Kevin Kavanagh, MD, is the founder and board chairman of Health Watch USAsm, a not-for-profit patient advocacy and healthcare policy research organization. Health Watch USAsm is a member of the National Quality Forum and has been designated as a “Community Leader” for Value-Driven Healthcare by the US Department of Health and Human Services. He served on the Centers for Medicaid and Medicare Services’ Hospital-Acquired Condition (HAC) Reduction Program Technical Expert Panel (TEP) from 2014 to 2019; the AHRQ Standing Working Group for Quality Indicators from 2016 to 2017; and the AHRQ Health Care Effectiveness and Outcomes Research (HEOR) Study Section. He has also served on the National Quality Forum’s Consensus Standards Approval Committee (CSAC). 

recently spoke with Kavanagh about the current state of infection control and where the industry might be going. 

How important do you think infection preventionists are to the workings of infection control in hospitals?

Infection preventionists are of utmost importance. Just in the last year we have seen a widespread acknowledgement that carbapenem-resistant 

 (CRE) has become endemic, and the fungi 

. Both of these pathogens can become totally resistant to antimicrobial agents; being a fungus, growth of 

can even be promoted by antibiotics. It will take complex- and situation-specific interventions to stop many of these pathogens. For example, 

 to quaternary ammonia based antiseptics and it’s very hard to contain its spread. Well-trained environmental cleaning services are crucial. Alcohol is also not an effective hand hygiene agent for 

, the flu virus, and the norovirus. Thus, hospital-wide training and monitoring of pathogens by infection preventionists is of utmost importance. 

Do you think that most hospitals utilize infection preventionists properly?  

Many hospitals do not even have a full-time preventionist. Many rural hospitals have only a part-time individual with limited resources. In a recent article by 

 current infection preventionist staffing needs to be 31% to 66% above current benchmarks. The progression of the epidemic of antibiotic-resistant organisms necessitates more, not less, staff. This is even more crucial in nursing homes where, according to the [US Centers for Disease Control and Prevention (CDC)], 

carriage of antibiotic-resistant organisms

 in some facilities is greater than 50%. Unfortunately, the vast majority of nursing homes lack both the guidance and staff expertise to confront this epidemic. Currently, a large portion of an infection preventionist’s time is devoted to 

record keeping and reporting of pathogens

. But having comprehensive real-time data to track resistance is crucial to formulate effective strategies. At this year’s Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria (PACCARB) meetings, a number of speakers were asked questions and their answers were that we are not tracking this or the data are not available. Data are needed to prioritize the development of antibiotics and evaluate strategies to prevent spread. The answer is the hiring and training of more preventionists, a “costly” intervention but I’m afraid only a small portion of what will be needed to stop this epidemic.

How do you weigh the goal of infection prevention against the costs of trying to do so? Does it become too costly at some point? 

Antibiotic resistance is on the verge of becoming a global catastrophe, impacting many facility services such as transplantation and chemotherapy. Even patients undergoing elective surgery or having a disease such as diabetes are at an increased risk [of contracting an antibiotic-resistant infection]. The argument that these organisms primarily affect the sick and frail is shortsighted, since most of us age and will fall into this category.
	The CDC estimates (at a minimum) that 

35,000 individuals die each year from resistant organisms

 with another 12,800 patients dying from 

. This does not count the long-term disability many of the survivors will endure.
	The United Kingdom’s 

 that by 2050 antibiotic resistance will have a cumulative cost to the world of $100 trillion dollars and 10 million lives will be lost each year. 
	Whatever the cost, we must bear it or risk closing facilities, [cutting] services, and shortening the human life span. I fear the concerns over the cost of hiring additional nursing staff may pale in comparison to the true cost to each facility, which may be millions of dollars per year in lost revenues and additional resources needed to control this epidemic.

Do you think environmental services departments are properly integrated into the infection control process?  

, in the hospitality industry, it takes 30 to 35 minutes to clean a hotel room. In hospitals, the time allotted is often much less. Since this article was published, the situation has only gotten worse. Too many facilities have discharge room cleaning times below the 40 to 45 minutes recommended in the 

Association for Healthcare Environment (AHE)

 guidelines.
	Dependence on fogging units and copper surfaces to lessen the need for environmental services and shorten room turnover time is ill advised. These interventions can be a valuable supplement, especially in rooms occupied by patients carrying dangerous pathogens. But it must be remembered that their effectiveness lessens with biofilms or thick droplet debris. Because copper is expensive, it has been recommended for high-contact areas. However, not all copper alloys have the same efficacy and knowing the contact time used to determine the bactericidal effect is crucial. Many alloys 

 on certain organisms, making primary dependence of this modality in high-contact areas unwise.
	Environmental control services need to be revamped. This is a highly technical and important function of a hospital. Some are suggesting certification with varying levels of expertise, with the highest levels for units such as the Intensive Care Units and operating room. Hospitals must invest significantly in trained environmental services, which can integrate with infectious disease services and modify their protocols depending upon the patient care setting and type of pathogen. CDC is currently formulating core strategies for the implementation of existing guidance. Hopefully this will result in cleaner and therefore safer patient care environments.

*This transcript has been edited for length and clarity. 

