Jack Murtha

In the 2016–17 flu season, government investigators found a series of promising statistics: In hospitals, vaccination coverage reached roughly 90% or more for various occupational groups, from physicians and nurse practitioners to assistants, aides, and nonclinical staff. The study1, published in the US Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report, also found that employer requirements and complimentary vaccinations were connected to greater vaccination rates.

But still, by that study’s numbers, vaccination coverage failed to reach roughly 10% of personnel. Outside hospital settings, the figures were even larger depending on the specific occupational group.

So, how can infection preventionists build a strategy to ensure that their healthcare workers-and, by extension, their patients-are prepared to ward off infection and illness? To find out, we spoke with Alma Jackson, PhD, RN, COHN-S, education director for the American Association of Occupational Health Nurses, who shined a light on where vaccination efforts are falling short and how infection prevention teams can improve the outlook.

What’s at stake when healthcare workers fail to receive vaccinations or prepare for respiratory season?

They get sick, and then they get everybody else sick.

For people who work in a hospital with acute care and even long term, there are certain vaccinations that are mandated by the health department. And I think it’s pretty equivalent between the states as far as the need to get measles, mumps, and rubella and a hepatitis B fighter or vaccination series. That way, you’re protected at least against hepatitis B if you get stuck with a dirty needle, but not HIV because there’s nothing else out there.

Since we’re ramping up for flu season, that’s the biggest concern right now. And so, the US Centers for Disease Control and Prevention extended the mandate that if you are working around patients and you don’t get the flu shot, you have to wear a mask all the time when you’re around patients, delivering patient care, because the flu is so easy to transmit.

 What do infection preventionists need to incorporate into their strategy to ensure that healthcare workers are up to date on their vaccinations and beyond?

 Sometimes it’s really just the mandates that get people in.

The last time I was doing the whole flu vaccine program at a hospital, people were given until Dec. 31 to get it or they could not work. You would be surprised at the number of people who just don’t take the time to get it. So, if you do the adult learning theory-what’s in it for me?-it’s not always the fact that you’re going to be well, but you also get to work.

And then it’s critical to provide updates, which happen all the time during the flu season, like from the CDC on the prevalence of flu in your area. Depending on how motivated people were, we would have drawings for things.

Hospitals face unique challenges heading into respiratory illness season. How can infection prevention teams stay ahead of the game?

Ironically, you have to order the flu vaccine months and months and months in advance to be able to get enough doses for your employees. We don’t really have control over whether it’s the right vaccine because we’re not the ones who create the makeup of how much is influenza A or B or any of the strings that are out there. So, I think just getting everything ready, announcing it months in advance, is key.

The Occupational Health Association is doing a webinar on flu that we’re already working on for next year in September. You need to ramp up people’s information and get them thinking about it, because otherwise they’ll forget to get a flu shot.

 What common oversight have you seen in infection prevention plans for occupational safety regarding vaccinations and respiratory illnesses? What can we be doing better?

 We’re actually not doing a bad job. The thing that sometimes falls through the cracks with vaccinations in general, is if there’s a series of three, like the hepatitis B, often people will fail to get the second or third one. And if they don’t get it on a timely basis, then they’re not going to develop the immunity for it. So, if you’ve got a large hospital system and you have some computer malfunction, then it’s pretty hard to track some of that stuff. Same thing with measles, mumps, and rubella and chicken pox.

And then with the flu shot, a lot of people don’t know that there is a different shot for people who are over the age of 65, and it boosts the immunity more. The AAP recommends FluMist Quadrivalent as a vaccination option for the 2019-2020 influenza season and advises families to vaccinate their children against influenza with either the flu shot or the nasal spray vaccine. So, sometimes it’s also really hard to keep current and keep up to date with the latest information that comes out.

 So how can infection preventionists overcome the challenges that you just described?

Sometimes it’s pulling teeth to get people to return for vaccines. In a hospital, after two emails, we notify the supervisor. And then, if that doesn’t work, then they can’t work.

I don’t know why some people are cavalier about it. If you look at epidemiology maps of places that are not in agreement with vaccines, like Boulder, Colorado, there are obviously more cases of measles, mumps, and rubella. You’ve heard of chicken pox outbreaks on the news. So, there’s that way of thinking, where people just don’t want to get them or get them for their kids.

The other part of it is that they just dismiss it as being unimportant. But if you’re going to work with patients, you’ve got to keep yourself healthy.

