Screening Employees for Tuberculosis

In my experience, few infection control topics confuse people as much as tuberculosis screening. Except maybe the chickenpox-shingles relationship, but mostly it’s TB.  Whether it’s who gets tested after known exposure, dealing with new employees with vague histories, or BCG vaccine, it’s always something.

I’ve gone in circles for hours with staff who’ve had BCG while they insist that not only should they not be screened for TB, the BCG has given them a force field that will magically repel TB for the rest of their days on earth.  There’s little point in trying to convince them otherwise, as they will, without exception, grab another foreign-born staff member who will vehemently confirm their beliefs, and say, “See, I told you so.  This is what we were told 30 years ago in {insert name of country here}.”  For added emphasis, I’ve had doctors confirm such beliefs for them. Topic for another day.

Another side of TB screening that I’ve seen pop up on infection control message boards lately is the frequency of testing. This is determined by the TB assessment done on your facility each year.  Like any assessment, you’ll consider the population you serve, the incidence of disease in the facility and the surrounding community, protections you have in place, and anything unique. Use it to classify your facility into a risk category according to that assessment-- low-, medium-, or ongoing risk, which will determine your testing frequency.  

TB screening involves a skin test or blood test, and a risk and symptom questionnaire.  If you are a facility at medium-risk, meaning you have cases of TB regularly or serve a high-risk population, then you need to be testing your staff.  Let’s first be clear on why we screen staff for TB.

1. We test new staff on hire to identify anyone with latent or active TB coming to work at your facility  
2. We offer treatment to anyone with latent TB before it becomes active
3. We remove any staff with active TB from the premises, and get them treated so they don’t infect staff or patients
4. We identify any current staff who may have been exposed to TB during their employment, so that you can do #2 and #3 above
5. We use #4 to identify lapses in infection control

I see so many variations on testing, that it seems we’ve forgotten what it’s for.  It is to identify exposed or sick staff, get them treated, and find out where your infection control practices went wrong. If your facility sees TB patients or those at high-risk, you need to make sure you are identifying them and protecting your staff.  This is done through annual TB testing (or more often in settings with ongoing risk, like TB hospitals or clinics). Not every 2 years, not every 3.  Not with a health questionnaire on odd years, and a skin test on even years.  And certainly not by testing everyone at the same time.  

If you have a low-risk facility, where you rarely or never have or anticipate TB patients, you don’t need annual testing.  So don’t test every 2 or 3 years just to make yourself feel better, or because it seems like a good idea.  Your staff are either at risk or at no/low risk.  Testing staff who are at low risk is expensive in the time it takes, the false positives it produces, and the lack of benefit it has.  This is not how diagnostic testing is meant to be used.  It’s the opposite.

If you have determined through your assessment that staff need regular testing, you must do it an interval that is useful.  You cannot pro-rate it, depending on what Human Resources finds convenient or financially acceptable.   You cannot test your contracted or agency staff less frequently than employed staff who are doing the same jobs with the same exposure risk.  You should not do all employees during the same week. And you cannot do one-step testing when 2-step is indicated.    

If you test your staff throughout the year (either on their date of hire or birthday), and some have a conversion, you will use that valuable information.  You will see what they had in common, where they worked.  Perhaps you’ll find no relationship.  But you must arrange your system so that you have every opportunity to find the issues if they exist.

Let’s say an unknown TB patient is present on unit/ward 4West in January, and he is discharged without ever getting a correct TB diagnosis.  If I perform annual testing on all of the 4West staff in February (because we’ve elected to follow a unit-based schedule), many staff will have been exposed, unlikely any will yet test positive in February, and we won’t know about the exposure until they are tested next February, at which point it’ll be quite late to determine which patient had TB.  

Similar caveat for testing staff based on job title.  Nurses will have the highest likelihood of exposure, as they often spend the most time with the patients.  So if I test all of the hospital’s nurses in January or February, I’ll miss the exposure yet again.

