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.

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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

The supply (or lack thereof) and utilization of personal protective equipment (PPE) has been one of the most frustrating aspects of dealing with coronavirus disease 2019 (COVID-19) for infection preventionists (IPs). Enacting emergency re-use and extended-use policies and protocols is not only a novel situation, but something that goes against our natural tendencies.

The COVID-19 pandemic shed light on the dependency we in healthcare and in the United States have on international suppliers and manufacturers of critical items, like PPE.

As Maryn McKenna noted in February, “According to data compiled by the US Department of Health and Human Services, 95% of the surgical masks used in the US and 70% of the respirators—thicker, tight-fitting masks that offer better protection against viruses—are made overseas. That leaves the mask supply vulnerable to labor disruption if a pandemic sickens manufacturing workers, as well as to flat-out diversion if a government decides to keep its own stock at home.”1 As the COVID-19 pandemic fluctuates and might be more severe in some countries, supply chains will likely be impacted.

Shortages extend beyond masks and gowns, but also into tubing, Foley catheter kits, disinfecting wipes, hand hygiene products, disposable laryngoscope blades, and much more. COVID-19 is a marathon, not a sprint, and ultimately represents the bigger issue of hospital preparedness and how we integrate critical aspects, like supply chain and surveillance. It is important to note that the battle to reduce and even prevent COVID-19 must continue as healthcare experts keep a lookout for a second wave. Instead of a stop-go-stop-go approach, it’s important we approach this from the perspective of perseverance and resolve.

One of the first ways we can work toward more sustainable efforts is to first focus on daily PPE counts. This is something most likely to do with larger international and national supply chains from manufacturers and distributers but, overall, this is a good measure to establish as a standard infection prevention and control (IPC) practice.

Moreover, are IPs simply evaluating what’s available day to day or are they also considering what will be needed in a surge? In many cases, the relationship between IP and the supply chain department is passive and fluctuates with emergencies or new products. What if, though, we worked to have a more proactive relationship that involved weekly meetings regarding the level of supplies, like PPE? Right now, many of us are getting daily reports on the number of supplies we have and how many usage days that translates to.

Working with the supply chain department to set up more continuous, proactive check-ins that are measured by days of supplies on hand and how that would fluctuate with varying surges can be immensely helpful. This also involves scaling or descaling PPE-focused efforts. For many, guidance from the US Centers for Disease Control and Prevention (CDC) is what actions are based on. When the CDC declares something an emergency, that is often the trigger point for most hospitals and healthcare facilities.

Perhaps, though, a more proactive approach is needed: indicators for scaling up PPE conservation efforts and then triggers for descaling. Continued monitoring of outbreaks locally and internationally can go a long way. Travel-based screening and education about existing outbreaks, like the current Ebolavirus outbreak in the Democratic Republic of the Congo, requires us to keep tabs on what’s going on in the world.

An outbreak anywhere is an outbreak everywhere and although some countries might have enhanced surveillance measures, COVID-19 has taught us that we are all uniquely vulnerable. While it might not change the outcome for millions, monitoring and helping guide preparedness efforts earlier could change the outcome for thousands of employees and patients. This requires support and a collaboration between infection prevention, administrative leaders, and key stakeholders like supply chain, laboratory services, and others.

In addition, IPs can possibly utilize more sustainable PPE. Full-face respirators have become more common with the COVID-19 pandemic. These offer an alternative to N95 respirators and, in some cases, combine eye protection. A benefit to these devices is that they are re-usable and able to be cleaned and disinfected between use. Like powered air purifying respirators (PAPRs), they offer a long-term alternative for extended use that is often more comfortable for staff. More importantly, they allow staff to re-use them with disinfection protocols that change the traditional disposable notion of PPE. Although IPs have traditionally thought of PAPRs for only emergency preparedness situations, perhaps full-face respirators offer a middle ground that can change pandemic preparedness in healthcare.

