It’s been a rough ride for nurses, infection preventionists, and other frontline healthcare workers ever since the coronavirus disease 2019 (COVID-19) began. “Until we can see the light at the end of the tunnel, it’s very crucial that we look out for one another and make sure we address our mental health and emotional needs,” Ernest Grant, PhD, the president of the American Nurses Association tells 

. Grant, the first man to hold that position, has a long history of rising to face the challenges of the moment. In 2002, President George W. Bush presented Grant with a Nurse of the Year Award. Grant received that distinction because of his work treating burn victims at the World Trade Center site after the 9/11 attacks. That’s just one of many of Grant’s accomplishments. He tells 

 of the challenges that nurses and infection preventionists have overcome during the pandemic, and what hurdles may still lie in store.

Has the COVID-19 pandemic changed the way nurses and infection preventionists do their jobs?

Absolutely. It’s changed the way nurses have begun to not only view their jobs, but also how they take care of patients. And, also, the profession itself is will be changed once this crisis is over as a result of COVID-19 in a number of ways.

The first thing we’re noticing is, obviously, the preparedness for when a pandemic such as this comes along. One of the things that we’re anticipating is that COVID-19 is just the latest of perhaps future and more frequently occurring pandemics. So being prepared for future pandemics is very high on the list. The other, of course, is the way that we will be prepared to provide care for the patients, also. One of the things that COVID has taught us is that not only with using PPEs and things of that sort, but also just modifying teamwork. Going in and caring for the very critically ill patient. And it’s having quite an emotional toll on nurses who are seeing so many deaths per shift. If you’re working a 12-hour shift, there’s a possibility that you may see anywhere from six to maybe 16 deaths occurring on your unit because of how critical the patients are. And that within itself creates quite a problem for the patients.

One of the most heartbreaking things about this pandemic is that so often people have to die alone without family members present. Often the only one in the room at the end of a life is the nurse.

Absolutely, the nurse is playing two roles, if you will. And that’s another aspect that has changed is that you’re also being the family member. You’re there either holding an iPad, so that the family member can view the patient, or the patient can communicate with the family member. You’re keeping them updated on their progress. Whereas, in the traditional method, I guess, air quotes there, the family member would be there in the room and be able to actually visualize what it is that you’re doing and how the patient is progressing. You have to set aside that special time several times a shift, I’m sure, to contact family members and give a progress report. And of course, that’s time that you’re having to take away from the patient. But that is still critically important because that family member, their encouragement, words that they can send to the patient, also helps to determine whether or not this patient is going to recover or not, or give them the incentive to want to go on and have a speedy recovery.

As I mentioned, a lot of my readers are infections preventionists and a lot of them have nursing backgrounds. How does a nursing background feed into the job of infection prevention?

Well, as nurses, we’re taught to look at the whole body, as well as the environment and we take that information and also try to personalize that, if you will, for the patients that we’re caring for. We try to get some idea of: How was this patient before this illness struck? And what are some things that we can design the plan of care for this person that is unique to them Even though the person in the next bed may have the exact same illnesses, and etc., they’re going to be treated differently because of who they are and their life’s experience. So, in a way, as a nurse, and as an infection control person, you’re sort of playing the detective, so to speak. And by doing that, then we can obviously be prepared to highlight our care for that one specific patient that is going to help them to get over that particular hump. So, taking in the environment, knowing that they may have got infected perhaps attending maybe a birthday party or being out in a very heavy crowd, or things of that sort. Those are some things that are going to also help to drive their care and help us to get a better picture of who it is that we’re caring for and what can we plan that’s going to be the best for them.

Infection preventionists also have to look after their healthcare colleagues. Does a nursing background help with that?

Oh, absolutely. One of the things you have to think about is someone may be in a patient’s room for several hours doing various nursing duties and tasks. You want to make certain that this person at least gets some sort of relief so that they’re not overwhelmed, or taxed. So we have to look out for one another, and look for those little subtle signs that this person may need to have a tap on the shoulder and say, “You know, why don’t you take a time out? Go have a bathroom break. Go have a Coke or get some lunch or something like that, while I watch the patient for you.” Because it can be very, very, very demanding. You’ve got a lot of technology equipment that you’re dealing with that is helping you to take care of this patient. You’ve got to interpret all that data. And, of course, be prepared to present that to our physician colleagues or our advanced practice nurses who may be helping to care for those patients as well. And so that you’re ensuring that the patient is getting the optimal care. Failure to do that, obviously, you’re going to have a nurse who is very tired. And studies have shown that when we’re tired, there’s the increased chance of the possibility of errors happening. We want to minimize that as best as we can. By recognizing that: Yes, this person needs some time out. They perhaps need to have a mental health day or refer them to some mental health resources. Because keep in mind, this crisis has been with us now for about eight months, and we don’t know where it’s going to end. Most crisis or disasters, usually we know that they’re going to end in about 24 to 48 hours or so. Everybody comes in, they triage and then go. Here, we don’t know when this is going to end, even though there’s promise of vaccines down the road. That still doesn’t mean that this crisis is going to be over. Until we can see the light at the end of the tunnel, it’s very crucial that we look out for one another and make sure we address our mental health and emotional needs.

When the COVID-19 vaccine comes along, do you think that getting vaccination should be a condition of employment for nurses?

That’s a very tough question. But obviously, it probably will be. I do know that in the majority of the healthcare institutions around the country, the flu vaccine is a 

 for healthcare personnel, unless there is some religious objection, or some other reason that they cannot take that. So, yes, I would say that it probably is going to be part of a requirement for employment, that that person gets that unless there’s some other reasonable objection that they may have.

What are some of the main hurdles to caring for COVID-19 patients these days?

You know, back in March and April, it seems like every day we were learning something new about the virus. So obviously, the questions surrounding those and also the policies and/or procedures, if you will, of providing the care to the patient will change as well. And in some cases, some of the questions have not changed. We’re still hearing from nurses that are on the frontline that there’s still a lack of PPE—personal protective equipment—particularly the N95 mask that is so desperately needed. We are working with the COVID-19 Task Force and other areas of the federal government to ensure that the supply chain is kept up to date so that the desperately needed supplies and other pieces of equipment are gotten to the places where they need to be. So that, again, life can be a little bit easier for those frontline workers. Patients will be on the ventilator. They would just be on their backs. Now we’re finding that they have better results turning the patients on their stomachs. Different medications that we may try. Steroids as well as the remdesivir helps quite a lot with the recovery. And so, again, as those are done, your nursing care is going to change as well. Because, obviously, as the patients are getting these medications, you need to be on the lookout for any particular potential challenges that they may have. Is the person having an allergic reaction to that and the sooner we’re able to catch it, the better, it’s going to be. Also, obviously, from an infection control standpoint, again, just making certain that everyone that goes into the room, that they’re properly gowned, masked and gloved and wearing the correct equipment. And then, also, when they step out of the room, that they take the equipment off in the correct order so that you don’t run the risk of spreading the virus to your colleagues, or worse yet, potentially taking it home to family members.

