Toeing the Party Line

So you say you want to work in Infection Control, but do you know what that really means? Lately, for me, it means gritting your teeth and saying things you might not whole-heartedly believe.  It means you’ll spend many valuable hours reporting data that offers little value to the patients or the public. It means you pledge to uphold published guidelines, even if the evidence is weak.  It means you don’t mind egg on your face when new evidence refutes whatever policy you’ve put into place based on those guidelines, then touted and spouted about for 2 years.

You can be a journal reader and a free-thinker and a researcher.  But if your conclusions don’t match the decade-old conclusions of a guideline-writing workgroup, you may find no support amongst your peers and little sympathy from auditors.

I can’t stand one more industry-co-written “research” article about how some instrument or device significantly reduced infections, when the study results are either not significant, important factors were not disclosed or ignored, or the intervention was a bundle when one part of the bundle is already proven to reduce contamination or infection.  But everyone is buying one.  Because of the ‘evidence’. And I look bad because I don’t buy the magic infection machine. “Oh, you don’t have one? When will you be getting one?”  Step up to the line.

I hate going to meetings to present infections that clearly aren’t, and saying “Well, this is the surveillance definition.” Nobody wants to hear that. Nobody understands why we are reporting and discussing “infections” that aren’t, those with no opportunity for improvement.  And neither do I. This AJM editorial came out recently and I briefly had fantasies of flinging a thousand copies of it into the air at the next infection control meeting and saying, ““Infection Control” isn’t even a thing.   Peace, out.”  Is my job the Truman Show?

I don’t like to be told by an inspector that the 50 hours I spent at conferences, my graduate degree in public health, my IC certification, the infection control assessment I do and the plan I write, the committee I run, and the initiatives I implement do not show evidence of my competence, and that I’ll have to come up with something else to prove I know how to do my job.

I’m on the fence about forcing people to get flu shots, and I’m about to fall off.  I believe 100% that healthcare workers should be vaccinated against communicable disease.  And for those that gripe about “their rights”, I don’t see any of them suing their parents for giving them a measles vaccine 30 years ago.  I’m frustrated by the lack of available data on EXACTLY HOW LONG FLU IMMUNITY LASTS.  Does it really cut out at the end of April? Not one second longer? Drops off to literally zero?  Like a little hourglass running out?  And how ‘bout those efficacy numbers?

But I put on my hat and tell staff they have to get a new one each year, even when it was exactly the same strains as last year’s vaccine. Have to.  Or they risk their jobs. Current recommendations from the party line.   I am, however, in favor of not hiring uncommitted clinical staff who don’t wash their hands, can’t bother to collect a proper culture, and show up sick, because they aren’t truly here for the good of the patient.  I’m in favor of hiring better staff. But I’m not sold on the flu shot mandate.  

I found a glimmer of hope, though, in APIC’s new public policy agenda.  It’s a lovely document identifying the challenges and priorities of the field, and what can be done to make improvements that do positively affect patient care and public health.  It advocates addressing gaps in knowledge and prioritizing HAI prevention activities and evaluating financial incentives.  It addresses accurate data collection (!) and standardization.  It tells me people are working on the things that frustrate me most.

The transparent agenda shows you the party line, and you can decide if it’s a party you want to join. And while the party continues to advocate for influenza vaccination mandates for healthcare workers, the agenda also contains guidance for how to lobby for change.  You are your profession, and you can participate and mold it.  So for all my frustrations, I will continue to participate and work towards change and promote the value of infection control, because I do believe in it.

But I will never wear a hand costume.

The Most Important Interview Question for an ICP to Ask

Good news: The demand for ICPs appears to be increasing.  Bad news: If you got the recent secret salary survey results from the MegaSurvey, you may be disappointed.  I’d like to think that my qualifications speak for themselves, but it’s important that we speak for ourselves also.  This is not an easy job, or not a job that’s easy to do well.  It requires advanced knowledge and constant education. Because crap just keeps happening out there in the world.  There is literally a new IC disaster of major proportions every year, if not more often.  From Ebola (horrible), to meningitis from contaminated pharmaceuticals, measles and mumps outbreaks, Zika, endoscopes, whooping cough, CRE...it’s never ending.  