Face shields are another piece to this puzzle. More research is being conducted on the feasibility of using face shields in several environments—for all triage staff as protective measures, but also as a potential alternative for community mask use.2 While these offer protection for eyes, respiratory protection will still be required for those in isolation requiring a mask (eg, surgical or N95). The use of face shields in the community as an alternative to face masks is an increasing topic of conversation. Changes cannot be made to current PPE protocols at the moment, but it will be interesting to see where this research leads.

Supply chain issues are a larger, more systemic aspect of healthcare and national preparedness. Although we may not be able to fix them individually, there are ways we can account for them and ensure the safety of our hospitals and healthcare facilities. Those aforementioned efforts shouldn’t focus solely on PPE, though.

A big piece to this is also about the collective efforts of IPs and hospitals. IPs are often under-represented when it comes to hospital preparedness and, often, many healthcare colleagues don’t even realize IPs exist, let alone the work IPs do. Now is the time for IPs to use their voice. Work with the Association for Professionals in Infection Control and Epidemiology’s Policy Group to help drive legislation and accountability locally and nationally. Engage with local leadership, hospital consortiums, and policy makers. Infection prevention voices and representation are critical to help not only drive change, but also spread awareness of the very real issues we see and manage daily. Moreover, work with local public health officials and departments.

Our public health personnel are some of our greatest allies. We often interact with them regarding reporting of communicable diseases, and they often offer committee feedback and training, and serve as a wealth of knowledge to understand how we all work together. IP representation on public health steering groups and committees is immensely helpful and not only gives us a voice, but also ensures that there is awareness for the intricacies of how healthcare operates. Moreover, continued engagement with public health agencies enhances the relationship that we are fundamentally reliant on.

Combatting COVID-19 will require a considerable amount of dedication, resources, and coordination. It will take time and there will be setbacks as IPs navigate through a pandemic. Infection prevention efforts, though, are so critical and extend beyond hospital and healthcare walls. We often act as the intersection between healthcare, public health, and emergency preparedness. Utilizing our knowledge and incorporating some of the lessons learned, especially about PPE and response, will be critical for not only COVID-19, but also future infectious disease outbreaks and events.

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.

Amid Coronavirus Fears, a Mask Shortage Could Spread Globally”. 

February 4, 2020. Available at https://www.wired.com/story/amid-coronavirus-fears-a-mask-shortage-could-spread-globally/

2 Perencevich EN, Diekema DJ, Edmond MB. Moving Personal Protective Equipment Into the Community: Face Shields and Containment of COVID-19. 

 Published online April 29, 2020. doi:10.1001/jama.2020.7477

Supply chain issues are a larger, more systemic aspect of healthcare and national preparedness. Although IPs may not be able to fix them individually, there are ways we can ensure the safety of our hospitals.

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

You had questions, she had answers. Infection prevention consultant Sharon Ward-Fore, MS, MT (ASCP), CIC, held sway recently in a wide-ranging, hour-long 

 webinar presentation that touched on a host of issues that infection preventionists (IPs) will need to be familiar with as society moves out of the shadow of coronavirus disease 2019 (COVID-19) and into the light of a new normal.

“Infection prevention basically remains the same,” said Ward-Fore, who is also a member of 

’s Editorial Advisory Board. “The same tools will work: surveillance, rounding, auditing, tracking, tracing, teaching, coaching, being the calming voice when chaos reigns. Be watchful of what is happening locally and elsewhere, maintain this heightened sense of awareness through vigilance.”

Ward-Fore spoke to an audience of fellow IPs and other healthcare professionals during the webinar, hosted jointly by 

 and Metrex. As society finds its bearings, IPs on will need to monitor workforce availability, facility considerations, testing capacity, personal protective equipment (PPE), infection prevention protocols, and regional considerations.

