JAN DYER is a writer and editor specializing in clinical topics. She lives in Suffern, New York.

Jan Dyer

In the 15th century, Niccolò Machiavelli, a politician who is famous for his canny strategic advice, wrote, “There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success than to take the lead in the introduction of a new order of things.”

This is still true. Say you’re trying to get a hand hygiene intervention tested in your hospital. You know there’s a clear need. You have historical and current data about infection incidence, you have anecdotal evidence from staff and patients, and you’ve seen with your own eyes how often the guidelines are breached. However, the people running the place don’t see it the same way, which is the problem you’d like to solve. What do you do?

Study after study of infection prevention and control (IPC) interventions and programs have concluded that you don’t get far without management support. Such support can take many forms, including funding for the project, communication about the project, and visible backing for the project. There is no question that to execute a project successfully, a team must be well rounded, with representation ideally from all stakeholders. That includes leadership.

It’s usually easy to find out where and why management support might be needed. Just ask the staff. For example, a Cochrane review observed 20 studies exploring the views of health care workers (HCWs) on adherence with IPC guidelines for respiratory infectious diseases.

 The HCWs said they weren’t sure whether to follow local guidelines if those differed from national guidance. They struggled to follow long or unclear guidelines, especially if the advice kept changing. In fact, nurses in one study termed impractical guidance as 

. They pointed to a lack of training about infection and how to use personal protective equipment.

One of the top findings was that adherence was influenced by the level of support HCWs felt they received from their management team. HCWs who perceived that hospital administration and managers were supportive and who openly demonstrated that support were more willing to engage with IPC. For example, one nurse was quoted, saying “The practice by administrators of making rounds on the units and offering words of encouragement was perceived as being supportive of staff.”

Other investigators who reviewed 56 papers on HCWs’ adherence with infection control (IC) measures found that leading by example was key—not just setting standards for IC practices but reinforcing them.

Communication, verbal and nonverbal, is perhaps the most important variable when you need to get parties of any kind to go along with something. “When I’ve encountered barriers along the way of opposition, it usually ends up being a case of miscommunication or misunderstanding. That is why communication with all impacted stakeholders is so important at the beginning,” Rebecca Leach, MPH, BSN, RN, CIC, told 

Leach, who is the director of infection prevention at a level 1 trauma center in Phoenix, Arizona, has experience in both trying to implement infection prevention (IP) practices and getting support from leadership to invest resources to build the IP program. “Implementing change brings about anxiety, which is a natural response,” she said. “It’s easy to get frustrated with a person or group who seems resistant. However, we have to be a bit of a psychologist and try to understand what the underlying fears are associated with the proposed change.”

It can also help to consider managerial style. Managerial styles reflect how the best managers “will achieve strategic goals through task assignment and resources allocation, and how they will use management information for controlling and monitoring the achievement of different strategic policies,” according to David Naranjo-Gil, of the Universidad Pablo de Olavide in Sevilla, Spain.

 For instance, the style might be proactive or interactive, focusing on solving problems before they have a chance to appear. Or it might be reactive or diagnostic, focused on responding to events after they have appeared.

“A proactive managerial style involves debate and dialogue among managers and subordinates at different organizational levels, which stimulates opportunity-seeking, proactive behaviors and encourages the development of new activities and actions. In contrast, a reactive or diagnostic managerial style focuses on controlling efficiency of prescribed tasks and on monitoring organizational outputs by comparison with preset standards to analyze potential deviations and correct them to achieve the intended strategic goals,” Naranjo-Gil wrote.

If you want to introduce a project, you need leadership to agree. But it isn’t enough to get a “go ahead”—you need commitment. “Countless quality and safety initiatives are launched with good intent but wither on the vine because of a lack of effective leadership,” said investigators from the Vanderbilt University Medical Center (VUMC) in Nashville, Tennessee.

They launched a system-wide initiative aimed at achieving and sustaining hand hygiene (HH) adherence and reported on the implementation and impact. Based on their experience, they recommend that project leaders continuously evaluate health system leadership support. Some questions they found critical to evaluating commitment include the following:

Is the project consistent with the system’s quality and safety priorities?

Does financial support exist, including support for key personnel?

Are system leaders willing to publicly affirm commitment to the goal and its associated metrics?

Are leaders willing to address nonadherent individuals?

“Too often, system leadership support is signaled initially but then disappears once difficult decisions arise, undercutting the authority of the project team,” the investigators said. To forestall that, before beginning the VUMC HH program, they secured leadership commitment. When individuals resisted elements of the HH plan, VUMC leadership was prepared and responded “in a measured and effective way.”

Of course, even with willing participants on all sides, it’s not uncommon to run into obstacles, such as a promising avenue getting blocked or support suddenly disintegrating. You find that Option A doesn’t work against Obstacle A, so you try Option B, then come up against Obstacle C. “This is typically where I apply the PDSA [Plan-Do-Study-Act] cycle,” Leach said. The PDSA cycle is a process for testing, evaluating, and improving a project or product.