So it’s important that your next employer recognizes your value, bringing all this apocalypse-averting knowledge with you. When you go for an interview, I hope you use the opportunity to interview the job, too.  Don’t sit there like a scared duckling, trying to cross the road, hoping to not get hit.  Ask questions.  Because bad jobs suck.  Employers are not likely getting a flood of qualified candidates when they post an ICP job. You are holding the cards right now. Get a good job.

I like to read other people’s CMS surveys.  You can find some of them online here: http://www.hospitalinspections.org/.  It’s like lawyers chasing ambulances:  I want to see the gruesome ones.  I want to see bad jobs where things go horribly wrong, so that it doesn't happen to me.  Here is a piece of one that I keep posted on my desktop. Possibly one of the worst:

VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES

Based on the request of documents and interviews, the hospital failed to ensure that there was an ongoing system in place for identifying, reporting, preventing, investigating, and controlling infections which included the following issues:

•     Failure to conduct ongoing active surveillance.

•     Failure to perform program evaluation and revision.

•     Failure to maintain a sanitary hospital environment.

•     Failure to maintain safe air handling in sterile processing.

•     Failure to practice safe food handling and sanitation techniques.

•     Failure to clean and disinfect environmental surfaces.

•     Failure to use disinfectants, antiseptics and germicides in accordance with manufacturers' guidelines.

The findings are:

A. Review of the Infection Control Program Manual did not indicate that the hospital had an active infection control surveillance program. In interview on 04/13/11 at 9:45 am, the Acting Infection Control Officer (ICO) stated that she walks around the hospital campus, takes notes and asks questions. However, review of the Infection Control Log revealed that none of her findings are recorded in that document.

B. On 04/13/11 at 9:45 am, during interview, the acting Infection Control Officer (ICO) was asked several questions regarding her knowledge and understanding of the hospital's infection control program. She made the following admissions:

•     That she had not been to all parts of the hospital during her rounds as the ICO.

•     That she did not document entries in an infection control log, but instead only sent e-mails to the Director of Quality (DOQ).

•     That no collection of infection control data had been done. She stated, "I probably would not have anything [infection control data] to show you at this time."

•     That no analysis of infection control data had been done.

•     That she had not monitored any negative trends identified from infection control data.

•     That she does not have a full understanding of how the infection control program is integrated into the hospital-wide QAPI. She stated, "I have not had an orientation to how the Infection Control program works with the Quality Assurance committee."

•     That she identifies and manages the Multi-Drug Resistant Organisms (MDRO), but just for the purpose of "seeing what is growing."

•     That she is unaware of how the operating rooms, intensive care units and isolation rooms' air handling system works.

•     That she had not observed a terminal cleaning of the operating rooms.

•     That she had not observed any aseptic technique practices used in the operating rooms while surgery was being performed; neither had she observed any aseptic technique employed outside of the operating rooms.

•     That she has not observed the sterilization process of surgical instruments. She admitted that she only knows where sterilization of the instruments is done.

•   That she was not able to ensure that disinfectants, antiseptics and germicides were being used according to manufacturers' instructions.

•   That her orientation to the infection control process has been inadequate.

The Director of Quality Management commented on 03/29/11 that the acting Infection Control officer "has caught on to the IC program very quickly and is doing a great job."

This is an infection control program that is NOT INTEGRATED into the facility’s operations.  The ICP does nothing and nobody notices, not even her.  If you are at your job and you are not pretty busy, something may be wrong.  She doesn’t even know what she doesn’t know.  If you fell into IC like this person, get yourself a mentor. Immediately.  A certified, qualified mentor.  [Or call me. I’ll Skype you through it.]

At your interview, you should ask: Who do I report to/ work with/ fall under and WHY?   IC doesn't really belong anywhere, because it’s everywhere.  Quality, nursing, education, patient care, administration? You want to know where you fit in. Above all, you want to know HOW INFECTION CONTROL IS INTEGRATED INTO THE FACILITY’S OPERATIONS.  Ask a million questions, but get that answer.

Some facilities just don’t know what they don’t know.  They simply do not have the infrastructure to run a hospital (or surgery center or care home, etc).  Even a place with a small number of patients needs a strong structure with qualified staff filling key roles.  And that costs money, and it’s hard to do when you have very few patients.  Some facilities simply fail to recognize the value of the IC role, or at the very least, the CMS mandate to fill that role and develop a program.  Some places pay lip service to the IC role, but offer no support.

