Infection preventionists are like coaches. We often facilitate the work of a team, assess strengths, teach skills where there are opportunities or gaps, devise strategies for preventing health care­–acquired infections, and look at long-term outcomes and goals. Like coaches, infection preventionists have different styles of collaborating with team members. Each infection preventionist brings personal experience and collaborative style to the role. Also, the culture of an organization can sometimes influence how relationships develop.

As novice infection preventionists, many of us learned how to function as leaders based on whom we trained with. Infection prevention remains a field in which training often is done through hands-on, learn-as-you-go methodology. Additionally, each infection preventionist brings a style of relationship building.

When I was a novice infection preventionist, I had the benefit of being trained by a mentor who exemplified how best to engage with clinical staff at all levels. My mentor had been in her role for many years and had worked for the organization as a staff nurse before moving into infection prevention. She made relationship building a priority for the program and knew how important it was to success. She taught me to listen first, learn what the needs of the clinical staff are, and communicate with empathy and compassion. Those techniques set the baseline for building trust.

Infection preventionists without clinical backgrounds in nursing sometimes have a more difficult path to earning the trust of clinical staff. However, the same skills are effective in beginning the collaboration: Approach clinical staff to learn about their field, treat them as the subject matter experts, and be open to learning from them.

Similarly, clinical staff can have a history of how they have worked with infection preventionists, quality, safety, and similar departments. Depending on the culture of the organization, an unspoken hierarchy can exist within which certain role groups interact. If an organization has this type of hierarchy, it can be challenging for nonclinical or administrative departments, such as infection prevention, to engage clinical staff. Without that engagement, infection prevention initiatives will not succeed.

Some of the interaction between professional groups stems from sociological and psychological dynamics of group relationships. The more infection preventionists can be aware of these dynamics, the better they will be at overcoming potential negative impacts. For example, concepts such as social identity and community of practice have inherent limitations to inclusiveness across professions and even within professional groups of different subspecialties.

 In these instances, the in groups see themselves as superior in knowledge and experience, and may value their own contributions as more important than those of other groups involved in patient care.

 These dynamics have been shown to inhibit quality initiatives and must be addressed early in the planning stages of programs.

There have been efforts to develop methodologies addressing these barriers in group dynamics. Overall, they are best overcome when the approach to solving issues is truly multidisciplinary and based on concepts similar to safety culture, in which there is no hierarchy, and each voice is valued and respected. Infection preventionists can also overcome some of these barriers by continuing to develop interpersonal relationships with clinical staff.

Infection prevention initiatives and programs need collaboration to be effective and to achieve desired outcomes. Health care facilities need to align with clinical staff to make changes, including cultural and behavioral shifts, to spread those desired changes across a multifaceted organization, and to sustain those changes in the face of evolving priorities and growth.

 Infection preventionists can start to address these challenges by identifying key stakeholders, learning what is important to them and what would get their buy-in, making relationship-building efforts a priority, and helping stakeholders take ownership of the changes.

On the positive side, studies have shown that training in teamwork and effective communication in health care settings does translate to improved patient outcomes.

 Additionally, studies have shown that teams with higher levels of trust and quality information exchange do have direct impacts on patients’ satisfaction, pain scores, and length of stay.

 These types of studies can very easily be translated to prevention of health care–associated infections as well.

In particular, transformational leadership styles have been associated with improved quality outcomes for patients.

 Transformational leadership is based on creating relationships and motivating staff through clear communication and shared vision.

 It is imperative that infection preventionists are aware of their leadership styles and attempt to build skills in areas where they may not have experience in order to utilize their position in the facility to act as leaders who will enhance patient outcomes through collaboration.

One positive outcome of the pandemic response has been an improvement in the relationship between infection prevention and clinical staff. Infection preventionists were often at the head of pandemic efforts, working early on to understand the guidance for COVID-19 response; tirelessly providing updates, education, and plans to health care teams; and working with facility administration on incident commands to help establish processes. The infection preventionist had the opportunity to engage with clinical staff at all levels and could provide updates on research, as well as offer an empathetic ear to staff feeling the burden of the unknown. In this role, functioning as part of that clinical team in such an emotionally charged setting, infection preventionists were able to increase trust and establish relationships with clinical staff that will carry forward in all other initiatives.

Building on collaborative relationships that arose from COVID-19 pandemic response, infection preventionists can use their social capital to maintain that momentum. Team building, meeting with unit-based councils, and involving direct care staff from the beginning are all ways to engage and sustain those relationships. Across the country, we have seen an increase in health care–associated infections since the pandemic started. Many years of improvements in quality and patient safety are seemingly reversed. The work of infection preventionists has not decreased since 2020. However, infection preventionists are not alone in their efforts. All of health care is delivered in the context of human relationships. The quality and safety of that care will be improved when those relationships are strong and at the center of an organization’s care delivery model.

Bartunek JM. Intergroup relationships and quality improvement in healthcare. 