What do you see as the main challenge going forward for nurses?

I think the main challenge going forward is the fact that, again, not knowing when this crisis is going to end. And nurses still having to face just so much death day in and day out on their shifts. The potential mental anguish that this is going to cause. And they’re not seeking the appropriate assistance that is offered to help deal with that. We are great at caring for patients, and others, but sometimes when it comes to caring for ourselves, we always put ourselves last. And in this case, the frontline workers need to recognize that it’s important that they take care of themselves first. Because you’ve got to operate at your optimum in order to take care of all the challenges that are going to come along. You’re not going to be very beneficial if you yourself are not up to par.

Any final words of advice for either nurses or infection preventionists?

Well, I would say for the nurses and all the frontline workers, thank you for all that you’re doing day in and day out. We will continue to advocate on your behalf, with trying to ensure that you get the proper equipment and such that you need. And for the infection preventionist as well, or infection control folks. Again, it’s extremely important that we continue to study this virus and make changes to our standard of care or standards of practice accordingly as we find out new information and get that education out there as soon as we possibly can.

This interview has been edited for length and clarity.

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Ernest Grant, PhD:  “Until we can see the light at the end of the tunnel, it’s very crucial that we look out for one another and make sure we address our mental health and emotional needs.”

Frontline Healthcare Workers Must Care for Themselves

As with every other holiday we’ve celebrated in 2020, Halloween will be held under the long shadow cast by coronavirus disease 2019 (COVID-19). Without much fanfare, and with little notice by the media, the US Centers for Disease Control and Prevention (CDC) issued 

 for Halloween and other upcoming holidays on September 21. Those holidays include:

These recommendations contain many important lessons both for Halloween and how we should be living our lives in general. The first is that these detailed recommendations are what CDC recommendations should look like. When generated in a free and unhindered environment, they can provide truly helpful examples and advisements. I only wish this amount of detail were available for all other types of venues, including schools, restaurants, and other high-risk areas.

Second, is that the virus is airborne. In two different areas the CDC describes a “Moderate Risk” activity as a person being outdoors, wearing masks and more than six feet apart. This would include costume parties. But “if screaming will likely occur, greater distancing is advised. The greater the distance, the lower the risk of spreading a respiratory virus.” Screaming will aerosolize the virus and being at a greater distance is necessary since the virus can spread much further, even outdoors.

Other “Moderate Risk” activities would include walks through haunted forests, and outdoor Halloween movies. You do not need to have a degree in epidemiology to generalize these recommendations to outdoor funerals, protests, demonstrations, political rallies and realize these would be “Moderate Risk” activities. And only if participants stayed 6 feet apart and wore masks. If they did not, then the risk would of course be higher.

High risk indoor events include haunted houses, where crowding and screaming are factors. One must also realize that similar venues such as indoor movies, funerals and political rallies would also be at high risk for spread, since loud vocalization often occurs which would be expected to aerosolize the virus.

One way to go about trick-or treating is with preset up individual wrapped goodie bags to grab-and-go, according to the CDC’s “Moderate Risk” activity guideline. I can see little difference between a grab-and-go goodie bag, and a grab and pay for bag of M&Ms you obtain from a grocery store shelf. Viral contamination is possible. Catching the virus from items you buy is not as likely as getting it from the air, but it can probably still occur. You should take precautions of cleaning the items and washing your hands before use.

Most importantly, traditional trick or treating is viewed as a high-risk-activity. Of course, we all knew Halloween would be problematic. An important caveat for Halloween is not to use your Halloween mask to prevent the spread of coronavirus. It will offer very little protection at best. The CDC also advises not to wear your Halloween mask and viral blocking mask at the same time, since it may not be safe.

Activities which are good to do and a low risk are: Carving pumpkins with your family, a family movie night, decorating your house, a virtual Halloween costume contest and a Halloween scavenger hunt with your family.

These advisements not only detail needed changes for Halloween but also for many different venues. The virus does not care where it is, its behavior will be the same. Applying them to the opening of schools is of utmost importance. In schools, social distancing, wearing of masks, hand hygiene and pristine air quality is of utmost importance. Air should be sanitized with complete air exchanges at least 6 to 10 times an hour. Similar steps need to be taken for other retail establishments.

We need to follow public health advice and learn to safely live with this virus until a vaccine or effective treatment has been developed.

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The real impact of these regs are what they mean for aerosolization, outdoor gatherings of any type and food handling practices.

Trick or Treat … or COVID-19?

As we enter an influenza season that might be complicated by not only the presence of coronavirus disease 2019 (COVID-19) but also a possible vaccination for COVID the question arises: Will mandatory vaccination for healthcare workers be necessary?

,that look at compliance with flu vaccination, answer that question with an emphatic “Yes!” One study looks at what happened at a large healthcare institution in the Midwest—BJC Healthcare in St. Louis—that made employment for healthcare personnel contingent on them getting the flu vaccine. The other looks at what’s going on in a hospital in Switzerland in which getting the flu vaccine isn’t mandatory. One is a success story; the other, not so much.

BJC Healthcare implemented a mandatory flu vaccination policy during the 2008-2009 flu season. Before the policy, about 70% of healthcare workers were vaccinated, according to the 

. After the policy’s implementation, that immediately jumped to 98.4% the subsequent year and remained above the 97% level during the next 9 years.

In the meantime, religious and medical exemptions from getting vaccinated decreased at the healthcare system’s academic medical systems and remained the same at the community hospitals that it owns. In addition, employees began to get the flu vaccine earlier in the flu season and employee opposition to the mandatory policy hasn’t grown since it started.

“Implementation of a mandatory influenza vaccination policy has produced sustained increases in staff vaccination coverage that greatly exceeded immunization coverage produced by alternative approaches to encourage and promote vaccination,” write the BJC investigators. “Implementation of a mandatory vaccination policy has allowed the organization to exceed the 2020 national objective for healthcare personnel immunization coverage during 10 influenza seasons.”

 conducted at the University Hospital Basel, Switzerland were underwhelming, as the Swiss investigators note. They’re thinking of making healthcare worker employment contingent on getting a flu vaccine.

“Mandatory influenza vaccination of HCWs was introduced in the United States a decade ago with excellent results, improving vaccination rates to more than 90%,” the Swiss study states. “Both administrative and attitudinal barriers to vaccination need to be addressed prior to such policy change. The right of self-determination was one of the most important reasons for non-vaccination in our study pointing to the challenges ahead prior to the introduction of a mandatory influenza-vaccination policy.”

