In his role as director of clinical epidemiology and safety systems at Scripps Mercy Hospital, Frank Myers, III directs infection control and safety and disaster management efforts on Scripps’ San Diego and Chula Vista campuses. Prior to coming to Scripps in 1994, Myers served as the AIDS surveillance officer for the state of Delaware. He is an accomplished speaker, making presentations at dozens of professional conferences throughout the country, as well as a prolific author of articles for professional medical and trade publications. He holds a master of arts in political science from the University of Delaware and a bachelor of arts in political science from the University of Pittsburgh. Certified in infection control, Myers is a champion of infection prevention and has sat for numerous interviews on the topic of infectious diseases with members of the media. He is a member of a number of organizations including the California Department of Health Services’ Healthcare-Associated Infections Advisory Committee, the San Diego County Medical Society Group to Eradicate Resistant Microbes (GERM Commission), and many more. In 2005 he was awarded National APIC’s Outstanding Chapter Leader, and in 2004, served as president of the California APIC Coordinating Council. He serves on the editorial advisory board of Nursing magazine, and is a reviewer for the American Journal of Infection Control and Nursing 2008. He was a speaker at the 2008 ICT Conference on Professional Development and has written articles for ICT magazine.
The following is a Q&A with Frank Myers III.
ICT: What makes you a good role model and educator?
FM: I think good role models are approachable. With a good role model, you understand why they do the things they do. They also share what motivates them and their passion is obvious and infectious. And they are willing to spend the time with people who want to learn. I think I educate best when I first establish my credentials with a group and then begin to share my experiences and my understanding. Establishing your credentials is essential. If you start out sharing mistakes you have made and the audience has no idea who you are, you may end up lacking the credibility that they need in order to feel comfortable taking the knowledge you are offering. That establishment of credibility may be done before you start talking if they have known you for years or it may be a brief introduction. Larger audiences are challenging in this area since what people need in order to find a source credible varies greatly. Some people want to hear how many years you have done this, others how many publications you have, while others will focus on leadership or committee roles you have. I think we have all been in presentations where the speaker tries to hit all those points, sometimes it comes off very impressive and sometimes it comes off like a tour d’ego. When I talk with people, even in a large group, I try to speak with them as if I was in a chair sitting next to them. I let them know what mistakes I have made and what I learned from them.
ICT: What do you enjoy most and least about your work?
FM: What I love has changed over the years. I used to think if you put me in a room with my data I would be very happy. I have always loved teaching. Now I love new problems and developing a hypothesis on how to solve them and then seeing if it works. Eliminating those problems still brings me the greatest joy. What I like least? I love interviews when they ask people that question and the interviewee answers “negative people” and then gives a laundry list of negative comments about negative people and pessimistic assessments of negative people’s damage to organizations and how they can’t be changed and the interviewee never sees the irony in that. So you can guess my answer won’t be negative people. What I like least is doing something because “it is the law” and forcing others to do so. If I can show you the harm of a behavior you’ll change your behavior but if I say it’s the law what’s your motivation? Fear. Fear doesn’t improve anything and can be easily ignored given other priorities. Even more disheartening is when the law drags resources from something that is working to something else with little in the way of benefits.
ICT: You are famous for admonishing people to “not eat poop.” How effective is humor in educating about infection prevention?
FM: No one wants to be at a mandatory in-service. No one wants to go to a bad in-service. Everyone wants the speaker to be good. So for me, humor is essential in these settings. At my facilities I haven’t taught bloodborne pathogens in years, we moved it over to a computer-based module with questions answered at the time they occur. Yet I still get people walking up to me in the halls saying, “Man, I wish we still had to take your bloodborne pathogens class, I used to love that.” So when people show up wanting to hear you, they are very receptive to what you have to say.
