Creating vaccines for coronavirus disease 2019 (COVID-19) and getting them approved by the US Food and Drug Administration (FDA) proved to be an arduous task fraught with scientific and logistical hurdles. Now comes the hard part: Getting those vaccines widely distributed to the right people. Where do infection preventionists (IPs) fit into this part of the pandemic response?

There are 2 overarching levels of vaccine implementation: regional public health mass vaccination planning and local, targeted efforts for specific populations. In both areas, IPs need to be involved in planning and implementation. IPs have both education and training in public health and outbreak response as part of their core concepts to become an IP. Also, many IPs work closely with local, regional, and state public health partners on a regular basis, so the relationships are already built.

The first wave of vaccination is focused on large-scale public health-driven efforts. These are being implemented at the state level for distribution to focus on healthcare workers and residents of long- term care facilities. These efforts clearly must be multi-disciplinary in order to have effective planning and viewpoints that can bring creativity to solve the problem of how to effectively distribute millions of doses of a vaccine that require very specific handling and storage parameters.

For example, the Pfizer-BioNTech vaccine requires ultra-cold storage and will be allocated in large dosage counts, requiring vaccination of large groups over a short time period. The teams need to include providers, pharmacists, public health, healthcare facility leadership, emergency management, and other local leaders. It is likely that members of these groups have not worked closely together before on such a large-scale task. It will be crucial to function with a hospital incident command system to keep the group moving forward with the same objectives and bring obstacles to the forefront quickly for rapid problem solving.

IPs have been working scenarios of mass vaccination for years, in preparation for pandemic flu primarily, but also with potential biological threats (anthrax, smallpox) and other outbreaks such as measles and pertussis. These skills and insights make IPs and their public health colleagues subject matter experts on the nuances of mass vaccination. For example, some hospital systems would take the opportunity to turn annual employee flu vaccination into a drill and treat it as if it were a mass vaccination event in collaboration with emergency management colleagues. These events would teach valuable lessons in the best way to reach all staff, including having multiple vaccination administration locations and the best way to handle the data collection necessary to track large scale vaccination efforts.

Infection prevention needs to be a partner in the large-scale planning that is occurring currently in most states and local healthcare facilities. These efforts are largely being led by public health on state or regional levels, but the local hospitals will also need to plan when vaccine is distributed in future tiers for local administration. Not only to help with logistics of vaccine storage, administration, documentation, and data collection and reporting, but also to focus on safety of the workers and vaccine recipients of the vaccine clinics. Staff use of personal protective equipment (PPE), workflow to ensure social distancing and decrease crowding, and cleaning and disinfection practices of the clinic site are all logistical concerns that should be addressed in the planning stage to avoid potential exposures or contamination concerns.

Another area for concern is the cold storage and transport of the vaccine. Specialized freezers and transport companies that can safely move vaccine shipments from distribution sites to clinics are necessary to maintain that cold chain delivery system. Specialized transport companies that have experience in this type of system will be in high demand and IPs can help evaluate the processes of these third-party vendors to ensure they will be able to accommodate the level of transport needed and maintain the storage parameters of the vaccines.

Data collection for the large-scale clinics will likely be mediated through health departments, but the details of tracking, knowing which employees did receive the vaccine, and communicating that to the local healthcare facilities will need to be addressed. Each state will likely have to determine the best way to communicate vaccine administration, but it will also be the responsibility of each employee to report their vaccination status back to the healthcare facility.

Hospital vaccine programs are historically a collaborative effort between infection prevention and employee health programs. As COVID-19 vaccine efforts continue, there will need to be consideration of how that will be managed within the context of the current hospital-based vaccination programs. How will a COVID-19 vaccine be handled at each facility? Will it be mandatory? Will it be given annually? Will it be a condition of employment? These are all questions that will need to be addressed. There are some unknowns at this point, including the need for annual boosters, required storage needs, and data reporting.

Infection prevention is also a key partner with employee health programs to promote vaccine uptake and educate on the mechanism of how the vaccine works and potential side effects. As these new vaccines are approved for distribution, it will be key for IPs to learn about the studies completed to date to have an understanding of these key points to help with staff education. Reviewing the articles published during the trials, as well as the recommendations from the federal programs will help IPs become knowledgeable about the vaccines. Also, key information that IPs will likely need to address will be side effects, efficacy, and recommendations of priority risk groups (such as healthcare workers, elderly, essential workers, etc). IPs can help address these questions through rounding and education opportunities, published newsletters and new employee orientation.

Planning for the logistics of how vaccine will be distributed locally will take much effort. Some items to consider are the timing of when staff will receive their dose and when they work their next shift. As virtually all healthcare facilities are screening for COVID-19 symptoms, the reactions to a vaccine may potentially meet some of those criteria, such as low-grade fever or malaise. It will be important to plan for this as an organization, to consider that with screening or plan for staff to have 24-48 hours after their dose before their next shift. The calculations will also need to include the fact that the vaccines are given in 2 doses.

Planning for this process should already be starting. As many healthcare facilities are operating under the hospital incident command system, the vaccine administration can be brought under that structure and would already have all the key departments at the table to help coordinate.

Data reporting for COVID-19 vaccination will likely be extensive. Many employee health programs may not have the reporting capabilities to handle the level of data collection and tracking that will be necessary for this initial wave of vaccination. Often employee health programs do not have electronic systems that integrate with other reporting programs or link to state health departments, therefore much of the work will be manual. Infection prevention needs to advocate for improved data systems for employee health tracking, which will not only be beneficial in the COVID-19 vaccine process but, going forward, for all other employee health activities.

One thing that IPs must remember: Vaccination is not the end of this pandemic. Most likely, the vaccination rate needed to provide sufficient population immunity to control spread is around 80%.1 It will take years to achieve that level of vaccination, if at all. So, the vigilance of basic infection control measures will need to be maintained in some fashion until such a point. This is part of the IP toolkit.

Having worked with vaccine preventable diseases for decades, IPs understand that vaccination is not the only way to prevent disease transmission.

