In 1918, the world was swept by a terrifying novel influenza pandemic that killed about 50 million people.1 The primary cause of death, however, was not the influenza virus itself but the secondary bacterial pneumonia that so often followed. Antibiotics wouldn’t be discovered by Alexander Fleming until 1928, so physicians during the 1918 pandemic had nothing with which to treat bacterial pneumonia. Before antibiotics, people were at risk of dying from the same common bacterial infections we so often take for granted being able to treat today. When Fleming received his Nobel Prize for the discovery of penicillin, he warned that misuse of antibiotics could lead to resistant bacteria. True to that warning, bacteria, and now yeast, have developed ways to resist antimicrobial treatment. And if we don’t act quickly to prevent and contain antimicrobial resistance, we may see a time in which the inability to treat common infections will once again be our reality.

The World Health Organization lists antimicrobial resistance as one of the top 10 global public health threats.2 Regarded as serious a threat as climate change, antimicrobial resistance threatens to rob us of the antibiotics we rely upon for the treatment of infectious diseases, and of many of our modern medical advances. A review about antimicrobial resistance estimated that “globally, at least 700,000 people die each year of drug resistance from illnesses such as bacterial infections, malaria, HIV/AIDS, or tuberculosis.”3 This same report warns that, without quick and strategic action, “this toll will exceed 10 million each year by 2050 and cost the world over 100 trillion USD in lost output.”3

Because of the role antibiotics play in the development of antimicrobial resistance, much of the conversation around containing resistance revolves around the stewardship and development of antibiotics. We need antimicrobials to treat infections and must therefore be judicious in our use of those antimicrobials. However, we have learned over time that the prevention and control of infectious diseases should never rely on 1 strategy alone. Instead, a combination of strategies enables us to most effectively prevent infections. To prevent the spread of antimicrobial resistance, we must address the horizontal transmission of antimicrobial-resistant organisms in addition to addressing antimicrobial stewardship. Antimicrobial resistance is worsening, but not solely because of the inappropriate use of antimicrobials. Resistance is spreading. Drug-resistant organisms and resistance mechanisms are spreading from person to person, primarily in health care settings, through lapses in basic infection prevention and control. To prevent this horizontal spread of antimicrobial resistance, we need infection preventionists (IPs) to lead in the fight against drug-resistant organisms.

When outbreaks hit or increases in infection are seen, we sometimes mistakenly look for a rare causative event, such as a contaminated medical device. However, more commonly, outbreaks and increases in infection are linked to lapses in basic infection prevention and control. To best prevent and decrease infection, including antimicrobial resistance, we have to get back to the basics. The US Centers for Disease Control and Prevention (CDC) notes that primary prevention measures for 

 a drug-resistant fungal infection, include hand hygiene, environmental cleaning, and adherence to transmission-based precautions—strategies that are all too familiar to IPs.4 Although these strategies are the foundation of infection prevention and control, all too often, we find that adherence to these basic measures is lacking. As IPs, we have an incredible opportunity to significantly reduce the transmission of antimicrobial-resistant organisms by focusing on improving adherence to the most basic of infection prevention practices. Sometimes, prevention really is that simple.

 The cornerstone of infection prevention and control will always be surveillance. Without effective systems in place to identify infections and outbreaks, we cannot prevent and control them. Antimicrobial resistance requires unique surveillance systems and close collaboration between clinical laboratories and infection prevention and control departments. IPs need to understand what their laboratories have the capability to identify and how they communicate when resistance is confirmed. Additionally, IPs need to have their own surveillance systems for reviewing, tracking, and trending antimicrobial resistance. The IP is usually the first to notice trends in antimicrobial-resistant organisms, leading to the identification of outbreaks and resistance.

 It is still not uncommon to find a provider who has never heard of 

 or the carbapenemase New Delhi metallo-beta-lactamase. Not only do health care workers need to be educated on novel and emerging resistance, but IPs also must have a firm understanding of these organisms and how they spread. As they say, knowledge is power, and so we must empower ourselves and our health care coworkers with the knowledge needed to win the fight against antimicrobial resistance. The Centers for Disease Control and Prevention (CDC) has developed a wealth of information for IPs, public health professionals, and health care workers on drug-resistant organisms including Candida auris and CRE.5,6

 Education, surveillance, and basic infection prevention are incredibly important to our efforts in containing antimicrobial resistance. But to be really effective at preventing and containing resistance, we must understand that resistance is not just an institutional problem but a regional one. And to fight a problem outside our own walls, we must establish clear lines of communication with other health care facilities in our region. Failure to document or communicate infection status or isolation needs is the No. 1 reason for antimicrobial resistance to spread across the health care spectrum. When a health care facility does not know that a patient is colonized with a drug-resistant organism, they fail to place the patient on the appropriate transmission-based precautions or put other measures in place that can aid in containing resistance. To fight resistance, we must all work together and develop ways to ensure communication during patient transfer. IPs can encourage the use of transfer forms, such as the Inter-Facility Infection Control Transfer Form from the CDC, to help ensure that isolation and infection status is always communicated as patients travel throughout the health care network.7

 Finally, IPs must seek to understand and collaborate with the efforts of state health departments that provide enhanced surveillance and response efforts for novel and targeted antimicrobial-resistant organisms. In the event that novel or targeted resistance is identified, state health departments and state public health laboratories may assist with facility and regional containment efforts. According to Jamie Rubin, infection prevention and control program administrator for the Maryland Department of Health, “When our public health lab identifies one of these novel or targeted organisms, they activate a coordinated response from the state health department team of infection preventionists, epidemiologists, and medical experts who then work with the health care facility to investigate potential contacts.” Occasionally, the identification of antimicrobial resistance will require enhanced surveillance methods to assist with prevention and containment, which state public health departments and laboratories can also assist with. “I hope IPs know that there is support available from their public health partners and that we can work together to reduce the development and spread of antimicrobial resistance,” Rubin said. IPs should seek to understand what their state’s health care-associated infections and antimicrobial resistance programs are doing to prevent and contain resistance.8 Furthermore, IPs should learn how they can partner and participate in public health containment efforts through ensuring their understanding of public health reporting requirements, participating in containment efforts, and quickly communicating resistance when it is identified.9 It is not alone but together that we will win the battle against antimicrobial resistance.

The world is quickly moving toward a postantibiotic era in which we may no longer be able to rely upon antimicrobials to treat infections. To prevent and contain antimicrobial resistance, we need to use a multilayered approach. It will take enormous effort and involve a number of disciplines.

