SHARON WARD-FORE, MS, MT(ASCP), CIC, FAPIC, is an infection prevention consultant located in Chicago. She is also a member of Infection Control Today®’s Editorial Advisory Board.

By Sharon Ward-Fore, MS, MT(ASCP), CIC, FAPIC

The importance of ventilation in health care and non–health care settings has become evident amid the COVID-19 pandemic. Decreased performance of health care facility heating, ventilation, and air conditioning (HVAC) systems, including filter inefficiencies, improper installation, and poor maintenance, can contribute to the spread of health care-associated infections (HAIs), according to various research findings. Infection preventionists (IPs) who have a basic understanding of ventilation systems and associated risks might feel more confident and comfortable collaborating with architects, facility designers, and engineers. COVID-19 is 1 of many diseases transmitted from a respiratory source.

How does air play a role in disease transmission? The aerosolized transmission of disease happens through droplet and airborne means.

 Droplet transmission of disease can occur when 

bacteria or viruses travel on relatively large respiratory particles that people sneeze, cough, or exhale through talking, singing, or shouting. These droplets travel short distances (usually less than 6 ft) before settling and can be loaded with infectious particles. Infectious particles that contact a person’s eyes, nose, or mouth can cause infection. If they fall on surfaces, they can be transferred onto the hand of someone who unknowingly rubs their eyes, nose, or mouth, causing possible self-contamination.

Airborne transmission is defined as infections transmitted through exposure to infectious, pathogen-containing, small droplets and particles suspended in the air over long distances that can persist in the air for long times.

 The main differences between these 2 transmission types come down to particle size and distance traveled: Droplets are thought to be larger and don’t travel as far; aerosols are smaller and can travel quite a distance. The Centers for Disease Control and Prevention (CDC) recommended isolation precautions for diseases like measles or chicken pox, which are airborne, and mumps, which is transmitted by droplet.

 IPs understand the importance of these precautions but may know less about how these measures work to protect patients and staff.

“The importance of good air quality in controlling and preventing airborne infections in health care facilities cannot be overemphasized,” wrote Anjali Joseph, PhD, the director of research at the Center for Health Design, a company that plans health care facilities, in a 2006 study. “Providing clean filtered air and effectively controlling indoor air pollution through ventilation are 2 key aspects of maintaining good air quality.”

Knowing how important air quality and ventilation are, IPs might better converse with health care architects, designers, and facilities groups if they understand the basics of clean, filtered air and ventilation. Basic terms include the following:

Filtration refers to controlling air quality at the source and is defined as the physical removal of particulates from the air, a key step toward achieving acceptable indoor air quality by removing contaminants.

Filters that are 90% efficient are sufficient for most patient care areas in ambulatory care facilities and hospitals, including the operating room.

High-efficiency particulate air (HEPA) filters should be used for special care areas of the hospital such as surgical areas, burn units, and protective environments for patients who are immunocompromised.

HEPA filters are required to be 99.97% efficient for removing particles 0.3 μm or larger (eg, COVID-19 = 0.06-0.2 μm; measles = 0.2 μm; 

 = 1.0 μm). This means for every 10,000 particles sized 0.3 μm in diameter, HEPA filters only allow 3 particles to pass through.

The principle of Brownian motion applies to HEPA filters for particles less than 0.3 μm. These smaller particles bounce off other molecules when they collide and move in random patterns. They hit the HEPA filter fibers and get stuck. So HEPA filters actually better capture these smaller particles.

Ventilation guidelines are defined in terms of air volume per minute per occupant. They assume that the people in the room and their activities are responsible for most of the contaminants in the space.

Supply vents are where conditioned air blows into the room, usually from the ceiling; return vents (exhaust) pull the room air in, usually near the floor.

Most ventilation rates for health care facilities are stated as room air changes per hour (ACH). ACH refers to the number of times that air gets replaced in each room every hour, mixing in outside air to dilute microbial contamination.

Peak efficiency for particle removal in an airborne infection isolation room (AIIR) occurs between 12 and 15 ACH, per CDC guidelines.

Ventilation rates vary with different patient care areas of a health care facility. Look at the most recent edition of the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) Standard 170, Ventilation of Health Care Facilities, which is now integrated into the Facility Guidelines Institute (FGI) Guidelines for Design and Construction of Health Care Facilities.