. 2011;20 Suppl 1(Suppl_1):i62-i66. doi:10.1136/bmjqs.2010.046169

The CAHPS Ambulatory Care Improvement Guide, section 4: ways to approach the quality improvement process. Agency for Healthcare Research and Quality. November 2015. Updated January 2020. Accessed February 13, 2022. https://www.ahrq.gov/cahps/quality-improvement/improvement-guide/4-approach-qi-process/index.html

Rosen MA, DiazGranados D, Dietz AS, et al. Teamwork in healthcare: key discoveries enabling safer, high-quality care. 

. 2018;73(4):433-450. doi:10.1037/amp0000298

Sfantou DF, Laliotis A, Patelarou AE, Sifaki-Pistolla D, Matalliotakis M, Patelarou E. Importance of leadership style towards quality of care measures in healthcare settings: a systematic review. 

. 2017;5(4):73. doi:10.3390/healthcare5040073

Articles


The COVID-19 pandemic strengthened the relationship between infection preventionists and clinicians, but how can both parties ensure continued collaboration?


The IP Relationship With Clinical Staff Is a Critical Partnership

I first wrote a commentary with a similar title more than 30 years ago during the 1985-1992 resurgence of drug-resistant tuberculosis (TB) in the United States.

 The point was to make clear the quantitative differences between the 3 recommended environmental control interventions at the time: ventilation (fans) and room air cleaners (filters)—both moving air—and upper-room germicidal UV (GUV). Ions (bipolar ions and related catalytic hydrogen peroxide [H2O2] generators) were not prominent interventions at that time. The purpose of this commentary is to update that discussion regarding airborne viral infections (COVID-19 but also seasonal influenza and possible future pandemics) and current technologies, including advances in GUV, air cleaners, and chemical air disinfectants.

The COVID-19 pandemic has stimulated a plethora of environmental solutions—some new, some old, some with a sound scientific rationale and independent evidence of efficacy and safety, others without a solid rationale or independent evidence. Despite their differences, promotions for these various environmental solutions almost always claim 99.9% or greater reduction in pathogens. Some basic principles may help in separating interventions likely to be effective from those less likely to be protective. I will emphasize 2 critical considerations not always evident in the current recommendations or reviews.

To be effective, the rate of air disinfection (pathogen removal) must be sufficient to exceed the rate of pathogen generation. For highly infectious viral pathogens like measles and the Omicron variant of COVID-19, the pathogen generation rate may exceed the capacity of entire categories of interventions, like mechanical ventilation or room air cleaners.

The most effective air disinfection is likely to be in the room where transmission is occurring—not in the building ventilation system.

To enable comparisons between engineering interventions it is convenient to use 1 of the 2 common ways in which building ventilation is quantified: room air changes per hour (ACH). For this approach, the required ventilation is determined by room volume independent of occupancy, although average room occupancy is assumed. The other common quantifying method is based on occupancy, for example 20 cu ft/min of outside air per occupant in office buildings.

 The total ventilation also assumes average occupancy for the space. The occupancy-based measure of ventilation makes most sense for air contaminants that increase with occupancy, like carbon dioxide (CO2) production and body odor. For airborne infection control, however, there may be just 1 infectious source case in a room of 10 or 20 individuals, and a volume-based ventilation recommendation makes more sense than an occupancy-based one; although, both are important and valid.

One air change in a well-mixed room removes 63% of room air contaminants. The next room air change removes 63% of what remains, and a third 63% of what remains, etc. Each subsequent air change removes a smaller absolute amount of contaminant at greater cost in terms of energy for heating, cooling, and dehumidification, as well as demands on the HVAC system ducts and blowers. The well-known Centers for Disease Control and Prevention recommendation

 of 6 to 12 ACH outside air for respiratory isolation achieves a high percentage reduction in air contamination but does not assume ongoing production of contaminants (ie, the presence of 1 or more infectious source cases in the room). With a highly infectious source like some Omicron cases, and with even 6 to 12 ACH, outside air is beyond the capacity of all but highly advanced ventilation systems in hospital isolation rooms, laboratories, and specialized manufacturing settings.

The requirement of outside air assumes that recirculating contaminants within buildings, although diluting them with air from contaminant-free rooms on the same ventilation circuit, still allows for contaminant buildup and possible room-to-room transmission. Although this has been observed with such infections as measles and TB, I am unaware of convincing reports of room-to-room COVID-19 transmission without in-room contact between individuals, even on ships. SARS-CoV-2 is an envelope virus, especially environmentally fragile compared with other viruses and bacteria. Turbulence, high-velocity impact on surfaces and on fan/blower blades, and high humidity are likely to inactivate SARS-CoV-2.