At the front line of the battle are IPs, armed with the knowledge and tools needed to prevent and control the spread of antimicrobial resistance. And through using best practices in basic infection prevention, implementing strong surveillance systems, collaborating with public health partners, educating about the problem of resistance, and communicating clearly across the health care spectrum, IPs can help win the war against antimicrobial resistance. p

HEATHER SAUNDERS, MPH, RN, CIC, is the director of infection control at Johns Hopkins Office of Population Health. She is also the owner and primary consultant for Broad Street Prevention, where she guides health care and business leaders in the prevention and control of infectious diseases.

1918 pandemic (H1N1 virus). Centers for Disease Control and Prevention. Updated March 20, 2019. Accessed July 16, 2021. 

https://www.cdc.gov/flu/pandemic-resources/1918-pandemic-h1n1.html

10 threats to global health in 2019. World Health Organization. Accessed July 16, 2021. 

https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019

Tackling drug-resistant infections globally: final report and recommendations. Review on Antimicrobial Resistance. May 2016. Accessed July 16, 2021. 

https://amr-review.org/sites/default/files/160525_Final%20paper_with%20cover.pdf

. Centers for Disease Control and Prevention. Reviewed July 19, 2021. Accessed July 20, 2021.https://www.cdc.gov/fungal/candida-auris/c-auris-infection-control.html

Candida auris. Centers for Disease Control and Prevention. Reviewed July 19, 2021. Accessed July 20, 2021. 

https://www.cdc.gov/fungal/candida-auris/index.html

Carbapenem-resistant Enterobacterales (CRE). Centers for Disease Control and Prevention. Reviewed November 9, 2019. Accessed July 20, 2021. 

https://www.cdc.gov/hai/organisms/cre/index.html

Inter-Facility Infection Control Transfer Form for States Establishing HAI Prevention Collaboratives. Centers for Disease Control and Prevention. Updated June 2019. Accessed July 20, 2021. 

https://www.cdc.gov/hai/pdfs/toolkits/Interfacility-IC-Transfer-Form-508.pdf

State-based HAI prevention activities. Centers for Disease Control and Prevention. Reviewed June 29, 2021. Accessed July 20, 2021. 

https://www.cdc.gov/hai/state-based/index.html

Containment strategy responding to emerging AR threats. Centers for Disease Control and Prevention. Reviewed June 27, 2019. Accessed July 20, 2021. 

https://www.cdc.gov/hai/containment/index.html

Articles

With seemingly reckless abandon, we are quickly headed toward an era in which the antibiotics we once used to treat infection will be rendered ineffective.

Antimicrobial Resistance Is Futile Without IPs’ Help

Last spring, investigators with the Centers for Disease Control and Prevention (CDC) had some good news to report about an infection that had for years sat at the top of the threat list: 

 infection (CDI) and associated hospitalizations, they said, had dropped 24% between 2011 and 2017, “owing to a decline in health care-associated infections [HAIs].”1

Despite that welcome decline, though, recurrent CDI remains one of the most important treatment challenges. In 2017, for instance, there were an estimated 38,500 health care–associated cases.2 Since the early 2000s, CDI has multiplied in incidence and severity, becoming the most common nosocomial infection.3 Part of that increase is due to more sensitive testing, which can contribute to higher case detection. And although health care-associated 

 has been trending downward, the same is not true of community-acquired 

 infection is costly—both in economic and human terms. Between 1986 and 2013, CDI was among the top 5 most expensive HAIs in the United States.3 The burden of CDI adds an estimated 3 to 20 extra hospital days per patient with an additional cost of $1 billion in the US.3

Avalere Health, a health care consulting firm, conducted a retrospective cohort study of more than 268,000 Medicare recipients diagnosed with 

 and recurrent CIDs (rCIDs) from 2010 through 2016. The investigators evaluated health care resource utilization and all-cause, direct medical costs associated with the infection. They found that 1 in 3 patients with 

 had a recurrence within 12 months, and more than half of the patients with at least 1 recurrence experienced 2 or more after that first episode. Patients with 

 spent 18 days in the hospital on average compared with 13 days for those with no recurrence.4

Total all-cause, direct medical costs per patient over 12 months were highest in those with 3 or more recurrent episodes, primarily driven by hospitalizations. Inpatient costs were $31,614 per patient with 3+ recurrences versus $22,722 per patient without an rCDI episode. Recurrent CDI was also associated with higher overall health care costs and higher out-of-pocket costs for patients.

“Significantly,” the Avalere investigators say, “during the 12-month follow-up period, hospital admission rates increased in parallel with the number of recurrences”: 13% of patients with CDI experienced 4 or more hospitalizations within 12 months, while 25% of those with 3 or more recurrences were hospitalized 4 or more times.

 carries a hefty price tag: $5 billion in direct health care costs annually.5 Most of the cost is due to morbidity and mortality. Between 1998 and 2008, the proportion of patients with complicated disease (eg, megacolon, perforation) jumped from 7% to 18%, and 30-day mortality nearly doubled, from 4.7% to 13.8%.3 More than 15,000 people die of CDI every year in the US; CDI and recurrent CDI is the seventeenth leading cause of death in people 65 and older.4,5

Co-infections are another complicating factor. COVID-19, for instance, manifests with GI symptoms similar to those of CDI.6 In a small Mayo Clinic study of 21 patients given a diagnosis of COVID-19 and CDI within 4 weeks of each other, 30-day mortality was 19%, mostly in the elderly. “Whether co-infection results in worsening mortality or more complications remains unanswered,” the investigators write. They note that the patients were not treated with antibiotics for COVID-19, and CDI seemed to have developed due to prior antibiotic exposure for other indications.

 and turbocharges it. In an online interview with 

7 about an Avalere study of patients with CDI, economist Christie Teigland, PhD, vice president, Advanced Analytics, Avalere Health, said, “The main takeaways [from the study] were really the very high rates of sepsis among patients who get 

 and particularly those who have recurring instances of 

. And that carried through with all of the health care resource utilization metrics we looked at, from inpatient stays to post-acute care use, lots of skilled nursing facility use, where they also have a high risk of sepsis and 

“The costs are strikingly high for these patients—$42,000 a year for patients with recurrent 

, with sepsis, and those were the patients who died, but the costs were even high in patients who did not die. For those who died, the follow-up was really short. I think the shortest was 12 days. These patients, once they have 

 and sepsis, have higher odds of dying. So, the whole message here is what can we do to, number 1, prevent 

 and number 2, sepsis, because the combination of those two is deadly.”

Many current estimates of the poor outcomes and costs associated with CDI “do not take into account the underlying severity of illness among patients who develop CDI and may overestimate the true attributable outcomes,” according to a 2020 meta-analysis that found a pooled incidence of hospital-onset CDI of 8.3 cases per 10,000 patient-days.8

This June, the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) released a new clinical practice guideline on management of CDI in adults. Since 2017, the authors say, when the guideline was last published, “new relevant evidence has emerged for treatment options.” This 2021 “focused update” specifically addresses the use of fidaxomicin and bezlotoxumab (a monoclonal antibody that targets toxin B produced by 

). Both agents have increased clinical efficacy and other advantages over older agents, the authors say, but implementation may be challenging because of initial monetary cost and logistics.