Articles

A Conversation With Kevin Kavanagh, MD: Infection Preventionists Are Underutilized and Underappreciated

In the middle of the night, while caring for her child in the neonatal intensive care unit, hospital staff told a mother to move to another room. “This transition would have been a lot more respectful and courteous with some warning...when we aren’t sleeping and recovering from severe trauma,” she recalled.

Another patient complained that a “nurse did not remember to put on gloves or sanitize [her] hands prior to dispensing medication.”

One had to deal with a “staph infection following surgery.” That required even more surgery “to patch a bursa sac on my shoulder.” 

And 1 man felt that his caregivers’ lack of communication proved that they had given up on him. This led to a difficult recovery that delayed discharge for a month and a half. 

These are just some of the stories gleaned from an open-ended survey of 242 patients at 1 pediatric and 1 adult care hospital published recently in the 

Journal of the American Medical Informatics Association

 Patients often react to these and other undesirable events (UEs) by either requesting different providers or transferring to another hospital, or by making their complaints known to hospital staff. 

Investigators at the University of Washington, who conducted the survey, developed a conceptual model of how informatics might be able to help patients better report and/or avoid UEs. 

Informatics can “support patients at all stages of their experience by increasing awareness of UEs, encouraging intervention and resolution, detecting and managing invisible harms [such as emotional trauma], and reducing barriers and sharing report updates,” states the study, funded by the Agency for Healthcare Research and Quality. 

The study categorizes 4 stages where information about UEs, and opportunities to prevent and/or respond to them, can be made: the occurrence itself, the window for intervention, identification of both visible and invisible harms, and reaction and response. 

Investigators noted that “existing patient-facing technologies,” such as electronic health records (EHRs), can allow patients to monitor their care and identify mistakes. 

However, “Despite extensive research demonstrating the safety-related benefits of such technologies, recognizing UEs is just 1 aspect of the patient experience,” the study states. 

What happens when patients’ concerns are not heard? 

For instance, 1 patient, whom the study described as a “caregiver,” stopped her 

providers from administrating the wrong treatment to her hospital roommate. She submitted a complaint, but the hospital didn’t follow-up. “I don’t know at this point if [the] team has been talk[ed] to,” she told investigators. “It would be nice to know that the follow-up continued that far.” 

What happens when patients feel too vulnerable to speak up, or are unaware of their rights in situations, or when the fast-paced tempo of treatment means that the damage is done before they get the chance to prevent it? 

Informatics can encourage patients to request a solution to their problems and can facilitate patient-provider mediation by offering tips on how to best navigate these possibly awkward conversations. 

Investigators also cite a tool-called MySafeCare-that “allows patients to intervene in UEs in a real-time, low-burden way that does not require direct interaction with providers. This nonconfrontational format helps patients speak up about concerns as they occur.” 

In addition, informatics might allow patients to trade information about their care with each other, which in turn would give them the confidence to speak out about UEs. 

“Multimodal reporting” would include email, text messaging, phone calls, patient portal forms, or voice-based technologies, such as Amazon Alexa and Google Assistant, that would help patients with cognitive or physical difficulties, due to illness or treatment, voice their concerns. 

Investigators offer tips on how to manage invisible harms such as emotional trauma and life burdens. As the “invisible” suggests, they are difficult to detect. 

“For example,” the study states, “researchers have studied social signal processing as a way for patients and providers in clinic to receive real-time feedback about the tone and empathy conveyed throughout their conversations. Similar social signal processing solutions could be adapted for the inpatient setting to surface negative emotions or reduced trust that patients might express after handling a UE.” 

Investigators acknowledged some possible limitations: voluntary participation may have caused selection bias, and the survey participants were patients at urban facilities, so the findings might not be applicable to the broader population. Still, some cautionary tales can only be told by the patients. 

One reported being administered infected shunt fluid. “[T]hey needed emergency surgery to help defeat my infection.” 

Haldar S, Mishra SR, Pollack AH, Pratt W. Informatics opportunities to involve patients in hospital safety: a conceptual model. 

. 2019 Oct 3. pii: ocz167. doi: 10.1093/jamia/ocz167.

Informatics can support patients at all stages of their experience by increasing awareness of UEs, encouraging intervention and resolution, detecting and managing invisible harms [such as emotional trauma], and reducing barriers and sharing report updates.

Informatics Can Get Patients  More Involved and Help Hospitals  Provide Better Care 

Think copper when considering how to best protect patients from bacterial infections while also bolstering the bottom line, argues a recent study in 

, a journal of the American Society for Microbiology.

study compared contamination of intensive care unit (ICU) beds outfitted with copper surfaces to traditional (plastic) beds. The research team tracked the bacteria-fighting efficacy of the beds for 23 months, from April 2017 to March 2019. In total, 350 samples were taken from the plastic beds; 215 from the copper beds. 

On average, copper beds harbored 94% fewer bacteria than conventional beds. 

“In spite of routine disinfection or terminal cleaning and disinfection (TC&D) efforts to reduce the microbial burden, 

hospital studies have shown plastic beds are significant reservoirs for microbes,” the study states. “In fact, beds have been shown to be among the most touched and heavily microbially burdened objects in [ICU rooms] and are considered high risk for infection transmission to and from patients, visitors, and hospital staff.” 