I guess I should share the “don’t eat poop” story. I moved from AIDS epidemiology to hospital epidemiology about 15 years ago. I had been doing infection prevention for about a week and the phone rang, it was a very irate hospital employee. He had gotten shigellosis from a patient he had cared for. The employee was pretty smart, he explained how he knew this, the incubation period matched, the organisms were the same and the sensitivities of the organisms to antimicrobials were the same. He had really spent some time on it. And then he yelled into the phone, “If you had told me the patient had shigellosis I would have taken the appropriate precautions.” And for a second I was guilt ridden. We hadn’t told him. Then a bunch of gears clicked. I said. “I’m sorry, I am new in the job. I came from public health. There are a lot of things I didn’t know I had to do in this job. So this doesn’t happen again, and again I apologize, I didn’t think I had to say this, but obviously I do. Don’t eat poop.” I used it in my first infection control training. Everyone got it. Eating poop is just a lot funnier than “oral fecal transmission.” Was he really saying he would know to avoid oral fecal transmission with that patient but for other patients without shigellosis eating poop was acceptable? In a job like ours it also lets people know that you may throw around a lot of polysyllabic words, but you are approachable to anyone in the hospital. It also started a conversation about the basics of infection prevention. Nurses had home-made signs up when I got here, “Nuetropenic precautions, good handwashing.” I would get the nurse and ask, “Can you show me which of your patients we can use bad handwashing with?” It started everyone thinking, “What do I really mean and what am I saying is acceptable standard of care for my patients?” We weren’t laughing at the staff, we were laughing together at our mistakes and learning to not make them again. In that setting you need to make sure the audience knows about your mistakes and that they share a laugh at those too or you can come off arrogant.
ICT: What are the specific challenges and knowledge gaps you face when educating healthcare professionals about infection prevention and how do you address them?
FM: There is so much that frontline staff are expected to know today and we as professionals have so much information coming at us it is easy for us to assume that they know more than they do. I was recently doing a presentation to community physicians on drug-resistant urinary tract infections. The talk addressed a lot of complex factors as to what population was being impacted and how it was impacting outcomes and what factors were driving its emergence. I made a passing reference to MRSA, and one physician didn’t know what MRSA was. It made me just step back and say to myself, “You need to continuously assess what your audience knows.” I remember doing a lecture in 2005 in Florida about bioterrorism. I had been lecturing for six or seven years on bioterrorism, so I assumed that most nurses had been to at least one bioterrorism lecture by then. So I prepared my talk around that assumption. I started and as an afterthought, asked for how many participants was this their first bioterrorism lecture, and 95 percent of the audience members’ hands went up. I changed the talk on the fly.
So I would say the challenge isn’t our audience’s knowledge gaps but our assumptions of what their knowledge is. At our institutions we need a good assessment of our audience’s baseline knowledge. We shouldn’t be asking what our staff want in the way of education but we should be measuring their knowledge against things we feel they need to know and address their knowledge deficits.
ICT: What are the most neglected areas of infection prevention in today’s hospitals?
FM: Environmental services (EVS) have been the most neglected area. Infection Control and Hospital Epidemiology has had a series of studies that showed just how poorly we were cleaning rooms at time of terminal clean. To find that less than half of the high-touch surfaces in patient rooms did not get cleaned after discharge is appalling yet not surprising. Subsequent reports have shown this can be improved. If we really look at how we trained EVS, such results shouldn’t be surprising. We could never really tell them how well they cleaned a room; we could tell them how quickly they could turn a room around. And so what could be measured, room turnaround, became the tool by which environmental services was measured. But now using a luminescent to validate whether a surface was cleaned, we can provide EVS staff with data as to how well they are cleaning. We can also validate that EVS staff know how to clean. We have rolled out a training program for EVS. I was watching an EVS staff member clean, she wiped all the high-touch areas, and I thought she did a great job. But when we validated it with the light it was obvious she wasn’t using enough mechanical action to remove dirt. We never would have been able to detect that without the light. Can you imagine doing your job and never knowing if what you did was working? It is kind of like driving a car but never hearing if you hit something or seeing any damage from hitting something or feeling the gentle bump of hitting the curb. With no feedback, how can anyone do a better job?
ICT: There’s a growing debate about the ability to get to zero when it comes to infection prevention; what’s your take on the issue?
