Florence and the machines, Part 2—The Environment. It’s everywhere.

After hand hygiene, the second cornerstone of infection control is using basic knowledge about disease transmission in and from the environment.   Patients need a clean, safe environment.  This includes clean equipment, clean rooms, and clean linens.  When you look around your facility, look at everything and ask yourself ‘How clean is that?’  To know if something is clean, you’ve got to know:

• Who cleaned it?
• How was it cleaned?
• How has it been kept clean?

If you ask who cleaned it, you’re likely to find orphan items.   I worked in an intensive care unit as a nurse for several years.  Later, I moved to the infection control department, and I suddenly had a new set of eyes.  After asking a few questions of the housekeeping staff and ICU nurses, I discovered that IV pumps were rarely cleaned, and flashlights were never cleaned.   The housekeeping staff said they didn’t clean critical patient equipment during their daily work, for fear of accidentally hitting a button that was critical.  Nursing staff certainly didn’t do any routine cleaning.  Only when the patient was discharged was the pump sent to central supply for cleaning.   So, our housekeepers cleaned tables and countertops and floors and chairs in a patient’s room, but never touched the equipment.  I imagine that after just a short time, the entire room was re-contaminated by staff hands touching these towers of germs in an otherwise clean room.  How silly. 

  

And the flashlights? They are left on the work counter in the ICU patient room for pupil checks.  Housekeeping didn’t clean them, neither did nursing.  “Orphan items,” things with no home and nobody to clean them.  Everyone assuming somebody else was doing it.  Do you have some of these?  Don't know til you ask.

How something was cleaned is also important.  Is your staff using an approved disinfectant?  Are they using it correctly?  A story from the lovely IP who trained me in my first job, that I’ve never forgotten:  I was making rounds in the operating room.   In a work room, I opened a cabinet to find dozens of bottles of isopropyl alcohol.  Having not been an OR nurse, I asked the technician nearby what all the alcohol was for (my primary concern then being a large quantity of flammable liquid not stored in a proper cabinet).  She said to me, ‘We use it to clean the counters.’  Eyebrows raised, I said, ‘Show me.’  She said, ‘When an OR case is completed, we sterilize the counters with alcohol.  We pour a half bottle of alcohol on the steel counters and wipe it off.’  I immediately met with the director to discuss what is meant by cleaning, what is sterilizing, and what products are appropriate and approved for use after an OR case.  You must always say ‘Show me.’  You’ll often be surprised by what you see.  What have you seen for cleaning methods?

Lastly, even when something has been cleaned, you’ve got to keep it clean until it’s used.  Clean linens on a bed are ready for use.  But if that bed is pushed into the hallway when it’s not needed for a while, and a lot of traffic passes by it, and occasionally someone puts items down on it, or even sits on it, and then it goes back into a patient room, it’s not really clean anymore, is it?  Not as clean as it could or should be.  I find these beds often in and around the emergency department.  The staff tells me they don’t have a place for the extra bed at the moment.  They can’t put it in storage because admissions are unpredictable: they might need it shortly.  That’s fine, you don’t need to move the bed.  You do need to take the sheets off, though, and put on clean ones for the next patient. Once clean, kept clean.  Apply this rule always. 

There is much, much more to keeping a clean environment than what’s here.  But this is the simple, “Florence Nightingale” approach.  I’ll talk more about cleaning and disinfection in another post.  I’ll probably call it “Why I Love Vendors.”  Which I do.

Florence, and the machines

The core of infection control is rather simple.  You don’t need a lot of fancy education, you just need a few ounces of common sense.  You can learn fancier stuff later.  When I teach infection control, either at new employee orientation, or to nursing or other departments (staff meetings, inservices, etc.), I talk about "Florence Nightingale nursing."   What I mean is a back-to-basics approach to preventing the spread of infection.  Most of what we do is dictated by what we’ve known for more than a hundred years.  These are the 3 tenets I always come back to, for new employees and in my own work:

1. Wash your hands
2. Keep the environment clean
3. Keep the sick away from the well

Now, not all of those ideas belong to the Lady with the Lamp.  But they are basic science that has been known for a very long time.  If you know nothing else, you can answer the grand majority of infection control issues with one of these 3 things. Let’s start with the first one.

