contain outbreaks of antibiotic-resistant infections;
maintain the efficacy of current and new antibiotics;
and develop and deploy next-generation diagnostics,
antibiotics, vaccines, and other therapeutics. The
National Action Plan is a must-read for every IP!
The goal of the forum was for participants to commit
Q. Why is the White House interested
in antibiotic stewardship?
The discovery of antibiotics in 1928 fundamentally
to combating antibiotic resistance by escalating their transformed healthcare, saving the lives of millions of
antibiotic stewardship efforts and to help shape the people in the United States and around the world. Today,
implementation of the National Action Plan. APIC mem- however, the emergence of drug resistance in bacteria
bers have asked many questions about my participation is reversing the miracles of the past 80 years, with drug
in the forum. Here are the most common. choices for the treatment of many bacterial infections
becoming increasingly limited, expensive, and in some
cases, nonexistent.3 The Centers for Disease Control
and Prevention (CDC) estimates that annually at least
two million illnesses and 23,000 deaths are caused by
APIC President Mary Lou antibiotic-resistant bacteria in the United States alone.3
Manning, PhD, CRNP, CIC,
The White House recognizes that the rise in antibiotic
FAAN, FNAP, comments during
the Forum on June 2, 2015. resistance is one of the top infectious disease threats
facing the world today and also threatens animal health,
agriculture, and the economy. The White House further
recognizes that antibiotic stewardship—or the ability
to detect, prevent, and control antibiotic resistance—
requires a strategic, coordinated, complementary, and
sustained effort. Success depends on the active engage-
ment of public and private sector leaders, healthcare
providers, governments, academia, veterinarians,
policymakers, the general public, and the agricultural
community, as well as international partners. Efforts
carried out as part of the National Action Plan will
help the Federal government curb the rise of antibiotic-
resistant bacteria with the goal of saving lives. This is
the first time a presidential administration has taken
on the public health problem of antibiotic resistance.

Q. What topics were discussed


during the forum?
The forum opened with remarks from Obama
Administration officials, followed by a panel discus-
sion moderated by CDC Director Dr. Tom Frieden. The
distinguished panel included leaders from the Hospital
Corporation of America, Genesis Healthcare, Walmart,
Elanco Animal Health, and Tyson Foods. The hospital

64 | fall 2015 | Prevention


be included as key members of stewardship teams.
Second, inpatient antibiotic management is a collabora- “In conjunction
tive effort among the physician, pharmacist, and nurse,
yet the problem of antibiotic resistance and antibiotic with the White
stewardship does not seem to be on nursing’s radar
screen. IPs can change this. As part of ongoing efforts
House Forum
to promote evidence-based HAI prevention strategies, on Antibiotic
IPs have credibility and significant contact with bed-
side nurses and can use their influence to Stewardship and
teach and engage these nurses in steward-
in support of
ship activities. Third, APIC has a wealth of
infection prevention resources for con- APIC’s patient
sumers and for healthcare profession-
als working across the continuum of safety mission,
care. Consider the resources for training
APIC launched
and education. Finally, IPs are uniquely
situated to participate and/or lead interprofessional its new Antibiotic
teams to improve judicious use of antibiotics. I believe
their involvement in the prevention of antibiotic resis- Stewardship
tance will significantly escalate.
Advocacy Agenda
healthcare leaders stressed that any good antibiotic
stewardship program begins with good infection preven-
tion, and a good infection prevention program begins
Q. W hat can you tell me about
APIC’s Antibiotic Stewardship
Advocacy Agenda?
on June 2, 2015.”

with effective hand hygiene. As an IP, this was music to In conjunction with the White House Forum on
my ears and provided a solid foundation for the ensu- Antibiotic Stewardship and in support of APIC’s patient
ing human health discussions throughout the day. The safety mission, APIC launched its new Antibiotic
opening session can be viewed at tinyurl.com/Forum- Stewardship Advocacy Agenda on June 2, 2015.
Antibiotic-Stewardship. When the panel concluded, APIC believes that successful efforts to combat
participants then moved to assigned human health or antibiotic-resistant bacteria must recognize the col-
animal health breakout sessions. I participated in the lective responsibility to protect the effectiveness of all
four human health sessions that discussed improving antibiotics—those we have today and those yet to be
inpatient, outpatient, and long-term care prescribing, developed; recognize the potential for these life-saving
and developing new tools for stewardship, better thera- drugs to be overused in both the human and agricultural
pies, and better diagnostics. Each breakout session sectors; and recognize that there are challenges on both
lasted about 90 minutes, began with a moderated brief the demand and supply side of the equation.
panel presentation, and was followed by robust par- APIC promotes antibiotic stewardship through
ticipant discussion. The forum ended with an overall clinical education and training, consumer educa-
summary, next-steps, and follow-up. Common themes tion, and public policy initiatives. Read the full
throughout all human health breakout sessions included advocacy agenda at tinyurl.com/APIC-ABX-
the importance of surveillance, data, and funding; the advocacy-agenda2015.
need for collaboration, partnership, education, and cul-
ture change; the active engagement of patients, families, Mary Lou Manning, PhD, CRNP, CIC, FAAN, FNAP,
and consumers; and the use of a holistic approach across is an associate professor at the Thomas Jefferson
University School of Nursing, and the APIC 2015
the spectrum of care. president.

Q. As an IP, what were the most


important points you were
trying to emphasize regarding
References
1. Fact Sheet: Over 150 Animal and Health Stakeholders Join White House Efforts
to Combat Antibiotic Resistance. Available at: www.whitehouse.gov/the-press-
office/2015/06/02/fact-sheet-over-150-animal-and-health-stakeholders-join-
the IP’s role in curbing antibiotic white-house-effo. Accessed July 17, 2015.
resistance? 2. National Strategy for Combating Antibiotic-Resistant Bacteria. Available at: www.
I emphasized several important points. First, IPs are whitehouse.gov/sites/default/files/docs/carb_national_strategy.pdf. Accessed
July 17, 2015.
highly skilled professionals with expertise in teach-
3. National Action Plan for Combating Antibiotic-Resistant Bacteria. Available at:
ing, promoting, and implementing evidenced-based www.whitehouse.gov/sites/default/files/docs/national_action_plan_for_com-
infection prevention practices and therefore should bating_antibotic-resistant_bacteria.pdf. Accessed July 17, 2015.

w w w.apic.org | 65
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