Look Closely

I recently trained a brand-new ICP.  There’s so much to teach, but if you get a good candidate, it’s easy, because so much of what we do is common sense.  She sometimes came to me after doing rounds, and remarked on something that didn’t look quite right, but she wasn’t sure how to handle it. So before she had read and memorized a thousand pages of infection control reference materials and guidelines and policies, she knew when something wasn’t right.  Infection control gives you new eyes on a place you’ve worked for years.   

The next step after recognizing an issue is knowing where to find the answer.  Does your issue really violate good infection control practices and patient safety? You need to know your resources, but you don't need to memorize every one.  Google is my best friend.  Because the problem you are facing is not likely the first occurrence of said problem in the history of modern healthcare, there is information out there somewhere on it.  Often my search leads directly to one of the published guidelines, and then I don’t have to know exactly which one it is off-hand.  I find the CDC MDRO and Precautions guidelines overlap a lot, and the SHEA compendium overlaps APIC.  So if you are looking for exact wording on your issue without reading through each one, just do an internet search with as many key words as you can.

Over the years, I’ve collected (and I’m sure many ICPs have) a number of photos of things that didn’t look right.

Exhibit 1:

This is a feeding pump.  Staff let the pediatric patients decorate it with adhesive stickers to make it look it more friendly.   Does it look not-quite-right to you?  It should.  All of that adhesive attracts debris, and you can’t clean adhesive.   In fact, those stickers are debris. Feeding fluids are full of sugars, proteins, and other nutrients that are great for feeding humans and bacteria.  There should not be adhesives on patient care items. Reference: CDC Guideline for Cleaning and Disinfection

Exhibit 2:

This is drinks at the nursing station.  I count 3 from this angle. Along with a personal bag.  We use this counter to put laboratory specimens, patient charts (gross), glcuometers, etc.  It is not a clean area.  Staff should have a clean area for food and drinks in a non-clinical space, and should have a work flow that allows for breaks for their own fluid intake.  This is up to the manager to police and enforce.  I always find more drinks after-hours than during the day.  Reference: OSHA blood borne pathogen standard.

Exhibit 3:

This is an isolation gown, hanging on the doorknob, ready to be worn again…..   Does it look wrong?  If you don’t see dozens of gowns on doorknobs, then one should strike you as an aberrancy, something out of the ordinary.  Isolation gowns are worn once.  They are considered contaminated once worn, and you would not be able to put it on again without recontaminating yourself.  This is wrong. Reference: CDC Guideline for Isolation Precautions.

Exhibit 4:

I didn’t take this photo; an environmental services manager did, and brought it to me.  He said, “Can they leave the ceiling open?” No, they can’t. This is open for work being done in a patient room.  He walked by the room and the door was open, and no worker was nearby.  As the room is empty, it’s likely been cleaned.  Does the Facilities staff know they need to contain debris from the ceiling in a patient area? That a ladder and open tiles shouldn’t be unattended?  Does the nursing staff know that they can’t just push the bed back in there, as the room needs to be cleaned again?   This is the result of poor project planning: Nursing needs to know what work is being done, Facilities needs to know how to do it safely, and everyone, including EVS, needs to be sure the room is clean after.

Exhibit 5:

What’s this?  I wish it was a better pic. But this is several layers of plastic (soft) containment set up during major construction in a hospital.  Is something wrong here?  Why, yes.  I can see the glowing exit sign at the end of the hallway they are working in.  This is 2 layers of containment, both open, gently blowing in the breeze, so that a person on the safe side with a camera can actually see all the way through the demolition area to the other end. Unacceptable. Containment is for containing debris and air contaminants, and protecting patients and staff.  This is doing neither.  This is where you may wield your authority, and tell the contractor to stop work until the containment is fixed.  Speak to your Facilities director immediately, as they are responsible for ensuring contractors are properly trained in infection control measures, and have ultimate responsibility for ensuring it happens.  Reference for both above: CDC Guidelines for Environmental Infection Control in Health Care Facilities

So if you wander about your facility and see something that doesn’t look quite right or something you’ve not seen in other facilities, trust your gut: it’s probably wrong.  Head back to your office, find your reference, and then go correct the problem like the infection-preventing deity you are.

Mind the Gap

The APIC Megasurvey gave us a lot of information about our profession: It’s aging (we are mostly over 50), less than half of us are certified (horrors!).  But what was missing from the survey, that I consider important, is about vacancy.  How many facilities have vacancies they can’t fill? How long are postings open before being filled?  Did the hiring manager get the type of person they advertised for, or did they settle for something less?

In my area, ICPs are becoming harder to find.  I see job postings linger longer.  I hear colleagues are retiring.  I  am leaving my position soon, and gave my employer nearly six months notice, knowing how hard it is to fill the position. We had only one applicant.  A part-time position I had last year called to see if I was interested in returning--the position has been open since I left a year ago.  Smaller facilities struggle, and most US facilities are smaller--2/3rds have less than 200 beds, and 28% have less than 50, according to NHSN data.  And that’s just acute care sites.  There are nursing homes and outpatient clinics and surgery centers and psychiatric facilities--all in need of good infection preventionists, but with a seemingly small pool of qualified talent to draw from.