Behavior modification, engineering controls, such as modifying traffic patterns and increasing ventilation air exchanges, and other active processes are key to a multi-focal prevention plan. Universal masking will continue in healthcare facilities and hopefully on a community level for some time, until population immunity is of a sufficient level or community spread is low to minimal.

REBECCA LEACH, RN, BSN, MPH, CIC, has been an infection preventionist since 2010, with a background in nursing and epidemiology. Leach, a member of Infection Control Today®’s Editorial Advisory Board, currently works at a healthcare system in Phoenix, Arizona, that includes 5 hospitals and more than 100 outpatient treatment centers.

1. Bartsch SM, MPH, O’Shea KJ, Ferguson MC, et al. Vaccine efficacy needed for a COVID-19 coronavirus vaccine to prevent or stop an epidemic as the sole intervention. Am J Prev Med. 2020;59(4): 493–503. doi: https://doi.org/10.1016/j.ajic.2020.10.018

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How will the COVID vaccine be handled at each facility?  Wil it be mandatory? Will it be given annually? Will it be a condition of employment? These are all questions that will need to be addressed.

Infection Preventionists to Play Crucial Role in Vaccine Efforts

In the United States, roughly 1.7 million healthcare-acquired infections (HAIs) occur annually in hospitals, resulting in total costs (direct, indirect, non-medical) estimated at up to $147 billion. Nearly 100,000 people die annually from HAIs in the acute care setting. Distressingly, when nursing homes are included, the number of annual deaths linked to HAIs soars to over 400,000. We appropriately employ tremendous effort to continually improve hand hygiene practices in hospitals, as hand hygiene is demonstrably the single most important practice to prevent and control HAIs—and, importantly, the effort has demonstrated a favorable impact. We also routinely use barriers to protect ourselves and our patients from infection—gloves for the hands, goggles for the eyes, gowns for the body, and covers for our shoes. In light of the persistent and stark reality of HAIs, however, opportunities to improve outcomes clearly exist, compelling us to address other fomites in the clinical setting.

The stethoscope, the most frequently used medical instrument with over 5.5 billion annual auscultations in the US alone, is commonly referred to as the “clinician’s third hand.” It is a ubiquitous, valuable clinical tool and an enduring symbol of the trust between healthcare providers and patients. Stethoscopes are a foundational tool in acute and clinic patient care settings. In addition to routine physical exams, various medical conditions demand thorough auscultation of the chest and abdomen for a comprehensive evaluation. Unfortunately, the stethoscope, carrying the same exact volume and diversity of pathogens as the clinician’s fingertips, is also a proven vector of disease transmission

It has become clear from the literature that the US Centers for Disease Control and Prevention (CDC) stethoscope cleaning guidelines are impractical and incompatible with the intensity of stethoscope use in the high-paced workflow characteristic of clinical settings. Recent observational studies reveal that stethoscopes are seldom cleaned between patients and, even when cleaning does occur, less than 4% of stethoscope diaphragms meet CDC cleanliness requirements

. Moreover, even in instances where cleaning techniques such as alcohol swabs are employed in accordance with the guidelines (60 seconds of continuous wiping), resistant and dangerous pathogens, such as c. difficile spores, frequently persist.

The CDC classifies the stethoscope as a non-critical surface, a characterization that does not reflect the severity of the transmission risk associated with its use. Additionally, the CDC states that weekly cleaning with alcohol is acceptable, unless the stethoscope diaphragm is visibly soiled. In light of the existing, and increasing, body of evidence demonstrating that stethoscope diaphragms are contaminated with the same pathogens as the hands and data showing that stethoscopes are capable of transmitting pathogens from patient to patient, the CDC should readdress its published guidelines on proper hygiene practices.

Disposable, “single-patient” stethoscope options, although increasingly popular in light of the COVID-19 pandemic, offer significantly compromised auscultation accuracy. An abstract presented at the American College of Emergency Physicians 2020 Annual Meeting showed that, in a study of >200 auscultations, nearly 11% of cardiac pathologies were misdiagnosed by clinicians using disposable stethoscopes

. Disposable stethoscopes also fail to address the fundamental risk of clinician-to-clinician infections from rotating use of a likely contaminated device

Alternative options for stethoscope hygiene have been limited. Individual patient stethoscope disk covers have been marketed but were not effective solutions because they required manually placing a clean disk cover on a contaminated stethoscope by hand, thereby contaminating the clinician’s clean hands. If clinicians, instead, placed the clean disk cover on the stethoscope before washing their hands, then the disk cover itself would become contaminated. Additionally, in both cases, the time required for this highly manual process proved to be incompatible with clinical workflow.

Although numerous interventions, educational programs, and attempts at improving stethoscope hygiene rates have been implemented over the years, none have proven successful. Each attempt to improve stethoscope hygiene has proven to be ineffectual, inconsistent, and almost never practiced. The roots of poor stethoscope hygiene practices are truly multifactorial in nature.

 identified 6 factors behind poor stethoscope hygiene compliance across clinical settings

Effective, compliance-enhancing techniques are exemplified by routine, simple methods implemented in standard workflows. Best practices are those that are easily applied by multiple staff without workarounds.

Technologies to help eliminate human error are the most effective and ensure that providers do the right thing, each and every time. Hand sanitizer and gloves immediately visible at the entrance of patient rooms, for example, enhance their routine use. A solution designed to provide effective stethoscope hygiene between each patient examination must consider and address obstacles to compliance in the clinical setting. A system should be compact, allowing it to be installed in each hand hygiene station or patient room, and capable of holding a significant number of single use disk cover barriers before replacement is necessary. The system should be capable of displaying visual reminders of the benefit of effective hygiene to encourage compliance by clinical staff.