ASHRAE Standard 170 speaks to the removal of airborne pathogens through a combination of filtration, direct exhaust of contaminated air, and dilution through introduction of outdoor air. Most IPs are familiar with ASHRAE and FGI. These resources are highly recommended and often consulted, especially when renovation and construction are planned for a facility.

Be aware that the Joint Commission, through its Environment of Care standards, also audits ventilation systems for appropriate pressure relationships, air exchange rates, and filtration efficiencies because it views the proper design and maintenance of isolation rooms as vitally important in preventing the transmission of disease through the air for patients, staff, and visitors.

Interestingly, studies have found that ASHRAE 170 2008 and the 2005 CDC guidelines recommendations for minimum ventilation rates of 12 ACH for hospital insolation rooms are not necessarily the optimum ACH to control infection transmission. Increasing ventilation airflow rate dilutes concentrations but does not increase ventilation effectiveness. The results of a study by Memarzadeh and Xusuggest that the most important contributing factor to contaminant transmission in an AIIR is the path between the patient and the exhaust, not the ACH.

 When this path is disrupted by airstreams, the contaminants can move to other to places in the room. If this path is not disrupted, then the contaminant is not likely to migrate, so changing the number of air exchanges does nothing for ventilation effectiveness.

This is why thoughtful ventilation design and placement of exhaust and supply vents in relation to patient placement in the room are important. Simply introducing extra amounts of outdoor air hoping to dilute the room air may not be effective in providing protection from airborne infection because it does not increase ventilation effectiveness. It is very important to not block the path to the exhaust and returns.

Humidity is defined as the concentration of water vapor present in the air.

The recommended relative humidity range for hospitals is between 40% and 60% (also check local standards). The minimum relative humidity level for an operating room should be 20% and the maximum level should be 60%, per ASHRAE Standard 170-2017, Ventilation of Health Care Facilities.

Relative humidity greater than 60% can promote growth of fungus.

Humidity control allows patients and health care workers to breathe easily, avoiding dryness of the respiratory tracts and reducing the amount of airborne dust in closed spaces.

According to Stephanie Taylor, MD, an infection prevention consultant at Harvard Medical School, “At low relative humidity, indoor air was strongly associated with higher infection rates. When we dry the air out, droplets and skin flakes carrying viruses and bacteria are launched into the air, traveling far and over long periods of time.…In addition to this increased exposure to infectious particles, the dry air also harms our natural immune barriers which protect us from infections.”

Ideal humidity conditions can also improve working conditions for health care workers and help medical electrical equipment operate properly by reducing static electricity (Figure 1 demonstrates the relationship between microorganisms and humidity.)

Room pressurization involves technology that controls movement of air contaminants by causing drafts between spaces, usually rooms and hallways. Pressurization can be positive or negative.

In health care, certain rooms are positively or negatively pressurized with respect to surrounding areas.

Negative pressure (depressurized) means airflow into the room.

AIIRs are set at negative pressure with respect to adjacent areas to prevent airborne microorganisms in the room from entering hallways, corridors, and other areas.

AIIRs provide negative pressure in the room (so that air flows under the door gap into the room), with an airflow rate of 6 to 12 ACH (6 ACH for existing structures; 12 ACH for new construction or renovation) and direct exhaust of air from the room to the outside of the building or recirculation of air through a HEPA filter before returning to circulation.

Positive pressure means air flows out of the room (pressurized).

Protective environment rooms, used to protect neutropenic patients, are set at positive pressure to keep airborne pathogens in adjacent spaces or corridors from coming into and contaminating the airspace.

The 2014 FGI Guidelines/Standard 170-2013 provides lists of rooms that should be positively or negatively pressurized with respect to surrounding areas. (Figure 2.)

•	Self-closing doors are mandatory for both of these areas to help maintain the correct pressure differential.
•	Variable pressure rooms (rooms where the ventilation can be manually switched between positive and negative pressure) are no longer permitted in new construction or renovation, and their use in existing facilities has been discouraged because of difficulties in assuring the proper pressure differential, especially for the negative pressure setting, and the potential for error associated with switching the pressure differentials for the room. Continued use of existing variable pressure rooms depends on collaboration between engineering and infection control. Both positive- and negative-pressure rooms should be maintained according to specific engineering specifications.