What does a strong infection prevention education campaign for healthcare worker vaccinations look like?

 Policies and procedures, which sound very boring, but they work. Also, of course, guidelines change, not often but often enough that to have an algorithm for what kind of vaccines people need is helpful. So, you have to have that first in order to be able to give the right stuff.

Say that they got the hepatitis B vaccine, and you draw it tighter because it’s been a while since they had it, and then they’re negative again. How many doses do you need to give them in order for them to boost their immunity? That algorithm can help.

And then, people on units can encourage each other to get vaccinated. Hospitals can also launch incentive programs where the first unit that has everyone vaccinated gets something.

Even if people aren’t cavalier about it, they still have to leave the unit to go get a shot or go visit their local Walgreens to get a shot. A lot of times, what we ended up doing was taking a flu cart to the floor for people who could never get away. Then we would give vaccines on the unit where they were working.

 How should infection preventionists personalize their educational messaging to suit specific target audiences, whether it be certain specialties or, say, environmental services workers?

 A lot of the educational information is still delivered on a sixth-grade reading level, because it has to be, which is unfortunate.
	Often around here and probably a lot of the United States, it can also be translated in Spanish or another language, depending on whatever your minority population is speaking, like navigational signs in an airport. If you can offer a class to your minority population-which is usually maintenance workers and housekeeping-offer it in Spanish so that they understand it better. And then we also have the consent forms and the information about it in Spanish, too.

Do you have any final advice for infection preventionists as they head into this flu season?

 Have plenty of stock of vaccines, masks, Band-Aids, alcohol wipes, and intramuscular needle sizes if they use the multidose vial. And just be ready for long days.

1.Black CL, Yue X, et al. Influenza Vaccination Coverage Among Health Care Personnel - United States, 2016–17 Influenza Season. MMWR Morb Mortal Wkly Rep 2017;66:1009–1015. DOI: http://dx.doi.org/10.15585/mmwr.mm6638a1

Articles

Alma Jackson, PhD, RN, COHN-S, discusses how to overcome this occupational hazard.

Are Your Healthcare Workers Armed With the Right Vaccinations?

Frank Drews, PhD, and his research team had interviewed many hospital employees, from environmental services workers to physicians, hoping to find the kind of clue that could advance patient safety. Before long, they noticed a peculiar habit. When these healthcare workers returned home after their hospital shifts, many of their shoes remained outside, near the door or beside the house.

“It’s because the healthcare workers knew that their shoes were the mostly likely area to be contaminated,” Drews, a psychology professor at the University of Utah who studies patient safety, told 

. “It’s for the healthcare workers themselves and it’s for their relatives.”

But pathogens didn’t require shoes to walk into the home. In their research, Drews and his team observed 48 healthcare workers as they doffed personal protective equipment (PPE), in this case disposable gowns, in 7 different departments at 2 hospitals. During the process, nearly half of the personnel potentially self-contaminated, and 42% failed to follow hospital-issued instructions for rolling up the gowns. Just 23% “avoided overt actions” linked to self-contamination, according to the study’s findings, published recently in the 

Investigators observed more than a dozen improper actions taken by participants, some of whom untied gown straps, used gloved hands to touch clothing, and rolled the gown with their bare hands. In some instances, they did not tie the gown at all and doffed while holding an electronic tablet. The contents of PPE trash cans overflowed onto the floor, while some items were disposed of outside the room.
	On its own, the frequency of deviation from US Centers for Disease Control and Prevention (CDC) and hospital guidelines concerned Drews. But the missteps also pointed to a larger problem in infection prevention: poor design.

Work on this research began with a grant from the CDC’s Prevention Epicenters Program, which had homed in on PPE and human factors. Drews, a cognitive psychologist focused on human performance in real-world settings, and his colleagues jumped at the chance to investigate PPE cues in a hospital context. The fusion of funding and interdisciplinary expertise made for an investigation of greater scope.

“By pulling in all the expertise from many, many areas to have a number of people looking at it very systematically, you can produce results that are more likely generalizable,” he said.

First, there was the design of the disposable gowns, particularly the strap and the closing mechanisms, which Drews said made procedural violations appear attractive to healthcare workers. For example, when partic- ipants tied the knot in the front, they might have later untied that knot because they could see it on their body, an error that increased the potential for self-contamination. Protocols, on the other hand, required healthcare workers to tie the knot in the back and pull off the gown.

