Linda Spaulding, RN, BC, CIC, CHEC, CHOP

Preventing surgical site infections has long been the goal of hospitals across the United States. Important components for preventing SSIs are:

Implementation of the US Centers for Disease Control and Prevention’s (CDC) 2017 updated guidelines for the prevention of SSIs.

Compliance with recommendations for proper prophylactic antimicrobial use for its efficacy against pathogens causing SSIs for specific procedures.

Self-monitoring of procedure and processes with the surgical suites.

Rounding by the hospital’s infection preventionist.

Following guidelines from credible organizations.

These are the key components to limiting or decreasing SSIs to 0 or as close to 0 as possible. This article will concentrate on surgical rounding by the hospital’s infection preventionist (IP). There are 4 key areas that the IP should focus on: the environment throughout the surgical 

suites, the surgical attire of staff, decontamination and the sterilization processes. New IPs can use this checklist to perform IP rounds in the surgical suite, decontamination areas, and sterile processing area. Included with each question is a rationale that can be used as training for the new IP.Developing well-run, infection-free surgery and post-surgical practices is important in today’s market of reimbursement that rewards good performance.

SSI rates are one of the key safety measures tied to value-based purchasing programs as well as the Afford- able Care Act Hospital Readmissions Reduction Program, in which the Centers for Medicare and Medicaid Services (CMS) will penalize hospitals for readmissions in some situations. To be successful, there must be a multidisciplinary effort that includes the surgical team, decontamination and sterile processing, infection prevention techniques, and training as to the post-op care of the patient and surgical site, as well as environmental services and plant operations.

The provided checklist is only a small sample of items that beginner IPs can utilize when making rounds in the OR, decontamination, and sterilization areas.

It is important for IPs to continue their education around this topic so they can continuously improve on their skills in identifying issues within the OR, decontamination, and sterile processing areas to ensure safety for patients. To learn more, a good resource is the 

1 published by the Inter- national Association of Healthcare Central Service Materiel Management (IAHCSMM) (page numbers in the tables refer to the manual).

Patel SN, Murray-Leonard J, Wilson AP. Laundering of hospital staff uniforms at home. 

Munk S, Johansen C, Stahnke LH, Adler-Nissen J. Microbial survival and odor in laundry. 

Nordstrom JM, Reynolds KA, Gerba CP. Comparison of bacteria on new, disposable, laundered, and unlaundered hospital scrubs. 

Articles

New infection preventionists can use this checklist to perform IP rounds in the surgical suite, decontamination areas, and sterile processing area.

Checklists for Infection Preventionists Working in ORs 

Even today, as of this writing and very likely as of your reading, many healthcare facilities in the United States—whether acute care, assisted living, or long-term care—are not equipped to handle a surge in coronavirus disease 2019 (COVID-19) cases, even though the world has wrestled with this history-altering pandemic since last year, and even though systemic problems should be fixed by now, but are not.

Some facilities continue to refine policies, procedures, and protocols for COVID-19. In some instances, healthcare is not succeeding with staff social distancing and proper use of personal protective equipment (PPE) (note: fabric and cloth masks ARE NOT considered PPE and should not be used within a healthcare setting) and proper cleaning of 

. There is still a lack of testing for COVID-19 as well as a lack of PPE and hand sanitizer—the basic items needed to protect healthcare workers and patients.

And just when many healthcare facilities thought it couldn’t get any worse, here comes influenza. Flu season on top of COVID-19 will make many hospitals and other healthcare facilities feel as if they’ve been caught in a whirlwind.

No one can really predict what is going to happen, but take heart, because seasoned infection preventionists (IPs) will be ready to accept and take on the challenge of the flu/COVID season. Novice IPs should use all the resources available to them to help them develop strong infection prevention and control programs within their facilities. Seasoned and novice IPs should reach out to websites such as:

https://www.cdc.gov/coronavirus/2019-nCoV/index.html

These organizations will keep IPs up to date on what is happening across the United States and the world so IPs can adjust practices as needed in their facilities.