An unsupported ICP role can be very lonely.  You may find that there is nowhere to bring your issues, or no structure to get something improved or resolved.  I often say, “I can’t wash their hands for them.”  And I can’t.  So how do you improve hand hygiene?  You need a team, you need leaders, you need accountability.  You can’t just walk around in a giant hand costume by yourself, trying to get staff to notice. It is very frustrating to work in a place that has no systems for action. If you are a team of one, who is helping you get things done?  

During your interview, you want to ask how the IC piece fits their puzzle.  When they are done asking about your strengths and weaknesses, ask “Can you tell me about a recent IC issue and how it was resolved?”  If there are none, you should be concerned.  Or this, ”How is the ICP informed about issues that arise?” If you get blank stares, this is not the job for you.  “Can you tell me about a recent PI project regarding infection control?  Who was involved in that?”

You want to know if you have support in your role.  Not on paper, but for real.  You want to talk to a few nurse managers on your second interview.  You want to talk to the facilities director, maybe the kitchen manager. Who was involved in that PI project?  You want to talk to them, and ask how they see their role in IC.  Do not take a job where you will sit in an office writing policies, never looking at or dealing with any issues. Because you are still responsible for the issues, even if you don’t deal with them!

Where does your data go?  If you have a million of one kind of infection, who knows about it, when do they know it, and is there a process improvement process? If there is moldy food in the patient refrigerators, and the nurses say Dietary should manage it, and Dietary says Nursing should manage it, what happens?  That’s a real world, every day type of problem which will be labeled an infection control issue, which will land on your desk, and unless you plan on inspecting and cleaning out refrigerators every day, you need to know what happens next here.  Do you have the authority to call a meeting? Is there an IC committee? Do you have liaisons or champions in different departments or units? If you ask nursing to manage it, will they? Who are they accountable to?  Or are you out there alone (cue tumbleweeds)?

Do not be afraid to walk away from a position that isn’t right.  There are more of them out there.  If you do find a great job, where you will be respected as the infection-preventing, staff-educating, regulatory-reporting beast that you are, then be sure to tell them what you’re worth. Because they truly don’t know.  

I hate to think that this female-dominated field is the victim of the gender wage gap...but seriously, it needs to be fixed.   So pull out your MegaSurvey results, find that measly median salary number, and bump it.  By 15% at least.  That’s your asking price.  You will not be sitting in an office crunching numbers.  You will be improving patient safety, educating staff, and integrating infection control into the facility’s operations--from Purchasing, to Facilities, to Food Service, to Employee Health, to Patient Care. Show them what an integrated program looks like.

How Many Jobs You Got?

If you are of a certain age, maybe you remember the In Living Color skit about the Hedley family, where the number of jobs a person had was a point for bragging rights. They’d often ask each other, “How many jobs you got?”  I have no idea if this was a stereotype or culturally accurate representation of hard-working people, but I thought of it the other day.  Because I got 3 jobs.

About 4 months ago, the housekeeping supervisor in one of our hospitals left. My director asked if I could take over in the interim, “just hold the place together for a few hours a week”  until a replacement is found.  Now, I had thought perhaps someday I’d be interested in an operations-focused role in healthcare.  And I do have a fondness for environmental services as it relates to IC.  How often does the ICP get a chance to totally control the environmental cleanliness of the facility?!  What an opportunity!  And here, opportunity knocked.  Then it punched me in the throat when I answered the door.

This is not a “few hours” job.  This is suddenly managing a full staff.  Well, not exactly: It’s managing a staff that’s missing 2 FTEs currently.  It’s interviewing, hiring, and training those people when nobody really trained me.  It’s scheduling and inventory and a laundry department. And it’s 4 months later.  4 months of learning-while-doing, of covering shifts when we have sick calls (yes, cleaning rooms), of trying to design and implement better training and operations systems.  4 months of trying to still do infection control full-time.  Some days, I definitely feel like I’m not doing very well at either job.  And I’m also still covering my other job--a very part-time gig doing IC at another place.  But I know the effort I put in now will leave that department better for the next supervisor, and honestly, for the patients as well.  This is my chance to get everything right.