However, if I test staff more randomly, by date of hire or alphabetically, I’ll be testing the 4West staff all year long, and as they start popping up positive, I may identify the issue in just 2 months time, rather than 12 months.  I’ll figure out which patient it was perhaps, identify how he went unnoticed, test the rest of the 4West staff, get them treatment if they want it, and put measures into place to prevent the next occurrence.

If I test every 2 years, I’ll never find that patient, some of my 4West staff will have moved to other jobs in parts unknown, and some may unfortunately develop active tuberculosis.  If I wait 3 years, well, what’s the point at all?

TB screening is not like insulin, where you adjust the dose depending on the blood glucose.   There isn’t “more” or “less” screening by spreading out the interval; there is one way to do it properly: testing at a useful interval, and using the health screening to improve the sensitivity and specificity of the diagnostic test.  Making unfounded adjustments alters the effectiveness significantly.

Ex-Foleyating Your Patients

I feel like I’ve talked to a dozen people about indwelling urinary catheters this week.  Sometimes a topic just keeps coming up.  So let’s review.

Doctors seem to rely on urinary output as a vital sign.*  It’s not.  If the patient is drinking and peeing, things are probably good.  If the urine is yellow, it’s good.  If you suspect retention, scan the bladder, or use a straight cath.  You could even palpate the bladder and actually physically assess the patient like they did in the old days.  Incontinence, while inconvenient, is OK.  Really.  I promise.  Very few patients need all of their urine collected and measured.  

Even dialysis patients.  A chronic dialysis patient will tell you if they make urine or not, and how often. The most accurate I&O comes from the dialysis run--it is the majority of the patient’s volume loss, and is accurately counted.  Use a less invasive method to measure the urine--bladder scan or straight catheter.  Acute renal failure?  Bladder scan to see if urine is being made.  Can I say bladder scan any more?

Indwelling catheters are only for a few select reasons (CDC, APIC)

1.      Critical illness.  When you absolutely need to count every drop in and every drop out.  This patient is in your intensive care unit, on several types of drips, unable to use a urinal or bedpan, experiencing some organ failure, or all of the above.  

There seems to be a lot of misunderstanding amongst physicians about what an “accurate” I &O is and when it is needed.   Your patient is on the telemetry/cardiac unit and is getting IV push Lasix every 8 hours.  Do you need an indwelling/Foley?  Nope.  This is a patient in mild to moderate heart failure. The diuretic will help (minus renal issues).  Your nursing staff will use a bedpan or a hat in the toilet.  If there is incontinence, they will document frequency and a semi-quantitative volume (small, medium, large).  They will monitor heart and lung sounds and edema.  The patient will or will not improve.  It doesn’t matter one bit if the output for a shift is 412mL or 523mL.   If your patient is on an intraaortic balloon pump in cardiogenic shock and can’t get to the toilet for fear of displacing the balloon, then you may have a Foley catheter. :)

2.      Immobility due to fracture.  Unstable pelvic, spinal, or hip fracture where getting on the bedpan is impossible, dangerous, or extremely painful.  Not an ankle fracture, and not a repaired hip fracture (unless ortho says so, but not until after a face-to-face talk).

3.      Non-healing perineal or sacral ulcers.   When you are desperately trying to keep a significant wound dry or a dressing in place, you can have a foley.  This is not a replacement for routine hygiene and incontinence care, or for a chapped bottom.  You do not use it as a preventive measure for skin breakdown.  You use good nursing care for that.  My son was incontinent for the first 3 years of his life. He turned out fine due to good hygiene, skin care, and frequent repositioning. :)

4.      Genitourinary or rectal surgery.  See above, for a site that must be kept dry.

5.      End of life care and comfort.   I’ve been here, personally and professionally.  By all means, the Foley.

6.      Acute urinary retention.  This is a bladder that isn’t working right now (not forever).  Usually due to meds like narcotics, anaesthesia, etc.  The plan is to get the bladder re-trained.  Take the catheter out after a few days, institute your bladder protocol (you have one, right?  No? get one.), and then bladder scan and straight cath until the bladder is working again.  Not working after a few days, then the Foley can go in and you start over.