•	ASHRAE Standard 170, Ventilation of Health Care Facilities, requires each isolation room to have a permanently installed visual device or mechanism to constantly monitor the air pressure differential of the room when occupied by a patient who requires isolation. The CDC states that airflow direction should be maintained and verified, preferably daily, even when the room is unoccupied, using either a visual means of indication (eg, smoke tubes and flutter strips) or manometers.



5.	Temperature is defined as the degree of hotness or coldness measured on a definite scale.
•	In health care, normal operating temperature set points should be maintained based on the existing licensing requirements for the space use and occupancy. Consult FGI for specific guidance.
•	ASHRAE Standard 170 requires temperatures ranging from 68 °F to 75 °F for most patient care areas. Cool temperature standards (68 °F–73 °F [20 °C–23 °C]) are usually related to operating rooms, clean workrooms, and endoscopy suites.
•	Temperatures above about 75 °F (24 °C) appear to universally lower airborne bacterial survival.


•	Virus survival, in general, decreases as temperatures rise. However, many factors, such as humidity, presence of organic matter, and whether they are DNA or RNA viruses, influence survivability. Much more research regarding temperature and its effect on viruses is ongoing.

As the above tutorial indicates, the current information on air in health care and public buildings can be overwhelming. The really heavy engineering and design details of ventilation are best left to the architects, engineers, and the facilities groups. But knowing the basics of air quality and air handling, as well as their relationship to possible disease transmission, could benefit IPs.



SHARON WARD-FORE, MS, MT(ASCP), CIC, FAPIC, is an infection prevention consultant in Chicago, Illinois. She is the Infection prevention adviser for Metrex Infection Prevention/Envista Holdings, an APIC Text clinical editor, and a contributing Editorial Advisory Board member of 

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Guidelines for environmental infection control in health-care facilities. Centers for Disease Control and Prevention. 2003. Accessed May 12, 2021. https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf

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Articles

In the new normal after COVID-19, infection preventionists will need to become more knowledgeable about and involved in the functionality of air ventilation in health care settings. 

What IPs Need to Know About Ventilation

Surface disinfection is key to containing viral outbreaks and has never been more important than it is right now. Fundamentally, the concept and importance of surface disinfection hasn't changed. However, the impact of the COVID-19 pandemic on today’s world makes it imperative to change how the health care community conducts proper surface cleaning and disinfection. It starts with mindset – because health care and lives depend on it.

Recent studies have shown that only 32% of the 110,000 objects in inpatient and outpatient health care facilities are thoroughly cleaned.

At iClean 2020, an evidence-based cleaning health care leadership conference, Didier Pittet, MD, MS, CBE, called for "urgent reform in our approach to cleaning and disinfection in hospitals and aged-care homes."

How cleaning is actually done today is based on time, the volume of room equipment, Environmental Services (EVS) staffing levels, experience and training, and the types of cleaning supplies available.

To mitigate the spread of potential pathogens that cause health care-associated infections (HAIs), infection prevention practices must evolve. Everyone practicing should know the following:

Proper cleaning and disinfecting are a top priority, and there is a definite distinction between the two

EVS plays a vital role in infection prevention

Everyone is responsible for infection prevention

Training about supplies must happen regularly and change based on the readily available supplies

Ruth Carrico, Ph.D., DNP, APRN stated at iClean 2020, "Reforming hospital and aged-care disinfection systems can not only help to continue to manage COVID-19 but also reduce the incidence of other hospital and aged-care facility-acquired infections."

So, what does success look like today, and how is it achieved? Here are 5 tips for getting cleaning and disinfecting right.

Between the trifecta of departments responsible for infection prevention—EVS, nursing and infection prevention—it’s every individual’s responsibility to ensure surface cleaning and disinfecting are done quickly and effectively to prevent potential pathogen transmission successfully. It all comes down to good teamwork and relationships with other IP experts, communication, accountability and unwavering protocol. Everyone must be on the same page.

Cleaning is a science. That means every element of the process matters, every single time—from quality cleaning with mechanical scrubbing to contact time to following CDC recommendations.