“With every new initiative or proposal to leadership, I do my best to anticipate the barriers, pull together key stakeholders ahead of time to get more information, and try to have a plan in place before things are implemented,” Leach said. “Of course, you will always have something come up or a plan that doesn’t work. One thing is not to take it personally, because we are working with humans, and you cannot control all the variables. Keeping flexibility, keeping your stakeholders engaged, and being open to changing the course to address new barriers is important.”

Some obstacles are recurrent. In fact, they might be said to be endemic. “Financial barriers are never a surprise, because typically, IP departments do not have budgets beyond personnel, so it is never our money being used for new products or to help implement change,” Leach said. The most common obstacle “tends to be competing priorities,” she said. “There are always several quality and safety initiatives going on at the same time, as well as other organizational challenges, such as staffing.” 

When Leach runs into that kind of recurrent issue, her practice is “to try to meet the team where they are, listen to what they perceive as barriers, and figure out how to integrate HAI [health care–acquired infection] prevention into everyday practices. Also by building trust and relationships and telling stories. Telling staff stories about patients they’ve cared for can be very impactful.” Basically, she gives a case summary about the patient, including what happened to them, where they went, and what their state upon discharge was.

What if the issue is not just about getting interventions or projects approved but about justifying the need for your entire department? “A few years ago, our [IPC] department was on the chopping block to reduce its size. We were 8 IPs covering a 900-bed acute care academic medical center with 5 other hospitals in our system,” one IP told 

®. The IP team was more than surprised. “The need to justify the existence of our department rocked our world.”

The main obstacle was the fact that IP was not a revenue generator. “The ‘powers that be’ were looking for ways to save money,” the IP said. “Fortunately, our medical director was determined to keep the staff and department. She began building a case based on patient safety—the main reason [IPC] exists—by outlining costs of HAIs. We listed everything IC laid hands on. We provided our medical director with a list of all the areas we covered, all the education we provided, all the surveillance we performed, all the construction projects we provided support to, [and] how closely we worked with risk and quality assurance, just to give a few examples. She was able to figure out how much money we saved the hospital by doing all the things we did.”

One of the more challenging tasks was “helping nonclinical decision makers understand all that infection prevention does,” the IP said. The main takeaway from the experience was that “everything comes down to money. If you can prove that your department—although not a revenue generator—saves the facility money, that’s a good start. Also be able to list [what] your department is involved in. That was a real eye-opener to the C-suite,” the IP said.

What’s the hardest part of getting buy-in? “Right now, the hardest part is that everyone is tired,” Leach said. “COVID-19 response has exhausted staff and leadership. [Although] many are eager to work on something other than COVID-19 response, we [must] acknowledge that there will be long-lasting impacts to the morale and mental health of HCWs. Similarly, we’ve had so much movement of staff, with people leaving, new graduates, travel staff, etc, [that there are now] so many new faces to educate...and try to bring into the fold.”

With so many variables to consider, including an overwhelming pandemic, there is always a potential for setbacks. Goals will change, great ideas will fall by the wayside, and you may need to pause and regroup again and again. But as the Taoist Sun Tzu teaches in 

, choose your battles. “He will win who knows when to fight and when not to fight,” Sun Tzu wrote. Over 2000 years later, this is still a useful concept.

“Sometimes you will not be able to overcome a barrier, and then you try to compromise,” Leach said. “I pick my battles and make sure my perspective is adjusted and that it’s not just me pushing something because I think it’s the best way to handle the situation.” It can be a bitter pill to swallow, but sometimes you have to let go. You can’t win them all.

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Naranjo-Gil D. Accomplishing water strategy policies in hospitals: the role of management information systems and managerial styles. 

Talbot TR, Johnson JG, Fergus C, et al. Sustained improvement in hand hygiene adherence: utilizing shared accountability and financial incentives. 

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Articles

Health care workers' adherence to guidelines and overall job satisfaction are influenced by the level of support they feel they receive from their management team. 

Getting Managerial Buy-In for Infection Control Efforts 

The water left in the shower drain. Dialysis water. Flower vases. That decorative waterfall in the lobby. The ice machine.

Water, water everywhere—and so easily turned into a pool for pathogens.

Reservoirs, meaning any place indoors or out where water can accumulate, in all sorts of places, expected and unexpected, are linked to nosocomial outbreaks of infections. Investigators from the University of North Carolina, for instance, tallied a multitude when they reviewed 1746 reports of health care­–associated outbreaks and infections linked to a water reservoir.

The reports varied widely in both origins of contamination and results. In one case, whirlpool tub water was contaminated from the drain when the tub was filled, leading to “strong causation” of bloodstream infection, pneumonia, and urinary tract infection in patients with leukemia. At another facility, an outbreak of 

 in the intensive care unit was traced to contaminated faucets. In another instance, patients developed postoperative wound infections after ice contaminated with 

 was used for cardioplegia. In a nursing home, patients who inhaled shower aerosols developed Pontiac fever.

An estimated 65% of HAIs are associated with wet biofilms, or the presence of moisture or liquid. 

