Meet our 2003 Educator of the Year
By Kelly M. Pyrek
Independent infection control consultant Linda L. Spaulding, RN, CIC, likens her job to that of a detective, tracking down the clues that will help her solve a client's contagious conundrum. As Infection Control Today magazine's 2003 Educator of the Year, Spaulding demonstrates her ability to answer the questions of who, what, when, where and why of an infectious outbreak and to solve the mystery. Sometimes the revelation doesn't come until the very end of the case, but that's part of the investigative chase.
"It's quite an adventure to never really know the ending until all the clues are in," she says. "Each case is different, adding to your detective knowledge base. The more you learn the faster you are able to answer the 5Ws."
As owner of InCo & Associates, founded in 1994 and based in Waipahu, Hawaii, Spaulding provides extensive consultation and education in infection control issues such as employee health, total quality improvement specific to infection control, compliance with state and federal regulations, training for facility inspection by the health department, Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and the Occupational Safety and Health Administration (OSHA), as well as lecturing on a variety of topics such as resistant organisms, surveillance, TB, latex allergies, hepatitis, bloodborne pathogens and isolation protocol. But one of her favorite services is outbreak investigation, where she confirms the outbreak, identifies the etiology, collects data, implements and evaluates control measures and presents her findings and recommendations to clients. Her hit-list of outbreak offenders reads like a microbiology textbook: vancomycin-resistant enterococcus (VRE), methicillin-resistant Staphylococcus aureus (MRSA), influenza and scabies, but one of her most interesting foes was the Norwalk Virus, which she says is normally not seen in Hawaii and was only one of three such outbreaks in the state's history.
"The facility reported five cases of patients presenting with diarrhea, nausea and vomiting, with all patients located on one unit," she recalls. "Staff also became ill with the same symptoms. I asked the facility to implement contact precautions for all patients with the addition of the staff using masks. I could not understand if the staff was following standard precautions, why they were coming down with the same symptoms. After meeting with management we started to think foodborne illness so I went through the kitchen but came up empty. The decision was made not to float staff to that unit and not to admit any new patients. After obtaining stool cultures and reviewing the literature the only thing that made sense was Norwalk-like Virus. The cultures confirmed this diagnosis five days later. The staff became ill because they didn't think they had to wear a mask; they thought standard precautions should have been enough. What the staff did not understand was that with Norwalk-like Virus, when you change the bed sheets the virus becomes airborne, and the staff became ill because they did not wear masks. It is thought a visitor brought in contaminated food for a loved one. That one resident became ill and because it became airborne, a total of about 20 patients and six staff were affected."
Spaulding also has learned that even outbreaks of the most routine virus can pose significant challenges.
"I was called to a facility because it had residents with high fevers and cold symptoms, and four residents were very sick. I arrived at the facility at 11 a.m., just two hours after the call, and the number of sick patients was now 12. I suspected it was a viral infection (possibly influenza) due to the fast transmission throughout the facility. Bacterial infections take a few days to a week to spread, and it was obvious this illness was spreading within minutes to hours. By 3 p.m., we had 42 sick residents. We immediately stopped all visitors from entering the facility, all staff was required to wear masks and all admissions were put on hold. The department of health (DOH) requested we do influenza cultures. Because the illness was so severe and spreading so rapidly I was concerned we were dealing with something we had not seen before."
"I have investigated many flu outbreaks but this one was worse than any I had seen before. We decided to place all employees and residents on amantidine. In a situation such as this the first 48 hours is crucial in stopping an outbreak situation. The facility was not licensed to give IV fluids so the challenge was to get enough fluids into feverish residents without an IV. Because we did not know what illness we were dealing with we were reluctant to transfer anyone out of the facility. As some residents became sicker we sent five residents to a local emergency room for IV hydration. After the second dose of amantidine was administered, we saw some improvement. Within a week the DOH confirmed it was A:Sydney, an influenza from Australia that had not been seen before in the United States. Even though A:Sydney was the flu for the influenza season, no community cases were reported again until early November. We gained a new respect for influenza and need for annual influenza vaccinations."