Despite the lack of evidence that room-to-room transmission is contributing importantly to the transmission of COVID-19, higher-level filtration (MERV 13) has been strongly recommended for HVAC systems in schools and other public places. Although higher-retention filters will remove some respiratory pathogens as well as pollen, dust, etc, they will likely have little impact on SARS-CoV-2 transmission if the virus is not being recirculated to a substantial degree. If greater flow resistance through higher-retention filters reduces HVAC flow rates, filters may increase the risk of in-room transmission. Finally, to an occupant sharing air in a room with an infectious source, there is little comfort knowing that air will be decontaminated 

In 1991, I wrote an article on the theoretical limits of protection provided by building ventilation against airborne infection, using the Wells-Riley equation to analyze an epidemiological investigation of extensive TB transmission in an office building with limited outdoor air ventilation. Whereas 40% of vulnerable occupants (27 of 67) had been infected at a building ventilation rate estimated at 15 cu ft/min outside air per occupant, the analysis showed that at twice the outdoor air ventilation—a very high ventilation rate for an office building—still 20% of occupants likely would be infected. Moreover, to reduce the rate to a still unacceptable 10% (7 individuals), an unrealistic 60 cu ft/min per occupant outdoor air ventilation rate per occupant would be needed (Figure 1). Clearly, ventilation alone, although adequate for removing CO2 and odors, is not adequate for preventing person-to-person airborne transmission of infection when the source is highly infectious or the exposure long, as in this case of TB transmission over a one-month period.

Building ventilation, normally designed for occupant comfort, is rarely adequate for effective air disinfection in the room where transmission is occurring. Comfort-level ventilation requires additional in-room air disinfection. Currently, there are 3 types of technology marketed for in-room air disinfection that I consider safe and effective. They are as follows:

chemical methods (H2O2 and bipolar ion generation)

Although there are industry-sponsored chamber studies suggesting that H2O2 and bipolar ions can be effective, these approaches vary greatly from product to product, and there is little peer-reviewed evidence of safety and efficacy 

. I will focus on room air cleaners and GUV.

The Cost of Adding Equivalent Air Changes

For any alternative air disinfection technology, when pathogens are reduced by 63%, 1 equivalent air change (EqAC) is said to have occurred (Figure 1).

This allows comparisons in terms of the cost of providing, for example, 6 ACH though mechanical ventilation vs room air cleaners or GUV. A study conducted in a TB hospital in Vladimir, Russia, in collaboration with the CDC, offered a head-to-head comparison by aerosolizing test bacteria in an unoccupied hospital room and measuring their removal by quantitative air sampling. The results of this unpublished study are shown in Figures 2a and 2b.

Room air cleaners are a theoretically sound approach to in-room air disinfection, but there are some major limitations. Countless models are marketed using filters, GUV, and even plasma technology claiming to destroy pathogens, not merely retain them in a filter. Whether organisms are inactivated by UV or another technology or retained in a filter is unimportant. All that matters from a room air disinfection perspective is the effective EqACH rate. Each room air cleaner has a clean air delivery rate (CADR) for a specific contaminant—the result of both the flow rate and the per pass removal/inactivation efficiency. Because the per pass inactivation rate for most pathogens usually approaches 100%, the CADR and total flow rate through the device are usually essentially the same. Advertisements often point to the high single-pass efficiency as proof of efficacy, but it is not. Unless the room is very small or the air cleaner is very large (or there are many of them), getting all room air through a fan-driven device at a rate equivalent to even 6 ACH is a challenge because of noise and drafts. Often, room air cleaners contribute just 1 or 2 EqACH. That may not be insignificant if there is little or no other ventilation, but it is hardly highly effective air disinfection. Short-circuiting of just processed air back into the device when intake and outlet are near each other is another reason why the ACH rate may not be an effective ACH rate. In Figures 2a and 2b, 3 different room air cleaners were tested against 2 microbial test aerosols in an actual unoccupied hospital patient room where HVAC system installing and operating costs were known and could be compared with the cost and effectiveness of upper-room GUV and 3 available room air cleaners, including an expensive model with plasma technology used in the Soyuz space capsule. The results show that the least cost per equivalent AC is upper-room UV. Upper-room UV was nearly 10 times more cost-effective than mechanical ventilation in that setting. The GUV fixtures used were inexpensive (less than $200 each) locally made devices to meet Russian performance criteria.

I have referred to several chamber studies in which test organisms are aerosolized and their reduction with GUV or air cleaners quantified. Because they are conducted under controlled conditions, such studies constitute much of the evidence that GUV is effective. But are there any real-world studies or field trials of GUV to show how well it works in reality? There are few because of how difficult such studies are to design and carry out. Perhaps the most impressive was conducted in schools outside of Philadelphia, Pennsylvania, where measles was shown to be prevented in 2 suburban schools by upper-room UV. Similar results were published for an observational study of seasonal influenza in a hospital already equipped with GUV for TB transmission control.

GUV air and surface disinfection technology has advanced greatly since the onset of the COVID-19 pandemic.

Conventional 254-nm mercury upper-room GUV has been joined by 265-nm to 275-nm LED upper-room sources. Most importantly, new 222-nm krypton chloride far UV lamps are being deployed for whole-room germicidal UV in occupied rooms.

 The efficacy and cost-effectiveness of upper-room GUV is attributable to the treatment of a large swath of upper room all at once as opposed to having to draw air through a box for filtration or internal UV treatment (Figure 3). Rising warm air in most occupied rooms with or without mixing fans allows the entire room air to be rapidly disinfected, equivalent to 10 to 24 ACH in some published reports without noise or risk to room occupants when properly installed.

