Summer 2015 Volume 8 number 2

Lessons
learned
Questions and concerns
regarding safety of
endoscopes and validity of
manufacturer guidance

+
Emergency preparedness
simulation exercises COVER PHOTO: Dartmouth-Hitchcock/Mark Washburn

Hand hygiene hurdles:

How can we overcome them?
Measles in the U.S.:
Discussions with public
health representatives
 Requirement #2:

www.rduvc.com

We look forward to seeing

you at APIC 2015. Please
visit us at Booth 1140.

Call 800.475.9040 or e-mail us at GSA Contract # FSS Contract #

info.northamerica@getinge.com. GS-07F-193BA V797P-4452b
Approved for use in all Federal Government facilities.
GPO Contracts: Premier, Novation and MedAssets
2015 Steriliz, Inc. Steriliz is a trademark of Steriliz, LLC.
 Getting patients
home safe is a
tough job.

Now, Environmental
Services has a
powerful partner.
PDI, a leader in infection prevention,
provides a full suite of products, education
and support designed specifically for
Environmental Services professionals to
help foster collaboration between
departments and reduce HAIs.

Together, we can get patients home

where they belong.

2015
Professional
Disposables
International, Inc.
All rights reserved.

Dont miss the Delivering the Difference contest winner presentation at APIC Booth 514.
Reduce S. aureus Nasal Carriage
Without Antibiotics

Our nurses and patients really like the Nozin program

and with the cost savings its been a true win-win.
-- Brian Kendler, Infection Preventionist,
Marshall Medical Center, CA

3 Perioperative Care
3 Same Day Decolonization*
3 Universal ICU Carriage Reduction
3 Eliminate Screen and Isolate
Nozin Nasal Sanitizer antiseptic combines ethanol with moisturizing emollients and is clinically
proven to profoundly reduce nasal colonization in one day.* No antibiotics. No iodine. With a Nozin
program, you can help protect patients and staff against the spread of infection, improve quality of
care and reduce infection control costs.

Contact us to learn more

and for professional samples.
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Think hand sanitizer for your nose.

*Steed L, et al. Reduction of nasal Staphylococcus aureus carriage. American Journal of Infection Control. Vol 42, Issue 8, 2014.
2015 Global Life Technologies Corp. All rights reserved. Made in USA. Nozin Nasal Sanitizer antiseptic is an OTC topical antiseptic drug and no claim is made that it has an effect on any disease.
 Contents
Summer 2015
Features

Lessons learned:
Questions and concerns
COVER PHOTO CREDIT: Dartmouth-Hitchcock/Mark Washburn

regarding safety of endoscopes Measles in the U.S.:

and validity of Discussions with public
manufacturer guidance health representatives
Questions and answers with experts

58
With the Cook County Department of Public Health,
Chicago Department of Public Health, and Maricopa

64
County Department of Public Health

Share Prevention Strategist articles with others.

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Check out the icons next to each article to help you navigate Prevention Strategist easily and identify
articles to share with others in your healthcare organization or beyond. Audiences include:

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6 | Summer 2015 | Prevention

VOICE
Envisioning the future  8
By Dr. Mary Lou Manning, 2015 Apic President

APIC 2014 scorecard: Tracking key metrics toward our goals 10

By Katrina Crist, APIC CEO

Change continues: Are you eligible? 12

By Kathy McGhie, 2015 CBIC President

DEPARTMENTS
Meet a CIC: Nancy Wood, RN, BSN, CIC 15

40
Briefs to keep you in-the-know 19
APIC honors global public health advocate with its
highest infection prevention award
APIC Strategic Partner: Aramark
New long-term care infection prevention skills pledge tool
Chief medical officer from Florida receives APICs
2015 Healthcare Administrator Award
Capitol Comments: New incentives improve healthcare quality, 22
cost, and public health
By Nancy Hailpern, Lisa Tomlinson, and Patricia Gray

Chapter Spotlight: APIC Greater LA 26

Take back your hashtags: An infection preventionists guide to Twitter
By Angela Vassallo