I know I’m not alone.  What you do as an ICP depends quite a bit on where you do it.  IC and Employee Health overlap heavily, and in many places, it’s one department (or one person).  In nursing care centers, IC is often a combined role with staff education or nursing administration. I’ve seen ads for an ICP/Wound Care nurse, an interesting skill set.  And colleagues who work in critical access hospitals tell me they wear even more hats.

Then there’s the other side: large facilities with many IC employees.  APIC just had a great article on how one facility divides the labor.  Then there’s this one on different levels of ICP roles, with organizational charts, and what job duties fall under each role.  In a big facility, you may not see everything.  You might be responsible for only one unit, or only one type of surveillance, or one type of infection, or one ICP domain like education or data management. How would you feel about just covering LDRP? Would your Employee Health skills fade? Would you welcome the chance to be an integral part of one department?

My interests have changed over the years, and in my next job search I may be seeking something a little different than what I have now.  So if you are new to this job, think about what type of work environment you are looking for. There’s certainly something for everyone out there.

What is truth, and where do you find it?

I often caution people, “Beware of where you get your information.”  Lately, I’m finding it harder to find reliable sources myself.

Several things got me thinking this week.  First was this article that was reposted on social media.  It’s an old NYT article, following a case of scientific fraud.  I don’t really read novels, but this was written like a novel, a great article, very well done.  It’s interesting to see how it unfolded in the age just before widespread computer use.  It involves peer review, scientific publication, and all that comes with being a published academic. Read it.

The second thing that settled on me this week was the decision by the Tribeca Film Festival to screen (and then, not screen) a documentary by Andrew Wakefield about (I assume) the harms of vaccination.  Mr Wakefield had published the notorious “evidence” that vaccines cause autism. Fraud was discovered, Mr Wakefield was discredited, but the impact that initial publication left is remarkable.  I was somewhat disappointed to hear that the film would not be viewed at the Festival. I think it’s important that people see how “science” and “documentary” films are really the works of an author.  It’s too bad that the result of Mr Wakefield’s work led to decreased vaccination rates, but there is a story in every documentary--the story the author wants to tell. How much fact-checking do documentaries undergo to determine if they are, in fact, non-fiction?

How do we know what is true?  Finding good evidence for my own practice is important to me.  I like to think that if I open a journal in my field, the content published there has merit.  I see some boring studies, some of minimal effort that perhaps do not advance the knowledge of the profession too much. I take these with a grain of salt, but I expect that they are valid

I am not a researcher.  The U.S. has many academic medical centers where  research is being performed.  However, there are many more community hospitals, critical access hospitals, specialty care centers, and nursing homes where ICPs like me work.  We rely on the work that is done by others.  I’ve written here about moving towards fewer patients on isolation precautions, mostly due to new research in the field.  But there are some who disagree with that research--people whose opinion I value.  Why do they disagree?

One reason I read recently is some people feel the studies that concluded no increased risk from not using gloves and gowns with certain MDROs were not adequately powered to show a difference.  If you aren’t familiar with “power” in a study, it’s how many people or events you need to observe to conclude with some (predetermined) degree of certainty that there was or was not a difference in the groups being compared.  

For example, say I’d like to know if eating eggs prevents the occurrence of a certain disease.  I take 2 groups of 100 people each, feed one group 2 eggs a day for 2 years, while the other group eats none. After 2 years, nobody has the disease.  I conclude the eggs group was the same as the no-eggs group--eggs didn’t help. What I didn’t consider was the likelihood of the event--if this disease occurs in one out of every 1 million people annually, then I didn’t have enough people-time to really see the effects. Of course nobody got it--it’s really rare.  And it had nothing to do with eggs. My study was underpowered.

A number of years ago, the CONSORT agreement was developed, requiring authors performing randomized trials to provide more detail about their data.  They needed to spell out who was included, who was excluded, how they were randomized, what happened to each participant, and how sample size was determined.  It increased transparency in what data was being included for analysis and reporting conclusions.  How the sample size was determined is similar to power--what assumptions did you make about the events or outcomes, what degree of difference between the groups was considered significant, and how many subjects were needed to show those outcomes.  This needs to be clear, and if it’s not, someone needs to ask why, before it goes to print.

