Rebecca Leach, RN, BSN, MPH, CIC, has been an infection preventionist since 2010, with a background in nursing and epidemiology. Leach, a regular contributor to Infection Control Today, currently works at a healthcare system in Phoenix that includes 5 hospitals and more than 100 outpatient treatment centers. She recently spoke to ICT about dealing with respiratory illnesses during the flu season, which usually runs from December to March. But this year the flu has struck early and hard. The US Centers for Disease Control and Prevention categorizes flu activity from 1 to 10, with 10 being the highest level. For the week ending December 28, 2019, 34 states and Puerto Rico reached that level. At the same point last year, 9 states had.
Infection Control Today: What are the broad strokes when it comes to how infection preventionists should approach respiratory illnesses during the flu season?
Leach: Infection preventionists can advise healthcare workers to get the annual flu vaccine and follow facility-specific policies regarding vaccination for employees. Practice appropriate and effective hand hygiene for every patient, every time. Stay home if you are feeling ill (ie, have fever, diarrhea, rash, or other signs and symptoms of communicable respiratory illness). Screen visitors coming to see your patients for signs and symptoms of flu and invite them to visit another day if they are not feeling well. Place patients in empiric isolation precautions based on your facility-specific policies if they have signs and symptoms of respiratory illness. Wear the appropriate personal protective equipment (PPE) for isolation and standard precautions when caring for patients with the flu or other respiratory illnesses. Be aware of your facility’s seasonal visitor restrictions that may be occurring and be a patient advocate for their health and safety while in your facility.
ICT: Are providers open to the suggestions that IPs present to them?
Leach: For the most part providers are open to the guidance from IPs regarding flu prevention. Now that many organizations have mandatory flu vaccination for employees, it is not as controversial of a topic, but initially there was pushback from staff when organizations started with it several years ago. Anecdotally, with the increase in anti-vaccination, we are seeing a little more of a surge in declinations.
As far as communicating with employees, that is always a challenge for all IP initiatives, not just flu season. Often the information does not trickle down to frontline staff. We have to use multiple methods of communication, ranging from email, newsletters, signage, meetings and huddles, walking rounds, social media, and committee meetings. It can be daunting, but we also collaborate with partners in occupational health, human resources, and nursing to spread the communication so it’s not just up to the IP for it all. There have been studies on recommendation for IP ratios to bed size. An older report, SENIC [Study on the Efficacy of Nosocomial Infection Control Project] from the [US Centers for Disease Control and Prevention (CDC)], recommended 1 IP to every 250 beds. That is now regarded as way too low based on current job duties and more recent work is suggesting 1:100 occupied beds.
ICT: How have those IP job duties changed?
Leach: The main influence in changing of job duties has been the mandatory reporting of HAIs [healthcare-associated infections] for state and federal programs such as [Centers for Medicare and Medicaid Services].
Since this initiative, as part of value-based purchasing, surveillance activities have become the majority of the job function for IPs. The time involved in not only the identification of HAIs, vetting them based on NHSN [National Healthcare Safety Network] criteria and then reporting them through the NHSN system, but also then working with local leadership and providers to help explain the background of the reporting requirements and how each facility ranks nationally has taken time away from the IP being in the units and providing education to staff. Since those reporting requirements, more time is devoted to surveillance for those particular HAIs and less time is available for other activities.
In regard to respiratory illness specifically, focus has been shifted to those reportable HAIs and respiratory illnesses are not considered a priority based on limited time and resources.
ICT: This sounds like a radical change in job duties.
Leach: Surveillance has always been a part of the duties, but the public reporting piece was new. And with that came the pressures that now these infections were tied to hospital reimbursement, which I think many IPs see as both a good thing and a bad thing. It was good because more resources and importance was placed on IP initiatives. However, the pressures to alter data to avoid penalties was felt. The specific HAIs that are federally reported are: catheter-associated urinary tract infections, catheter-associated blood stream infections, Clos- tridioides difficile infections, [methicillin-resistant Staphylococcus aureus] blood stream infections, and surgical site infections for colon procedures and total abdominal hysterectomies.
ICT: You mentioned screening visitors coming to see your patients for signs and symptoms of flu and invite them to visit another day if they are not feeling well. How often do you think this happens in real life?
Leach: Screening of visitors for illness is something that really should be happening year-round, but especially during respiratory season. I think it happens more so in areas like ICU, NICU, and oncology wards because those patients are more high-risk and the nurses say they are doing this already in those areas. Places like a NICU also tend to have strict visitation policies in place already, so it is not much of a change in their practice.
We have developed scripting for staff to help bring up the subject, just reminding visitors that we want to ensure the safety of their loved one and, if possible, to please visit when they feel better. It is true that some staff are more comfortable with it than others. We cannot force visitors to stay home, but it really is about educating and reducing risk.
ICT: You said: “Practice appropriate and effective hand hygiene for every patient, every time.” Will this problem ever be solved?
Leach: Hand hygiene is always going to be an issue. There are many reasons why healthcare workers cannot maintain compliance, ranging from time management, lack of sinks, non-effective placement of sanitizers, dermatitis and drying of hands, overuse of gloves, and just plain forgetting. Especially for nurses and aides, there are so many opportunities to perform hand hygiene in a shift, it is just odds that they will not be 100% compliant.
And for the most part, it’s not an education issue, it really is all those other things. It’s a behavior and culture change.
There have been some automated tracking systems that provide real-time feedback and data has shown them to be effective to increase compliance. Those systems tend to be cost-prohibitive for most facilities.
And once those systems are removed, hand hygiene compliance reverts back to prior levels. Having peer-to-peer reminders has also been shown to be effective, however that requires culture shift and breaking down hierarchy within the healthcare system. So, to solve the problem, it really is a multi-dimensional answer and needs constant reinforcement.
ICT: Are there any healthcare facilities known for setting the bar when it comes to handling respiratory illness?
Leach: Since hospital-acquired respiratory illnesses are not a publicly reported infection, it can be hard to know who really is doing it the best because we don’t know what national numbers look like. If something is published it tends to either be a research project or an outbreak response, so just to see on an annual basis what the numbers are of influenza cases acquired in healthcare facilities, there is no data available.
Johns Hopkins has a nationally known, strong IP program, so often they are a resource. CDC guidelines are the best resource available for IPs at all levels. Also, pediatric hospitals deal more heavily with respiratory illness and can be a good resource for IPs to learn what works, but that would mostly be through networking.
I would not assume that everyone who works in IP would just know what needs to be done, especially in those small, rural facilities or long-term care. Often the people in those roles have multiple responsibilities, and do not receive formal training in IP and have a lot of on-the-job learning.
So, if someone is new to their role, they would potentially struggle a bit to find the resources they needed. I would suspect most people would turn to the CDC first, and then APIC [the Association for Professionals in Infection Control and Epidemiology] or their local health departments.
ICT: Is there anything else you’d like to stress to your peers during respiratory illness season?
Leach: Another way IPs can be prepared for respiratory season is to monitor the surveillance data that comes from CDC and local health departments for flu and RSV as a way to help determine when spikes are going to occur.
Also, it’s very important for staff to have buy-in, so working with bedside staff if you’re going to implement visitor restrictions or anything that would be a new process would help make the program more successful since frontline staff can tell you what is really happening and have ideas on how to improve.
* This interview was edited for clarity and length.