Global Insight: Perspective from AustraliaRoutine culturing and

surveillance of endoscopes 33

44
By Dr. Cathryn Murphy

Infection prevention leadership: My personal journey 37

By Timothy Bowers

PREVENTION IN ACTION
Emergency preparedness and infection control: 40
Teaming up to create meaningful staff simulation exercises
By Kristine Sanger

Focus on long-term care and behavioral health outbreaks: 44

Clostridium perfringens
By Steven J. Schweon

A family-centered care model to reduce pediatric CAUTI 46

By Vicky Uhland

My Bugaboo: Hepatitis CThe silent epidemic 50

By Dr. Irena Kenneley

Hand hygiene hurdles: How can we overcome them?

Q&A with Dr. Timothy Landers
By Vicky Uhland
55
55
w w w.apic.org | 7
PRESIDENTS MESSAGE

Prevention
The Ebola crisis in the United States highlighted the fact that infection pre-
Envisioning vention and control programs are generally under-resourced and have limited
surge capacity. This has led to the growing question echoed among infection
the future preventionists (IPs) and healthcare epidemiologists: How do we influence
S u m m e r 2 015 VO L UME 8 , I S S UE 2
organizational decision-makers to invest in infection prevention and control
programs to assure we have the critical resources to prevent and manage infections Board of Directors
on a day-to-day basis and be prepared to rapidly respond to the inevitable, but President
unpredictable, appearance of emerging (and re-emerging) infectious diseases? Mary Lou Manning, PhD, CRNP, CIC,
FAAN, FNAP
While this question is important, recent national and global events have opened President-Elect
a large window of opportunity to bring forth a bolder question: In this era of Susan A. Dolan, RN, MS, CIC
rapid health and healthcare transformation, is now the time to reimagine the Treasurer
Marc-Oliver Wright, MT(ASCP), MS, CIC
strategic role and functions of infection prevention and control programs in an
Secretary
increasingly complex and interdependent world? Connie J. Steed, RN, MSN, CIC
Reimagination requires inviting new ideas, exploring possibilities, and envi- Immediate Past President
sioning the future. As an infection prevention community, we need to span Jennie L. Mayfield, BSN, MPH, CIC
boundaries outside our own circles to deliberately engage with others to create
partnerships, alliances, and other forms of collaboration to tackle this complex Directors
Joseph A. Bosco, III, MD
question. APIC has forged strategic relationships with many organizations and
Kim Boynton-Delahanty, RN, BSN, PHN,
continues to scan the environment for additional partners, all of whom can MBA/HCM, CIC
provide insight. As infection prevention leaders, boundary spanning may require Gail Fraine, RN, MMHC, BSN, CIC
new skills in order to proficiently reach across professions, functions, sectors, or Deborah G. Friberg, MBA, FACHE
By Mary Lou
Manning, organizations to build relationships, interconnections, and interdependencies Brenda Grant, RN, BSN, MPH, CIC, CHES
PhD, CRNP, CIC, in search of different perspectives and knowledge. According to the Center for Janet Haas, RN, PhD, CIC
FAAN, FNAP Creative Leadership, boundary spanning leadership involves creating direction, Karen K. Hoffmann, RN, MS, CIC, FSHEA
APIC 2015 PRESIDENT alignment, and commitment across five types of boundaries:1 Linda McKinley, RN, BSN, MPH, CIC
Vertical: class, seniority, authority, power Ann Marie Pettis, RN, BSN, CIC

