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Summer 2015 Volume 8 number 2

Questions and concerns
regarding safety of
endoscopes and validity of
manufacturer guidance

Emergency preparedness
simulation exercises COVER PHOTO: Dartmouth-Hitchcock/Mark Washburn

Hand hygiene hurdles:

How can we overcome them?
Measles in the U.S.:
Discussions with public
health representatives
Requirement #2:

We look forward to seeing

you at APIC 2015. Please
visit us at Booth 1140.

Call 800.475.9040 or e-mail us at GSA Contract # FSS Contract # GS-07F-193BA V797P-4452b
Approved for use in all Federal Government facilities.
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2015 Steriliz, Inc. Steriliz is a trademark of Steriliz, LLC.
Getting patients
home safe is a
tough job.

Now, Environmental
Services has a
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PDI, a leader in infection prevention,
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Environmental Services professionals to
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2015 Global Life Technologies Corp. All rights reserved. Made in USA. Nozin Nasal Sanitizer antiseptic is an OTC topical antiseptic drug and no claim is made that it has an effect on any disease.
Summer 2015

Lessons learned:
Questions and concerns
COVER PHOTO CREDIT: Dartmouth-Hitchcock/Mark Washburn

regarding safety of endoscopes Measles in the U.S.:

and validity of Discussions with public
manufacturer guidance health representatives
Questions and answers with experts

With the Cook County Department of Public Health,
Chicago Department of Public Health, and Maricopa

County Department of Public Health

Share Prevention Strategist articles with others.

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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
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6 | Summer 2015 | Prevention

Envisioning the future  8
By Dr. Mary Lou Manning, 2015 Apic President

APIC 2014 scorecard: Tracking key metrics toward our goals 10

By Katrina Crist, APIC CEO

Change continues: Are you eligible? 12

By Kathy McGhie, 2015 CBIC President

Meet a CIC: Nancy Wood, RN, BSN, CIC 15

Briefs to keep you in-the-know 19
APIC honors global public health advocate with its
highest infection prevention award
APIC Strategic Partner: Aramark
New long-term care infection prevention skills pledge tool
Chief medical officer from Florida receives APICs
2015 Healthcare Administrator Award
Capitol Comments: New incentives improve healthcare quality, 22
cost, and public health
By Nancy Hailpern, Lisa Tomlinson, and Patricia Gray

Chapter Spotlight: APIC Greater LA 26

Take back your hashtags: An infection preventionists guide to Twitter
By Angela Vassallo

Global Insight: Perspective from AustraliaRoutine culturing and

surveillance of endoscopes 33

By Dr. Cathryn Murphy

Infection prevention leadership: My personal journey 37

By Timothy Bowers

Emergency preparedness and infection control: 40
Teaming up to create meaningful staff simulation exercises
By Kristine Sanger

Focus on long-term care and behavioral health outbreaks: 44

Clostridium perfringens
By Steven J. Schweon

A family-centered care model to reduce pediatric CAUTI 46

By Vicky Uhland

My Bugaboo: Hepatitis CThe silent epidemic 50

By Dr. Irena Kenneley

Hand hygiene hurdles: How can we overcome them?

Q&A with Dr. Timothy Landers
By Vicky Uhland
w w | 7

The Ebola crisis in the United States highlighted the fact that infection pre-
Envisioning vention and control programs are generally under-resourced and have limited
surge capacity. This has led to the growing question echoed among infection
the future preventionists (IPs) and healthcare epidemiologists: How do we influence
S u m m e r 2 015 VO L UME 8 , I S S UE 2
organizational decision-makers to invest in infection prevention and control
programs to assure we have the critical resources to prevent and manage infections Board of Directors
on a day-to-day basis and be prepared to rapidly respond to the inevitable, but President
unpredictable, appearance of emerging (and re-emerging) infectious diseases? Mary Lou Manning, PhD, CRNP, CIC,
While this question is important, recent national and global events have opened President-Elect
a large window of opportunity to bring forth a bolder question: In this era of Susan A. Dolan, RN, MS, CIC
rapid health and healthcare transformation, is now the time to reimagine the Treasurer
Marc-Oliver Wright, MT(ASCP), MS, CIC
strategic role and functions of infection prevention and control programs in an
increasingly complex and interdependent world? Connie J. Steed, RN, MSN, CIC
Reimagination requires inviting new ideas, exploring possibilities, and envi- Immediate Past President
sioning the future. As an infection prevention community, we need to span Jennie L. Mayfield, BSN, MPH, CIC
boundaries outside our own circles to deliberately engage with others to create
partnerships, alliances, and other forms of collaboration to tackle this complex Directors
Joseph A. Bosco, III, MD
question. APIC has forged strategic relationships with many organizations and
Kim Boynton-Delahanty, RN, BSN, PHN,
continues to scan the environment for additional partners, all of whom can MBA/HCM, CIC
provide insight. As infection prevention leaders, boundary spanning may require Gail Fraine, RN, MMHC, BSN, CIC
new skills in order to proficiently reach across professions, functions, sectors, or Deborah G. Friberg, MBA, FACHE
By Mary Lou
Manning, organizations to build relationships, interconnections, and interdependencies Brenda Grant, RN, BSN, MPH, CIC, CHES
PhD, CRNP, CIC, in search of different perspectives and knowledge. According to the Center for Janet Haas, RN, PhD, CIC
FAAN, FNAP Creative Leadership, boundary spanning leadership involves creating direction, Karen K. Hoffmann, RN, MS, CIC, FSHEA
APIC 2015 PRESIDENT alignment, and commitment across five types of boundaries:1 Linda McKinley, RN, BSN, MPH, CIC
Vertical: class, seniority, authority, power Ann Marie Pettis, RN, BSN, CIC

Horizontal: expertise, function, peers Katherine S. Ward, RN, BSN, MPH, CIC
Kathy Ware, RN, BSN, CIC
Stakeholders: partners, constituencies, value chain, communities
Demographic: gender, generation, nationality, culture, personality, ideology
Geographic: location, region, markets, distance Katrina Crist, MBA
Infection prevention and control is an inherently boundary-spanning enter-
prise. The work of the infection prevention team, while specialized, cannot be Disclaimer
performed independently and requires interdependent and coordinated action Prevention Strategist is published by
the Association for Professionals in
across multiple and overlapping boundaries. However, the engagement is often Infection Control and Epidemiology,
related to specific initiatives such as implementing interventions to prevent Inc. (APIC). All rights reserved.
APIC is healthcare-associated infections or in response to acute events, such as outbreak Reproduction, transmission,
distribution, or copying in whole
conducting investigations. Deliberate strategic relationship-building actions will be required or in part of the contents without
express written permission of
a member to bring groups together to achieve the larger purpose of envisioning the future.
APIC is prohibited. For reprint
During the past decade, infection prevention and control programs have been
MegaSurvey to and other requests, please email APIC makes no
presented with an unending series of challenges and expectations. The challenges,
determine the more often than not, have resulted in additional responsibilities, functions, and
representations about the accuracy,
reliability, completeness, or timeliness
current state of workload. Collectively, IPs have responded professionally and graciously sharing of the material or about the results to
be obtained from using this publication.
the infection their expertise, talents, and time to meet the many challenges. However, there You use the material at your own risk.
comes a time when it is necessary to step back and reflect on where we have APIC assumes no responsibility for
preventionist any injury and/or damage to persons
been, where we are now, and thoughtfully consider our preferred future. Toward or property as a matter of products
profession. this end, APIC is conducting a member MegaSurvey to determine the current liability, negligence or otherwise,
or from any use or operation of any
state of the infection preventionist profession. To all who participated, please methods, products, instructions,
accept my sincere appreciation for your time and careful responses. If you have or ideas contained in the material
herein. Because of rapid advances in
not yet participated, please do so. With you, I look forward to the results that the medical sciences, in particular,
will create a baseline of data to map out our desired future. independent verification of diagnoses
Reference and drug dosages should be made.
Let us continue this discussion in Nashville during APIC 2015. I look forward Although all advertising material
1. Lee, L, Horth, DM, & Ernst, C. Bound-
ary spanning in action: Tactics for to connecting! is expected to conform to ethical
transforming todays borders into (medical) standards, inclusion in
tomorrows frontiers. Center for this publication does not constitute
Creative Leadership 2014. Accessed a guarantee or endorsement of the
March 24, 2015. Available at: www. quality or value of such product or of the claims made of it by its
boundarySpanningAction.pdf. Mary Lou Manning, PhD, CRNP, CIC, FAAN, FNAP manufacturer.

8 | Summer 2015 | Prevention

Empower patient compliance
with the Clorox Healthcare

4% CHG Skin Cleansing Kit.

Provide patients with everything

they need in one kit, and youve helped
them enormously. And youve taken
another important step in your SSI
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4 oz. 4% CHG Bottle: Evidenced-based

literature shows 4% CHG bottles
are equally effective for infection
prevention as 2% CHG pre-saturated
cloths when patients receive
standardized instructions.1

Patient Reminder Systems:

Offer multiple contact points

shown to enhance compliance for
preoperative skin cleansing.2

Waterproof Instructions Card:

Includes large text and visual icons,
which studies show are effective for
promoting understanding.3
A e yo
Ar you co
n den
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tss hav
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av follllllow
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yo ur pre
ur reop
atiivve sk
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*While supplies last. Limit one per customer. Business or institutional customers only.
1. Edmiston CE, Medical College of Wisconsin, Milwaukee, WI. Evidence for using Chlorhexidine Gluconate Preoperative Cleansing
to Reduce the Risk of Surgical Site Infection. AORN Journal. Vol 92. No 5. (2010): 509-518.
2. Edmiston CE, et al. Empowering the Surgical Patient: A Randomized, Prospective Analysis of an Innovative Strategy for Improving
Patient Compliance to the Preadmission Showering Protocol. Journal of the American College of Surgeons 219.2(2014): 256-264.
3. Hibbing, A., A Picture Is Worth A Thousand Words, The Reading Teacher; 2003. Learn more and get a free sample* at
2015 Clorox Professional Products Company, 1221 Broadway, Oakland, CA 94612. NI-28708
APIC 2014
THE FIVE STRATEGIC priorities as part of Strategic Plan 2020 (
patient safety, implementation science, competencies and certification, Prevention
advocacy, and data standardizationare critical to measuring APICs
Tracking key success. The scorecard below provides a snapshot of key metrics. We are S U M M E R 2 015 VO L U M E 8 , I S S U E 2
making exceptional progress to date with high probability of meeting 10
metrics toward out of 12 targets by 2020.
Katrina Crist, MBA
our goals Two targets have already surpassed the 2020 target. APIC has exceeded
its initial 100,000 consumer engagement target with a huge leap of more
Janiene Bohannon, MS
than 120,000 consumer engagement points in 2014 alone. This brought
the 2014 total to more than 155,000. This measurement includes actions Julie Blechman, MPH
taken by a consumer such as downloading information from the con-
sumer site (, tweeting or sharing ADVERTISING
Brian Agnes
a Facebook post, taking an educational bug quiz, or sending an e-card.
It excludes visits to the website absent any further action. This quick level GRAPHIC DESIGN
Deb Churchill Basso
of engagement was unexpected and is testimony to the publics interest
and demand for infection prevention and control information. PRODUCTION
The other target that exceeded the 2020 goal is reaching 1,000 facili- Heather Williams
ties with APIC-related training and resources for effective infection
prevention and control programming. APIC has reached more than EDITORIAL PANEL
1,500 facilities with 991 in acute care, 236 in long-term care, and 362 George Allen, PhD, CIC, CNOR
Kristine Chafin, RN, MBA, CIC
BY KATRINA CRIST, in ambulatory surgery, through collaboration with the Health Research Megan Crosser, BS, MPH, CIC
MBA, APIC CEO and Educational Trust on CAUTI and SSI related education. The APIC Mary L. Fornek, RN, BSN, MBA, CIC
Brenda Helms, RN, BSN,
Board of Directors is considering resetting these two targets to achieve MBA/HCM, CIC
even higher impact by 2020. Linda Jamison, MSN, RN, CIC, CCRC
Irena Kenneley, PhD, APRN-BC, CIC
The most ambitious target to achieve by 2020 will be 10,000 CICs. Kari L. Love, RN, BS, MSHS, CIC
Nearly 6,000 infection preventionists (IPs) have done their part already, May M. Riley, RN, MSN, MPH,
but APIC will be mobilizing forces to reach 10,000 to strengthen the role Steven J. Schweon, RN, MPH,
and value of the IP through greater adoption of this standardized credential MSN, CIC
that demonstrates core competency in infection prevention and control. CONTRIBUTING WRITERS
Please visit the Vision and Mission page under About APIC at Timothy Bowers, MT(ASCP), MS, CIC to view the full scorecard with details on measures, metrics, Demian Christiansen, DSc, MPH
Katrina Crist, MBA
and outcomes. James Davis, MSN, RN, CCRN,
Sincerely yours, CIC, HEM
Patricia Gray, RN, BAHSA, CIC
Nancy Hailpern
Irena Kenneley, PhD, APRN-BC, CIC
Timothy Landers, PhD, RN, CNP, CIC
Mary Lou Manning, PhD, CRNP, CIC,
Katrina Crist, MBA FAAN, FNAP
APIC CEO Kathy McGhie, RN, BScN, CIC
Cathryn Murphy, RN, MPH, PhD, CIC
Frank Myers, MA, CIC
2014 Change from On
Strategic Priority 2020 Target Kristine Sanger, BS, MT (ASCP)
Progress last year Track Steven J. Schweon, RN, MPH, MSN,
Patient Safety 100,000 consumer interactions 155,266 123,163

Tammy Sylvester, RN, BSN

Lisa Tomlinson
Patient Safety 60 organizational communications 14 9 Vicky Uhland
Angela Vassallo, MPH, MS, CIC
Implementation Science 100 courses and published resources* 65 6 Nancy Wood, RN, BSN, CIC
Implementation Science 1,000 facilities 1,589 1,589 MISSION
IP Competencies/CIC 10,000 CICs 5,944 260 APICs mission is to create a safer
world through prevention of infection.
IP Competencies/CIC 1,000 advanced practice designation n/a n/a The associations more than 15,000
members direct infection prevention
IP Competencies/CIC 450 participants in research training n/a n/a programs that save lives and improve
the bottom line for hospitals and other
Advocacy 3,000 subscribers to advocacy update 1,907 334

healthcare facilities. APIC advances

Advocacy 5,000 clicks on regulatory resources 3,553 1,117 its mission through patient safety,
implementation science, competencies
Advocacy 3,000 clicks on public policy agenda n/a n/a and certification, advocacy, and data
standardization. Visit APIC online at
Data Standardization 40 organizations supporting NHSN 31 2
Data Standardization 3,700 members take action* 1,154 1,154 API-Q0215 1061

*non-cumulative n/a = initiative in development Green = High probability of achieving 2020 target
Yellow = Medium probability of achieving 2020 target Red = Low probability of achieving 2020 target

10 | SUMMER 2015 | Prevention

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

If you dont 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.

Chief Medical Ofcer 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
Healthcare workers

Many HAIs [healthcare-associated infections] are transmitted by

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

reduce these infections.


afliate of the American Hospital Association
Celebrating Excellence

Are you

In my last column I introduced you to the new content outline that resulted from the 2014 Practice
Analysis survey. The new examination forms based on this outline will be piloted in July 2015. Once
the pilot period is complete, cut scores can be established to determine the standard for passing the
examination until the next Practice Analysis is conducted. You can learn more about cut scores by lis-
tening to our podcast, Passing Rate and Score of the CIC Exam at
Review of the Practice Analysis also provided us with a contemporary evaluation of current infec-
tion prevention and control practice and prompted us to review and update the eligibility criteria. The
updated requirements demonstrate the changing practice and reflect the full spectrum of healthcare
practices that are involved. We believe the updated requirements expand the profession.

By Kathy McGhie,
2015 CBIC PRESIDENT Eligibility requirements (as of July 1, 2015)
You must meet ALL requirements. You are 1. Identification of infectious disease processes
accountable for infection prevention and control 2. Surveillance and epidemiologic investigation
activities/program in your setting and this is 3. Preventing and controlling the transmission
reflected in your current job description; of infectious agents
AND And at least two (2) of the remaining five (5)
You have a post-secondary degree (e.g., associ- components:
ates or baccalaureate degree); 1. Employee/occupational health
AND 2. Management and communication
You have had sufficient experience (recom- 3. Education and research
mended: two years) in infection prevention 4. Environment of care
and control that includes all three (3) of the 5. Cleaning, sterilization, disinfection, and
following: asepsis

Key changes

Without Work in a healthcare setting is no longer required. Accountability for infection prevention and control activities
must be reflected in your job description. This reflects the variety of work settings of infection preventionists.
continual The basic education requirement is now a post-secondary associate or baccalaureate degree. It is not
growth and required that this be in a healthcare-related field.
progress, The experience component has been updated to reflect the current content outline. It is our belief that
such words as the application of knowledge and experience gained in a clinical practice setting is an essential component
that supports our mission to protect the public through the development, administration, and promotion
improvement, of an accredited certification in infection prevention and control. The assessment of sufficient experience
achievement, is individual to the candidate and can vary; however, CBIC recommends two years of experience in infec-
and success have tion prevention and control. Candidates who are comfortable with their knowledge and experience may
no meaning. sit for the exam whenever they are ready. However, analysis of our data has demonstrated greater success
amongst candidates with at least two years of experience in the field.
Benjamin Franklin
We understand that there will be individuals who do not meet the requirements but still seek certifica-
tion. Recognizing that practice settings and job descriptions vary greatly, CBIC will continue to have a
candidate appeal and review process for individual assessment of eligibility when requested.
More change will come as we strive to improve.