The aseptic single use disk covers that the system dispenses must be proven to prevent patient exposure to pathogens while not damaging the stethoscope diaphragm and not interfering with the acoustic quality of the auscultation. It must be easy to use—preferably with no formal training required—instantly and reliably applying disk covers to the diaphragms of professional stethoscopes on demand and fit into the regular workflow for healthcare providers. Lastly, such a system must be completely touch-free, ensuring the aseptic status of the disk cover for each patient examination. As patients are alarmingly and continually exposed to unclean stethoscopes, we now know that stethoscope transmission of pathogens from patient to patient can undermine the efforts of hand hygiene programs. Infection control professionals can partner with other clinical leaders (physicians, nurses) to educate and advocate for better stethoscope and hand washing hygienic practices. Effectively promoting “third hand” hygiene best practices could reduce infection rates. In turn, Infection control professionals can decrease healthcare costs (including reducing antibiotic use and complications) while improving the patient experience—the three cornerstones of the Institute for Healthcare Improvement’s “triple aim.”

ALPESH AMIN, MD, MBA, MACP, SFHM, FACC, FRCP (LOND), is a Professor of Medicine, Public Health, Nursing Science, and Biomedical Engineering and Executive Director of the Hospitalist Program at the University of California, Irvine. Dr. Amin also serves as a scientific advisor for AseptiScope (www.aseptiscope.com).

Longtin Y, Schneider A, Tschopp C, Renzi G, Gayet-Ageron A, Schrenzel J, et al. Contamination of stethoscopes and physicians’ hands after a physical examination. 

Boulée D, Kalra S, Haddock A, Johnson TD, Peacock WF. Contemporary stethoscope cleaning practices: What we haven't learned in 150 years. 

. 2019 Mar;47(3):238-242. doi: 10.1016/j.ajic.2018.08.005. Epub 2018 Nov 2.

Mehmood et al.Comparing the auscultatory accuracy of health care professionals using three different brands of stethoscopes on a simulator. 

Whittington, A.M., G. Whitlow, G, Hewson, Thomas C, and Brett, S.J. Bacterial contamination of stethoscopes on the intensive care unitAnaesthesia, 2009, 64, pages 620–624

J. Muniz et al. Predictors of stethoscope disinfection among pediatric health care providers.American J Infect Control. (2012) 

Stethoscope diaphragms are contaminated with the same pathogens as the hands and they are capable of transmitting pathogens from patient to patient. The CDC should readdress its published guidelines.

Keeping the Stethoscope, the Clinician’s Third Hand, Clean

The coronavirus disease 2019 (COVID-19) pandemic has taught several painful lessons. With the United States experiencing more than 200,000 cases a day, a new high of 4000 deaths a day, and the initial vaccine deployments underway, this is a pivotal time.

 As we move into the next phase of COVID-19, not only in terms of the current surge, but also in this period of vaccination for healthcare workers and essential workers, there is still a critical need for infection prevention measures against COVID-19.

Early on in the pandemic, we in healthcare were trying to piece together the right guidance to try to protect against the novel coronavirus, much of which was sure to change—from masking to the role of environmental transmission. One of the biggest mistakes we made in communicating during the pandemic was not preparing the public for the fact that guidance would likely evolve with the science. One of the largest pieces to that is that risk reduction is additive. In essence, infection prevention and control isn’t just one measure, such as personal protective equipment (PPE), but many practices and strategies taken all together. Each layer is imperfect but plays a critical role in reducing risk.

For years in harm reduction this has been called the Swiss Cheese approach but, more recently, it has been updated and harnessed. Virologist Ian Mackay, PhD, recently updated this model to address the need for defense against respiratory pathogens, such as SARS-CoV-2, the virus that causes COVID-19.

 In one succinct image, this captures what we do in infection prevention—stress the additive layers that are needed to reduce the spread of infection. From masking to government messaging and vaccines, these layers all work cohesively to reduce the risk of not only COVID-19 infection, but also transmission. Really, this is a concept we have been reinforcing and growing in the field of infection prevention—a wholistic approach to disease prevention.

Although this layered, wholistic approach to infection prevention is not new, Mackay’s visualization of this for COVID-19 has been a welcome educational tool. The layers are broken into personal and shared responsibilities. When we apply these layers to infection prevention, there are several more revealing lessons to be learned.

For personal responsibilities, these include physical distancing and staying home if sick, masks, hand hygiene, cough etiquette, avoiding touching one’s face, and limiting time in a crowded space. For those shared responsibilities, fast and sensitive testing/tracing, ventilation/outdoors/air filtration, government messaging and financial support, quarantine and isolation, and vaccines. Many of these layers though are more telling of systemic issues within not only infection prevention, but also within healthcare.

If we break these down, there are so many critical pieces that we’ve struggled with in infection prevention and control. As roughly 1 in 5 people with COVID-19 are asymptomatic, the staying home when sick can be particularly challenging, but even more so in healthcare when we have a notoriously bad habit of working while sick.

 This also becomes increasingly important as healthcare workers can continue working, with PPE, after exposures, and with the somewhat non-specific symptoms of COVID-19, it’s easy to see how this can happen.

For infection prevention though, how can we emphasize this during our education and training of staff? The truth is that COVID-19 has emphasized the importance of workplaces allowing their employees to not only call out when sick but encouraging it. This ultimately goes back to a cultural shift that is so desperately needed in healthcare. There is a desperate need for administrative buy-in not only for infection prevention measures like cleaning and disinfection, but also for encouraging people to stay home when sick.

If we look to another layer, like crowding, this is particularly relevant in crowded emergency rooms and double-occupied patient rooms. Challenges in ensuring faster response to emergency rooms and urgent cares would require additional staffing, which is particularly hard in an industry with high turnover and an exhausted workforce. For patient rooms, we have long been moving away from double occupancy, but with COVID-19, many are forced to move to this strategy in order to handle surge capacity.

As this is an increasingly uncommon practice, this can be a wonderful teaching moment for staff. When and how can we safely put 2 patients in the same care space? Focusing on the same infections and discussing when we wouldn’t put 2 patients together goes back to the core of what infection prevention is about: education and patient safety. When we invest the time in training staff about various infections and how things like putting 2 cystic fibrosis patients together can be devastating, they have a stronger foundation of what infectious diseases are and their transmission dynamics.