Protocols for individual patient care areas, including frequency, method and process, should be based on the risk of pathogen transmission. The probability of contamination is based on the patient’s care area, the vulnerability of the patient to infection (immunocompromised versus general patient), and the potential for pathogen exposure, ranging from high-touch to low-touch surfaces. For example, patient toilet areas should be cleaned last in the process because of their patient exposure, frequent contamination and higher risk of pathogen transmission.

The CDC recommends the following core practices for environmental cleaning and disinfection

Require routine and targeted cleaning of environmental surfaces as indicated by the level of patient contact and degree of soiling.

 Clean and disinfect surfaces close to the patient and frequently touched surfaces in the patient care environment on a more frequent schedule than other surfaces. Promptly clean and decontaminate spills of blood or other potentially infectious materials.

Select Environmental Protection Agency (EPA)-registered disinfectants with microbiocidal activity against the pathogens most likely to contaminate the patient care environment.

Follow manufacturers’ instructions for proper use of cleaning and disinfecting products.

 Consider the manufacturer’s dilution guidelines, contact time

, material compatibility, storage, shelf-life, safe use and disposal. The shorter the contact time and the more convenient disinfectants are to use, the more often they get used!

Tip 3: Pay attention to detail, provide coaching along the way and articulate success

Share these tips with your team so they can measure and evaluate cleaning quality

: EVS personnel and their supervisors should inspect their completed work to ensure that visible evidence verifies that basic cleaning is complete.

 Expert infection preventionists suggest that the evidence of the efficacy of the team’s cleaning is literally “on the wipe’ and easy to spot.

Adenosine triphosphate (ATP) bioluminescence test

: Place environmental surface swabs in the ATP reagent and a luminometer reads the amount of light. The results indicate whether the level is acceptable or unacceptable based on the number of relative light units (RLUs).

: Apply an invisible fluorescent mark onto the soiled surface. If the fluorescent mark is visible under a UV light after the surface is cleaned, the surface requires recleaning.

: Quantitative environmental cultures such as swabs and Replicate Organism Detection and Counting (RODAC) plates can be used as markers of thorough cleaning; less than 2.5 CFU/cm2 is considered acceptable.

Armed with the right tools, products and knowledge, everyone involved in health care facility cleaning and disinfection is empowered to play a vital role in the lives of all who set foot inside—which is just as crucial of a role as patient care. Involving every team member in the surface disinfectant conversation helps solidify their buy-in.

Standards can also help empower professionals. The CDC recommends these core components for a successful environmental cleaning and disinfection program

 environmental services into the hospital's safety culture.

 all HCP responsible for cleaning and disinfecting patient care areas.

 appropriate cleaning and disinfection technologies and products.

 setting-specific cleaning and disinfection protocols.

 effectiveness and adherence to cleaning and disinfection protocols.

 on success and quality of cleaning and disinfection to staff and stakeholders.

Tip 5: Instill awareness and adherence of turnaround time

In the approximately 40-to-45-minute turnaround time window

 for room cleaning, every moment counts. Team members have to work together quickly and effectively within their allotted timeframe without cutting corners to achieve successful pathogen eradication.

For example, in a typical terminal discharge, nurses need time to clean equipment properly before rolling it out of the room and into the hallway, paving the way for EVS to clean and disinfect the room. The equipment moved to the hallway has to be wiped down again and returned to its place in the room. Having to do all of this in a limited timeframe makes it crucial to follow standardized guidelines that everyone can follow and for IPs to monitor.

Tip 6: Know what to value in cleaning and disinfecting products

When it comes to surface disinfection, success is priceless. However, it's no secret that cost is a consideration for a facility’s financial decision-makers. When weighed against product efficacy and contact time, however, the best tools for the job will be those that can be relied on to get infection prevention right the first time.

For example, choosing a disinfectant product with a U.S. Environmental Protection Agency (EPA) Emerging Viral Pathogen claim for all virus types (enveloped, large and small non-enveloped viruses) is a wise investment to help protect patients and health care workers. According to the National Institute of Allergy and Infectious Diseases, emerging viral pathogens like SARS-CoV-2 are those “that have newly appeared in a population or have existed but are rapidly increasing in incidence or geographic range.”

To qualify for the EVP claim, a disinfectant must be an EPA-registered surface disinfectant and kill at least two 

 types of small non-enveloped viruses—those that are difficult to kill. The EPA created this claim to establish parameters for disinfectant products to carry specific off-label efficacy claims for new and harder-to-kill viruses during a pandemic. When you use disinfectants with an EVP claim, you are using products formulated to meet current and future infection prevention needs, thus anticipating unpredictable public health crises.

