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

I reached out to people in different disciplines, settings, and states. I wanted to know what lessons we’ve learned from the carnage caused by COVID-19 at various types of health care facilities.

I had to do this because one thing that will haunt me and many health care personnel forever is that so many people died without a family member at their bedside.

So many families will suffer forever knowing that they were not with their mother, father, brother, sister, grandparent, or child when that loved one died. This is not right, and we need to do better. We need to take this experience and make sure we develop ways to prevent anyone from dying alone or with the only connection to family being an iPad or a cell phone on their pillow. We are better than this. Where there is discussion and empathy, there is a solution to never letting this happen again. So, I reached out.

I spoke to a member of a purchasing department (sometimes called supply chain). I spoke to an infection preventionist (IP) in a pediatric acute care facility. I talked to the director of quality and infection control in Port Angeles, Washington, as well as an administrator from Palolo Chinese Home in Honolulu, Hawaii. They shared their stories.

Rhonda Bowen, CIC, CPPS, CPHQ, CPHRM
Infection Preventionist
Olympic Medical Center in Port Angeles, Washington

Bowen has 15 years of experience in quality, patient safety, and patient experience evidence-based practices and is proactive with risk assessments and process improvement for quality and infection prevention. She is a certified infection preventionist who takes patient safety to heart. I met Bowen a few years ago when she was preparing her hospital for its Certification in Infection Prevention (CIP). Bowen is the director of safety and infection prevention and control. Olympic Medical Center holds the designation of CIP. This is a certification designated for the top hospitals in the United States, which few had been able to obtain. The certification is bestowed by DNV GL Healthcare, an independent foundation based in Cincinnati, Ohio, that accredits acute care and critical access hospitals. I asked Bowen how the hospital certification better prepared Olympic Medical Center for this pandemic.

“I think we have done well during COVID-19 because of our ability to work together within our organization and with our community partners, such as our local and neighboring public health teams and health care providers/clinics,” Bowen said. “Because of CIP, infection prevention and control is solidly integrated throughout our organization. CIP keeps us continuously focused on improvement and all things infection control, from hand hygiene and personal protective equipment (PPE) to antimicrobial stewardship, emergency management, and cleaning and disinfection. Incident command/senior leadership has led the way and been able to rapidly deploy and obtain resources when and where needed. Strong communication efforts, including multiple forums, communication tools, and just-in-time training have been effective in sharing the constantly evolving information and processes to our staff and patients. I think the most important thing for IPs to focus on is communication and rounding. You are a partner in staff and patient safety—a conduit of knowledge and empowerment. Continue building relationships by taking time every day to talk with staff at all organizational levels. Listen to their questions, concerns, and ideas. Assess how you can share or clarify information such as the disease/issue (to the best of our current knowledge), transmission, precautions, and effective cleaning processes, or just reassurance that they are doing what they are doing exactly right and thank them. And finally, for future pandemics…a healthy stock of PPE and essential cleaning supplies!”

Darin Yoshimoto
Long-Term Care Facility Administrator, Palolo Chinese Home
Honolulu, Hawaii

Yoshimoto has worked in the health care industry for more than 15 years, holding various positions, such as director of rehabilitation, activity, social services, and now administrator at a long-term care facility (LTCF) for the past 8 years. Because of his varied experience, he has been able to guide Palolo Chinese Home through the COVID-19 crisis. He wanted to share his thoughts on what he has learned.

“Infection control practices are a vital part of nursing facilities’ operations and procedures. Having a solid infection control program and plan, consistent implementation, and daily practice for all types of infection concerns is instrumental in facilities being prepared for any sort of new pandemic or infection influx.

“At this time most infection dangers will likely fall into already known categories for risks of spreading and exposure. Having strong practices in place best prepares facilities from the start to protect all individuals, whether it is from known dangers or a new pandemic, while the world needs time to learn and understand the infectious dangers. In the end, with COVID-19, the mitigation and protection strategies are known, although some are more commonly in practice than others.

“As we learned more about the COVID-19 virus, it was a matter of putting multiple strategies in place to defend ourselves against this new threat. We understood and practiced contact precautions, droplet precautions, proper use of PPE, and hand hygiene.

“With COVID-19, and its highly infectious nature, we also learned the level to which we must adapt procedures and be flexible to quickly implement new strategies as more knowledge is gained of new pandemic issues. We needed to incorporate social distancing, stringent mask wearing at all times for both residents and staff, and screening strategies in addition to what we were already doing. As this pandemic spread, COVID-19 taught valuable lessons: 1) the importance of having a strong infection control program and practices, and 2) the effectiveness of practices when implemented properly and consistently.”

Anonymous
Manager
Purchasing/Supply Chain Department

She is a registered nurse by trade with over 22 years of experience and manages a purchasing department. She knows the importance of value analysis and how important things like PPE are for frontline workers.

