By Kelly M. Pyrek
Hospital epidemiologist Susan Dolan is on the move. It's 8 a.m. and she'salready pulled reports from the microbiology laboratory, the first clues as tohow her busy day at The Children's Hospital in Denver will be spent. As InfectionControl Today magazine's 2002 Educator of the Year, Dolan proves that beingan educator requires both mobility and the ability to multi-task.
"My day starts with basic surveillance, where I look at all of thesignificant cultures that are positive for the day and decide what I need toinvestigate," Dolan says. "It also prepares me for our dailymicrobiology meeting." Lest she or her colleagues should be slowed down,these meetings are held standing up and are characterized by a quick exchange ofpertinent information about specific cases. "Much of my time is spent atmeetings where special projects, like addressing an infection control issue, areaddressed. Many of these are issues that require input and consensus, so I workcollaboratively with almost all of the departments at the hospital. This awardis a reflection of those with whom I work closely every day, for they are myteachers. Without the support from people in epidemiology, microbiology,virology, medical education (residents), and infectious diseases-- I truly wouldnot be able to do my work to such a high standard."
Dolan is determined to make the most of her meetings, using them as anopportunity to educate other department personnel about epidemiology andinfection control.
"The key is to go to meetings prepared, and have the best research-basedinformation available. You bring your data and your gut feelings and presentissues in a way that gives you credibility and helps you develop into aninstrumental person who identifies and solves problems. Or, sometimes you haveto present epidemiological data in a way that indicates there is aproblem. This happened recently with a department involving a surgicalprocedure. After presenting their infection rates, we showed them that theircurrent targeted antibiotic prophylaxis may not be addressing the organisms thatcomprised a significant portion of their post-operative infections. This led toa discussion about appropriate antibiotic utilization and new recommendations.In addition, they said, 'We think we can make your data even better, we need tostratify it by risk factors unique to our patient population.' We realized this,but it was nice to have them suggest it. Also, once they get to know who youare, then when you see them in the OR or when there's an issue, they know who tocall and how we can help them."
Dolan's sense of teamwork was fostered during her early years as a staff RNand charge RN in pediatrics, and was further cemented as a member of thepediatric nursing faculty at Jamestown Community College in New York. She cameto The Children's Hospital in Denver in 1987, working as a clinical nursespecialist in the hospital's community health program. In 1994 Dolan became thefacility's epidemiologist, responsible for the management of its infectioncontrol program. She received her certification in infection control andhospital epidemiology in 1997. Dolan holds a master of science in pediatricnursing from the University of Rochester and her bachelor of science in nursingfrom State University of New York.
As part of her job, Dolan develops educational materials for monthlydepartment meetings and quarterly infection control committee meetings, oftenincorporating what she has learned at her monthly Mile-High chapter meetings ofthe Association for Professionals in Infection Control and Epidemiology (APIC).(Dolan has served in many capacities, including serving on the nominatingcommittee in 1997, serving on the program committee in 1998, the board ofdirectors in 1999, and now as the membership coordinator.)
With so many opportunities to compare notes on infection control issues,Dolan says nosocomial infections are high on her hit list, and she makes aconcerted effort to partner with her APIC infection control colleagues to raiseawareness on the part of patients and healthcare workers.
"I think it's an important issue for everyone to know about," shesays. "We have targeted the high-risk areas where we can performintervention techniques and make a significant impact on reducing theopportunities for nosocomial infections to develop.This allows us more time toexamine a specific department's risk factors. For example, we've specificallytargeted bacteremia related to central lines in our ICU, NICU, and oncologydepartments, where the majority of these infections occur. We also are usingthis data to compare ourselves with other Children's Hospitals throughout thecountry."
According to Dolan, one of the more urgent challenges to infection control isthe nature of the patient population at her facility. "At a children'shospital, you have a higher percentage of patients who need isolation. Ourfacility doesn't have all private rooms, so we've been very creative with ourcohorting. We examine this closely, especially during the winter months becausenot only do we have the issue of shortage of beds, there's an increase ofpatients being admitted. We recently submitted a paper for publication thatincludes data showing that we were able to utilize cohorting without having anincrease in our infection rate."
Dolan says smart planning and careful surveillance not only help keepinfection rates stable, they help hospital staff track down the culprit organismin event of an outbreak or sentinel event. Dolan also believes every infectionis an opportunity for education.
The Children's Hospital had experienced an outbreak of gram-negativebacteremia associated with the introduction of pre-filled heparin and salinesyringes, according to Dolan.