7.      Outlet obstruction.  Physical issues of the urinary tract that don’t allow urine out: large prostate, strictures, blood clots.

If you qualify for one of these reasons, great….for today.  It’s not a season pass to the catheter club. Tomorrow you reassess all over again to see if the issue has resolved.  You should also have a nurse-driven catheter removal policy.  This is an evidence-based practice.  If the patient doesn’t meet one of those reasons, nurses can remove it.  I’ve heard docs say they didn’t know their patient had a catheter, so don’t wait on them to remove it.  My practice as a nurse was to be sure I saw every inch of my patient on first assessment.  So, sadly, it’s nursing who tells the docs their patient has a catheter.  Or a pessary.  Or that the patient’s contact lenses are still in on day 8.

And give feedback to units, nurses, and doctors.  It’s super simple to make a graph of catheter utilization, using the NHSN 50% median as your benchmark.  Is your unit doing better or worse than other similar units in the US?  And to anyone who says, “Well, our patients are much sicker/older/different”, they’re not.  You’re not special.  There are 5000 hospitals reporting into NHSN. If you are significantly worse than most, you need to improve.

After encouraging more careful assessment of catheter use at my facility last week, a nurse manager called me in a panic on Wednesday.  She said, “We have a young female patient, a new mom who was a multi trauma.  She’s trying not to use narcotics, because she’s pumping breast milk. Unfortunately she’s screaming in pain trying to get on a bedpan.  We took the catheter out yesterday and she wants it back in.  Can we?”

First, holy cow.  Bless you nurses out there on the floors.  

Second, Yes, put that thing back in.

Third, you don’t need to call me to bless your catheter placement.  Be thoughtful about it, be careful and creative to avoid use, but never forget the patient.  I know you are doing your very best.  Do those things, and don’t worry about our utilization rates, or NHSN, or anything else I tell you that you need to worry about.  If you are practicing good care, they will work themselves out.

*I hear other ICPs ask how they can get their docs on board with current guidelines. They use words like 'conservative,' and 'senior' to describe their physicians. These are euphemisms for "Out of Touch With Current Science." Don't be that doctor. As a nurse, I know nothing about Case Management. But if I need to, I'll ask the Case Management nurses. For physicians who don't know current infection control practice, ask your staff...so they don't tell all their colleagues how outdated your practices are.

A Moment (or 5 moments) For Giving Thanks

I’m sure it was not only my mother who encouraged us to finish our dinner by saying, “Eat your food. Children in Africa are starving.”   We were never sure how clearing our plates would help those poor children across the world.  We wondered, Were we supposed to feel guilt for not eating? Shouldn’t we feel guilt for eating? Wouldn’t it have been more helpful to not finish, and send the leftovers to them? Only as a parent myself now do I understand---be grateful for what you have, for others do not have so much.  Show your gratitude by using what’s been given to you.

Recently, the World Health Organization celebrated the 10th anniversary of the Global Hand Hygiene Initiative.  While following all the social media promotions, I was reminded of the WHO’s Self-Assessment Tool for Hand Hygiene.  It’s not that I forget about the WHO, but I’ll admit that I more readily retrieve CDC documents when looking for a resource.

If you have not seen it, or not in a while, the WHO HH document is an assessment tool of your HH program's needs.  It’s divided into domains like systems change, education, etc, and you work through the questions, scoring your HH program on whether or not it satisfies each item.  At the end, you have a score for each domain, which you use to guide your program improvements.  Areas with the lowest score need the most attention.  WHO provides resources for improving each domain, including slide sets for training coordinators and observers, tools for soap consumption, posters, patient engagement materials, template letters to management requesting support, and more.

I think I  had become overconfident in my ability to understand and implement all the components of a successful HH program.  Faced for the first time in my ICP career with poor HH compliance numbers at a new facility, reviewing this tool refocused me on identifying exactly where the problem is--not just, “Nobody washes their hands here.”  From this moment on, I promise, hand over heart, to pull out the WHO tool at each new job I have.