“Promoting better communication to staff throughout the hospital when replacement items are being distributed because the product the staff is used to using is no longer available [was something we learned on the fly]. Communication is important if staff is seeing a different item. If health care workers are used to using particular products, they might feel uncomfortable if they think the replacement items are inferior. Keep staff in the loop that they can expect to see a replacement item until the item they are used to is back in stock.

“Creating backups to the backup [is important, and] having a centralized database on the [specifications] for PPE, hand sanitizers, disinfectant wipes. If the heath care facility has a database of like PPE, then when there is a shortage of products, supply chain can go to see what is on list 2. If list 2 supplies are not available, they can go to list 3, knowing that the quality of the product is the same, it is just going to come from a different vendor. Vetting companies and products ahead of time decreases stress during a pandemic. Hospitals could use their IP department to assist them in reviewing products in advance. With the list of PPE, the company name, contact person, and phone number, product review should be done annually to be sure the list is still accurate, the company is still in business, and the quality of their product has not changed. This could be done by sending a single spreadsheet to the vendors of all their products on your list and asking them if the products still meet standards and are still the quality hospitals prefer.”

Anonymous
Infection Preventionist in an Acute Care Pediatric Hospital

“There is a need to reassess the number of airborne isolation rooms the hospital has and [whether there is] a way to rapidly change the ventilation to provide more negative pressure rooms if the need arises. Assess alternatives to N95 masks to increase the numbers and types of masks that will provide the same protection. And there is a need to formalize and clearly define what is considered an aerosol-generating procedure.

“Infection preventionists need to be at the table when designing and constructing new departments and work environments so airborne infection isolation rooms can be designed to meet the needs of a facility. Infection preventionists should work with industry leaders to identify new and innovative strategies to make standard patient rooms negative pressure that can be easily employed and cost-effective. IPs should work with their purchasing department leaders to identify products on the market that offer the same level of protection as N95 respirators and lobby NIOSH [the National Institute for Occupational Safety and Health] if alternatives are not sufficient.”

If you had asked me 2 to 3 years ago how I think we would have handled a pandemic the magnitude of COVID-19, I would have said it would not go too smoothly.

I have never regretted being right so much.

I anticipated resistance from the general public because people who live in different regions of the country have different beliefs and thought patterns. Some are well-informed, and some are not. Some are followers; some are leaders. However, even in my worst-case imaginings, I would not have guessed it was going to be out of control for so many months.

For years, the federal government provided annual grants to hospitals and state agencies to prepare for any type of emergency, from a plane crash to bioterrorism to a pandemic.

Hospitals practiced drills annually and improved their emergency response plans. We knew who to contact for extra medical equipment. We had been told there were strategic stockpiles of PPE in various regions of the US that would be dispensed to hospitals if they needed it. The missing link was that in many regions of the country, LTCFs and assisted living communities (ALCs) were not included in the drills or in the funding for preparedness. These facilities were left on their own with no professional resources to help them develop a strong emergency preparedness program.

LTCFs and ALCs were set up to fail. Emergency managers in many states worked with acute care and neglected LTCFs. LTCFs were told, “Don’t worry, we will be here for you if something happens.” From my experience working with LTCFs—and I contract with more than 70 of them—this did not prove true when it mattered.

COVID-19 was transmitted among residents and staff of LTCFs, and patients were transferred from acute care hospitals to ill-prepared facilities because acute care ICUs were overwhelmed. LTCFs were not provided education or enough PPE, including N95 masks. Staff were not fit tested or taught how to use N95 masks properly. Staff in LTCFs never had N95 masks in the past because if there was a need for N95 masks that meant the resident had to be transferred to acute care.

They were on their own in many places across the country. Then COVID-19 happened and when they were told to use N95 masks, they couldn’t buy them because acute care was getting them, and they came last. It has been an epic failure on the part of federal, state, local, and facility emergency management programs.

So, as we move forward and out of the COVID-19 pandemic, emergency managers across the county will look at how to make improvements to their programs. Let us do it better next time. Let us take what we have learned and change how we provide health care, so we are better prepared for the next pandemic. Let us come up with ways to prevent people from dying alone. Let us be better prepared to stand on our own and not completely rely on federal, state, and local government. And better prepare all agencies that provide health care to focus on everyone’s preparedness, not just acute care facilities.

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

Articles

One thing that will haunt me and many health care personnel in both acute care and LTCFs forever is that so many people died without a family member at their bedside.

Postcards From the Edge: Lessons Taught by COVID-19

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. 

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.

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

Articles

Postcards From the Edge: Lessons Taught by COVID-19

Checklists for Infection Preventionists Working in ORs

Infection Preventionist Guide for Dealing With Flu and COVID-19

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