Ultimately, it’s these lessons that help strengthen infection prevention in the most wholistic manner possible. This also applies to crowded spaces indoors, like breakrooms and charting rooms where people might be eating and drinking. Even if distanced, we know there is still a risk for those in such spaces for a period of time without masks. Hospital breakrooms have become a source of COVID-19 transmission and this is a prime example of how the Swiss Cheese model works. Even if we’re distanced, the indoor environment and time likely spent unmasked around others all adds up.4 Distancing helps, but it is only one piece to this puzzle, whereas masking and consideration for those indoor spaces must also be included.

Layers like quarantine and isolation are also so important to our efforts in infection prevention. Although we most commonly focus on isolation precautions within the healthcare setting, we increasingly are having to teach those exposed to COVID-19 about quarantine. What is the best way to do this for families or when patients are discharged but still require isolation? These are the lessons that clinical staff will need in science communication and the tips/tricks we’ve learned over the years in infection prevention. This is an important layer, meaning it’s that much more valuable to invest the time in helping to train staff about making those calls or teaching patients about home isolation. It’s important we give patients and their families the best chance for success when they leave the healthcare setting.

Surely, we could spend time breaking down each layer of this model and how it plays into infection prevention inside and outside the healthcare setting. One particular question, however, is: Should there be more pieces of cheese? A few things could be added—for example, cleaning/disinfection is an important piece to prevention efforts for many infectious diseases. Although surfaces are not the primary route of transmission, cleaning and disinfection is still an important message in COVID-19 prevention. Second, mental health support that encourages people to stay home and healthcare workers to continue in their critical tasks. Harm and risk reduction require us to use careful language to not add shame or blame to actions and part of this is when we support people to stay home and not shame them for making a decision out of a need for social interaction. Let’s provide safer, more abundant options for this need that we can all appreciate right now.

The Swiss Cheese model is a wonderful representation of all that goes into infection prevention efforts. It’s not just isolation and PPE, but also the government messaging and financial support for those people to stay home. These are lessons that not only stem from our infection prevention efforts, but also directly translate to actions we should take to grow and expand our efforts, things like government messaging can also be read as administrative messaging. How supportive of your program is the hospital administrative team? How quickly are results shared from the lab to the unit? Are healthcare workers and ancillary staff encouraged to stay home when sick? These are the pieces to infection prevention that are critical for not only patient safety, but also staff safety and they require a wholistic, layered approach to risk reduction.

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.

COVID-19 Tracking Project. Accessed December 11, 2020. 

Siobhan R. The Swiss Cheese Model of Pandemic Defense. 

https://www.nytimes.com/2020/12/05/health/coronavirus-swiss-cheese-infection-mackay.html

Jared K. Healthcare workers often work despite illness. 

https://www.contagionlive.com/view/health-care-workers-often-work-despite-illness

Carolyn C. Hundreds of Mayo Clinic staff test positive. WebMD. November 19, 2020 

https://www.webmd.com/lung/news/20201119/hundreds-of-mayo-clinic-staff-test-positive

In essence, infection prevention and control isn’t just one measure, like personal protective equipment (PPE), but all of these layers. Each layer is imperfect but plays a critical role in reducing risk.

Swiss Cheese Model—How Infection Prevention Really Works

When many hear the words “frontline healthcare worker,” roles of physicians, nurses, or other healthcare professions are usually what come to mind first. Many ancillary roles within healthcare also hold essential positions, and one such area that is often overlooked by both the public and by staff is that of the environmental services (EVS) team. The EVS department is an indispensable team that is often left unnoticed when things are going well. However, if patterns of hospital-acquired infections (HAIs) emerge, the role of the environment is an area that is quickly emphasized to review.

The arrival of coronavirus disease 2019 (COVID-19) has brought a focus on how the environment plays a part in the potential transmission of infections. Although just how much contact surfaces contribute to the transmission of SARS-CoV-2, the virus that causes COVID-19, is unknown, routine disinfection is still one prevention strategy that is important to stop the spread of COVID-19.

As the hospital room and its surroundings are so critical to the wellbeing of patients and staff and the prevention of the transmission of infections, it is vital that infection preventionists (IPs) work closely with the EVS department to ensure that both teams are on the same page with best practices.

The partnership between IP and EVS is multifaceted. Many hospitals have moved away from hiring their own EVS employees and instead contract out to larger EVS companies. When this is done, the contracting company usually puts together a cleaning and disinfection plan for the hospital based off of a standard for their company. Although there are many positives to this process, as many of the methods used have been tried and improved at other facilities, it is still important for IPs to be involved in ensuring the standards that the EVS team is using are appropriate for the facility.

If the EVS department is not contracted, the IP relationship may have to be closer to help to provide recommendations and options for common disinfection processes. Regardless of whether your EVS department is contracted, the following items are important for every IP department to be aware of as it relates to a facility’s EVS program.

There is a large variety of disinfectants that are available in the hospital setting and the disinfectant wipes that may be routinely found on the units are often not the same disinfectants that the EVS team will use for daily and terminal cleaning of rooms and areas throughout a facility. The IP department should be aware of the disinfectants the EVS department uses for different surfaces as well as the contact wet time for each chemical. The EVS department should always have a bleach or sporicidal disinfectant at minimum to ensure disinfection against organisms such as Clostridioides difficile and Candida auris. Oftentimes at least 2 main disinfection chemicals will be used so as not to degrade equipment if using only bleach.

IPs spend a large amount of time educating healthcare providers on how important the prevention of the transmission of infections is in the healthcare environment and encouraging everyone to follow best practices and be comfortable in the work that they are performing. When providing this education, it is also essential to also target EVS staff and to do so on a routine basis. Explaining the different isolation signs and the personal protective equipment (PPE) that is associated with each isolation is critical to ensuring that the EVS team not only ensures its safety, but also minimizes the risk of transmitting infections to another room as further rooms are cleaned each day.

When educating EVS staff, IP staff should be cognizant of the methods used. As EVS practices are manual, providing more visual education through in-services is often more helpful to staff than providing handouts or writing emails. Additionally, when providing education on PPE donning and doffing, it is helpful to provide practice sessions so that staff feel comfortable with wearing PPE. Stressing the role PPE plays to EVS staff is important to help alleviate any fears in entering patient rooms as well.