Water-damaged plaster caused an outbreak of 

. Deionized water from a hospital pharmacy caused an outbreak of 

Because the issue often is the entire water system, everyone in the hospital is at risk all the time. The enemy is always at the gates. According to a 2019 presentation at an Association for Professionals in Infection Control and Epidemiology (APIC) Greater NY chapter meeting, for instance, 70% of all building water systems contain 

Think of all the ways water is used in a hospital. How do you protect against waterborne infections when water itself is nearly ubiquitous?

The first step for a health care facility is to develop or improve a water management program.“They should first ensure that they have a water management program team, a multidisciplinary group including representation from facility administration, facilities management, facilities engineering, and infection prevention, with other team members included depending upon expertise and needed roles,” Kiran Mayi Perkins, MD, medical officer and team lead, Outbreak and Response Team, CDC, told 

® (the CDC has a Healthcare Facility Water Management Program Checklist to help health care facilities develop a program

Having a team is important, but Kari Brisolara, ScD, MSPH, associate professor of environmental and occupational health sciences at Louisiana State University’s School of Public Health in New Orleans, told 

® that “one aspect that tends to have the most impact but tends to be lacking from the priority list is the importance of managerial buy-in. The ideas of proactive vs reactive managerial styles and how education and outreach programs are prioritized by upper and midlevel management within a facility are just as important as the engineering design in some cases.”

Once the team is pulled together, the process is multistep: Members need to describe the building water systems using flow diagrams and a written description to identify areas where 

 and other opportunistic premise plumbing pathogens (OPPPs) could grow and spread. Thereafter, the steps are programmatic: Decide where control measures should be applied and how to monitor them, establish ways to intervene when control limits are not met, make sure the program is running as designed and is effective, and document and communicate all activities.

What are some areas most likely to be overlooked? Rasha Maal-Bared, a wastewater treatment specialist at EPCOR, a utility company in Edmonton, Alberta, Canada, gives some pointers, with particular reference to 

Maintain water temperatures outside the ideal range for 

 can live and proliferate in a facility’s water system at a wide range of temperatures: from below 68 °F, at which the pathogen survives but is dormant, to 151 °F, at which 99% of the pathogen dies within 2 minutes of direct contact.

Identify areas in the facility where aerosolization and cross-contamination are likely.

 especially in medical and dental devices.

Maintain premise plumbing, equipment, and fixtures

 to prevent sediment, scale, corrosion, and biofilm, all of which nurture pathogens. (Maal-Bared notes that the ASHRAE 188 standard does not require building managers to test for 

, given the lack of scientific consensus on the topic. Teams that do decide to test for 

 must have a clear idea of sampling methods, tests, sites, and frequency ahead of time; and what corrective actions will be taken should 

Maal-Bared adds an important recommendation: Develop “a robust relationship” with the utility in the jurisdiction to get notifications of changes in water quality due to main breaks, infrastructure repair, construction, or depressurizations.

Perkins points out another area of clinical care that may often be overlooked:respiratory therapy. “Many outbreaks due to water-related organisms have involved respiratory infections,” she says. “Providing respiratory therapy may involve potential routes of transmission of water-related organisms, for instance via nebulized products and respiratory equipment that uses water, either intentionally or inadvertently.”

Every day about 1 in 31 US hospital patients receives a diagnosis of at least 1 infection related to hospital care alone.

 The cause of many of those? Water. An estimated 65% of health care–acquired infections (HAIs) are associated with wet biofilms or the presence of moisture or liquid.

It is not always easy to pinpoint the culprit. Investigators from University Hospital of Montpellier in France assessed the spread of OPPPs through secondary water routes (outside the plumbing system) in an adult hematology unit. They identified 6 secondary routes. 

, as well as nonpathogenic OPPP indicators, were detected in water collected upstream of antimicrobial filters. 

 was the sole OPPP retrieved from tested surfaces; the same clone of 

 spread from water source to dry surfaces in the same room and cross-contaminated 2 sinks in different rooms. Three clones of nonpathogenic OPPP indicators spread more widely in different rooms.

Perkins says that because of the complexity of HAI outbreaks,“most investigations of water-related infection outbreaks do not identify a definitive source of infection. For this reason, it’s difficult to rank the sources of health care outbreaks involving water-related organisms. However, anecdotally and based on CDC experience in supporting health departments and health care facilities with such investigations, we have found that preparing medications and storing or placing patient care items near water sources, such as the splash zones of sinks, are often identified as potential sources of infections.”

The most common uses of water in health care facilities are typically related to domestic and restroom (about 35%) and cooling and heating (about 20%), says Brisolara. “But it’s important to examine all variations of use within the health care setting to look for risks and opportunities for minimizing use and vulnerabilities,” she continued. These include, for instance, ensuring that the water entering the facility meets all applicable quality standards; that the plumbing within the facility is designed and maintained with the goal of minimizing growth and spread of waterborne pathogens from both the supply and waste transport sides; and that exposure to potentially contaminated water sources is minimized.