Hand Hygiene

If we did more of this, we’d have to worry less about #2.  We, the supposed bringers of health, spread infection all over the place.  We touch the patient, the IV pump, the meal tray, the patient’s toothbrush, the patient, the bedsheets, the IV site.  And our hand washing is dreadful.  We do it wrong, we don’t do it enough, and we don’t do it at the right time.  A common measurement for hand hygiene compliance is to watch a worker entering and leaving the patient room.  Did that nurse clean her hands on the way and on the way out?  Yes?  Put a check (tick) in the box.

That’s nice.  But if she washed on the way in to the room, then emptied the bedpan, and flushed the toilet, then gathered the patient’s supplies for hygiene, then helped the patient brush his teeth with the same hands that just emptied the bedpan…?!  Then the hand washing on the way in the door isn’t worth much, is it?  Now the patient has a mouth full of his own bedpan germs on his toothbrush.   The World Health Organization promotes “5 Moments for Hand Hygiene”.  This is great.  This is what staff SHOULD be doing.  What happens in the room is key; not just on the way in or out. But it’s a lot harder to monitor while you are making rounds on the unit. 

I think sometimes, the staff think that’s all I do.  “Are you watching us wash our hands?” someone will always ask when I’m out on the floors making rounds.  They ask with that half-kidding/half-not-kidding smile/sneer.   No, I think: I’m reviewing charts, looking at the damaged ceiling tiles the contractor left, seeing if our new disinfectant smells too strong, checking the levels on the sharps boxes to see if our waste contractor is coming often enough,  and checking high dust in the waiting rooms.   No, I’m not washing you wash your hands.  I did that yesterday.  “Not today,” I smile.

So, they think that’s all I do.  Then why don’t they think, “We’ve hired someone whose sole job is to watch hand washing.  It must be that important.  I should do more of it.”

Hand Hygiene is also the answer to most of the employee health questions I get.  'I took care of Mr. B before we knew he had MRSA.  What do I do now?'  Well, did you wash your hands? There is no shortage of hand hygiene products, formulations, and dispensers available on the market and in facilities.  Why don’t staff perceive risk, and wash more often?  Once, an employee called out sick with a new diagnosis of C.difficile.  She called the Employee Health office to find out if her sick time would be paid under workers’ compensation.  No, it isn’t.  If you got it here, it’s because you ate it.  I told you to wash your hands. 

Patients need hand hygiene, too.  This is such an overlooked area, I think.  It was nice to see some presentations and posters at the SHEA conference last month focused on patient hand hygiene.  In the acute care setting, maybe we don’t think about it is as much because the patients are in their beds most of the time.  But I’ve worked in acute rehab and in behavioral care, where the patients are out of their rooms as much as in.  They share meal times, exercise equipment, activities and supplies.  They are in contact with many more people, many more environments, and all the germs that come with increased mobility. A hand hygiene program should include the patients.   Sanitizer dispensers can be out of reach.  Little packets of wipes on the meal try have been shown to be literally impossible to open for some patients.  Patient hand hygiene needs to be actively promoted and implemented by their caretakers, helping them when they can’t help themselves.  Like hand hygiene rounds.  Sort of like when we have toileting schedules.  Practical?  I don't know.  Valuable? Absolutely.

 What’s your practical patient hand hygiene solution?

Know What You Don't Know

Ok, so what next?  How do I learn all this stuff?   Well, first, you need an assessment—of yourself.  You need to know what areas you are lacking.  If you are a healthcare professional, you probably already have some body of knowledge—nurses know some stuff, lab techs know some stuff, respiratory therapists know some areas.  If you’re an MPH without clinical experience, you have a different body of knowledge.   But you have to find out what you don’t know.

Look at the content of the certification exam.  Do any of those topics sound completely unfamiliar?  Then that’s where you should start.  APIC has a roadmap for new ICPs—what you should know in your first 60 days, first 6 months, first year, etc.   They also produce a text with everything you need—either an enormous book or online access.  Join APIC to get access to the roadmap and the text.  Go ahead, pay the membership fee: it’s a very small investment towards your career.