The new guideline also notes that the FDA has published 3 separate safety alerts on fecal microbiota transplantation (FMT) (which is recommended, although only for patients with multiple recurrences of CDI for whom antibiotic treatments have failed, and where appropriate screening has been performed). Two alerts document transmission of pathogenic 

 from donor to FMT recipients. The other alert concerns the potential for transmission of SARS-CoV-2. According to researchers from Mayo Clinic, with appropriate screening, FMT is safe to perform during the pandemic. In their study of 57 patients who underwent FMT for rCDI, none developed COVID-19.9

CDI is an old enemy and health care professionals have gathered an armamentarium of weapons against it, but it can be relentless. “Clearly,” says Teigland, “we know that hospitals and nursing homes take precautions to prevent sepsis and prevent 

.… The impact is just so devastating in this frail elderly population, you know, they’re already suffering from multiple chronic conditions, hypothyroidism, hypertension, diabetes, asthma, COPD, many comorbidities. 

 and sepsis on top of all that is just devastating. Ultimately, more attention needs to be paid to those high-risk patients.” But, she adds, “We can predict who’s high risk because we know what the preceding risk factors are. Our study even looked at what the risk factors were in the most recent 7 to 12 months, right before the 

 happened. Their conditions got much worse in the 6 months right before they had their first case of 

. So when you see those worsening effects happening, you really need to pay much more attention to the protocols that they have in place already. We know hospitals have protocols in place to prevent sepsis and 

, you really need to pay attention to these patients because it’s still happening way too much.”

The bedside is still a good place to keep watch. A paper-based bedside 

 screening tool to reduce inappropriate testing could make a big cost difference to the 25% of hospitals that don’t use clinical decision support in their electronic health records, say investigators from Adventist Health-Simi Valley. Nurses used the screening tool to determine whether stool should be sent for 

 testing. The researchers collected data on the number of 

 stool tests performed before and after the intervention: They found a 31% drop in the mean monthly number of tests performed and a 56% reduction in CDI diagnoses.10

In an intervention tested at Hospital General Universitario Gregorio Marañón, in Madrid, after a positive 

 test, patients immediately received a bedside visit from an infectious disease physician. The timely visit allowed for more targeted treatment, reducing overdiagnosis. Identifying the patients who do not meet the criteria for diarrhea and are simply carriers makes it possible to withdraw treatment from a large contingent, the researchers say.11

The ID physician was instrumental in identifying 29 cases as only colonized with 

, in which fecal sample collection was unnecessary. In 22 of those cases (76%), physicians in charge accepted the ID consultants’ recommendations to stop or not initiate CDI treatment in asymptomatic patients. Unnecessary non-CDI antibiotics were discontinued in 19% of cases. Only in 13% of the 214 cases were the ID recommendations not accepted by physicians in charge.

The cost of the intervention was estimated at €6800 (approximately $7800) during the study period, while the estimated costs of savings from antimicrobial discontinuations only were estimated at €1799 (approximately $2000).

The CDC investigators who reported on the decline in health care-associated 

 infection say several factors were probably involved, including a decline in the epidemic strain ribo-type 027, which might be partly driven by reduced fluoroquinolone use.1 They cite a 2020 study that found hospitals that reduced fluoroquinolone use by 30% also saw a 19% reduction in hospital-onset CDI. They also point to a “greater emphasis on diagnostic stewardship” and reducing inappropriate testing.

Sometimes, less is more. Most hospitals implement interventions simultaneously in “bundles,” say researchers from the University of Michigan and the University of Wisconsin, and more than half of the bundles in a recent review included at least 6 components. But that may be costly overkill.

In their economic evaluation study, these researchers used an agent-based simulation of 

 transmission at a 200-bed model tertiary acute care hospital to compare the cost effectiveness of nine single-intervention strategies and 8 multi-intervention bundles. They defined cost effectiveness by two measures: cost per hospital-onset CDI averted and cost per quality-adjusted life-year (QALY).5

Five of 9 enhanced-level strategies were “dominant,” reducing cost, increasing QALYs and averting CDI: Daily cleaning was the “most clinically effective and cost-effective intervention by far,” saving $358,268 and 36.8 QALYs annually, while averting 26 CDIs. Next came health care worker hand hygiene, patient hand hygiene, terminal cleaning, and reducing intrahospital patient transfers. (Daily cleaning prevented more than 16 times as many infections as the patient transfer intervention.) Contact precautions, while a mainstay of CDI prevention programs, are based on slim evidence, the researchers say, given that 

-targeted studies are lacking. In their study, they found neither health care worker nor visitor contact precautions were cost effective. Enhanced-level health care worker contact precautions cost $123,264 per QALY, and the ideal-level implementation $136,135 per QALY. “The results were even worse,” they say, for the visitor contact precaution interventions, with the ideal level costing $1,669,089 per QALY.

The bundles were only as cost effective as the parts they assembled. For instance, adding patient hand hygiene to the health care worker hand hygiene intervention saved a mean of $32,588 and 4.2 QALYs annually. When screening, health care worker hand hygiene and patient hand hygiene interventions were sequentially added to daily cleaning to form bundles, the incremental cost-effectiveness ratios for the additions were $29,616, $50,196, and $146,792 per QALY, respectively. Patient hand-hygiene, which, the researchers point out, is “rarely incorporated into 

 bundles,” was cost saving at both the enhanced and ideal levels. Their back-to-basics advice: Institutions should “seek to streamline their infection control initiatives and prioritize a smaller number of highly cost-effective interventions.” Daily sporicidal cleaning, for example, they suggest, might be more useful and money-saving than minimally effective, costly strategies, such as visitor contact precautions.

Suggesting using fewer (albeit highly effective) interventions “runs contrary to the current infection control climate,” the researchers acknowledge. And while many of the interventions in their study saved money, they were not without upfront costs. Even at the enhanced level, each intervention required additional infection control nursing staff.

“Hospital administrative buy-in and financial support is key,” they emphasize, “to both the initial implementation of an intervention and sustaining its long-term success.” Throwing more money at the problem isn’t the solution—but throwing the right kind of money could be.

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

Guh AY, Mu Y, Winston LG, Johnston H, et al. Trends in U.S. Burden of 

 2020; 382:1320-1330. doi: 10.1056/NEJMoa1910215. Accessed 07/26/21.