But there was more to it.  What I used to, perhaps, brush off as a document for poor countries, was so much more.  It was suddenly a very unpleasant reminder of challenges faced by others doing my job without the resources.  Not resources like, “I need an admin assistant to help with meeting minutes,” but real resources, like no hand sanitizer or clean running water.  

The questions posed by the WHO document include such things as whether or not sanitizer is budgeted for, is there clean water and sinks, and if there is a qualified person to train others.  Do you have times where there just isn’t any more money for sanitizer or soap?  Me neither.

In the US and Canada, we call this time of year the season of Thanksgiving--a moment where we are grateful for what we have, and recognition that many have much less.  And while cleaning our hands in rich countries does not help others around the world, perhaps a new approach to the apathy about hand hygiene compliance is to make staff aware of those who have less.  We are fortunate to have all the resources we need.  We need to be using them. We don’t do it out of guilt, but out of gratitude.  

Alas, I have become my mother.

Reading the Fine Print

Recently I had an opportunity to talk to a few medical device engineers who had questions about how to clean a product they were developing.  They wanted to know if it would need to be sterilized or disinfected, high-level or intermediate, what products, and how they would write the instructions.   So first, I had to thank them for even considering me, and for considering that there will be an end-user of their product who will want to know how to clean it.  Many times, not a lot of thought goes into it, and the user takes all the risk.

We once purchased some special glasses for interventional radiologists to wear for xray protection. They came from a small manufacturer. The radiology tech called me when she received the glasses. It came with a small piece of paper that said, "Cleaning Instructions: Sterilize in alcohol." Well, that's not too helpful. First, they are glasses. They were to be left in the procedure room, and available to any physician or staff doing a procedure. They are non-critical, and would not need sterilization. What kind of alcohol? Not many sterile processing departments do alcohol sterilization that I know of. Also, the glasses had a rubber strip around the nose and eyebrow ridge. This would surely dry and crack after alcohol immersion.

So we abandoned those instructions, and disinfected them with a surface wipe. We felt that was safe for shared usage. Manufacturers know they should include some kind of cleaning instructions, but that doesn't mean they are reasonable or appropriate for the product. Unfortunately, you are often tied to their instructions--for the safety of the staff, the patients, and for survey or audit compliance.

We’ve just had a little accreditation survey, and as expected, they touched on environmental disinfection.  They wanted to know if staff know how to use their disinfection products properly and safely.  They asked for MSDS sheets and were not satisfied that we were following all the proper safety recommendations.  Unfortunately, we had on hand the MSDS for a cleaning product in it’s concentrated form, not the “as-used” diluted product.  Newer MSDS or SDS sheets differentiate the two, and you may find that while eye protection is required for one, it’s not for the other.

So we took a ding on that, even though we weren’t wrong.  We were wrong in not having the most up to date or correct SDS form.  While we were marked for the eye protection, on our own we later saw that one of our products required long sleeved clothing during use.  All of our housekeeping staff have short-sleeved uniforms, so this is an issue.   Another SDS stated that eye protection is required--except for “consumer use.”  This is confusing, as everyone who buys and uses the product is the consumer.  Does this mean for home use, as opposed to industrial or hospital use?  Again, unclear.   It’s not just reading the product label anymore--make sure you are reading your SDS forms to be sure you can actually comply with the instructions.

Also this week, an employee got a splash of disinfectant in his eye.  When we went to the SDS sheet, there were first aid instructions, but it also referred you back to the product label!  This is awful.  First, you’ve got chemicals in your eye.  Hopefully, you are flushing it for 15 minutes, while simultaneously completing the incident report, calling Employee Health, and finding someone to cover your patients.  But now you’ve got to go get the product to make sure you didn’t miss anything important, and read (with one eye) a 3-page, tiny print, disinfectant label full of kill claims, alternate uses, and dilution instructions to find any additional first aid measures.  

Check your SDS’s and compare them against the product label.  Do they say the same thing?  Is it clear what protective equipment is required, by whom, and for what type of use?  Is there vague wording like “eye protection, as deemed necessary?”  Compare section 2 of the SDS (Hazard Exposure) to Section 4 (First Aid) and Section 8 (Protective Equipment).  If it says it causes irreversible eye damage in Section 2, there should be adequate protection recommended in Section 8.