The wearing of masks and face shields or goggles have become part of healthcare workers’ uniforms. The responsibility of IPs and management continues to be reminding 

 disciplines within the healthcare facility to wear their PPE appropriately and to social distance. All disciplines must work as a cohesive group to remind and protect each other. If you see something, say something. Let coworkers know when they may have breached infection control practices such as forgetting to wash their hands, not wearing PPE properly, or missed opportunities to clean high-touch surfaces. Whether dealing with influenza or COVID-19, practices are the same. The only difference is that COVID-19 is more 

infectious and transmittable and more deadly

As of August 15, the United States has seen a total of 5,285,546 cases of COVID-19, with 167,546 deaths. Data have been collected for 3,924,574 people, but healthcare personnel status was only available for 879,436 (22.4%) individuals. For the 134,397 cases of COVID-19 among healthcare personnel, death status was only available for 93,236 (69.4%). Among the data available for healthcare workers, there have been 

The 2019-2020 US flu season data reported on April 17, 2020, showed that the number of flu illnesses reported were between 39,000,000 and 56,000,000, with between 24,000 and 62,000 flu deaths occurring from October 1, 2019, to 

. This was a total of 7 months. When deaths from influenza are compared with deaths from COVID-19, there have been fewer cases of COVID-19 than influenza, but there have been more than double the number of deaths from COVID-19 than from influenza.

So, what do we know for sure about influenza and COVID-19?

Key to balancing safety and success during influenza season in the middle of a global pandemic:

Educate staff and management about new information that is published by professional organizations and associations. We cannot anticipate what will happen if patients are co-infected with influenza and COVID-19. Monitor reputable sites for guidance.

Utilize other IPs in other facilities for advice if an unusual situation arises.

Utilize local department of health epidemiology branch.

Rounding in all patient care areas and monitor use of PPE/hand hygiene and surface cleaning and disinfecting.

Encourage the buddy system for donning and doffing of PPE.

Hold listening sessions with staff and management to let them express what they see as needs or problems.

Monitoring staff and visitors for symptoms of influenza/COVID-19.

Contract tracing once COVID-19 is identified is a must for COVID-19. US Centers for Disease Control and Prevention (CDC) has good online contact tracing education.

Vaccination to protect against influenza is extremely important. And when the flu is here, there are also a lot of other respiratory viruses circulating. It’s not just influenza A and influenza B that’re seen during flu season. Healthcare professionals only test for the virus that they suspect is going to cause the most deaths for that year. That’s how the government decides what the flu vaccine is going to be. There is still respiratory syncytial virus (RSV) among young kids, and even the elderly.

Infection control personnel really have to monitor closely all respiratory viruses that are out there and be sure to work with management to put in place whatever needs to be put in place. Communicate well with the nursing staff and communicate well with all departments because if environmental services teams see nurses wearing a particular PPE, but they’re not being given it to wear, they’re going to be scared and wondering “why do they get better protection than me?”

IPs need to have all lines of communication open and really work hard at it. This can get very complicated.

LINDA SPAULDING, RN, CIC, BC, CHEC, CHOP, is an infection prevention consultant and founder of InCo and Associates International.

If you see something, say something. Let coworkers know when they may have breached infection control practices such as forgetting to wash their hands, not wearing PPE properly, or missed opportunities to clean a high-touch surfaces.

Infection Preventionist Guide for Dealing With Flu and COVID-19

It’s 5 pm on a Friday. Five residents are presenting with diarrhea, nausea, and vomiting. The director of nursing (DON) has already left for the weekend. The facility’s infection preventionist’s last day was Wednesday and no one has been hired yet. The DON tells the staff to call the medical director who orders stool cultures for 

By 7 pm, 10 residents have the same symptoms.

The staff report back to the DON. The DON is not sure what to do but knows that the facility’s former IP is still in town. She calls her. The former IP says that it might be norovirus and that the state Department of Health’s (DOH) after-hours number should be called. The number is in the infection control manual for reportable diseases. The IP also says there is a policy for norovirus, but no one knows where to find it.

This is an example, based on real events, of an infection prevention and control (IPC) program that has not outlived a person. Staff did not know what to do and the DON did not know she should call the DOH. Nobody knows what report forms are required to report the outbreak to the DOH and they don’t know the phone number of the DOH epidemiology branch to report the outbreak. This facility’s IP practices were dependent on a single person, not facility practice.