Copper surfaces “kill bacteria through a multi-modal mechanism through its ability to disrupt bacterial respiration, generate superoxide, and destroy genomic and plasmid DNA 

Investigators with the Medical University of South Carolina compared the 2 types of beds at the intensive care unit at Highpoint Health in Lawrenceburg, Indiana. The 8 rooms in the ICU are arranged in an “L” shape. “Researchers recorded the occupancy status of each room when beds were sampled,” according to the study, which was funded by an unrestricted research grant from Bed Techs Inc., a company that manufactures and supplies hospital beds. “Throughout the study, select hospital staff members directly observed hand hygiene and utilized the Qualaris monitor system. Observed compliance rates were routinely greater than 93%.” 

Counting staff and visitors, about 83 people enter a patient’s room each day. The study found that the antimicrobial action of copper on near-patient surfaces-such as bedside tables, bedframes, or infusion stands-kept those surfaces below microbial TC&D risk levels. 

“Further,” the study states, “it is anticipated that encapsulated copper surfaces will have a higher likelihood of reducing the inherent risk associated with near-patient surfaces than will adjunct, intermittent, and discontinuous disinfection technologies entering the market place, such as ultraviolet irradiation, and vapor phase hydrogen peroxide; and indicator glow markers, covertly placed on near-patient contact locations, intended to identify surfaces that [environmental services technicians] endeavored to clean, rather than whether the surfaces are, in fact, microbiologically clean.”

that “the findings suggest that antimicrobial copper beds can facilitate infection control efforts to keep healthcare surfaces cleaner between regular cleanings and reduce the potential risk of transmitting microbes associated with healthcare associated infections.” Schmidt is a professor of microbiology and immunology at the Medical University of South Carolina and the study’s corresponding author. 

Unfortunately, as Schmidt points out, copper hospital beds are not yet commercially available. “We are hopeful...that this [study] will acquaint the decisionmakers that they now have a new tool to help them in their fight against [healthcare-associated infections (HAIs)].” 

The study’s outlining of the potential cost-effectiveness of copper beds might help that case. The copper beds-outfitted with copper rails, foot boards, and bed controls-are a continuous intervention. That cuts down on the time spent making a standard bed microbially safer. A copper fitted bed costs about $2,200, or about $1.20 per day over 5 years. That, according to the study, represents less than 10% of the costs of other cleaning options, such as additional daily cleaning (~$12-$13 per room), ultraviolet radiation (~$10 per room), or hydrogen peroxide vapor phase deposition (~$100 per room), when labor, supplies, and equipment costs are included. In addition, “it is the only adjunct to act continuously, actively killing bacteria 24 hours/day and only adding a modest increase to the environmental services/infection control budget,” the study notes. 

About 2 million patients in the United States contract an HAI each year, and an estimated 75,000 of those will lose their lives. 

that “as copper is a continuous acting intervention, we believe that employing an intervention such as a completely encapsulated copper bed should lead to reductions in the HAI acquisition rate when used in concert with other infection control interventions.” 

Reference
	Schmidt MG, Attaway HH, Fairey SE, Howard J, Mohr D, Craig S. Self-disinfecting copper beds sustain terminal cleaning and disinfection effects throughout patient care. Appl Environ Microbiol. 2019 Dec 13;86(1). pii: e01886-19. doi: 10.1128/ AEM.01886-19. Print 2019 Dec 13.

On average, copper beds harbored 94% fewer bacteria than conventional beds.

Copper Beds Vastly  Cut Down on Amount  of Surface Bacteria 

The arrival of Thomas Eric Duncan at Texas Health Presbyterian Hospital Dallas 5 years ago was a scenario we probably should have anticipated, but since no hospital in the United States had ever really expected to treat a patient with a viral hemorrhagic fever, this quickly became a “learn as we go” event. In short, Duncan was seen in the emergency department, sent home, and later returned via ambulance when suspicion for Ebola virus disease (EVD) grew. During his care, 2 nurses became infected with the virus and, although they survived, Duncan did not. 

The chaotic days and weeks that followed revealed a healthcare system with a woefully inadequate preparedness for infectious diseases on a national level. Since this was a novel situation, guidance for personal protective equipment (PPE) isolation precautions, and even treatment was in a state of flux. One of the infected nurses in Dallas sued the hospital, highlighting its lack of preparedness and adequate response to ensure healthcare workers were protected. Although the lawsuit was settled privately, findings from it note that the hospital failed to provide the necessary protection for nursing staff. 

Although the Dallas Ebola cluster taught us a lot about the state of readiness within US hospitals, special pathogens preparedness is an important conversation for infection preventionists (IPs). We now have proof that in these situations, the IP is the subject matter expert and will ultimately play a vital role in educating staff and ensuring response efforts run smoothly. 

We are perhaps the only healthcare professionals who understand the full spectrum of disease transmission through the lens of healthcare-from disinfection and sterilization, PPE utilization, patient movement and transport, and risk of medical devices and procedures. Moreover, IPs work across the spectrum of roles within healthcare, from the medical provider to the environmental services worker. IPs are uniquely cognizant of how our healthcare workers function and what will put them at the greatest risk. 

Infection preventionists’ knowledge of transmission and interventions, mixed with their emphasis on education across different professions, means that they are especially skilled at responding to outbreaks. Moreover, IPs are already working across nearly every profession within the healthcare environment, which makes them acutely skilled in bringing forth key stakeholders. 