The first thing to keep in mind as COVID-19 case counts decline that it’s not really going away for good. “We know a second wave is coming,” Ward-Fore said. “We don’t know when or how bad it might be. So be prepared. Prepare by assessing your medical supplies, your equipment, and your PPE frequently, and don’t forget your staff. Make sure your staff is doing OK.”

It will also be necessary to again train other professionals the way IPs have historically trained them about infection prevention, because a lot of the old rules had to be set aside when COVID-19 surged. For instance, the PPE shortage led some hospitals to say that gowns need not be worn for patients with bacterial infections such as extended spectrum beta-lactamase-producing (ESBL) organisms, vancomycin-resistant 

“This is a little different from our normal contact precautions for these kinds of organisms,” said Ward-Fore. “How do we justify the use of PPE when the pandemic is over for things like MRSA and VRE? When now we’re saying it’s OK to not use it?”

Ward-Fore suggested that IPs should be “tracking transmissions and strain typing, because right now the cat is out of the bag, so to speak, and how do we go back to our normal standard infection prevention protocols without a lot of pushback? The way we do that is starting to collect data now so that we have some information for what lies ahead. When everyone says, ‘We didn’t wear our PPE during the pandemic, why do we need to wear it now?’, IPs will have an answer.”

IPs will also need to monitor PPE donning and doffing. “IPs, it’s up to you to audit practices and give real-time feedback,” said Ward-Fore. “This is really important. I have walked through a hospital—I can’t tell you how many times—and seen people using PPE incorrectly.”

When Ward-Fore questions some professionals about how they’re using PPE, they’ll often tell her that they’d never been trained. “We have to train how to properly store and reuse PPE if it’s in short supply. We need to get out there and help our fellow healthcare workers learn how to do the right thing consistently, so they don’t make themselves sick.”

Ward-Fore brought her real-world experience to bear on guidelines by the US Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). At one point she featured a WHO slide showing 11 steps for good hand hygiene.

“This WHO diagram demonstrates how hand hygiene should be performed every time,” Ward-Fore said. “It’s almost like performing a surgical scrub. When it’s performed this way, meticulous and thoughtful, it can really make a difference in staff and patient safety. The challenge now, as it has been in the past, is how do we build in the time to perform like this for every patient encounter? If any of you figure that out, please let me know.”

That’s not to say she didn’t find WHO and CDC guidance useful. In fact, just the opposite. Ward-Fore praised guidelines created by both organizations and relied on them throughout her presentation.

For instance, when it comes to workforce availability, Ward-Fore said that IPs in the post-COVID world should always keep in mind the second wave. As soon as IPs spot a symptomatic worker, they should make sure that worker’s face is covered, inform the worker’s supervisor, and send the worker home.

“Now, the CDC has a lot of guidance around this in the Interim US Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19,”

 said Ward-Fore. “It’s a mouthful, but it’s a really great resource that will help you figure out what to do with your staff and how to conduct a risk assessment to find out the different ways that you can manage your staff through a positive exposure or potential exposure.”

A good resource for staffing questions can be found on the CDC website under Strategies to Mitigate Healthcare Personnel Staffing Shortages,

 said Ward-Fore. “Lots of great tools and checklists to kind of help you maneuver through this quagmire of so many different questions with so many different answers.”

Try to maintain low patient volumes throughout the facility in the reopening phase. Place chairs 6 feet apart in waiting areas. “Now I’d like you all to close your eyes and visualize what some of your waiting rooms look like [currently],” Ward-Fore said. “I see a waiting room where patients are sitting shoulder to shoulder and back to back. Even in the best of times, this really is not a good setup. Think about the cold and flu season. People are right next to each other spreading and shedding. We need to think about ways to reduce crowding in waiting rooms.”

The post-COVID-19 healthcare facility should be full of visual reminders for patients, staff, and visitors, said Ward-Fore. “You should consider printing and placing signage throughout your facility to remind patients about the social distancing standards, respiratory hygiene, and cough etiquette, and hand hygiene,” Ward-Fore said. “They say you should place visual alerts such as signs and posters actually all over the place. So that nothing is missed, and these would be things on hand hygiene, respiratory hygiene, and cough etiquette.”