A strong, well-run IPC program costs more time than money. An initial investment toward training a facility’s IP and instituting a well-developed program is well worth the money and will save funds in the long run (which also means saving lives) for long-term care facilities (LTCFs). The right approach means not having to break the bank to install an effective IPC program.

How can this be done? Does a LTCF need a full-time certified IP on staff? No. What it needs is a well-developed program that belongs to the facility and not to a person. People come and go. There is no reason to redevelop your IPC program every time a person leaves the facility. Building a strong infrastructure is the key to a good long-standing program.

A well-developed IPC program helps to proactively manage and reduce any risk associated with healthcare-acquired infections (HAIs). IPC needs to be a balanced approach addressing risk of infection, not just looking at the treatment of infections. By using the risk approach to preventing infections, money is saved with the decrease in antibiotic cost, decrease in cost of personal protective equipment (PPE), decease in mortality and morbidly, decrease in nursing care, and a decrease in the risk of bad publicity.

In the time of coronavirus disease 2019 (COVID-19), many LTC facilities have found themselves on the front page of newspapers, in the headlines of the news media, and all over social media. The importance of well-developed and managed IPC programs has been front and center for months now. It is a great time for all healthcare organizations to review their IPC programs and decide how they can manage the risk going forward. It’s time to find the weak points in programs and strengthen them to win back the support of families and employees.

It is time to adopt a structured robust approach to managing the risk that comes with infections. LTCFs must manage these challenges, measure performance, and manage the changes that should come out of the worst pandemic this world has seen since the influenza pandemic of 1918.

There has been little change in ICP programs after severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), and H1N1 influenza. These epidemics struck, and then many healthcare organizations quickly went back to what they were doing previously. All healthcare facilities should have programs that are designed around the facility needs and performance measures. And, as mentioned, they should be facility-driven, not person-driven. ICP programs should be based on trigger points for infection risk within a particular facility, and not based on a person’s knowledge of infection prevention. With a strong program in place, any person should be able to come into a facility and pick up monitoring IPC where the last employee left off. LTCFs must understand that infection prevention flows through all the organization, not just in a department called “Infection Prevention and Control.” That is just a name, not a practice.

Every department head should be aware of what their infection prevention and control role is. If the facility does not ensure this knowledge is embedded into their organizational infrastructure, there will never be a program that outlives a person. Once this is understood, there should be an immediate improvement in facility process.

COVID-19 shows us that LTCFs have always been the last to receive the support they need. LTCFs can no longer simply rely on an annual survey by the US Centers for Medicare and Medicaid Services (CMS). The survey reviews facilities in accordance to the standards that are written. If a situation identified as a problem by staff does not fit inside one of the standards with the CMS regulations, the problem will not and cannot be addressed by the surveyor. This is a great disappointment to staff who hoped the surveyors would cite the problem so it would get fixed. Staff do not speak up and tell surveyors where the problem areas are out of fear of being fired. When staff members have constant input in infection prevention practices, they have the opportunity to discuss and address issues of concern. A trust must be built within the facility so all employees can state their concerns and have them addressed.

The unfortunate truth is not all problems fit within a standard. The message to staff is no one cares. The message to management is “we didn’t get cited so it must be OK.” It has been this way for years, but it does not have to be.

There are specific components of an IPC program that should remain strong in any facility when there are changes in staff. Every facility needs support and action from the top down. Once a program is in place, each new hire gets oriented to the way the facility program is run and managed. New employees should not be hired to come in and reinvent the facilities’ IPC programs. These inconsistencies not only cost more money but can also cause injuries and death.

All staff in the facility should have the proven ability to apply essential knowledge and skills, and the ability to prevent infections and the cross-transmission of infections while caring for residents. Hands-on education is an important factor. A multidisciplinary group should include management, RNs, LPNs, CNAs, dietary staff, environmental services personnel, plant operations, purchasing, IP, risk management, and the quality management director.