When disinfecting a room, one should work from the area that is most to least dirty. Many contracted EVS companies have their own standard approach to room disinfection so that each employee follows the same order when disinfecting a room to limit variation and also allow staff to remember the process. IPs should review this process as well and offer feedback on any opportunities for improvement they may notice.

Apart from daily room disinfection, it is important that a system is in place for EVS teams to be aware of patient discharges so that terminal cleaning of rooms can be completed as soon as possible. In doing so, a system should be in place for notification upon discharge to EVS, and also so that the EVS team is aware if the room being disinfected is an isolation room. Depending on whether or not the room housed a patient who was on isolation, PPE may need to be worn during the disinfection process. Some ways to ensure this transparency is to allow the EVS team to connect with a hospital electronic medical record system so that they can view whether or not a patient was on isolation or, if isolation signs are used throughout the facility, to keep the sign on the door after a patient has been discharged so that the EVS team is aware of the isolation when it arrives to perform a terminal disinfection.

As the importance of the role the environment plays in the prevention of hospital-acquired infections has continued to stay relevant, additional disinfection methods to pair with manual terminal cleaning have been explored. Two such common methods to reduce surface contamination after manual cleaning are ultraviolet (UV) light devices and hydrogen peroxide systems. Multiple studies have demonstrated the benefits regarding using one of these methods in addition to already established disinfection practices. These methods will not remove soil from items but can disinfect and inactivate organisms that may still reside on surfaces. Although these devices can be beneficial, they do come at a large cost. When providing a business case to your facility on the utility of using an additional device, a plan must be developed for how to staff the machine to get the most use out of it. If one of these machines lays idle, it brings into question the utility of its purchase, and so it’s helpful to provide this information as a part of the business case for its purchase. Validating the compliance of following the disinfection expectations is a way to provide education to the EVS team of potential opportunities for improvement. IPs can work with EVS leadership to implement a routine practice for quality assurance checks that EVS leadership can follow. These metrics can then be reviewed as an aggregate with the IP department to target whether further education may be beneficial. Two such ways to perform a review of disinfection practices are through blacklight inspections and Adenosine triphosphate (ATP) monitors.

Blacklight inspections are the process of an individual marking different surfaces with a fluorescent gel or powder prior to disinfection of a room. After the room has been disinfected, the marked areas can be checked using a blacklight. If the area that was marked was disinfected properly, the fluorescence will no longer be present. If, however, the area was missed, the area will light up.

ATP monitors work by using bioluminescence to detect residual bioburden on swabbed surfaces. ATP devices can be found through a variety of healthcare vendors and give off a number to identify the amount of bioburden on a surface in relative light units. EVS teams can use this method to swab high-touch surfaces such as bedrails, doorknobs, call lights, and tray tables, to identify whether or not bioburden had been removed from these surfaces. Higher numbers through these swabs can signify the need for re-education and feedback to staff.

As we learn more about COVID-19 and its role in the environment, keeping your EVS team informed is critical to maintaining their trust in IP and in the work that they do. COVID-19 has not limited the work that the EVS team does but rather has increased its workload and so it is vital to always make sure the team is aware of the positive impact it has each and every day.

ANJALI BISHT, MPH, CIC, is the lead infection preventionist at an academic medical center that comprises a number of hospitals and an extensive primary care network in the Los Angeles region.

Infection preventionists can work with environmental services (EVS) leadership to implement a routine practice for quality assurance checks that EVS leadership can follow. These metrics can then be reviewed as an aggregate with the IP department to target whether further education may be beneficial.

How to Train Environmental Services Teams

During the first surge of the coronavirus disease 2019 (COVID-19) pandemic in March 2020, infection preventionists (IPs) had to figure out how to use/reuse single use personal protective equipment (PPE) and train staff to do the same. IPs had to change their message from “please don’t reuse that” to “please don’t discard that just yet.” This was not normal, and everyone knew it. The sheer volume of patients infected with COVID-19 drastically changed everything healthcare personnel (HCP), especially IPs, knew about PPE used to protect their health and safety while caring for patients.

In response to these nationwide PPE shortages, the US Centers for Disease Control and Prevention (CDC) developed an entire section on its website dedicated to strategies for optimizing PPE supplies titled “Optimizing Supply of PPE and Other Equipment During Shortages.”

 It describes how patient surge, defined as “the ability to manage a sudden increase in patient volume that would severely challenge or exceed the present capacity of a facility” can be used to help monitor PPE use for facilities experiencing shortages. There is a quick reference chart that summarizes the CDC’s strategies to optimize all PPE, providing detailed strategies for N95 respirators, facemasks, gowns, and gloves. It also includes links to the CDC’s full guidance documents on optimizing supplies. It is a very detailed chart meant to be implemented sequentially, based on conventional, contingency, and crisis capacity, which is clearly spelled out. Every IP should have this readily available.

In addition to the quick reference summary chart, the CDC, in collaboration with the National Institute for Occupational Safety and Health (NIOSH), developed the Personal Protective Equipment (PPE) Burn Rate Calculator.

The calculator was designed to help estimate how many days a PPE supply will last given current inventory levels and PPE “burn rate” or consumption. Originally a spreadsheet-based model that helped healthcare facilities plan and optimize their use of PPE for response to COVID-19 in the initial surge, it is now also available as an app for both iOS and Android, called the “NIOSH PPE Tracker App.”

To use the calculator, you enter the number of full boxes of each type of PPE in stock (gowns, gloves, facemasks, surgical masks, respirators, and eye protection/face shields) and the total number of patients at your facility. The tool calculates the average burn rate for each type of PPE entered in the spreadsheet. This information can be used to help estimate how long the remaining supply of PPE will last, based on the average burn rate. Using the calculator can help facilities make order projections for future needs. This is a really handy app for anyone to have who orders supplies, especially supply chain and unit managers, as we again begin to experience PPE shortages.

