Can something as simple as handwashing prevent the spread of coronavirus disease 2019 (COVID-19)? Today, handwashing is as important as ever. Prevention becomes essential to stopping the spread of the virus because there is no vaccine to prevent it and no treatment for anyone experiencing the illness.

Mitigation is the only tool we have at our disposal to fight this novel virus. Science has consistently proven that handwashing is the only way to prevent viral and bacterial diseases. Healthcare providers know that hand hygiene protocols reduce the rates of healthcare-associated infections (HAIs), yet providers continue to miss opportunities to perform hand hygiene. COVID-19 will have a lasting impact on hand-hygiene practices if we reevaluate what outcome we want to achieve with the provision of education on hand hygiene.

Coronavirus is spread by droplets. So anytime we talk or sneeze or cough, there are droplets that come from our mouth and nose. The virus is on our face, hands from covering our sneeze by habit, or even with the use of tissues. The virus can land on surfaces. If a contaminated surface is touched then one is at risk for contracting the virus via hand contact with their face, nose, eyes, and mouth. During the COVID-19 pandemic, handwashing becomes even more important. How can healthcare providers serve as credible educators for the general population, on the critical issue of hand hygiene, when healthcare providers are not consistently practicing hand hygiene? How can we prevent the transmission of disease when we neglect to provide patients with an opportunity to properly wash their hands?

Healthcare workers now have an increased need to wash hands. Hand hygiene should be completed prior to donning and after doffing personal protective equipment. Healthcare providers are also wearing masks for the duration of their shift in healthcare facilities. Hand hygiene should be performed after adjusting their mask as well.

Healthcare workers have many reasons for not performing hand hygiene. Edmonds, et al includes some of the following reasons for not washing hands: inconvenience, I forgot, I was wearing gloves, lack of education, hands full, skin breakdown, frequent entry into room, and hand hygiene products have a strange odor or leave a film on hands.

 The reasons for lack of hand hygiene are only important if we use the noncompliance reasons to improve systems such as: promoting hand hygiene, trialing new products, or changing behaviors of healthcare providers.

What can professional development educators and infection control specialists do to encourage hand hygiene? We need to consider what outcome we would like to achieve with hand hygiene compliance.

Have professional development educators and infection control specialists consider the objective of hand hygiene education. Is the objective of hand hygiene education to increase the compliance rates of hand hygiene or is the objective of hand hygiene to prevent the transmission of disease?

If the objective of hand hygiene is to prevent the transmission of disease, then our educational content needs to be redesigned. We need to transform our education programs and campaigns. Education needs to include content related to how easily germs are spread and transmitted in the hospital environment, how healthcare employees contaminate the environment, how the environment is contaminated with social media devices, how staff contaminate themselves, how patients can contaminate their environment.

We need to create educational programs for patients, families, and visitors, as well as staff. Education can no longer be “wash in and wash out.” Professional development educators and infection control specialists need to design educational programs that create a lasting behavior change in all constituents.

The only education that should remain consistent is the procedure for washing hands. The procedure

 for handwashing, according to the US Centers for Disease Control and Prevention (CDC), should be adopted in all healthcare facilities. The procedure is:

Wet your hands with clean, running water (warm or cold), turn off the water, and apply soap.

Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails.

Scrub your hands for at least 20 seconds. Twenty seconds can be measured by Singing the song “Happy Birthday” or the “ABCs” song from beginning to end twice.

Rinse your hands well under clean, running water.

Dry your hands using a clean towel or air dry them.

Now is the time to change our educational methods. We need to change our content. We need to get the message out that the goal of hand hygiene is to prevent the transmission of disease. We need to ask staff if they have stopped the spread of your germs today? We cannot just put the handwashing flyer reminder somewhere out there in healthcare facilities. We need to change the signage and location of the information frequently, so the message remains on the minds of the providers. The message needs to be innovative. We need to create educational interventions that promote a change in personal behavior.

A major educational deficit that remains in the healthcare system is patient hand hygiene. How often do we encourage patients to perform hand hygiene while in the healthcare facility? Do we have signage to encourage patient handwashing? Is hand sanitizer available to our nonmobile patients? Do we offer an opportunity for patients to wash their hands before and after meals? After using a bedpan or commode, has the patient been provided with access to soap and water? Is the opportunity available in your healthcare facility for a patient to perform hand hygiene after coughing or sneezing? Are patients offered a chance to wash their hands after a procedure outside their room? Is hand sanitizer or soap and water available to the patient after a physical, occupational, or speech therapy session? Have we taught patients to complete hand hygiene after touching a wound or dressing?