It is also crucial to be on the lookout for pathogens not typically considered waterborne but that turn up in the water, say investigators from Flinders University in Adelaide, South Australia.

 They reviewed studies that investigated the role of water and water-related devices in the transmission of antimicrobial-resistant bacteria. Biofilms were a “hot spot,” they found, for disseminating genes responsible for survival functions. (Also, because different types of bacteria may contaminate the same drain, antibiotic-resistant genes may be transferred between bacterial species.)

 were common in the potable water supply and on plumbing surfaces, such as faucets. Antibiotic-resistant pathogens, including extended-spectrum β-lactamase–producing Enterobacteriaceae and methicillin-resistant 

, were located in a hospital sink bowl, hospital bathroom sink taps, and a hospital bathtub. Faucet spouts were more contaminated than sink bowls and drains. The researchers also point to “flawed sink design,” such as shallow bowls that make it easy to splash contaminated sink contents onto patient care items, hands, and the broader environment.

Hospitals may seem like worlds unto themselves, but they are also working parts of a larger, complex, interconnected system. In an article on monitoring coliphages, Brisolara and Maal-Bared discuss a “One Water” concept: managing all water in an integrated, inclusive, and sustainable manner.

 This posits that components of the water system have “overlapping and interactive impacts” on other aspects of the system. Such inclusiveness can have a major impact on public health and hospital populations: For instance, monitoring wastewater in communities for fecal bacterial pathogens has provided evidence of COVID-19 clusters—information that can help health officials assess spread.

Individual states develop their own water quality standards, but state rules must be at least as strict as the federal rules (ie, the federal rules represent the minimum standards). Some states choose to just follow the federal regulations, Brisolara says, but most opt for more stringent rules, usually based upon special environmental situations such as water usage restrictions and wetland protections. She adds that hospital wastewater has industry-specific effluent guidelines that facilities must meet prior to discharge into the public wastewater system.

The One Water framework emphasizes the need for multisector coordination and collaboration. Prevention of waterborne infectious diseases requires a comprehensive response because the water cycle encompasses surface and groundwater, drinking water, wastewater, stormwater, and reused or reclaimed water. The overall concept may seem simplistic, Brisolara concedes, but she says there are aspects that can be complex, including the dependency of the kinetics on climate, season, and geography.

“It allows us to look at the full picture,” Maal-Bared says. “Particularly where the pathogens are coming from. It allows us to look outside the boundaries of one building or facility and explore external changes in the distribution system or source water that will introduce hazards that require control.”

For example, although municipalities treat their water with disinfectants, several factors may help propel pathogens into a building’s water distribution system. Maal-Bared gives some examples:

 (including renovations and installation of new equipment) can cause vibrations and changes in water pressure that dislodge biofilm and release 

 or other waterborne pathogens. Biofilm in pipes can give pathogens a safe harbor from disinfectants.

 Changes in water pressure can dislodge biofilm and release waterborne pathogens, as well as introduce dirt and other materials into the water that use up all the available disinfectant.

 can increase sediment, lower disinfectant levels, increase turbidity, or cause pH to be outside recommended ranges. Also, if a supplier changes the type of disinfectant it uses, this change can impact how the water management program team should monitor its building water systems.

Taking a holistic approach comes naturally to many in health care, and it can make a difference in everything from building the water management team to teaching staff how to reduce risks in the patient’s room. “In health care, the importance of ‘One Health’ and ‘One Water’ is clear,” says Brisolara. She highlights the value of an interdisciplinary, interprofessional team. “The team is not just defined within the discipline of health care, but should include public health, engineering, water resources, environmental justice, social services, and most importantly, the community served. This is the only way to create sustainable solutions that will allow for the holistic approach to work.”

Keeping patients and staff safe from flotillas of pathogens is a daunting mandate. Perkins, Brisolara, and Maal-Bared all offer their top advice for hospitals and facilities.

“Health care facilities should remain vigilant in keeping these organisms from reaching patients through effective and strong infection prevention and control practices,” Perkins says. “They should also ensure that they’re ready to respond to signals of patient harm due to potential water-related organisms.” Moreover, health care facilities should bear in mind that it is not just about 

, she warns. Water management programs should address the many other organisms that inhabit health care water systems and pose a risk to patients.

Brisolara, proponent of the holistic One Water concept, says, “Think outside of your facility and comfort zone when forming a team to plan and evaluate your water.”

For Maal-Bared, it is basic: “Never underestimate the power of a good, well-thought-out water safety plan.”

Kanamori H, Weber DJ, Rutala WA. Healthcare outbreaks associated with a water reservoir and infection prevention strategies. 