Spaulding's experience with this outbreak landed her in the media spotlight, conducting interviews with local TV news and The Wall Street Journal, and just this year, Spaulding was the principle investigator of antibiotic-resistant E. coli, the first time this organism has been identified in the United States.
Her detective role aside, Spaulding says her other true love is teaching and providing inservice programs. "Seeing the light bulb turn on for the participants is a wonderful thing," she says. "Being an educator allows me to learn something new every day, from the research I do, to the people I meet, to the places I have traveled to teach or consult."
From her early healthcare experience as a nursing assistant in her hometown of Conneaut, Ohio, to later years as an LPN and RN, Spaulding grew in her respect for the healthcare profession and her desire to help others. She has worked as a staff nurse on a medical surgical unit, as a crisis nurse handling as many as half a dozen traumas or cardiac arrests daily, and as a manager of a busy medical/surgical ICU. Prior to specializing in infection control she was the nurse manager of a telemetry/transplant unit.
"After assisting in surgery with my first heart transplant patient I made a decision to gain more experience in infection control. One of the biggest issues with transplant patients is the prevention of nosocomial infections, so when a position opened up in the infection control department, I jumped at the chance to expand my knowledge. It was one of the best moves I ever made."
Her clients agree. Jay Duquette, administrator of Maluhia Hospital, nominated Spaulding for the Educator of the Year award because of her exceptional educational programs and her ability to problem-solve. "We had a problem with Dengue fever and her educational program on this subject was so good she lectured on it around the state for the department of health. She then was asked to go to Japan to present the same program."
Among numerous other clients, Spaulding serves as the infection control consultant to Maluhia Hospital in Honolulu as well as to the Hawaii Health Systems Corporation, which runs state hospitals primarily in rural areas.
"Linda's knowledge as an educator is phenomenal" Duquette adds. "The combination of her intelligence and her complete understanding of the whole realm of infection control makes her a stand-out. People really like her and even if we have an infection control issue, we're more than happy to have Linda come in and manage it for us. Obviously, we don't like to see her that often because that means there's a problem, but it is reassuring when she does show up. We look forward to hearing what she has to say and we take her advice."
Spaulding says that the most challenging aspect of her work is communicating to her clients about why infection control principles and practices are so critical, especially when she and facility management may be at odds as to what makes sense from an infection control standpoint. "Infection control is not a money generator for any facility so most of the time it's a last priority," she says. "One of my biggest challenges is to help facilities understand even though infection control may not make money, when it's set up properly, it can generate large savings in the form of reducing length of stay because an infection was averted, or a savings in buying the right supplies or equipment and a reduction of risk to personnel."
Being able to pass along the most up-to-date information recommendations to her clients is essential, so Spaulding keeps her skills current by attending educational conferences, including the Association for Professionals in Infection Control and Epidemiology (APIC). She says she stays in close contact with the Centers for Disease Control and Prevention (CDC) and subscribes to numerous infection control publications. She says she surfs the Internet to find new guidelines and newly published regulations and utilizes the local educational branch of OSHA. She also stays in touch with other infection control practitioners across the country and believes being an active member of professional organizations is a way to stay sharp.
"If I am dealing with a complicated problem for the first time, my professional organizations afford me the opportunity to ask for other professionals' opinions," she says. "I can talk to infection control practitioners (ICPs) locally or around the world and receive the information I need. If I have a difficult outbreak investigation, I can call the local epidemiologist or the CDC for advice and guidance. The ability to network is extremely important if you want your job to be easier, and serving on various boards helps me grow and gain more knowledge that I share with my clients and participants in my educational programs. I often learn of better, easier ways to provide education and services."
Spaulding has been active in APIC since 1992, having served on various committees and a member of the board of directors from 1997 to 2002 and served as chapter president from 1999 to 2001. She also is active in the Hawaiian Island Chapter of the American Association for Critical Care Nurses, serving on the program, audit and marketing committees. Her participation in these organizations parallels the 50-plus professional courses she has taken on everything from immunizations to epidemiology to disinfection and sterilization and a host of emerging infectious diseases. She is a sought-after lecturer, having presented more than 20 infection control-related programs in the last few years and has participated in the development of island-wide conferences in conjunction with APIC, OSHA and JCAHO, addressing topics such as bioterrorism, latex allergies, outbreaks, benchmarking and occupational exposure. She also has written extensive infection control manuals and infection control education training programs for InCo and Associates and ICP Associates Publishers.