Horizontal: expertise, function, peers Katherine S. Ward, RN, BSN, MPH, CIC
Kathy Ware, RN, BSN, CIC
Stakeholders: partners, constituencies, value chain, communities
Demographic: gender, generation, nationality, culture, personality, ideology
EX OFFICIO
Geographic: location, region, markets, distance Katrina Crist, MBA
Infection prevention and control is an inherently boundary-spanning enter-
prise. The work of the infection prevention team, while specialized, cannot be Disclaimer
performed independently and requires interdependent and coordinated action Prevention Strategist is published by
the Association for Professionals in
across multiple and overlapping boundaries. However, the engagement is often Infection Control and Epidemiology,
related to specific initiatives such as implementing interventions to prevent Inc. (APIC). All rights reserved.
APIC is healthcare-associated infections or in response to acute events, such as outbreak Reproduction, transmission,
distribution, or copying in whole
conducting investigations. Deliberate strategic relationship-building actions will be required or in part of the contents without
express written permission of
a member to bring groups together to achieve the larger purpose of envisioning the future.
APIC is prohibited. For reprint
During the past decade, infection prevention and control programs have been
MegaSurvey to and other requests, please email
editor@apic.org. APIC makes no
presented with an unending series of challenges and expectations. The challenges,
determine the more often than not, have resulted in additional responsibilities, functions, and
representations about the accuracy,
reliability, completeness, or timeliness
current state of workload. Collectively, IPs have responded professionally and graciously sharing of the material or about the results to
be obtained from using this publication.
the infection their expertise, talents, and time to meet the many challenges. However, there You use the material at your own risk.
comes a time when it is necessary to step back and reflect on where we have APIC assumes no responsibility for
preventionist any injury and/or damage to persons
been, where we are now, and thoughtfully consider our preferred future. Toward or property as a matter of products
profession. this end, APIC is conducting a member MegaSurvey to determine the current liability, negligence or otherwise,
or from any use or operation of any
state of the infection preventionist profession. To all who participated, please methods, products, instructions,
accept my sincere appreciation for your time and careful responses. If you have or ideas contained in the material
herein. Because of rapid advances in
not yet participated, please do so. With you, I look forward to the results that the medical sciences, in particular,
will create a baseline of data to map out our desired future. independent verification of diagnoses
Reference and drug dosages should be made.
Let us continue this discussion in Nashville during APIC 2015. I look forward Although all advertising material
1. Lee, L, Horth, DM, & Ernst, C. Bound-
ary spanning in action: Tactics for to connecting! is expected to conform to ethical
transforming todays borders into (medical) standards, inclusion in
tomorrows frontiers. Center for this publication does not constitute
Creative Leadership 2014. Accessed a guarantee or endorsement of the
March 24, 2015. Available at: www. quality or value of such product
ccl.org/Leadership/pdf/research/ or of the claims made of it by its
boundarySpanningAction.pdf. Mary Lou Manning, PhD, CRNP, CIC, FAAN, FNAP manufacturer.

8 | Summer 2015 | Prevention

 Empower patient compliance
with the Clorox Healthcare
TM

4% CHG Skin Cleansing Kit.

Provide patients with everything

they need in one kit, and youve helped
them enormously. And youve taken
another important step in your SSI
prevention strategy.

4 oz. 4% CHG Bottle: Evidenced-based

literature shows 4% CHG bottles
are equally effective for infection
prevention as 2% CHG pre-saturated
cloths when patients receive
standardized instructions.1

Patient Reminder Systems:

Offer multiple contact points

WAIT.
shown to enhance compliance for
preoperative skin cleansing.2

Waterproof Instructions Card:

Includes large text and visual icons,
which studies show are effective for
promoting understanding.3
A e yo
Ar you co
con
n den
n ent you o r pa
pati
tien
ents
tss hav
avee fo
av follllllow
ow
wed d
your
yo ur pre
ur reop
oper
operrat
atiivve sk
s in cle
lean
ansi
an siing prooto
oco
c ls ls?? Online Video Instructions: Easy to
follow and drive correct product use.