Are your SDS’s up to date?  Manufacturers don’t always let you know when a new update is available.  You could buy a subscription to an SDS management service that keeps updated copies, but we’ve found errors there as well.  You need to do random audits on them to make sure you’re getting what you paid for.   

You might be thinking that none of this is your job.  It’s housekeeping’s job, or the safety officer, or the materials manager.  But the ICP is a crucial piece of disinfectant selection, and we don’t work in a vacuum.  You can’t select a product for its efficacy, and leave everyone else to figure out the safety piece.  It has to be right for everyone.  You want cleaning staff to be safe, and you want to be able to comply on a survey.  After our survey, we had to abandon one product as an everyday cleaner because it became clear that it was difficult to comply with safety recommendations.  When evaluating a new product, ask for and review disinfectant SDS sheets upfront, and cleaning instructions for equipment.

Next week is Environmental Services Week!  Show your appreciation to the staff who are physically doing the infection control every day.

Just a thought

What if we got a reporting holiday.  A one year sabbatical where we weren’t required to report anything externally.  What if we took those hours and used to them to read and learn, to teach and talk to each other, to plan and implement all the things we want to do.  What would the data look like when we came back and started reporting again?

Defending your hospital against its data

Recently Consumer Reports published hospital quality data using its well-known “dot” system, a 5-dot ranking system of best to worst (sources explained here).   Lots of local news outlets picked up on it and published articles on the rankings of hospitals in their area, using CMS and HCAHPS data (here, here, and here).  I don’t spend a lot of time on quality metrics other than those that are infection related, but I know how fraught with issues our NHSN data is.  They also reference HAC data (when I say “coded infection data”, you yell “NO”).  And then to have all that information boiled down to 5 colored dots that regular people, and health journalists, will try to analyze to compare hospitals is beyond frustrating.  Without a doubt, ICPs will be called on to discuss their facility’s data. This is an endless process that repeats itself each time data is published.

Last week, my state published facility HAI and flu vaccination data.  It’s a giant report, with some summary data, and then a nice one-page graphic on each facility.  I sent the preview to my director because the executive team WILL see this, and they likely will NOT know how to interpret it.  This is what our HCW flu vaccination data looks like at 2 of our small hospital sites:

Name	Total Vaccinated	Total HCP	Percent Vaccinated	95% Confidence Interval	Hospital % compared to state %
Hospital A	21	21	100.0	86.7, -	Similar
Hospital B	243	243	100.0	98.8, -	Higher

We have 4 hospital sites.  Each site vaccinated >97% of its staff.  The state average is 93%.  However, 2 of our sites are listed as “better” than the state average, and 2 are listed as “similar”.  Why is that, asked my director.  It’s because they use a probability, which comes with a range of likelihood (confidence interval), and our 2 smallest facilities have a larger range of likelihood (less precision in the measure) which overlaps the state average, and are therefore not solidly better, but similar to the state average.  But we vaccinated 100% of our staff at Hospital A.  That is better than the state average of 93%.  To a regular person, yes, it is.

So, if you, Cathy Consumer, were going to choose a hospital by how many staff were vaccinated, which would you choose?  The one similar or better than the average? Trick question.

C.difficile is another hot quality metric.  Unfortunately, public agencies are calling this HAI, but it isn’t.  This is the surveillance definition, acknowledged by CDC and NHSN as DIFFERENT from the HAI definition.  But this flawed proxy measure is what is publicly reportable.  The numerator is cases in patients who have been inpatients for >3 days, but the denominator is all patients, of which not too many stayed greater than 3 days.  This is basic incidence-prevalence-Epi 101.  The denominator should not have people that are not eligible for the event (numerator).  While I appreciate the attempt to standardize the rates with bed size and local prevalence data, whatever C.diff “rate” you’re getting from NHSN is far lower than your real rate because of that enormous denominator flaw.  Anyplace I’ve worked, I’ve kept 2 sets of data on C.diff: the stuff we report to NHSN, and then the actual HAIs which we have opportunity to improve.  THOSE are the cases we focus on in quality improvement.