Each department should identify what infection control risks fall to their area. The IP can then help research each area, identify risks, and provide information on how to decrease that risk. For example, plant operations: Every time a wall is removed or some construction is performed, no matter how small, it will stir up dust, and within that dust might be 

 spores, which are common in the environment. If there is a resident with chronic obstructive pulmonary disease (COPD), asthma, or who is on a ventilator, this airborne 

 is now a risk for residents with a compromised respiratory tract system. It can cause 

 pneumonia leading in many instances to death. If a solid barrier had been put up before that dust was generated, the 

 would be confined to behind the barrier and would not have caused an adverse event and harm to a resident.

The plant management director’s last day was Wednesday, but he has not finished implementing the water management program that was required to be in place in November. It is now January. The hospital hired a new director for this department in December. CMS surveyors want to see the facility’s water management plan. The quality department director calls the new director in plant management and asks him to bring the water management plan to her. The director states he doesn’t have a water management plan. The new director and old director never talked about it. Again, this facility was not in control of its practices and policies did not outlast the person. Another example of a system breakdown with change management.

CMS now requires facilities to have a water-management plan. This affects plant operations again, but it also affects every employee, resident, and visitor. The water-management plan is designed to identify any area of risk within the facility that can cause bacteria to grow in the water that residents drink or bathe in. The same water is aerosolized when the residents are bathed, exposing the healthcare worker (HCW) who is bathing the resident.

The aerosolization of the water is then breathed into the lungs of the resident and the HCW. This can lead to 

 infections of the lungs. Any area throughout the waterline where there is standing water can lead to growth of 

, and other water-borne bacteria leading to an increased risk of infections.

If the facility has piped-in oxygen and the oxygen tanks that pump in the oxygen to the building are not maintained, they can become contaminated. If shower heads are not cleaned or changed on a rotating basis, the shower heads can become a source of infection. Aerators on sinks have been linked to many outbreaks of 

 infections. How a toilet plunger is carried through the facility can contaminate the environment with coliform bacteria.

These are just some examples of how IPC is part of a plant operation department. Employees of this department need to know the policies and procedures for mitigating risk.

Once these are in place, all future employees should be following the same practices, not reinventing the practice. Any policy and procedure in this area should provide guidance for a new employee on how the process is done unless they can provide documentation of updated standards, guidelines, or regulations that justify a change in practice.

This is just a start to creating an effective IPC in an LTCF, but it’s a good start. The important thing is: Start!

Linda Spaulding, RN, CIC, BC, CHEC, CHOP, is an infection prevention consultant and founder of InCo and Associates International, Inc.

Infection control at LTCFs needs to be a balanced approach that addresses the risk of infection, and not just the treatment of infection. Money is saved when this approach is used.

How to Build Cost-Effective Infection Prevention Programs at Long-Term Care Facilities

I was recently asked whether I think coronavirus disease 2019 (COVID-19) will change regulations within long-term care facilities (LTCFs)LTCFs). I decided I wanted to look at it from the perspective of what went wrong in the utilization of current US Centers for Medicare and Medicaid Services (CMS) regulations. The current regulations are written in a way where, on paper, the regulations are easy to survey, but what is missing is the ability to ensure LTCFs have a strong infrastructure that supports infection prevention and control success in the LTC arena. 

First, I decided to see what is happening across the United States related to outbreaks of COVID- 19 in the nursing homes. I have been working as an infection prevention and control consultant for LTCFs and other healthcare arenas since 1992. I would have predicted that LTCFs would be on the losing end of COVID-19 if someone did not step in early to educate and assist these facilities. LTCFs could not handle this type of a communicable disease on their own. 

Some may not have believed COVID-19 was a big deal and they could handle it like they do influenza. Others may have not wanted an outsider to suggest they do something different from how they always do things. Some people don’t like change and may not have been able to wrap their head around the extreme changes they would have to make to deal with this type of a pandemic. 

Recent publications are reporting the elderly are more likely to experience severe complications stemming from COVID-19 infection. We have known this from the beginning of the pandemic, but it does not appear that anyone was proactive enough when it came to concentrating on how LTCFs could deal with an outbreak. Did they have enough staff? Did anyone reach out to assess LTCFs needs related to staffing, personal protective equipment (PPE), or disinfectants? Many outbreaks were happening in LTCFs before anyone was paying attention to them. 