*While supplies last. Limit one per customer. Business or institutional customers only.
1. Edmiston CE, Medical College of Wisconsin, Milwaukee, WI. Evidence for using Chlorhexidine Gluconate Preoperative Cleansing
to Reduce the Risk of Surgical Site Infection. AORN Journal. Vol 92. No 5. (2010): 509-518.
2. Edmiston CE, et al. Empowering the Surgical Patient: A Randomized, Prospective Analysis of an Innovative Strategy for Improving
Patient Compliance to the Preadmission Showering Protocol. Journal of the American College of Surgeons 219.2(2014): 256-264.
3. Hibbing, A., A Picture Is Worth A Thousand Words, The Reading Teacher; 2003. Learn more and get a free sample* at
2015 Clorox Professional Products Company, 1221 Broadway, Oakland, CA 94612. NI-28708 www.CloroxHealthcare.com/CHGKit
CEOS MESSAGE
APIC 2014
scorecard:
THE FIVE STRATEGIC priorities as part of Strategic Plan 2020 (www.apic.org)
patient safety, implementation science, competencies and certification, Prevention
advocacy, and data standardizationare critical to measuring APICs
Tracking key success. The scorecard below provides a snapshot of key metrics. We are S U M M E R 2 015 VO L U M E 8 , I S S U E 2
making exceptional progress to date with high probability of meeting 10
metrics toward out of 12 targets by 2020.
PUBLISHER
Katrina Crist, MBA
kcrist@apic.org
our goals Two targets have already surpassed the 2020 target. APIC has exceeded
its initial 100,000 consumer engagement target with a huge leap of more
MANAGING EDITOR
Janiene Bohannon, MS
jbohannon@apic.org
than 120,000 consumer engagement points in 2014 alone. This brought
ASSISTANT EDITOR
the 2014 total to more than 155,000. This measurement includes actions Julie Blechman, MPH
taken by a consumer such as downloading information from the con- jblechman@apic.org
sumer site (www.apic.org/InfectionPreventionandYou), tweeting or sharing ADVERTISING
Brian Agnes
a Facebook post, taking an educational bug quiz, or sending an e-card. bagnes@naylor.com
It excludes visits to the website absent any further action. This quick level GRAPHIC DESIGN
Deb Churchill Basso
of engagement was unexpected and is testimony to the publics interest print20h@naylor.com
and demand for infection prevention and control information. PRODUCTION
The other target that exceeded the 2020 goal is reaching 1,000 facili- Heather Williams
hwilliams@naylor.com
ties with APIC-related training and resources for effective infection
prevention and control programming. APIC has reached more than EDITORIAL PANEL
1,500 facilities with 991 in acute care, 236 in long-term care, and 362 George Allen, PhD, CIC, CNOR
Kristine Chafin, RN, MBA, CIC
BY KATRINA CRIST, in ambulatory surgery, through collaboration with the Health Research Megan Crosser, BS, MPH, CIC
MBA, APIC CEO and Educational Trust on CAUTI and SSI related education. The APIC Mary L. Fornek, RN, BSN, MBA, CIC
Brenda Helms, RN, BSN,
Board of Directors is considering resetting these two targets to achieve MBA/HCM, CIC
even higher impact by 2020. Linda Jamison, MSN, RN, CIC, CCRC
Irena Kenneley, PhD, APRN-BC, CIC
The most ambitious target to achieve by 2020 will be 10,000 CICs. Kari L. Love, RN, BS, MSHS, CIC
Nearly 6,000 infection preventionists (IPs) have done their part already, May M. Riley, RN, MSN, MPH,
ACNP, CCRN, CIC
but APIC will be mobilizing forces to reach 10,000 to strengthen the role Steven J. Schweon, RN, MPH,
and value of the IP through greater adoption of this standardized credential MSN, CIC
that demonstrates core competency in infection prevention and control. CONTRIBUTING WRITERS
Please visit the Vision and Mission page under About APIC at Timothy Bowers, MT(ASCP), MS, CIC
www.apic.org to view the full scorecard with details on measures, metrics, Demian Christiansen, DSc, MPH
Katrina Crist, MBA
and outcomes. James Davis, MSN, RN, CCRN,
Sincerely yours, CIC, HEM
Patricia Gray, RN, BAHSA, CIC
Nancy Hailpern
Irena Kenneley, PhD, APRN-BC, CIC
Timothy Landers, PhD, RN, CNP, CIC
Mary Lou Manning, PhD, CRNP, CIC,
Katrina Crist, MBA FAAN, FNAP
APIC CEO Kathy McGhie, RN, BScN, CIC
Cathryn Murphy, RN, MPH, PhD, CIC
Frank Myers, MA, CIC
2014 Change from On
Strategic Priority 2020 Target Kristine Sanger, BS, MT (ASCP)
Progress last year Track Steven J. Schweon, RN, MPH, MSN,
CIC, HEM, FSHEA
Patient Safety 100,000 consumer interactions 155,266 123,163

