Everything is Infection Control. Everything.

Gather round for a story, about all the things that you should know because the people whose job it is to know them don’t always know them.

Our pharmacy director mentions in passing that the state board of pharmacy is coming in to one of our small sites.

“They are here to review the moving of the pharmacy”

Me: We’re moving the pharmacy? [which is just a small, dry storage room with a computer. No mixing.]

Her: Yes, we are swapping the nurses’ medication room with the pharmacy.  Nurses need more space.

Me: How did I not hear about this construction project?

Her: Oh, there’s no construction, just a swap.

Me: The nurses’ med room has to have a sink.  The current pharmacy space doesn’t have a sink.

Her:

Me:

Her: Really? Are you kidding?

Me: Nope, not kidding.  The facilities manager should have known that.

Her: Who says you have to have one?

Me: First, it’s good practice.  You should have one for handwashing, making G-tube slurries, disposing of IV bags.  For patient safety, all med prep should be done in one area---without having to leave the med room for things like water.  From an infection control view, staff should be washing hands immediately before med prep.  From a regulations view, it is definitely in the FGI guidelines, but there might be a different code book we are following.  But even if it’s not in there, I’d want a sink.

Her: mumbling and swearing as this makes a giant mess of a plan that was about to happen in a few days’ time. And she wants proof that this needs to be done.  Many phone calls are then made to many important people.  Nobody is happy. I have turned a furniture-moving event into major plumbing and renovation.

So I call the Facilities Director, who knows nothing about sinks in med rooms, or which guidelines we are following, or about any other AHJs in this matter.  So I ask if I can have access to his FGI guidelines.  Which he doesn’t have.  Seriously, does not own.  He refers me to the International Building Code, which, while applicable, is not useful in this situation. (IBC tells you what gauge of electrical wire or type of cement to use, not interior design and function). 

The guidelines that direct how to design, construct, and renovate healthcare facilities is not in the possession of the person who is in charge of these things. The read-only copy (which I’ve read, and so should you) is available free online, but it can be tedious to search.   So at 7pm, from home, I shell out $200 on my credit card for the applicable edition of the FGI manual.  And share a screenshot of the medication room guidelines with all interested parties.  All plans come to a screeching halt.  And that was my last day on that job, so I have no idea what happened after. (The pharm director was a very conscientious person, so the sink likely happened, or the move didn’t happen.)

Projects planning committees are crucial.  You must be on them.  Projects that nobody thinks are projects are often projects.  This is one of a dozen stories I could tell. 

There is a webinar coming up soon on using the FGI guidelines.  I hope you’ll sign up if you aren’t familiar with them.  You never know when you might need to know how to do someone else’s job for them.

https://www.fgiguidelines.org/aia-fgi-webinar-the-2018-guidelines-how-to-use-and-major-updates/

Respect my authority

There was an article recently that sort of triggered me, and I wanted to talk about it a bit.  It’s about being the only voice in Infection Prevention, and sometimes being frustratingly powerless to make necessary changes for patient safety.  If you work in a large organization, you might not know what I’m talking about.  But I’ve spent most of my time in small places where I am the only voice. It doesn’t happen always, but often enough that it has made me wonder why I do this job.

I have worked in a few different arrangements:

• A mid-sized hospital, with another ICP, and 2 ID physicians who: saw patients, chaired the IC committee, provided consults to colleagues, took call overnight, and were involved in antibiotic usage.
• A small hospital, where I was the only IP.  One ID physician who: covered many facilities on consult and had an outpatient practice, was supportive, but very busy, came to IC committee, but I did all the work.
• A small hospital where I was the only IP. All calls were mine. The ID physician was on consult to the IC program, did not see patients at the facility, employed elsewhere, engaged at quarterly IC committee, but mostly unavailable otherwise.
• A very small hospital where I was a consultant ICP for just a few hours a week.  No ID physician.  All calls were mine. I ran committee, and an MD was present and signed off.

When there is an issue in infection control, and there is no readily available physician or other staff, it is up to me to present the issue and my suggestion for ameliorating it.  I am confident in my knowledge and skills, but frequently this is not enough.  I simply have no authority to implement significant changes without support from administration.

When a CRE patient presents from an outside facility, I gather the key players, and explain current CDC guidance for patient care.  I print fact sheets for patients and staff.  I make myself available on the unit for questions and support. But I cannot implement the recommended staffing changes.  I am told that it isn’t possible for the nurse to have only one patient.  Maybe it’s a budget issue, or a planning issue, or they don’t completely understand the implications of CRE spreading.  But I cannot control it.

When the OR staff reports that a surgeon doesn’t wash his hands due to a skin condition, I approach my boss.  She agrees this is serious.  She arranges a meeting with the surgeon.  He explains his issue.  I grit my teeth while she suggests other options out loud: double gloves, a dermatology consult, different soap.  I explain the standards.  She asks me to see if he has a higher rate of infections in his patients.  The numbers are too small for meaningful comparison.  She takes this as ‘no.’  She tells me we can’t take away his job. He continues to practice.

I find expired skin antiseptics in a supply closet.  I let staff know they need to be thrown away and replaced.  They tell me that then they won’t have any because the secretary does the ordering and she’s off next week.  I ask how they check for expired supplies.  Blank stares.  I find many more.  I have no boss in this small organization.  He left 6 months ago, and they haven’t found a replacement.  Next in line is the CEO.  I do not know who he is, and he likely can’t order supplies.  At the next committee meeting, it’s agreed that someone should be in charge of checking and ordering supplies.  The nurse manager says her staff don’t have time. There is literally no solution anyone can agree to, and I am stunned.