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Erspamer, R. Liquitech. Waterborne Pathogens: Where They Come From, Why they Matter, & Paradigms to Protect Your Facility. Association for Professionals in Infection Control and Epidemiology Greater NY Chapter 13 Meeting; May 15, 2019; New York, NY. 

http://apicnyc.org/2019-meetings-and-programs.html

Healthcare facility water management program checklist. CDC. Updated November 17, 2021. Accessed February 15, 2022. https://www.cdc.gov/HAI/pdfs/Water-Management-Checklist-P.pdf

Healthcare-associated infections (HAIs): HAI data. CDC. Updated October 5, 2018. Accessed February 15, 2022. www.cdc.gov/hai/data/index.html

Yiek WK, Coenen O, Nillesen M, van Ingen J, Bowles E, Tostmann A. Outbreaks of healthcare-associated infections linked to water-containing hospital equipment: a literature review. 

. 2021;10(1):77. doi:10.1186/s13756-021-00935-6

Baranovsky S, Jumas-Bilak E, Lotthé A, et al. Tracking the spread routes of opportunistic premise plumbing pathogens in a haematology unit with water points-of-use protected by antimicrobial filters. 

. 2018;98(1):53-59. doi:10.1016/j.jhin.2017.07.028

Hayward C, Ross KE, Brown MH, Whiley H. Water as a source of antimicrobial resistance and healthcare-associated infections. 

. 2020;9(8):667. doi:10.3390/pathogens9080667

Healthcare-associated infections (HAIs): reduce risk from water. CDC. Updated September 11, 2019. Accessed February 15, 2022. https://www.cdc.gov/hai/prevent/environment/water.html

Fitzmorris-Brisolara K, Maal-Bared R, Worley-Morse T, Danley-Thomson A, Sobsey M. Monitoring coliphages to reduce waterborne infectious disease transmission in the One Water framework. 

. 2022;240:113921. doi:10.1016/j.ijheh.2022.113921

How do you protect against waterborne infections when water itself is nearly ubiquitous?


Water: Life’s Vital Necessity Can Also Be a Pool for Pathogens

Picture a busy outpatient clinic: physical therapy, oncology, cardiac, dental, urgent care. Over the course of a day, dozens of people—even amid COVID-19—may pass through its rooms: staff, patients, parents, caregivers, delivery people. In the US, outpatient visits have climbed steadily, to nearly a 

. According to the CDC’s “Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care,” the past several decades have seen a “significant shift” in health care delivery from the acute, inpatient hospital setting to a variety of outpatient and community-based settings. More than three-fourths of all operations in the US are performed in settings 

But although they have the same main players—health care providers, other staff, patients—outpatient settings are not like inpatient settings. They have unique requirements and circumstances, including those related to infection prevention and control.

Epidemiologist Joe Perz, DrPH, who works for the CDC’s Prevention and Response Branch, told 

) that “compared with inpatient care in a hospital setting or congregate care in long-term care settings like nursing homes, the outpatient environment has a ton more variety, in terms of the types of care provided. While core practices like hand hygiene and environmental cleaning apply to all patient encounters, outpatient settings also provide more specialized forms of care that come with more specialized infection control requirements. Plus, the volume of patient encounters is staggering, and this is spread across an enormous number of individually operated facilities, many of which do not have clear lines of oversight for infection control. These distinctions present significant challenges.”

If Perz had to list the top 3 of those challenges, here’s what he would choose: “Broadly speaking, I’d cite awareness, attention, and consistency. Traditionally, many outpatient settings had infection control quite low on their list of priorities and concerns. Too often it was out of sight and out of mind. Not surprisingly, knowledge of even the basics of infection control was lacking and we saw many gaps in terms of things like hand hygiene, injection safety, cleaning, and even device reprocessing. There were attention deficits and a lot of inconsistencies in terms of how outpatient providers practiced infection control.”

The result? The CDC says data similar to those for hospital-acquired infections are lacking for most outpatient settings, but “numerous outbreak reports have described transmission of gram-negative and gram-positive bacteria, mycobacteria, viruses, and parasites. In many instances, outbreaks and other adverse events were associated with breakdowns in basic infection prevention procedures.”

Case in point: In 2015, a CDC research team reviewed investigations of health care-associated infection outbreaks in Los Angeles outpatient settings between 

. Of the 28 investigations, 79% revealed more than 1 infection control breach.

Lapses in infection control were suspected as the source for 16 (57%) of the investigations, such as using single-use medications multiple times or reusing fingerstick blood glucose meters. Bacterial agents were implicated in half of the identified outbreak investigations. Breaches were frequently associated with injection safety, equipment processing and sterilization, and environmental cleaning. An investigation of a urology office, for instance, revealed that the facility had been improperly cleaning and disinfecting cystoscopes for more than 10 years.

The investigators were perturbed by their findings. “The lack of change in 5 decades related to outbreak source and infections resulting from preventable unsafe behaviors is alarming,” they wrote in their report for 

, “Most outbreaks documented could have been prevented by using standard precautions and practicing basic infection control. These findings highlight a need for more infection control oversight of outpatient settings, as well as better reporting from outpatient settings.”