The Swiss investigators surveyed 1454 healthcare workers (HCW) from 2007 to 2019, finding a range for vaccinations in those years from 14.7% to 31%. The study states that that 31% demonstrates that far too few HCWs get the flu vaccine, but it actually represents a minor success in terms of the study’s goals. That was the rate of HCWs at the hospital who got the vaccine for the 2013/2014 flu season. The rate for the prior flu season was 14.7%.

Investigators launched an all-out campaign to encourage more HCWs to get the vaccine, with the goal of reaching at least 30%. So, in that sense, the campaign was successful. Still, a “vaccine uptake of 31% is still unacceptably low, given that 25% of HCW are infected with influenza each year,” the Switzerland study states. And when HCWs are infected, they can pass that infection on to patients. In the following seasons, HCW vaccination rates remained stable, ranging from 26% to 28%.

During the 2013/2014 flu vaccination campaign, the Swiss hospital offered free vaccinations that were easily accessible to all employees, as well as educational lectures and handouts that addressed misconceptions about the flu vaccine. In addition, peers and role models at the hospital also tried to raise awareness of the importance of compliance.

The reasons for not being vaccinated were compared between 4 different groups: nurses, physicians, and HCWs other than physicians or nurses with or without patient contact.

Eighteen-point-eight percent of HCWs surveyed said that they had had negative experiences with the flu vaccine, mainly related to side effects. Then came perceived vaccine failure (55.8%), the lack of vaccine availability (5%). The side effects that were reported included pain at the puncture site (9.8%), muscular pain 6.8%, general malaise (6.5%), discomfort 3.2%, headache 3.1%, and fever 2.1%.

“We have found higher vaccination coverage in physicians (as compared to other occupational groups) and employees of an internal medicine ward,” the study states. It continues: “Higher vaccination rates among physicians may be an indication that our current educational campaigns are better suited for physicians than nursing staff, leading to higher acceptance rates among physicians as compared to other professions.”

Meanwhile, over the 12-year period since its mandatory flu policy, the employee population of BJC Healthcare grew from about 26,000 to about 31,000. The system comprises 15 acute care hospitals in rural, urban, and suburban locations.

During the two years before the mandatory vaccination policy, the peak dates for employee compliance were October 30 and November 1. When the mandatory policy was implemented the next year, the peak date was October 15, and now it occurs in late September or early October.

Earlier vaccination “increases the likelihood staff are vaccinated and have sufficient time to develop immunity before significant community transmission of seasonal influenza begins.”

The study also states that one of the purposes of the mandatory flu vaccination policy “was to increase employee vaccination rates to enhance herd immunity and protect patients, visitors, and staff who have not been immunized.”

In order for a mandatory vaccination program to work, it’s crucial that a healthcare organization’s leaders push for that outcome, the study states. Even to the point of terminating employees who refuse to get vaccinated if they don’t have a legitimate religious or medical reason for not doing so.

“Leaders throughout the organization have endorsed the goal of vaccinating employees and are aware of the annual immunization requirement, publicize its existence and facilitate the use of occupational health and internal resources to further this aim,” the study states.

BJC Healthcare implemented a mandatory flu vaccination policy during the 2008-2009 flu season. Before the policy, about 70% of healthcare workers were vaccinated, according to the study. After the policy’s implementation, that immediately jumped to 98.4% the subsequent year.

Mandatory Vaccinations for Healthcare Employees Work

The coronavirus disease 2019 (COVID-19) pandemic has challenged us in a variety of ways. From personal protective equipment (PPE) to testing roadblocks, and the sort of persistence that exhausts us all—this has been a trying time. As the world inches closer to a year of this pandemic, what have we learned? Moreover, what are the changing and shifting perceptions of this virus and infection? Two main topics really stuck out this week—aerosols and age distribution.

Change Age Distribution of the COVID-19 Pandemic in the United States

 (MMWR) from the US Centers for Disease Control and Prevention (CDC) evaluates a shift in the age distribution of the COVID-19 illness within the United States. Early on, those impacted by the virus were older adults, but recent months have seen a shift in terms of younger people acquiring the disease. From June through August of this year, researchers identified that the highest incidence was in those aged 20-29 years. This age group accounted for more than 20% of all confirmed cases and researchers noted that those younger adults also played a role in community transmission.

The authors noted that “the shift toward younger ages occurred in all four U.S. Census regions, regardless of changes in incidence during this period, and was reflected in COVID-19–like illness-related ED visits, positive SARS-CoV-2 RT-PCR test results, and confirmed COVID-19 cases. A similar age shift occurred in Europe, where the median age of COVID-19 cases declined from 54 years during January–May to 39 years during June–July, during which time persons aged 20–29 years constituted the largest proportion of cases (19.5%)”. Overall, this trend points to a critical need to target prevention and testing efforts within this age group and to push communication on community-based prevention strategies.

Aerosols and Droplets—A CDC Website Debacle

The CDC found itself the subject of some controversy. Last Friday, the agency posted something new on its website about COVID-19 spread but then backtracked, and the update had been taken down by Monday with the disclaimer that the new information had been “

.” The communication that was withdrawn noted that transmission of the virus is through “respiratory droplets or small particles, such as those in aerosols, produced when an infected person coughs, sneezes, sings, talks, or breathes,” and that inhalation is thought to be the main way the virus spreads. Moreover, it noted that transmission can occur even if people observe the 6-foot social distancing guidance.

The posting and then withdrawing of the comments couldn’t have come at a worse time with trust in the CDC starting to ebb, but also as the community navigates the haphazard use of “airborne” by many. It has been widely known for months that close-range, small aerosols do contribute to transmission, as we’ve seen in super-spreader events and clusters related to indoor exposures despite distancing. Moreover, this guidance does require careful explanation of what it means for the community. Realistically, it will likely stay the same—masks, distancing, ventilation, cleaning/disinfection, hand hygiene, and avoiding crowded indoor environments. The challenge though is communicating that, as such terms carry weighted meanings in various fields, like healthcare and epidemiology.

The means of transmission of SARS-CoV-2 and the age group most likely to transmit the virus—people in their 20s—garnered headlines this week, as well as controversy for the CDC.

Infection Preventionists Need to Know About These COVID-19 Hot Topics

 recently, ultraviolet (UV) light holds great potential as a disinfectant in general, and as a way to stop the spread of coronavirus disease 2019 (COVID-19) in particular. However, it can be tricky to use. Well, a Japanese company called Ushio thinks it might have found a way around one of the problems with UV disinfection. The company says it has developed a UV lamp that disinfects rooms even when there are people present. The product, called the Care 222 UV lamp, emits a UV wavelength of 220 nanometers. The company developed the lamp with the help of scientists at Columbia University.

Conventional UV lamps up until now have emitted a wavelength of 254 nanometers, which can harm people, penetrating skin and eyes and possibly causing genetic defects. “Thus, the germicidal lamp UV disinfection systems can mainly only be used in unoccupied spaces,” says a study in the 

) by investigators with Hiroshima University Hospital that helped pave the way for the manufacturing of the CARE 222 UV lamp.