 Far UV has the advantage of directly treating the air around room occupants, interrupting airborne viruses between the infectious source and other occupants. EqACH of 35 or more have been reported in test chamber studies.

Safety concerns have been a barrier to the wide application of upper-room GUV, but less so for far UV. Between 254 nm and 275 nm UV must be confined to the upper room to avoid eye exposure above a well-established dose; this is referred to as threshold limit value (TLV).

 Accidental overexposure can cause transient but painful eye irritation and skin reddening, which is similar but less severe than more penetrating UV A and B in sunlight. Properly installed upper-room UV should cause no adverse effects of any kind. Workers who are directly exposed to GUV lamps, whether during painting or cleaning of the upper room, may quickly exceed the TLV and experience the equivalent of welder’s flash. Although painful, there are no long-term consequences of acute GUV eye injury. Normal corneal cell turnover replaces damaged cells over the course of a few days. However, 222 nm penetrates human tissues so little that symptomatic eye overexposure is highly unlikely, especially when fixtures are ceiling mounted and shine downward as in the installation pictured in Figure 4.

Barriers to the wider use of GUV remain and include the primarily accessible technical expertise to plan, install, and maintain GUV systems. This is rapidly changing with greater use.

In summary, I have emphasized that effective air disinfection for highly infectious pathogens like the Omicron variant of COVID-19 needs to be high—more than the 6 to 12 ACH recommended by CDC, and in the room where transmission is occurring as opposed to in the ventilation system. Although room air cleaners can be effective in relatively small rooms, in large-volume spaces it is difficult to achieve high rates of effective EqACH due to noise, drafts, short-circuiting of air, and the flow-limits of the machines themselves. The most effective and cost-effective approach to large volume rooms to achieve the high rates of EqACH needed for the Omicron strain is GUV upper room and, increasingly, 222 nm far UV.10 The role of chemical air disinfection, bipolar ionization, and H2O2 generators is less clear pending additional research, especially in application-like settings.

1. Nardell EA. Fans, filters, or rays? Pros and cons of the current environmental tuberculosis control technologies. 

. 1993;14(12):681-685. doi:10.1086/646669

2. Nardell EA, Keegan J, Cheney SA, Etkind SC. Airborne infection. Theoretical limits of protection achievable by building ventilation. 

. 1991;144(2):302-306. doi:10.1164/ajrccm/144.2.302

3. Nardell EA. Indoor environmental control of tuberculosis and other airborne infections. 

. 2016;26(1):79-87. doi:10.1111/ina.12232

4. Centers for Disease Control and Prevention. Guidelines for Environmental Infection Control in Health-Care Facilities (2003). CDC website. Updated July 23, 2019. Accessed February 22, 2022. https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html

5. Nardell EA. Air disinfection for airborne infection control with a focus on COVID-19: why germicidal UV is essential †. 

. 2021;97(3):493-497. doi:10.1111/php.13421

6. Wells WF, Wells MW, Wilder TS. The environmental control of epidemic contagion: I. An epidemiologic study of radiant disinfection of air in day schools. 

1942;35(1):97-121. doi:10.1093/oxfordjournals.aje.a118789

7. McLean RL. The effect of ultraviolet radiation upon the transmission of epidemic influenza in long-term hospital patients. 

8. Buonanno M, Welch D, Shuryak I, Brenner DJ. Far-UVC light (222 nm) efficiently and safely inactivates airborne human coronaviruses. 

. 2020;10(1):10285. Published correction appears in 

9. Mphaphlele M, Dharmadhikari AS, Jensen PA, et al. Institutional tuberculosis transmission. Controlled trial of upper room ultraviolet air disinfection: a basis for new dosing guidelines. 

. 2015;192(4):477-484. doi:10.1164/rccm.201501-0060OC

10. Bergman R, Brenner D, Buonanno M, et al. Air disinfection with germicidal ultraviolet: for this pandemic and the next. 

. 2021;97(3):464-465. doi:10.1111/php.13424

11. Nardell EA, Bucher SJ, Brickner PW, et al. Safety of upper-room ultraviolet germicidal air disinfection for room occupants: results from the Tuberculosis Ultraviolet Shelter Study. 

. 2008;123(1):52-60. doi:10.1177/003335490812300108

12. First MW, Weker RA, Yasui S, Nardell EA. Monitoring human exposures to upper-room germicidal ultraviolet irradiation. 

. 2005;2(5):285-292. doi:10.1080/15459620590952224

Rethinking the application of air disinfection in the era of COVID-19.


Fans, Filters, Rays, or Ions?

As the health care setting progresses from focusing primarily on COVID-19 toward living with the disease, infection preventionists (IPs) are also grappling with how to continue a new era of infection prevention. Basic infection prevention principles, which may have been placed on the back burner for 2 or more years, are reemerging. Staff members are now coming to IPs for recommendations in areas where IPs previously may not have had as much oversight.

One subject IPs may start to see as being ideal for more feedback and collaboration involves environmental infection prevention. The role the area around us plays in infection prevention has become more evident throughout the pandemic. As health care systems restart projects that may have been put on hold, these opportunities may now be revisited. Some common environmental areas where IPs can provide valuable input include construction projects, water safety, and ventilation.