According to the National Center for Health Statistics there are more than 1.3 million residents in nursing homes; 811,500 residents living in res- idential care communities such as assisted living and intermediate care facilities and an estimated 1.5 million individuals are employed in these facilities.

 CMS released guidelines to reduce the effect of COVID-19 on these types of facilities. This guidance included visitor restrictions, infection control guidelines, and designating separate areas for those who were diagnosed with COVID-19. 

But it fell short of the federal requirements to report COVID-19 outbreaks. Only during the week of April 19 did information start being released to the general public regarding how nursing homes have been affected by COVID-19. 

reports at least 2300 nursing homes have reported cases of COVID-19. The impact on nursing homes is far greater than what is being reported by the federal government. 

 reports that 37 of the 50 states have reported cases of COVID-19 and more than 3000 deaths among long-term care residents. It has been reported that neither the US Centers for Disease Control and Prevention (CDC) nor CMS were tracking the number of US nursing homes with COVID-19 cases. The case fatality rates are also not being tracked. Reports have shown when states such as Florida were asked for data they did not respond. Florida is known for its high number of elderly residents, as well as millions of seasonal visitors during the winter months. These millions of visitors typically return to their home states in April. If they have become colonized or are sick with COVID-19, they will take it back to their home states and more outbreaks will continue. Thirteen states could only provide partial data and could not differ- entiate residents infected or staff infected. 

Even during non-pandemic times, many nursing homes across the country have received infection control citations. 

Healthcare workers in LTCFs deserve to have honest communications from their administrators so they can also protect themselves and their families. Like acute care facilities, LTCFs need help obtaining PPE. Many LTCFs and assisted living facilities are privately owned. Is this the reason reporting is lacking with this group of LTCFs? 

On April 19, 2020, 4 months after the pandemic began, CMS released guidance requiring nursing homes to report cases of COVID-19 to the CDC. The death rate that have been reported as of April 23, 2020: More than 10,000 residents and staff died because of COVID-19. Yet very few states are being proactive in testing all residents and staff in these facilities. Many hospitals haven’t had access to testing. How would LTCFs get access without states stepping in and providing the support? 

CMS requires that all LTCFs must follow accepted national standards. The infection prevention and control program (IPC) shall include at a minimum:

·       A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement.

·       Written standards, policies, and procedures for the IPCP, including but not limited to a system of surveillance designed to identify possible communicable disease or infection before it can spread to other persons in the facility; reporting requirements for possible incidents of communicable disease or infection; standard and transmission-based precautions to be followed to prevent spread of infection; circumstances in which generally, isolation should be used for a resident; the circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if the contact is likely to transmit the disease; and the hand hygiene procedures to be followed by all staff as indicated by accepted professional practice. 

·       Require that the facility designate an Infection Prevention and Control Officer (IPCO) who is responsible for the IPCP and who has received specialized training in infection prevention and control.

The above is just the section of the CMS regulations that should have been used during the COVID-19 pandemic. Many LTCFs have interpreted the require- ment for them to have an IPCO, as this person must be a permanent hire and it excludes them from relying on an expe- rienced infection prevention consultant who can provide mentoring, training and advice to an inexperienced IPCO. 

The requirement for IPCO training was basic training related to infection prevention, but it was lacking any mea- sures for determining competence of the IPCO. The area lacking in LTCF regulations is the issue of the inexperience of the facilities’ IPCO related to understanding how to identify infection issues. 

Some facilities lack administrative sup- port for a good understanding of what to do when infection prevention issues arise yet if asked, they will state they know everything about infection prevention and do not need help, lacking the insight that infection prevention is more involved than just the basic knowledge of washing your hands and putting PPE on. 

Sick-call policies in many healthcare arenas are based on disciplining employees who call off sick requiring a physician note to return to work. Many times, employees can obtain a physician note to return to work before they are cleared of a commu- nicable infection. In some cases healthcare settings as well as LTCFs have let staff work with respiratory tract infections because of limited staff or an inability to pay overtime. This practice has been linked to flu outbreaks every year. It’s unfortunate that this time it was not the flu, but in the case of COVID-19 which, if practices are reviewed when the pandemic is under control, some of these LTCF outbreaks were due to letting employees work sick because of poor staffing. Also in play was the inexperience of the facilities’ IPCO to be able to identify an outbreak of COVID-19 or because of lack of testing of healthcare workers (HCWs) who were asymptomatic carriers. 