Now is the time to provide education to patients encouraging the patients to ask for an opportunity to wash their hands while a patient in the healthcare facility. We need to educate patients to speak up for access to hand hygiene to prevent the transmission of disease. Access to soap and water or hand sanitizer is a necessity for patients in the healthcare facility. Professional development and infection control specialists can make a difference in the health of our patients. Emphasizing patient hand hygiene can only serve to decrease the infection rates in patients and stop the transmission of disease.

Our methodology for collecting hand hygiene compliance data needs to change. We need to ask ourselves tough questions. Do we truly empower our hand hygiene observers to conduct in-the-moment education with staff? Can all employees stop the line? Do we truly create a culture of do no harm? With the increased necessity for hand hygiene, is now the time to invest in technology to measure hand hygiene compliance? Do we need to begin to measure hand hygiene compliance in the patient population?

In this time of the global pandemic, patients are afraid to return to healthcare settings for routine care, elective procedures, and even emergent life-threatening procedures. Can we convince the public to return to the healthcare system for elective or life sustaining treatment with improved hand hygiene? COVID-19 has changed the world in which we live. Can we respond with increased rigor to prevent the spread of disease? Would you feel safer as a patient or a healthcare worker if we stopped transmitting disease?

Mary Jean Ricci, MSN, RN-BC, is the director of clinical education at Drexel University College of Medicine. She’s also a nursing supervisor at Fox Chase Cancer Center in Philadelphia.

Edmonds, M. Landon, E. Larson, E.& Price, C. Infection prevention in hospitals: the importance of hand hygiene. 

Centers for Disease Control and Prevention. Guidelines for hand hygiene in healthcare settings. CDC website. 

https://www.cdc.gov/handhygiene/index.html

Articles

Professional development educators and infection control specialists need to design educational programs that create a lasting behavior change when it comes to hand hygiene.

Handwashing: Is a New Normal Possible?

The United States has long lacked the needed infrastructure for the reporting of resistant organisms. Outbreaks have largely gone undocumented and, in many cases, ignored. Nursing homes largely flew under the radar for infectious disease reporting and accountability.

The healthcare industry cites the burden of reporting and lack of resources as justification for its inaction. Infection preventionists (IPs) are stretched to the limit with both reporting and patient responsibilities with an unwillingness of facilities to prioritize infectious disease prevention in their operating budgets. In addition to financial concerns, accountability was also at the heart of the inertia in implementing the infrastructure needed for a comprehensive national reporting system for dangerous pathogens.

All of this changed with coronavirus disease 2019 (COVID-19). After decades of reluctance to implement a national reporting system, we witnessed almost overnight the formulation of case definitions and comprehensive national reporting from all healthcare facilities. One must ask the question: Why has this not been done for other dangerous pathogens?

Intense concern has been focused on nursing homes. On May 6, 2020, the US Centers for Medicaid and Medicare Services (CMS) issued an interim final rule regarding COVID-19 cases among residents in nursing homes.

 Nursing homes are now required to report COVID-19 resident and staff infections to the US Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN) and to the other facility residents along with their families and/or representatives. The regulation states: “Inform residents, their representatives, and families of those residing in facilities by 5 pm the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or 3 or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other.”

Health Watch USAsm has called for a national tracking system for both employees and patients/residents of all facilities for all dangerous pathogens.

Of the CDC’s 5 urgent bacterial threats only one—

—has required reporting, but participation is only mandated for hospitals, and only those which participate in Medicare’s prospective payment system. Thus, critical access hospitals are not included. Carbapenem-resistant enterobacteriaceae (CRE) is not required to be reported on a national basis, even though its bloodstream infections have close to a 50% fatality rate. 

 are also not required to be reported. Of the CDC’s 11 Serious Threats, only methicillin-resistant 

 is required to be reported, and only in hospitals.

 Nursing homes, surgery centers, dialysis centers, critical access hospitals, along with private physician offices are not required to report in a national system.