We may not have seen the end of Ebola in the United States, and we certainly haven’t seen the end of it globally. Currently, there is an outbreak raging in the Democratic Republic of the Congo (DRC), resulting in more than 3300 cases and 2200 deaths. 

Similar to what was seen in the 2013-2016 outbreak in West Africa, healthcare workers have been at increased risk as nosocomial infections have been prolific. In fact, the World Health Organization notes that healthcare workers are 21-32 times more likely to be exposed and infected. The current outbreak is, as of now, the second largest in history, with the 2013-2016 outbreak resulting in over 28,000 cases and 11,000 deaths. 

Until Duncan, we had never cared for a patient with EVD in regular, acute care hospitals that were not designated (like Emory) for treating patients infected with special pathogens. The advanced medical setting inherently increases risk for healthcare workers, and this was just one of many lessons learned. 

Another was the need to install a tiered hospital system to ensure continued readiness. Having all hospitals prepare for, and act as, treatment hospitals is not sustainable. Not only was expertise limited but maintaining the training and supplies for such infrequent events was extremely taxing on hospitals and healthcare workers. For many, the memories of learning the donning/doffing process for the enhanced PPE that is required for Ebola, are times of stress and excitement. In some ways, it was highly interesting learning a new mechanism to protect against unusual diseases, however the changing guidelines and extreme precision that is needed for PPE was stressful. A single misstep in the process could result in deadly infection. Originally the tiers were frontline, assessment, and then treatment hospitals. 

Now, this includes regional Ebola and other special pathogens treatment centers (RESPTC). There are roughly 10 RESPTCs, 63 Ebola treatment centers, 217 assessment hospitals, and more than 4800 frontline hospitals. The RESPTCs were added onto this, which creates a total of 4 tiers. The expectation is that the majority of hospitals are frontline (there are roughly 6000 hospitals in the United States) that can quickly identify, isolate, and inform possible Ebola patients, while assessment hospitals can safely receive and isolate to help determine infection through laboratory measures over 96 hours. Treatment hospitals and RESPCTs are expected to care for one or more patients with special pathogens and provide the highest level of care within biocontainment units. These treatment facilities tend to have a handful of beds and are expected to be able to safely receive a patient within 8 hours. 

Assessment and treatment hospitals can apply for and receive federal funding from the Hospital Preparedness Program (through the US Department of Health and Human Services (HHS)) to help offset the cost of these efforts as it can be extremely costly to develop and maintain biocontainment units. It is estimated that the development of 45 treatment centers cost nearly $54 million and the development of a single treatment center cost $1.2 million. 

In addition to the development of this tiered approach, there are also training and education opportunities available to healthcare workers through the Center for Domestic Preparedness, (CDP), which provides free courses on enhanced PPE. The National Ebola Training and Education Center (NETEC) was also created, which provides training for healthcare workers and first responders. However, it is not free and requires travel. Fortunately, NETEC offers a wealth of free information online. Hospitals can also apply for funding through the Hospital Preparedness Program (HPP), which provides grants through HHS. 

Lastly, it is important to note that there has been increased regulatory focus on emergency preparedness in hospitals. The 2017 Centers for Medicaid and Medicare Services (CMS) Emergency Preparedness Rule required that hospitals maintain and engage in certain levels of preparedness annually to maintain Medicare reimbursement. Unfortunately, this is not specific to infectious diseases and allows the hospitals to determine what they view are hazards and vulnerabilities. 

This all sounds wonderful but, unfortunately, the level of readiness we saw in 2014 is not the same as in 2019. When the tiered hospital approach was developed and the outbreak was slowing, the push to throw resources to improve preparedness also waned. Hospital administrators no longer felt the need to spend thousands of dollars on PPE and training when the risk of Ebola was gone. A recent survey of hospital administrators found that while they feel better able to deal with Ebola than in 2014, roughly one-third of them could not state which tier their hospital fell into and that there were competing priorities that diminished the likelihood that they would continue to buy the PPE. 

Also, administrators noted that responding to Ebola and special pathogens requires certain knowledge that emergency preparedness people lack, and IPs have. Now, our focus has gone back to preventing health-care-associated infections (HAIs), and the more day-to-day tasks of infection prevention and control. Providing the training and acquiring the PPE for maintaining readiness for special pathogens has nearly fallen off the radar or is something that IPs are limited in doing as it so heavily relies on administrative support. 

Nevertheless, it is important to maintain a level of bio-preparedness in healthcare. When nosocomial infections occur, it becomes obvious that there is a breakdown of IPC measures along the way. But this particular outbreak wholly revealed the role of IPs during infectious disease events and emergencies. Research following the outbreak found that in the United States, IPs were primarily responsible for Ebola-readiness efforts within their healthcare facilities, and such work consumed 80% of their time. These findings point to the increasingly important role of IPC in infectious disease preparedness, but also the changing role of IPs as emerging infectious disease threats evolve. 

Although the odds of another patient with EVD walking into your emergency department are slim, wouldn’t you rather be prepared? Moreover, working to enhance infectious disease preparedness in staff can help engage them in routine IPC processes, like rapidly identifying and isolating infectious patients, and informing the necessary parties. Have those frank conversations on infectious disease threats and how those important questions (international travel within 21 days, signs/symptoms, relevant exposures) can make a huge difference. 