Patient screening will become a more important aspect of care. “Infection preventionists have known the importance of patient screening for quite a long time,” Ward-Fore said. “As an IP that covered the ED, basic everyday patient screening and triage was very, very important.”

When diseases like pertussis or measles were circulating, IPs would ask the patient if he or she had traveled recently and, if so, where. Screening questions were developed to help identify 

Treatment protocols should be based on what’s relevant to a particular healthcare institution: hospital, primary care practice, urgent care center, or mini-clinic. “When I was an IP, I worked in the emergency department and I developed this thing I called the respiratory hygiene algorithm for the ED staff,” Ward-Fore said. “And it was simply a list of communicable diseases like mumps, measles, pertussis.”

She needed to determine: What actions needed to be taken? Did patients need to go into negative airflow rooms? Were droplet precautions needed?

“And it was just the way to simplify how patients move through triage,” said Ward-Fore. “It provided a quick guidance on symptoms, presentation, masking, a need for additional precautions. So, think about how you might be able to develop your protocol and make it simple.”

IPs will also, as always, have to monitor the environmental services (EVS) staff. “Practices drift,” Ward-Fore said. “Staff may be in a hurry. And sometimes staff think more is better. And I actually saw this at my former institution where the staff thought if you use 3 squirts, then 10 squirts is better. So be sure that you’re monitoring this regularly, and train, train, train and audit to make sure everyone’s following the same protocol.”

Clean from top to bottom, clean to dirty, clockwise or counterclockwise. “Clean before disinfection,” Ward-Fore said. “I can’t tell you enough how important this is. If there is bioburden on a particular item, a medical device or a patient tray in their room, unless you remove that bioburden the disinfectant is not able to touch those surfaces. It’s really important to clean before disinfection.”

IPs should know who is responsible for cleaning what. But more than that, everybody should know who’s responsible for cleaning what.

“This is a process that seems to break down fairly regularly,” said Ward-Fore. “When I covered surgical services, this happened fairly often. People would point the finger at each other and say, ‘Oh, well anesthesia cleans this but EVS cleans that.’”

IPs also need to specify how often something should be cleaned. Waiting rooms and other areas where patients tend to congregate for a long time should be cleaned more frequently.

Make sure there’s a plan to thoroughly clean and disinfect all patient care items. Exam rooms are different than public waiting rooms and not all waiting rooms or exam rooms are the same.

“What you really need to do also is try and limit the amount of supplies and equipment in the room to make it easier to clean,” said Ward-Fore. “Keep your supplies stored in cabinets or drawers. That’s actually why they’re there. And be sure you can close them. There’s no need for seven days’ worth of linen or enough IV bags on the counter for an entire week’s worth of surgeries. IPs, does this sound familiar? Probably.”

Finally, IPs should be aware of who among their fellow healthcare workers seems stressed out. “Recognize the toll this prolonged heightened awareness may take on staff physically and emotionally,” said Ward-Fore. “The staff worldwide have been troupers but how long can they maintain that? So be cognizant of that. Let each other know that you have each other's backs and that you’re there for each other.”

1: World Health Organization. Wash hands when visibly soiled. WHO website. https://www.who.int/gpsc/5may/How_To_HandWash_Poster.pdf?ua=1

2: Centers for Disease Control and Prevention. Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19. CDC website. 

https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html

3: Centers for Disease Control and Prevention. Strategies to Mitigate Healthcare Personnel Staffing Shortages. CDC website. https://www.cdc.gov/coronavirus/2019-ncov/hcp/mitigating-staff-shortages.html

It will also be necessary to again train other professionals the way IPs have historically trained them about infection prevention, because a lot of the old rules had to be set aside when COVID-19 surged.

Navigating the New Normal in Infection Prevention

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

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?

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

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

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.

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.

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