States may have additional requirements and a few states have comprehensive mandatory reporting laws. This is the case for the state of Kentucky,

 which implemented a comprehensive reporting law in October 2016 which mandates all healthcare facilities to report outbreaks of dangerous pathogens to the NHSN and to confer rights of the Kentucky Health Department to access NHSN data. There are a few important points which need to be explained:

State health departments only have delayed access to NHSN data. Healthcare facilities need to give them permission, or permission granted by state law, for state health departments to have access to the actionable current data.

The definition of an outbreak is defined by the CDC as an infection rate above a facility’s baseline. The baseline is defined by the facility, so it is in the eye of the beholder. The Kentucky regulation closes this loophole by defining an outbreak as “2 or more cases, including HAIs (healthcare-associated infections), that are epidemiologically linked or connected by person, place, or time, or a single case of an HAI not commonly diagnosed.”

A healthcare facility is defined as any place, building or agency which is “operated, or designed to provide medical diagnosis, treatment, nursing, rehabilitative, or preventive care and includes alcohol abuse, drug abuse, and mental health services.”

A long list of dangerous pathogens and definitions is also specified. One shortcoming of the law is that public reporting and report verification is prefaced by “may,” which means it may not happen.

However, this type of a comprehensive system, whether through statue or regulation, is lacking on the national level.

A comprehensive reporting system is not just needed for infections solely caused by dangerous pathogens but also for co-infections which all too commonly affect those inflicted with COVID-19.

 It is known that when death occurs with viral pneumonia that there is often a bacterial co-infection. Bacterial co-infections occurred in up to 95% of fatal cases with the Spanish flu.

. Secondary infections were identified in 50% of COVID-19 fatalities.

 Obviously, if these co-infections are caused by antibiotic resistant bacteria, then one would expect the fatality rate to increase.

During the March 11 Senate HELP committee hearing on COVID-19, Sen. Mitt Romney asked CDC Director Robert Redfield, MD, why the CDC has not established an accurate real time data site for hospitalization and treatment data at the CDC.

 Redfield responded: “…the reality is there is an archaic system a non-integrated public healthcare system. Each public health department has their own systems. This nation needs a modern highly capable data analytic system that can do predictive analysis. I think it is one of the many shortcomings that have been identified…It is time to get that corrected.”

CMS’s COVID-19 Focused Survey of Nursing Homes also requires screening of all staff at the beginning of their shift for COVID-19, including temperature and signs of illness.

 Deborah Birx, MD, the White House’s Coronavirus Response Coordinator, called for testing all nursing home residents and staff in the immediate term. The CDC’s Anthony Fauci, MD, agreed with Birx and took the recommendation a step further.

“In the long range we will have to have infection control capabilities in nursing homes that are really pristine and really unassailable,” Fauci said. “We have to do the kind of surveillances and have to have the capability of when you identify someone you get them out of that particular environment so that they don’t spread the infection throughout. General testing for all, I think, is a good start, but you look where are you going to go in the future. There has to be a considerable degree of surveillance capability.”

It is of utmost importance to screen healthcare staff and patients for dangerous pathogens along with the establishment of a national tracking system. In addition, an economic and healthcare safety net for healthcare workers needs to be established.

However, national data for healthcare worker acquisition of dangerous pathogens can only be found for cases of SARS-CoV-2, the virus which causes COVID-19. So far, more than 69,000 cases are reported. Of these, there are over 350 deaths, but this is an underestimate because the final disposition of cases is not known in many of the reports. Even with this degree of reporting of COVID-19, there is no guarantee of workers’ compensation benefits. Some frontline workers do not even have paid sick leave. Healthcare workers and, through them, their families are also at risk of acquiring a myriad of drug-resistant dangerous pathogens. Active screening of workers, along with the provision of health benefits and an economic safety net, needs to be enacted.

A dangerous pathogen is a dangerous pathogen; we should not discriminate on our approach to COVID-19. The frequency of an outbreak should not be used to deter a policy that an outbreak of a dangerous contagious pathogen should be publicly reported in real time. The nursing home reporting policies for COVID-19 need to be adopted systemwide for all dangerous pathogens and our infrastructure permanently enhanced.

One may think that enhancement is a forgone conclusion. But we did not learn these lessons from the 1918 Spanish flu or from the Ebola, severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS) outbreaks. Six months or 6 years after this epidemic our resolve may wane. IPs need to document their experiences and keep telling their stories so our memories of this horrific ordeal do not fade.