Let’s talk about the MRSA “rates”.  This is MRSA bacteremia.  How silly.  Why, why, why would we only care about one subsegment of one organism in the bloodstream?  I could have a thousand MSSA infections and nobody would care (unless you’re in PA, where everything is reportable).  This LabId event is another proxy measure--where we don't review the chart AT ALL--not an HAI measurement, which counts only one thing: a lab test.  Doesn’t matter what the source is, whether it’s contamination, drawn from an old line, pneumonia from the nursing home, or a surgery gone wrong.  That number now defines your hospital’s quality in the eyes of your community.

How about CAUTIs, where you are immediately punished for reducing the number of catheters, since reducing your denominator raises your rates?  But don’t worry, everyone will do better next year since the definition changed this past January.  Look!  Your hospital just got better!  Good job!

CLBSIs?  Sicker patients at higher risk with more lines get counted the same as patients at lower risk, without accounting for that risk. I hope you don’t treat transplant or cancer patients.  I bet all those MBIs are adding up.  No place to put those non-preventable infections?  Just add them to the CLBSI pile, and send a press release to the papers. Unless you’re gaming the system (intentionally or not), then your rates are lower. 

And lastly, “avoiding surgical infections”.  All that’s reportable here is colons and hysterectomies.  Lumped together.  Nuff said.  

Low volume denominators skew everything, and then it's all boiled down to the SIR or "better, similar, or worse."

So is there any value in any of this data?  Sure, they do standardize the data so you can see somewhat where you stand against similar facilities.  I oversaw a large dialysis clinic once and we had no idea how bad our CLBSI rates were until dialysis clinics started reporting to NHSN and getting data back. We immediately made major changes in both product and process, with great success.  So that was useful.  But I can’t say it’s been helpful since then.  Oh, device utilization, that’s good, too (although accurate collection in a small facility with no EHR is a real issue).  But the infection rates, not so much.

 Depending on how in touch your executive team is with all of this data, you may be called upon to explain what is being published on websites and in magazines about the care provided at your hospital.  Or the care that WAS provided, since the information is usually a couple of years old by the time it gets out there.  It can be tricky to explain how it all works, or doesn’t, and why reporters might be calling for explanations.

What's your data story? What does your newspaper say about YOU?

I didn't come here to make friends

So you’re new at this, a new job, new facility? You’re going to need some friends, because you can’t do infection control alone.   You cannot wash people’s hands for them, nor scrub the hub for them.  Which is why I say I don’t really control anything. But you need them--to work with you and for you.

Know thyself

I am an introvert on one of those personality tests.  No kidding--I didn’t need a test to tell me that.  Could I please just work from home where the phone doesn’t ring?   Nope, you gotta be out there and work with PEOPLE.  Other people.  So. many. people. *sigh*

Go ahead and take a personality test.  There’s more than one kind--you’re either one of four types, or one of 16 types.  They usually get me spot on. Know who you are and what you’re style and outlook is, and recognize that other people are one of the other types, perhaps your polar opposite.   Really look at those and see that they are valid descriptions of how other people think and see the world.  Recognize them in others and know how they communicate best. They aren’t that way just to annoy you (darn perky morning people) and you cannot be effective if you don’t know who you are working with.  So learn to identify someone else’s type.

Shut up and smile

It’s tempting to bring your enormous (or slightly less than enormous) body of knowledge to dump on all these new people, but you can’t, because it’s very difficult to do politely and effectively in the beginning.  If you started calling strangers on the phone and telling them about something you read in the paper last week that they should implement in their life right now, they’ll hang up. But if you call your friend with the same story, the expectation is that you are telling them something that is either a) beneficial or interesting to them, or b) a shared interest you can both discuss.  A friend will listen.  Right?