Ushio says that it will sell the lamp to medical facilities first. “To protect healthcare workers and to help stop the spread of SARS-CoV-2, more thorough prevention and control practices are needed,” the 

 study states. “Since COVID-19 has become a pandemic and there are asymptomatic patients, attention is being focused on environmental disinfection in public spaces beyond healthcare settings in which many people come into contact with various surfaces.” However, the company foresees the lamps eventually being used far and wide—in buses, trains, elevators, and offices.

, the Care 222 UV lamp would be installed in ceilings. When it emits the UV light, it kills 99.7% of viruses and bacteria in the air and on surfaces of objects within 8 feet of the lamp. The application takes between 6 and 8 minutes.

The device weighs 2.6 pounds and the company plans to sell them for around $2,800 a piece.

, Ushio notes that “it is important to use filtered 222nm UV-C light in occupied spaces. Unfiltered 222nm UV-C lamps will emit radiation in the 230nm (UV-C) to 320nm (UV-B) range. Irradiation without blocking these higher wavelengths of light has been reported to cause erythema and damage to the cellular DNA at considerably lower levels than filtered 222nm light.”

 study notes that “SARS-CoV-2 is mainly transmitted through infected respiratory droplets and close contact with infected people. Recent studies showed that SARS-CoV-2 can remain viable for days on surfaces under controlled experimental conditions. Furthermore, surfaces in hospitals treating patients with COVID-19 were found to be contaminated by SARS-CoV-2, suggesting that the hospital environment could be a potential medium of transmission. Therefore, if environmental disinfection is not effective, SARS-CoV-2 may spread widely and cause nosocomial infections.”

The Japanese company Ushio says that it will sell the Care 222 UV lamp to medical facilities first for about $2,800 a piece. The company also foresees the lamps being used on buses, trains, elevators, and offices.

Ultraviolet Lamp Said to Kill COVID, Leave People Unharmed

In late March 2020, Cedric Steiner was keeping watch on the case numbers of a new threat to nursing home residents: coronavirus disease 2019 (COVID-19).

Steiner was interning at a nursing home in Lancaster County, Pennsylvania, completing state and federal requirements for a license as a nursing home administrator. The facility’s COVID-19 task force, which he served on, was looking for solutions to what seemed an inevitable crisis. The Pennsylvania Department of Health “epi curve” chart showed that cases in that state were spiking scarily fast, from just a handful at the beginning of March to 40 and climbing within a 

Reading everything he could get on how to protect nursing home residents and healthcare workers from COVID-19—particularly scientific solutions—Steiner came across a 2017 study led by 

Shelly Miller, PhD, and Nick Clements, PhD

. In it, they described how they had turned a regular hospital unit into a negative-pressure isolation space virtually overnight by modifying the existing 

Could something like that work for a larger area—say, an entire wing of a nursing home? With a potential pandemic looming?

Steiner reached out to Miller on March 28 to ask if she’d be willing to help his nursing home replicate what she and Clements had done.

Negative pressure isolation space is an effective method to meet needed surge capacity during a healthcare crisis like the COVID-19 pandemic, Miller has written, and being able to create it rapidly is a boon, especially in nursing homes and other congregate living areas. She and Clements had shown that “rapid” means “rapid”—in 24 hours they converted a 30-bed hospital ward to an airborne infection isolation area in anticipation of a flu pandemic.

Steiner broached the idea to the task force, which included the CEO, vice president of healthcare, director of nursing, and infection control nurse. It wasn’t an immediate sell, he acknowledges. But after he rounded up donations in materials and money (including from himself) to reinforce the feasibility, they were willing to try it. Valerie Hatt, RN, the infection control nurse, says, “I wasn’t sure that we would have the capability, but our environmental services director is very knowledgeable and thought it could be done.” She notes that the respiratory therapist also thought it was a good idea.

Nursing homes designed on a hospital model (ie, with rooms branching off central corridors with corresponding HVAC systems) are architecturally able to sustain negative pressures that meet or exceed CDC guidelines, Miller says. The hall being modified in this case is on the bottom floor of a wing of a larger building. It had 13 beds within 7 rooms, 6 double-occupancy rooms, and 1 single-occupancy room, each with a single bathroom. The single-occupancy room included an anteroom with a separate sink and medical cabinet. The rooms each had a sealed solid glass window facing the hall and an exterior window. Heating and cooling were self-contained in each room with designated units, fans, and air ducts.

The director of facilities, John Becker, determined that he could make the necessary adaptations to the HVAC system similar to those done in the Miller study. The engineering and environmental services teams began the HVAC and plastic barrier modifications on April 2 and finished on April 6. They added 2 new blowers, turned off the incoming outdoor ventilation fan using a breaker, and mounted an exhaust to the outside of the intake grate on the side of the building traditionally reserved for incoming outdoor ventilation, thus reversing the flow of air and converting the hall to 100% exhaust. They removed the preconditioning unit of the energy recovery ventilator and closed the fire damper. Originally, HEPA filters were placed in the energy recovery ventilator (ERV) but, due to restricted air flow, these units proved prohibitive. The solution, Miller says, was to use Minimum Efficiency Reporting 8 filters and cordon off a 15.2-meter 

radius around the exhaust vent on the east side.

They installed 2 sets of 3-sheet plastic barriers to construct a temporary anteroom (the fire door was still usable). The barriers were rolled at the bottom just above carpet level and taped at the sides to identify separations for healthcare workers to access. The anteroom contained a 240 clean-air-delivery rate HEPA purifier fitted with ductwork to exhaust air into the hallway and toward the extremity of the wing.

In 4 days they had created a “cascade” of negative pressure zones between the isolation space, the anteroom, and the rest of the facility.

Once it was all in place and operational, they left it alone, Steiner says. “It worked very well from the outset. We didn’t adjust anything after that point on the timeline.” Acting as the go-between—the “boots on the ground”—Steiner went to meetings and “conveyed suggestions,” collected data, and made sure everything was working.

A lot of things took on significance they hadn’t had before, such as wind. One day, Steiner recalls, they had fierce winds, with the alarming prospect of blowing virus particles into the rest of the facility. But that never happened, he says. According to continual data being recorded on a laptop, even with high winds it all kept working just fine.

The respiratory therapist gave nursing staff (RNs, LPNs, CNAs), nurse practitioner, and physical therapy staff who needed to enter the negative pressure space a 2-day training in donning and doffing protective equipment (PPE). The nurse practitioner conducted the SARS-CoV-2 testing. By April 6, Steiner says, everyone was operating on a higher PPE standard than in most similar settings.

Then, on April 8, they had to put it all to the test: The nursing home accepted its first COVID-19-positive patient. Steiner says the facility was unusual in this, as the only nursing home taking in COVID-19 patients in those early days of the pandemic. They were seen as “reckless,” he says: “Why are you doing this? You’re endangering everybody.”