Kevin Kavanagh, MD, is the founder of the patient advocacy group Health Watch USAsm and a frequent contributor to

1. Centers for Medicare and Medicaid Services. Interim final rule updating requirements for notification of confirmed and suspected COVID-19 cases among residents and staff in nursing homes. CMS website. 

https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/interim-final-rule-updating-requirements-notification-confirmed-and-suspected-covid-19-cases-among

2. Kavanagh KT, Abusalem S, Calderon LE. View point: gaps in the current guidelines for the prevention of methicillin-resistant staphylococcus aureus surgical site infections. 

. 2018; 7: 112. Published online 2018 Sep 18. doi: 10.1186/s13756-018-0407-0

3. Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2019. CDC website. 

www.cdc.gov/DrugResistance/Biggest-Threats.html

4. Law: Reportable disease surveillance. 902 KAR 2:020 (2016). Reportable Disease Surveillance. Kentucky Administrative Regulation. 

https://apps.legislature.ky.gov/law/kar/902/002/020.pdf

5. Diamond F. Q&A: how bacterial infections can complicate COVID-19 cases. 

https://www.infectioncontroltoday.com/covid-19/qa-how-bacterial-infections-can-complicate-covid-19-cases

6. Morris DE, Cleary DW, Clarke SC. Secondary bacterial infections associated with influenza pandemics. 

. 2017;8:1041.doi: 10.3389/fmicb.2017.01041.

7. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. 

. 2020;28;395(10229):1054-1062. doi: 10.1016/S0140-6736(20)30566-3.Epub 2020 Mar 11.

8. Sen. Romney: Despite being months into the COVID-19 pandemic, we still lack real-time data. Senate HELP Committee. Washington DC. May 12, 2020. 

https://www.youtube.com/watch?v=ssdEtsOiABE

9. Fauci, A. Testimony. Senate HELP Committee. Washington DC. Timeline 2:43:35. May 12, 2020. 

https://www.help.senate.gov/hearings/covid-19-safely-getting-back-to-work-and-back-to-school

After decades of reluctance to implement a national reporting system, when COVID-19 
 came along we witnessed almost overnight the formulation of case definitions and comprehensive national reporting from all healthcare facilities. 

National Reporting System for All Dangerous Pathogens Needed

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.

Before 2000, I was uncommon in the United States. I’ve become much more common since, and though health experts don’t know just how many people I infect each year, they can say with certainty that I am a major cause of infections in healthcare settings.

Bug of the Month: You Don't Want Me Visiting During Your Hospital Stay

Let’s assume that hand hygiene compliance has increased during the coronavirus disease 2019 (COVID-19) pandemic. Now the challenge for infection preventionists (IPs) and others on the frontlines of infection control and prevention: Sustain those gains. But how?

Employ the concepts of behavioral change, including informal leaders, social pressures, cultural norms, and immediate and personal feedback. Informal leaders are people within a work area who are respected and seen as individuals who can be trusted and followed.

Informal leaders can either undo an intervention or change it if they don’t accept it, or they can vastly move a program forward if they are brought in as a stakeholder from the beginning. Social pressures and cultural norms exist on a large scale down to a small scale, such as a profession, hospital, unit within a hospital, and even a shift within the unit. These norms dictate acceptable behaviors, and social pressures can change the norms to reflect changes in what is acceptable for that particular culture.

Finally, personal feedback can help reinforce the behavior that is desired by noticing and praising the person when it’s done. Also, personal feedback that is done through consideration can also be used to help identify when a norm or behaviors don’t meet expectations and to help the person understand what behavior is expected. Successful feedback needs to be timely, specific, and focus on the actions or behavior that is observed.

IPs could perform informal surveys of staff perceptions of hand hygiene in this time and use that information to help find the reasons why people are doing the right thing. They can also use that knowledge to develop campaigns and materials that will continue to encourage positive change. Studies have shown that to enact social change, only about 25% of a group needs to adopt the change and move the rest of the group forward.