The fastest way to turn people off is by starting every other sentence with how great things were where you used to work.   Your first month on a new job, just close your mouth.   Do a lot of listening and watching.  Ask questions (not, like, “Why would you do something like that?”).  Gather facts.  Learn the system.  Ask if a manager will give you a short tour of their department.  Ask about their concerns.  Write stuff down.  Do not spout advice unless specifically asked, and even then, delay the advice-giving until you have more information. Strangers do not want your opinion, either on the street, or at work.

Just make one friend

You need one friend in each department.  I once worked at a hospital where the facilities director did not want to be my friend.  He did not want to tell me about projects, plans, or issues. So I befriended the maintenance staff, his direct reports.  Everyone was polite and my office was on a common hallway, so some would say hello on their way by.   After some time, a gentleman stopped by and lingered for a moment.  I asked about his son, who had just gotten a new job. After a chat, he said, “you know, down in the *unnamed* department, we are doing *xyz* on the night shift, so that it looks ok for the 6am check.  But it really doesn’t work well all day. I thought you should know.”  Wow.

The understanding was that I was not supposed to know about this coverup/workaround for a system that wasn’t working, but after a period of time, I think he felt he was betraying a friend.  It was understood that I would not say where I got this new information from.  I hope his disclosure came from realizing that my job was to help patients and staff, and not to penalize or police anyone. The value of friends is immeasurable.

Learn to speak another language

To make friends in a foreign department, you need to speak their language and learn their culture.  If you are not a nurse, or not familiar with nursing at this facility, go to the orientation the newly-hired nurses go to, and be a student with them.  It might be a few days, but it’s worth your time.  See the equipment, learn the practices and policies, and meet a small group of new nurses, and the nursing educators (key allies).  Look (and be) humble and willing to learn.  Always.

If you don’t speak Environmental Services, join your local and/or national AHE chapter.  I belong to AHE: they have a ton of great (free) webinars, and I even went through a 2 month online course on ES management--staffing, contracts, flooring, and basic infection control, etc.  It was intended for new ES managers or supervisors, but I learned a lot about the challenges and decisions the industry faces.  I even went to the national conference one year in place of an infection control conference.  It was amazing.  That was 3 years ago, and I still refer to my notes from that conference.

Togetherness, and other warm fuzzy things

AHE had a nice program a while ago, intended for infection control and housekeeping departments to watch and use together.  It was presented jointly through AHE and APIC. There was also one for ICPs and the micro lab.  They are helping you build bridges, and learn about each other.  And nothing says togetherness better than sitting in a conference room watching a webinar about C.diff with an ES manager. Can you feel the love?

There are definitely days where I want to scream, “Why doesn’t everyone just do what I say?!  You hired me for infection control, but you keep trying to implement stupid no-evidence processes that won’t work. Clearly I’m not needed here.”  But I don’t say that (out loud). I consider my audience, ask for everyone’s input, accept that it might take 6 months (instead of 6 minutes) to move something forward, and save the emotional collateral that I’ve built with my new friends to use on another day.  Namaste.

Go ahead, guess my Myers-Briggs personality type: ___________

I been in the lab, with a pen and a pad...

So said Dr. Dre, and he’s a doctor, so he must know something. And I think he’s right.

 I was speaking with a colleague last week who has been an ICP for a few years, and she mentioned that she needs to go get her certification soon.  I’m nervous, she says, pulling her CIC study guide off her desk.  Without really even thinking, I said, Don’t be.  You’re a lab tech.

There are several paths into Infection Control, and I am unique in that I came to it having traveled three routes.  I am a medical technologist, or clinical laboratory scientist. It was my first degree, and it has served me very well.  I am a registered nurse.  I went into nursing when I realized I wanted to know more about those people whose names were on the samples I tested.   I have a Master’s in Public Health/Epidemiology, which was my goal from early on, but life derailed my plans for 15 years until I finally finished it.

So here I am in Infection Control, and on many days I wonder how most people do it without a lab science background.  CAN you do it?  Of course! You can learn anything.   And I recently discovered while reading an ICP salary survey that the overwhelming majority of ICPs have a nursing degree, and far fewer a lab science degree.  So that’s proof right there.  But I wonder how hard it is, and after a very long conversation with our reference lab last week discussing their methodology and requirements for CRE testing, I wonder if some new ICPs struggle trying to learn or get comfortable with the microbiology that is embedded in our daily work.