Tammy Sylvester, RN, BSN

Lisa Tomlinson
Patient Safety 60 organizational communications 14 9 Vicky Uhland
Angela Vassallo, MPH, MS, CIC
Implementation Science 100 courses and published resources* 65 6 Nancy Wood, RN, BSN, CIC
Implementation Science 1,000 facilities 1,589 1,589 MISSION
IP Competencies/CIC 10,000 CICs 5,944 260 APICs mission is to create a safer
world through prevention of infection.
IP Competencies/CIC 1,000 advanced practice designation n/a n/a The associations more than 15,000
members direct infection prevention
IP Competencies/CIC 450 participants in research training n/a n/a programs that save lives and improve
the bottom line for hospitals and other
Advocacy 3,000 subscribers to advocacy update 1,907 334

healthcare facilities. APIC advances

Advocacy 5,000 clicks on regulatory resources 3,553 1,117 its mission through patient safety,
implementation science, competencies
Advocacy 3,000 clicks on public policy agenda n/a n/a and certification, advocacy, and data
standardization. Visit APIC online at
Data Standardization 40 organizations supporting NHSN 31 2

www.apic.org.
PUBLISHED JUNE 2015
Data Standardization 3,700 members take action* 1,154 1,154 API-Q0215 1061

*non-cumulative n/a = initiative in development Green = High probability of achieving 2020 target
Yellow = Medium probability of achieving 2020 target Red = Low probability of achieving 2020 target

10 | SUMMER 2015 | Prevention

What do you do for
hand hygiene compliance
at point of care?

If you dont make it [hand hygiene

products] convenient right there at
that second, no one is going to go
around the corner and wash their
hands. It must be available in the
flow of what the employee is doing.

WILLIAM PARKS, MD
Chief Medical Ofcer at Memorial

Hermann The Woodlands

Point of Care refers to the moments when healthcare

workers are in contact with patients and are at the highest
risk of spreading infections.

Increase hand hygiene compliance, improve HCAHPS

scores, and reduce HAIs (healthcare associated infections)
with these Symmetry Point of Care items:

50 ml Suction Cups*
Over-bed tables, Computers on wheels *Suction Cups
550 ml Suction Cups* contain Ion Pure, an
Bedside tables, Nurse stations,NICUs antimicrobial agent
550 ml Wire Brackets approved by the
Dietary carts, Phlebotomist carts, FDA, EPA, and NSF.
Bedside commodes
Lanyards
Healthcare workers

Many HAIs [healthcare-associated infections] are transmitted by

health care personnel, and hand hygiene is a primary means to

reduce these infections.

HEALTH RESEARCH & EDUCATIONAL TRUST

afliate of the American Hospital Association

www.symmetryhandhygiene.com
Celebrating Excellence

Change
continues:
Are you
eligible?

In my last column I introduced you to the new content outline that resulted from the 2014 Practice
Analysis survey. The new examination forms based on this outline will be piloted in July 2015. Once
the pilot period is complete, cut scores can be established to determine the standard for passing the
examination until the next Practice Analysis is conducted. You can learn more about cut scores by lis-
tening to our podcast, Passing Rate and Score of the CIC Exam at www.cbic.org/certification/media.
Review of the Practice Analysis also provided us with a contemporary evaluation of current infec-
tion prevention and control practice and prompted us to review and update the eligibility criteria. The
updated requirements demonstrate the changing practice and reflect the full spectrum of healthcare
practices that are involved. We believe the updated requirements expand the profession.