In the past, when there have been major national health threats, such as anthrax attacks and Ebola, the federal government earmarked funding for grants and programs that would be used for public health efforts or for hospitals to obtain training or personnel to focus on preparedness efforts. If funding becomes available for healthcare facilities as a result of increased government grants or programs, it would be ideal to use some of those funds to invest in technology that would improve hand hygiene compliance, such as the electronic monitoring systems.

Another option is telemedicine, using electronic communication to decrease the number of times staff have to come in and out of the patient rooms, therefore removing one of the known barriers to hand hygiene compliance. But ultimately technology cannot solve all the barriers for hand hygiene compliance and, to truly have sustained change, a cultural shift must occur within the facility.

Role modeling, timely feedback, consistent monitoring, and data reports all help support the clean hands culture that is needed in healthcare facilities. At this time, months into the COVID-19 pandemic, some of the behavior change will start to normalize. Before habits return to pre-COVID ways, IPs have the opportunity to build on the renewed importance of hand hygiene in healthcare and start to build the foundations of a new hand hygiene campaign in their facilities.

Leadership involvement is key, as well as finding those informal leaders in the unit level who can be local champions and the role models needed to help drive overall behavior. The core of much of what an IP does requires them to become change agents. A strong change agent needs to be curious, persistent, and collaborative. There are many examples of research on how to influence behavior change and how to utilize some of the informal leaders, social pressure, and feedback to create that culture shift within an organization. An IP does not receive formal education on behavior change science, but it would be beneficial to seek out some of these resources and perhaps work with local and national professional organizations to offer course work, online classes and other avenues to include these topics into the IP trainings.

Behavior change during a pandemic is related to several factors: risk assessment, personal fears, social factors, informational campaigns, and cultural expectations.

 Social factors in a healthcare setting are peer pressure, role modeling, and social comparisons with other units or departments. Also, patients are more acutely aware of the role of hand hygiene in a pandemic and are another source of social pressure to perform.

Hand hygiene has always been the most common way that IPs have talked about preventing the spread of infection, and that has been true with COVID-19. The first item listed on the US Centers for Disease Control and Prevention (CDC) website on how to prevent the spread is hand hygiene and it has been consistently educated to the public. During this time, as the pandemic is making disease transmission and the chain of infection come to life for everyone, hand hygiene is again being seen as everyone’s responsibility.

One challenge to understanding how hand hygiene habits changed in healthcare during COVID-19 is the ability to accurately measure and report compliance data. Hand hygiene is most typically monitored via secret shopper observations. During times of pandemics, the staff who would typically be doing these observations, such as nursing supervisors, ancillary staff, and infection preventionists may be pulled into other duties or not available. Monitoring and observing for hand hygiene may not be a top priority when other patient care concerns are paramount.

Also, secret shopper observations have an inherent flaw in observational bias and Hawthorne effect, which have been recognized as a well-known shortcoming of data reported using that type of data collection. These limitations create a gap in knowledge to understand whether compliance increased or whether that is a perception or assumption.

Changing the culture won’t be easy. It’s been tried again and again and points back to the most basic of questions: Why do healthcare workers not perform hand hygiene, even when they understand the importance of that task to prevent the transmission of infections? Many studies have looked at common reasons why hand hygiene opportunities are missed including: inconvenient placement of dispensers/sink; broken dispenser/sink; distractions; perception of lack of time; inappropriate glove use; skin irritation; workflows do not provide opportunity; and frequent entry and exit of the patient care area.

Healthcare facilities have struggled with achieving and sustaining high compliance rates of hand hygiene, despite the awareness and knowledge of its importance for centuries. Semmelweis was the first hand hygiene champion in 1858, and was met with disdain at first, eventually gaining some acceptance before being sent to a mental institution.

 Studies have found that, on average, compliance is usually around 50%, with some healthcare workers having more than 100 opportunities for hand hygiene during a normal work shift.

Electronic hand hygiene monitoring systems have been shown to provide more reliable data and also can improve compliance rates.

 These systems help remove the Hawthorne effect and observation bias associated with secret shopper programs. Also, some have reminder capabilities that would help notify staff when they have nearly missed a hand hygiene opportunity. Another benefit of these programs is the data analytics and ability to share nearly real-time data with staff and leadership. One of the biggest barriers for IP programs to adopt electronic monitoring is the cost associated with establishing and sustaining these programs.