Although IPs generally have limited involvement with supply chain, it might be worthwhile to find out more about supply chain and how it works so you can understand the process of bringing in products. This knowledge might help answer questions when you are rounding on your areas and questions about supplies that come up from HCP. Knowing who the person is who keeps your areas stocked with supplies is also a very valuable relationship to nurture.

And don’t forget what happened in the first surge of COVID-19-positive patients. To conserve PPE for use by HCP on the frontlines, the CDC provided guidance on methods to reduce PPE use for patients on transmission-based precautions such as contact precautions for multidrug-resistant organisms (MDROs)—specifically vancomycin-resistant Enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA).

 Typically, contact precautions is the single use of gown and gloves when caring for patients who are either colonized or infected with one or more MDRO. But during the first COVID-19 surge, a “bundled” approach for patient care, to not using some PPE at all, with an emphasis on glove use and hand hygiene, was recommended by the CDC for HCP caring for patients in isolation precautions other than COVID-19. Much about the previous use of PPE in many facilities was deferred until supplies were replenished or COVID-19 patient volumes decreased to manageable levels.

Historically, PPE has been used to “break the chain” of transmissible disease. But PPE alone cannot reduce organism transmissions. A comprehensive program that includes antimicrobial stewardship, hand hygiene, chlorhexidine bathing, a cleaning and disinfection program of the patient environment and equipment, and decolonization, where appropriate, should be considered as a “bundled approach” to preventing transmissions.

The initiation of isolation precautions should be considered by the infection control program based on local, state, regional, or national recommendations, and be of clinical and epidemiologic significance for that particular hospital or region.

Last, healthcare institutions should have a process in place to remove isolation precautions since the necessary duration of contact precautions for patients treated for infection with an MDRO, but who may continue to be colonized with the organism at one or more body sites, remains an unresolved issue.

According to the latest updated CDC guidelines “Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006,”

 contact precautions can be discontinued when 3 or more surveillance cultures for the target MDRO are repeatedly negative over the course of a week or 2 in a patient who has not received antimicrobial therapy for several weeks, especially if there is:

no evidence implicating the specific patient in ongoing transmission of the MDRO within the facility.

But being able to do this is a lot harder than it might seem. Issues with frequent admissions and transfers within and outside of facilities, and monitoring antibiotic use makes this especially difficult, so patients sometimes remain on contact precautions for MDROs like VRE and MRSA indefinitely, despite the best efforts by IPs.

Those facilities that have been performing some kind of surveillance on VRE and MRSA transmissions during COVID-19 should look at their data. The ability to compare transmission data for patients on contact precautions using the recommended full complement of PPE versus transmissions for patients on contact precautions when PPE was being utilized differently or not at all, would be very valuable information for a healthcare facility to have.

Now would be the time to determine the value of how PPE is used for contact precautions, with facility level data regarding patient transmissions—one of the main reasons for PPE use.

Your facility could reap the benefits of lower costs, higher patient and staff satisfaction, a greener future for our planet, and a method to always have enough PPE on hand. But remember to audit this process and track transmissions. As most IPs know, practices drift. So, stay on top of it! 

SHARON WARD-FORE, MS, MT(ASCP), CIC, is an infection prevention consultant located in Chicago. She is also a member of Infection Control Today®’s Editorial Advisory Board.

Centers for Disease Control and Prevention. Optimizing Supply of PPE and Other Equipment during Shortages. Centers for Disease Control and Prevention website. Updated July 2020. AccessedNovember 6, 2020. 

https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html

Centers for Disease Control and Prevention. Personal Protective Equipment (PPE) Burn Rate Calculator. Centers for Disease Control and Prevention website. Updated April 7, 2020. Accessed November 6, 2020. 

https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/burn-calculator.html

National Institute for Occupational Safety and Health. Personal Protective Equipment. NIOSH PPE Tracker App. National Institute for Occupational Safety and Health (NIOSH) website. Updated June 2020. Accessed November 6, 2020. 

https://www.cdc.gov/niosh/ppe/ppeapp.html

Centers for Disease Control and Prevention. Clinical Questions about COVID-19: Questions and Answers. Centers for Disease Control and Prevention website. Updated November 18, 2020. Accessed November 20, 2020. 

https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html#Infection-Control

Young K, Doernberg S, Snedecor RF, Mallin E. The things we do for no reason: Contact Precautions for MRSA and VRE. 

. 2019 March;14(3):178-180 | 10.12788/jhm.3126

Centers for Disease Control and Prevention. Management of Multi-Drug Resistant Organisms in Healthcare Settings – Duration of Contact Precautions. Updated February 15, 2017. https://www.cdc.gov/infectioncontrol/pdf/guidelines/mdro-guidelines.pdf

Centers for Disease Control and Prevention. Management of Multi-Drug Resistant Organisms in Healthcare Settings Updated February 15, 2017

https://www.cdc.gov/infectioncontrol/pdf/guidelines/mdro-guidelines.pdf

The Effect of Hospital Isolation Precautions on Patient Outcomes and Cost of Care: A Multi-Site, Retrospective, Propensity Score-Matched Cohort Study

. 2017 Mar; 32(3): 262–268. Published online 2016 Oct 17. doi: 10.1007/s11606-016-3862-4

Compare transmission data for patients on contact precautions using the recommended full complement of PPE versus transmissions for patients on contact precautions when PPE was being utilized differently or not at all.

Time to Update Personal Protective Equipment Protocols?

They called it a “natural experiment.” It wasn’t a randomized controlled clinical trial—there was no working hypothesis, no end points were set. The “intervention” group was the 24 counties that complied with Gov. Laura Kelly’s June 9 statewide mandate on mask wearing, effective July 3. The control group was the 81 counties that chose to opt out (as permitted by state law). The test site was Kansas, population 2.9 million—of whom some 1 million were not convinced of the need for masks.

On August 5, in a televised news conference, Lee Norman, MD, secretary of the Kansas Department of Health and Environment, showed a simple chart that basically described what had happened in Kansas between July 12 and August 3, plotting the difference in COVID-19 cases between counties requiring masks and those that didn’t. The chart would spark controversy—but also, perhaps, change.