Johnson S, Lavergne V, Skinner AM, Gonzales-Luna AJ, Garey KW, Kelly CP, Wilcox MH. Clinical Practice Guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 Focused Update Guidelines on Management of 

Gupta A, Ananthakrishnan AN. Economic burden and cost-effectiveness of therapies for 

Teigland C, Parente A. The burden and costs of recurrent 

.https://avalere.com/insights/the-burden-and-costs-of-recurrent-clostridioides-difficile. May 7, 2020. Accessed 07/26/21.

Barker AK, Scaria E, Safdar N, Alagoz O. Evaluation of the cost-effectiveness of infection control strategies to reduce hospital-onset 

. 2020;3(8):e2012522. Published 2020 Aug 3. doi:10.1001/jamanetworkopen.2020.12522. Accessed 07/26/21.

Sehgal K, Fadel HJ, Tande AJ, Pardi DS, Khanna S. Outcomes in patients with SARS-CoV-2 and 

. 2021;14:1645-1648. Published 2021 Apr 28. doi:10.2147/IDR.S305349. Accessed 07/26/21. Published online.

Walter K. Christie Teigland, PhD: The cost of c difficile and sepsis.HCPLive.Accessed 07/29/21. Published online 05/21/21.https://www.hcplive.com/view/teigland-cost-c-difficile-sepsis

Marra AR, Perencevich EN, Nelson RE, et al. Incidence and outcomes associated with 

infections: A systematic review and meta-analysis. 

. 2020;3(1):e1917597. Published 2020 Jan 3. doi:10.1001/jamanetworkopen.2019.17597. Accessed 07/26/21.

Khanna S, Tande A, Rubin DT, Khoruts A, Kahn SA, Pardi DS. Fecal microbiota transplantation for recurrent 

infection during the COVID-19 pandemic: experience and recommendations. 

. 2021;96(6):1418-1425. doi:10.1016/j.mayocp.2021.04.005. Accessed 07/26/21.

Lenz A, Davis G, Asmar H, Nahapetian A, Dingilian J, Nathan RV. Using a nurse-initiated bedside tool to decrease inappropriate testing for 

Olmedo M, Valerio M, Reigadas E, Marín M, Alcalá L, Muñoz P, Bouza E. Clinical impact of a 

bedside infectious disease stewardship intervention. 

, Volume 2, Issue 3, September 2020, dlaa037, 

C. diff infection is an old enemy and health care professionals have gathered an armamentarium of weapons against it, but it can be relentless. 

Can We Ever Get Rid of C. Diff?

The emergence of the SARS-CoV-2 virus swiftly effected change in every facet of society, with health care delivery being the frontline to the COVID-19 pandemic. This agent of change spared no population. Rapid process changes infiltrated neonatal intensive care units (NICUs) to protect the most vulnerable newborn babies who made their entry into the world during a global pandemic. Just as the virus has adapted to its global host with variant strains, health care delivery in the NICU has adapted with evolving and sustainable practices.

The NICU at the Hospital of the University of Pennsylvania provides care to a level 3 NICU patient population. The American Academy of Pediatrics defines a level 3 NICU as a hospital setting that offers expertise of care providers and specialized equipment needed to provide “comprehensive care for infants born < 32 weeks gestation and weighing < 1500 g and infants born at all gestational ages and birth weights with critical illness.”1 Four open bays comprise the 38-bed unit with only 2 negative pressure capable isolation rooms located in 1 of the bays. The NICU includes a separate resuscitation space adjacent to the labor and delivery (L&D) unit with 3 available bed spaces. To adapt to potential census fluctuations, many bed spaces are capable of accommodating overflow and multiple gestation infants in a single-bed space footprint.

Operational challenges in the NICU were quickly unveiled with the emergence of COVID-19. Staff illness or exposures to COVID-19 from community and workplace venues resulted in prolonged furlough periods.Severe supply chain shortages in personal protective equipment (PPE) and disinfectant products compounded these operational challenges, prompting conservation and reuse.2 The NICU was thrust into a crisis capacity mode from a baseline of conventional capacity operations.3 Unlike other areas of the hospital, the NICU could not reduce admissions or defer scheduled procedures. This prompted emergent planning for contingency operations.4

To continue safe delivery of care, immediate process changes were developed by a collaborative multidisciplinary team. Expert guidance was enlisted from the NICU and L&D nursing leadership and physician provider teams along with hospital partners from infection prevention and control, lab and pathology services, perioperative services, environmental services (EVS), facilities, and materials management (MM). Internal and external supply chain shortages of disinfectant products prompted EVS and MM to forge a plan to make and distribute disinfectant wipes.

Infection prevention in the NICU begins in the L&D setting. Prior to the availability of universal COVID-19 testing for the antepartum population upon admission, the patient history and physical (H&P) included screening for community exposure to COVID-19 and presence of signs or symptoms of COVID-19 infection.5 Any positive findings on the H&P resulted in a person under investigation (PUI) for COVID-19 status with laboratory testing to confirm diagnosis.6

Three negative pressure L&D rooms were designated for PUIs or COVID-19–positive patients. An operating room (OR) for cesarean-section deliveries was also designated for this patient population, with terminal cleaning commencing at the end of the case or upon discharge of the patient from the L&D room. A hospital nursing team of subject-matter experts (SMEs) was deployed to enhance PPE training with donning and doffing procedures as well as safe handling of N95 masks that were reused.7

An infant who was born to a mother who was a PUI required airborne and contact isolation pending the maternal COVID-19 result. This challenged the limitation of 2 NICU isolation rooms, prompting the conversion of the adjacent open bay to a negative pressure airflow to accommodate a third infant who would require isolation. Precipitous deliveries leave little time for the NICU to prepare for an admission, requiring airborne isolation resources to be in a state of readiness.

The admission of a third patient to the negative pressure bay requires imminent transfer of up to 4 other patients to other locations in the NICU. For this reason, the goal is to preserve this open bay for the most stable patients. Testing of the infant of the COVID-19–positive mother requires 2 negative COVID-19 tests 2 days apart. This time delay adds to the challenge of ensuring available isolation beds.

See the below slideshow for a demonstration of donning and doffing of PPE for the NICU (Photographer: Kelly Convery; Nurse donning and doffing: Christina Minnissale; Nurse in isolation room: Melanie Gabriel)

Donning and Doffing for the NICU

Because of the highly specialized nature of the neonatal population, the NICU adapted the hospital nursing SME model and implemented a unit specific team of SMEs. This core group of RNs served as trained observers for appropriate donning and doffing of PPE in the delivery room and during the admission and stabilization of the infant in the isolation bed space. This role quickly evolved into a dedicated resource for the interprofessional staff of the NICU. The acronym COPE was coined by a team member, Jennifer Roman, BSN, RN, CBC, to describe the team of COVID-19 operations and patient-care experts. In this role, nurses served as communication liaisons for unit leadership to disseminate the rapid evolution of guidance in the initial wave of the pandemic, which led to rapid process changes.