That was 6 years ago. Has time made a difference? Time that has included COVID-19? Things have changed, after all. A 2020 data analysis found visits to ambulatory practices declined nearly 60% by early April 2020. Even after a rebound (across all specialties), numbers were still roughly one-third lower than 

And in a 2021 study, investigators tallied outpatient visits between January 1, 2020, and June 15, 2020, among 16,740,365 

. They found in-person visits from January 1 to June 10 dropped from 102.7 to 76.3 (a decrease of 26.4 or –30.0% change). By the last 4 weeks, the percent change from baseline ranged from –73.2% in Hawaii to –16.0% in Alaska.

No matter how few the visits, though, the basic problems remain. Kelsey OYong, MPH, CIC, supervising epidemiologist at Los Angeles County Department of Public Health and lead author on the investigation review, tells 

 that “other than COVID-19 in the past 2 years, lapses in infection control continue to be the most common source of outbreaks.”

Though this varies by outpatient setting type, says OYong, her department continues to see reuse of single-dose vials and equipment as outbreak sources. Culprits also include environmental contamination and improper cleaning and disinfection of equipment.

“In a way,” says OYong, “the COVID-19 pandemic has highlighted the importance of infection prevention generally, and specifically in the realms of respiratory hygiene, personal protective equipment, source control, and employee health. Many outpatient settings are improving infection control practices and knowledge as it relates to respiratory diseases. We hope that this knowledge translates to other diseases, spread by contact or procedures, as well.”

The ultimate goal in all this is not only good health care, but safe health care (take another look at the title of the CDC guide, however; it sets the bar for safe care with “minimum expectations”). Many vulnerable patient populations rely on “frequent and intensive use of outpatient care to maintain or improve their health,” the guide says. Each year, for instance, more than 1 million cancer patients receive outpatient chemotherapy, radiation therapy, or both. But according to CDC data, since 2002, at least 9 serious infectious disease outbreaks, including unsafe injection practices, have occurred in cancer clinics. Hundreds of patients were infected; thousands more required notification and testing for 

Obviously, building—or reinforcing—a stronger foundation for infection control would help. Compared with inpatient acute care settings, the CDC says, outpatient settings have traditionally lacked infrastructure and resources to support infection prevention and surveillance activities. And, to restate more of the obvious, outpatient settings are not like inpatient settings.

“In the broader context of all the hardships we’ve experienced, on the provider and patient sides of ambulatory care, there is greater appreciation of infection risk,” says Perz. “And we are seeing this across the spectrum, from primary care to specialized outpatient settings.” But, he adds, “to maintain effective outpatient care, there needs to be a foundation of protections, for both patients and health care workers.

OYong agrees. “The pandemic has stretched health care workers to their professional and emotional limit. For many settings, the majority of staff time is now spent on COVID-19 response efforts, taking away especially from surveillance and adherence monitoring activities. Stress and burnout are serious concerns for the health care workforce.”

They’re not only worn out; they’re also being stretched intolerably thin.“For infection preventionists in the outpatient setting,” she says, “juggling many different roles is a big challenge. They often play the role of infection preventionist, employee health director, risk manager, health educator, and health care epidemiologist, plus their normal nursing and clinical roles.”

Moreover, she points out that “sometimes designated infection preventionists [Ips] in outpatient settings don’t have the same access to resources or community that inpatient IPs have. They often work independently if they’re not part of a larger health care system or network and may not have access to community best practices or policies.”

That’s beginning to change, though, Perz says. “One very positive development I’d like to highlight is 

, CDC’s national infection control training collaborative. Project Firstline’s content is designed so that, regardless of a health care worker’s previous training or educational background, they can understand and apply the infection control principles and protocols needed to protect themselves, their facility, and their patients from all infectious disease threats, such as COVID-19.” (“The COVID-19 pandemic has underscored gaps in infection control knowledge and practice in healthcare settings nationwide,” the 

Project Firstline teams up a coalition of academic, public health, and health care partners plus 64 state, local, and territorial health departments through the Epidemiology and Laboratory Capacity for Prevention and Control of Emerging Infectious Diseases Cooperative Agreement. One of the initiatives integrates “enhanced infection control content” into community college classrooms. The program designers say they chose community colleges because they educate a significant portion of the US nursing and allied health care workforce; know how to meet the unique training needs of a diverse, intergenerational health care workforce; and are equipped to tailor training and educational resources to fill critical gaps in underserved communities.

While those up-and-coming health care providers are being trained, what to do about the ones with boots already on the ground? OYong has some suggestions for how to handle the persistent challenges she and the other investigators identified in 2015. For instance: Make it a group effort. The pandemic naturally changed practice. It also may have changed attitudes about “my job” vs “their job”; we’re truly all in this together.

“Building an infection prevention team helps mitigate all of those responsibilities falling to a single person,” she says. “Creating a facility-wide culture of safety helps all staff take accountability for infection control. Empowering all staff to speak up when they see issues with PPE, injection safety, etc. helps stop lapses at their source.”

Perz says “thepandemic experience taught us a lot about keeping our guards up to keep infection risks down. This begins when patients enter—or even approach—an outpatient facility. We are now all much more sensitive to the needs for things like screening, triage, and source control. We have been forced to be more mindful of the needs for worker protections, which were often taken for granted. These needs were all present prior to the pandemic but were vastly underappreciated.”