The majority of us in the US are ICPs in small facilities.  It can be very frustrating to be expected to maintain the same standards that large facilities have.  I want everything for my patients--the safest care, according to recommended practice standards.  But in all but one site I have worked in, the IC department didn’t even have its own budget.  Nothing specifically allocated to education, to supplies.  Just a salary, for someone to come in and fill that CMS required role.  And directors who look surprised when you show up holding guidelines and asking for support and action.  Perhaps they hoped I would just sit in the office and tabulate things.  Instead, I sit in the office and document things.  Because when something goes wrong, I will have evidence that I did everything I could within my power to inform those who do have the power.  And it will not be on me.

Bombs away

I stepped away for a bit.  I gave plenty of notice, trained a new person, and left my job 6 months ago.  It was a good time for me.  With a little help from Mr.MoneyMustache, I got some perspective, put things in order, and took some time for myself.  

Sometimes you’re too busy to do the job well.  The days can be long, and I was barely keeping up with new regulations and standards.  Reading that I had planned to do later just wasn’t getting done, because by the time I got home I did not want to do more work.  As a salaried employee, it’s often required, and I get that, but something was just missing for me, and I wasn’t enjoying it much anymore. In my time off, I enjoyed summer vacation with my family, went to a 3-day conference that I would never have been able to get to if I was still working, and read through a growing stack of journals and regulations from the comfort of my front porch.  And I picked up a part-time job in the microbiology lab, where I go 2 days a week, and happily punch out after 8 hours.  I needed to put my hands on something real, something that felt like patient care. I also joined the board of my local IC chapter, which I had long wanted to do. But I’ll be back to infection control soon.

I’m still on staff at my old job, just on the periphery, supporting the newbie through any crisis.  And I have a bit of a different perspective watching her work.  She can get overwhelmed by the crises.  You should know that bombs drop on Infection Control on the regular (or irregular. Or regularly irregularly).  You can’t get flustered.  This, too, shall pass.

The key is being prepared.  You need to leave mental room in your workflow and in your stress level for bombs that will drop.  (Great time mgmt piece, here..Almost all pertinent to IC). You will be plugging along, preparing docs for meetings, calculating your hand hygiene, doing new employee orientation every other Monday...and a bomb will drop on your desk.

 A kitchen worker has a positive Hepatitis A test.   Are you kidding me?  Call Employee Health, make sure he’s out and under the care of a physician.  Just get him out of the workplace and figure out the rest after.  Check your patients, is anyone sick?  Call your board of health, if they haven’t called you first, about that positive test.  Nobody is sick. Good.  When did he work last?  Find your guidelines on Hep A--state, local, or CDC.  Who needs to be vaccinated? Anyone? Can pharmacy get vaccine?  Administration wants a huddle about this.  NOW.  

This is a bomb.  It will require you to stay late, write a lot of things down, call a lot of people, wait for them to call you back, provide education, and maybe pretend that it’s totally under control.  Which it will be, in 2 or 3 days.  So hopefully, your mandated data reporting isn’t due tomorrow.  Or your report to the hospital board.  You’ve got to leave yourself a small buffer.  Do not be a procrastinator in this job, because you don’t know when the next crisis will hit.  Sometimes even a little crisis (like falsely positive Hep A tests, which happen a lot) takes a couple of days to sort out.  A major crisis (like staff drug diversion with multiple exposed and infected patients), takes weeks.  

When something super major happens, you can be assured that your state board of health will step in, or a federal authority, heaven forbid.  And you will have support, or you may even be pushed out of the way.  But small bombs are all yours.  If you’re new, or in a small or resource-weak setting, you should have a mentor, or a resource somewhere.  Maybe an ICP from a nearby hospital, someone with a little more experience under their belt, who can point you towards the right guidelines and documents.  Try to make connections at a local conference.  Just be honest, and say, “Hey, I’m all alone at our 12-bed hospital.  Do you think I could give you a call to talk through something if I get a tough situation?”  Hopefully, that person is flattered that you asked, and you get a few phone numbers to keep in your pocket.

It can definitely feel like nobody listens to me when I tell them to wash their hands or document the patient’s stools carefully.  But in a crisis situation, I’ve sat in the C-suite with everyone looking at me for what to do next.  It’s the only time I have a modicum of authority (IC is tons of responsibility, zero authority). The very first step in crisis control is to stop the offending issue immediately, and then head to your office to find your guidelines, review your policy, and make a phone call.  CDC has good resources on the steps of an outbreak investigation, and plenty of disease-specific resources for illness in healthcare settings. (And know that you are not the first person to have faced such an issue before--whether it’s mold in the OR, faulty sterilizers, hepatitis A in food service staff, or flu amongst the patients.)

No matter how new you are, you are still the most knowledgeable person in your facility regarding infection prevention and control.  Put on a confident face (and a decent shirt), and tell what you know, and what you don’t, what your next steps are, and what you need from them.  People are looking to you. And you’re going to do great.

 **Patient notification is the last step in a crisis, when necessary.  Don’t ever notify anyone of anything until you have every last piece of info, and the local health department is on board. It’s a very big deal. Do not attempt any part of patient notification alone.