Decision-makers should also look for a surface disinfectant on the EPA's List N–a list of products that the EPA recognizes to be able to effectively kill SARS-CoV-2 when used according to label directions.

Recognizing the importance of proper surface disinfection to help eradicate emerging viral pathogens is the first step in making this life-saving change. Taking responsibility, paying attention to detail, empowering staff, adhering to best practices and knowing what to value—which ultimately saves lives—are crucial factors for success.

Sharon Ward-Fore, MS, MT(ASCP), CIC, serves as Metrex’s Infection Prevention Advisor. Sharon is also an independent infection prevention consultant and is a member of the editorial advisory board of Infection Control Today®.

Rutala WA. New technology in environmental cleaning and evaluation. Presented at 40th Annual APIC Conference, Fort Lauderdale, FL, June 10, 2013. Available at: 

http://disinfectionandsterilization.org/slide-presentations/

Global healthcare needs infection control reform, say experts 

http://hospitalhealth.com.au/content/clinical-services/news/global-healthcare-needs-infection-control-reform-say-experts-957448066#ixzz6WWvpZBtJ

Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings – Recommendations of the Healthcare Infection Control Practices Advisory Committee. 

https://www.cdc.gov/hicpac/pdf/core-practices.pdf

Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. Update: May 2019. 

https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines-H.pdf

https://text.apic.org/toc/infection-prevention-for-support-services-and-the-care-environment/environmental-services/#book_section_references

Healthcare-associated Infections. Reduce Risk from Surfaces. 

https://www.cdc.gov/hai/prevent/environment/surfaces.html

Patient Room Turnover – A Balance of Speed and Quality 

https://www.eonsolutions.io/blog/patient-room-turnover-a-balance-of-speed-and-quality

What is an emerging viral pathogen claim? 

https://www.epa.gov/coronavirus/what-emerging-viral-pathogen-claim

List N: Disinfectants for Use Against SARS-CoV-2. 

https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2

Between the trifecta of departments responsible for infection prevention—EVS, nursing and infection prevention—it’s every individual’s responsibility to ensure surface cleaning and disinfecting are done quickly and effectively.

More to Surface Disinfection Than Meets the Eye

 as “the action or process of providing someone or something with an official document attesting to a status or level of achievement.” When certification pertains to health care, the definition is “a voluntary process by which a nongovernmental agency grants a time-limited recognition to an individual after verifying they have met predetermined and standardized criteria.” To become certified, an individual must meet eligibility requirements and pass an assessment.

Infection preventionists (IPs) can attain this level of achievement, or certification, through the Certification Board of Infection Control and Epidemiology (CBIC) examination once they meet the eligibility requirements and feel ready to take the exam. This initial exam, although not perfect, does assess many of the areas that an IP with 2 years of health care experience should know.

It is a broad assessment of the subject matter that all IPs in a health care setting should be familiar with:

Identification of infectious disease processes

Surveillance and epidemiologic investigation

Preventing/controlling the transmission of infectious agents

Cleaning, sterilization, disinfection, and asepsis

This list may look daunting, but 2 years of on-the-job experience goes a long way toward helping you prepare for the initial exam. The daily tracking and tracing of transmissions, working on the construction and renovation of infection control risk assessments, participating in EOC rounds, auditing insertion practices, and reporting and investigating outbreaks are what that initial certification examination is all about. Preparing for the exam helps us learn, grow, and become better IPs.

 Better IPs means better outcomes for patients, and this is what infection prevention is about.

This day-to-day learning can only come from actual experience in a health care setting. I firmly believe this is the best way to help IPs become the best they can be. I am a visual learner and learned most of what I know from being out on the floors, watching, listening, and questioning everyone who would let me bother them. What an eye-opener it can be to watch actual practices versus a training module on central line insertion!

That’s why the eligibility requirements for first-time or lapsed candidates are scheduled to be changed on June 1, 2021.