Many IPCOs are assigned multiple tasks such as wound care, director of nursing, unit charge nurse, or unit super- visor, which can interfere with performing proper infection prevention and control. Many facilities cannot get physicians to see residents in LTCFs because they do not get reimbursed enough to make it worth their time. Pay in some LTCFs is also exceptionally low and does not match the quality of nursing care seen in acute care facilities. 

Many healthcare facilities, not only LTCFs, have turned to online training for staff and then designate the employee as competent to do their job. Online training does not prove competency; it provides training. The survey process does not look at competency of staff, it looks to ensure all employees have completed their annual training require- ments for infection prevention. There is no measurement of competency. Many employees in LTCFs are task-orientated individuals who work extremely hard and long hours and will do as they are instructed. If the person instructing them does not identify when there is an outbreak of any disease, whether flu or COVID-19, and provide clear instructions with follow-up with those employees that what was being requested was actually done, there will continue to be breaks in infection prevention practices. 

Many CMS surveyors have basic training in infection prevention but they also have limited experience doing infection prevention and it is easy to miss where infection prevention breaks are that enable facilities to identify when they have a problem before it gets to be a big issue. 

As for the COVID-19 pandemic and what is happening in LTCFs-many were destined to fail at infection prevention. Because much of the focus was on hospitals in need of PPE and ventilators, no one was checking in on LTCFs and determining what their needs were. Many LTCF staff did not show up for work. LTCFs that did try to get disinfectants and PPE were last on the list because acute care took priority. 

Many LTCFs work with one vendor to obtain their PPE and facility disinfectants. If their vendor does not have what they need or decides to sell to acute care first because they can sell to acute care at a higher rate, then LTCFs lose out. Many do not know what other companies they can buy supplies from. 

So where do we go from here to make sure LTCFs are set up for success in the future? I believe there needs to be a thorough assessment of all LTCFs in each state after this pandemic to identify answers to many questions and identify what is needed to set them up for success. COVID-19 is our influenza pandemic of 1918. What haven’t we learned and what do we need to do now to be ready the next time there is a pandemic? How are we going to deal with the next round of COVID-19? 

My suggestion is each state needs to retrieve data from all LTCFs:

·       When did the facility go into lockdown?

·       When did the facility start putting in orders for more PPE and disinfectants?

·       Who and how many vendors did they contract with?

·       What education was given to the employees and when did that education happen? Reviewing exactly what education information was provided.

·       When did staff start wearing masks?

·       How often were masks changed?

·       What was the first date that an employee or resident became sick?

·       What was the first date that the facility considered they had a problem with COVID?

·       When did the facility reach out for help?  

·       Who did they ask help from?

·       What response did they get when they asked for help or reported illness within their facility?

·       How many staff did not come to work because of fear?

·       Did the facility have access to a physician or physicians coming into the facility to help manage and prepare for COVID-19?

·       Did the facility reach out to the local hospitals?

·       Did anyone reach out to LTCF and if so, what happen?

Did they reach out to anyone to ask to transfer their residents and were refused?

·       When did they notify their local department of health to ask for help with sick residents or to obtain PPE and disinfectants?

·       Did they reach out to local emergency preparedness agency?

·       Do they qualify for federal or state help if they are privately owned?

The answers to these questions and many more could help build stronger infection prevention programs within LTCFs as well as trouble shoot problem areas not identified before the pandemic, so they are set up for success. Is the elderly in the US seen as an important part of the community or are they vulnerable because they are ignored and left to die during a pandemic? Let us prepare LTCFs for success, but owners of these facilities must want to participate, put up the money, and provide protection for residents and employees. 

Linda Spaulding, RN, CIC, BC, CHEC, CHOP, is an infection prevention consultant and founder of InCo and Associates International, Inc. 

Many healthcare facilities, not only LTCFs, have turned to online training for staff and then designate the employee as competent to do their job. Online training does not prove competency; it provides training.

Linda Spaulding, RN, BC, CIC, CHEC, CHOP

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