The COPE team was tasked with remaining knowledgeable on current processes, readily guiding the interprofessional team to unit resources and protocols and providing direct and indirect support to staff. In order to sustain preparedness, the COPE team created specific checklists and supply par levels that are utilized by all staff members to ensure isolation admission spaces are always at the ready. Identifying appropriate supply par levels and paring down admission supplies to the necessities also aided preserving supplies and minimizing waste during the terminal cleaning process of isolation spaces.

This population based SME team allowed for streamlined and systematic information communication to the unit staff members. The COPE team members were able to filter out the overwhelming volume of information being shared hospital-wide, much of which did not pertain to the specialized neonatal patient population, and provide concise, timely, and pertinent information to the neonatal team.

Ongoing assessments of patient and staff safety prevailed as more information about the transmission of SARS-CoV-2 virus and supply chain challenges became available. The interdepartmental collaboration and frequent virtual communications sustained the contingency plans and required resources through the peak of the pandemic, providing a pathway to a new conventional capacity operations model. Increased testing capacity and widespread vaccination for the SARS-Cov-2 virus has alleviated the contingency capacity operations with improved supply chain and decreased staffing burdens.

Sustained changes in the delivery of care in the NICU have forged new conventional capacity operations in the setting of the COVID-19 pandemic. Negative pressure in L&D rooms is no longer a requirement because updated information became available. A designated OR remains in use for COVID-19 positive patients as intubation may take place. Terminal cleaning procedures follow use of the L&D room or designated OR used for a COVID-19–positive patient. Infant resuscitation continues to be performed in the delivery room or in the OR. Delivery teams for COVID-19–positive patients continue to be limited to essential personnel with N95 masks used in aerosolizing procedures. The responding neonatal team has expanded to include pre-pandemic staff level participation.

Due to the increased potential for a neonate to require an aerosolizing procedure including initial resuscitation steps, neonatal responders continue to utilize N95 masks and viral filters for all neonatal respiratory equipment in L&D. Clean supply carts are maintained outside the room with a “clean” team member to hand off the supplies as needed to the delivery team. A daily checklist for supplies in each NICU isolation room is utilized to ensure capacity for airborne and contact isolation. Universal testing for hospital admissions continues. Visitors and employees are screened for symptoms of COVID-19 infection or exposure to sick contacts upon entry to the facility.

COPE team members continue to provide the necessary emotional support for the interprofessional staff during times of extraordinary stress and anxiety.8 The team serves as a sounding board for the other staff members and were able to bring forth staff concerns to unit based leadership for discussion and potential solution creation. Having dedicated “experts” who were specific to the unique population and space constrains of the NICU alleviated much of the staff worry, anxiety, and concern related to providing safe patient care. The COPE team continues to support the NICU interprofessional staff and has helped sustain unit readiness throughout several waves of COVID-19.

Surveillance for all hospital acquired infections as required by the state of Pennsylvania continued throughout the pandemic. No central line associated bloodstream infections (CLABSIs) were identified in over 400 days, nor were any other device-associated infections identified. There was no increase in nondevice–associated infections. Recent hand hygiene observations conducted by college co-op/volunteer students on all shifts revealed 95% compliance in 175 observations for 1 month.

This infection surveillance data indicates proven success in both contingency and new capacity models, with COVID-19 serving as an agent of change to facilitate improvement in infection prevention. A recently published study demonstrates the increased risk of maternal complications and preterm birth when COVID-19 infection occurs in pregnancy.9 This is a critical reminder that contingency planning and sustained operations are essential to the needs of our maternal and NICU population.

MICHELLE FERRANT, DNP, CNS, RN, RNC-NIC, ACCNS-N, CBC, is a clinical nurse specialist in the level III Intensive Care Nursery at the Hospital of the University of Pennsylvania.

JENNY HAYES, MSN, RN, CIC, CAIP, CASSPT, has 15 years of experience as an infection preventionist, serving both in-patient and ambulatory care populations in multidisciplinary settings. She is an infection preventionist at the Hospital of the University of Pennsylvania.

American Academy of Pediatrics Committee on Fetus and Newborn. Levels of neonatal care. 

 2012;130(3)587-597. doi:10.1542/peds.2012-1999

Summary for healthcare facilities: ​strategies for optimizing the supply of PPE during shortages. Centers for Disease Control and Prevention. Updated December 29, 2020. Accessed July 30, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/strategies-optimize-ppe-shortages.html

US Department of Health and Human Services. Hospital operations toolkit for COVID-19 patient care policies/processes: crisis standards of care.November 30, 2020. Accessed July 31, 2021. 

https://files.asprtracie.hhs.gov/documents/hospital-operations-toolkit-for-covid-19-patient-care-crisis-standards-of-care.pdf

COVID-19 sustainable response planning. Centers for Disease Control and Prevention. Updated January 4, 2021. Accessed July 30, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/global-covid-19/sustainable-response-planning.html

Altendahl M, Afshar Y, de St. Maurice A, Fajardo V, Chu, A. Perinatal maternal-fetal/neonatal transmission of COVID-19: a guide to safe maternal and neonatal care in the era of COVID-19 and physical distancing. 

Flannery DD, Gouma S, Dhudasia MB, et al. SARS-CoV-2 seroprevalence among parturient women. medRxiv. Published July 10, 2020. 

Andonian J, Kazi S, Therkorn J, et al. Effect of an intervention package and teamwork training to prevent healthcare personnel self-contamination during personal protective equipment doffing. 

Aloweni F, Ayre TC, Wong WHM, Tan HK, Teo I. The impact of the work environment, workplace support and individual-related factors on burnout experience of nurses during the covid-19 pandemic. 

 December 26, 2020. Accessed July 27, 2021. 

https://pragmajournals.com/journals/journal-of-nursing-and-patient-safety/fulltext/the-impact-of-the-work-environment-workplace-support-and-individual-related-factors-on-burnout-experience-of-nurses-during-the-covid-19-pandemic

Villar J, Ariff S, Gunier RB, et al. Maternal and neonatal morbidity and mortality among pregnant women with and without COVID-19 infection. 

Testing of the infant of the COVID-19–positive mother requires 2 negative COVID-19 tests 2 days apart. This time delay adds to the challenge of ensuring available isolation beds.