First-time candidates, candidates who have not successfully passed the examination, and those whose certifications have lapsed and who wish to become certified again will need to have all these requirements:

Complete postsecondary education in a health-related field including but not limited to medicine, nursing, laboratory technology, or public health

Direct responsibility for the infection prevention program activities in a health care setting

Work experience, defined as active engagement in infection prevention and determined by a current job description, for compensation, for a minimum of:

00 hours of infection prevention work experience earned during the previous
3 years

And that’s not all. The infection prevention activities must include:

Identification of the infectious disease processes

Preventing and controlling the transmission of infectious agents

Cleaning, disinfection, sterilization, and asepsis

AND at least 2 of the remaining 3 components:

These requirements are the meat and potatoes of infection prevention and are what, I believe, give it value and prestige. This certification is not for everyone because it shouldn’t be. It should be for those actively working in health care supporting health care providers by providing education and training. It is for those who have earned the right to take the test not just because they have a degree but because they learned by “boots-on-the-ground” everyday practice.

This certification shows your dedication to your craft. This is how we distinguish ourselves and stand with other professionals. So take this opportunity to distinguish yourself and get the credit you deserve for your education, experience, and perseverance. Stand with the 7000 other IPs who decided it’s important to be certified. It isn’t easy, but the satisfaction of achievement far outweighs the preparation needed to pass.

This year I am due to recertify my Certification in Infection Prevention and Control (CIC). I have recertified by self-achievement recertification examination (SARE) once and will now recertify using continuing education (CE) credits, such as infection prevention units (IPUs) training, a new option instead of taking the SARE. Recertification feels even more important to me than ever.

During this pandemic everyone thinks they know infection prevention—from my hairdresser, who I have not seen in a year, to the gym attendant, who I have also not seen in a year. They will tell you they are experts in infection prevention. So when I strike up a conversation with someone and mention that I am 

in infection prevention, they are somewhat impressed but mostly curious.

What exactly is recertification? According to the dictionary, it is “to renew the certification of 

”That really doesn’t cover it for me because the intent of CIC recertification is so much more. Recertification of the CIC revalidates all the education and experience that continues to accrue while working as an infection preventionist. Health care is not a static environment. The amount of information, practices, and procedures that change is overwhelming. Recertification challenges IPs to keep up with changes and continue to learn.

Do you remember the definition of certification as it concerns health care from the beginning of this article? 

: “a voluntary process by which a nongovernmental agency grants a 

 to an individual after verifying they have met predetermined and standardized criteria.” 

. The key words to striving to keep up-to-date with what is happening in your profession. Recertification every 5 years is not exactly popular, but I believe it is necessary so our thinking and practices don’t become stale. It pushes us to keep up-to-date.

The CBIC is responsible for administering these exams. And to its credit, CBIC heard the issues about the SARE and came up with the CE/IPU option for recertification. You can still sit for the SARE or input 40 hours of CE/IPU, the choice is yours.

And the 40 hours of CE must include 6 of 8 of the following learning domains:

They are the same categories that are tested in the initial certification exam and the recertification SARE. So you can’t just input a bunch of nonsense. You must participate in specific domains of learning. Even if you work in only 1 setting type, you are expected to stretch yourself professionally and attend other educational learning. This is a good thing. It forces us out of our silos.

I have begun the process of inputting all the necessary CE/IPUs into the CBIC system. Word of advice: Input the CE/IPUs as you get them. Don’t wait and enter them all at 1 time as I have done. It is time consuming. But as the infection prevention professional that I have worked so hard to become, CIC certified, I will keep on plugging. I see the value in the certification and the CE for recertification. You should too. Just do it.

SHARON WARD-FORE, MS, MT(ASCP), CIC, is an infection prevention consultant located in Chicago, Illinois. She is also a member of the Infection Control Today® Editorial Advisory Board.

. Certification Board of Infection Control and Epidemiology. Accessed March 25, 2021. 

https://www.cbic.org/CBIC/2020CandidateHandbook.pdf

Stand with the 7000 other infection preventionists who decided it’s important to be certified. It isn’t easy, but the satisfaction of this achievement far outweighs the preparation needed to pass.

Infection Control Certification: What Are You Waiting For?