12 | Summer 2015 | Prevention

Daily Patient Bathing

Dont just cleanse

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 ghting 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 le. Mlnlycke Health Care. Study R05-0225.

Hibiclens, the Hibiclens logo and Mlnlycke are registered trademarks of Mlnlycke Heath Care AB.
Distributed by Mlnlycke Health Care US, LLC, Norcross, Georgia 30092.
2013 Mlnlycke Health Care AB. All rights reserved. 1.800.843.8497.

Meet a CIC
Nancy Wood, RN, BSN, CIC
Infection Prevention Specialist
Canton-Potsdam Hospital
Potsdam, New York

Q: What inspired
you to become
an infection
preventionist (IP)?
From an early age I knew I wanted to be
Q: Why did you pursue
board certification
in infection
prevention and
control (CIC)?
My CIC designation gives
either a nurse or a teacher because those Board certification validates my personal
people across our health were the two clear career options for women commitment to infection prevention and
system a trusted resource. at the time. After I completed my nurses conveys to others that I have mastered the
No one has to deal with training, I worked in medical, surgical, and art and practice of infection prevention and
infection prevention case management departments. My nurse control. I work in a very rural area in north-
manager, who was also my mentor, recog- ern New York so I am able to serve as a ready
issues alone. nized my eye for detail and she encouraged resource for both my facility and for my
me to apply for the position in infection professional colleagues serving other facili-
prevention. The infection prevention direc- ties. Infection prevention is a field thats rap-
tor, who was also a CIC, inspired me to idly expanding; certification demonstrates
reach for my full potential, which included commitment to professional growth, staying
attending the basic training course and current, and sharing best practices.
taking the CIC exam. As I grew in the
profession of infection prevention, I found
that the teacher and the nurse in me were
melding together to form a truly reward-
ing career. I had without a doubt found
my niche! In my role as an IP, I pay it
Q: How did you
prepare for the
CIC exam? What
I like that old saying, You eat an elephant
forward by mentoring our new nurses and one bite at a time. I committed to blocks of
providing education to the nursing staff. study time, which I scheduled on my calendar.
As evidence-based best practices emerge, I did a self-assessment and identified my weak
I can honestly say I learn something new areas. I then used APIC resources, concentrat-
every day and I appreciate that professional ing on one weak area at a time. I went through
stimulation. Once Ive provided education the APIC Certification Study Guide cover to
to others, Ive empowered them to deliver cover. I reviewed every module in the Study
safer care. I still have that eye for detail; I Guide and completed every test question.
seem to see things others might miss and If I got something wrong, I looked it up in
fill in those gaps. Working toward a full the answer key, and (if needed) I went to the
understanding of diseases and how to keep APIC Text to ensure I really understood the
them from spreading is one of the most material. Im a visually oriented learner, so I
fulfilling parts of my work. use highlighting a lot. I can recall information
if I have that visual cue.

w w | 15
Q: In what ways
has your CIC
benefited you?

CIC has benefited me in two important

Q: In what ways has
your CIC benefited
your healthcare
My CIC designation gives people across our
Q: Can you share some
study tips for
others who wish
to pursue their CIC
ways. First, CIC exams test your knowl- health system a trusted resource. No one has I have found over the years that ongoing
edge in six key areas: disease identification, to deal with infection prevention issues alone. review of infection prevention publications
surveillance and epidemiology, prevention Our system is built on collaboration among like the American Journal of Infection Control
and control of infections, employee health, our affiliates as well as various community and Hospital Infection Control and Prevention
leadership and education, and research, agencies, such as public health. Responding (among other credible sources) benefits me
which I can then put into practice. These to an emergent threat of infection, such as the when it comes time to take the exam. I fre-
six areas serve as a framework as I develop recent Ebola virus outbreak, relies on having quent the APIC IP Talk site daily to stay
and manage the infection prevention plan already laid the groundwork for collaboration abreast of current issues that other IPs are
for my facility, keeping in mind key educa- and seamless lines of communication among dealing with in a variety of healthcare set-
tion and communication strategies, as well organizations responsible for protecting the tings; this usually prompts me to look at my
as thinking about ways to provide effec- communitys health. CIC is also becoming a own practices. Pursuing CIC designation is
tive education for the new generation of must for healthcare facilities that are pursuing a personally and professionally rewarding
healthcare workers who have entered the accreditation status, such as with The Joint experience. Its not easy, but it is well worth
workforce. Second, recertification every five Commission and DNV [Det Norske Veritas]. the commitment to achieve.
years ensures that I stay up to date and that
the knowledge Im sharing is relevant to
infection prevention and control as we move
forward in a rapidly changing healthcare

16 | Summer 2015 | Prevention

734814_Cleanis.indd 1 5/12/15 6:09 PM
Visit for your free trial sample.
Briefs to keep you in-the-know

APIC honors global public health

advocate with its highest infection
prevention award
APIC will honor Cathryn Murphy, RN, Journal of Infection Control editorial board
MPH, PhD, CIC, of Queensland, Australia, for more than a decade, reviewed various
with the prestigious 2015 Carole DeMille APIC Elimination Guides and position
Achievement Award. papers, authored many peer-reviewed arti-
The award, which will be presented during cles, and formally mentored IPs throughout
the opening session at APICs 42nd Annual her career. Cath credits and will always be
Conference in Nashville, Tennessee, is given grateful to APIC, its members, leadership,
annually to an infection preventionist (IP) and staff as well as previous Carole DeMille
who best exemplifies the ideals of Carole Achievement Award winners for their collec-
DeMille, a pioneer in the field. tive and individual interest and investment
We are honored to award Dr. Murphy in her professional and personal development
with the Carole DeMille Achievement and opportunities.
Award for her lifelong dedication to infec- Dr. Murphy remains committed to build-
tion prevention, said APIC 2015 President ing global IP capacity, ensuring that the
Mary Lou Manning, PhD, CRNP, CIC, profession continues to grow in each of its New Zealand, Philippines, Singapore, South
FAAN, FNAP. Caths contributions to the facets: clinical, research, governmental, and Africa, Thailand, the United Arab Emirates,
field of infection prevention are expansive academic. Dr. Murphy became Australias the United States, and Vietnam.
and have contributed greatly to the improve- first PhD-qualified infection prevention- Currently, Dr. Murphy serves as executive
ment of infection control practices globally. ist in 1999. As a founding member of the director of Infection Control Plus Pty Ltd.
As APICs only non-North American APIC Asia Pacific Society of Infection Control The late Carole DeMille was among the
president in 2010, she broke down barriers, (APSIC) and a regular consultant to the founders of APIC who later became an
proving that there are no borders to infection World Health Organization, she has dem- internationally recognized authority in the
prevention and control. onstrated her dedication to globally expand- developing field of hospital infection control.
As an active APIC member for more ing best practice infection prevention. She She was known for her vision and optimistic
than 25 years, Dr. Murphy has played a has consulted on infection prevention issues approach to present-day infection prevention
fundamental role in advancing APICs in Australia, Canada, China, Hong Kong, methods. The award was established in her
mission. She has served on the American France, Japan, Korea, Malaysia, Macau, honor in 1979, following her death.

APIC Strategic Partner: Aramark

The winter 2014 issue of Prevention Strategist featured the APIC Strategic Partner Program in the article, What makes a healthcare company an
ideal candidate to participate in APICs Strategic Partner Program. In this issue, we showcase Aramark, a long-standing APIC strategic partner.

APICs Strategic Partnership strengthens Aramarks commitment to the infec- To learn more about
tion prevention community and has helped support our mission to enrich and Aramark, visit Booth
nourish lives of those who serve.Our five-year standing relationship allows us to #630 at the APIC 2015
gather insights from infection preventionists to help us deliver innovative solutions Annual Conference or
that impact patient care.We proudly sponsor national conferences and engage visit www.aramarkuniform.
locally at chapter events to educate IPs on the importance of environmental com/healthcare.
cleaning and laundering practices as part of their overall infection prevention
program.We act as a conduit to environmental services to create collaborative
team experiences focused on hard and soft surface bacterial management.

w w | 19
Briefs to keep you in-the-know

New long-term care infection prevention skills pledge tool

e ... tice !

le dg prac tion skil
ls A new long-term care (LTC) infection prevention skills tool titled Take the Pledge

e P infect
ion p
re autio
n s
is available on the APIC website. The tool encourages facility leaders, frontline

ard s
to pra
ctice ad of ge
staff, residents, and family members to adhere to four key technical skills for
dge p the sp another.
I ple st o n to
preventing infections in LTC facilitieshand hygiene, environmental cleaning,
lp o
to he one pers nd hy
n by from ing ha
clea rform
nds cording
pe y
an by policies. ge m k,
y ha nds cle d chan
, mas

standard precautions, and antimicrobial stewardship. The LTC pledge tool was
c gown m blood
ep m giene a lp
I will: ep my ha my facility y day an as a
to ke
y e Ke rding to thes ever iled. ) such t myself
p le dge g hand h cies to h acco an clo come so equipmen ed to prot
t (PPE ec
I poli
ea r be e ne
s. W thes if they protectiv n when I ed.
perf facilitys d of germ sick.

developed by APIC and Health Research and Educational Trust under contract
act clo rson al tio y. ni tiz r is
t cont otec our polic d sa be ad
y ear pe eye pr an an staff mem sily spre
to m e sprea siden cilitys r
ter re W es, and s and pe ent cle or ea
th and af ing to my
fa e care glov id uipm resident s that can with the
stop fore provid dy flu and eq a rm ts
nds be acco
om or and bo rfaces r if I think k with ge siden elbow
ts ro th re

to the Agency for Healthcare Research and Quality (AHRQ) as part of the
my ha ocedures siden ep su rviso o are sic s or wi in my
clean in pr e a re theter Ke my supe wh room coug
I will ter certa : I le av no t Te ll en ts iva te g or will
ng ter y ca so I do sid pr zin esI
and af s, includi r and af h a urinar ids ep re le in snee all tim
ie te gloves Ke her peop zes by es at
polic fore I en ter I touc or body flu ask, and to ot germs. d snee practic ion.

train-the-trainer materials for the AHRQ Safety Program for Long-Term Care:
Be an d af oo d , m of e hs an io n
a gown nt inject inject
fore any bl s ll: amou sam my coug
safe th every resident. evention
Be r I touch ter I wear body fluid ter, I wi ying the ve r ev e. rm
te d
Af re and af blood, an soap and water, ap
wa pl
nds Co per sle I perfo needle wi only that fection pr ents, an
to ha ring or up sure that
Be h germs, nds with , running ufacturer seconds
cove and n for tional in aff, resid
ake ringe lin pe di st
M a new sy ts insu ted on ad tions to of germs.

HAIs/CAUTI. This AHRQ-funded project focuses on reducing catheter-

touc sh my ha th clean an 20
the m r at least use e residen be star ecau spread
n I wa nds wi d by ese pr
Whe et my ha mmende orously fo rs e th s to the
W uct reco er vig d finge Us ent need explain th prevent
th an re sid w ill he lp
prod nds toge e hands g wa
ter towe
l If a tions
,I can
of th th runnin sposable per towe er, I will: they

associated urinary tract infection (CAUTI) and other healthcare-associated

b ha precau milies so
Ru surfaces s wi an di able
sanitiz fa d ed
all y hand using a cle e dispos ed hand their d an te use
nse m s
Ri my hand ucet with alcohol-b e hand
th as rstan a
unde appropri
y fa rs un
Dr off the s with palm of on d finge e to
infections (HAIs) in nursing homes and LTC facilities.
nd s an
d g e
I ple about th
rn ha e are
Tu clean my uct to th y hand aff, s that ousand
nI od er s of m her st germ
Whe ply the pr s togeth l surface lp ot rs with fections. -resistant
Ap my hand t over al e and
will he othe biotics. infect
ions in iotic
b uc e. anti those e antib
Ru the prod dry hygien nd hygien o f rious to treat es

LTC facilities can customize the tool by adding their logo in the bot-
b ha nd t se d of th
Ru hands ar ck on my tice good
ha le ge ne sult
of peop tics desig direct re
my ba ac ns io a
e feed milies pr dents Millio nt to antib ch year as , not
e resi ent
I wel nts, and resis
die ea ctions
l infe fine.
ep th ople

tom left-hand corner. Download the tool at

reside m of pe ns. cteria feels ea and
to ke nd equip read of r. io
that: work to tre .
at ba person ng naus sistant
dge a e infect en a di
I ple onment op the sp to anoth ge rms I
rstand ly flu ed wh
unde tibiotics on a cold or not need e effects, and antib escribe
inclu iotic-re
envir to help e person with e , pr
ated r a lo
ng An ctions lik generally rm and sid fections properly

in s fo fe ar e ha t in to
n n ntam surface ecting in s e as rtant
clea s from o be co
may can live on and disinf proper
tibiotic n caus
An iotics ca ic reactio that it is
ns, ye impo prescr
ean s with
germ at lo
ok cl e germs
m Clea
ning tand the en I use
An rhea, alle derstand
tibiotic .
ces th hands. So hers sick. s. I unde dations fected:
wh diar I un to an eded
surfa ions. tics. ives ly ne
I know n get on
my and ot e germ mmen d disin infect e antibio s alternat is tru
ak e me ove thes rers reco clean an bl e soil d us to discus an tibiotic
ca m m t si an an
that n re actu en e vi ay k if
and ca ne to help e manuf environm remov Its ok sidents. ents to as
time th ents t to
be do llow pmen and re for resid
must and will fo the resid d equi s
s okay
s to ke
ep ces an sident. ll germ It
icals n surfa a re t to ki
chem ill clea using it on pmen
1: I w d equi rface
Step and afte
r ces an nt. ing su
re ec t surfa a reside clean
befo nf th at
ill disi using it on ilies
2: I w r r fam of germs.
Step and afte d thei
re nts an the spre
ad Sign
reside t
n to lps preven
I will uipment
ahed red in g Date
b y
an d eq
lezadtion . g es logo
iz e ur lo g o
to mdd yo y s
C u s Ar fa c il it
y o u

20 | Summer 2015 1| Prevention

734850_Ivera.indd 5/7/15 8:44 PM
Chief medical officer from Florida
receives APICs 2015 Healthcare
Administrator Award

William J. Maples, MD, currently chief improvements to IPs, including training

medical officer for Professional Research in root cause analysis.
Consultants and executive director for The His support is also evident in the invest-
Institute for Healthcare Excellence in Ponte ment made in an electronic surveillance
Vedra Beach, Florida, has been named system that minimizes infection prevention-
the 2015 recipient of APICs Healthcare ists time to manually input data. During
Administrator Award. Prior to his cur- the Ebola crisis, Dr. Maples empowered
rent roles, Dr. Maples was the chief quality IPs to take on leadership roles in planning,
officer and senior vice president at Mission training, and logistics, and reinforced their
Health System in Asheville, North Carolina recommendations with other senior lead-
(December 2010-March 2015). ers. He made sure that the work of IPs and
The award, which will be presented the achievements in reducing healthcare-
Dr. Maples is a at APICs 42nd Annual Conference in associated infections were understood by
Nashville, Tennessee, is given annually to senior leaders as contributing to operational
passionate advocate a member of a healthcare facilitys executive goals and helping to sustain the systems
for patient safety and team who champions infection prevention
efforts within his or her organization.
overall financial health.
Dr. Mapless colleagues agree that he was
a vigorous supporter We are honored to present Dr. Maples instrumental in instilling a true culture of
with this well-deserved award, said APIC safety throughout Mission Health System,
of infection prevention 2015 President Mary Lou Manning, PhD, instituting weekly leadership rounds to
CRNP, CIC, FAAN, FNAP. Dr. Maples discuss successes and barriers in achiev-
and control. is a passionate advocate for patient safety ing the goal of harm reduction. Under his
and a vigorous supporter of infection pre- direction, quality data included infection
Mary Lou Manning, PhD, vention and control. His commitment is prevention metrics and was posted and
CRNP, CIC, FAAN, FNAP evident through his ongoing efforts to reviewed on a weekly basis.
engage consistently with infection preven- In particular, Dr. Maples committed
tion teams, push for improved processes resources to prevention of surgical site
to protect patients from harm, and tie the infections with the introduction of process
work of infection prevention to broader improvement teams focused on colon, spi-
quality efforts throughout the Mission nal fusion, and hysterectomy surgical site
Health System. infections. As a result, infections at Mission
Under his leadership at Mission Health, Health following spinal fusion and refu-
the infection prevention department grew sion surgeries dropped below the Centers for
from five infection preventionists (IPs) at Disease Control and Preventions National
one hospital to a system-wide department Healthcare Safety Network weighted bench-
that now includes 12 IPs and spans seven mark. The teams focus on reducing immedi-
hospitals. With infection prevention and ate-use steam sterilization has also paid off,
control as part of the quality department with a marked decrease in use of this process
Dr. Maples brought a number of process for sterilizing surgical instruments.