“I think what we demonstrate here is really a cascading sequence of problems,” Drews said. “It is indeed originated by a certain design decision that is made when people develop these types of gowns.”

The solution, however, could be simple. He pointed to a different kind of a gown designed by his research team. Rather than tying a knot to secure the garment, healthcare workers who wear this gown may use a glue strip, ensuring they close access in the correct place.

Systematic Challenges and Self-Contamination

When asked to point to one thing that infection preventionists could do to reduce undesirable doffing behavior, Drews scoffed. For too long, the one-problem-at-a-time approach has stifled the evolution of infection prevention programs, he said.

“We’re dealing with a system that has many, many burdens imposed on people working in the system. And often, people have time pressure. They have limited resources. They have limited attention,” he added. “We’re often looking at problems in an isolated fashion, so we solve some problems, but we fail to acknowledge that an intervention might actually lead to a lot of surprises.”

Consider this: Several years ago, Drews and his colleagues examined the delivery of oral care for patients using a ventilator. If clinicians were required to perform an extensive search for the last known date that oral care was delivered, they opted to forgo care. But when investigators placed a sticker containing that information on the oral care pack in the patient’s room, clinicians completed the task. The problem dissipated thanks to easy access to pertinent information.

Encouraging Best Practices in Infection Prevention

Infection preventionists who aim to scale positive behavior in activities must anticipate the consequences of interventions, Drews said. If a gown is confusing to don or doff, how might a person react? To gain understanding, infection preventionists need to identify the factors that motivate their colleagues.

“As someone working in infection prevention and control, I’d want to understand what is getting in people’s way and then try to understand how we could solve the problem without creating new problems,” he said. “No one is doing this out of maliciousness.”

Success lies in the products and protocols that make it simple for healthcare workers to do their jobs. Otherwise, Drews noted, it’s possible that clinicians will overlook doffing procedures in favor of quicker patient care.

Self-Contamination Risk Is Real. Can a New Approach Help?

Healthcare workers face unique occupational hazards. In what other field can an employee so readily experience burnout, chemical exposure, and sharps injuries that introduce pathogens to the body? Now, a new study has further bolstered the list of healthcare workers’ concerns, suggesting that medical waste handlers are at increased risk of hepatitis B virus (HBV).

, the meta-analysis of 9 cross-sectional studies found that although just 3 of the papers revealed statistically significant relationships between HBV and medical waste handling, the pooled odds ratios for all studies showed a significant association overall. The chances of a medical waste handler contracting HBV were higher in Africa than elsewhere, likely due to insufficient infection control knowledge, according to the study.

“This meta-analysis documented an urgent problem, especially in African healthcare settings. This problem is potentially preventable if the right precautions are taken,” study co-author Ahmed Arafa, MBBCh, MS, a PhD student at Osaka University in Japan, told

 via email. “Of note, we detected a weaker association between medical waste collection and HBV in studies conducted in non-African health settings- with better infection control programs-than studies conducted in African ones.”

Why Infection Control and Prevention Must Prevent HBV 

Public health officials take great issue with HBV for several reasons. For one, according to the study, the virus affects 240 million patients globally each year, particularly in sub-Saharan Africa and Southeast Asia. With high morbidity and mortality rates, acute HBV infection stole more than 165,000 years to disability and resulted in 111,000 deaths, according to the World Health Organization. The virus also raises
	economic costs, touching everything from outpatient expenses to hospital admissions for related disease.

Because HBV infects people primarily through infected blood and bodily fluids and requires only limited exposure to wreak havoc, healthcare workers are at risk of contracting the virus. What’s more, as many as 66,000 HBV cases per year stem from lapses in sharps safety, according to the meta-analysis.

The problem is especially pronounced for medical waste handlers, Arafa said. As a physician in Egypt, he saw many of these individuals, who typically work on temporary hospital contracts, neglect to don personal protective equipment.

In a prior study, Arafa analyzed the knowledge, attitude, and practice of healthcare workers, including medical waste handlers, and came to concerning conclusions.

“I found that medical waste collectors had suboptimal knowledge, negative attitude, and careless practice,” he said. “Therefore, it was, somehow, predicted that medical waste handlers may carry the heaviest burden of blood-borne hospital-acquired infections.”

In Africa, where the risk of HBV to medical waste handlers is higher, it’s clear that leaders throughout the hospital should place more importance on infection control, Arafa noted. The sense of responsibility must extend into the C-suite.