It’s almost hard to believe the United States has been dealing with coronavirus disease 2019 (COVID-19) since January 20, 2020. The virus is still raging around the world. Health care is still struggling to keep up. Many businesses, large and small, have closed for good. Everyday activities such as getting your hair cut, going to the grocery store, gathering with friends, going to school or work, and eating at your favorite restaurant have changed drastically. These struggles and changes, in the health care and non–health care sectors, may affect things forever, at least in some ways. Fortunately, COVID-19 vaccine distribution has already started for frontline workers and long-term care/congregate facilities. Essential workers will be next in line for vaccination to help to revive the struggling non–health care sector. However, it will be too late for many working in restaurants and other businesses that lacked the same resources and level of preparedness as the health care industry.

Those working in health care have learned a lot during the pandemic about keeping patients and staff safe; managing supply chain items such as personal protective equipment (PPE), disinfectants, and other critical supplies; and preparing for shortages of staff and their emotional needs. Preparedness planning was something most facilities reviewed annually. Now, they are reviewing plans to determine when it might be safe to resume elective surgeries and other procedures placed on hold, as the pandemic becomes more manageable due to vaccination. Health care relies on specific guidance from the Centers for Disease Control and Prevention (CDC), and state and local agencies. They have plenty of resources available, including staff such as infection preventionists (IPs) to safely guide them along the journey to reopening and fully resuming care.

Dentistry has a very strong COVID-19 program guided by the CDC in collaboration with the American Dental Association (ADA). And they should have, as most of what they do involves performing aerosol-generating procedures, placing dentistry into a high-risk group category. The 

ADA offers a robust Return to Work Interim Guidance Toolkit and a COVID-19 Hazard Assessment & Checklist with recommendations for before, during, and after appointments to protect dentists, patients, and staff.1 Dentists and their staff were already well versed in using PPE and cleaning and disinfecting patient care equipment. Typically, they designate someone as their infection control person who can answer questions and provide guidance and training. They were able to ramp up procedures and see patients safely, gradually resuming the provision of dental services.

The American Veterinary Medical Association (AVMA) also had a tremendous number of resources for safely managing their practices and patients during the pandemic.

They produced a comprehensive risk management guide, Resuming Veterinary Practice Operations During the COVID 19 Pandemic (described as a “playbook to help our veterinary practices recover by addressing specific issues that relate to your team, patients and clients, property, and the practice’s profitability”).2

The CDC also provided additional guidance for veterinarians, including specific recommendations about companion animal practice, recommending screening companion animals for exposure to people with COVID-19. Additionally, veterinarians are familiar with PPE use, cleaning, and disinfection,3 and had many resources to guide practice and answer questions. Their practices were up and running fairly quickly with mitigation procedures in place to keep staff, clients, and pets safe.

Health care, be it for animals, humans, or teeth, had plenty of experience with the nuts and bolts of providing care. They had PPE use, disinfectants, and a wealth of resources at their fingertips, including financial ones.

However, the non–health care sector—corporations, schools, fitness centers, libraries, hair salons, restaurants, and other businesses—was not so fortunate. They did not have access to an abundance of resources, exposing a huge, glaring knowledge and resource gap that threatened their existence. Very few, if any, had a preparedness plan. Their guidance has been general, mostly “one size fits all,” at best, from the CDC, the World Health Organization, and state and local agencies.

This is not to fault any agency, because saving lives was and still is the priority; health care was overwhelmed with patients, so resources were naturally directed to patient care. But the non–health care sector was left to struggle more or less on its own, interpreting guidelines that were ambiguous at best, with terminology and processes that few were familiar with, such as contact time and PPE. Their experience was not in PPE or pandemics but in cutting hair, preparing food, providing fitness classes, teaching children, and helping you find a good book. And we thought health care had been turned on its head!

As an IP, I was shocked and worried about my safety and others’ when I ventured out to a grocery store or small business. I saw single-layer bandanas open at the bottom, gaiters soaked in water in hopes of preventing virus spread, a homemade face shield made from a plastic page protector attached to a cloth headband, face shields without masks, welding helmets, and even a swim mask with a snorkel attached—I kid you not. The vast, creative interpretation of PPE took my breath away. And everyone seemed to touch or adjust their mask every few seconds. It was maddening. And don’t get me started on social distancing.

Human resource departments, store managers, librarians, hair stylists, and restaurant owners were thrown into the role of figuring out for themselves how to continue to operate safely for their employees and clients. No 2 businesses are alike. There are lots of similarities, but just enough differences to make many physical setups unique. Most businesses, unlike health care, had no one to walk through their space with them and talk through risk mitigation strategies such as using physical barriers, adequately spacing out tables and chairs, establishing occupancy limits, and setting up or improving ventilation so they could safely continue to operate.