Norman compared the number of cases per 100,000 people in each county in the 2 groups, on a 7-day average. An orange line on his chart showed a distinct and drastic drop in cases in the compliant counties, versus a blue line cutting a steady course through the noncompliant counties. “What we’ve seen through this,” Norman said, “is that [in] the counties with no mask mandate, there’s been no decrease in the number of cases per capita.” In fact, there was an increase. By mid-August, the seven-day rolling average incidence had dropped by 6%, to 16 cases per 100,000, in the mandated counties. By contrast, it had increased by 100%, to 12 per 100,000 in the non-mandated counties.

The mask mandate itself was extremely controversial in Kansas. So, it wasn’t surprising that the chart also inspired pushback. The information wasn’t inaccurate, but the way Norman presented it was, the critics charged. The lines for the 2 groups followed separate vertical axes, making the differences appear “more dramatic.” An analysis by 2 leading newspapers, the Kansas City Star and the Wichita Eagle, however, “broadly confirmed” Norman’s data.4 And a November 20 US Centers for Disease Control and Prevention (CDC) report further supported Norman’s July findings: During those first 2 weeks, “Kansas counties that had mask mandates in place appear[ed] to have mitigated the transmission of COVID-19.”3 This, despite the fact that the mandated counties started out with high case rates.

At least 13 of the 24 mandated counties also recommended or mandated other mitigation strategies, such as limits on the size of gatherings and restaurant occupancy, which may have had a “synergistic effect,” the CDC report says. But sensitivity analyses pointed to mask use as being critical.

For months, Kansas had kept the case numbers down. Kelly was the first governor in the country to close school buildings, for instance. But the advantage disappeared. Norman tweeted in July that Kansas was a “shining example of success, only to squander it.”5 “Sad,” he wrote. “Kansas is now as of today in the top 14 states for the MOST rapid COVID-19 spread and in the top 14 states for having the LEAST restrictions on activities. [Another analysis put it at a tie for 13th place.] Do you think those 2 things are related?”

Inevitably, the lines between the 2 groups blurred. Borders between counties are permeable, people mingle. One week into the statewide mandate, 1 in 4 Kansans was under no obligation to wear a mask.

Thus, hospitals have been flooded with patients from both “sides” of the issue. According to the Kansas Department of Health and Environment, between July 18 and November 25, the number of adults hospitalized with confirmed or suspected COVID-19 went from under 300 to nearing 1200.

 Statewide, about 37% of staffed ICU beds were available at the end of November. Hospitals in Topeka, Wichita, and Kansas City were holding patients in recovery rooms, emergency departments, and converted hallways while they waited for beds.

The counties with mandates account for about 2/3 of the state’s population and contain most of the urban areas. October was the deadliest month of the pandemic in the Kansas City metropolitan area, surpassing 50,000 total cases, with 176 deaths.8 And that was before the Thanksgiving holiday.

A map of Kansas shows a few lonely islands of mask wearing in a sea of noncompliance. Winfield, in Cowley County, is one. William Newton Hospital, Winfield’s main hospital, has a catchment area of about 5 counties. The number of cases in Cowley County has increased significantly over recent weeks, with at last count 1579 cases (Winfield, the county seat, has a population of just over 12,000). That’s actually at the low end. In neighboring noncompliant Sedgwick County, which has another mask-wearing island in Wichita, for instance, cases topped 27,000 at last count, with 150 deaths.

The hospital is as prepared as possible. Melanie Burnett Wilson, clinical educator and infection control coordinator, says, “We’re doing OK for [personal protective equipment (PPE)]. We look daily, we count daily, and we re-fit–test our staff for the multiple sizes of N95s that we’ve had to purchase. We do that because their safety is the number-one thing for us. Our CEO has been amazing with realizing the lengths we have to go to protect our staff. He doesn’t want the staff to take chances with their safety.”

Wilson has worked in infection prevention for 4 years, but says, “I guess you could say I’ve actually worked even longer than that—every nurse works in infection prevention and I’ve been a nurse for almost 18 years here at the hospital.” To meet the pandemic-related demands, she says, “I’ve held additional training on donning and doffing of PPE, handwashing, and safely transporting patients. Together with the environmental services manager, we’ve worked with the environmental services (EVS) staff to ensure that they’re well trained on the proper time to wait before going in to clean, and how to properly clean the COVID-19 rooms after dismissal or transfer.”

The coronavirus came late to the Midwest, especially to the rural areas that make up huge swaths of Kansas. In part because for months it seemed to be a “coast/city” problem, doubts about its seriousness have lingered. But long before the case count picked up speed, health professionals knew that wearing masks was one thing that could help slow it. And that made watching the soaring hospital admissions even more difficult. “I keep seeing the younger patients come in, and those being admitted to the units at my colleagues’ hospitals,” Wilson says, “and it makes me sad. Sad that more people won’t take it seriously, sad that it was made a joke of by so many on social media, and sad that such a simple gesture as putting on a mask to protect those around you is such a hardship. I see many of the healthcare providers so worn out from working themselves to the bone to take care of these patients now that it has hit the Midwest, and then we leave and we see people walking in and out of the stores with no mask. We want to stop and get something to eat on the way home from work, but do we dare, when the people inside the restaurant aren’t wearing masks? Not even those that are serving the food? Nope, we turn around and head home for a PB&J, safer and we know who made it and we can go to bed with a little peace of mind.”

The increasing pressure on hospital services is intensified by a winter that experts say will bring a double whammy of a third wave of COVID-19 cases as well as influenza before it’s all through. At William Newton, Wilson says, “We’re preparing for the addition of 2 more COVID-19 rooms on our med/surg floor by making the change to a negative pressure airflow.” But, she adds, “we have to keep the balance between COVID-19 preparation and keeping enough staff and medical care available for our normal cases of winter illness or falls or influenza.

“It will be tricky this year no doubt,” she says, in what may be an understatement.