FM: A goal is better than no goal. When I started I was taught by people I respect immensely that we could only prevent one-third of all infections. Boy, were we wrong! Does that mean we can reach zero? Absolutely not. But if we set our goal at a one-third reduction, that’s what we’ll get and we will have fallen far short of what we are capable of. I don’t have much time though for those who declare “hospitals are filthy now.” Things used to be far worse. I was in a pediatric ICU in 1976. I came in as a blunt force abdominal trauma and I left with three urinary tract infections, one bloodstream infection and one pneumonia. I was informed that my surgeon’s nickname was “Puss Fingers.” I am deeply grateful to that surgeon for saving my life. But can any of us imagine that many infections in one previously healthy patient as a norm? Hygiene has improved immensely but I feel we’ll look back on this time as we do the renaissance age today. An amazing advancement over where we were before but still only baby steps from the dark ages.
ICT: You are a strong advocate of building relationships to advance an infection prevention agenda; what is your best advice for getting buy-in from hospital stakeholders?
FM: My advice is to recognize that you can’t know it all. There are people who know far more about crucial elements of our job than we do. The head of sterile processing knows much more about sterilization than most of us. Use those resources and work with them. Recognize too that when we need resources selling it to other departments before we sell it to administration makes our case stronger. When I started in hospital epidemiology my facility had probably the best information system for infection prevention in the nation. All reportable illnesses were reported by one keystroke each morning; five keystrokes would give me all patients on vancomycin in the house. It did much more; all on a pre-Windows platform. So how did infection prevention get such a great software package? They sold it to pharmacy. Pharmacy saw how the software could save lots of money, simplify antibiotics and detect medical errors. They went to administration. It wasn’t one lonely person but two departments.
But most importantly when confronting a problem the quality improvement literature is quite clear as to whom we should work with. We tend to work with those whom we’ve worked with before. That isn’t always the best approach. It is often most successful to work with those most displeased with the status quo. We should talk to the front line staff and see who sees the problem and is most willing to work to change it. As is often said; success breeds success. If our usual allies are reluctant or invested in the status quo, we will spend a lot of energy convincing them to try a change. Their standards for success will be higher and tougher to meet. We will spend more effort to get the ball rolling and will therefore have less energy to convince those truly tied to the status quo. So each new problem we address we should look for the best people to work with on that problem and not necessarily our usual allies.
ICT: What do you think is the future of infection prevention, given a current lack of resources in many programs and an even greater demand for IC’s services?
FM: We may be approaching the zenith of our influence and power. But we are getting to a point where it is obvious to all that we can’t do everything on our plate. And we are ceding a lot to the quality folk. That’s not bad. I don’t think you need the skill set we have to look at process measures. One of the benefits of the changes that are ongoing is that infection prevention is being infused into the organization. I was recently told by someone in government, “I think you are missing the silver lining in all this. We have finally given you so much you can’t do it all and your organizations have to help you.” For those of us lucky enough to work in an organization which will dedicate the resources we need, we will have very strong programs compared to where we were before. For those organizations that ignore the current wave of regulations and interest that wave will bury the infection preventionists working in those organizations.
One of the more frightening things we see are laws that are dictating infection prevention priorities to the facilities. These well-intentioned laws have come about because the perception is we have failed to control infections. At a recent public meeting I noted that according to NNIS (now NHSN) we have cut the rate of central line-associated bloodstream infections due to MRSA in half in the NHSN participating ICUs from 1997 to 2004. I was told I was horribly misinformed and that MRSA was out of control and I just needed to watch the news. I would be the first to concede we need to be doing a lot more. But obviously our literature is not reaching the media. Frankly, success doesn’t make the news, failure and doom does. These new laws and media coverage has resulted in some infection prevention programs developing a “bug of the month club” mentality. What I mean by that is facilities make their infection prevention program organism centric. For example a program will focus all its efforts on MRSA control and eradication. This sometimes occurs without looking at the opportunity costs to their program. Many feel that such an organism centric approach ignores the ecology of the hospital. Darwin tells us that when we eliminate one organism another will fill its role in that ecological niche. We need a holistic approach to infection control an approach the eliminates the niches and by doing so eliminates not only MRSA but the other pathogens that fill that niche.