Construction projects in the health care setting greatly increase the possibility of pathogens such as mold and fungus being present in the environment. Organisms such as 

 can be found in environments where construction was or is occurring if proper infection prevention practices are not followed. In healthy individuals, this organism may not cause any harm or even be detected. However, in patients who are immunocompromised, this organism can cause respiratory illness that can be difficult to treat.

The Facility Guidelines Institute (FGI) is an organization that provides guidance around the planning, design, and construction of health care facilities.

 FGI requires that a tool, the infection control risk assessment (ICRA), be completed before all construction projects begin.

An ICRA organizes a construction project by classifying the type of work that will be occurring along with the level of risk involved should a project not be performed correctly. Depending on how the type of work and risk align, different expectations are listed for how the project should be carried out.

The ICRA document is to be filled out by the project manager of the construction site who will be providing oversight on compliance. Once a draft of the scope of work has been completed, it should be sent to the other key stakeholders such as those in safety and infection prevention. If there are questions on the scope of the project, IPs should feel comfortable asking for a job site walk-through.

Once the project is under way, and especially if there is high risk to surrounding patient care areas, IPs should go around the site weekly to ensure that the ICRA is being followed. Any concerns should be brought to the project manager for immediate rectification.

A water management program in a health care facility is key in mitigating the spread of infections. Common practices in health care systems, from providing oral care to patients to the reprocessing of medical devices, require use of water. If microbial growth is allowed to occur in any of these areas, it can pose a serious risk to patients. Among other organisms, a water management plan aims to mitigate 

 a genus of bacteria that can be transmitted to immunocompromised patients if they inhale contaminated water.

The CDC provides resources for better understanding of a facility’s current state regarding water safety. The agency’s guide, “Developing a Water Management Program to Reduce 

 helps explain the steps that should be taken in creating a water management plan.

IPs who may not know much about their facility’s water management plan should reach out to their facilities team to discuss and partner in the creation of a plan. One of the first priorities is to create a diagram of how water enters and leaves the facility. This allows potential hazards such as fountains, stagnant water, and high-risk units to be better identified. With these risks recognized, mitigation strategies can be put in place.

As has been emphasized during the pandemic, proper ventilation can lead to decreased risk of infection. The concept of ventilation as a means of reducing infection transmission risk has been a part of health care expectations since well before COVID-19.

The American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE), along with FGI, helps to provide best practice expectations for health care facilities relating to heating, ventilation, and air conditioning (HVAC) systems.

 Because air circulation is critical to reducing airborne transmission of communicable diseases, ensuring areas are regularly meeting the minimum air exchanges (MAC) for outdoor air is crucial.

In addition to MAC, the use of high efficiency particulate air (HEPA) filters is an added way of trapping particulates that may be present in the air. When deciding what type of HEPA filter to use, it is important to determine whether it has met HEPA classification and to know how often it needs to be replaced.

Because air is circulated through facilities throughout the year, the changing temperature and humidity of the outdoors can affect the HVAC system indoors. To curb the potential for microbial growth, it is important to review temperature and humidity standards as provided by ASHRAE and FGI for each area, to monitor regularly, and to know what to do if levels get out of range.

The risk of infection transmission in construction projects, water safety, and ventilation all reflect how these projects require multidisciplinary oversight. Professionals from environmental health and safety, facilities, infection prevention, and more must work to ensure that when changes are made to a facility, patient safety is kept at the forefront. Similarly, even during periods of stagnation, it is also important to review current workflows to ensure no additional changes need to be made.

Guidelines for Design and Construction of Hospitals

. Facility Guidelines Institute. 2018. Accessed February 10, 2022. 

https://fgiguidelines.org/guidelines/2018-fgi-guidelines/

Developing a water management program to reduce 

 growth & spread in buildings: a practical guide to implementing industry standards. CDC. June 24, 2021. Accessed February 10, 2022. 

https://www.cdc.gov/legionella/downloads/toolkit.pdf

ASHRAE offers course on the role of HVAC systems on infection control. News release. American Society of Heating, Refrigerating and Air-Conditioning Engineers. March 23, 2020. Accessed February 10, 2022.  

https://www.ashrae.org/about/news/2020/ashrae-offers-course-on-the-role-of-hvac-systems-on-infection-control

IPs can provide valuable input on construction projects, water safety, and ventilation.


Pandemic Places Importance of Preventing Environmental Infection at Center Stage

Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in healthcare facilities today. Each column explores the Bug of the Month's etiology, the infections it can cause, the modes of transmission, and ways to fight its spread. The pathogen profiles will span bacterial, viral, fungal and parasitic species. We encourage you to use Bug of the Month as a teaching tool to help educate healthcare personnel and start a dialogue about microbiology-related imperatives.

Click here to guess the April Bug of the Month

Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in healthcare facilities today. 