w w | 21

New incentives improve

healthcare quality, cost, and
public health

Statistics are people with

the tears washed away.
Victor Sidel, MD, co-founder,
Physicians for Social Responsibility

22 | Summer 2015 | Prevention

The Affordable Care Act of 2010 led Medicare reimbursement is determined
to development of the National Quality by compliance with measures, and whether By 2018, 90 percent of
Strategy, first developed in 2011 with the those measures show improvement in out-
three-pronged goal of improving health- comes. The purpose of measures makes Medicare payments will
care quality, decreasing healthcare costs, sensewe cant monitor improvement be tied to value, rather
and creating healthier communities. All without a baseline for comparison. But than volume of services
of these goals are being addressed through another challenge is the large volume of provided.
regulatory initiatives, most of which impact measures that are used for the variety of
Medicare. Since Medicare is the largest programs within HHS. Measures are used
payer of healthcare in the U.S., both the to determine compliance with electronic
carrot and the stick it uses to enforce statu- health record (EHR), quality reporting,
tory regulations is payment adjustment value-based purchasing, readmissions
incentives for improved performance and reduction, and hospital-acquired conditions
penalties for static or deteriorating perfor- reduction programs. Some measures are
mance or for noncompliance. Performance based on chart-abstracted coding data and
is evaluated through the use of measures. some are reported into NHSN using stan-
Because measures are a basis of comparison dardized surveillance definitions. Measures
against a standard, ideally measures would are constantly being added or removed by
be developed and endorsed by a consensus CMS, reported to CDC, adopted for use
organization, such as the National Quality by the Agency for Healthcare Research and
Forum (NQF). Quality (AHRQ), and re-evaluated and
updated by NQF. In addition to federal
Quality requirements, most states require some level
U.S. Secretary of Health and Human of HAI reporting of measures which may
Services (HHS) Sylvia Mathews Burwell or may not correspond to federal require-
signaled a refocus of the way healthcare ments, adding additional responsibilities
is delivered when, in January 2015, she for IPs. Although CMS has made an effort
announced a timeline for changing the in recent years to align measures used for
way Medicare pays for health services. different programs within its jurisdiction,
According to this new timeline, by 2018, the number of measures that currently must
90 percent of Medicare payments will be be monitored presents a burden to already
tied to value, rather than volume of ser- under-resourced facilities and depart-
vices provided. Because of the amount ments. In order for measures to be useful in
of healthcare facility revenue that comes improving healthcare quality, they must be
from Medicare, this change will impact aligned between programs, focused on out-
all providers and receivers of healthcare. comes, and not unnecessarily tax healthcare
Infection preventionists (IPs) have and will personnel. The good news is that current
continue to play a role in attainment of all proposed regulations are making inroads
of these goals. in all of these areas.
The first challenge is determining what
is meant by value. Terms like value and Cost
quality are difficult to quantify, and can A 2014 report by the Commonwealth
mean different things to different stake- Fund found that although the U.S. has the
holders, depending on various perspectives most expensive healthcare system in the
as patients, providers, payers, employers, world, we rank 11th out of the 11 coun-
consumers, or the government. For IPs, tries studied (Australia, Canada, France,
this will mean continued focus on health- Germany, the Netherlands, New Zealand,
care outcomes by reducing and preventing Norway, Sweden, Switzerland, the United
healthcare-associated infections (HAIs). Kingdom, and the United States) in health

w w | 23

Although CMS has made

an effort in recent years
to align measures used for
different programs within its
jurisdiction, the number of
measures that currently
must be monitored presents
a burden to already
under-resourced facilities
and departments.

outcomes. Similarly, the World Health IP, including educating staff and patients, infection prevention education of person-
Organization ranks the U.S. healthcare developing policies and procedures geared nel in schools, community centers, daycare
system 37th out of 190 nations included in to non-hospital settings, and monitoring centers, and other places where populations
its rankings of healthcare systems, despite compliance with infection prevention congregate and knowledge about how infec-
having among the highest per capita health- practices across the continuum of care. A tions are spread, and about appropriate pro-
care expenditures. necessary step will be the IPs involvement tective practices and equipment. Expanding
The traditional Medicare fee-for-service in developing EHRs that are interoper- partnerships with public health agencies
payment system encourages increased care, able across care settings and providers, as will be an important step in improving
but more care does not necessarily mean well as with government-based systems, and sustaining infection prevention for the
better care. Higher volume of procedures such as NHSN. It will require focus in all future of population health.
has meant higher Medicare reimbursement, facilities and at all levels on improving care
regardless of whether the treatment has transitions. Summary
good outcomes or not; however, more treat- As healthcare continues to change in all
ment might also mean longer hospital stays, Population health aspects of care delivery, IPs will need to
increased use of devices, more antibiotics, Keeping the population healthy will continue to play a key role in improving
which raises both infection risk and costs. reduce healthcare costs by keeping people healthcare quality in all environments, pro-
The majority of healthcare dollars are out of healthcare facilities. In addition moting the use of meaningful, value-driven
spent on end-of-life care. Healthcare of the to improved behaviors such as increas- infection-related measures that accurately
future will have to change its focus away ing physical activity and improving diets, reflect healthcare outcomes. As always, IPs
from sick care and more toward preven- preventing infections from spreading in will continue to pursue healthcare without
tive care, and hard decisions will be made a population also includes compliance infection in order to create a safer world
about effectiveness of treatment options. with vaccine recommendations, antibiotic through the prevention of infection.
Reducing costs will also mean provid- stewardship from the farm to the hospi-
ing care in the most appropriate settings, tal, hand hygiene, and other practices that Nancy Hailpern is APIC director of
often outside the traditional walls of the have long been the concentration of infec- Regulatory Affairs, and Lisa Tomlinson is
hospital environment. This will mean tion prevention and public health. Sharing APIC vice president of Government Affairs
expanding infection prevention to other information through EHRs can ensure bet- and Practice Guidance. Patricia Gray, RN,
types of facilitiesambulatory care, long- ter knowledge of where potential infec- BAHSA, CIC, is network manager, Infection
term care, rehabilitation, behavioral health, tion challenges exist in order to prevent Prevention and Control, for HonorHealth in
and other settings. It will also mean an them. The spread of community-acquired Scottsdale, Arizona, and APIC representative
expanded focus on traditional roles of the infections can be decreased through basic to the National Quality Forum.

24 | Summer 2015 | Prevention



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Chapter Spotlight: APIC Greater LA chapter #3

Take back your hashtags

An infection preventionists guide to Twitter
By Angela Vassallo, MPH, MS, CIC

Have you ever been to Los Angeles? If you infection prevention conversation. Once
Whether we choose to be have, you probably remember the beauti- you get the hang of it, youll see its an
part of the conversation on ful weather, the picturesque views from easy and beneficial way to obtain timely
the canyons to the ocean, the lean and infection prevention information, engage
social media in regards well-dressed people, and of all things with peers, improve communications dur-
to infection prevention the traffic. It can take us Angelenos two ing disasters, and ensure IPs are represented
or not, the worlds ability hours to go 10 miles during rush hour. So in the public eye.
to share news and get as a result, weve become experts at find-
ing creative and crafty ways to get where Getting creative to
information instantaneously we need to go in a rush. We often start improve communications
has already left the station, off meetings and parties comparing how APIC GLA is constantly looking for bet-
and were late to the train. attendees arrived to our new destination. ter methods to communicate quickly and
You took the 101? Seriously. Are you mad? efficiently with such an expansive, diverse
How long have you lived in LA? Oh, well audience. We decided that the easiest and
that explains it; youre still a new transplant. cheapest way for us to promote infection
I recommend you try the Cahuenga Pass and prevention in our community and engage
then make a turn at... And so our days go, our members was to improve our online
attempting to connect with one another presence.
in the City of Angels. By early 2014, APIC GLA was the first
Now imagine you are a member of APIC chapter to create Facebook and
the second largest APIC chapter in the Twitter accounts. As fate would have it,
U.S.Greater Los Angeles (GLA), chap- national APIC was in the midst of improv-
ter #3 and your monthly meetings are ing its online presence, as well as that of
held on Tuesdays at noon in downtown local chapters at about the same time. Thus,
Los Angeles. And hence, you understand we worked with national APIC to develop
our predicament. Our chapter serves Los our own APIC GLA website: http://com-
Angeles County, which has more than
100 hospitals and more than 10 million You dont need to love social media to use
people in a 4,000 square mile radius.1 We it and benefit from it. Although I constantly
have more than 200 members, including refer people to our new, shiny website, Im
infection preventionists (IPs), epidemiolo- not a Facebook or Instagram lover. I am,
gists, nurses, microbiologists, pharmacists, however, a recent Twitter convert. I think
doctors, and vendors. there is a major difference in the useful-
With this in mind, our chapter uses ness of these applicationsespecially with
social media to engage members and regard to daily infection prevention work.
others in our community around the Facebook, Instagram, and Pinterest seem

26 | Summer 2015 | Prevention

Angelas Twitter cover photo shows her during interview with comedian Judy Greer on public restrooms for the web series, Reluctantly Healthy at

to be most useful for communities to chat, tweeting with interesting people about already communicated with my peers at
share pictures and invitations to events, and exciting infection prevention/infectious UCLA to get more information and offer
exchange ideas. I often look at national disease topics while in my pajamas on the them a hand. Next case in point, during
APICs Facebook page (www.face sofa at nightno make-up and minimal the 2014 Ebola outbreak in West Africa,
APICInfectionPreventionandYou) to see whats effort on my part. Yes, please! Sign me up I used Twitter to get up-to-the-minute
happening in our community. But if I have tout de suite. information. Healthcare workers, govern-
a question that I need answered right now, Let me give you a couple of examples to ments, news agencies, and pretty much
I go to Twitter. Social media applications illustrate my point further. Although my everyone who had a major stake in the
can be brilliant tools for staying connected hospital is only four blocks from UCLA, outbreak were tweeting information as
in todays world. I found out about the recent CRE out- it happened. I remember seeing the news
Twitter is an immediate and concise way break with ERCP duodenoscopes first on on Twitter that Dr. Kent Brantley and
for people to get information. In a recent Twitter when UCLA tweeted the infor- Marian Wrightbold were being flown to
CID article, Twitter was promoted as the mation. Several hours later when I came the U.S. as they boarded the plane. And
only platform that allows one to connect, home from work that day, I saw it on the by the time I got home that night to watch
engage, learn, and educate oneself and oth- evening news. Keep in mind that by the the evening news, it was, to be frank, old
ers in real-time on a global scale. 2 When time I saw it on the evening news, I had news. The Internet had already exploded
I read these words, I envisioned myself already known about it for hours and had with conversations about Ebola in the U.S.

w w | 27
Chapter Spotlight: APIC Greater LA chapter #3

before the evening news could even air Top six reasons to use Twitter as an IP
Organizations to
follow on Twitter
the breaking story.
Whether we choose to be part of
the conversation on social media in
1 I f used appropriately, it could be a vir-
tual listserv available 24/7. In addition
to using IPTalk (,
APIC @apic regards to infection prevention or not, all you would have to do is look at Twitter
the worlds ability to share news and to get your answers on hot topic infection
AJIC @ajicjournal get information instantaneously has prevention issues at that very moment.
CDC @cdcgov already left the station, and were late Warning: there is no guarantee that the
WHO @who to the train. No one really reads the answers will be accurate. So do your own
newspaper anymore and most people research and check sources.

CBIC @cbic dont wait for the evening news to learn It could be used to improve communi-
(They tweet CIC and SARE test what is happening in the world right cation during disasters. Right after the
questions on a weekly basis) now. I understand how social media first plane hit the World Trade Center,
APIC GLA @apicglac can seem like one more thing to do in I was frantically trying to call my father
your already overloaded life. However, who works in downtown Manhattan.
APIC DFW @apicdfw
social media can enhance our work as Cell phones were jammed for hours and
APIC Kentucky @kyapic42 IPs. At work, I am constantly looking families like mine sat in panic waiting to
I PS @ips_infection for information and asking questions, get through. It still chokes me up today.
(Infection Prevention and I know you are, too. He later got through to let me know that
Society in the UK) The issues you are facing at work he was fine. But Ill say it now because
today could be easily and quickly dis- I say it all the timeI wish our family
I PAC @ipaccanada cussed on Twitter, in addition to APICs had been using Twitter on 9/11.
(Infection Prevention and
Control Association in Canada)
IPTalkas long as you are maintain-
ing confidentiality and understanding
that all information has limitations.
3 Viral forecasting/digital epidemiology
are changing the way we understand
how diseases move and mutate. Dr.
ID Week @idweek2015
Wouldnt it be helpful to quickly write Nathan Wolfe presented the APIC 2013
SHEA @shea_epi
a question down and within seconds Annual Conference closing plenary on
IDSA @idsainfo have people respond with answers? this very topic.
Imagine the immediate usefulness of
Twitter during a survey or response to
a disaster.
4 You can instantly network with your
peers. Ive met some really interesting
and helpful IPs in Canada and the UK

28 | Summer 2015 | Prevention

The more IPs
join and
use social media
sites, the more
represented well be in
the public eye.

on Twitter. Shout-out to our IP peer in created my account last year it was, fol-
Toronto, Canada (@barleychironda), lowing interesting things and fascinat-
the most prolific IP tweeter in the world! ing people. Then, I decided to make it

5 You would be staying up to date

even to the very minutewhen
infection prevention issues occur
more interesting. So now it is, small but
mighty epileptic epidemiologist. Perhaps
it is a bit TMI (too much information
around the world. about me), but which person would you Learn more at the
6 The more IPs join and use social media
sites, the more represented well be in
the public eye. Perhaps youve heard the
rather follow?

3Follow people/organizations who

interest you and watch what they
APIC 2015
Annual Conference
phrase the world is getting smaller. tweet in your timeline. Find Want to learn more about social media? Dont
Infectious diseases that exist in one part Twitter mentors and follow them. miss this #APIC2015 session!
of the world are everyones problems. Ask them questions. Watch how they
How the Los Angeles APIC Chapter Uses
So why not use social media to posi- engage their followers. There certainly
Social Media: TweetingOur Way Through
tion ourselves as experts in our field is an art to it.

LAOne Infection at a Time
and showcase the great work IPs do on Then, when you feel readysend your
the frontlines of infection prevention first tweet. Try to say something use- Sunday, June 28, 34 p.m.
to control and prevent these infections? ful in a 140 characters or less. Its not A  ngela Vassallo, MPH, MS, CIC, direc-
as easy as one might think, is it? Keep tor, Infection Prevention/Epidemiology,
10-step Twitter 101 in mind that when Shakespeare said, Providence Saint Johns Health Center,

1 Create an account with a username

and password. Go to Twitter (https:// and think of a catchy user-
Brevity is the soul of wit, he prob-
ably had no idea that Twitter would
one day be invented. In other words,
Santa Monica, California.
Jessica L. Silvaggio, MPH, CDC/CSTE
Applied Epidemiology Fellow, Los Angeles
name for yourself. Its what people see being concise is something weve been County Department of Public Health, Los
when they are reading your tweets. For grappling with for generations, and Angeles, California.
instance, @suegk0123 is much less com- Twitter is helping us achieve it. Crystal R. Moohn, BS, associate direc-

pelling than @suethehandwashingIP.
Create a compelling bio. It will be read
when someone looks at your account.
5 Tweet messages with key hashtags
(This # is called a hashtag) so that
when people search a #phrase, your
tor, Membership & Component Relations,
Association for Professionals in Infection
Control and Epidemiology, Washington,
Heres an example of how mine has messages will appear. The hashtag is District of Columbia.
evolved over the past year. When I what I inaccurately referred to as the Visit to learn more.

w w | 29
Chapter Spotlight: APIC Greater LA chapter #3

pound sign for several months until a

younger, savvier tweeter corrected me. 7  etweet using RT and not by
just clicking on the retweet but-
by hashtag or looks at the original
tweeters profile, your profile will be

6 Tweet messages with meaningful

links. An example would be to put a
link in your tweet to the FDAs expla-
ton. This is a more advanced prac-
tice, but I thought you should know
nonetheless. Start your tweet with
connected and people will get exposed
to you. Voilyou are now part of
the conversation.
nation for the Olympus ERCP scope
outbreak. The characters used in a web
address do not count toward your 140
RT: and then copy the persons
message that you want to retweet
with quotations into your new tweet.
8 Tweet messages directly to people
with whom you want to engage in
a conversation or who you think
count maximum. Isnt that awesome? When someone searches this topic might follow you/share information
with you. You do this by putting their
@username in your message.

9 Update your photo and improve your

bio from time to time to keep things
fresh and interesting. Im not sug-
gested you pose for the perfect angle and
selfie yourself into oblivion. But when
W you change things up, it makes people

Infection 10
want to hear what you have to say.
Embrace the constant change!