But the specialized unit, Steiner says, offered patients who went through the “revolving door,” from nursing home to hospital and back, a place to quarantine safely in familiar surroundings. The healthcare workers also saw the isolation unit as a safe space—they were requesting to work there, in fact, Steiner says.

“As we took on COVID-19 patients from the hospital setting who were on the mend, it seemed like we had a good thing going,” says Hatt. “We didn’t have any ourselves.”

Miller, Clements, and Steiner, along with Debanjan Mukherjee and Joseph Wilson, from the University of Boulder (CO) environmental engineering program, began collecting data on May 14 for a study on the 

. Two to 4 known patients with SARS-CoV-2 were being treated in the isolation space during the study. From April 8 on, the facility had no known positive result within its own population. None of the healthcare workers assigned to work in the isolation space presented with symptoms or tested positive thereafter. Mandatory testing on July 24 revealed some asymptomatic staff and residents, but Steiner says to his knowledge, as of early September, “COVID never came out of that place.”

The isolation unit and the rest of the facility had different experiences. “We had an outbreak on the second floor,” Hatt says. “We took some of the residents downstairs to the COVID Hallway, but then started to treat in place, not wanting to move them through the building. We lost 11 of our own residents.” Among those lost was Hatt’s own mother, who had asthma when she contracted the virus.

Again, the short answer, from those involved, is “yes.” The isolation unit isn’t meant to be permanent, Steiner says. It was meant to serve an emergent need, to protect healthcare workers and give patients a safe place to be treated.The bonuses, as the researchers pointed out, were that the community benefited from the expansion of available health services and reduced community spread in facilities that lacked sufficient mitigation strategies, and residents were spared the stress of transfers to and from emergency facilities.

As for lessons learned, Hatt says, “Both nursing and non-nursing staff learned the proper way of wearing isolation gowns. Also, we didn’t have a reason to use N95 in the recent past and are now comfortable with fit testing and wearing N95s.” Moreover, “I think staff all learned new or refreshed seldom used procedures and will be more aware of spreading infection and how to prevent it in the first place.”

Miller says, “From my point of view, the only thing we could have improved was more pressure measurements (we only had 1 device to do the pressure measures) and the ability to measure the outdoor air ventilation rates in each room on the hallway. Oh, and try to make the bathrooms more negative with respect to the rooms, but that is much harder to do.” The researchers also suggest adding upper-room germicidal ultraviolet lights within the area to inactivate any airborne virus, and using air purifiers to exhaust air from each room to the outdoors.

The man who initiated the project, Steiner, says many of his business classes focused on caring for employees. “I felt you had to give your clinical workers the best situation so they could succeed.” But “the emotional side of this can’t be lost, even in a dynamic, unique situation. We had to address the ability to say good-bye to loved ones.”Making it possible for family to suit up in PPE to spend valuable time with their relatives meant a great deal to them, Steiner says. He remembers one son: “A big guy, with tears in his eyes. He was so thankful that they had a place to go for their mother, because at the hospital they couldn’t see her. He wanted to give me a bear hug, but we did the ‘elbow thing’ instead.”

Thanks to this on-the-job experience, Steiner and a partner are now working on projects to help facilities manage isolation solutions and infection control. He wants to design buildings with the same “on-off deal”—that is, flexible designs that allow areas to be converted into negative-pressure as needed. “We have to make a healthy building. We have to make an environment that’s protection for residents and healthcare workers.”

Cedric Steiner: “We had to address the ability to say good-bye to loved ones. A big guy, with tears in his eyes. He was so thankful that they had a place to go for their mother, because at the hospital they couldn’t see her. He wanted to give me a bear hug, but we did the ‘elbow thing’ instead.” 

How to Build Negative Pressure Rooms in Nursing Homes During COVID 

There was life before coronavirus disease 2019 (COVID-19). And there was a busy work life, as well, for infection preventionists (IPs) that had nothing to do with the Johnny-come-lately SARS-CoV-2. The work of the infection preventionists stretches far beyond the current pandemic and should continue because that work is important. For instance, about 72,000 Americans die of healthcare-acquired infections (HAIs) each year. Sylvia Garcia-Houchins, MBA, RN, CIC, the director of infection prevention and control at the Joint Commission, recently sat down with 

 to discuss how IPs need to say on top of HAIs, the Joint Commission’s approach to accrediting healthcare organizations, and how the pandemic slowed the Commission down for a bit, but it’s now ready to restart the accreditation process. “We had been surveying less for a while,” says Garcia-Houchins. “We had to put a stop on on-site surveys. While this was all sorting out, many of our organizations just couldn’t handle being ready for the for the pandemic. Their emergency response plans were being activated.”

One of the key functions of infection prevention and control programs is overseeing and following up on healthcare-acquired infections. But with the COVID-19 pandemic going on for months, and knowing that it might be some time before we get a vaccine, some are concerned about how it has affected the day-to-day operations, and resources, so infection control programs. How are infection preventionists managing the oversight and prevention of healthcare-acquired infections these days?

It’s really interesting, we’ve been hearing a lot of different things depending on where in the country the person is, what’s the level of transmission that’s happening. I think initially, everybody said: “Oh, my gosh, we have a pandemic happening.” It’s sort of a dead stop everywhere. And we’ve got to get ready. We’ve got to be prepared. We need to get everything lined up. And so, I started thinking about what was going to happen. Many organizations at that point, the infection preventionist was really put into a position: Put my resources here? Put my resources there? I need to get a plan. I need to make sure we’re ready. So that initial part, some people didn’t have the backups on wards to just do the routine stuff that we would normally do to manage healthcare-acquired infections. As this pandemic has played out, some areas have now gone pretty much low-level transmission. Things are operating well. Sort of on the back burner. We’re ready. PPE is stabilizing. We’ve got a process to make sure that it’s still there. And it’s coming regularly. And anticipating right? Other organizations still are in that flight or fright part; that adrenaline rush is still on. They’re seeing cases. They’re seeing increases. What’s happening today? And those are really the organizations that are struggling. Day-to-day operations is not happening. And so, they may not have the resources to look at those other healthcare-associated infections. And we’re hearing reports of this in our office of patient quality and patient safety. You know, we’re starting to hear: “I don’t have the right gown to go into an isolation room.” Or, “This isn’t a COVID patient. It’s a patient with an MDRO. And they’re asking me to put on gloves, but we don’t have gowns. They’ve asked me to preserve the gowns for something else.” It’s really a struggle. Infection preventionists need to have good resources, and good references to make those judgment calls on what it is they’re doing day to day. I mean, that really has changed with the CDC stuff.

But the reality is they haven’t had the resources they need. In the meantime, healthcare-acquired infections continue. And they continue sometimes with COVID, right?