APIC is an excellent professional organization.  You get emails when anything major happens: new regulatory requirements, new research, new outbreaks, new documents you need.  They have job listings, a consulting service, there’s an online forum where you can ask questions and people from all over the place answer you.  There’s a huge annual conference, and there are local chapters that you can join.  My local chapter covers a large area and hosts two large conferences each year with great speakers and the chance to meet with product vendors.  So get going, start learning what things you don’t know.  Then come back soon, and I’ll tell you practical ways to learn about what you don’t know.  J

A Day in the Life

If you want to find out more about the job, go find the person who manages Infection Control at your facility.  Ask if you can shadow for a day, or a few hours.  You’d be amazed at the variety of things your ICP does in a day.

What I did today:

Made rounds on the units. I found 4 disposable razors in a trash barrel in the shower room when I stopped in to check my hair in the mirror. I look around and see that there are no sharps containers in the shower rooms.  Emailed the therapy director (therapists help our rehab patients shower and do ADLs) what the usual process is for the razors.  I put on some gloves, removed the razors from the trash and found a sharps container for them.  {Safety}

Went to our monthly Quality and Process Improvement meeting.  I present every 3 months on infection control.  Today I presented progress on our hand hygiene, and showed our data for catheters and central lines, which is new since we implemented a new data collection method in January.  Data is more accurate, I think, now.  So we can start looking for opportunities for improvement now that we have good data. {Process Improvement and Quality}

One outpatient site wants new hygiene stands for their waiting room.  The manager sends me product link.  I forward it to Purchasing—can we get these?  No, they’re not from our preferred vendor.  I look through the online catalog for our preferred vendor—lots of model numbers, but no pictures.  How can I order something if I don’t know what it looks like?  Email other outpatient managers—does anyone else want a hygiene station?  It’s cheaper if we order 10 or more.  {Environment of Care}

Met briefly with my director about a positive TB test.  Debating if this warrants an investigation for a source (our patients are very low risk).  We agree to meet later with others. {Employee Health}

Prepared for Infection Control Committee meeting in 2 days.  My lead hospitalist emails: he can’t make it. I’m bummed; he’s practical, like me.  The kitchen tells me they are overcommitted and can’t provide lunch.  We can have cafeteria vouchers instead.  I'm secretly thrilled. For some reason, ICC is a lunch meeting here.  I’m relatively new at this facility, but lunch just makes the meeting take longer.  I’d rather get through the data without the chicken Caesar salad wrap. Impractical. {Administrative/Reporting}

Ran into the unit manager in the cafeteria.  I ask her about the razors.  Patients usually shave in their rooms with nursing, she tells me.  Near the sharps box.  She wants to know who should be responsible for replacing full sharps boxes in patient rooms.  Her nurses are busy, and don’t really have time.  Could we give it to housekeeping?  Housekeeping is busy too, I tell her.  It’s not built into their workflow right now.  You’ll have to meet with their staff to talk about it.  Labor shifting is cost shifting and you can’t just dump a major task on another department without some planning.  Then she asks who is supposed to be cleaning the microwaves…..*sigh*  Eventually, I eat my lunch. {Environment of Care}

I meet with my director, the HR director, and Employee Health nurse about the TB test.  Managing possible exposures happens regularly at many facilities, but not here.  We all agree that it’s unlikely that the facility is the source of the exposure. They’re a little nervous. They want to make sure we’ve got all the details right.   I say, follow CDC guidelines.  It makes everything easy.  Then you’re not having meetings on a case-by-case basis all the time.  Make a plan (evidenced-based), and use it every time.  Process:  It’s my favorite thing. 

Assembled binders with antibiotic utilization guidelines. The PharmD student helped me pull the info together, and she made the algorithms all pretty in color.  This is a no-brain paper project I save for the end of the day when I can't think.  'Infection Control Scrapbooking', I call it.  I make pretty cover pages for the binders. {Antibiotic Stewardship}

And so today dictates tomorrow: Tomorrow’s to-do list:

Share central line data with nursing units, meet with administration about the TB investigation I think we should do to close the paperwork loop on this, ask the director of housekeeping about the microwaves, waiting to hear from therapy director about the razors, put in a work order for sharps box in the shower room, finish PowerPoint for IC Committee, find out how many offices want hygiene stations, try not to get involved in the discussion between housekeeping and nursing about changing the sharps boxes.