Often IP does not have a budget, and the costs can be substantial, therefore the approval to spend the funds must be made from top leadership of the organization. IPs can help make the business case for these programs, focusing on where other organizations have seen success and published results, use those numbers to get an idea of the changes that could happen and try to equate that to HAIs prevented and potential cost savings for the organization.

During a time of pandemic, many hospitals are actually struggling financially because the usual elective patients are not coming to the hospital. Therefore, there is even less room in budgets to invest in an electronic program.

The process for establishing the cost-benefit analysis of these electronic systems can improve hand hygiene compliance and therefore improve the ability to respond to future outbreaks and keep patients and staff safe.

Given so many reasons why hand hygiene is not performed, as an IP it is important to acknowledge these barriers and attempt to address them within the organization to ensure that healthcare workers can feel supported to do the right thing and be given the type of environment that supports hand hygiene. Part of this includes developing a safety culture within the organization that will encourage compliance with all infection prevention protocols and initiatives.

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.

Catherine A. Sanderson, CA. Changing social norms in the time of a pandemic. 

https://www.psychologytoday.com/us/blog/norms-matter/202003/changing-social-norms-in-the-time-pandemic

Samson, A. Under pressure: good behavior in the COVID-19 pandemic. 

https://www.psychologytoday.com/us/blog/consumed/202005/under-pressure-good-behavior-in-the-covid-19-pandemic

. What causes hand hygiene noncompliance? 24 issues.Becker’s website.

https://www.beckershospitalreview.com/quality/what-causes-hand-hygiene-noncompliance-24-issues.html

Sohn, E. The shockingly recent history of people actually washing their hands

https://www.popularmechanics.com/science/a31982721/history-washing-hands/

Centers for Disease Control and Prevention. Hand hygiene in healthcare settings. CDC website. 

https://www.cdc.gov/handhygiene/science/index.html

Radtke, J. Improve your hand hygiene compliance rates: three insights from the University of Tennessee Medical Center. 

https://www.psqh.com/analysis/improve-your-hand-hygiene-compliance-rates-three-insights-from-the-university-of-tennessee-medical-center/

To enact social change such as better hand hygiene, only about 25% of a group needs to adopt the change and move the rest of the group forward.

Hand Hygiene in the Post-COVID-19 Era

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

By 7 pm, 10 residents have the same symptoms.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Napoleon said (supposedly), “An army marches on its stomach.” In other words, they can’t fight if they aren’t fed. In a sort of twist, it could be said that a hospital—fighting a deadly pandemic—depends vitally on the people who clean the floors and baseboards, curtains, mattresses, elevator buttons, and handrails.

The frontline healthcare workers rely on that “other” frontline. In the Lompoc Valley Medical Center newsletter, Environmental Services Director Deanna Hall called her staff “behind-the-scenes heroes protecting our physicians, nurses, respiratory therapists, patients, and employees by stopping the spread of infectious disease.”

Not just any old infectious disease, either. It may have taken many in the general public a long while to grasp the size of the viral tidal wave heading their way, but back in January hospitals were already anticipating the need to batten down the hatches. When the disaster did begin to hit, though, it was more like isolated hurricanes and tornados—massive disruption in some places, nearly nonexistent in others. Washington, New York, and California were among those that took the initial brunt, but few would be spared.

The US Centers for Disease Control and Prevention (CDC), the American Hospital Association, and state hospital associations have issued guidelines for dealing with the pandemic, but as the Occupational Safety and Health Administration’s (OSHA’s) 

Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and Healthcare Employers

 says, “Although a pandemic will be a nationwide event, it will be experienced on a local level.”

 That is, individual hospitals would have to work out what was best for them, their staff, and their patients.

As the virus began its devastating sweep, hospital associations and other groups began updating protocols that were generally intended for influenza outbreaks or less common events like Ebola and severe acute respiratory syndrome (SARS). Then it became more and more evident that coronavirus disease 2019 (COVID-19) was 

 like influenza. It couldn’t even rightly be compared to SARS, even though they’re related.

“I’ve been in environmental services for 17 years and I have never seen anything like this,” Glen Rogers, assistant director of environmental services at the University of Iowa Healthcare, tells 

“The coronavirus is changing all of our lives,” said the California Hospital Association’s Coronavirus Response page.

 The California Department of Public Health “All Facilities Letters” revealed the changing focus: From application processes and notices of stakeholder meetings on January 17 to health updates and interim guidance on COVID-19 beginning January 23.