Even if IPs are unable to acquire the administrative support to update their PPE stockpiles and provide extra training for staff, there are small measures that can help instill readiness. Implement travel screening questions on admission and educate staff on what travel abroad signs and symptoms could mean. Provide voluntary classes for staff who want to learn more about special pathogens and what the PPE is like. Do small mini-educational rounds with emergency department staff about which rooms they would put a high-risk patient in. Create a gap analysis and identify the weak points if a patient with Ebola is treated in your facility. Ensure your negative pressure rooms are truly functioning. What PPE would you use if you had a patient under investigation for Ebola? 

All of these are small tasks that can enhance readiness for a range of situations, whether it be Ebola or measles. Special pathogens preparedness builds on basic infection prevention practices, so if nothing else, we can focus on building our existing infection control efforts to ensure there is a strong foundation in the face of bigger infectious disease threats. 

Saskia v. Popescu, PhD, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist. During her work as an infection preventionist, she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She holds a doctorate in biodefense from George Mason University where her research focuses on the role of infection prevention 

in facilitating global health security efforts. She is certified in infection control and has worked in both pediatric and adult acute care facilities. 

1. Details of Duncan’s reatment reveal a wobbly first response to Ebola, New York Times. 10-25-14. NYT website. https://www.nytimes.com/interactive/2014/10/25/us/ebola-dallas-timeline.html. Accessed December 8, 2019.
	
	2. World Health Organization, Ebola in the Democratic Republic of the Congo-health emergency update. WHO website. https://www.who.int/emergencies/diseases/ebola/drc-2019. Published November 2017. Accessed December 2019.
	
	3. Assistant Secretary for Preparedness and Response. Regional treatment network for Ebola and other special pathogens,” November 2017. ASPR website. https://www.phe.gov/Preparedness/planning/hpp/reports/Documents/RETN-Ebola-Report-508.pdf.
	
	4.  Herstein JJ, Biddinger PD, Kraft CS, et al. Initial costs of Ebola treatment centers in the United States. Emerg Infect Dis. 2016 Feb;22(2):350-2. doi: 10.3201/eid2202.151431.
	
	5. U.S. Department of Health and Human Services Office of Inspector General. Hospitals reported improved preparedness for emerging infectious diseases after the Ebola outbreak. HHS website. https://oig.hhs.gov/oei/reports/oei-06-15-00230.pdf. Published October 2018. Accessed December 2019.
	
	6. Morgan DJ, Braun B, Milstone AM, et al. Lessons learned from hospital Ebola preparation. Infect Control Hosp Epidemiol. 2015 Jun;36(6):627-31. doi: 10.1017/ice.2015.61.
	
	7. Popescu S, Leach R. Identifying gaps in frontline healthcare facility high-consequence infectious disease preparedness. Health Secur. 2019 Mar/Apr;17(2):117-123. doi: 10.1089/hs.2018.0098.
	
	8. McCullough JM, Fowle N, Sylvester T, et al. Cost analysis of 3 concurrent public health response events: financial impact of measles outbreak, Super Bowl surveillance, and Ebola surveillance in Maricopa County. J Public Health Manag Pract. 2018 Jun 20. doi: 10.1097/PHH.0000000000000818. [Epub ahead of print].

Although the odds of another patient with EVD walking into your emergency department are slim, wouldn’t you rather be prepared?

Preparing for Special Pathogens: An IP Perspective

resist all 3 classes of antifungals and 1 in 3 patients infected with the fungus dies. And carbapenem-resistant 

causes pneumonia in addition to wound, bloodstream, and urinary tract infections. 

No wonder then that when the US Centers for Disease Control and Prevention (CDC) released its report updating the state of infection prevalence and antibiotic-resistance threats in November, the agency added those 2 pathogens to its “urgent” category (joining 

, carbapenem-resistant Enterobacteriaceae, and drug-resistant 

5 altogether. The other 2 categories are “concerning” and “serious”). 

first popped up in Asia in 2009 and has quickly spread, becoming a cause of severe infection worldwide. It triggers outbreaks at healthcare facilities, and patients can carry it on their skin without being infected (making them silent carriers). What’s more, common healthcare disinfectants can’t always eliminate it. 

Intensive care patients are particularly vulnerable to carbapenem-resistant 

. It frequently contaminates surfaces and shared medical equipment. Some 

resists nearly all antibiotics and few drugs are in development to treat it (there’s not much profit in it). 

caused an estimated 8500 infections in hospitalized patients and 700 estimated deaths in the US, according to the CDC. It’s a little more difficult to pinpoint the number of people in the US who’ve died from 

because patients often simultaneously suffer from other life-threatening illnesses. 

These challenges, daunting as they may seem, are surmountable, says Arjun Srinivasan, MD, the associate director for healthcare-associated infection prevention programs at the CDC. “The strategies that we recommend to address antibiotic resistance are fundamentally the same for these 2 pathogens as they are for many of the others,” he says. “It’s working on improving antibiotic use, and in the case of 

are “quite hardy in the environment,” says Srinivasan. They spread easily to surfaces and can stay a long time. “So proper environmental cleaning and hand hygiene become even more important for these 2 pathogens.” 