So I went back and looked at the power of one MDRO-glove-gown study.  I see the authors have a section detailing how they determined their sample size. I don’t see the actual calculation there, but I suppose I could plug the numbers into a statistics calculator. What I don’t know is if their assumptions are correct. And this is where it’s hard to be the end-user of research. Do I really need to check if every study I read is adequately powered?  Shouldn’t this be part of the peer review process?  If there were doubts, how did it get published?  Who is responsible for putting that paper in that journal?  What are their standards, and what do they owe their readers?  

There’s a “new” study this week, garnering a lot of press--about the effects of moderate alcohol consumption.  It’s not really anything new, it’s a reanalysis of old stuff--with some studies left out, and some put in.  Moving mosaic tiles around to make a new picture, really; or “selecting” data to tell a story.  It’s not my area of interest, but similar things come up in infection control. It’s a lot to weed through for a regular person like me, and I’m feeling a little discouraged lately with this "science."  Right now, I have the latest issues of two journals in my kitchen--both still in plastic.  I usually dive right in, but now, I feel kind of….meh.

How do you assimilate new research into your work?  Do you trust your sources?  Do you wait for your professional society or a higher organization (like CDC or HICPAC or WHO) to collate it into new guidelines?  Do your policies have current references?  Any references? Do you update the references, or check to see if they are still applicable, when you update policies?  Do you just do what the person before you did?  Are your policies written by committee, with little or no scientific evidence? Just a vote on what’s most convenient?

Can't Clean It? Don't Buy It.

Dear Manufacturers,

Today we are not buying any of your products, although our patients would benefit from them.  Please enlist assistance from an Infection Control or disinfection expert when crafting your instructions for cleaning and disinfecting your multi-use healthcare items.

Signed,

The Practical ICP

I’m about to start calling out some of these device manufacturers by name.  I know that endoscopes are everyone’s priority right now, but I’ve got 2 new non-critical items in front of me for evaluation, with inadequate cleaning and disinfection instructions.

One says (under “Hospital Instructions”) to ‘clean’ it by using a damp cloth or spray it with Fantastik.  If you’re not familiar, Fantastik is a household cleaner.  There are no disinfection instructions on this item.  I could use our approved wipes or sprays, but I don’t know that I’m not at risk of damaging the equipment or voiding the warranty.  So when I go to Products Committee next week, this patient device gets a NO vote from me.  Next.

Item #2 is a soft item, which says no “benzyl” products.   Benzyl isn’t a chemical, as far as I know--more of a formulation of a chemical.  So this rules out our quaternary ammonium products we have, all of which have some benzyl formulation. Also, our hydrogen peroxide product which contains benzyl alcohol.  Do you think I’m going to buy a new product to clean this item with?  Would that be practical? No, I’m not.  Staff cannot remember which product goes with which device, nor are they likely to carry a list.  This gets a No.    

Fortunately, I have a competitor product to look at for Item #2, which is machine-washable.  It says wash at 135F-145F.  Our washers are preset.  We do not measure or log, and cannot guarantee that it will be washed at this exact temp.   This is an actual safety device for a patient, and if a higher or lower wash temperature will compromise it’s integrity, I can’t risk it.  Is this small range crucial to the functioning of the product?  Why is this specified? I don’t know.  But I do know I can’t comply with the instructions, yet again.

I guess the benefit is that we saved money on all this stuff we can’t buy.

The Cost of Doing (This) Business

My retirement account is hurting badly this week with the market, so let’s talk instead about the investment in yourself.  What does it cost to do this job?

What you need to do well in infection control:

Part of being good at your job is staying informed.  You can do a lot of reading (from expensive reference books or free online publications), you can go to meetings (near or far), and you can take classes (online or in person).

I see questions on the IC community page from people who have clearly never opened any publication related to infection control or hospital epidemiology.  C’mon folks, put some effort in! My 2nd-grader was taught at school “Use your resources.”  This means before raising their hand to ask, they need to use their tools--a dictionary, a worksheet from yesterday, etc--to find the answer.   Also, one lunchtime teacher tells them “Ask 3, then me.”  This means if you can’t get the screw top off your water bottle, ask 3 classmates for help before the teacher.   Anywho, I heard somewhere once, “If you’re going to be in the profession, be IN the profession.”  Any profession.  You can’t half-a$$ this job.  People’s lives depend on your knowledge.   If you’re going to do this, make the commitment and do it.  Learn what you need to know.