We actually heard of little clusters of outbreaks that were happening in organizations where they had set up cohort units for COVID. It put all the COVID patients together, and wear the same PPE the same way. And the same gown and gloves because you don’t have enough between multiple patients where normally we would have someone with 

 or resistant acetobacter. And we were being very careful as IPs to make sure our staff knew to take off the PPE, do hand hygiene, put on new PPE for the next patient in the cohort. That wasn’t possible. So, we were hearing about clusters of infection. The other thing that happened is, you know, initially, staff was scared. Priorities may have changed a little bit. We need to save this person’s life. We need to protect our staff from being exposed. And so some of those routine things that we would have probably done for a patient, for example, on a ventilator, routine oral care, keeping the head of the bed up, right? Pulmonary toileting for someone who’s starting to walk and get better, may not have been done because of limited PPE, or just overwhelming number of patients. Those routine practices may not have been possible for a time and still may not be possible in some organizations. That’s the real hard part is keeping a handle on that. Making sure that people know, yeah COVID’s important, but if they end up with a ventilator-associated pneumonia, that could kill them too.

It didn’t help that regulations and requirements kept changing.

As we talk about regulation and requirements, we need to think about what’s a requirement, meaning there’s legislation that says you must do; versus a recommendation or guidance. CMS is an example of an organization that puts out regulations. Right? And so, if they say this is a regulation, and it is a requirement—keyword, requirement—then organizations have to do it. If they put out information that says this is guidance or recommendation, then there’s that gray area. Do I have to do it? Or do I not have to do it? That’s caused some real issues here during this pandemic, because some things that everybody thought were requirements aren’t actually requirements. And some of the things that people thought were recommendations that they could have some leeway on are now coming to light. People are saying: “Well, depending on what state you’re in, it’s not a requirement.”

What’s the Joint Commission’s mission?

We don’t actually grade hospital performance. We’re an accrediting organization. As an accrediting organization, we go into organizations who may be deemed. Meaning that we are serving for compliance on behalf of CMS. Or they may not be deemed, which means they’ve invited us in to help them to ensure they’re providing the best quality of care for their patients. We’re not a regulatory agency. That’s an important part to start with. We are an accrediting organization.

But didn’t the Joint Commission make healthcare-acquired infections a priority around the same time as CMS did?

Yes, we did. And, and we actually this year have changed. It used to be a national patient safety goal to reduce certain particular healthcare-acquired infections. But we weren’t prescriptive. We said you need to look at the guidance. And we need to put in processes in place to implement those best practices and recommendations that are applicable to your care and services and settings. We don’t do a one-size-fits-all.

Has the Joint Commission, in light of COVID, altered or adjusted their approach to accreditation regarding healthcare-acquired infections?

Nope. We’re still doing the same things. We’re still expecting organizations to continue to follow those practices to reduce healthcare-associated infections that have remained throughout this pandemic. Now, how organizations do that…. For example, if we go into an organization and the organization’s policy and procedures say that the nurse should perform oral care every four hours, and we go and we see they’re not doing it, right? So, they’re not in compliance with their own policy and best practices to reduce ventilator-associated pneumonia. We’re going to start pulling that thread. “Why aren’t you doing this?” Now, there are a lot of reasons today why they might not be doing it. One of the key reasons may be because they can’t get the supplies. If they can show us, “Look, we’re trying but we can’t get the supplies and instead we're doing X to try to mitigate that risk,” we would consider them in compliance. Now, if they’ve got a policy in place they’re supposed to be doing every four hours oral care and the person just says, “Well, I don’t have time to do this.” We’re going to start pulling that thread. What’s the issue here? We really do survey to what practices have they put in place. What practices have organizations put in place to reduce the risk of healthcare-associated infection? And are they implementing them? Regardless of the pandemic? Are they implementing them? If they can’t implement them, that’s one thing. If they don’t have the supplies or the equipment, how would they modify those practices to try to reduce that risk versus they’re just not doing it? Remember, if we’re going out to survey, that organization has told us they are ready for survey.

Have you been surveying less since the pandemic struck?

We have been. We had been surveying less for a while. We had to put a stop on on-site surveys. While this was all sorting out, many of our organizations just couldn’t handle being ready for the for the pandemic. Their emergency response plans were being activated. We could not risk distracting them from that important task. As things have leveled out, and we’re seeing decreased outbreaks or clusters of COVID and prevalence is going down in some areas, we’ve now got criteria for when we will have our surveyors go out. We work with those organizations to say, “Are you still operating under your emergency management plan?” “Are you ready for a survey?” “Can we come out?” We don’t want to distract from their ability to care for patients. If they say, “Yep, were ready.” And they’re considered, we have criteria for what level of transmission there can be in the community. You want to protect our surveyors, too. If they meet certain criteria, then we can schedule a survey. They are still unannounced surveys. But we’re proactively going through what’s on our list in the next three months, who’s up for survey. We were trying to get rid of the backlog and look at as areas get safer, and I know that’s a relative term, but if they have less COVID. We’re looking at that, but we did stop surveys for a while. We are now back up and surveying. We’re doing a lot fewer surveys right now, just because people aren’t ready. Or there’s significant transmission occurring in the community. What might work in my organization from an evidence-based guideline, may be different in another person’s organization. It may not work. So that’s the part that organizations get to choose. We look at that. We say what are you doing? That looks like you made some good choices. Show us how you’ve implemented it? Show us how it’s impacted your infection rates. Right? Your CLABSI rate: Was it 2 and it’s now at 0.5? Wow, you’re doing well. Or you were at 0.5 and now you’re at 3. What are you doing about it? It’s not supposed to be confrontational. We’re not inspectors.

Any final words for your fellow infection preventionists who are dealing with healthcare-acquired infections and COVID-19?

Yes, don’t lose sight of the overarching point, which is all healthcare-associated infections are important. We want to prevent morbidity and mortality of all of our patients. We need to make sure that we’ve got processes in place that look at everything. Sometimes we get focused on one thing and making it perfect and we don’t look at everything else. We need to have that eye on the ball. The goal is to decrease all healthcare-associated infections, not just one.

This interview has been edited for clarity and length.

Sylvia Garcia-Houchins, MBA, RN, CIC:  “I think initially, everybody said: ‘Oh, my gosh, we have a pandemic happening.’ It’s sort of a dead stop everywhere. And we’ve got to get ready. We’ve got to be prepared…. In many organizations at that point, the infection preventionist was really put into a position: Put my resources here? Put my resources there? I need to get a plan.”

Joint Commission Feels Infection Preventionists’ Pain

Today we finally had some good news in our fight against coronavirus disease 2019 (COVID-19). Eli Lilly announced preliminary results to their SARS-CoV-2 neutralizing antibody product, LY-CoV555, which was reported to have 

. In an investor news release they stated that in a Phase 2 randomized double-blind controlled trial they observed a 72% decrease in hospitalizations or ER visits with LY-CoV555.