These will be among the many prevention and containment responses that infection preventionists (IPs) will help drive, says Sylvia Garcia, the director of infection control and prevention at the Joint Commission. She adds, however, that “we cannot lay this issue at only the IPs’ door. Superbugs require attention from the housekeeper to the CEO.” 

IPs need information and the time to sort through it, says Garcia. That might include data specific to the organization about resistance patterns. They’ll want to check antibiotic stewardship programs, and hand hygiene compliance. They’ll need the most up-to-date information about effective control measures, including the latest from the CDC and the Society for Healthcare Epidemiology of America. 

needs to create and implement a rational approach to controlling development and transmission of superbugs,” says Garcia. “I usually recommend that the IP be an active participant but not the leader of a multidisciplinary team to ensure that organizations’ specific risks are identified and real action plans are developed and implemented.” 

Garcia’s responses beg the question: In this era of superbugs, do IPs get the respect they deserve? “I don’t think they do,” says Srinivasan. “I think that they have been underrecognized for a very long time and that they work incredibly hard. They have a very, very challenging job and they do it well.”

Just ask Scott Lorin, MD, the president of Mount Sinai Hospital’s Brooklyn campus. In May 2017, an elderly man died in the hospital’s intensive care unit. “We cultured essentially every aspect of the room 

. “And this was a huge surprise for us.”  

In fact, Lorin calls it his “aha” moment. With the possible exception of 

, you don’t usually see that amount of contamination by infectious diseases, he says. “We realized that we needed to put together a new approach, and that this was the most insidious and invasive bug we had ever witnessed.” 

The hospital’s response involved a “hyper focused” approach in managing patients with 

, which “puts a lot of burden on our infection control team. Your infection control team really manages and coordinates the care of these patients. And that’s something that they didn’t have to do previously.” They also “intensely monitored the quality of environmental cleaning and the staff’s compliance with precaution measures.” 

For instance, Mount Sinai’s infection control team made sure that nurses donned gowns and gloves before going into patient rooms. Then they made sure that nurses changed into other gowns and gloves before moving on to another patient’s room. 

Srinivasan calls this the bread and butter of infection control. “The challenge is making sure that [these processes are] done all the time. Many of the infection preventionists are focusing on monitoring and making sure those practices are happening. Talking to providers when they’re not happening to try to find out why. And see areas where we can better implement working with environmental services to improve environmental cleaning practices.” 

At the time, says Lorin, there was a dearth of literature on 

. “We had to put together our own roadmap, essentially a comprehensive plan that included special infection prevention protocols with direct support and system leadership.” 

When CDC issued its report on antibiotic-resistant pathogens, New York state health regulators issued a report at about the same time that named the healthcare facilities that cared for someone infected, colonized, or possibly colonized with the fungus. 

When CDC issued its report on antibiotic-resistant pathogens, New York state health regulators issued a report at about the same time that named the healthcare facilities that cared for someone infected, colonized, or possibly colonized with the fungus between January 1, 2016, and June 28, 2019 (Lorin’s hospital is on the list). They had kept the names of the particular facilities under wraps up until then. 

The information was meant to help patients deciding on where to get care, but the New York report also notes that “the detailed information [in the report] is primarily intended for use by hospital infection preventionists....” 

The report measured the number of IPs on the staffs of 175 hospitals. IP staffing levels in New York are measured as the number of patients for which 1 full-time equivalent IP is responsible. In 2018, the average IP in New York State was responsible for 89 inpatients and 228 total patients per day. 

IPs in New York spent most of their time on surveillance (36%), department rounds (12%), daily isolation issues (8%), quality and performance improvement (8%), administrative policy and procedure development (7%), environment/construction rounds (6%), prevention in outpatient areas (5%), employee and occupational health (4%), emergency preparedness (4%), staff education, risk management, and other issues (9%). 

As Srinivasan earlier alluded, time-or the lack of it-is the enemy when it comes to dealing with superbugs. “It takes time to put on a gown and gloves,” he says. “It takes time to clean your hand. It takes time to clean the environment. And when you’re running from patient to patient to patient, that is time that is precious, and it’s hard to make that time to do the right thing every single time. We need innovations in that area. I don’t think that’s a problem that we’ve solved. We’re not going to be able to solve it by adding time to the day.” 

Lorin says that money is also an issue. “There’s a very significant cost for taking care of these patients, and none of us have budgeted for it,” says Lorin, adding that his hospital is currently doing some number-crunching research. “There’s the cost of 1-to-1 nursing or 1-to-1 nursing assistants, the cost of cleaning a room multiple times a day, the cost of isolating the patient, and the cost of dedicating equipment to the patient’s room.” 

For instance, a dialysis machine stays in the room for the duration of the care for a patient with 

is. These measures sound intense, but it’s been “100%” successful, says Lorin. “We have not had a case in a year and a half.”

enters a hospital via transfer of patients from skilled nursing facilities (SNFs), Lorin says. “That was the source of the outbreak.” 

Mount Sinai includes 7 different campuses and Lorin says that he has shared the protocols he developed with his sister hospitals, the CDC, the New York City Department of Health and Mental Hygiene, and the New York State Department of Health. They’re available to any SNFs that might want them, as well. 