As the COVID-19 cases have skyrocketed, Gov. Kelly has issued a new statewide mask mandate, which went into effect November 25.

 Like the previous one, the new mandate allows counties to tailor the rules, giving them flexibility, Kelly said in a news conference. Counties without a local order will come under the statewide restrictions, although state law still gives county commissioners the ability to opt out.

Maybe the escalating COVID-19 numbers have changed some minds—especially since that “natural experiment” provided visible irrefutable proof that masks could be effective. A number of counties recently decided to “opt back into” the original mandate, Kelly said, and “we’ve seen more that have created their own ordinances.” The mandate also picked up “a surprising amount of support” from the Republican-led state legislature, and a variety of groups around the state, including the Chamber of Commerce. “It’s encouraging, quite honestly,” Kelly said.

A public health campaign led by the Kansas Hospital Association, Kansas Chamber of Commerce, Kansas Farm Bureau, and others is urging Kansans to wear masks, get tested when necessary, and avoid mass gatherings. Kelly has also launched an “influence” campaign, in which community leaders, such as pastors, business owners, and coaches, will “use their influence to combat the virus.”

 Kansas is at a “make or break moment,” Kelly said.

But will it be enough to stem the tide? Time will tell. So far, the “experiment” is ongoing—and it’s ever more frustrating for overworked healthcare professionals.

Wilson says, “We look at one of the kids being wheeled in that can’t breathe because they went to a party a few days ago, they hadn’t been to one in months, ‘it was just for an hour,’ and today they just can’t stand that headache any longer, the sinus problem is a bit worse today, and they can’t seem to smell anything. They just wanted to check because they live with their 90-year-old grandma and she hasn’t been doing too well the last few days.”

Kansans are tired of hearing about the virus, tired of being told what to do, she says. But “we, as healthcare providers, are also tired of hearing about ‘it.’ Tired of wearing masks, tired of dry skin from washing our hands hundreds or thousands of times.” Emphatically, “We’re tired of all of ‘it.’”

In an article posted on the Kansas City Star’s website in November, Kansas House Minority Leader Tom Sawyer said, “whether we like it or not, the pandemic isn’t going away…. It’s a harsh reality to face, but we must face it.”

As the times change, some tunes change. Also, in November, Kansas House Majority Leader Dan Hawkins—who in August accused Norman of misleading the public about masks—said Kansas can turn the corner on the virus “if everyone takes personal responsibility, treats the virus seriously and respects one another.”

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

1. Shorman J, Hardy K. ‘People don’t want to be forced.’ How Kansas mask mandate became political tussle. The Wichita Eagle. July 08, 2020 04:49 PM, Updated July 09, 2020 06:52 AM. https://www.kansas.com/article244091222.html. Accessed 11/30/20.

2. Kansas’ ‘natural experiment’ shows masks work, state health official says. Wyandotte Daily. Aug. 5, 2020.
http://wyandottedaily.com/kansas-natural-experiment-shows-masks-work-state-health-official-says/. Accessed 11/30/20.

3. Van Dyke ME, Rogers TM, Pevzner E, Satterwhite CL, et al. Trends in county-level COVID-19 Incidence in counties with and without a mask mandate – Kansas, June 1 – August 23, 2020. MMWR Morb Mortal Wkly Rep 2020 Nov 27;69(47):1777-1781. doi: 10.15585/mmwr.mm6947e2. Accessed 11/30/20.

4. Shorman J, Hardy K. Kansas began requiring masks, then virus cases dropped. Weeks later, ‘the data is solid.’ The Wichita Eagle. Aug. 16, 2020 05:00 AM, updated Aug. 16, 2020 09:31 AM. https://www.kansas.com/news/politics-government/article244959870.html. Accessed 11/30/20.

5. Shorman J. Kansas Gov. Kelly issues new statewide mask mandate as COVID-19 infections soar. The Kansas City Star. Nov. 18, 2020 04:01 PM, updated Nov. 19, 2020 10:51 AM. https://www.kansascity.com/news/coronavirus/article247270469.html. Accessed 11/30/20.

6. Tidd J. Kansas has 13th-fewest restrictions and 13th-fastest coronavirus spread, studies find. The Wichita Eagle. July 07, 2020 09:01 PM, updated July 07, 2020 08:31 PM. https://www.kansas.com/news/coronavirus/article244071972.html. Accessed 11/30/20.

7. Kansas Department of Health and Environment. COVID-19 cases in Kansas. Hospital capacity: Adult hospitalizations. Chart. https://www.coronavirus.kdheks.gov/160/COVID-19-in-Kansas. Accessed 11/30/20.
https://www.kansascity.com/article246748236.html. Accessed 11/30/20.

8. Moore K. Kansas City’s deadliest month: October hits record 176 COVID-19 deaths. The Kansas City Star. Oct. 28, 2020 10:09 AM. Accessed 11/30/20.

9. The New York Times. Kansas COVID-19 Map and Case Count. Updated Nov. 29, 2020, 8:33 PM ET. https://www.nytimes.com/interactive/2020/us/kansas-coronavirus-cases.html. Accessed 11/30/20.

10. Associated Press. GOP Leader says Kansas health chief misled public on masks.
https://www.ksn.com/news/health/coronavirus/coronavirus-in-kansas/gop-leader-says-kansas-health-chief-misled-public-on-masks/. Aug. 11, 2020 08:01 AM CDT, updated Aug. 11, 2020 08:05 AM CDT. Accessed 11/30/20.



What’s the matter with Kansas? Well, for one thing, counties could choose whether to follow state health department guidelines on masking. COVID-19 case-count differences between counties that did and those that didn’t is striking.

Infection Control Today, January/February 2021 (Vol. 25 No. 1)

Infection Preventionists to Play Crucial Role in Vaccine Efforts

Keeping the Stethoscope, the Clinician’s Third Hand, Clean

Swiss Cheese Model—How Infection Prevention Really Works

How to Train Environmental Services Teams

Time to Update Personal Protective Equipment Protocols?

A Great Divide: Kansans Line Up on Opposite Sides of a Mask Mandate