A huge portion of what I do each day, I do with ease because of my lab tech education.  I review cultures and antibiotic patterns almost mindlessly.  I know where diptheroids  and bacillus are normal and where they might not be.  I’ve never confused the flu with Haemophilus influenzae,  or Enterobacter with enterococcus.  I know what strep groupings are, and the difference between mycoplasma and mycobacteria.  And I don’t need to think about it.

Now nurses know microbiology.  They read patients’ lab reports all the time, and administer antibiotics.  All nurses take a microbiology class.  But it’s often not the same as the kind the lab techs take.  Lab techs take general micro, clinical micro, virology, parasitology, immunology, and bunch of other stuff.  Most of those classes are lectures with labs.  I remember our small class bringing in our own samples for labs—throat swabs, urine and stool cultures, etc.  Almost as much fun as learning phlebotomy on each other.  If your micro class was a long time ago, or was pretty basic, it might be time for a refresher.

I know that if you come to infection control from a lab background, you’ve got other things to learn, like nursing practice, surgery, and sterilization. If you came from a public health background, you’ve got statistics, study design, interventions, and community health practice under your belt, but the clinical application might be your challenge.  And in none of my education did I learn enough about antibiotics to prepare me for how much I need to know now. (Desperately waiting for an ICP-focused, soup-to-nuts, antibiotics course to become available from someone.  APIC? Pharmacists?  Anyone.) [crickets]

Maybe I’m wrong, maybe it’s just my own experience, but I do meet ICP’s (experienced ones) who still seem to struggle with some basic concepts.  Maybe they don’t know what they don’t know.  When I hear that people are evaluating a disinfectant by the number of organisms listed on the label, I know they need a micro class.  Or that they refuse a product because Staph aureus is on the label but MRSA isn’t.  When it’s not clear why non-enveloped viruses are harder to kill than enveloped viruses, you need a micro class.  If your lab lets you know about a change in their test methodology and you don’t know how it affects your infection rates….  When you don’t know which organisms are non-fermenters in a research paper….Why Hepatitis A doesn't need to be in your post-exposure blood panel...The difference between α-hemolytic strep and group A strep in a blood culture... That you’ve failed the CIC exam more than once.  These are all actual things that have come up in conversations I’ve had with ICPs.  

I might sound like a lab snob, thinking that my lab education is soooo much better than your nursing degree.  But I’m not, because I can tell you from experience that I came to infection control far better prepared with a lab degree than a nursing degree.  They are a very nice complement to each other, but if I had to pick one to recommend, it would not be nursing.  I write this so that it might be helpful to someone out there.  

I’ve worked in different environments, but mostly outside of the academic medical centers (by choice).  I went to a meeting once as an affiliate hospital of a large medical center.  We were supposed to send our IP staff.  All the community affiliates sent their one or two ICPs, while the flagship site sent their 7 ICPs, 3 hospital epi MDs, 2 fellows, and their ID pharmacist.  Um, wow.  I can see that if you work in a place with that much support, you might not need to know everything.  But most of us don’t work like that.  We work alone or in pairs.  We may or may not have an ID doc with any hospital epi experience.  He may even be a consultant off-site.  You’re on your own, and you’d better know your stuff.

I’d like to know if CBIC keeps track of who does better on the exam, or is more likely to pass it on the first try—the lab techs, the MPH’s, or the nurses.  I could be totally wrong.  But I’d like to see that data.  You could learn everything from a book.  You could use your CIC study guide and maybe get it all.  But learning for a test, and really getting it, are different and some stuff is just easier to learn in a structured setting.  If you’re thinking a micro class is what you need, find your nearest center of higher education that runs a clinical laboratory science program, and get yourself into that class.  Make sure it includes a lab where you put clinical specimens on plates and you learn to read them and make Gram stains.  Bring a pen and a pad. Then come back and tell me if I was right.  

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