“Certainly, if they reached out to us-which they haven’t-we’d be happy to provide guidance or advice.” 

Srinivasan wasn’t talking specifically about Lorin when he said that hospital administrators play a crucial role in fighting superbugs, but he might as well have been. “They are the ones who really are able to marshal the resources that might be necessary to deal with some of these problems,” says Srinivasan. “They have to support their infection prevention and control, and antibiotic stewardship programs.” 

As Srinivasan said, and Lorin can attest to, 

took those on the frontlines of infection control somewhat by surprise. That was not the case with carbapenem-resistant 

was already on the threats report list,” reminds Srinivasan. “It was previously designated as multidrug-resistant 

, and it was in the serious category.” One of the enzymes contained in 

can deactivate carbapenems. “And that is conferring carbapenem resistance to 

, and that’s new. So that is something that we are concerned about.” 

Despite their lethality, infection by superbugs is still a relatively rare occurrence in a country of almost 330 million people, and that makes tracking difficult. 

“We have struggled somewhat on the healthcare side to get the type of data that we want and need to track these pathogens,” says Srinivasan. “The growth of the electronic health data that we use for the threat report in 2019, though, does give us a system that does allow us to get some of these estimates of the burden of these pathogens.” 

Help for responders came in 2016 when CDC launched the Antibiotic Resistance Laboratory Network (AR Lab Network).

“That is not just looking and counting, that’s a response network,” says Srinivasan. “We know that there are thousands and thousands of isolates of concern that hospitals and health systems are sending into that AR Lab Network, and then getting real time information so that they cannot just track, but they can respond faster.” 

Both C. auris and carbapenem-resistant Acinetobacter are quite hardy in the environment. It takes a lot to control spread.

How Infection Preventionists and  Hospital Administrators Can Tackle 2  New Superbugs on the CDC’s Urgent List 

Data analysis showed a spike in surgical site infections (SSIs) among Cesarean section (C-section) patients between January and July in 2017 at MaineGeneral Medical Center. Following a focused postoperative infection reduction strategy implementation, we were able to lower rates by 65% over 8 months. 

C-sections account for 32% of all inpatient deliveries in the United States each year. Three to 15% of these procedures result in surgical site infection, with variation stemming from the surveillance methodology and/or patient population.

Upon completion of the 2017 annual Infection Control Risk Assessment (ICRA) for our institution, we recognized an opportunity to include C-section as one of the targeted surgical procedures for surveillance. A comprehensive review of these procedures, including entry into the National Healthcare Safety Network (NHSN) database, provided a means to compare the facilities’ expected number of infections based on multiple patient risk factors, and allowed for multifacility comparison with facilities throughout the country. The initial analysis of our C-section data unveiled an opportunity for improvement, specifically with the occurrence of superficial SSI. 

There are multiple risk factors that exist pertaining specifically to the development of SSIs following C-section procedures. Pregnancy related risk factors that cannot typically be modified include: emergent delivery, prolonged rupture of membranes, or chorioamnionitis.

Few evidence-based guidelines currently exist addressing post-operative wound care after discharge to prevent SSIs in this population. 

Strategies currently in place in our operating room suite and C-section delivery rooms for SSI prevention include pre-operative antibiotic administration, hair removal when appropriate, adherence to the Association of Operating Room Nurses (AORN) standard for surgical attire, intra-operative skin antisepsis with an alcohol/chlorohexidine product, maintaining traffic control during procedures, and monitoring hand hygiene. Multiple closure methods are used by surgeons. These methods typically include staples, sutures, or a subcuticular closure with steristrips. All surgeons routinely used sterile gauze for the dressing. 

The root cause uncovered that, upon discharge, patients were instructed to remove the gauze dressing at home. Patients were also provided written and verbal instructions for wound care and signs of infection, including erythema, increased pain/tenderness, purulent and/or malodorous discharge, or fever > 100.4. Despite these instructions, surgeons surveyed noted that the wound care instructions were not often followed and the same dressing was still in place at the 2-week post-op visit.

Postoperative factors have traditionally been considered to play a relatively minor role in causing SSIs. An increasing body of evidence suggests that many SSIs occur as a result of pathogens gaining access to surgical wounds either hematogenously or through slowly healing wounds, despite the use of routine antibiotic prophylaxis pre-operatively.

Patients are typically discharged home within 48 hours after surgery to a variety of environments and circumstances and our surgeons indicated discharge instructions were not being followed. 

Review of the current literature noted success in reducing superficial SSI rates among colorectal patient populations after the implementation of a standardized post-operative wound cleansing strategy, which included wound cleansing after dressing removal with a chlorohexidine gluconate

 (CHG) product. The strategy was cost-effective and simple enough for patients to perform on their own. A decision was made to implement post-dressing surgical wound cleansing with CHG soap (Hibiclens) in an attempt to decrease the number of superficial SSIs for patients undergoing C-section procedures. 

A multidisciplinary team, including infection prevention along with a surgeon champion, worked to update patient infection reduction strategies and increase the post-operative education provided to patients. The surgeon champion was invaluable in bringing the physicians on board. Staff were educated on the new post-operative wound care process that would include enhanced discharge education for patients and how to implement. 