Bug of the Month: I'm Mostly Harmless, Until I Contaminate Your Food

When it comes to staffing hospitals, public and private health care officials strive to reach a balance between the safety of HCPs and the ability of institutions to function properly, especially during COVID-19 surges. The issue came to the fore last December when the Centers for Disease Control and Prevention (CDC), with an eye on critical staffing shortages in the health care industry, which has lost about 20% of its workforce since the beginning of the COVID-19 pandemic, shortened the recommended isolation time for health care workers exposed to COVID-19 in high-risk situations from 10 to 7 days (Sharon Ward-Fore, MS, MT[ASCP], CIC, FAPIC, a member of the 

] Editorial Advisory Board [EAB], clearly spelled out the dos and don’ts of the recommendations in a 

spoke with Graham M. Snyder, MD, MS, medical director for Infection Prevention and Hospital Epidemiology at University of Pittsburgh Medical Center, and associate professor, Division of Infectious Diseases at University of Pittsburgh School of Medicine about a study on this topic. Snyder was the lead author on the 

 titled “Health care personnel early return-to-work program after higher-risk SARS-CoV2 exposure: A learning health system quality improvement project,” published in the 

). Snyder says, "In this quality improvement study, the lesson was in the learning." 

National Nurses United, a union representing more than 175,000 members, immediately 

 agaomst the study, arguing that the recommendation puts nurses on the front lines of the COVID-19 wars in jeopardy. And despite a recent 

 in hiring in the health care sector, hospitals and other health care facilities must still deal with staffing shortages.

Investigators with the University of Pittsburgh Medical Center wanted to see just what the effects of shortened quarantines might be. They concluded that HCPs can safely return to work (RTW) after 7 days of quarantine if they test negative for COVID-19 on days 5 to 7.

“To optimize employee health, patient safety, and health care capacity, extraordinary efforts are needed to address contingency and crisis planning to mitigate staffing shortages before the next wave of COVID-19 cases,” investigators reported in the study. “Implementing an HCP early RTW program is one strategy to increase staffing availability and therefore reduce burden of staffing shortages on the health care workforce, while maintaining a low risk of SARS-CoV-2 transmission.”

The observational study included HCP working at a 40-hospital integrated health care system in central Pennsylvania in which employees faced a higher risk of either workplace or non-household community exposure to COVID-19 in 4 or fewer days. HCPs could return to work 8 days after exposure “if they remained asymptomatic through day 7 with day 5-7 SARS-CoV-2 nucleic acid amplification test result negative,” the study states.

Investigators tracked 384 HCPs between January 4 and June 25, 2021, who followed the recommendations. Of the 384 participants, 333 (86.7%) remained asymptomatic. Of these, 323 (97%) tested negative and were thus eligible to return to work.

“Median day of early RTW was 8 (range 6-9, IQR 8-8),” the study states. “Mean days saved from missed work was 1.84 (SD 0.52). A total of 297 (92%) HCP did RTW ≤ 10 days from exposure and days saved from missed work was 546.48.”

Investigators note that COVID-19 may last for years, and Omicron might not be the last variant to emerge and challenge health care systems. The way those systems can meet future challenges will be to be as fully staffed as possible. The 10-day quarantine was established as a “conservative” way to manage risk of exposure to COVID-19, the study notes. While the CDC offers quarantine recommendations, many hospitals and other health care facilities will use different standards.

That’s a point made recently by Linda Spaulding, RN-BC, CIC, CHEC, CHOP, an infection prevention consultant and another 

 that “if nurses are still sick at day 5, they shouldn’t be coming back to work yet. But they’re feeling pressure by their hospital to return to work because of the nursing shortage.”

Spaulding added that infection preventionists can’t provide much help to stressed nurses. “IPs can listen to the nursing staff but they’re pretty much powerless if the administration [of a hospital] is requiring them to return to work,” says Spaulding. “From what I hear from nurses, they’re going to try hard to take care of patients with COVID-19. But as soon as this surge is over, they’re going to leave nursing and if there’s another surge, we’re going to have even less staff than we have now.”

 study state that the system they use builds in flexibility.

“We were able to flex the 7-day quarantine period in the program back to a 10-day quarantine period when staffing constraints eased and resume the 7-day early RTW program when the pandemic surged again,” the study states. “As a learning health system, we used these findings to inform new methods for Employee Health specimen collection, including a program for symptomatic self-testing with results typically available within 1 day.

Investigators concluded that "adaptability is critical in pandemic response, as is real-time evaluation of interventions like the early RTW program. Outcomes from this program were reviewed no less than weekly to ensure a safe work environment for HCP and safe patient care.”

Snyder also mentions in the interview that a new study is coming soon on how quickly HCWs can come back if they are sick and contagious. The investigators are looking at the HCWs returning as soon as 5 days. 

Videos

Investigators concluded that HCPs can safely return to work after 7 days of quarantine if they test negative for COVID-19 on days 5 to 7.

Calculating Return-to-Work COVID-19 Policies Is a Balancing Act for Hospitals

There are more than 700,000 individuals in the United States with end-stage kidney disease (ESKD) and the prevalence is estimated to be increasing by 20,000 cases a year.