Some hospital associations adapted others’ existing protocols. The COVID-19 updates from the California Department of Public Health, for instance, direct healthcare providers to the “Update and Interim Guidance on Outbreak of 2019 Novel Coronavirus (2019-nCoV) in Wuhan, China,” distributed by the CDC Health Alert Network.

Still, the swiftness and severity of the virus spread meant some hospitals were scrambling to adjust. “The entire pandemic came on too quickly, so we were initially slow to get going,” Sharon Ward-Fore, MS, MT(ASCP), CIC, a Chicago infection prevention consultant and member of 

The Missouri Hospital Association released 

A Framework for Managing the 2020 COVID-19 Pandemic Response

“Ideally,” the authors said, “this document would have been developed through a deliberative process involving many stakeholders and reviews. However, the need for established guidance at this critical time necessitated the expedited development of a framework for Missouri Hospitals.” They based their guidance on other “well-established plans such as the Utah Crisis Standards of Care.”

The University of Iowa Healthcare started to modify its plan in early March. “We started proactively adapting to the situation in many ways to keep providing a clean safe environment,” says Rogers. “We immediately put in place a conservation protocol for our disinfectants to reduce end-of-the-day waste and changed how we distributed them. We researched and found alternatives to our current disinfectants and secured those products. We retrained all our staff on cleaning protocols to keep them safe. And we worked with epidemiology to sequence our cleaning to reduce risk to other patients.”

Rebecca Leach, RN, BSN, MPH, CIC, the infection prevention coordinator at HonorHealth in Scottsdale, Arizona, says her hospital started preparing in late January, and has been “going ever since. We’ve had incident command at our organization since mid-March,” when they had their first COVID-positive patients.

Environmental services (EVS) staff were limited from going into the rooms, Leach says, to conserve PPE and limit staff member potential exposures. “We have one dedicated EVS person for the cohort units who focuses on cleaning the shared spaces, nursing station, med room, and so on, as well as performing the terminal and discharge cleaning.”

But Leach’s hospital also had some extra staff members at the ready. “We already had a fleet of UV disinfection robots that we were utilizing prior to the pandemic,” says Leach, who is also a member of 

’s Editorial Advisory Board. “We had assigned those robots to specific departments or areas based on healthcare-acquired infection [HAI] levels or service line.” When the pandemic took hold, the hospital expanded and shifted the UV robots to COVID cohort units or rooms where COVID patients had been discharged or transferred from, widening the scope of the program.

The adjustment to a more intensive protocol, on top of the daily strain of dealing with quarantines and cutbacks, adds to the stress of long hours. “In the beginning, 16-hour days were the norm,” Ward-Fore says. “As we worked through things, 12 hours seems to be the new norm.”

Overall, Leach says, “Dealing with the pandemic for my infection prevention department has been tiring, inspiring, challenging, and collaborative. The demands on our time have been extreme, as most IPs would likely agree. The preparation and training before our patients arrived was very consuming, and once we started getting patients and our first wave, that was all we worked on. We were on call 24/7, working 12- to 14-hour days in the hospital, and then working from home at night and sometimes through the night and through weekends. The days all blended together.”

Support and collaboration help, though. “I feel supported by my hospital,” Leach says. “Other members from other departments help with some of our tasks and duties to ease the burden. I think for IPs, we are the subject matter experts in a pandemic, so we will be relied on heavily, and since you typically have a limited number of IP staff, you feel stretched.”

Rogers also emphasizes the importance of a supportive and collaborative environment. Hours fluctuate constantly in EVS, he says, but he cites the amount of time spent focusing on the pandemic. “Luckily we have a great management team here that we could rely on to keep the day-to-day operations going as we worked on pandemic-specific issues.”

On the other hand, the hospital staff are prey to the same things the general public are: anxiety and fear of contracting the virus. Ward-Fore says the pandemic “caused a drain on staffing, by illness and fear. All the education in the world could not help those that refused to work due to fear.” But she adds, “Having enough PPE and using it as we normally would have helped alleviate the fear.”

It also helps to have flexibility. As Rogers recalls, “Some of the new protocols presented challenges for staff, but we then used them as learning opportunities.”