So what does it cost to do this?

This can be cheap and easy, or not.  Here’s what I spent last year:

• Second nursing license for a job in a facility that covers more than one state (although there is no reason on earth why you need to be a nurse (even in one state) to do this job): $120 for license, $50 for fingerprinting
• The new APIC guide to construction: $126 plus TWENTY TWO DOLLARS for shipping.  No, the author did not personally deliver a signed copy to my home, as I expected for such an exorbitant shipping fee.  [What the heck, APIC?  US Postal Service ships anywhere for 5 bucks.]
• Regional APIC conference, (which I rarely attend because it is hosted at the same place, twice a year, in the most western part of my region where hardly anyone lives.  So everyone is driving almost 3 hours to get there. 6 hours of driving is a lot for one day. I think.): $125. Nice lunch, though.
• National conference: $699 +airfare + hotel +car +meals [$266+$780+$50] (no car last time).  My employer paid for half.  Benefits include almost all the continuing ed credits I need for the year.  My share: $897.50
• Professional memberships (4), which give you a discount off conferences, texts, journals, some free education, and meetings: $456
• APIC text (online version): $169
• Nursing license, renewal fee: None this year, but every other year, 2 licenses ($80 + $120), so yearly average of $100.
• Online course: $25

Grand Total: not an insignificant percent of my income. $2552.50

I consider my memberships and the APIC text to be the bare minimum necessities for this job.

What’s wrong with Omaha? 

The problem with conferences for me is the distance:

I’ve attended a national conference for one of my professional organizations each of the last three years.  The average distance from my house to one of these events was 2004.6 miles, and I live in the continental US.  Does nobody who plans a conference ever look at the population distribution of our country?  I looked back at past conferences (from several organizations) to see that none had been within 500 miles of my house, and I live in a very populous part of the country.  The most populous part, in fact.

If you live on the east coast, a west coast conference is especially brutal because you lose a day coming back.  Conference ends at 12noon on Sunday, and if you can’t get on a 2pm flight, you take the 11pm (there’s nothing in between), putting you back east at 7am the next morning on practically no sleep.  Then try to get out of that airport city during morning rush traffic.  Are you going into work?  I’m not. This is a feeling that reminds me of college: nauseous, dehydrated, and exhausted. Day lost.

Organizers put these things sometimes in a “fun” city, and your brochure will tell you all the things you probably won’t see.  If I’m spending my boss’s money and my time, I’m going to every session I can.  In the past, that’s been from 7am to 7pm.  Would I like to venture out into a strange city after dark by myself?  Nope, thanks.  Heading back to my hotel room to catch up on email and call my kids to say goodnight.   So don’t bother with Orlando or San Francisco.  Put the next one in Omaha, which is equidistant for most people, mild weather most of the time (unlike San Antonio in June. Seriously.), and not packed with activities, landmarks, and events that I’ll never see. Or Missouri, which is the population center of the country.

I value the information at conferences, but in this day, when you can Skype, GoTo, FaceTime, and stream everything, why do I physically need to sit in Anaheim to watch a powerpoint presentation?  I am a sole practitioner at my facility.  This kind of travel, while it’s paid work time, is lost work time.  I really cannot give up 5 days of work time.  There is no way to make that up.  I’ve got kids that are still in school, and it’s an inconvenience to ask for favors from the grandparents for a week of drop-off and pick-up.  So, this is the type of investment I’ve decided not to make in myself this year.  I can’t do another one.  

I would gladly pay half the conference fee for access to the presentations, which I can watch at my leisure, either at my desk, or on my couch. And my employer would gladly not pay hotel, airfare, rental car, and meals.  Talk about wasting our healthcare dollars. I think we might need to rethink the conferences.  Can we move them back and forth along the 39th parallel, or just make Omaha the conference capital of the country? I’m sure they’d appreciate it.

What do you think is reasonable expense for your job? If your employer pays for a resource book, will you leave it behind when you go to your next job, or take it with you?