 The treatment of choice for ESKD is kidney transplant but, because of a lack of available organs, most patients will rely on dialysis as a life-sustaining measure. Dialysis replaces many functions of the kidney by removing wastes and excess fluid through natural (peritoneum) or artificial (hemodialyzer) membranes. Most patients in the United States currently receive treatments using hemodialysis (HD) that is performed in outpatient clinics 3 days per week, but use of alternate sites such as long-term care facilities or the patient’s own home is growing in popularity. Regardless of setting, the process of dialysis poses unique challenges to infection prevention and control. Some of the most impactful practices for preventing infection are discussed below.

Infection is a leading cause of hospitalization and the second-leading cause of death in patients on dialysis. The process of HD puts patients at risk because the normally sterile bloodstream must be accessed several times per week. The risk varies with the type of device used to access the bloodstream, with a central venous catheter (CVC) carrying a risk 7 times higher than that of a native vessel called arteriovenous fistula (AVF).

 Reducing risk requires optimal care of the access site, such as using chlorhexidine gluconate for skin antisepsis, disinfecting CVC hubs before access, and keeping the exit site clean and dry. The CDC has published a set of evidence-based practices called Core Interventions for Dialysis Bloodstream Infection Prevention that have been shown to reduce risk of bloodstream infection in patients on dialysis by about 50%.

 Dialysis facilities should ensure that these interventions are incorporated into their policies and practices.

Despite a focus on decreasing catheter use and increasing use of AVFs, many patients receive dialysis through a CVC, which increases their chances of catheter-related bloodstream infection and potential need for antibiotic therapy. Annually, it can be expected that intravenous antibiotics will be administered to approximately 1 in 3 patients receiving maintenance HD. Frequent antibiotic administration may increase the likelihood that the patient becomes colonized or infected with a multidrug-resistant organism and faces challenges of antibiotic resistance. Inappropriate use and overuse of antibiotics are also associated with 

Standard and Transmission-Based Precautions

The proximity of patients on dialysis to one another and to health care workers can increase transmission of infection. Standard precautions can reduce risk of transmission of many common germs when used for every patient encounter across the continuum of care. The practices included in standard precautions are hand hygiene, use of personal protective equipment, respiratory hygiene, appropriate patient placement, careful handling of textiles and laundry, and safe injection practices.

 Chief among these is hand hygiene, which has long been a cornerstone of infection prevention and control. Alcohol-based hand sanitizer is more convenient and efficient than handwashing with soap and water and is the preferred hand-sanitizing product for these types of care settings.

Transmission-based precautions are used to prevent spread of certain germs through direct or indirect contact, respiratory droplets, or airborne particles. Respiratory illnesses such as influenza or COVID-19 can rapidly spread in congregate settings such as a dialysis clinic. Identifying infected patients and quickly implementing droplet respiratory precautions can prevent transmission of respiratory viruses between patients. Infections requiring airborne isolation (such as tuberculosis) are not as easy to manage in dialysis because the use of negative pressure and respirators is not routinely available in the outpatient setting.

Contact transmission is known to play a major role in the spread of bloodborne pathogens such as hepatitis B (HBV). HBV can survive for long periods on surfaces outside the body, and it is through this mechanism that chronically infected patients can infect others. Patients with HBV and the equipment used to treat them are isolated from susceptible patients on dialysis. Hepatitis C (HCV) and HIV are not as easily transmitted as HBV, and these patients and their equipment do not have to be isolated. Contact precautions are not routinely recommended for patients on dialysis who are infected or colonized with multidrug-resistant bacteria. This is mostly because contact transmission is not well documented in HD centers; it occurs less frequently in these settings than in hospitals, and environmental contamination is also less likely in dialysis facilities than in acute care settings because the patient is in the facility for a relatively brief period.

Screening is an important tool for detecting disease early and preventing transmission, especially when cases of infection have been epidemiologically linked to transmission in dialysis facilities. It is recommended that all new patients on dialysis be screened for HBV, HCV, and tuberculosis. This allows patients to be treated or isolated before there is opportunity to transmit the infection to others. After initial screening, it is recommended to continue screening for HCV every 6 months. Any newly identified HCV in a dialysis population should be reported to the local health department and investigated for potential transmission within the dialysis facility.

Immunization is an effective way to provide protection to susceptible patients. Patients on dialysis have a high incidence of respiratory infection with mortality rates significantly higher than the general population, and it is recommended that they be vaccinated against pneumococcal disease, influenza, and COVID-19. Additionally, if found to be nonimmune to HBV during screening, the HBV vaccine series is recommended. Immune response to vaccines in patients with ESKD is less robust than in healthy individuals because of changes in the immune system. Vaccine dose and administration schedules are different for patients with ESKD than for others, and it is important to review dosage and vaccine schedule for this population.

The HD setting presents a challenge for environmental cleaning and disinfection because of the demand for rapid turnover of stations. Dialysis center staff often feel rushed to complete tasks, especially when transitioning patients on or off machines. Under these pressures, personnel may eliminate or take shortcuts in steps essential for preventing infection transmission. If contaminated surfaces that are turned over quickly are not adequately cleaned and disinfected, bloodborne and other pathogens may remain alive and infectious for days. Dialysis centers should allow adequate time between patients for thorough cleaning and disinfection.