You can call me Al

You’re a what?  I’m an infection control practitioner.  If you do a job search on Indeed.com, we are called all sorts of things:

• Infection control professional  (ok)
• Infection control officer (badge not included)
• Infection control nurse (you don’t have to be a nurse to do this job.  In fact, I recommend  you’re not)
• Infection control coordinator (this is my current job title.  I rarely coordinate anything)
• Infection Control/Wound Care nurse (laughed out loud when I saw this job posted.  It’s like Mechanic/librarian. 2 totally different skill sets.  Some facility trying to get the most for their money.  Don’t apply.)
• Infection preventionist  (Type it into Word.  It’s underlined.  It’s not even a word.  Always sounds silly to me)
• Hospital Epidemiologist (sometimes this is the same as those above, sometimes not.  Also, nurse epidemiologist).

The Association for Professionals in Infection Control and Epidemiology is our primary professional organization.  They prefer “Infection Preventionist” (which Word is underlining in red right now).  This is why I don’t: Prevention is only one part of what I do. It would be great if it was all I did.  But, “Infection Control” includes prevention of infection when possible, control and/or containment when it happens, and treatment.  I think it’s a broader term that is more accurate.  But that’s just me.

So if you’re looking for a job in this field, those are some of the titles you’ll find.  They are all about the same.  But really, you’re looking for any job with “Director” in the title.  J

There is a major medical center near me that sometimes posts a position for an “Associate Infection Preventionist.”  It’s for someone with interest and the right background, but no experience.  They train you into the job.  This is awesome.  They can do this at a large facility because they have a team of ICPs, infectious disease doctors, and fellows.   At most facilities, which are smaller, there may be only one ICP.  There is nobody there to train a new person into the job, and that’s why it is hard to get into this field.  You might apply for a job as the sole ICP, but it’s unlikely you’ll get hired.  If you do get hired with no experience, you might have a tough time figuring out what to do on day one.

Yes, but what IS it?

So what DO I do?  My job is essentially a healthcare quality job.  I make sure we provide good, safe care to our patients.  My focus is on the health and safety of patients, staff, and visitors as it relates to infections.  I try to ensure nobody gets sick as a result of our workplace, and if they do, it is with the least amount of harm. No patient should get an infection related to their visit to our facility; First, and most importantly, because it is our duty as healthcare providers to provide the very safest care possible.  And a very distant second reason is because we are pushed to provide quality care by those who pay our bills.  Money.

Infection Control is the practice of reducing risks related to infection.   It’s process improvement: Find a problem, or potential problem, read the literature, use current best practices, apply common sense, and find solutions or improvements to the problem.  If you know where infections come from, you know where to put your efforts to prevent them. And there are a lot of sources of infections. So the ICP is focused on all of them, including:

• The patients—some people come with infections.  How do we keep it from spreading to others?
• The staff—some staff come with infections, or contract them while working
• The visitors—see above
• Equipment—equipment, if not cleaned correctly, can spread infection.  You’ve heard about the duodenoscopes, right?
• Procedures—certain invasive procedures, like surgeries or catheterizations can result in infections
• The building—everything from the ventilation system to the ceiling tiles and the plumbing can be a source
• The environment—local air quality, water quality, wildlife, etc

You need to know about all of it!   The Certification Board in Infection Control is the organization that certifies infection control professionals.  They publish what the content of the certification exam is—that is essentially all the things you need to know about (at a minimum) to function in this job.  And you don't need to pass the exam to work in the field.  In fact, they recommend you spend a couple of years working before taking the exam.  You can learn most of it from books, but you really solidify your knowledge on the job.

Getting Started

Did you ever think you want a job in Infection Control?  You did?!   We want you! 

Who does this job?  Healthcare professionals who love what they do, want to make care better, and have an odd affinity for infections.  Like me.   I’m an infection control practitioner at a hospital.  We exist in practically every type of healthcare facility.

I love my job, I love my profession, and I wish there were more of us out there.  Like lots of healthcare careers, there are more of us retiring than entering, and now it’s become a bit of a tricky field to get into because there is no clear path to get there.  You’re supposed to just show up on the first day fully qualified, ready to hit the ground running.  Good luck with that. 

But if you’re interested in what I do, stick with me and I’ll point you in the right direction, share some stories about life on the job, and maybe get you thinking that this is the job for you.  This will be a simple blog that covers the basics of this profession.  I don’t like a lot of commotion, can’t stand people who don’t think, and think most problems can be solved simply, practically.