Months of long days without let-up take a double toll: both professional and personal. Leach says, “At first I didn’t even have time to think about how the pandemic was affecting me, my kids, my family, my friends. It was exhausting, I had moments of total meltdown and times when I was so proud of what I do for a living. I think it finally hit me that my personal life has changed and my kids and family were experiencing this in a totally different way than I was about 2 months into the pandemic. I realized how much loss I was feeling and how much stress and grief I was holding in, just to get through the days and be supportive and effective in my work. I was totally compartmentalizing my own personal experience so that I could do my job. I think I’m still figuring out how I feel about things and sorting through my emotions. I think those of us working in IP right now have a unique perspective on resiliency during a pandemic.”

“A sustained crisis” is how OSHA describes an influenza pandemic.

 It contrasts such a pandemic with mass casualty and weapons of mass destruction events, which are “typically a surprise.” By contrast, a pandemic may come and go in waves, taxing morale and mental health of the people who must face it again and again. As of this writing, many parts of the country are still on the uphill part of the climb in the crisis, and others are relapsing after beginning to reopen. Arizona, where Leach is located, saw an alarming surge in cases and hospitalizations in mid-June.

 Chicago, where Ward-Fore is, was not out of the woods as it “cautiously” reopened around the same time: The chart of daily COVID-19 deaths was admittedly heading down, but in a very spiky way.

And Rogers’ home, Iowa, despite a downward trajectory, has ongoing virus hotspots.

And a second, perhaps even harder, wave is expected to hit in the fall. The more intensive protocols may not be needed forever, but certainly their time is not done. “At this point,” Leach says, “we know that this work will continue through the year, so we have to think about burnout of the IP staff and how we can sustain our work through other methods that are not dependent on us being there at all times.”

Every disaster brings lessons. Hard-won though they may be, they can inform the way forward. In May, the Association for the Health Care Environment held a webinar to provide guidance in “transitioning back to normal, albeit a new normal.” On the discussion list: What to do with rooms outfitted with special equipment, or the space that’s been converted to COVID care? What do environmental services leaders need to do to ensure facilities return to their “pre-crisis state”?

“We’ll continue with this process now, likely until we get to a place where we can stand down our COVID cohort units,” Leach says. “We also have enhanced cleaning procedures within our public areas as we re-opened for elective surgery and procedure to ensure more frequent disinfection of countertops, door handles, and other high-touch places in those common spaces where patients and visitors are coming through. We’ll likely keep up the UV disinfection protocol for COVID patients after the pandemic is over. I hope we sustain the frequent cleaning of shared spaces and waiting rooms as well, but that will depend on staffing.”

“Some of the new protocols were temporary, like using alternative products,” says Rogers, “and they will go away as the availability stabilizes. Others, like enhanced training, will stay because it has proven to be a valuable tool.”

Draining and demoralizing as the battle has been at times, there has been an upside, he feels. “It took the whole department coming together to make sure that we were prepared and, most importantly, safe through this. I feel like we have learned to be nimble and adapt much quicker than was required in the past. Overall, I feel our department will only be stronger because of this experience.”

Not only that: “Our department has gotten tremendous support from our hospital and from the community as well,” Rogers says. “I feel that the need to keep things clean and safe has helped to elevate environmental services.”

is a writer and editor specializing in clinical topics. She lives in Suffern, New York.

Wallace N. Environmental Services Fighting COVID-19. LVMC News. 

https://lompocvmc.com/blog/125-press-releases/1308-environmental. 04-22-20

Occupational Safety and Health Administration. U.S. Department of Labor. Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and Healthcare Employers. 

https://www.osha.gov/Publications/OSHA_pandemic_health.pdf

California Hospital Association. Coronavirus Response. 

The swiftness and severity of the COVID-19 spread meant some hospitals were scrambling to adjust. Environmental services often led the way.

Infection Control Today, July/August 2020 (Vol. 24 No. 06)

Handwashing: Is a New Normal Possible?

National Reporting System for All Dangerous Pathogens Needed

Bug of the Month: You Don't Want Me Visiting During Your Hospital Stay

Hand Hygiene in the Post-COVID-19 Era

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

Environmental Services During COVID-19: No Longer ‘Unsung’ Heroes

IPs Must Ensure the Supply of PPE for COVID-19’s Second Wave

Navigating the New Normal in Infection Prevention