In the meantime, here’s his best evidence- and experience-based advice: “Remember that your efforts to stem the spread of infections are making a real difference. As health care providers, your mission has always been to protect health and promote quality of life. More than ever, infection control is central to this mission.”

Jan Dyer is a writer and editor specializing in clinical topics. She lives in Suffern, New York.

Outpatient settings are not like inpatient settings. They have unique requirements and circumstances, including those related to infection prevention and control.

Infection Control in Outpatient Settings: Old Challenges, New Realities

Bacteria love surfaces. They need them to survive and thrive. Through adhesion to surfaces, they can form biofilm, a slimy extracellular matrix, that makes them hundreds of times more effective in resisting antibiotics.

Viruses also love to cling to things. That’s why one of the first responses to SARS-CoV-2 was to find out just where and how long it survived outside the body.

And early research duly alarmed the world. Laboratory studies suggested that the virus could last anywhere from hours on clothing to 3 days on paper money to 6 days on hard surfaces such as plastic and stainless steel. In early 2020, scientists identified RNA of SARS-CoV-2 on a variety of surfaces in the cabins of both symptomatic and asymptomatic infected passengers aboard the 

up to 17 days after the cabins were vacated but before disinfection procedures were conducted.

 They could not at the time determine whether there was any transmission from surfaces.

More recently, investigators have found that surfaces can be positive for the COVID-19 virus but that the viral material isn’t actually able to infect cells. Transmission of COVID-19 via surfaces is rare. Emanuel Goldman, PhD, a professor of microbiology at Rutgers New Jersey Medical School, became irritated by the way COVID-19’s viability on fomites (inanimate surfaces or objects) was being tested. In a comment letter to 

in August 2020, Goldman wrote that the risk was being exaggerated.

 Although investigators were claiming virus survival of up to 6 days, he said, they were placing very large initial virus titer samples on the surface being tested.

“None of these studies present scenarios akin to real-life situations,” he said. In an interview with 

 published in January 2021, he said, “The viral RNA is the equivalent of the corpse of the virus. It’s not infectious.”

So how to deep-clean contaminated surfaces? One relatively new way is with electrostatic sprayers (ESSs). The method has been used for more than 50 years in agriculture to reduce spray drift when applying pesticides to crops, but it has been used only in the past 10 years or so in health care settings. Thanks to COVID-19, the past 2 years have been profitable for disinfectant manufacturers. By the end of 2020, global sales of surface disinfectant totaled $4.5 billion—a jump of more than 30% over the previous year.

 To give that context: In 2019, the market size was expected to cross just $1.9 billion by 2025.

The COVID-19 virus does not last long on surfaces that have a lot of holes or microscopic grooves, nooks, or crannies, said Frank Esper, MD, in an article for Cleveland Clinic’s website—but those areas are where ESS shines.

 Most pathogens love complex surfaces and, given the chance, will settle right in. Norovirus, for instance, which can infect with minute amounts, can stay transmissible on objects and surfaces for days or weeks. Moreover, it can survive some disinfectants.

ESS offers a fast way to clear out pathogens from wide areas. EvaClean, which is certified by the Occupational Safety and Health Administration, has an ESS that uses disinfecting tablets registered with the Environmental Protection Agency (EPA). EvaClean states it takes approximately 30 to 45 minutes to clean and disinfect a hospital room using traditional methods but its ESS can reduce those times by 40%.

 Moreover, depending on the disinfectants used, the ESS can kill 99.99% of bacteria found in biofilm, 

, and other viral and fungal infections, EvaClean states.

An ESS is based on the universal interaction between positive and negative forces. (Remember rubbing a balloon to create static and then sticking the balloon to a wall or your head? Same general principle.) Most surfaces have a (grounded) negative surface charge. The sprayer positively charges the disinfectant as it passes through the sprayer nozzle, and the charged disinfectant droplets seek out and stick to negatively charged surfaces—that is, they produce static.

Like magnets that shoot away from each other when held rear to rear, the positively charged particles in the droplets repel each other and spread out—at many times the force of gravity—looking for exposed surface. The spray droplets can also reverse direction, moving against gravity and coating all sides of the target object. Thus, one of the advantages of electrostatic spraying is that it offers “wraparound” coverage, meaning it can quickly coat high-touch surfaces that may be time consuming to clean such as pens, light switches, faucets, and keyboards.

Because the solution comes out in a thin mist, it covers the targeted area evenly. Sprayers with smaller droplet sizes may be safer for sensitive equipment. Surfaces that are already covered will repel the charged droplets, which redistributes them, making the task that much more efficient and reducing the chance of overapplication.

In addition to time savings, the ESS offers cost savings. Used properly, the ESS can save on disinfectant and cut cleaning time by 50% or more, compared with spray-and-wipe methods. Moreover, according to an EPA decontamination study, because an ESS provides more uniform distribution, using a minimal amount of solution, it significantly reduces waste streams and costs associated with liquid hazardous waste disposal. Compared with a backpack sprayer, the ESS generated almost 75 times less liquid waste.