By Kathy McGhie,
RN, BScN, CIC
2015 CBIC PRESIDENT Eligibility requirements (as of July 1, 2015)
You must meet ALL requirements. You are
accountable for infection prevention and control
activities/program in your setting and this is
reflected in your current job description;
AND
You have a post-secondary degree (e.g., associ-
ates or baccalaureate degree);
AND
You have had sufficient experience (recom-
mended: two years) in infection prevention
and control that includes all three (3) of the
following:
1. Identification of infectious disease processes
2. Surveillance and epidemiologic investigation
3. Preventing and controlling the transmission
of infectious agents
And at least two (2) of the remaining five (5)
components:
1. Employee/occupational health
2. Management and communication
3. Education and research
4. Environment of care
5. Cleaning, sterilization, disinfection, and
asepsis

Key changes

Without Work in a healthcare setting is no longer required. Accountability for infection prevention and control activities
must be reflected in your job description. This reflects the variety of work settings of infection preventionists.
continual The basic education requirement is now a post-secondary associate or baccalaureate degree. It is not
growth and required that this be in a healthcare-related field.
progress, The experience component has been updated to reflect the current content outline. It is our belief that
such words as the application of knowledge and experience gained in a clinical practice setting is an essential component
that supports our mission to protect the public through the development, administration, and promotion
improvement, of an accredited certification in infection prevention and control. The assessment of sufficient experience
achievement, is individual to the candidate and can vary; however, CBIC recommends two years of experience in infec-
and success have tion prevention and control. Candidates who are comfortable with their knowledge and experience may
no meaning. sit for the exam whenever they are ready. However, analysis of our data has demonstrated greater success
amongst candidates with at least two years of experience in the field.
Benjamin Franklin
We understand that there will be individuals who do not meet the requirements but still seek certifica-
tion. Recognizing that practice settings and job descriptions vary greatly, CBIC will continue to have a
candidate appeal and review process for individual assessment of eligibility when requested.
More change will come as we strive to improve.

12 | Summer 2015 | Prevention

Daily Patient Bathing

Dont just cleanse

HIBICLENS
HIBICLENS, a 4% chlorhexidine gluconate solution, delivers high levels of protection from
pathogens.1,2 Patient bathing helps stimulate circulation, promotes range of motion, and improves
patient comfort levels.3 SHEA and IDSA recommend routine bathing of patients with antiseptics such
as HIBICLENS to reduce the risk of infections.4
In recovery, patients have bigger battles to win than ghting hospital-acquired infections. By using
HIBICLENS as part of the daily bathing routine, you can deliver the power of 4% CHG with a product
that is gentle enough for everyday use.5
References: 1. Climo MW, et. al. Crit Care Med. 2009 Jun; 37(6):1858-65. 2. Rupp ME. Infect Control Hosp Epidemiol 2012;33(11). 3. Caroline Bunker Rosdahl.
Textbook of Basic Nursing 2007. 4. Calfee, David MD, et. al. Strategies to Prevent Transmission of MRSA in Acute Care Hospitals. Infection Control and Hospital
Epidemiology. October 2008, Vol. 29, Supplement 1, Page S - 73. 5. Data on le. Mlnlycke Health Care. Study R05-0225.