We can see that when we emphasize the organism over the environment that allows it to thrive, what happens. Some have remarked that it seems to them unsurprising that some facilities with high profile anti-MRSA programs have suffered from large Clostridium difficile outbreaks or multi-drug resistant Acinetobacter baumannii clusters. The holistic approach of overall risk reduction like the CLIP and VAP bundles have dramatically reduced not just MRSA but other organisms as well. I feel some of the efforts on validating environmental cleaning will produce much the same results as the bundles. If we continue to just squeeze one organism it will be like squeezing a balloon other organisms will increase to fill that role.
Another future trend I see is who we hire into this profession. I think nurses and microbiologists make great infection preventionists. But these are two professions which are having fewer and fewer people enter. I still see a number of infection prevention programs open only to nurses and medical technologists. Do we really want to try to compete in a field with fewer and fewer people or do we want to look elsewhere where trainable resources may be more available? I think we need to look seriously at MPHs in infectious disease epidemiology. We need to understand that they may not understand some of the medical procedures or the hospital organization but they have graduate training in infectious disease, interventions, health education and risk stratification. These are skills that most nurses and MTs entering the infection prevention field don’t have. Let me make it clear I think we need RNs in an infection prevention program but to rely on them solely I think may make our programs weaker. Some of us may have overstated how prepared some of the nurses we recruited into the field were for their job. I was recently speaking with a RN who I admire about MPHs and she said, “They can work, they just take longer to train.” I asked her what she knew of sterilization when she started or OR procedure, or cleaning an endoscope or how policies got written, or how the infection control committee worked when she started. She admitted as an ICU nurse she knew close to nothing about these. I am suggesting neither do the MPHs we shouldn’t assume that they will take longer to overcome their ignorance than it does for RNs or MTs.
It also should be noted that our pay scale may not have kept up with the rest of nursing. In areas where three 12-hour shifts for nurses are the norm and infection prevention positions salaried, I often hear my fellow infection prevention leaders laugh, that it is tough to recruit a nurse from 3-12s to 5-12s with weekend calls for a small pay increase and no overtime. In this area MPHs see the pay as attractive compared to what many public health departments offer. Lastly, using LVNs as additional resources for infection prevention programs is novel and very interesting and offers some promise. I have to admit my program doesn’t have them yet but it is something I am looking seriously at as our responsibilities grow.
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HAI Education Bus is an Innovative Infection Prevention Education Program
ICT acknowledges Kimberly-Clark Health Care’s “Not On My Watch” Campaign and HAI Education Bus program as a significant infection prevention education program. Kimberly-Clark recognizes the critical role of education in infection prevention, as education goes a long way toward reducing the possibility that a patient will develop a healthcare-acquired infection (HAI). To help update healthcare workers’ knowledge of infection management and meet their required hours, Kimberly-Clark has developed and executed the HAI Education Bus program, which provides educational resources to hospitals across the country.
As part of its commitment to working with hospitals to reduce HAIs, Kimberly-Clark has launched an awareness campaign called “Not On My Watch.” This includes a toolkit for facilities with the elements necessary to implement an internal HAI campaign of their own. The campaign is completely education driven for caregivers and includes patient safety tips that hospitals can share with the communities they serve.
A major element of the campaign is the Kimberly-Clark HAI Education Bus, which began its tour around the country in March and will continue its 2008 tour through November. The Bus is a 45-foot customized mobile classroom that is dedicated to providing interactive, research-based education programs to help healthcare workers reduce the incidence of healthcare-associated infections in their patients.
On the bus, caregivers have access to expert speakers, group presentations, round-table discussions, and individual workstations offering useful information on preventing infection. Ultimately, the bus serves as a practical resource for helping healthcare professionals refresh their knowledge of techniques for addressing HAIs ranging from surgical site infections to ventilator-associated pneumonia. The bus has visited so far 53 hospitals in 49 cities, and has delivered more than 4,000 certificates to both physicians and nurses at facilities across the country.