Country Mouse Goes to the City

After some time away, I went back about 6 months ago.   I had been working in a post-acute setting, helping a former director set up a good program.  When I accomplished that, I decided to move on.  Imagine my surprise to hear a recruiter tell me I was “not a competitive candidate” for a job in acute care since my last position was in post-acute. My job search took much longer than I expected, and I suspect this was part of the issue.  

It is unfortunate that hiring managers are often unfamiliar with the actual work of infection control.  Skills in one setting are nearly entirely transferable to another setting.  One doesn’t immediately lose all of their past knowledge when they haven’t used it in a couple of years.  Maybe you need to brush up on some things, but resources are readily available. I haven’t driven to Pennsylvania in a decade, but I know which direction to go, and I know where to find a map.  I didn’t forget how to drive, and I won’t end up in Toronto.

I was also looking for part-time work, which appears to be an infection control unicorn. I don’t know why employers don’t offer part-time positions in this field around here.  So I took a full-time job at a mid-sized academic medical center-- a little different from the community hospitals, rehabilitation, and psychiatric settings I was used to, but I wanted to work with other people.  I’d almost always worked by myself in the past.  It’s been quite a change in some ways, but there are really no infection control things that are different.  What I learned from working alone for many years is, well, everything.

Being the sole practitioner is a bit like being the country doctor.  They deliver babies, set broken arms, treat coughs and stomach pains, provide palliative and end of life care, and everything in between.  Same with the country ICP.  I’ve given thousands of flu shots as I’ve worked with Employee Health in the past.  This year, I gave none: we’ve got a department that manages that.  I’ve taken all that vax data, sorted it (sometimes by hand on paper), to enter into NHSN.  Not here: they’ve got a fancy employee scanner machine that uploads all that.  I’ve planted and read hundreds of TB skin tests, but now we use blood tests. In the past, I’ve answered dozens of phone calls from staff about their own symptoms, an infection their mom had, or a rash on their child.  Not here. Not one.

Once upon a time, I did lots of education: orientation sessions for new employees, covering BBP and tuberculosis, demonstrating PPE, talking about the failure rate of exam gloves, and using good hand hygiene. Every other Monday, for 40 minutes, for years.  I did small group sessions with the new medical residents, talking about our IC policies and infection-related quality metrics.  I met with new nurses and new nursing aides each month for an hour to review precautions, specimen collection and diagnostic stewardship, and appropriate infection documentation.  Not here: other people do all that.  Too bad, it was a nice opportunity to meet staff and build relationships.

Elsewhere, I went to nursing staff meetings to talk about new initiatives and policies.  Now, everything is delivered through an education department. I don’t really talk to staff directly.  I used to work on process improvement projects from the annual risk assessment. I’d research them, develop them, engage other leaders, and move forward.  Now, if I want to initiate something, I need to review it with a lot of people.  Policies go to many committees.  Things take a very long time. In the big hospital, infection control projects are going on in other areas, and nobody asks for help from us.  Sometimes we find out later about departmental initiatives.

I used to manage all of my own PI data (and some other departments’ data, like antibiotic stewardship), and present it at half a dozen meetings--regulatory preparedness, process improvement, clinical operations, environment of care, safety and emergency management, etc.  Here, we have a data analyst to manage most of that, and the doctors present everything at meetings. You might be wondering what it is I do all day now: Surveillance, lots of electronic surveillance.  Thousands of surgical cases, dozens of potential device-related infections. I’ve gained about 8 pounds in 7 months sitting at my desk. Some days, I never leave the office.

But what I do have is other people. Most importantly, they are people who know infection control. I don’t have an ID physician who comes to the monthly meeting and is never seen again.  I have FIVE ID docs who work in the hospital, all day long.  And I have a hospital epidemiologist, who is a walking encyclopedia of every piece of infection prevention and control knowledge written since the beginning of time.  I could call any one of them, at any time, and they’ll have something thoughtful to say about an issue.  They have an ID case conference each month, where they discuss interesting things.  The microbiology staff and the pharmacy staff join in, and it’s a very nice learning environment.

When there was an outbreak of something in the past (food illness, TB exposure, influenza), I’d call the health department, fax all the records, call or interview patients (have you ever done a food illness investigation? Brutal: 5 pages of food--have you eaten any sausage? Bratwurst? Knockwurst? Weisswurst? Kielbasa? Chorizo? Hot dogs? Chinese sausage? Chicken sausage? Breakfast sausage? How about cheese?), create any internal messaging, help set up a phone line, and work 18 hours some days.   

Here, we had a little outbreak thing.  An executive team member deftly led an emergency meeting.  The communications team created the messaging and notifications, the epi MD spoke to the board of health, nurses notified all affected inpatients, telecommunications set up a big phone bank, and nurse leaders called all the discharged patients, and pharmacy helped secure vaccine while nurses vaccinated anyone who needed it. I wrote the phone script, and went home at 4pm.  I called zero patients. I gave zero vaccines. I spoke to the health department just once. I am definitely not in Kansas anymore.

My past experiences gave me both a broad and deep knowledge of much of the infection control discipline, mostly out of necessity. I’ve worked in a variety of settings, purposely, to gain more skills.  I don’t regret any of it.  I find that my varied experiences have made me much better at this job. And while some may not like my resume of shorter stints, I find that most people who’ve worked at the same place for 30 years have a very narrow and often unmoveable view of how to do something, as they’ve literally never seen any other way.  It’s like never leaving your house. I’ve seen 6 ways to do everything, and can usually see, or at least present, a solution for a certain situation.

There’s so much to see in this field.  Go see it.

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.

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.