Control I hope Ive convinced you to create a

Twitter or some sort of social media account
and join us in the #infectionprevention con-
versation online. We need to take ownership
' of our own hashtags such as, #infectionpre-
tto minimize splashing vention and #handhygiene. And remember
to use the #APIC2015 hashtag this year for
and reduce the spread
the annual conference in Nashville. Right
of infectious disease.
o now, conversations about infection preven-
tion issues occur all day long with very few
IPs involved. We are the experts, yet we have
Offset drain position Oversized backsplash Sloped rear basin wall very little representation on social media. So
keeps water from minimizes splashing get out there IPs and take back your hashtags!
has coved edges and
splashing directly into of water stream and P.S. #thanksforlettingmerantaboutso-
helps to keep water
drain and aerosolizing FUHDWHVFLUFXLWRXVRZ cialmedia.
contents of the trap. toward drain. to drain.
Aquasurf solid surface color options:
Angela Vassallo, MPH, MS, CIC, director of
infection prevention/epidemiology at Providence
Saint Johns Health Center in Santa Monica,
Sandstone Bone Red Coral Black White Grey Glacier Nocturnal Sea
California, is president of the APIC Greater
Granite Granite Granite White Blue Green
Los Angeles (GLA) Chapter #3. Under Vassallos
Now we're even leadership, APIC GLA was the first APIC chap-
easier to specify! ter to use Twitter and Facebook. Vassallo was
nominated as Healthcare Manager of the Year

2015 Willoughby Industries Inc.

1. L.A. County population pushes past 10 million, highest in

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800.428.4065 |ZZZZLOORXJKE\LQGFRP 2. Goff DA, Kullar R, Newland JG. Review of Twitter for Infectious
Diseases Clinicians: Useful or a Waste of Time? Clin Infect Dis.
2015 Feb 4. doi: 10.1093/cid/civ071.

30 | Summer 2015
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Perspective from Australia:

Routine culturing and surveillance
of endoscopes
By Cathryn Murphy, RN, MPH, PhD, CIC

Since 1995, Australias two leading gastro- Nurses College of Australia, developed a To date, Australias long history of cultur-
enterological associations have recommended web-based training module on endoscope ing endoscopes has been contrary to North
routine surveillance of endoscopes, (including reprocessing.2 The module contains detailed, American practice.3 Policy makers, regulators,
duodenoscopes) and automated endoscopic practical advice regarding implementation of and researchers have considered the increasing
reprocessors.1 Like many infection prevention the endoscope culturing quality monitoring. trend among other countries to recommend
and quality control measures in Australia, this It specifies recommendations for: routine culturing. Debate has focused on the
recommendation is not mandated by legisla- Standardized culturing timing, specimen return on investment (e.g., the likelihood that
tion, regulation, or accreditation criteria. The collection, and frequency according to routine endoscopic culture provides a timely
extent to which various Australian states and scope type including loan scopes; indication of faulty endoscopes, incomplete or
territories have adopted it is unmeasured and Action in the event of positive cul- incorrect reprocessing, and the extent to which
there is no publically available repository of ture of an organism of epidemiologic culturing potentially reduces the likelihood of
data relating to endoscopic culture. Regardless, significance; iatrogenic pathogen transmission).
the author is aware anecdotally that Australian Suspension of endoscopic services until The debate remains unresolved with
infection preventionists and gastroenterological clearance; opponents citing that in one three-year
specialists, in general, accept and comply with Determination of the need for a lookback period in New Zealand, the culture of
the recommendations. or patient recall; and more than 7,000 endoscopes yielded
In 2011, the Queensland government, in col- Repeat reprocessing, repeat culturing, and only one occasion of improper reprocess-
laboration with the then Gastroenterological endoscope clearance. ing and nine other occasions of damaged

w w | 33
endoscopes. Additional recent debate has identified by two separate and unrelated cases the intricacies and complexities of endoscope
considered the sensitivity and specificity of items remaining in endoscopes despite reprocessing and also comply fully with best
of new methods to monitor reprocessing the scopes having been subjected to multiple practice recommendations can be reassured
adequacy.4 However, recent U.S.-based cleaning and reprocessing cycles.6 Clearly, cul- that the quality of their work will be subject
endoscopic-related outbreaks and trans- turing endoscopes is an incomplete method of to periodic review as measured by the act of
mission of multidrug-resistant organisms mitigating risks associated with poor quality routine endoscopic culture.
seem to have spearheaded U.S. adoption reprocessing. Correlating contamination of Coordinating, over-seeing, interpreting,
of an endoscopic culturing regime similar a specific component, channel, or intricate and acting upon periodic endoscopic culturing
to Australias.5 part of the endoscope through sampling is part of the typical infection preventionists
Australias FDA-equivalent, the Therapeutic of flushed sterile water may be imprecise. role and function in Australia. To date, it has
Goods Administration, has also recognized Rather, when coupled with standardized work served us well, although we acknowledge it
deficiencies in endoscopic reprocessing practices, staff who are knowledgeable about is most easily undertaken in large teaching
hospitals with onsite microbiology laboratory
services. For smaller standalone facilities such
as day-only endoscopy suites that are similar
to U.S. ambulatory care services, compliance
with the endoscope culturing recommenda-
tions may initially require provision of some
services and loan scopes by external providers.
The author welcomes questions from APIC
members seeking additional information
about Australian practices. Useful information
is also available on the Gastroenterological
Nurses College of Australia (GENCA) and
Queensland Health websites as listed in the
reference list below.

Cathryn Murphy, RN, MPH,

PhD, CIC, is executive director
of Infection Control Plus Pty Ltd
in Queensland, Australia. Dr.
Murphy served as APICs first
and only non-North American
elected president in 2010. She is an internation-
ally recognized infection prevention expert who
has worked in infection prevention continuously
since 1989 in senior positions in clinical, research,
government, and academic settings.
1. Gastroenterological Nurses College of Australia (GENCA). Infec-
tion Control in Endoscopy. 2010. Accessed 5 April, 2015 at www.
2. 6.4 Microbiological Testing. Queensland Government, 2014.
Accessed 5 April, 2015 at
3. Petersen B. Commentary: Monitoring of Endoscope Reprocessing:
Accumulating Data but Best Practices Remain Undefined. Infection
Control and Hospital Epidemiology 2014;35:995-7.
4. Fernando G, Collignon P, Beckingham W. ATP bioluminescence
to validate the decontamination process of gastrointestinal endo-
scopes. Healthcare Infection 2014;19:59-64.
5. Interim Protocol for Healthcare Facilities Regarding Surveillance
for Bacterial Contamination of Duodenoscopes after Reprocessing.
Accessed 5 April, 2015 2015 at
6. Endoscopes reprocessing procedures. Australian Government,
2014. Accessed 5 April, 2015 at

34 | Summer 2015 | Prevention

741111_Sage.indd 1 5/8/15 4:40 PM
Infection Prevention Leadership

My personal journey
By Timothy Bowers, MT(ASCP), MS, CIC

ve been greatly affected by those around me and owe much of my career to the right
people giving me the right focus at the right time. Im going to tell you about my start
as a medical technologist, finding infection prevention, and realizing it was more than
just a jobit has been an incredible personal and professional journey.

My start as a medical technologist was the first time I was able to interact with labora-
My path to finding medical technology was a complete tory administration and with individuals outside of
and utter accident. A very average student in high school, I microbiology. The previously mentioned supportive
took an extra class in exploring medical careers. Our class staff played roles in preparing for the initiative. It was
toured the lab and observed a laboratorian handling an petrifying. I stammered, hesitated, worried, and lost sleep
engorged organ when it ruptured. Blood went everywhere, over connecting with these individuals. It lead to doing
and I was immediately in love! significant research for the meetings so I couldnt be
I went on to earn my bachelors degree in medical caught off guard, which occasionally happened anyway,
technology, and for some of my elective classes I took but gave me the ability to educate administration on
leadership development, which was very motivating in a the thought processes behind the initiative. In short, it
personal capacity as I hadnt had the opportunity to use was one of the best learning experiences in my career at
those skills professionally. that point. It also coincided with beginning my master
Upon completion of my clinical rotations, my first posi- of science in health policy.
tion was in Thomas Jefferson University Hospital clinical
microbiology. I originally wanted to be in blood banking, Finding my way into infection
but Im glad I took the path I did. The lab leaders were very prevention and control
supportive in allowing me to learn all of the areas includ- I applied for my first infection prevention and control
ing bacteriology, virology, and serology.They were also position toward the end of my masters course work.Many
supportive of the development of an educational program of the experiences from my program were included in the
when the American Society for Clinical Pathologystarted job description.When researching what the job entailed,
requiring us to maintain our certifications. it peaked my interest intellectually. I got the job, and it
meant big changes for me, and the real life transition was
A firstand scary scary. I was out of the lab, in a new health system, dealing
step to work on leadership skills with nurses, physicians, and occasionally patients!Starting
I took my micro experience and some of the leader- out in infection prevention and control was rough, and for
ship learned in undergrad and developed an educational a while it didnt look like it was going to last. Thankfully,
system for the lab so we could keep up our skills and early on the two seasoned infection preventionists (IPs) at
maintain compliance with those new regulations. It the facility really helped me stay on track. They mentored

w w | 37

me on the technical aspects as well as the development. One of the few director posi-
soft skills (e.g., communication and inter- tions in the area, responsible for more than
personal skills) needed to be effective.Ill one hospital, became available and I applied.
never forget my first important lesson on It wasnt academic medicine and it was in
soft skills. My first draft email outside the a different state with a further commute. I
department was five paragraphs, three col- wasnt in infection prevention very long and
ors, bold, underlined, and italics. Luckily, still had a lot to learn. There were so many
I asked the lead IP to review it before I hit reasons not to apply, and yet I sent in my
send. The lead IP helped me get it down resume. I thought it was a long shot, but I
to four sentences and one color (and taught got an interview.
the word concise to me). The interview lasted all day and involved
It wasnt until completing APICs EPI many different individuals, including
101 course and applying what Id learned the infectious disease/Infection Control
at our facility that I really started becoming Committee chairman. We ended up debat-
engaged in the job and connecting the dots. ing every question asked for more than an
I was also fortunate to have an incredible hour. It was intense. There was no yelling,
first experience with a supportive struc- but we took opposite positions on almost
ture in place already.Nurse managers and every aspect of the job. I supported my
nurses helped fill in patient care science and positions with as much information as pos-
procedures; attending physicians allowed sible (e.g., NHSN definitions, CDC recom-
participation in teaching rounds to absorb mendations). I left the interview thinking if
the medical education given; our medical nothing else it will help me be successful in
director educated me on disease processes; my next interview, if it were to ever happen.
the other practitioners in the department Regardless of our differing opinions, I
helped fill in the multitude of gaps that was offered the position because (as the
existed, as well as keeping me focused on infectious disease/infection control chair-
As Mark Twain noted, the task at hand. I was finally flourishing man noted) of the way I handled differing
Never argue with a fool, in my position as an IP. I then went on to opinions and communicating my position
earn my board certification in infection with literature. This interview was one of
bystanders cannot tell prevention and control (CIC). the best, most terrifying, experiences of
the difference. I believe Taking it to the next level
my life. My previous experiences set me
up for a successful interview and it set the
that professionalism isnt With a few years of experience under my course for many more leadership learning
never being yelled at; it is belt and my new CIC certification, I had the opportunities I would soon experience in
audacity to apply for the ultimate test of my my new position.
never yelling back.

38 | Summer 2015 | Prevention

Bowers leadership tips
Gaining respect from colleagues and leadership isnt something that occurs overnight. Looking back, and asking colleagues
who know me best, there are a few things that stand out in terms of their opinion of what I do that makes me a leader and
worthy of their respect.

Tip 1 Tip 4
Learn from your mistakes. Learn from previous mistakes,
especially in communication. If your message doesnt seem to
be resonating with the intended audience and youre not getting
results, then take a hard look at what youre doing or how you could
improve the delivery of the communication. Are you providing all the
Remain calm under pressure. As Mark Twain noted,
Never argue with a fool, bystanders cannot tell the difference.
I believe that professionalism isnt never being yelled at; it is
never yelling back. People notice a calm demeanor and will
respect you for it.
relevant information? Is the mode of delivery appropriate (e.g., email
or in-person meeting)? Is he/she the correct person to receive the

Tip 5
message? Is your tone appropriate? Completely remove all ego and
concentrate on whats importanteffective communication.

Tip 2
Find great mentors. They may not search you out, but you
should search for them. Many non-traditional roles have influenced
me greatly throughout my career. Administrative assistants,
Justify everything with evidence and science. The
graduate medical education surgical residents, co-workers,
connection with leadership depends on your technical ability to
colleagues, and in my current position my staff have helped
understand the issues, as well as your ability to communicate
continue to push my development. Some gave me a goal to attain,
to those who dont understand infection prevention on the same
some showed me how to be a leader, others showed me behaviors
level. That skill will separate leaders from technical experts.
to reduce or eliminate. Some have illustrated the fall from grace. On
Always come to a meeting armed with evidence/science and
that last note, be humble (oh, the irony!).
prepare on your communication tactic ahead of time.

Tip 3 Tip 6
Dont let fear hold you back. Sometimes we are our own worst
enemies. Try to suppress the inner voices that tell you that you cant
or its not possible. Make an effort to act confident, even if you dont
feel it. Walking with nurses or nurse managers into a room to suppress
staffs fear or misconception is something Ive done on several occasions.
Constantly be a student of your skills. Keep up with
AJIC and ICHE for IP skills, but actively work on your leadership
developmentespecially those crucial soft skills.

Watching surgeries seems tame, but walking into a room with a very
unlikely rule-out Ebola case can be just as frightening if youve never done
either. Think of everything as a learning opportunity. Do something every
day that scares you. Baz Luhrmann (Mary Schmich)

Leadership is a lifelong venture that should be sharp when you need it, even if that need is not every minute of
every day.

Timothy Bowers, MT(ASCP), MS CIC, is corporate director of infection prevention & control for Inspira Health Network
in Vineland, New Jersey. He is also a member of APICs Communications Committee.

w w | 39

Emergency preparedness
and infection control:
Teaming up to create meaningful
staff simulation exercises
Tips for success
By Kristine Sanger, BS, MT(ASCP)

s an infection preventionist (IP) turned
emergency preparedness professional, I
see many similarities within the fields
and even more opportunities to collaborate. One
of those opportunities is in the realm of disas-
ter simulation exercises. For years, emergency
preparedness professionals have been designing
disaster simulation exercises on many levels to test
the preparedness of their organizations. Most are
testing surge capacity and emergency departments
(ED). I rarely see simulation exercises go beyond
the ED, but they should. The safety of patients
relies on it. Simulation exercises should include all
departments of the hospital, clinic, or long-term
care facility. A great place to start is teaming up
with the infection prevention department.

Nursing staff initial clean up during a norovirus exercise at an outpatient surgery center.

40 | Summer 2015 | Prevention

When planning a simulation exercise, number of participants is more than what
consider six very important things: is beneficial to the entire exercise. This

Plan for success. The Homeland Security is often referred to in the exercise world
Exercise Evaluation Program recommends as avoiding Armageddon.
a progressive approach to simulation exer-
cises.1 This entails beginning the process
small with a discussion-based exercise and
to gradually increase the capacity and
3 Develop clear, well-written objectives.
Objectives need to be the full driving force
behind the development of any simulation
exercise. A good objective is clear, concise,
capabilities of the exercise as your staff and focused on performance. For example,
becomes more familiar with the process. if you want to test your plan to respond
All too often, staff are put to the test with to an outbreak of measles in your campus
a plan with which they are uncomfortable childcare center, you need to determine
and/or unfamiliar, and the exercise ends
up only frustrating staff rather than acting
which tasks within the plan are to be tested
and stick to them. A good objective in
as a learning opportunity. that example would be, By the end of
more about
2 Manage expectations. Sometimes when
simulation exercises are developed, the
scope of the exercise is lost during the
the exercise, participants will have notified
the health department and the daycare
customers of the risks and exposure within emergency
many hours of organizing and in the
many minds that are participating. Too
12 hours of the initial case identification.
Again, this should be based on what is preparedness
at APIC 2015
often, the functions to be tested become written in the current plan.
more than what is manageable and the
4 Involve new people. The ED is the
single most tested department when
it comes to disaster simulation exer-
cises. This is appropriate because the
021Measles Emergency Response:
ED will likely be the one department
Lessons Learned from a Measles Exposure
that is always affected by a disaster, but
in an 800-bed Facility
they arent the only ones. In a shooting
023The Creation and Rapid Deployment of
event, the operating room will be in
a Preparedness Plan for Ebola Virus Disease:
high demand; in an Ebola outbreak,
Lessons from a Large Healthcare System
all departments will be needed. The
purpose of a simulation exercise is to Workshops
provide practice for a real event. All
3102Emergency Preparedness:
people in your facility will benefit from
The Infection Preventionist (IP) as Part of
this practice.

the Team
Get creative. Dont fall into the trap of
always doing the same familiar commu- Concurrent session
nity exercise. This leads to frustration,
3200Infection Prevention Emergencies
non-participation, and an attitude of
on Friday Afternoon at 4:30!
apathy with the exercise itself.

6 Know the regulatory requirements of

your audience. If your facility is regu-
lated by The Joint Commission (TJC),
know what TJC expects and requires
To learn more, visit

for yearly compliance. If the Centers for

Medicare & Medicaid Services are the
regulators, become familiar with their
requirements. You are much more likely
to gain buy-in from staff and leadership
if your simulation exercise is going to

w w | 41

of how to know when food is not cooled

properly and potentially dangerous to
serve. Prepare menu plans for the next five
to seven days with only the supplies that
they have in house in case of prolonged
power failure and a need to shelter in

4 Environmental services: Test an infec-

tious disease exposure plan with a noro-
virus incident scenario (oatmeal makes it
very realistic). Have staff go through the
clean-up process with proper personal
protective equipment. This could be done
with other infectious diseases as well.