This is excellent news after the mediocre findings of the recent randomized trial of remdesivir which found outcome differences of “

Eli Lilly stated LY-CoV555 was “well tolerated” without the observation of any drug-related serious events. And that adverse events were similar to placebo. However, the exact incidence of milder drug reactions which could affect patient acceptance were not given in the news release.

Eli Lilly also observed that most hospitalizations occurred in patients who had an increased age or BMI. Underscoring the importance of the co-morbidities of age and obesity in COVID-19 disease.

A related product, convalescent serum, was found to have clinical efficacy when it was given within 3 days of diagnosis and in high concentration. And although given an FDA emergency authorization, its overall benefit has since been panned in the news media.

One may ask, why are the Eli Lilly results different from the positive, but somewhat disappointing, results of convalescent serum? The short answer is, they are not. LY-CoV555 targets the same clinical sweet spot where convalescent serum was found to be most effective.

In the Eli Lilly trial, LY-CoV555 was given to patients with mild to moderate symptoms and within 3 days of their diagnosis. In other words, similar to convalescent serum, initial results demonstrate that LY-CoV555 is effective if given in the early stages of the disease, soon after diagnosis. In addition, Eli Lilly’s product is designed to be composed of highly effective neutralizing antibodies.

Meeting these patient administration requirements on a mass scale is almost an impossible task with convalescent serum. There just is not enough to have it in everyone’s urgent treatment center. But the Eli Lilly product is composed of a high concentration of highly effective neutralizing antibodies, which hopefully can be manufactured in great enough quantities to become a bridge to a vaccine.

One cautionary note was a statement: “Viral RNA sequencing revealed putative LY-CoV555-resistance variants in placebo and all treatment arms. The rate of resistance variants was numerically higher in treated patients (8 percent) versus placebo (6 percent).”

Thus, as with any anti-viral agent, viral resistance might possibly develop. This is to be expected. Nature adapts and RNA viruses are known to have a proclivity to mutate. This is often observed in phage therapy where there is described a dance of mutations between the bacteria and 

. However, in this instance, the viral mutations are beneficial when you are wanting to kill an evolving bacteria, but are detrimental when targeting the virus itself.

LY-CoV555 targets an “epitope in the SARS-CoV-2 spike region”. This is the same region many vaccines are targeting. So far, SARS-CoV-2 has not appeared to mutate at a very fast rate regarding its spike protein region. However, the development of resistance to LY-CoV555 will still need to be carefully monitored, since the emergence of a new resistant viral strain could impact the efficacy of not only monoclonal antibodies but also of future vaccines.

There would be less of a concern if LY-CoV555 was targeted and effective in the few who were severely sick, but it appears its application is most beneficial when given early and possibly to the masses. But, it is probably not realistic that LY-CoV555 can be produced in high enough volume to be available to all. No SARS-CoV-2 product to date has been able to even approach this goal. As observed in the Eli Lilly study, those newly diagnosed patients who are obese or have advanced age are the most likely to become hospitalized, and I feel initially this innovative product should be targeted toward these high-risk patients.

Eli Lilly stated LY-CoV555 was “well tolerated” without the observation of any drug-related serious events. And that adverse events were similar to placebo. However, the exact incidence of milder drug reactions which could affect patient acceptance were not given.

Eli Lilly Neutralizing Antibodies: Breakthrough for COVID-19 Treatment?

, infection preventionists need to be able to separate good from not-so-good data when it comes to coronavirus disease 2019 (COVID-19). In that vein, our parent company, MJH Life Sciences, will host the webinar “Fact or Fiction? COVID-19 Myths and Controversy” next Tuesday, September 29, at 6 p.m. Eastern Time. 

: This promises to be a fascinating presentation on the realities of information and misinformation that healthcare professionals must deal with each day.

Featured speakers will include Saskia v. Popescu, PhD, MPH, MA, CIC, a senior infection prevention epidemiologist who will be moderator; Angela Rasmussen, PhD, of Columbia University Mailman School of Public Health; and Emily Ricotta, PhD, MSc, of the National Institute of Allergy and Infectious Diseases, National Institutes of Health.

Sign up today for a live webinar to hosted next Tuesday night in which experts will discuss how to separate good from misleading data dealing with COVID-19. 

Fact or Fiction? Live Webinar Will Look at COVID Controversies

In his long and distinguished career, the Brent James, MD, an internationally known health care expert, worked on both the insurance and provider sides. James is currently pushing a system called direct to business, which allows large employers and large hospital systems in a region to contract directly, cutting out the health insurer middleman. James recently sat down with 

 and provided examples of how such a system might bolster infection control and prevention. “Time after time, I’ve seen it dramatically improve clinical outcomes and reduce costs,” says James.

Direct to business arrangements. What are they? How they come about?

Why did they set up in the first place? You know, the best way I know to introduce it: Some years ago, I was asked to chair a strategic planning committee at Intermountain. Eventually it produced our population health initiative. In the committee, I had senior executives from across the system, including the three senior leaders from our own health plan, Intermountain Select Health, the largest commercial insurer in the region. Well as we were working our way through, I asked a question. I said: “Exactly how does an insurance company add value?” We came up with a list of 10 major items, there are lots of smaller ones just to give you a flavor for it. They do something called transaction processing, insurance claims processing—surprisingly difficult, by the way, real expertise around that. Actuarial risk analysis. Part of that is reinsurance. When you reinsure a patient. It’s for really high-cost patients. They did a certain amount of benefit design. They did a certain amount of customer support. Oh, a big one. They did network formation, where they found a sufficient number of hospitals, clinics, physicians to supply all health needs for the uninsured population. The list goes on. We did the analysis. The thing that we found is, number one, almost all of them were available as commodities in the general market. You could purchase them, outsource them, the claims process and the actuarial risk analysis, for example. You could purchase them at very good prices competently done in the external market. The only element that they couldn't outsource was network formation. But we realized that the system was large enough that it could form its own network. They had a sufficient blend of physicians and facilities that they can handle that on their own. The second piece, we came back next and said, “All right, given that this is the value add, how much should it cost?” We express it as percentage of the premium dollar. The answer we got was between 4% and 8% of the premium dollar. Seemed low. But I checked in our community. We had a number of nonprofit insurers. Desert Mutual Benefit Administrators, the DMBA, that’s the LDS Church’s self-insurance plan. PEHP, that’s the public employees health plan. It’s a consortium of public employee groups from around the state [Utah]. Educators Mutual, that’s for schoolteachers. They were all running at about 4%. That’s roughly where Medicare runs too, just in passing. It turns out the 4% to 8% estimate was pretty reasonable. Oh, the trick. Major for-profit insurers will pull somewhere between about 15% and 20% of the premium dollar to put on to their bottom line in the stock market. And it was that difference, let’s say between 6% and 18%. Twelve percent of the premium dollar is a lot of money. And that was the economic argument that if a large integrated system could go direct to self-insured employers, ERISA plans, that they could then through negotiation, decide how to divide that pie of 12% of the premium dollar. Now, frankly, given that it’s the health system that puts it together, and the health system that has to do the care management within it, I’m prejudice. I think it ought to swing a little bit more to the care delivery system side. But that’s what made it so very attractive. Now let’s shift gears and go to the other side, the care management side. A lot of insurance companies claim that that’s how they added value. That’s how they justified the additional spend. Fact is, we’ve proven that care management works much better at the level of the care delivery system than at the level of insurance. And we had our data showing that makes sense. It happens better if it’s closer to the point of action, where a patient interacts with the system, and the insurance companies are kind of two giant steps away. We knew that, “Oh, if you start to manage care, that’s where you get into the whole population health thing.” We estimated that we could drop the cost of care by 30% to 50%. So, you’ve got, let’s say, 14% here, but then you’ve got over here, you’ve got waste elimination to better care management. The cool thing about the waste elimination, the way you get it is to improve your clinical outcomes. The money aligns to your mission, better clinical outcomes, lower costs. And you’ve got an even bigger pot of money to share.