She says she loves bringing back knowledge from conferences that she can share with clients and adds that her educational style is variable, depending on the client's needs or the type of educational program needed. "I experiment with many types of educational styles," she says. "I love working with the computer and generating computer-based education programs and e-learning programs. Many healthcare workers (HCWs) are unfamiliar with the computer so I will do lecture sessions, competency sessions, self-teaching modules and role-playing. If I'm lecturing to a group that does not read or write then I will prepare more interactive demonstration programs and won't use slides and handouts. It depends on the learner's need and the overall goals of the course. Flexibility is key; know your audience and give them what they need to do their job today, in a way they can understand."
One topic requiring continual education is compliance with handwashing and aseptic technique. "Teaching staff is the easy part of the job; ensuring compliance is extremely difficult," Spaulding says. "Every year during department of health visits to healthcare facilities there are citations because staff are observed not washing their hands between patient contacts. All infection control practitioners deal with this problem. One of the best teaching tools I've used in stressing the importance of handwashing is the Glow Germ ultraviolet light. Often people need to have something visual in order to understand how important handwashing is when it comes to preventing infections. There is a saying in nursing, "If it's not documented, it's not done," and in the case of pathogens, people often believe if you can't see it it's not there. Even though aseptic technique is taught in nursing school what I find from an infection control standpoint is that many HCWs think they are saving money for the facility by cutting corners when it comes to aseptic technique. There are times when clean technique takes the place of sterile technique. It's an ongoing issue to monitor and ICPs across the country struggle with this."
Spaulding uses a variety of teaching techniques depending on the audience and topic upon which she is presenting. "My belief is that the more the learner has to participate in the learning process the more they will learn and retain. I enjoy using games and crossword puzzles. A mentor of mine, Gail Bennett from Rome, Ga., and I have written more than 30 infection control education programs that we market on my Web site. We felt that by putting together Powerpoint education programs with lectures it would give other ICPs an opportunity to present their inservices to staff without having to spend hours preparing a lecture and handouts. The programs that I have developed for a company in Japan were converted into interactive, animated programs utilizing a computer program called Flash that enables the participant to view a movie-like presentation while having the lecture read to them in their own language. Gail and I have been working with Clearstone Health Training to develop e-learning programs in infection control and other topics needed in the long-term care and acute-care arenas.
Spaulding describes her philosophy toward educating as, "Don't teach it if you don't know the subject. I had a boss that wanted me to teach a cardiac lecture. I didn't know the subject very well but she told me to read a particular article and I could then teach it. That's an example of someone who really doesn't understand what it means to educate. I could reiterate in a lecture what I read in the article but that would not be educating the audience. To educate, I must provide as much experiential learning as possible. I don't pretend to know 100 percent of any topic I teach but as an ICP for many years I come with lots of on-the-job experience and I'm passionate about sharing this to help others learn. My best advice to new educators is know your audience, know where to look for educational resources, know what is important to teach and most importantly know when to say 'I don't know.'"
Having occasion to review numerous facilities' infection control programs, Spaulding says one of the most fundamental elements of a good program is using good epidemiologic science to prevent adverse outcomes in patients and reduce the number of nosocomial infections. "We must always practice high-quality science even when rigid laws, rules and regulations are not always based on proven infection control strategies. It is imperative that ICPs keep up to date with the literature and know about new resources being developed because this is the only way we will obtain new knowledge and protect our patients from nosocomial infections that may lead to negative outcomes."
Being in the business of advising, guiding and teaching, the one piece of advice Spaulding imparts to other ICPs would be to "love what you do." She adds, "Ask yourself each morning, 'What can I learn today to make the facility safer for just one patient instead of what problems do I have to deal with today?' Every problem we deal with on a daily basis will teach us something. Look at what you're being taught, not that you have to deal with one more problem."