Operating room/maintenance: Test the
knowledge of infection control procedures
by creating a flood in the supply room,
an HVAC shutdown, a loss of steam, or
a construction barrier failure. Talking
through these procedures could help
introduce staff to the idea that infection
prevention starts with the environment.
The most important thing to consider
when planning a simulation exercise
is who you are training and what you
want them to learn. After completing
any simulation exercise, success should
be measured and documented. In addi-
tion, appropriate training should be pro-
vided in response to opportunities for
improvement. As long as the simulation
exercise is designed and followed up on
based on audience and objectives, the
success and learning of the well-planned
exercise will be undeniable. Being pre-
Exercise actor using oatmeal to simulate an uncontrolled vomiting episode. pared for unexpected events on all levels
creates an environment of patient safety
contribute to compliance with the regu-
latory agencies of your organization. 2  aternity: Test your infectious disease
exposure plan and your media relations
plan by having staff respond to a sibling
that your staff and patients will appreciate
and expect.

Getting creative with infection visit with measles. Add to the scenario Kristine Sanger, BS, MT (ASCP),
prevention simulation exercises that the patient had been in the hallway is director of Hospital Training
There are many creative ways to merge visiting area with other patients and that and Exercise Programs, Center
the expertise of infection prevention in the sibling had been coughing at the for Preparedness Education at the
simulation exercises. Listed below are just time. Have simulation participants col- University of Nebraska Medical
a few that are quick, easy ways to engage lect names of all patients that had been Center in Omaha, Nebraska and associate executive
new groups and promote infection preven- exposed, the staff that had been exposed, director of the Association of Healthcare Emergency
tion in simulation exercises. All of the ideas and discuss how it might affect staffing for Preparedness Professionals (AHEPP). She is also
listed could be done in a discussion-based the immediate future. Its likely that staff a member of APICs Emergency Preparedness
exercise or elaborated further in a full-scale members would have children at home Committee.
scenario. who would be at risk, so another more
public exposure could also be added to the Reference

1  harmacy: Test an infectious disease expo-

P scenario to gauge staffing rates. 1. Federal Emergency Management Agency. 2013.

Homeland Security Exercise and Evaluation Pro-
sure plan by having staff pull all supplies Food services: Test a power outage in the gram. Available at:
needed in the event of an anthrax exposure. kitchen. Ask the staff to provide details data/20130726-1914-25045-8890/hseep_apr13_.pdf.
Accessed March 24, 2015.

42 | Summer 2015 | Prevention



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monitoring to microber damaged by improper laundering, these problems can contribute to the
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Focus on long-term and behavioral health outbreaks

Identify the pathogen:

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

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/behavioral health setting,
infection preventionists (IPs) will glean additional knowledge and apply this informa-
tion to hopefully prevent future infections, and infection clusters in their facilities.
This quarterly column will assist the IP with heightening awareness of appropriate
interventions for preventing an outbreak.

While everyone A recent Morbidity and Mortality Weekly Report removed from cooling at three different times for
(MMWR) describes 42 residents and 12 staff additional preparation steps, before being served
is susceptible members at a state psychiatric hospital who expe- as cold chicken sandwiches or chicken salad. The
to Clostridium rienced vomiting, abdominal cramps, and diar- state sanitarians inspected the hospital kitchen
rhea.1 Within 24 hours, three patients had died. and found no violations of the sanitary code.
perfringens food The three patients who died were taking medica-
Background on Clostridium perfringens
poisoning, the very tions with anti-intestinal motility side effects. An
investigation revealed that eating chicken served Clostridium perfringens is a Gram-positive,
young and elderly at dinner was associated with illness. spore forming bacterium that is found on raw
are at the greatest Based on your education and training, you meat and poultry, environmental sources, and
suspect the following pathogen(s): in the intestines of humans and animals.2 Some
risk for infection and Norovirus strains produce a toxin in the intestines that
complications, with Astrovirus causes gastroenteritis. The Centers for Disease
Staphylococcus aureus Control and Prevention (CDC) estimates this
illness lasting up to Clostridium perfringens organism causes nearly one million cases of food-
two weeks. Clostridium perfringens enterotoxin was borne illness annually.2 Clostridium perfringens
detected in 20 of 23 stool specimens from ill infection usually has a sudden onset, lasts for
residents and staff members. This organism was less than 24 hours, and results in diarrhea and
also found in the chicken. abdominal cramps.2 Fever or vomiting does not
An investigation revealed the chicken was usually occur. The infection is not transmitted
cooked approximately 24 hours before serving. person-to-person; use of Standard Precautions is
It was not cooled properly, per the facility policy, sufficient when caring for the patient. The incu-
and there was a delay with the required tem- bation period is six to 24 hours.3 This organism
perature checks. Additionally, the chicken was is also the causative agent for gas gangrene and

44 | Summer 2015 | Prevention


This illustration depicts a photomicrographic view of a Gram-stained

culture specimen from a patient with gas gangrene, and revealed the
presence of numerous Clostridium perfringens Gram-positive bacteria.

side effects, may have impaired gastroin-

testinal motility; this will delay elimina-
tion of the toxin and may result in severe
intestinal damage and possible death.
Any food that has been left out too
long may result in illness, despite a normal

Steven J. Schweon, RN, MPH,

an infection prevention consul-
tant with a specialized interest
in acute care/long-term care/
behavioral health/ambulatory
care infection challenges, including outbreaks.

1. Centers for Disease Control and Prevention. Fatal foodborne
Clostridium perfringens illness at a state psychiatric hospital-
Louisiana, 2010. MMWR. 2012;61(32). Available at: www.cdc.
gov/mmwr/pdf/wk/mm6132.pdf. Accessed March 27, 2015.
2. CDC. Clostridium perfringens. Food safety. 2014. Available at: Accessed
March 27, 2015.
3. U.S. Department of Health and Human Services. Clostridium
perfringens. 2015. Available at:
causes/bacteriaviruses/cperfringens/. Accessed March 28, 2015.
can be produce enough toxins in
used for the intestines and cause illness.2
biological warfare. Spores germinate between 54140 degrees
While everyone is susceptible to Clostridium Fahrenheit; the bacteria grow very rapidly more at the
perfringens food poisoning, the very young between 109117 degrees Fahrenheit. APIC 2015
and elderly are at the greatest risk for infection To prevent illness, foods should be cooked Annual
and complications, with illness lasting up to thoroughly at the recommended tempera-
two weeks. tures, then kept either warmer than 140 Conference
degrees Fahrenheit or cooler than 41 degrees
Diagnosis and treatment Attend Steven Schweons session at
Fahrenheit, which prevents spore growth.2
APIC 2015, June 2729 in Nashville,
Clostridium perfringens food poisoning is Food that is reheated must also be pre-
diagnosed by either detecting the bacterial pared at the recommended temperature; oth-
toxin in the feces or determining the number erwise, live bacteria may become ingested. Outbreaks on Behavioral Health
of spores per gram in the stool. Antibiotics are Units: What Happens When Intensive
not recommended for treating the infection. Take home messages for the LTC/ Inpatient Psychiatric Therapy Meets
Rehydration therapy is used to replace fluids behavioral health IP: Communicable Diseases
and electrolytes lost due to diarrhea. There is
no vaccine available to prevent illness.
It is critical to strictly adhere to recom-
food cooking and storage tem-
Monday, June 29, 9:3010:30 a.m.
Learning objectives:
peratures to prevent illness. Identify one reason an outbreak may
How does food poisoning occur?
Common food sources containing this
During environmental rounds in your
facilitys kitchen, review temperature logs
go undetected in a behavioral health
organism include beef, poultry, gravies, to ensure policy compliance.
State two evidence-based best
and dried or pre-cooked foods. Although
this organism may be part of the normal
Include Clostridium perfringens as a
possible pathogen when suspecting food
practices to prevent outbreaks.
intestinal flora, illness is due to ingesting poisoning on the milieu or in a LTC unit. Describe one intervention to halt
an outbreak.
food contaminated with a large number
of Clostridium perfringens organisms that
Patients taking psychiatric medications,
or other medications with anticholinergic

w w | 45

A family-centered
care model to
reduce pediatric
By Vicky Uhland

hen the staff of Akron Childrens Hospital in Akron, Ohio, decided Between 2012
to implement a catheter-associated urinary tract infection (CAUTI) and 2013, the burn
prevention program, they knew they faced some challenges. Unlike center reduced
most adult CAUTI prevention programs, pediatric CAUTI initiatives require catheter days by
both patient and family participation. Fortunately, Akron Childrens already had
75 percent, from
a robust patient- and family-centered model of care delivery when it enacted its
618 to 245. The
CAUTI prevention program three years ago. And the team, co-led by infection
prevention staff, had the added benefit of being able to participate in the Ohio number of CAUTIs
Childrens Hospitals Solutions for Patient Safetya pioneering pediatric col- dropped from
laborative to prevent serious harm from hospital acquired conditions including seven in 2012 to
healthcare-associated infections (HAIs). two in 2013. The
burn center has
Akron Childrens is the largest pediatric health- CIC, manager of infection prevention and control,
gone more than
care system in northeast Ohio, with about 800,000 evaluated nursing sensitive quality indicators and
patient visits a year. It operates two hospitals and has found that the burn center and pediatric inten- 330 days without
about 80 locations across the region. The hospital sive care unit (PICU) had the highest CAUTI
has earned Magnet designation for excellence in numbersmainly because they served many criti- a CAUTI.
nursing care. In 2012, Akron Childrens infection cally ill patients who required catheters. Using the
prevention team, including Cheryl Christ-Libertin, Rosswurm-Larrabee model for planned change in
DNP, CPNP-PC, RN-BC, NE-BC, evidence-based practice based on evidence, the team first developed
practice coordinator, and Tina L. Bair, MSN, RN, a pilot study for the Paul and Carol David Regional

46 | Summer 2015 | Prevention

Akron Childrens nurse provides patient- and family-
centered care for quality outcomes.

photo courtesy: Akron Childrens Hospital.

Burn Center. The surgeons and nursing staff for Patient Safety network for reduction Pros and cons of an RN-driven catheter
helped individualize the infection preven- of catheter days, Christ-Libertin said. removal algorithm
tion plan to the burn injured patients and Between 2012 and 2013, the burn cen- The team implemented a decision-making
measured reliable use of the insertion and ter reduced catheter days by 75 percent, algorithm that determined when catheters
maintenance bundles, as well as strategies from 618 to 245. The number of CAUTIs should be used or removed. The algorithm,
to reduce catheter days. dropped from seven in 2012 to two in which Christ-Libertin said came from pub-
In 2013, they joined efforts with the Ohio 2013. The burn center has gone more lished literature, focused on RN-driven cath-
Childrens Hospitals Solutions for Patient than 330 days without a CAUTI. And eter removal.
Safety network and spread the work to the 2013 CAUTI rate of 1.27 notably During the trial period, the nurses com-
the PICU. Key drivers to prevent CAUTI outperformed the National Healthcare pleted the algorithm and recorded their
included use of clinical criteria for catheters, Safety Networks pooled mean of 4.10. decision about catheter removal for each
use of insertion and maintenance bundles, American Burn Association (ABA) veri- patient. Then the providers recorded what
and daily evaluation of the need for the fication surgeons took note and called their decision would be. Christ-Libertin said
catheter. Interventions tested encompassed the center to discuss its strategy. The suc- the infection prevention team was looking for
everything from a catheter removal decision- cesses were shared at the ABA regional 95 percent agreement, and got 90 percent.
making algorithm to a patient information and national conferences. The PICU We found that nurses wanted to keep the
handout for family members. In 2013, Bair pediatric intensivists and nursing staff catheters in more often, she said. The provid-
and an administrative intern instituted a reviewed progress toward established goals ers wanted to take the catheters out more often.
hand hygiene improvement program using monthly. The team also reduced catheter So the team decided to abandon the
Lean Six Sigma methodologies. days and established highly reliable use algorithm. Unlike in the adult world, our
The results have been impressive. We of the bundles (greater than 95 percent). pediatric intensivists and acute care nurse
were recognized as a top-five network hospi- They reduced CAUTI from five in 2012 practitioners are onsite and round at three
tal among the more than 80 hospitals in the to two in 2013. The PICU shared its suc- scheduled times a day in the PICU. The nurs-
National Childrens Hospitals Solutions cesses at the American Nurses Association ing staff and providers use a shared team
Quality Conference. decision-making approach. Christ-Libertin

w w | 47

said. We found that discussion in rounds can

Read more about CAUTI in replace the algorithm.
The clinical staff added review of the number
the American Journal of of urinary catheter days to its rounding tool that
Infection Control details the topics to be discussed during rounds.

Changing procedures and staff buy-in

Using electronic medical records to increase the efficiency of catheter-associated urinary
tract infection surveillance for National Health and Safety Network reporting, Shepard, John After realizing that operating room (OR)
et al., American Journal of Infection Control, Volume 42, Issue 3, e33-e36. staff places more than half of all catheters used
in the hospital, the infection prevention team
Nurse-directed catheter removal protocols to prevent catheter-associated urinary tract
infection: Strategies for implementation, Hebden, Joan N., American Journal of Infection Control,
expanded its CAUTI prevention program to
Volume 42, Issue 6, 670. Surgical Services. The OR and PICU teams
began evaluating pre-connected catheter sys-
A comparison of the microbiologic profile of indwelling versus external urinary catheters, tems, which were not widely used in childrens
Grigoryan, Larissa et al., American Journal of Infection Control, Volume 42, Issue 6, 682-684. care.
Impact of catheter-associated urinary tract infection bundle on other health care-associated Because the OR has restricted space, the
infections, Cheng, Wei-YaLin, Yu-HsiuLai, Chih-ChengChao, Chien-Ming et al., American Journal of OR education coordinator led staff practice
Infection Control, Volume 43, Issue 2, 197-198. with inserting the systems on training man-
Risk factors for catheter-associated urinary tract infection in Italian elderly, Vincitorio, Daniela nequins. This had the added benefit of helping
et al., American Journal of Infection Control, Volume 42, Issue 8, 898-901. staff develop a best-practices insertion method
without interference with a surgery. In addition,
Introducing a catheter-associated urinary tract infection (CAUTI) prevention guide to patient all new nurse hires receive simulated insertion
safety (GPS), Saint, Sanjay et al., American Journal of Infection Control, Volume 42, Issue 5, 548-550.
training, and all nurses complete ongoing edu-
Emergence of extended-spectrum -lactamase-producing Escherichia coli in catheter-asso- cation on catheter insertion, maintenance, and
ciated urinary tract infection in neurogenic bladder patients, Takaba, Kei et al., American Journal CAUTI prevention best practices. The anesthe-
of Infection Control, Volume 42, Issue 3, e29-e31. sia team evaluated practices and reduced cath-
Clinician practice and the National Healthcare Safety Network definition for the diagnosis of eter days for patients with epidural catheters.
catheter-associated urinary tract infection, Al-Qas Hanna, Fadi et al., American Journal of Infection Christ-Libertin said not all nurses were com-
Control, Volume 41, Issue 12, 1173-1177. fortable with the new catheter methods. We
actually needed more buy-in from hospital staff
What we dont know may hurt us: Urinary drainage system tubing coils and CAUTIsA
prospective quality study, Kubilay, Zeynep et al., American Journal of Infection Control, Volume 41,
than from patients families, she said. The
Issue 12, 1278-1280. literature tells us that nurses and providers may
believe that CAUTI are fairly benign and dont
Trends in catheter-associated urinary tract infections among a national cohort of hospital- cause much harm. Competing priorities for care,
ized adults, 2001-2010, Daniels, Kelly R. et al., American Journal of Infection Control, Volume 42, catheter [care] can get lost.
Issue 1, 17-22.
The team also developed a patient informa-
tion handout on CAUTIs, detailing things like
the definition of a CAUTI, symptoms of a UTI,
what staff will do to prevent a CAUTI, and
Learn more at the what patients and families can do. The handout
APIC 2015 Annual Conference review process included review by the hospital
Parent Advisory Council. Christ-Libertin said
Attend these CAUTI sessions at APIC 2015, June 2729 in the handout guides staff on information to
Nashville, Tennessee. review with families on the topic of CAUTI.
3205Plastic Rounds: A Nurse-Centric Approach to At the heart of patient- and family-centered
Reducing Catheter-Associated Urinary Tract Infection (CAUTI) care is the recognition that parents are the con-
and Central Line-Associated Bloodstream Infection (CLABSI). stants in their childrens lives. They hold the
 3500NHSN CLABSI and CAUTI Surveillance 2015. most complete understanding of each childs
3002Proper Collection of Blood and Urine Cultures: Potential past, present, and future, Christ-Libertin said.
Impact on Central Line-Associated Bloodstream Infections Our biggest insight is that we may think we
(CLABSI)/Catheter-Associated Urinary Tract Infections (CAUTI) know the best thing for the patient, but unless
Surveillance. we involve them and their families, we wont
know for sure.
3103Using CUSP to Prevent CAUTI: Key Lessons Learned
from a Large National Clinical and Fellowship Project.
Vicky Uhland is a medical writer for Prevention
48 | Summer 2015 | Prevention

My bugaboo

Hepatitis C
The silent epidemic
A microbiological
overview of
Hepatitis C

50 | Summer 2015 | Prevention

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 preventionists (IPs). Obviously, the impact of microbial disease cannot be overstated.
Traditionally, the teaching of microbiology has been based mostly on memorization of facts (the bug parade). Too much information makes it
difficult to tease out what is important and directly applicable to practice. This quarters My Bugaboo column features information about the human
pathogen Hepatitis C. The intention is to convey succinct information to busy IPs for common etiologic agents of healthcare-associated infections.