"The pre-filled heparin and saline syringes were first introduced to ourhome healthcare department; since it's easier to teach families if the solutionis already drawn up and that's where the syringes had their initial trial,"Dolan explains. "We also implemented them in our oncology unit, which is apopulation where we use lots of flushes and central lines. During the next twomonths we saw a dramatic increase in gram-negative sepsis. The morbidity wassignificant--some kids got ill very quickly. At the time we didn't know what wascausing the outbreak, but we traced it back to home healthcare and in-patientoncology."
Dolan continues, "We looked at the products they had received the weekbefore, with the common thread being pre-filled heparin syringes. People neededto realize when the pre-filled syringes were taken out of the bag, they were notsterile as stated on the product label, while the other syringes used previouslywere sterile when the peel-paks were opened. However, we believe the product'sdesign and some techniques used by the staff contributed to the introduction ofgram-negative bacteria. We pulled them immediately, once we felt strong enoughthat they were the link, the problem stopped and our rates returned tobaseline."
To this end, she uses the outbreak as a teachable moment in the use of thenewer needleless or safety devices. When evaluating the new devices, sherecommends examining the patient outcome as well as the worker protection aspectas well as healthcare workers' reliance on their safety even when usedimproperly.
"I tell healthcare workers to think twice and not assume anything aboutthe safety of medical devices and products because not all of them work likethey are supposed to. I say this so many times that they'll see me coming downthe hallway and they'll say, 'What did we do now?" she says, laughing.
At the risk of becoming the hospital "nag," Dolan says being on thelookout for a teachable moment is key to being a good educator. She adds thatmany healthcare personnel at The Children's Hospital as well as at otherhealthcare facilities in the region seek her out. She's a walking 4-1-1, andDolan wouldn't have it any other way.
"Much of my time is dedicated to being accessible to people and gettingthem the right resources," Dolan says, adding that she fields inquiriesfrom staff nurses, infection control practitioners at other facilities, evenpediatric infection control professionals from hospitals nationally. "Weshare our experiences, research and best practices, comparing notes and seeinghow we can help each other. A lot of my time is spent being a resource andseeking out resources; I send information through e-mail, faxes, throughwhatever mechanism possible. Yesterday I bet I did it more than 50 times. Forexample, I received a call from another infection control nurse needinginformation on staff who have bloodborne pathogens, and I was able to send her asummary of the current literature we had reviewed. Staff members often call forinformation, wanting to know why do we do what we do and what theepidemiological support is for a certain procedure. And sometimes, I amresponsible for creating policies that don't exist, such as the protocol forpatients who do their own laundry at the hospital."
"Susan is very committed to making sure the education gets to all levelsof staff and that they understand completely," says Rose Seavey, directorof sterile processing and the person who nominated Dolan for the award."She has presented topics nationally as well as locally, but most of allit's her commitment to keep digging until she finds the right answer. She isrelentless about finding solutions to problems and is never too busy for any ofthe staff."
"My favorite part of what I do is when I can help someone with an issuethey are worried about, whether it's a personal question about an illness or anexposure at work," Dolan emphasizes. "I like getting them back ontrack through education, either putting their minds at ease or helping them workthrough the process. And if I don't know something, I am fortunate to work withwonderful, top-notch people from whom I learn every day."
While Dolan spends much of her day disseminating information within herhospital, she and her colleagues work closely with the county and state healthdepartments to perform daily epidemiological reporting, prophylaxis, and thelike.
"We now are working on issues that have never been explored before, suchas what do you do about a child in the community setting that is MRSApositive," Dolan says. There have been some precedents set in a few states,but that issue is now showing up in Colorado. And no one has the exact answer.The state health department has decided to create a task force of community andhospital representatives to address the issue and develop consensus guidelinesthat will help community settings (e.g., schools) manage these children."
Multi-drug resistant bacteria are not the only issues with which Dolan saysshe grapples. Headlines about vCJD or the potential for bioterrorism serve asfurther impetus to examine what The Children's Hospital is doing to prepare fora contingency.
"With any potential threat I ask myself, what departments are mostinvolved?" Dolan says. "I read what the experts have to say, reviewthe literature and then I get people together to discuss the issue. If it's notan immediate threat, there's a tendency to let it sit on your desk due toprioritization needs. But when something happens, it propels you into action. Iwas working on vCJD for some time now when an incident occurred just a fewblocks away at a hospital I can see from my window, and it's a wake-up call. Iask myself, when things like this happen, it's an opportunity to get or raisepeople's attention about the issue and make sure we are prepared for everyeventuality."
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