2003 Educator of the Year First Runner-Up
Deborah Hirsch-Temple, MA, RN, has 29 years of experience ranging from ICU, ER, recruitment and infection control. She holds a diploma in nursing from Kings County Hospital in Brooklyn, N.Y., a bachelor's degree in nursing from Long Island University and a master's degree in nursing administration from New York University. She also was in the last 1200 G Infection Control Training class at the CDC. She has worked in infection control for nine years and is the infection control manager for three hospitals in the Veterans Administration New York Harbor Healthcare System.
"I enjoy my work because it is fulfilling in so many ways," Hirsch-Temple says. "I am an advocate to patients and a resource to staff. I have the Executive Office's total support to identify and correct infection controls issues and make patient care safer within the Harbor, making my job easier and more enjoyable."
An APIC member and a member of the board for the local chapter through 2004, Hirsch-Temple also co-chairs numerous professional committees and boards, has planned infection control symposiums, participated in JCAHO training videos and has presented at medical conferences. She conducts weekly infection control rounds on three hospital campuses and keeps her skills current by actively participating in professional organizations and local and national seminars.
"I try to get people to enjoy what they are learning whether in the context of a formal presentation, daily rounds or inservices. I use pictures or video clips in my presentations as much as possible and encourage audience participation. The challenges of teaching staff and ensuring compliance are an everyday thing for me and for our nurses. While doing surveillance, we are always looking for breaches in technique. We then take the time to teach employees one on one."
Hirsch-Temple has become proficient in bioterrorism-related topics, swinging into high gear after the Sept. 11 terrorist attacks when she joined the system's emergency management committee and collaborated with others to create decontamination policies and procedures. She created an anthrax response team to investigate suspicious instances of white powder throughout the hospital and developed algorithms for treating patients with exposures to suspicious powders that was shared with hospitals through New York City and the VAMCs nationally. She also developed a patient health education pamphlet on anthrax and smallpox. She launched an environmental surveillance program for the mailroom and its employees to prevent occupational exposure to potentially contaminated mail, and became a member of the Bioterrorism Taskforce and actively worked with this interdisciplinary group to develop policies and procedures for the evaluation and treatment of casualties resulting from agents of biological terrorism.
"Debbie has vast amounts of infection control knowledge, is committed to excellence in nursing and is a steadfast supporter of her colleagues, but perhaps her greatest strength is a combination of her communication skills and highly effective educational practices," says nominator Elvira Miller, EdD, RN. "She is very adept at explaining infection control practices and policies, getting staff to understand their importance and gaining their support in making necessary changes, even when this means changing the status quo."
2003 Educator of the Year Second Runner-up
Rebecca Kjonegaard, RN, CIC, is the infection control practitioner for Grossmont Hospital, in the Sharp Healthcare System in San Diego County, where she was named Nurse of the Year in 1997. She has worked as a staff developer, cardiovascular case manager, senior staff nurse, preceptor and trauma nurse for 13 years, and has worked in infection control for the past five years. She served on Grossmont Hospital's Clinical Practice Committee and was the assistant coordinator of The Critical Care Monitor. She is an active member of numerous professional organizations, including APIC and the American Association of Critical Care Nurses. She also has served on the case management committee and the staff development system-wide committee for Sharp Healthcare.
Maryann Cone, chief nurse officer at Grossmont Hospital, makes no bones about why she nominated Kjonegaard: "Rebecca is the best infection control manager I have ever worked with. She is an excellent practitioner and a tremendous communicator. She is committed to her job and is always the first person to take charge. Rebecca makes everything a learning experience and an opportunity for growth. She is always ready to show others a better way of doing things but she is never a know-it-all. She has a tremendous amount of knowledge she willingly shares with others, using her experience and knowledge to impart her expertise to others, always in a quest for improvement."
For more details about our winners, log on to www.infectioncontroltoday.com
2003 EDUCATOR OF THE YEAR AWARD PROGRAM SPONSORS
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