Please feel free to contact me with questions, suggestions, and comments at


he Hepatitis C virus (HCV) has been referred to as the silent epidemic because estimates
indicate that approximately four million Americans are infected with this bloodborne patho-
gen. In the USA, the incidence of HCV fell between 1992 and 2003, but no further decreases
have been documented since that time.1

Liver failure caused by HCV is one of the Severe symptoms can occur with HCV; how- Outbreaks of HCV infection have
most common reasons for liver transplants ever, there have been reported cases in which occurred in outpatient settings, hemo-
in this country. Approximately 75 percent of there was no damage to the liver. Chronic dialysis units, long-term care facilities,
people infected with HCV become chroni- liver disease with no overt symptoms is much and hospitals. Both healthcare workers
cally infected and will remain infected indef- more common.1,2 and patients are potentially at risk. This
initely. Furthermore, HCV infected persons Cancer may occur as the direct result of risk has been associated with unsafe
may not be aware of their chronic infection HCV infection. Worldwide, HBV infection is injection practices, reuse of needles,
because they have no signs or symptoms. the most common cause of liver cancer; how- fingerstick devices, syringes, and lapses
Unfortunately, these infected people serve ever, in the U.S. it is more likely to be HCV.1 in infection prevention and control
as a source of transmission to others.1,2 protocols.1,3
Hepatitis C is an RNA virus in the Background
Faviviridae family. In the past, it was known HCV occurs in all ages, although the high- Risk factors for HCV infection
as non-A non-B virus.1 est incidence of acute HCV is found among Recommendations have been devel-
persons 2039 years. African Americans and oped for persons considered at higher risk
Clinical significance and epidemiology whites have similar incidence rates of acute for HCV infection. These laboratory tests
HCV infection shares many character- disease with higher rates in persons with include routine blood work/serum testing
istics of Hepatitis B virus (HBV) disease, Hispanic ethnicity. Vertical transmission is for anti-HCV antibodies. Risk factors are
but is much more likely to become chronic. also possible.2 listed in Table 1 on the following page.1,3

The Hepatitis C virus (HCV) has been referred to as the silent epidemic because
estimates indicate that approximately four million Americans are infected with this
bloodborne pathogen.

w w | 51

Table 1. Risk factors for HCV infection

Contact with a person with confirmed or suspected
Persons born between 19451965
HCV infection
Employment involving contact with human blood Persons who currently inject drugs or who have injected drugs in the past, even if once
Receipt of blood transfusion or blood products or many years ago

Dialysis or kidney transplant Recipients of clotting factor concentrates before 1987

Injecting drug use Recipients of blood transfusions or donated organs before July 1992
Number of different male sex partners Long-term hemodialysis patients
Number of different female sex partners Persons with known exposures to HCV (e.g., healthcare workers after needlesticks,
Hospitalization and/or surgery recipients of blood or organs from a donor who later tested positive for HCV)
Intravenous infusions or injections received in an
HIV-infected persons
outpatient setting
Residence in a long-term care facility Children born to infected mothers (do not test before age 18 months)
Patients with signs or symptoms of liver disease (e.g., abnormal liver
Dental work/oral surgery
enzyme tests)

Acupuncture/tattooing/body piercing
Puncture with a needle or other object contamination Donors of blood, plasma, organs, tissues, or semen
with blood

Laboratory testing and use of standardized diagnostic hepati- HCV RNA by reverse transcription poly-
HCV is usually diagnosed with a blood test tis panels for testing symptomatic patients, merase chain reaction verifies HCV infection.1
for antibodies to the virus. The clinical signs including all serologic markers mandatory
and symptoms of acute disease caused by the by state laboratory reporting requirements. Infection prevention and control
hepatitis viruses are similar. This makes sero- Serologic markers include IgM anti-HAV, There is currently no vaccine available for
logic testing necessary to establish a diagnosis HBsAg, IgM anti HBc, and anti HCV.1,2,3 HCV. There is also no effective post-expo-
in persons with jaundice or other signs and/or Asymptomatic chronic HCV infected per- sure prophylaxis. Implementation of primary
symptoms of acute hepatitis. Persons with acute sons should be tested for infection based on prevention practices that have proven to be
HCV infection generally exhibit the follow- risk factors for infection and/or elevated liver effective to reduce the risk of HCV infection
ing: anorexia, nausea, malaise, vomiting, dark enzymes, such as ALT and AST. A positive include: standard precautions, hand washing,
urine, clay colored or light stools, and abdom- test result for HBsAg or anti-HCV by enzyme and educating of healthcare personnel about
inal pain. Centers for Disease Control and immunoassay (EIA) should be verified by a safe injection practices. Secondary preven-
Prevention (CDC) encourages implementation supplemental antibody assay. Detection of tion activities are focused on outbreak inves-
tigation and the reduction of liver disease
and other manifestations of HCV-related
chronic infections.1,3,4
Additional resources The current treatment regimen for HCV
is ribavirin plus pegylated interferon ther-
CDCViral Hepatitis: Index of information from the CDC on hepatitis viruses, including apy. These treatments are not considered
hepatitis B virus and hepatitis C virus. curative, but may prevent further damage to
the liver. In 2011, two new protease inhibi-
CDCProtecting Healthcare Personnel tor drugs were approved for treating HCV.2
Recent advances in HCV therapy have
given those infected an improved chance for
CDCHepatitis B and the Healthcare Worker: CDC answers frequently asked questions longer lifeessentially considered a cure.
about how to protect healthcare workers Cure means the HCV is not detectable in
the blood three months after treatment ends.
A new regimen that has been approved by

52 | Summer 2015 | Prevention

the Food and Drug Administration (FDA)
includes sofosbuvir, which was the first drug Read more about Hepatitis C
that did not need to be used with interferon in the American Journal of
therapy. Protease inhibitors have also been
approved by the FDA in the treatment of
Infection Control
chronic HCV infection: simeprevir, bocepre-
vir, and telaprevir. HCV treatment in adults
is changing constantly with the advent of new Outbreak of Hepatitis C among patients admitted to the Department ofGynecology,
therapies and other developments.5,6 Obstetrics, and Oncology, Rorat, Marta et al., American Journal of Infection Control, Volume
42, Issue 1, e7-e10.
Hepatitis C in Cardiac Patients Investigation Leads to Opportunities for Improvement in
The CDC recommends that all states Preventing the Transmission of Bloodborne Pathogens, Sturm, Lisa, et al., American Journal
and territories conduct surveillance for of Infection Control, Volume 39, Issue 5, E205.
acute viral hepatitis, including Hepatitis
A, B, C, and non-ABC. Case reports are Hepatitis C transmission due to contamination of multidose medication vials: Summary of
transmitted weekly by state health depart- an outbreak and a call to action, Branch-Elliman, Westyn et al., American Journal of Infection
ments to the CDC. However, the state- Control, Volume 41, Issue 1, 92-94.
based databases of persons reported as Evaluation of a universal vs a targeted Hepatitis C virus screening strategy among pregnant
anti-HCV positive vary considerably and women at the Vienna University Hospital, Diab-Elschahawi, Magda et al., American Journal of
have not been standardized.1,7 Infection Control, Volume 41, Issue 5, 459-460.
To date, information on cases of viral
hepatitis reported nationally has been main- Outbreak of Hepatitis C virus infection associated with narcotics diversion by an Hepatitis C
tained by the CDC in two surveillance sys- virusinfected surgical technician, Warner, Amy E. et al., American Journal of Infection Control,
tems. Information collected by the National Volume 43, Issue 1, 53-58.
Notifiable Disease Surveillance System
(NNDSS) includes diagnosis, event dates,
and basic demographic data. Additional
information is collected by the Viral
Hepatitis Surveillance Program (VHSP),
which includes clinical and serologic test
results, and risk factors for infection.1,7 Learn more at the
Irena Kenneley, PhD, APRN-BC,
APIC 2015 Annual
CIC, is associate professor at Case Conference
Western Reserve University,
Attend this special microbiology workshop at
Frances Payne Bolton School of
APIC 2015, June 2729 in Nashville, Tennessee.
Nursing in Cleveland, Ohio.
Swimming in Alphabet Soup?
References A Cant-Miss Opportunity to Review the
1. Centers for Disease Control and Prevention. Guidelines Latest in Microbiology!
for Viral Hepatitis Surveillance and Case Management.
Atlanta, GA. 2005. Available at: Monday, June 29, 810:30 a.m.
2. Cowan MK. (2013). Microbiology Fundamentals: A Clinical
Learning objectives:
Approach. McGraw Hill: New York NY. Discuss the human/pathogen interaction, from
3. Centers for Disease Control and Prevention. Health Care exposure to outright infection.
Settings and Viral Hepatitis. 2011. Available at: www.cdc.
gov/hepatitis/Settings/HealthcareSettings.htm. Interpret microbiology and immunology patient
4. Centers for Disease Control and Prevention (HICPAC). Guideline reports.
for Isolation Precautions: Preventing Transmission of Infectious
Agents in Healthcare Settings. 2007. Available at: www.cdc. Apply infection control and prevention interven-
5. Centers for Disease Control and Prevention (HICPAC). Guid-
tions to real-life situations common in various
ance on Public Reporting of Healthcare-Associated Infections: healthcare delivery settings.
Recommendations of the Healthcare Infection Control Practices
Advisory Committee. 2009. Available at:

w w | 53


t Legionella and waterborne pathogens testing
t Water safety plans
t Risk assessments and outbreak response 37
Construction and design review O O T H 10
t B
t Training and seminars
Accredited and CDC-ELITE certied for Legionella testing.


734896_Special.indd 1 04/05/15 6:57 PM

54 | Summer 2015 | Prevention

747795_Editorial.indd 1 5/20/15 7:47 PM

Hand hygiene hurdles:

How can we
overcome them?
Q&A with Dr. Timothy Landers

or most of the last decade, Timothy Landers, PhD, RN, CNP,
CIC, has been focused on effective hand hygiene programs.
Therefore, it makes perfect sense that he would help write the
latest in the series of APIC Implementation Guides, Guide to Hand
Hygiene Programs for Infection Prevention, sponsored by GOJOa
long-standing Strategic Partner. Dr. Landers, who is an assistant
professor in The Ohio State University College of Nursing and
a Robert Wood Johnson Foundation nurse faculty scholar,
said the guide examines the historical and regulatory con-
text for hand hygiene programs, and also delves into the
latest science. Its designed as a best-practices primer
for beginning to intermediate infection preven-
tionists (IPs), their clinician colleagues, and
healthcare facility executives.

w w | 55

Why do you have an receive; there are local variations in all of
interest in hand hygiene? those things.
My area of interest is in the pre- An off-the-shelf program that anyone can
vention of antibiotic-resistant bacteria, so simply take and implement doesnt exist.
the more I learned about the importance of Having a successful hand hygiene program
hand hygiene in preventing these types of requires trained, knowledgeable, and expe-
bacteria, the more I wanted to focus on it and rienced IPs to examine their local settings
develop effective programs. Hand hygiene is and study their local cultureseven things
the cornerstone of our infection prevention like the humidity and temperature variations
credit: troy Huffman, The Ohio State University

activities; so as IPs, it should be the core of that affect users preferences for hand hygiene
what were doing. products. The guide highlights the important
Not to brag too much about IPs, but the role IPs have in developing these programs.
work we do to prevent infections makes many
other advancements in healthcare possible.

Clinicians are able to do highly technologi- What is the future of hand
cal, highly invasive, lifesaving procedures hygiene in healthcare
like brain surgery or chemotherapy because settings? What do you
were focused on preventing infections that see as the major scientific issues
would otherwise kill people who are having related to hand hygiene that still
Timothy Landers, PhD, RN, CNP, CIC. these procedures. need to be addressed?
Practical questions need to be answered,
like what are the best practice recommenda-

Prevention Strategist chatted What are the key points tions around glove use and hand hygiene?
with Dr. Landers recently about that IPs need to know Work also needs to be done on designing
in order to design well-tolerated hand hygiene products that are
specifics of the new Guide to and implement hand hygiene effective against the full range of pathogens
Hand Hygiene Programs for programs? in our healthcare settings. This is something
Infection Prevention, and his This is the most exciting part of hand industry is working on, but I think more
thoughts on how hand hygiene hygiene research in generalthat is, the needs to be done there.
idea of a multimodal program is absolutely Understanding behavioral aspects of hand
can be improved in every type of essential. Some of the key components of hygiene is important, as well as what can be
healthcare setting. a multimodal program are education and done as the healthcare system evolves. With
training, providing effective products where the emphasis on being efficient and having
theyre needed, providing cultural and lead- good patient safety and patient outcomes,
ership support for hand hygiene efforts and how can we leverage that interest to really
monitoring, and then linking that back to encourage hand hygiene?
education and training. Its really the syn- Work should be done to pinpoint the
ergy of when all those components of hand most effective monitoring strategies, includ-
hygiene programs are working together effec- ing feedback on the best formats and ways
tively that we see the biggest change. to deliver monitoring results. The role of
The guide presents what the individual the patient in hand hygiene is an important
components of a hand hygiene program area that has been overlooked and needs to
might look like, and also helps IPs think be addressed. We havent really developed
about how the different modes or interven- recommendations or products for patients
tions could work together. That is the biggest to be able to perform hand hygiene in
take-home message. healthcare settings.
Look for the new This guide is unique in that it gives IPs In our guide, weve outlined a best-prac-
the tools to adapt national and international tices approach, and we discuss advancements
Guide to Hand Hygiene hand hygiene guidelines to their local set- in products, culture, behavioral change, and
Programs for Infection tings. A majority of hand hygiene activity monitoring. Essentially, the guide is meant
depends on a supportive environment and a to help IPs be on the lookout for these things
Prevention at culture that places patient safety at the center. as they emerge. However, it doesnt neces- Successful hand hygiene activity also depends sarily make recommendations about one
implementationguides. on the selection of products and the monitor- thing over another, except for whats based
ing and training that healthcare professionals on solid science.

56 | Summer 2015 | Prevention

Based on your work, what well-functioning hand hygiene program. that are led by highly skilled and engaged IPs
do we know about hand For instance, it could mean doing chief who are able to adapt the program specifically
hygiene and glove use? executive rounding to get executive buy-in. for their environment.
More work must be done in this area. Overall, the guide reinforces the impor-
The interesting facet of hand hygiene and tance of highly skilled IPs. It takes knowl-

glove use is that, in general, we think about edgeable and engaged IPs to recognize the It seems like weve known
hand hygiene protecting patients from the needs of different audiences and develop about hand hygiene for
transmission of these dangerous organisms hand hygiene strategies and approaches for so long, but there are
or pathogens, and we tend to think about different groups. still issues. What barriers remain
glove use as protecting ourselves as healthcare in implementing hand hygiene
workers. Thus, there is an intrinsic motiva- programs?

tion for glove use and extrinsic motivation  hat does successful hand
W In the non-infection prevention world, an
to perform hand hygiene. hygiene implementation idea exists that hand hygiene is a simple act.
Others have called for the glove use guide- look like? But its really a complex act that has deep
lines to be based on more solid evidence. I Successful hand hygiene programs need motivations. We need to understand that
believe well see more evidence on this topic to be multimodal, coordinated, adequately hand hygiene is complex but is worth doing
in the next two to three years. resourced, and be an institutional priority to keep patients safe.