Patient understanding of the risk for SSI in relation to adherence to instructions would be essential to ensure compliance with utilizing CHG during the post-operative period. Staff educated patients verbally on CHG product use. Since patient stays often extend to 48 hours after C-sections, wound dressings were removed and CHG was provided for use with the initial post-operative shower during their inpatient hospital stay. Post-operative discharge instructions were updated to provide explicit guidance on wound care, including specific instructions for CHG usage. In addition, signs and symptoms of infection were reviewed with the patient as previously noted. Documentation of education and distribution of 4% CHG soap was added to the electronic medical record (EMR) documentation. Patients were instructed to perform wound cleansing daily with CHG until the remainder of the product was gone, or until being instructed by their provider to discontinue use. All protocol changes were incorporated into the EMR and staff were instructed to document that patient education was given and that a bottle of Hibiclens 4% foam was provided. 

Process adherence was reviewed through the continuum of care both to monitor the current state of compliance and identify potential gaps with the evidenced-based guidelines in use. C-section procedures during the baseline and intervention periods were surveyed for 30 days post-operatively. 

Data to identify superficial SSIs included: 

§Documented information included in the EMR; 

Post-operative questionnaires sent to all OB/ 

GYN providers requesting identification of all superficial SSIs;

Compliance information collected via patient phone calls. 

During the trial period, patients were contacted with the following questions: 

Was Hibiclens product provided upon discharge? 

Can I address any questions/concerns you have about the product? 

Phone inquiries included discussions regarding patient compliance with dressing removal and daily wound cleansing utilizing CHG. Any issues or concerns with the post-operative wound care protocol were noted along with any signs/symp- toms of infection. 

C-section superficial surgical site infections were identified utilizing NHSN criteria.

Tracey Shaw started her career in healthcare as a laboratorian prior to moving into the field of healthcare quality, and more specifically infection prevention. Her passion is to improve patient quality and safety across the continuum of care by educating families, patients, and staff on strategies to mitigate risk of healthcare-acquired infections. 

1. Hsu CD, Cohn I, Caban R, et al. Reduction and sustainability of cesarean section surgical site infection: An evidence-based innovative and multidisciplinary quality improvement intervention bundle program. Am J Infect Control. 2016 Nov 1;44(11):1315-1320. doi: 10.1016/j.ajic.2016.04.217. Epub 2016 Jun 14.
	2. Temming LA, Raghuraman N, Carter EB, et al. Impact of evidence-based interventions on wound complication after cesarean delivery. Am J Obstet Gynecol. 2017 Oct;217(4):449.e1-449.e9. doi: 10.1016/j.ajog.2017.05.070. Epub 2017 Jun 8.
	3. Money L, Eyer M, Duncan K. Creating a surgical site infection prevention bundle for patients undergoing cesarean delivery. AORN J. 2018 Oct;108(4):372-383. doi: 10.1002/aorn.12371.
	4. Manian, FA. The role of postoperative factors in surgical site infections: time to take notice. Clin Infect Dis. 2014 Nov 1;59(9):1272-6. doi: 10.1093/cid/ciu552. Epub 2014 Jul 14.
	5. Cima R, Dankbar E, Lovely J, et al. Colorectal surgery surgical site infection reduction program: A national surgical quality improvement program driven multidisciplinary single-institution experience. J Am Coll Surg. 2013 Jan;216(1):23-33. doi: 10.1016/j.jamcollsurg.2012.09.009. Epub 2012 Nov 2.
	6. Centers for Disease Control and Prevention. Patient Safety Component Manual. CDC website. https://www.cdc.gov/nhsn/pdfs/pscmanual/psc-january-2019-revisions-508.pdf. Published January 2019. Accessed December 2019.

Post-Operative Strategies for Reducing Surgical Site Infection After Cesarean Section 

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 

currently works at a healthcare system in Phoenix that includes 5 hospitals and more than 100 outpatient treatment centers. She recently spoke to 

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. 

What are the broad strokes when it comes to how infection preventionists should approach respiratory illnesses during the flu season? 

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. 

: Are providers open to the suggestions that IPs present to them?

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. 

: How have those IP job duties changed? 

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. 

: This sounds like a radical change in job duties. 

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, 

] blood stream infections, and surgical site infections for colon procedures and total abdominal hysterectomies. 

: 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? 

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. 

: You said: “Practice appropriate and effective hand hygiene for every patient, every time.” Will this problem ever be solved? 

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. 

Rebecca Leach, RN, BSN, MPH, CIC, speaks to Infection Control Today about dealing with respiratory illnesses during the flu season.

Infection Control Today January/February 2020 Vol. 24 No. 1

A Conversation With Kevin Kavanagh, MD: Infection Preventionists Are Underutilized and Underappreciated

Informatics Can Get Patients More Involved and Help Hospitals Provide Better Care

Copper Beds Vastly Cut Down on Amount of Surface Bacteria

Preparing for Special Pathogens: An IP Perspective

How Infection Preventionists and Hospital Administrators Can Tackle 2 New Superbugs on the CDC’s Urgent List

Post-Operative Strategies for Reducing Surgical Site Infection After Cesarean Section

Tackling Respiratory Illnesses During the Flu Season Takes Persistence, Time

January/February 2020 Bug of the Month