They had no one trained in hand hygiene, respiratory etiquette, cleaning and disinfection, or PPE selection and how to wear it, and who could work with their staff. There was no one to call or page in the middle of the night with questions. They were essentially figuring it out for themselves to the best of their abilities. As the pandemic wears on, the toll it has taken on businesses of every kind, both large and small, is enormous. Livelihoods are at stake. The non–health care sector needs more than a bunch of guidelines to help them.

In response to this need, some programs became available for businesses or individual employees, such as an online course covering what COVID is and how it spreads; masking, hand hygiene, and cleaning; and basic safe workplace practices. Upon completion of one 50-minute course you can be “COVID certified.” These basic courses are a good start but may also lead to a level of competency that isn’t really there. Passing a computerized course, putting what was learned into place, and making sure it “sticks” are not easy to do.

As an IP, I know that practices drift, not everyone learns in the same way, and auditing practices are vital, especially those you are unfamiliar with.

What is required is a more robust program specifically fine-tuned to a particular business. A relationship such as the one IPs have with their units—someone designated to guide them, answer questions, and be there for them—would be ideal. And there are IP consultants who work with non–health care sectors in exactly this way.

They provide hands-on training, auditing, and protocols, and act as a resource to help those in the non–health care sector operate safely during the COVID-19 pandemic.

I spoke with Phenelle Segal, RN, CIC, FAPIC, the president of Infection Control Consulting Services, LLC, to get her take on the struggles of the non–health care sector. She said, “The challenge for the non–health care industry has been the extensive volume of guidance coming from nationally recognized agencies. Guidelines are often confusing, and the non–health care sector has done a good job of interpreting general guidelines and adapting them to the best of their ability. The gray areas subject to interpretation and finer details are definitely challenging, and that is where external assistance is needed.

“Our experience has been very positive as these industries rely on our expertise to guide them to…keep their employees and customers or clients as safe as possible. We are amazed at the conscientious approach of our non–health care clients and their level of involvement to do the best for their employees and customers or clients. Several clients had already implemented policies and procedures…and needed us to validate and provide further guidance.” This is what is needed to help the non–health care sector survive and thrive during COVID-19—an ongoing relationship with an expert who is there for them every step of the way.

Unfortunately, there will be other pandemics and outbreaks in the future. So, I see this as an opportunity for IPs, specifically, to use what they have learned in their health care roles to help guide the non–health care sector to success. IPs have the skill set to provide guidance beyond the health care setting. We know how to select PPE and how to use it. Cleaning and disinfection are like breathing to us. Issues concerning construction and renovation, including heating, ventilation, and air conditioning systems and the importance of air exchanges, are something we deal with all the time. We routinely train others, answer questions, and provide guidance and resources. We can and should begin to look at helping the non–health care sector so they can safely thrive now and in the future. Perhaps, working with our local public health departments, we can model the approach health department inspectors use for restaurants, salons, schools, and businesses, focusing on COVID-19 mitigation and staff training. We can visit businesses and help them make a plan. The need is there: we can help guide the non–health care sector and validate their best practices so they can safely open their business, school, or church during the pandemic. Their employees need us. Our economy needs us. We should think about how we can step up and help because this is what we are good at. We can do this.

SHARON WARD-FORE, MS, MT(ASCP), CIC, is an infection prevention consultant located in Chicago, Illinois. She is also a member of the Infection Control Today® Editorial Advisory Board.

Get the Return to Work Interim Guidance Toolkit. ADA. Accessed December 18, 2020. https://pages.ada.org/return-to-work-toolkit-american-dental-association?utm_campaign=covid-19-Return-to-Work-Toolkit&utm_source=cpsorg-alert-bar&utm_medium=cpsalertbar-virus&utm_content=covid-19-interim-return-to-work&_ga=2.148380273.75969005.1610378717-1039469849.1610378717

Infection preventionists have the skill set to provide guidance beyond the health care setting. We know how to select PPE and how to use it. Cleaning and disinfection are like breathing to us.

By Sharon Ward-Fore, MS, MT(ASCP), CIC, FAPIC

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