A downside is that although the droplets give the disinfectant sustained contact with the contaminated surface, the protection doesn’t last forever. The sprayer’s ability to deposit smaller amounts of disinfectant over a wide area may be both an advantage and disadvantage, according to the EPA. With less disinfectant applied, disinfection efficacy may diminish if the surface does not remain wet for the required contact time.

The required time often is specific to the pathogen. One study, for instance, found a 5-minute contact time was required for 

spores were reduced but not eliminated completely after a single spray application of the disinfectant. The investigators say that failure to eliminate the spores is partly because curved or vertical surfaces typically had drying times of approximately 2 minutes. Thus, in settings where 

 is a concern, they say, repeated application may be required to maintain 5 minutes of wet contact time. Moreover, left intact, the solution will last long enough for the pathogen to be deactivated, but only until the surface is touched again.

Some of the advantages of ESSs depend on the components.

A team of EPA investigators compared several spray parameters for 6 electrostatic sprayers, 2 foggers, and 1 hand-pumped garden sprayer.

 “The electrostatic spray process is complicated and involves multiple physical phenomena,” they wrote in 

 One on November 30, 2021. Parameters that might affect a disinfectant’s ability to inactivate the virus on surfaces include spray droplet size distribution, electrostatic charge, ability of the spray to wrap around objects, and loss of disinfectant chemical active ingredient due to the spray process. Also, not all electrostatic sprays carry the same charges. In this study, 2 ESSs that used alternating current had a negative charge, whereas the battery-powered ESS carried a positive charge.

The investigators tested the sprays on a variety of surfaces, including a metal trashcan and other surfaces such as a stepladder, a clip-on lamp, and a fold-out chair.

For all the devices evaluated, “[w]e were surprised to find there was not much of a ‘wrap-around’ effect of the spray from ESS, a claim that some ESS suppliers use for marketing—albeit this is just based on the limited tests we did,” Joseph Wood, senior research engineer with the EPA’s Center for Environmental Solutions and Emergency Response, and primary author on the study, told 

. For instance, the deposition was greatest at the front of the trashcan, with some minor amounts of spray deposited on the sides and only minimal amounts deposited on the back of the can.

Due to the range in recommended ESS surface coverage, types of surfaces and materials, varying disinfectant chemistries and parameters such as droplet charge, and site-specific environmental conditions, surfaces may not remain wet for the required contact time of the disinfectant. Wood’s top recommendation for using ESS: “Ensure that the surface you are disinfecting remains wet for the required contact time of the disinfectant you are using, and follow all label directions, including use of PPE [personal protective equipment].”

On the plus side, the investigators found that little of the active ingredient in dichlor- and hydrogen peroxide–based disinfectants was lost to the air (ie, below occupational health levels of concern) and the active ingredient concentrations collected 3 feet away from the nozzle did not decrease.

Those are serious considerations. For one, although ESSs allow for contactless cleaning, aerosolized disinfectant can hang in the air for long periods of time, especially if the area is not well ventilated. Aerosolized disinfectant can irritate skin, eyes, and airways.

The Centers for Disease Control and Prevention and EPA advise extreme caution when using ESSs, stating that they should be used only:

by a trained professional wearing appropriate PPE and who is alone in the room;

with disinfectants approved for this method of application (if the label doesn’t include directions for use with electrostatic spraying, the EPA has not reviewed any data on safety and effectiveness; see 

EPA’s List N: Disinfectants for Use Against SARS-CoV-2

according to manufacturer instructions for safety, use, and contact time.

Other advice from experts about ESS includes as follows:

wipe surfaces physically clean prior to disinfection because ESS solution only kills pathogens, it does not remove surface grime;

stay out of the area for the time indicated in the product label and specified by the application device (usually around 40 minutes);

open windows and doors after use, if possible, to air out the space;

remove chemical residue, which can pose health risks, before others enter the room;

follow product label directions for wiping or rinsing residue after the appropriate contact time has been achieved; and

An ESS does indeed kill nearly 100% of pathogens. It also kills the COVID-19 virus. But is that last function overkill? Fomite transmission of COVID-19 is a “ghost problem,” according to Joseph Allen, associate professor and director of the Healthy Buildings program at the T.H. Chan School of Public Health at Harvard University; Charles Haas, professor of environmental engineering at Drexel University; and Linsey Marr, professor of civil and environmental engineering at Virginia Tech.

in December 2020, they advised that it’s much better, when dealing with an airborne virus, to “shift our effort toward cleaning shared air, not shared surfaces.”

They wrote, “We don’t have a single documented case of COVID-19 transmission from surfaces. Not one….When we look at [the] entire causal chain, it’s easy to see that if fomite transmission is happening, it’s minor and certainly not driving the pandemic.”

The electrostatic sprayer method kills nearly 100% of pathogens. It also kills the COVID-19 virus. But is that overkill?

Jan Dyer

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