What are some of the
explanations for variations in
hand hygiene compliance? Read more about hand
Compliance varies by discipline. Training hygiene in the American
and background sometimes emphasizes the Journal of Infection Control
importance of hand hygiene in different
ways. We also may see levels and frequency
of hand hygiene differing depending on levels Impact of sink location on hand hygiene compliance for Clostridium difficile infection, Zellmer,
of interaction with patients. Unfortunately, Caroline et al., American Journal of Infection Control, Volume 43, Issue 4, 387-389.
infection prevention and control measures
dont have as much of an immediate effect on Sustained increase in resident meal time hand hygiene through an interdisciplinary inter-
a patient as giving the wrong drug or using vention engaging long-term care facility residents and staff, ODonnell, Marguerite et al.,
the wrong surgical technique. So in infection American Journal of Infection Control, Volume 43, Issue 2, 162-164.
prevention, the outcome is somewhat distant Impact of the first hand sanitizing relay world record on compliance with hand hygiene in a
from the intervention. hospital, Seto, Wing Hong et al., American Journal of Infection Control, Volume 43, Issue 3, 295-297.
Its important for IPs to be aware of the
various ways different professionals respond A multifactorial action plan improves hand hygiene adherence and significantly reduces
to infection prevention initiatives, and how central line-associated bloodstream infections, Johnson, Linda et al., American Journal of
interventions need to be based on empirical, Infection Control, Volume 42, Issue 11, 1146-1151.
validated data. Leadership also must make Comparison of hand hygiene monitoring using the 5 Moments for Hand Hygiene method
a commitment to a hand hygiene program. versus a wash in-wash out method, Sunkesula, Venkata C.K. et al., American Journal of Infection
Leadership sets an example and provides Control, Volume 43, Issue 1, 16-19.
resources for integrating multimodal hand
hygiene programs. Face touching: A frequent habit that has implications for hand hygiene, Kwok, Yen Lee Angela
Throughout the guide, we present ways et al., American Journal of Infection Control, Volume 43, Issue 2, 112-114.
to facilitate cultural change and overcome See one, do one, teach one: Hand hygiene attitudes among medical students, interns, and
hand hygiene compliance variations. Three faculty, Polacco, Marc A. et al., American Journal of Infection Control, Volume 43, Issue 2, 159-161.
unique ways include:
1. Positive deviance. This includes novel Impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional
ways of managing change. hand hygiene approach in 3 cities in Brazil, Medeiros, Eduardo A. et al., American Journal of
2. Frontline ownership. This involves get- Infection Control, Volume 43, Issue 1, 10-15.
ting direct caregivers to commit to hand Systematic qualitative literature review of health care workers compliance with hand
hygiene as their core metrics. hygiene guidelines, Smiddy, Maura P. et al., American Journal of Infection Control, Volume 43,
3. Writing a business case. This includes Issue 3, 269-27.
learning how to converse with corpo-
rate leaders about the economics of a

w w | 57
Questions and concerns
regarding safety of
endoscopes and validity of
manufacturer guidance

R eports of carbapenem-resistant Enterobacteriaceae (CRE)

infections related to endoscopic retrograde cholangiopancrea-
tography (ERCP) duodenoscopes raised concerns among infec-
tion prevention experts, federal agencies, and the public. In February 2015, Ronald
Reagan UCLA Medical Center notified 179 patients who underwent ERCP that
they may have been exposed to CRE from contaminated duodenoscopes. Ronald
Reagan UCLA Medical Center reported that only patients who underwent ERCP
procedures from October 3, 2014, to January 28, 2015, were at risk of CRE infec-
tion as a result of these procedures. UCLA Medical
Center noted that it processed the scopes according
to the standards stipulated by the manufacturer. As
of February 23, a total of seven UCLA patients were James Davis,
infected and two died. MSN, RN, CCRN, CIC, HEM
Senior Infection
Among infection preventionists, this incident has Prevention Analyst
raised many questions about appropriate cleaning ECRI Institute Headquarters
Centers for Disease Control Plymouth Meeting, Pennsylvania
and disinfection of endoscopes, surveillance cul-
and Prevention (CDC) James Davis represented APIC as part of the
turing process of endoscopes, and the validity of Division of Healthcare Quality Promotion working group that helped develop the CDCs
manufacturer guidance. Here, we present common Atlanta, Georgia duodenoscope surveillance protocol.
questions that have arisen about these issues and
answers from experts.

58 | Summer 2015 | Prevention

Answers from experts

Q: How did the FDA

approve the sale
of endoscopes that are not
properly validated to be
reused without the risk of
infection when manufacturer
guidance is followed?

Frank Myers: Press reports have

stated that some of the ERCP
scopes linked to some of the
outbreaks were not approved
by the FDA in the configura-
tion used. Manufacturers are
allowed to make small changes to a design
that does not significantly change the func-
tion or cleaning of the device. In this case, the
company in 2010 felt the changes were not
significant enough to warrant a new 510(k)
approval.The FDA has since become aware
of the changes and requested a new 510(k)
application be submitted.Both the FDA and
the manufacturer have supported using the
scope in the interim despite not having 510(k)
approval.Other scopes linked to outbreaks
have been approved by the FDA.Because
of this, the FDA has reached out to APIC
and others to give input on new validation
approaches for these scopes.
Frank Myers, PressAnnouncements/ucm437804.htm.
Infection Preventionist III
Infection Prevention
Clinical EPI
UC San Diego Health System
San Diego, California
Frank Myers represents APICs Practice
Guidance Committee and is APIC liaison to the
Association for the Advancement of Medical

w w | 59
PHOTO COURTESY: Dartmouth-Hitchcock/Mark Washburn
Q: Does the cleaning and disinfection
issue apply to just ERCP endoscopes
or to other items with a similar
Q: If a facility is considering sending their ERCP
endoscope(s) out for ethylene oxide (ETO) gas
sterilization, what things do infection preventionists and
administrators need to consider and plan for?
elevator channel structure such as endoscopic
ultrasound scopes (EUS)? James Davis: Infection preventionists and administrators need to consider
and plan for:
1. The tracking and management of scopes leaving and returning to the
CDC: All endoscopes should undergo medical facility.
appropriate reprocessing in accordance 2. Performing due diligence related to cost and quality for companies that
with the manufacturers instructions. perform such work (consider the use of a due diligence checklist).
Given the complex design of duodenoscopes, spe- 3. Knowing who is responsible if a scope is damaged during transport or reprocessing,
cial attention should be paid to the cleaning and how it will be replaced, and whether or not loaner equipment is available until a
disinfection of the elevator mechanism located at replacement is purchased will be important to know up front.
the distal tip of the duodenoscope and to ensuring 4. R eviewing the contract for assignment of liability related to lapses in reprocessing/
complete drying of all the channels and the elevator sterilization by the contractor.
mechanism. Training and oversight of individuals 5. Knowing who provides the transport containers and how sterility is maintained
performing endoscope cleaning and disinfection is during transport.
an essential component of successful reprocessing. 6. Conducting a FMEA [failure mode and effects analysis] prior to initiating the
Clusters related to transmission of bacteria from system change.
EUS have not been reported to CDC; however, since 7. S imulating the process in-situ. (The best laid plans may need to change once the
these scopes have similar design features to duode- process is simulated where the work happens.)
noscopes, similar challenges for transmission might 8. Contacting the endoscope manufacturer regarding warranty issues related to off-IFU
also exist with these endoscopes. CDCs interim [instructions for use] reprocessing, and whether or not the manufacturer support will
surveillance protocol ( change if using ETO.
cre/cre-duodenoscope-surveillance-protocol.html) is
primarily intended for duodenoscopes; however,

the measures outlined in the protocol could also be
applied to these devices. ETO gas sterilization is known to degrade medical equipment after
multiple exposures. Is any data available regarding how many times
Frank Myers: While the FDA and
ERCP endoscopes may be treated with ETO before they degrade?
other organizations guidance have
focused on the ERCP scope, many
institutions have begun to look at and James Davis: The scope Frank Myers: I agree with
speak about elevator scopes as being manufacturer will need to James comments. I would add
problematic. This grouping includes both ERCP provide that answer based that some institutions switch-
and EUS.Since elevator scopes share a number on validation and testing. ing to ETO have reported sig-
of similar characteristics, it is being proactive to One should also contact the nificant losses in the number
also look at processes and cleaning issues around manufacturer regarding warranty issues of scopes because of degradation.If your
these scopes.The American Gastroenterological related to off-IFU reprocessing. institution is considering ETO sterilization,
Association (AGA) Center for GI Innovation and it would seem prudent to query institutions
Technology convened a meeting, Getting to Zero, that have or are using ETO sterilization on
in March with experts in gastroenterology, epidemi- scope models that your institution will be
ology, and infectious disease; the endoscope manu- sterilizing. Asking about their experiences
facturers Fuji and Pentax; and representatives from with ETO sterilization, including attrition
the U.S. Food and Drug Administration (FDA), rate, will allow your institution to plan for
CDC, and ECRI Institute to discuss how to prevent all the issues around ETO sterilization.
these infections and recommended treating all ele-
vator-channel endoscopes the same, including both

FNA echoendoscopes (EUS) and duodenoscopes.
There has been one outbreak linked to EUS, sug- James Davis: Refer to the
gesting their design may not be different enough to What turnaround
time should facilities answer of question three.
prevent the issues seen with ERCP scopes. Simulation/FMEA of the pro-
who move to ETO
cess will be the only real way to
noscope-infections-300054158.html. gas sterilization expect (e.g.,
answer the question given the
transportation, sterilization,
variability of distance transported, facility
and aeration time)? processes, and contractor load and lead time.

60 | Summer 2015 | Prevention

Q: Is the surveillance culturing process recommended by CDC validated
such that it assures endoscopes that are surveillance cultured

Q: Should facilities that chose

to perform surveillance
cultures on endoscopes
perform these cultures on all
cannot transmit infection?

CDC: CDCs interim surveil-

lance protocol represents one
James Davis: The CDC has pro-
vided an interim protocol to help
endoscopes or just ERCP endoscopes? possible approach to culturing guide facilities. Validation of a cul-
of duodenoscopes and has not yet been ture method is possible; however, to
validated, i.e., the sensitivity, specificity say that the validation of the culture
and limits on quantitation or detection method will eliminate the risk of infection from
CDC: In the United States, bacte-
are not established for all organisms. As a fomite is improbable. One must consider false
rial transmission associated with
such, a negative culture result should not results/negatives and an individual laborato-
endoscopes for which no obvious
completely exclude the possibility of a con- rians performance of the task. Each facility
reprocessing breaches were identified have
taminated duodenoscope. In the event of that will be performing screening will need
thus far been linked to only duodenoscopes.
a suspected outbreak linked to duodeno- to design a system that validates their own lab
In light of this, CDC developed an interim
scopes, negative surveillance cultures alone processes and performance.
protocol specifically for duodenoscopes that
should not be used to exclude duodeno-
can serve as a guide for facilities consider-
scopes as a source of cross-contamination. Frank Myers: No, the CDC has
ing cultures of duodenoscopes to assess the
stated explicitly that the sensitivity of
adequacy of their duodenoscope reprocessing.
this culturing method is not known,
Although there is no requirement to perform
meaning false negatives are a distinct
duodenoscope cultures, some facilities have

possibility.Unpublished reports have
elected to perform regular surveillance cul-
stated that some scopes implicated epidemiologi-
tures as part of their response to the issue. This Who should perform cally in outbreaks have cultured negative using
is not a replacement for ongoing training and the processing, this method.
oversight to ensure that cleaning and disinfec- culture, and Citation:
tion steps are performed correctly; however, it identification of resultant bacteria sampling.html
does provide facilities considering duodeno-
from the samples collected?
scope cultures with a consistent starting point
for a protocol that can be adapted for use.
Some groups outside the United States have CDC: Samples should be
recommended routinely performing surveil- processed by personnel with
lance cultures of other types of endoscopes, microbiological understanding
in addition to duodenoscopes. However, the of culturing principles and identification of
benefit of this approach is not known. common environmental and clinical bacteria.
Facilities should use discretion in determining
personnel best qualified and trained for these
Learn more at the

activities. A multi-disciplinary team should be
brought together to decide the best approach for APIC 2015 Annual
Is it recommended that facilities
the individual facility. The facility can consider Conference
test each endoscope or a random
using an external laboratory for the laboratory
sample of endoscopes? If the Attend these scope and CRE-
protocol (e.g., academic environmental micro-
latter, what is the recommended interval? biology laboratory associated with the hospital
related sessions at APIC 2015,
June 2729 in Nashville,
or private contract laboratory, etc.) if necessary.
CDC: Facilities choosing to perform 3006Preventing the Next
James Davis: Culturing meth-
surveillance cultures of duodeno- Hospital Outbreak of Carbapenem-
odology should not deviate from
scopes should consider obtaining Resistant Enterobacteriaceae (CRE).
the standards currently used by a
post-reprocessing cultures of each duodenoscope 3101Swimming in Alphabet
facility/industry. If a facility does
that is in service. However, the optimal frequency Soup? KPC, CRE, IgG, IgM: A Cant
not conduct environmental or
of surveillance cultures has not been determined Miss Opportunity to Review the
fomite-based cultures, consider consultation
and could range from after each duodenoscope Latest in Microbiology!
with an environmental hygienist or an experi-
use (after reprocessing) to interval sampling, e.g., 2306Reprocessing Endoscopes
enced contractor. As for who should culture,
monthly or after every 60 procedures for each in Ambulatory Care Settings: What,
if facility-based, the laboratorians (culturing
duodenoscope. International guidelines have When, Why, and Where?
is what they do). If non-facility, confirm the
recommended intervals ranging from every four 2306The Evidence behind New
contract stipulates the competency and training
weeks to annually. Guidelines for Reprocessing Flexible
the culturing staff receives.

w w | 61
Q: Do facilities need to quarantine the endoscopes until results are known? If
not, what should the recall process be for endoscopes that culture positive
but have already been used on a patient?

CDC: Facilities could consider holding duodenoscopes out of use while surveillance
culture results are pending, especially if surveillance cultures are performed after each
use. For facilities that choose to not quarantine duodenoscopes, and a high-concern
organism (as defined in CDCs Interim Duodenoscope Surveillance Protocol) is detected through
surveillance cultures, the duodenoscope should be taken out of use until remedial actions are taken and
cultures no longer detect presence of the organism. The decision to notify exposed patients should be Read more about
made in consultation with appropriate facility staff, including infection prevention staff and hospital endoscopes in the
epidemiologists, and public health authorities. Patient notification should generally target all patients American Journal of
who underwent a procedure with the contaminated duodenoscope since the time of the last known Infection Control
negative duodenoscope culture. Facilities should routinely document the specific endoscope used for
each patient to facilitate the identification of exposed patients in the event of a patient notification. Aldehyde-resistant mycobacteria
bacteria associated with the use of

endoscope reprocessing systems,

Significant caution must be

observed when performing
surveillance cultures to
prevent contamination. What type of
Q: Is there any work being done
with the manufacturers to
change the design of ERCP
endoscopes so that they can be adequately
Fisher, Christopher W. et al., American
Journal of Infection Control, Volume 40,
Issue 9, 880-882.

Establishing a clinically relevant bio-

room or location should be used for burden benchmark: A quality indi-
cleaned and disinfected? cator for adequate reprocessing and
duodenoscope sampling?
storage of flexible gastrointestinal
James Davis: I am unaware of any endoscopes, Alfa, Michelle J. et al.,
CDC: Duodenoscopes should be design revisions being proposed. American Journal of Infection Control,
sampled on a clean surface away However, a company may want to inves- Volume 40, Issue 3, 233-236.
from traffic, obvious airflow (e.g., tigate such an option. A scope design An Outbreak of Carbapenem-
vents), and potential contamination with that would perform the same ERCP as resistant Klebsiella pneu-
water. A sectioned-off area of a reprocessing the traditional elevator channel type scope and has moniae Infections Associated
room or a separate room can be designated for been designed with reprocessing ease in mind, would with Endoscopic Retrograde
duodenoscope sampling. likely provide that company with a sales edge over the Cholangiopancreatography (ERCP)
competition. Procedures at a Hospital, Sanderson,

Roger et al., American Journal of Infection
What future standards regarding endoscope cleaning do you expect we will see? Control, Volume 38, Issue 5, e141.

Validation of adenosine triphosphate

to audit manual cleaning of flexible
James Davis: Healthcare is a hands-on of all of the users who come in contact with the endoscope channels, Alfa, Michelle
business, always relying on humans who device. If industry does not answer the call, in my J. et al., American Journal of Infection
need to perform tasks in order for the sys- opinion, there should be standards set forth that Control, Volume 41, Issue 3, 245-248.
tem to function. ERCP scopes combined ensure human factors and ergonomics are addressed
with the CRE organism have shown a for each stage of the devices use. Early identification and control of
potential weakness in high level disinfection/cleaning 2. Certification/licensure of reprocessing/steriliza- carbapenemase-producing Klebsiella
methods. However, where there is weakness there are tion staff: Medical devices that are reprocessed pneumoniae, originating from con-
opportunities for improvement. range in complexity from a simple pair of hemostats taminated endoscopic equipment,
1. Human factors/ergonomics: As is the case with to the ERCP-type duodenoscopes being discussed. Alrabaa, Sally F. et al., American Journal
most instruments used by proceduralists, the Each device type is processed in a certain way by a of Infection Control, Volume 41, Issue 6,
instrument is designed around the procedure. The certain method. Due to the complexity and exact- 562-564.
reprocessing of said equipment will vary in level ness of the tasks reprocessing staff must perform,
of difficulty as the complexity of the instrument several states have proposed bills that would make
increases. The ERCP scope has been designed to do certification or licensure a requirement. Currently,
Note from the editor: APIC thanks
a very specific job within the human body; it has I am unaware of a federal proposal for certifying or Mary C. Virgallito, RN, MSN, CIC,
been designed to not only perform the procedure, licensure; however, the combination of ERCP and APIC Public Policy Committee
but aide the proceduralist in completing the tasks CRE has proven to be a warning of what is pos- member, and Susan A. Dolan, RN,
related to the procedure. One may ask if the ERCP sible. I would expect to see more stateand perhaps MS, CIC, APIC president-elect and
scope design has prioritized reprocessing at the same federallegislation introduced that would require senior advisor to APICs Public
level as procedural performance. Industry may want formal validation of competency that sets standards Policy Committee, for developing
to look at future design and address all of the needs for reprocessing staff. the questions for this article.