All surfaces of the dialysis station, including the machine and patient chair, should be cleaned and disinfected using a United States Environmental Protection Agency–registered hospital disinfectant. Cleaning and disinfection should commence once the patient has left the station to prevent cross-contamination. Internal surfaces of the dialysis machine should be regularly disinfected following the manufacturer instructions for use. Written protocols outlining the steps should be in place, and the use of a log can help to document and keep track of cleaning and disinfection. Elsewhere in the facility, clean and contaminated areas should be separated, with clean supplies and medication preparation areas having adequate spatial separation from contaminated equipment storage.

Water safety is extremely important in the dialysis setting. Potable water from municipal systems often contains a small amount of bacteria harmless when ingested because of the inhospitable environment of our stomachs. However, even a minute number of normally harmless bacteria in the water poses a great risk of infection to the patient on dialysis because the bacteria bypass the normal protection of skin and stomach acid and are directly introduced to the bloodstream during dialysis. An additional consideration is that, in HD, patients’ bloodstreams are exposed to 300 to 600 L of water per week during treatments; a small number of bacteria normally allowed per liter of water is quickly magnified given the volume of water exposure.

These are a few reasons why water quality is strictly monitored in the dialysis setting. Water systems are specially engineered to further soften and filter the municipal supply to ensure that toxins like chlorine and endotoxin, and hazards like bacteria and sediment, are removed. Alternatively, reverse osmosis portable water systems may be used in some settings, but the objective is the same: to have the purest water possible. Chemical and biological standards established by the Association for the Advancement of Medical Instrumentation give allowable and action levels for each hazard. Routine monitoring of bacteria and endotoxins in product water, along with periodic disinfection of the water system, is recommended.

Effectiveness of infection prevention and control techniques requires that interventions be consistently applied and reliably followed. Staff should be well trained on hire and competency routinely assessed. Whether staff receive education through a formal trade school or college or on-the-job training, it is important to provide annual training to ensure competency is maintained. Provide training on an ongoing basis for new products and policies. Hand hygiene observations should be performed to monitor for adherence, and the monitoring results should be shared with staff. Discussion of the results and reinforcement of best practices are extremely important.

The facility’s competency program should cover the Core Interventions for Dialysis Bloodstream Infection Prevention identified by the CDC as proven methods for improving care and reducing bloodstream infections. Adherence is more likely if the order in which steps are to be performed is standardized. A checklist of steps can help to ensure adherence and can be used to assess and provide feedback on performance. The CDC has a series of checklists and audit tools that may be used in dialysis centers for this purpose.

Dialysis is a life-sustaining treatment for individuals with ESKD; however, infection continues to be a major cause of morbidity and mortality in this population. Several agencies and work groups have published guidelines to help reduce the risk of infection in the dialysis setting. However, research has shown that these recommendations are not uniformly implemented nor followed in some facilities. Each member of the dialysis team has a responsibility to ensure that prevention practices are in place and followed, and the role of the infection preventionist is often delegated rather than dedicated. Because of this, dialysis facility leaders should ensure that there is training on hire and annually and that competency is periodically assessed to protect patients from avoidable harm.

Saran R, Robinson B, Abbott KC, et al. US Renal Data System 2016 annual data report: epidemiology of kidney disease in the United States

. 2017;69(3 suppl 1):A7-A8. doi:10.1053/j.ajkd.2016.12.004

Hoen B, Paul-Dauphin A, Hestin D, Kessler M. EPIBACDIAL: a multicenter prospective study of risk factors for bacteremia in chronic hemodialysis patients. 

. 1998;9(5):869-876. doi:10.1681/ASN.V95869

Dialysis safety: core interventions. CDC. Updated June 15, 2016. Accessed February 11, 2022. https://www.cdc.gov/dialysis/prevention-tools/core-interventions.html

Dialysis safety: audit tools and checklists. CDC. Updated September 25, 2017. Accessed February 11, 2022. https://www.cdc.gov/dialysis/prevention-tools/audit-tools.html

The hemodialysis setting presents a challenge for environmental cleaning and disinfection because of the demand for rapid turnover of stations.

Infection Prevention and Control Are Crucial in Dialysis Settings

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.

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.

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


Infection Control Today, April 2022, (Vol. 26, No. 3)

The IP Relationship With Clinical Staff Is a Critical Partnership

Fans, Filters, Rays, or Ions?

Pandemic Places Importance of Preventing Environmental Infection at Center Stage

Bug of the Month: I'm Mostly Harmless, Until I Contaminate Your Food

Calculating Return-to-Work COVID-19 Policies Is a Balancing Act for Hospitals

Infection Prevention and Control Are Crucial in Dialysis Settings

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

Sanofi and GSK to Seek Regulatory Authorization After “Robust Efficacy” Proven by COVID-19 Vaccine

Best Handwashing Technique: WHO’s 6-Step Process Is Effective, but Data Inconclusive

Handrails, Equipment Controls Among Most Contaminated High-Touch Surfaces in Long-Term Care Facilities

COVID-19 Boosters: New MMWR Report Explores Waning Immunity

Hospital Mattress Failure Is a Potential Threat to Patient Safety