But in countries where infection control is more advanced, infection preventionists and health system administrators can also do more to protect medical waste handlers-and thus patients-from the scourge of HBV.

“I think that the first step is to emphasize... the fact that medical waste handlers are part of the medical staff, and therefore they should receive protective equipment, free vaccines, and awareness programs, just like physicians, nurses, and lab technicians,” Arafa said.

Arafa A, Eshak ES. Medical waste handling and hepatitis B virus infection: A meta-analysis.

 2019 Sep 11. doi: 10.1016/j.ajic.2019.08.011.

When Medical Waste Handling Goes Wrong

It might be tempting to eyeball a surgical instrument and declare it clean, but guidelines call for quantitative assessments of apparatuses after they undergo sterile processing. Is the payoff-presumably, improved patient safety-worth the effort? If you ask Lauren Fitts, MPH, an infection preventionist at Missouri Baptist Medical Center in St. Louis, Missouri, the answer is clear: Of course.

She should know. As an intern, Fitts and her colleagues examined the cleanliness of tough-to-sterilize instruments used in hip, spinal fusion, and colon procedures. They used 3M’s Clean-Trace ATP System in a 450-bed community hospital to collect and analyze bioluminescence data. The research team ultimately found that 43 of 44 (97.7%) tested instruments logged an acceptable relative light unit (RLU) score, meaning they were deemed clean, according to the findings of the study, published recently in the 

“I can understand why people would say that it’s not necessary to perform these quantitative assessments. We got great results,” Fitts told Infection Control Today. “But when you have one wrong turn, especially with an instrument or an invasive device, that can cost someone their life, money, and quality of life.”


	Knowing that mere visual inspections had been proven insufficient, investigators set out to collect baseline adenosine triphosphate (ATP) testing data for surgical instruments. They hoped to bolster quality improvement programs and to develop a process in compliance with existing standards. Fitts and her colleagues zeroed in on a hospital with 23 operating rooms that performed roughly 60 surgical procedures per day, inspecting the most challenging instruments: Kerrisons, laparoscopic Metzenbaum scissors, Ochsners, and large Rongeurs.

During the course of the investigation, which ran for roughly 1 month in spring 2018, workers processed the instruments per Association for the Advancement of Medical Instrumentation guidelines and manufacturer instructions. This process included spraying the instruments with Steris Pre-Klenz, visual inspections, tagging and tracking, swabbing, manual wash, and a standard 24-minute machine wash.

But to assess the sanitization of each instrument, Fitts and her team turned to a relatively new method. Using bioluminescence, they measured ATP levels, which provided insights into the level of bioburden on a surface, potentially hinting at degree of cleanliness or contamination. The test relies on a swab and a reacting agent for a machine to determine how many RLUs, the unit for measuring ATPs, an instrument contains.

“ATP is the least labor-intensive, most cost-effective kind of biological test,” Fitts noted.

As per instructions from the test manufacturer, investigators defined cleanliness as an instrument with a readout of 151 or fewer RLUs. The mean RLU number after the machine wash was just 47, according to the findings.

Overall, the examination suggested that the community hospital’s central sterile processing department had done its job. That confirmation could provide peace of mind when things are running properly, but it could also serve as the sounding of an alarm if a breakdown in sterile processing were to occur, Fitts said.

“To get this process started, it ends up being like any other thing in a hospital, where you’re checking, you’re double-checking, and 9 times out of 10, everything’s great,” she said. “But you want to be sure that you catch that one time before it really has a negative impact.”


	As an early-career infection preventionist, Fitts appreciated the opportunity to shine a light on the often-overlooked central sterile processing department. She said she hopes her findings-and their implication that, at least in one hospital, the unit had executed well-would further underscore sterile processing’s crucial role.

“That’s a really critical part of the patient experience,” Fitts added, “and I think it needs to be treated with attention.”

Fitts LN, Yegge J, Goris A, Vinson S, Dubberke E. How clean is clean enough? An observational pilot study to assess central sterilization processing efficacy with adenosine triphosphate levels. 

. 2019 Sep 10. pii: S0196- 6553(19)30750-3. doi: 10.1016/j.ajic.2019.08.006.

Jack Murtha

Articles

Are Your Healthcare Workers Armed With the Right Vaccinations?

Self-Contamination Risk Is Real. Can a New Approach Help?

When Medical Waste Handling Goes Wrong

Spotlighting the Strength of Central Sterile Processing With Bioluminescence