How does it standardize care and prevent defensive medicine?

Well, a classic. It was an infection control case. The patient went in for open heart surgery. He developed an infection, a post-op infection from a staph epidermidis, a common bacterium that lives on everyone’s skin and it’s usually completely innocuous. This was a strange variant. The patient had a very fast, bad course and died. Shortly after he died, his estate sued the hospital and the physicians because we didn’t prophylax that staph epidermidis. Turns out it was right in the protocol. They had a list of organisms that we did prophylax. They had a list that they purposefully did not. It turns out that we had the evidence based best standard. It doesn’t say you have to do everything. He just says that you deliver good care, and by consensus in our infectious disease staff, and the consensus among our physicians and nurses, that was best care. And what we did is we pulled out the protocol and then showed it to the plaintiff’s attorney. Once again, another lawsuit dropped fairly quickly before you go through all the trouble of preparation. That’s where the real money goes, by the way, in discovery and preparation. We had a long list of those cases. Now imagine the opposite happens. Imagine you have the standard, and you need to verify. All right, well, two things. We had built into every protocol, it was just boilerplate our attorneys have helped us with, it said this protocol is designed for the general use of most patients, but may need to be adapted to specific use of a particular patient by the patient’s caregiver. All right, it was right there in the protocol. It was honest, it’s exactly how we used it. It also became number two. That’s when you need the note. When you need that six-word note is when you choose to vary. You just need a clinical explanation, but it became a marker: “Oh, this is where I need the note to protect me.” You see, I have to tell you honestly on long experience, it reduced our malpractice risk because it established a legitimate written standard of care. And it told us in the document so on that our malpractice risk went down.

What about defensive medicine? That’s a big problem.

There are two elements to that too. The first was this. What turned out what was happening…. We investigated this a bit. So, you measure variation in care. one guy’s doing it one way, another person is doing it a different way. Third person’s doing it differently still, and we go back and ask him why, why did you do that? And nearly always they come back and say defensive medicine. It was a really common response. What we discovered, though, is it probably wasn’t defensive medicine that was just plain old garden variation. I was doing it in my opinion with very little support. Right. So, it was a marker for variation, and it probably wasn’t a legitimate answer. To be honest. It’s just a handy hook to hang your hat on when somebody challenges about why you’re doing this in this crazy way. You see, well, that kind of went away, but you have to give that pressure relief valve. On average, you know, we did this for over 125 protocols. You vary about 5% to 15% typically. I used to say it this way to my colleagues just to make it real easy: “Look, guys, we’re tracking protocol brands. You will get as much scrutiny for complying with protocols as for complying too little. If you’re different from your colleagues, we want to take a look. The first time that really played out was in infectious disease interestingly enough. John Burke, the head of infectious disease, had a system. If you had an inpatient who developed an inpatient infection, it was like he got a console from ID in about three or four seconds. You just called up the program. You had to tell it the sites of infection you’re interested in, but then it did an epidemiologic evaluation of that patient. The first screen listed: Here are the most likely causative pathogens in our experience at this hospital. It gives you a differential of causative pathogens. There’s a 72% chance it’s this one. Oh, with this pattern of sensitivities, there’s a 59% chance it’s this one. There’s a 31% chance with this one. With each sensitivity in probability order. If you went one screen ahead, it said, here’s the best antibiotics to treat this set of infections. It actually gives you several choices. It was in priority order by efficacy number one, and then if it had several similar efficacies, it prioritized them in cost order. And if you saw one you like, give me a number two. It ordered the drug, it alerted the nurses. If you had level testing, it automatically did the level testing. Now initially, people were really kind of watchful around this thing. Did it deliver good care, as you would expect from any good group of clinicians. But it turned out to work and it worked pretty well. The real problem is, oh, two months later, they came to us and said, “You know, we don’t really need to see the differential. Just show us a list of antibiotics. It will shorten our time.” And then they came back and said, “Don’t show us the whole list of antibiotics. We pretty much always want the one on the top. Just show us the top one.” It reduced it to a single click, single return. And it took the time that when I was practicing surgery, it used to take me 10 to 15 minutes. It probably cut it by half. You see, that was really popular. But then we saw the downside. The downside was John Burke, using the same system, started to pick up cases where they should have buried, and didn't. It made it so dang easy to follow the protocol that, you know, people aren’t thinking as hard as they should. But it turns out the same system that detected it…. At the time at LDS hospital, you might get a console from ID even if you didn’t order one. Because John Burke was monitoring the whole hospital and he’d come by on cases that looked like they needed a little expert oversight and just show up. They learned how to interact with their colleagues in a positive way. What we saw—by the way, this was published in 

—was a rather dramatic drop in…. Well, it was infection related mortality was what they were tracking in that study. And side-by-side with it, a drop in costs. I love the way that one of our ID docs said it. He said it was more targeted therapies where you were getting the right therapy to the right patient at the right time.

You know, I’ve been looking for my whole career for things that make this happen faster and better. Time after time, I’ve seen it dramatically improve clinical outcomes and reduce costs. Sometimes it’s a real uphill fight. And frankly, on my side, it mostly has to do with administration worried about the revenues. When you move into these straight to business relationships, technically, it’s a form of shared savings, and it solves the financial side so that medically we can do what’s right. And I’m pretty sanguine about it. I like it a lot. I think it’s a good way to practice medicine that will make us better doctors, help us learn faster, and help us deliver dramatically better care to our patients. I hope it takes over the world. I think it will make us better doctors and a better practice in general.

Oh, yes. Oh, yes. The examples I just used were all infection, weren’t they?

Brent James, MD: “If you had an inpatient who developed an inpatient infection, it was like he got a console from ID in about three or four seconds. You just called up the program. You had to tell it the sites of infection you’re interested in, but then it did an epidemiologic evaluation of that patient.”

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