COVID-19 Gave Birth to Changes in Neonatal Intensive Care Units

COVID-19 spotlighted some deep-rooted systemic problems in health care. The underfunding and lack of proper infection and prevention methods at long-term care facilities, for instance. The pandemic also brought to the fore inequities in access to health care. Many racial and ethnic minority groups are more at risk of 

 from COVID-19 than whites, according to the Centers for Disease Control and Prevention (CDC). Now, they are less likely to get the 

. These problems in part point to the social determinants of health (SDOH), says G. Rumay Alexander, EdD, RN. Alexander is a clinical professor in mursing at the University of North Carolina–Chapel Hill. She is also the American Nurses Association scholar-in-residence working with the Commission Addressing Racism in Nursing. Alexander was one of the speakers this week at the 

 hosted by the Association of periOperative Registered Nurses (AORN), where she talked about SDOH. She recently sat down with 

) for a wide-ranging discussion about health care inequalities and how infection preventionists and operating room nurses can deal with that problem. “There’s a lot going on with people when they’re in environments where they’re not able to have the basics, where they’re not able to flourish, where they’re not in a healthy space to live, work, play, worship,” she tells 

. This doctor of education touts the benefits of always being willing and able to learn. “You want to maximize curiosity and minimize certainty. Curiosity means you ask questions, you don’t assume.”

How do you define the social determinants of health? How would an operating room nurse or an infection preventionist apply that in their everyday jobs?

 Really great question. Actually, social determinants of health have been a part of public health and community health curriculums and conversations and dialogue of for many, many, many, many decades. It seems that all of a sudden now it’s just surfacing in a very visible way, probably because COVID-19 really gave it a light. COVID-19 just actually pulled the curtain back and brought to the surface inequities of care, inequities in access to health care, inequities in the ability to communicate with different populations. So social determinants of health care is really about the principle, 1, that individuals have places where they live, work, play, and observe religious values. Quite frankly, if we don’t understand that, we don’t understand our patients. And so, at the end of the day, the goal is for health equity. If you think about it, there are 2 places where people don’t forgive thoughts or behaviors that treat them inequitably because [those places] proclaim themselves to be places free of bias, places 

that really focus on what I would call a level playing field in relationship to how they’re seen, how they’re treated, how they’re perceived. And those 2 places are in health care and the other 1 is in religious institutions. We’re a bit more unforgiving when those 2 places don’t live up to what they say they are about. And that it doesn’t matter what you look like; it doesn’t matter about your race or your gender or your economic status. So social determinants of health are around the environments that people live in that are basically man-made, or human-made, situations. They come out of systems that set people up for either an equitable form of care or an inequitable form of care. And so, if you think about it, it’s like a pathogen, but it’s a pathogen, not as in the microscope, and a virus, or bacteria, but it’s in the air, it’s in the ethos. Quite frankly, we’re all products of our environment. So where we live and where we worship, and where we play matter. About 80% of health outcomes are related to the physical environment, the social determinants, and behavioral factors. Only 20% of a person’s health and well-being is related to access and quality of care. As people who are providing people care—we must understand them. And in order to do that, you have to really understand how social determinants play into the whole matter of thinking. You’re thinking about things like socioeconomic factors. You’re thinking whether there’s education or job status or family supports or community or income. You could be thinking about health behaviors like tobacco use, or diet and exercise, or alcohol use, or sexual activity. And then there’s the whole access to care piece, economically. “I can’t afford health insurance,” right? Then what’s done for me, or not done for me, is based on whether I can pay for it or not. That. As health providers, we’re responsible for understanding the whole being of a person. We’re literally going to be giving postsurgical instructions, discharge planning. We’re going to give preadmission instructions. If we can’t communicate with the patient, then now we’ve created what I call a moral insult that says that you don’t value me as a human, and therefore that affects my trust. Now my stress level is up. I’m not in my best place for surgery because these things are playing out in physical ways in my body. This is important work. This is also about…we’re on interprofessional teams now. Professions have their own cultures. They’re different, even though we’re all under the health care umbrella, right? Physicians are socialized to come toward the patient in a certain way. Nurses, another. Anesthesiologists would be another. The point is, if you think about culture as the way we do the things you do—to quote the Temptations, and I know that’s aging me, but they’re great philosophers…they say it best. Culture is how we do what we do, the way we do the things we do. That’s about decision-making. That’s about policy development. That’s about how we approach individuals. This is all a part of understanding the determinants of health. What determines good health? What determines the best outcomes? How to get the optimal health outcome for a patient. It’s proper for an organization to really help its members understand the environment that people live in but also who we’re working with. And when we’re not communicating, or we’re misunderstanding each other, or when racism or supremacy eats into our relationships, people shut down and stop talking to each other as professionals, because we’re all human, right? And all of us want to be respected. None of us wants to be insulted. Once health care providers aren’t talking to each other, the patient is really at risk and danger. You can see how this permeates the operating room, the larger health care organization itself—the hospital or the surgery center, where people are—and it messes with our relationships and our ability to come together for the good of the patient, which is why we’re all in the business we’re in.

 Do you see concern about the social determinants of health care forcing hospitals into a more activist role in communities?

 There’s what I call the business of health. And then there’s the business of health care. Now, the business of health care says you need to understand your market share. You need to understand who it is in your community that has access to your service. And you want to be culturally appropriate and culturally relevant to that market share. Because these are the people who are going to be coming in. And they need to have great customer satisfaction so that they can recommend that other people come. Or when they need to—and hopefully, they won’t have to do that often—but when they do, they need to know they’re coming into a respectful place and a place that understands them. “They get me.” [An institution] that knows about my cultural tendencies. Now, that’s not to mean generalization, as [when some might] say all Hispanics are Catholic, or all people of 1 group is biased, and another group is not. In fact, that’s an interesting thing that I just said, because we all have our biases. It has no color. That issue in itself, understanding your own biases, which play into who we’re willing to care for, and how we’re willing to care for them. And so, yes, this pushes you into understanding your community, and having community responsibilities around understanding those individuals, so that you can be in the business of health. The two go together. One should not supersede the other. It’s not about the inhumane piece. It’s about the humane piece as well. One of my mottos is “all encounters are cultural encounters.” You’re never in a place where you’re not having a cultural encounter. And people come not only with their bodies, but with their experiences of people who are surrounding them for the care. When experience shows up, it speaks, and it speaks loudly. It usually shows up as a feeling, or a thought, or a belief, or a decision about who’s worthy of getting the best care, or the minimum amount. And that’s tied to many other factors that come into play. We live in a society now that’s going to be more and more diverse. And, in fact, the numbers have been predicted for quite some time. And there’s a shift going on right now in who’s majority, who’s minority. And that matters. Because as the majority typically is making decisions, it’s making decisions [based on] its own value systems, its own beliefs, its own experiences. And unless by design, you work on understanding those who are not of the majority, you’re going to do harm. We’re in the business, and we take the oath to do no harm. We’re responsible for understanding everyone, not just the majority, and we’re responsible for serving everyone to the best of our ability. And this is why understanding those social determinants and what people have the agency to do or not [is so important]. Because at the end of the day, it’s the systems that set people up for the conditions they live in. You need to understand that full array. It’s not that they’re just lazy people, or they’re just not [intelligent] people. They’re often held hostage in situations that they did not themselves decide to live in. The decision to put the toxic waste dump in a certain neighborhood, or to put lead in the water like they did in Flint, Michigan, and intentionally give it to certain populations knowing that it would harm and not giving it to others, because we value them more. All of that’s tied into the social determinants of health.