62 | Summer 2015 | Prevention

Additional CRE and scope resources

Visit APICs CRE webpage ( for resources and guidance from CDC and others on preventing
infections associated with duodenoscopes. Here is a small sampling of what youll find on this page:

Government resources Reprocessing Medical Devices in Health Care APIC CRE reporting map
Centers for Disease Control and Prevention Settings: Validation Methods and Labeling, issued Summary of state CRE reporting requirements
resources 3/12/2015 APIC Government Affairs resource
Interim Duodenoscope Surveillance Protocol Safety communication, issued 2/19/2015
Interim Duodenoscope Sampling Method Olympus validates new reprocessing instructions APIC communications
Interim Duodenoscope Culture Method for model TJF-Q180V duodenoscopes, issued resources
Stop Infections from Lethal CRE Germs Now (Vital 3/26/15 Key talking points for infection preventioniststo
Signs report) Agency for Healthcare Research and Quality ensure effective reprocessing of ERCP duodeno-
resources scopes to reduce the risk of infection
Guidance for control of Carbapenem-resistant
Carbapenem-resistant Enterobacteriaceae (CRE) The APIC and Society for Healthcare Epidemiology
Enterobacteriaceae (CRE)
control and prevention toolkit of America (SHEA)press release
Tracking CRE
ERCP procedures and duodenoscopesfrequently
Management of multidrug-resistant organisms in Other resources asked questions for consumers
healthcare settings ECRI Institute recommends culturing duodeno-
Laboratory protocol for detection of carbapenem- scopes as a key step to reducing CRE infections
resistant or carbapenemase-producing Klebsiella ECRI Institute, March 3, 2015
spp. and E.colifrom rectal swabs How to stop duodenoscope infectionsAmerican
U.S. Food and Drug Administration resources Gastroenterological Association, March 23, 2015
FDA releases final guidance on reprocessing of Superbug reveals challenges with high level dis-
reusable medical devices, issued 3/12/2015 infectionThe Joint CommissionQuick Safety
advisory,March 2015

741284_GOJO.indd 1 w5/13/15 11:30 AM | 63

in the U.S.
Discussions with public health representatives
Photo courtesy: CDC/Amanda Mills.

64 | Summer 2015 | Prevention

LEFT: This image depicts a young boy who was receiving an injection in his right
lateral thigh muscle. This is known as an intramuscular injection, and in this case,
was delivering the requisite vaccination appropriate for his age group.

he United States declared measles eliminated in 2000. But less than 15 years later, U.S.
public health officials have seen cases of measles skyrocket, with a total of 23 measles
outbreaks in 2014 resulting in 668 measles cases reported from 27 states. The Centers for
Disease Control and Prevention (CDC) noted that this is the greatest number of measles cases since
measles elimination was documented nearly 15 years ago. The 2014 case count is in stark contrast
to the case count of 2013, when the U.S. reported only 58 measles cases.1
Public health officials are still grappling with increasing cases of measles in 2015. From
January 1 to May 29, 2015, 173 cases of measles have been reported from 21 states and the
District of Columbia72 percent of these cases were linked to a large multistate outbreak
associated with an amusement park in California.1 The measles case count continues to grow.

Prevention Strategist had the opportunity to interview public health officials and departments
that have been contending with measles in their regions.

MEET THE panel Q: Measles was declared eliminated in the U.S. in

2000. Was that a premature declaration?

Demian Chicago Department of Public Health: Endemic

Christiansen, transmission of measles in the U.S. ended in 2000.
DSc, MPH However, since measles remains prevalent in other parts of the world
Cook County where MMR [measles, mumps, rubella] vaccine isnt readily available,
Department of Public Health imported cases still continue. We live in a global community, and many
Dr. Christiansen is interim director of places around the world lack access to the measles vaccine; therefore,
Communicable Disease Control for the Cook there is a continued risk of imported cases of vaccine-preventable illness.
County Department of Public Health in Forest
Park, Illinois. Demian Christiansen, DSc, MPH: With the recent out-
break associated with a California theme park that has resulted
Chicago in at least 159 cases across 18 states, it certainly makes sense
Department of to ask this question. This declaration meant that sustained
Public Health transmission ended in the United States, but we always expected to see
imported cases, which seems likely to have sparked the recent multi-
state outbreak. In fact, in the five years prior to our most recent daycare
Tammy Sylvester, RN, BSN outbreak this past February, travel history for all measles cases had
Maricopa County Department perfect positive predictive value. Unfortunately, this is no longer the case.
of Public Health
Sylvester is communicable dis- Tammy Sylvester, RN, BSN: Yes, the U.S. did achieve
ease nursing supervisor in the Office of measles eliminations in 2000.McLean defined measles elimi-
Epidemiology, Disease Control Division of the nation as interruption of year-round endemic measles trans-
Maricopa County Department of Public Health mission.2From 2002 through 2007, measles cases in the U.S.
in Phoenix, Arizona. averaged 60 reported cases per year.1 Not until 2014 did the U.S. reach
an all-time high more than 600 reported cases.1

w w | 65
Q: How has public health
played a role in recent Q:Sthehould public health have taken a more active role in educating
public about the importance of vaccines 1015 years ago
measles outbreaks? when there was an increase in the anti-vaccine movement?

Chicago Department of Chicago Department providers but rather to point out that
Public Health: Public health of Public Health: many had never seen a measles case
plays a major role in disease surveillance Public health has always promoted because of the past measles vaccina-
and control. This includes provider educa- vaccines as a means to prevent the tion successes. Without their patients
tion, contract tracing, and laboratory testing transmission of vaccine preventable having had a clear link to the California
of specimens. It is important for public health illness. Parents want to do whats right theme park or travel to an area with
departments to maintain a high level of com- for their children; however, there have ongoing measles transmissioncou-
munication with local healthcare providers to been certain instances where misinfor- pled with a dearth of measles cases
ensure they have the resources necessary to mation influenced their decision not to in recent years in suburban Cook
educate their patients on the importance of vaccinate. One of the best ways for the Countyit may indeed be difficult for
vaccines, recognize and diagnose illnesses, public to increase its understanding of many healthcare providers to Think
report infected individuals to public health, the benefits and safety of vaccines is to Measles. We hope this is changing
and follow the proper post-exposure infection make sure healthcare providers have now. Our own daycare-associated out-
control protocols. the information they need to educate break of measles along with the larger
their patients. Numerous studies have multi-state outbreak should have been
Demian Christiansen, DSc, shown that a healthcare provider rec- a wake-up call.
MPH: Measles is one of the most ommendation for a vaccine increases Beyond that, however, public health
highly contagious diseases known, the likelihood of a patient accepting the needs to change with changing times.
and we are seeing what happens vaccine. Public health has and contin- The Internet, in general, and social
when just a small number of people are not ues to partner with healthcare provider media, in particular, have revolution-
vaccinated against this disease. To contain the organizations (e.g., American Academy ized the ways messages are created,
spread, each of us has a role, whether it is iden- of Pediatrics, American Academy of how they are packaged and deliv-
tifying cases and investigating them as quickly Family Physicians, American Nurses ered, and how they are consumed and
as possible, identifying exposed individuals Association) to make educational assimilated. Public health knows the
and notifying them, educating parents of well opportunities and materials available message is Get Vaccinated! We just
children to abide by recommended immuni- to their members. We know that the need to find the right way to deliver
zation schedulesall of these are required to MMR vaccine is safe and effective, so that message. We have much to learn
control outbreaks and prevent further spread. public health officials are committed from our marketing brethren! In some
It takes all of us, working in concert. to educating the public directly and cases, outraged parents delivered
through healthcare providers about the the message their own waytaking
Tammy Sylvester, RN, BSN: importance of vaccines and ensuring to social media and blogs, angry that
Measles is spread in communi- that residents have the opportunity to their children, some extremely ill,
ties that are missing herd immu- get the vaccines for themselves and may have been exposed to measles
nity.Herd immunity is when groups their children. because some chose not to vaccinate.
of people are vaccinated to protect the herd Many such exposures could have been
from rapid disease spread.In the cases of Demian Christiansen, easily avoided.
reported measles, the majority of people DSc, MPH: Public health
who got measles were unvaccinated.1 In fact must lavish health education Tammy Sylvester, RN,
an unvaccinated child is 35 times more likely and health literacy with the BSN: Public health took an
to contract measles as compared to a vacci- same attention and resources it pays to active role in educating the
nated child.3 Public health has issued multiple disease surveillance and control. We public about the importance
campaigns about herd immunity, the impact of can always do more to educate people of vaccines.People were very afraid
disease, and the need to vaccinate on the local, about the importance of vaccinations. of autism because of the false reports
state, national, and international level. Much But we have an uphill climb. The stark by Andrew Wakefield stating an asso-
work was done in every city to notify the public reduction in measles cases beginning ciation between autism and MMR [vac-
and providers about the outbreak, as well as in the mid- to late-1960s was, in some cines].This was a very difficult barrier
to provide algorithms and contact information ways, a victim of its own success. In to overcome and not much more could
for consultation on suspected cases.Public our recent measles outbreak associ- have been done at the time. Public
health provided fliers for healthcare facilities ated with a daycare, we had several health, especially the CDC, worked very
that warn of the outbreak and to tell individuals children with fever and rash illness hard to study the claims and were able
with rash not to enter a healthcare facility or who were misdiagnosed. This is not to to show that no association between the
waiting room.FAQs were issued to clinicians lay blame at the feet of those healthcare two existed.
to give information about the outbreak.

66 | Summer 2015 | Prevention

Q: What did the U.S. do correctly to eliminate measles in the
past and what can we use to do the same now?

Q: What are the plans to

eradicate measles?
Chicago Department
of Public Health: After
Demian Christiansen, DSc,
MPH: Vaccinate, of course!
the first measles vaccine was licensed We have an excellent, safe, and
in the 1960s, there was a dramatic effective vaccine to prevent
Chicago decrease in the number of cases. Prior measles. A single dose of measles vaccine,
Department of to that, there was a very high prevalence usually given as MMR vaccine provides
Public Health: Measles remains of measles cases in the U.S. Furthermore, 93 percent protection against measles.
prevalent in many parts of the world. once a second dose of vaccine was rec- Getting the recommended two doses of
In order to fully eradicate measles, ommended in the 1980s, the number of MMR brings that level of protection up to
the vaccine needs to be made avail- cases continued to drop even further to 97 percent. Vaccination against measles
able in places where healthcare the point that endemic transmission in results in lives saved and avoids perma-
systems are underdeveloped or do the U.S. ended in 2000. nent disability. In 2014, CDC estimated that
not have the means to obtain the among children born during the past 20
vaccine. Current global efforts to years, vaccinations, including MMR vac-
eradicate polio are nearing success, cine, prevented 21 million hospitalizations
and those same core public health and prevented 732,000 deaths.4 Thats the
approaches can be applied to elimi- equivalent of preventing a child from being
nating other vaccine-preventable ill- hospitalized every 30 seconds. Thats an
nesses like measles. amazing success story.

Demian Christiansen,
DSc, MPH: No doubt,
Should the MMR vaccine be mandated for children to
local and state health
start school?
departments along with
CDC will bring the multistate mea- Chicago Department of Public Health: School vaccine require-
sles outbreak under control in short ments contributed to the high levels of vaccine coverage that have
order, if they havent already. But as been achieved among school-aged children. They are regulated at the state level
everyone knows, we live in an inter- and as a result, vary from state to state. Some states allow individuals to opt out of
connected world. Truly, nothing in the required vaccines if they have a personal belief or religious belief that prohibits
recent memory has demonstrated receipt of the vaccine. In Illinois, the MMR vaccine is required for students who attend
this more clearly than the Ebola daycare centers, preschools, elementary, middle, and high schools, and religious
Virus Disease epidemic affecting and medical exemptions are allowed. The MMR vaccine is still required for most
West Africa. As we have seen, any individuals who attend daycare or school and do not have underlying medical condi-
disease can be on our doorstep in tions that would prevent them from receiving the vaccine. Because there is a small
a matter of hours. It simply isnt pos- percentage of individuals who cannot receive the vaccine, it is important for those
sible to ignore what is going on else- who can receive it to do so. This concept of community immunity helps protect those
where in the world. Several years who are more vulnerable to illness.
ago, the theme for World TB Day was,
TB Anywhere is TB Everywhere. Demian Christiansen, DSc, MPH: MMR vaccine is mandated by all
This certainly applies to measles and states for children to start school. However, we know that there are gaps
countless other infectious diseases. when individuals, or groups of individuals, opt out for religious or philo-
For measles to be eradicated, we sophical reasons. There are several states looking to tighten requirements
need to ensure it is eliminated here for parents who seek exemptions. The Illinois General Assembly voted on such a bill.
in the U.S.and everywhere else Ultimately, though, everyone must understand that when it comes to vaccinations,
around the world. Measles eradi- what each individual does affects the groupfor better or for worse.
cation will take a worldwide effort
and political and economic will not Tammy Sylvester, RN, BSN: It is.The problem is the ease to which
dissimilar from those required to exemptions are facilitated.Some schools are passing rules to only allow
eradicate smallpox. physical exemptions documented by the primary care provider.Others
are allowing religious exemptions if signed by a pastor and requiring
parent to go to corporate district office to pick up exemption forms.The thought is
that when it is more difficult to be exempt than to go get immunized, only the ones
that really need to be exempted will go through the work.

w w | 67
ost parents turn to the Internet for
information. What can be done to Q: How can infection preventionists assist in
the eradication of measles?
educate this population about the use
of credible websites?
Chicago Department of Public Health: Public
health professionals work closely with infection
Chicago Department of Public
control practitioners in healthcare settings to report commu-
Health: Healthcare providers and public
nicable diseases, identify individuals who were exposed to
health professionals rely on evidence-based guidelines
infectious patients, and implement protocols that help prevent
to educate patients and families about healthcare-related
transmission when patients with communicable diseases seek
concerns. Although there are websites that do rely on sci-
and receive care. These efforts are ongoing to ensure that indi-
ence-based medicine, many others that are easily acces-
viduals who are ill receive the proper care, but also that others
sible do not use these same evidence-based guidelines.
in healthcare settings are protected as well.
The best thing parents can do if they have questions about
a certain healthcare issue is to contact their provider. Those
Demian Christiansen, DSc, MPH: Infection pre-
who do not have a provider should reach out to their local
ventionists are the closest partners we have in com-
public health department, many of which have vaccine
municable disease control. Their everyday work is
programs for those who are uninsured or underinsured.
geared toward preventing the spread of communicable
diseases, which is obviously a goal we share. Together, we work
Demian Christiansen, DSc, MPH: This
every day to eradicate diseases. But we cannot do it alone. We
is crucial, and once again, this is an issue of
need to continue emphasizing vaccinations and being creative
health education and health literacy, impor-
in the messaging. Debunking myths about lack of vaccine safety
tant themes in communicable disease control.
and educating the public with culturally sensitive and linguisti-
Credibility is key, but for a website to be useful, it must
cally appropriate language is key.
be well-organized, quick, and it must make technical
information accessible to parents. At the end of the day,
Tammy Sylvester, RN, BSN: Quick reporting of
we tend to listen to those we trust; healthcare providers,
suspect cases (e.g., phone calls to local public health),
especially nurses, have a vital role in providing credible
protocols in place for rash illnesses, and continued
and trustworthy information to their patients. It starts with
close working relationships with local public health.It
educating ourselves first so we can direct our patients and
takes a team, and we all want the same thing: optimal community
the public to the right resources.
and patient outcomes!

Note from the editor: APIC thanks Mary L. Fornek RN, BSN, MBA, CIC, head of Kenrof IC Consulting and Prevention Strategist editorial
panel member, for developing the questions for this article.
1. Centers for Disease Control and Prevention (2015). Measles Cases and Outbreaks. Accessed April 24, 2015. Retrieved from:
2. McLean, H. (2012). Measles United States, 2011. CDC Morbidity and Mortality Weekly Report 61(15), 253-257. Retrieved from:
3. Vara, C. (2013) Explaining measles outbreaks despite high vaccination status. Shot of Prevention. Retrieved from:
4. Centers for Disease Control and Prevention (2014). Report shows 20-year US immunization program spares millions of children from diseases. Accessed April 10, 2015. Retrieved from:

Read more about measles

Learn more at the APIC in the American Journal of
Infection Control
2015 Annual Conference
Measles in health-care settings, Maltezou, Helena C. et al., American Journal of
Attend these measles-related sessions Infection Control, Volume 41, Issue 7, 661-663.
at APIC 2015, June 2729 in Nashville, Measles investigation: A moving target, Helmecke, Megan R. et al., American
Tennessee. Journal of Infection Control, Volume 42, Issue 8, 911-915.
3402California Measles Outbreak:
Impact of a Measles Exposure in an Emergency Department, ODonnell, Anna
Epidemiology and Public Health
et al., American Journal of Infection Control, Volume 38, Issue 5, e41-e42.
Response, December 2014April 2015.
021Measles Emergency Response: Measles and pertussis outbreaks: Animportant role for travel clinics, Rapose,
Lessons Learned from a Measles Alwyn, American Journal of Infection Control, Volume 41, Issue 11, 1140.
Exposure in an 800-bed Facility. Measles Outbreak Management at a Minnesota Childrens Hospital in 2011,
LeBlanc, Julie et al., American Journal of Infection Control, Volume 40, Issue 5, e67.

68 | Summer 2015 | Prevention



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