There is a yawning gap between some people genuinely interested in this career, and the career, because there is not always a way to take one’s suitable education and get a job whilst having no experience.  I don’t believe we have clearly laid out a path into this profession.  We are failing ourselves and our discipline. Yes, there are a few online graduate programs now, but some are MSN programs--only good if you have a BSN.

I met a lovely woman recently, looking for a US ICP job.  She “only” had international experience and couldn’t seem to get a job here.  I say “only” because I would simply die at my good fortune if a multilingual, master’s prepared, well-spoken person applied to my department fresh off a stint implementing an infection control and sanitation program in a resource-poor setting.  THIS is public health, THIS is program planning, THIS requires innovation, THIS is someone I want to talk to.   But she had no US hospital experience, and employers couldn’t see past it.

What she needed was an internship or mentorship of some kind.  Bigger hospitals or systems can mentor a new person in to the job (grow your own), but smaller sites don’t have anyone to do it, especially if the last ICP is leaving or has already left.  This is really an unfortunate set-up. Hospitals willing to do so could offer a mentorship or internship to interested professionals, as a type of schooling, but it would likely be unpaid, and thus they’d need candidates who could afford to spend several months working with the ICP, full time, for no money.  There aren’t many candidates who could afford to do that.

Also, it seems employers can’t see past the “infection control nurse” title.  You. don’t. need. to. be. a. nurse.   But the hiring manager or director is often NOT an ICP.  They are perhaps the quality manager, the nursing director, the vice president of patient care, and don’t always fully understand what skill set it takes to be successful.  The large number of nurses in any facility clouds one’s view of all of the other professions who have equal, although different, education and skills.  Some nurses are only diploma-educated.  Your respiratory therapists are much more qualified than that nurse. I can see a process management person doing well in this job.  Certainly anyone with epidemiology training can succeed.  It is the process improvement piece that is the bigger part of  this job, much bigger than the nursing piece.   Employers are limiting themselves, and very qualified people are being left out. Employers that can’t fill positions sometimes go to contract agencies.  I’ve looked at these jobs, and most list the position as “RN required.”  And I think, maybe if you changed your requirements, you would have been able to fill the position.  Now you’ve just turfed the problem to someone else.

We need a gap closer.  We need that middle mentorship piece.  We need to educate employers about the position, and what skill sets will be successful. We need to advertise the career.  The APIC Roadmap is great, once you’re in, but we need a map of the path that leads to the road.

This is what we came for

I am here as a resource: to my coworkers, to my professional colleagues, and to anyone in this career.  If I can help you in some way regarding infection prevention and control, then I am happy.   I often say to staff, “If you’ve spent more than 3 minutes on the CDC website, you’ve done too much.  Just call me.  Either I already have the answer or I know where to find it.”  Let me help you; this is why they hired me.

I don’t know everything, not even close. I’m Googling while you’re asking me a question on the phone.  But I know my resources.  You’re looking for a professional connection in your area?  Let me put you in touch with one of my tweeps or the local chapter leadership there.  Your kid has an itchy bottom and the doctor wants you to do something bizarre with a piece of adhesive tape?  Let me explain what they’re looking for and how to get a good sample.   Your patient says the other hospital staff wore gowns when treating him?  Let me call their IC department.  The hand sanitizer bothers your skin? Let me get some other samples for you.

There are certainly days when you feel overwhelmed and underappreciated, but if you continue to build your knowledge, identify your resources, and offer people calm and rational information, they will come to rely on you (in a healthy way).  And that is probably one of the best compliments you can get in this job.  Or in any job.

Here is a blissful little story from my week.  A staff nurse notes a new issue, and brings her concern to her manager.  Her manager sees that there might be an infection concern, and calls me.  She doesn’t even try to solve it, because she knows I am the resource she needs.  I identify the problem, and what we need to fix it.  I could spend hours looking for the solution, but I have something better.  I have a vendor I trust.  I send him an email that explains exactly what I need.*   Do you have a product that meets this need?  Yes.  Yes, he does.  He is my resource.  I know he has the information I need, and I don’t need to spend hours looking for it.  Surround yourself with people like this. His company isn’t our preferred vendor, but he’s my first go-to, because he saves me endless amounts of time.

Today, our solution arrived.**  The manager and I opened the packages, and I did a little dance.  It was everything we hoped for, and exactly what we needed. All the stars aligned, it was a good day, someone needed me and I came through (because someone came through for me).   I feel like I reached a little milestone in my career. It’s bittersweet because I have decided to leave this fabulous job in a few months. I work with great people who do amazing work, but I need a short break, and I’m not sure what’s next for me.  But I wish you days like this in your career, when you feel your value, no matter what your work is.

*[I need to disinfect floors in an outpatient area that has no housekeeping staff.  It needs a long shelf stability because it won’t be used often. It needs a disposable component because there is no laundry service. It must be ready to use because there is no dilution system. It needs to be compact for storage, and must require minimum PPE for handling so staff aren’t at risk mixing or diluting chemicals.]

**We got the Diversey Pace mop and the SmartMix chemicals--which is a fabulous, amazing, genius thing.  I rarely rave about anything.  But this is so exactly perfect for our setting that I’m going to gush over it as only an ICP can about disinfectant products.