 What part does trust play in this? If I’m a Native American and the government says to me, “Hey, we’ve got a vaccine for you. Do you want to come and get it?” I might have second thoughts about that. How do you deal with that?

 Trust is a huge, huge piece. You just went back to the experience that Native Americans have had when they trusted the system, and they expected it to be thoughtful about them, caring about them, and having their best interests at heart. And they can point to times when that wasn’t true. The same is true with African Americans and the 

 where trust was an issue. We’re living right now dealing with trust issues. In order to be trusted, you have to be trustworthy. Trustworthy means that you do what you say you’re going to do. This is why I made that comment earlier about the people not forgiving institutions who proclaim that “we treat everybody with the best of intentions to the best of our ability,” when [those groups have] had an experience that’s different. Nurses are the most trusted profession in the country, of all the professions, and have been for the last 18, 19, 20 years. And so when we are a part of a system that is not giving that kind of thought to who it is we’re caring for, and we’re making differences in how we treat them, and we as nurses don’t advocate for the patient, or speak to those issues—or any health provider—then we have created this distrust which we pay for down the line like we’re doing with the vaccine distribution. They’re not isolated events. Experiences aren’t isolated events. The narratives that get passed [down] generationally about how someone like us from a certain identity group are treated impacts the future about what people are willing to do, where they’re willing to go, what they might even consider to be honest information. Now we’ve got this vaccine hesitancy for reasons that really date back to…one of the reasons obviously, there are some myths out there that aren’t true...but one of the reasons is our historic memory. We haven’t always been valued. In fact, some of us have been treated very inhumanely, or dehumanized is another way of thinking about it. Once you dehumanize someone, you can do anything to them. So why would I place myself in your hands if I don’t trust you? There’s a power inequity there. If I’m unconscious on the table, and you’re in charge, I’ve turned over my agency and my power to you. Something that valuable—be it my child, my wife or husband, my grandmother, my mother, my father or grandfather, people who are precious to me—if I turn that over to you, and I’m vulnerable at that point, then I need to be assured. I need to be able to trust that you’ve got my best interest at heart. And so that’s going to take decades because trust is something that you build. You can destroy it in seconds. And then it takes you years again to build it. And what we’re talking about now are decades of places where people can point to when you didn’t have my best interest at heart for reasons other than thinking of me as human. We’re kind of in that rehumanizing phase and rehumanizing is part of gaining that trust back. But rehumanizing is also part of the social determinants. They all come full circle. A bad decision can have really long-term consequences. And I’ll tell you something that I use often that sounds like a health care statement, but it’s more of a parenting statement. And quite frankly, it’s something that my mother used to tell us—me and my two sisters as children—but it works even in work settings. And that is: “You can’t talk your way out of what you behaved your way into.” That kind of wraps up what I mean, by the trust factor: You’re saying one thing; you’re doing another.

 The two groups who least want to get the COVID-19 vaccine are African Americans and Republican males. It’s strange how this lack of trust can manifest itself in such different groups.

 Trust is a very human factor, just like empathy is. And you were talking a minute ago about putting yourself in someone else’s place. Part of the ability to be culturally appropriate and relevant is that ability to have empathy for others, to put yourself in their shoes. If I lived where they lived, and if I were born at the time they were born, would I be different? How would I feel? “Here I am. I made it. I don’t know why you can’t make it.” One of the things that is really tied to this whole social determinants piece—and notice it’s social, meaning man-made—is what’s called deaths of despair. There are about 20 million Americans experiencing what is called a demographic depression. And most of them are relatively young, they’re predominantly White, less than college-educated, and have not benefited from economic growth, or they’ve lacked access to care, they’ve suffered from debilitating pain on a daily basis, usually due to some form of disability, which is often observed in later life. But there’s this—with these groups, as I said, it’s predominantly White, but it’s also populated by all the other racial and ethnic groups as well—[there’s] a higher rate of death. And the researchers refer to it as deaths of despair: suicides and alcohol- and drug-induced deaths. And that has contributed to a decline in life expectancy by 3 to 4 years. There’s a lot going on with people when they’re in environments where they’re not able to have the basics, where they’re not able to flourish, where they’re not in a healthy space to live, work, play, worship. It’s an important piece for us to understand, and if trust isn’t there, and I am someone who is self-medicating to cope with my despair, and I don’t trust that you will understand that so I don’t tell you in the patient history, you [the provider] could have an outcome that you can’t explain. Or you could be administering something or doing something that normally you wouldn’t, and have an adverse outcome. But because they didn’t trust you and you were missing that piece of information which was vital, you now have a bad outcome. That bad outcome could lead to being in intensive care. If that person doesn’t have insurance, the cost of care goes up because they don’t have the coverage. My point is 1 feeds the other. The healthier we are as a whole of people, the more the systems are healthy as a whole.

 Is there something that I neglected to ask that you think is pertinent to this conversation that you want your fellow health care professionals to know?

The main thing is we have to remember that we’re in the business of patient care. And we need to be patient-centered in all of our thinking. We should really give some thought to how our decisions are being made. We need to really work on self-awareness. And that’s an important piece, understanding what pushes your buttons, asking yourself questions about “Why do I think this?” about this individual or not. And like I said, we all have biases, most of them are invisible, but they’re operating—unconscious bias or implicit bias. The more you know what your biases are and you’re working on them by design, you’re going to give better care. You’re going to naturally start working on “How can I be the best health care provider for this person who’s in their most vulnerable state, and has turned their life, or the life of their precious one, [over] to me?” Which is a space that’s sacred, and it’s a space that not everybody gets exposed to. If we’ll just think about ourselves, or think about our mind, like a computer with a “maximize” and “minimize” button: You want to maximize curiosity and minimize certainty. Curiosity means you ask questions; you don’t assume. Curiosity means you go learn things. That you come to an honest place of saying, “Here’s what I don’t know.” Because that’s what true education is about. Getting to know what you don’t know and learning it—filling in that void. I think when we do those things, we’re bringing our best selves. And we’re meeting our obligation to our patients. And I think that’s where I’ll leave it. p

This interview has been edited for clarity and length.

Videos

G. Rumay Alexander, EdD, RN: “When experience shows up, it speaks and it speaks loudly. It usually shows up as a feeling, or a thought, or a belief, or a decision about who’s worthy of getting the best care, or the minimum amount.”

Approaches to Curing Racial, Ethnic Inequality in Health Care

The COVID-19 pandemic underscored the need for infection preventionists (IPs) to work closely with other departments in hospitals such as 

 teams. There’s also been discussion about how, despite 

, because the pandemic forces schools, businesses, public agencies—almost every segment of society—to become more familiar with common infection prevention and control processes.

But even IPs who intend to stay with hospitals might need to expand their reach beyond the walls of those facilities, according to a 

An outbreak of mucormycosis among transplant patients spurred the intervention of IPs and administrators at the hospital. According to the Centers for Disease Control and Prevention (CDC), mucormycosis is a rare fungal infection. “Mucormycosis mainly affects people who have health problems or take medicines that lower the body’s ability to fight germs and sickness,” 

 states, “mucormycosis is an increasingly well-reported invasive fungal infection that affects recipients of solid-organ transplant … and hematopoietic stem cell transplant and is associated with a high morbidity and mortality.”

The CDC says that mucormycosis “most commonly affects the sinuses or the lungs after inhaling fungal spores from the air. It can also occur on the skin after a cut, burn, or other type of skin injury.”

 study, the IPs at the hospital investigated and found that health care linens (HCLs) delivered to the facility by an outside vendor were contaminated by Mucorales, one of the causes mucormycosis. They conducted an on-site inspection of the laundry service, according to investigators with the University of Pittsburgh School of Medicine who conducted the 

 study, which helped them find the source of the infection and implement mitigation strategies.

“Targeted laundry facility interventions guided by site inspections and step-wise culturing significantly reduced Mucorales-contaminated HCLs delivered to our hospital,” the study concludes. “Collaboration between infection prevention and laundry facility teams was crucial to successful remediation.”

When the problem first surfaced, IPs began conducting Replicate Organism Detection and Counting (RODAC) cultures of linens when they arrived at the hospital. When they inspected the laundry service, they found a significant number of Mucorales cultures despite the fact that the processes and layout of the laundry facility met industry standards.

“Prior to remediation, 20% of HCLs were culture-positive for Mucorales upon hospital arrival,” the study states. “Laundry facility layout and processes were consistent with industry standards. Significant step-ups in Mucorales and mould culture-positivity of HCLs were detected at the post-dryer step (0% to 12% (p=0.04) and 5% to 29% (p=0.01), respectively). Further increases to 17% and 40% culture-positivity, respectively, were noted during pre-transport holding.”

) has reported, IPs need to become more cognizant of the crucial role ventilation plays in infection prevention and control at 

 and other health care facilities such as 

It could be argued that ventilation plays a crucial role in infection prevention in every building, including laundry facilities, as investigators found out. “Site inspection revealed heavy Mucorales-positive lint accumulation in rooftop air intake and exhaust vents that cooled driers; intake and exhaust vents that were facing each other; rooftop and plant-wide lint accumulation, including in the pre-transport clean room; uncovered carts with freshly-laundered HCLs,” the study states. “Following environmental remediation, quality assurance measures and education directed toward these sources, Mucorales culture-positivity of newly-delivered HCLs was reduced to 0.3% (p=0.0001); area of lint-contaminated rooftop decreased from 918 m 2 to 0 m 2 on satellite images.”

The study also highlights another point made repeatedly by experts who’ve spoken to 

“Remediation was designed and implemented by infection prevention and facility leadership teams,” the study states.

Despite the fact that the processes and layout of the laundry facility met industry standards, infection prevention teams found a significant number of mucormycosis-causing cultures.

Infection Preventionist Team Kills Cause of Laundry Contamination

In fall 2016, I was on my way to work at 8 AM on a Monday when my cell phone rang. It was the surgical department of a 350-bed acute care hospital in Texas where I served as an infection prevention (IP) consultant. They wanted to report that some instruments were used on a patient over the weekend even though the biological indicator failed.

To be of help in an operating room (OR) an IP must grasp 4 key concepts about biological indicators: what a biological indicator is (an indicator that goes into each pack of surgical instruments to determine that each instrument gets sterilized), where it is placed in the instrument pack (in the middle), how it is documented (in a freestanding notebook in the OR), and what to do with a patient who had surgery with potentially nonsterile instruments (notify the infection control department).

Luckily, I knew all these things because I have the experience of being a consultant and working for many hospitals. I reviewed the case, then set up a protocol to monitor the patient for possible infection.

Although that was resolved quickly, what happens if the scenario is more complicated, as it was for me in summer 2019? At 5 pm on a Friday, I received a call moments after I turned off my computer eager to start the weekend.

The surgery department of a 250-bed acute care hospital in Washington needed my help because they had experienced problems during the week with wet packs (packages or containers that hold surgical instruments that become moist after sterilization is completed). They were frustrated because they couldn’t figure out why.

I was told they had already reviewed all documentation showing that staff members followed policies and procedures. Because there was a record of staff who had signed off indicating that the sterilizer trap was cleaned twice a day, they didn’t suspect that was the problem. Meanwhile, they called the sterilizer company to come troubleshoot the issue. However, the staff wondered if there was something else they should do.

I thought about factors that could lead to wet packs and asked:

“Has the trap of the sterilizer been cleaned?” Their response: “Yes. We have staff documenting that it is cleaned and checked every morning.”

“Were the packs overloaded?” Their response: “No.”

“Is there a problem with the function of the sterilizer?” Their response: “The vendor is coming to check this.”

“Is there a problem with how packs are stored post sterilization?” Their response: “We don’t think so.”

I decided to go to the OR to verify and validate everything I had been told. I reviewed the department’s practices to see if I could determine the problem and work with the department to develop an action plan. I did a quick walk-through of the area to look for anything that might be causing the problem but found nothing. So I decided to look at the documentation for each sterilizer, paying close attention to the sterilizer for which the problem packs were processed.

The staff had documented that all Bowie-Dick, biological, and chemical indicators had passed inspection.

Many infection preventionists trust that everyone working in the operating room knows what they are doing and many times shy away from going into the OR. That's a mistake.

Infection Control Today, September 2021 (Vol. 25 No. 7)

Antimicrobial Resistance Is Futile Without IPs’ Help

Can We Ever Get Rid of C. Diff?

COVID-19 Gave Birth to Changes in Neonatal Intensive Care Units

Approaches to Curing Racial, Ethnic Inequality in Health Care

Infection Preventionist Team Kills Cause of Laundry Contamination

This Way to the OR, Infection Preventionists