Hibiclens, the Hibiclens logo and Mlnlycke are registered trademarks of Mlnlycke Heath Care AB.
Distributed by Mlnlycke Health Care US, LLC, Norcross, Georgia 30092.
2013 Mlnlycke Health Care AB. All rights reserved. 1.800.843.8497.
CIC PROFILE
Meet a CIC
Nancy Wood, RN, BSN, CIC
Infection Prevention Specialist
Canton-Potsdam Hospital
Potsdam, New York
Q: What inspired
you to become
an infection
preventionist (IP)?
From an early age I knew I wanted to be
My CIC designation gives
either a nurse or a teacher because those
people across our health were the two clear career options for women
system a trusted resource. at the time. After I completed my nurses
No one has to deal with training, I worked in medical, surgical, and
infection prevention case management departments. My nurse
manager, who was also my mentor, recog-
issues alone. nized my eye for detail and she encouraged
me to apply for the position in infection
prevention. The infection prevention direc-
tor, who was also a CIC, inspired me to
reach for my full potential, which included
attending the basic training course and
taking the CIC exam. As I grew in the
profession of infection prevention, I found
that the teacher and the nurse in me were
melding together to form a truly reward-
ing career. I had without a doubt found
my niche! In my role as an IP, I pay it
forward by mentoring our new nurses and
providing education to the nursing staff.
As evidence-based best practices emerge,
I can honestly say I learn something new
every day and I appreciate that professional
stimulation. Once Ive provided education
to others, Ive empowered them to deliver
safer care. I still have that eye for detail; I
seem to see things others might miss and
fill in those gaps. Working toward a full
understanding of diseases and how to keep
them from spreading is one of the most
fulfilling parts of my work.
Q: Why did you pursue
board certification
in infection
prevention and
control (CIC)?
Board certification validates my personal
commitment to infection prevention and
conveys to others that I have mastered the
art and practice of infection prevention and
control. I work in a very rural area in north-
ern New York so I am able to serve as a ready
resource for both my facility and for my
professional colleagues serving other facili-
ties. Infection prevention is a field thats rap-
idly expanding; certification demonstrates
commitment to professional growth, staying
current, and sharing best practices.
Q: How did you
prepare for the
CIC exam? What
helped?
I like that old saying, You eat an elephant
one bite at a time. I committed to blocks of
study time, which I scheduled on my calendar.
I did a self-assessment and identified my weak
areas. I then used APIC resources, concentrat-
ing on one weak area at a time. I went through
the APIC Certification Study Guide cover to
cover. I reviewed every module in the Study
Guide and completed every test question.
If I got something wrong, I looked it up in
the answer key, and (if needed) I went to the
APIC Text to ensure I really understood the
material. Im a visually oriented learner, so I
use highlighting a lot. I can recall information
if I have that visual cue.
w w w.apic.org | 15
Q: In what ways
has your CIC
benefited you?
CIC has benefited me in two important
ways. First, CIC exams test your knowl-
edge in six key areas: disease identification,
surveillance and epidemiology, prevention
and control of infections, employee health,
leadership and education, and research,
which I can then put into practice. These
six areas serve as a framework as I develop
and manage the infection prevention plan
for my facility, keeping in mind key educa-
tion and communication strategies, as well
as thinking about ways to provide effec-
tive education for the new generation of
healthcare workers who have entered the
workforce. Second, recertification every five
years ensures that I stay up to date and that
the knowledge Im sharing is relevant to
infection prevention and control as we move
forward in a rapidly changing healthcare
environment.
16 | Summer 2015 | Prevention
734814_Cleanis.indd 1
Q: In what ways has
your CIC benefited
your healthcare
organization?
My CIC designation gives people across our
health system a trusted resource. No one has
to deal with infection prevention issues alone.
Our system is built on collaboration among
our affiliates as well as various community
agencies, such as public health. Responding
to an emergent threat of infection, such as the
recent Ebola virus outbreak, relies on having
already laid the groundwork for collaboration
and seamless lines of communication among
organizations responsible for protecting the
communitys health. CIC is also becoming a
must for healthcare facilities that are pursuing
accreditation status, such as with The Joint
Commission and DNV [Det Norske Veritas].
Q: Can you share some
study tips for
others who wish
to pursue their CIC
designation?
I have found over the years that ongoing
review of infection prevention publications
like the American Journal of Infection Control
and Hospital Infection Control and Prevention
(among other credible sources) benefits me
when it comes time to take the exam. I fre-
quent the APIC IP Talk site daily to stay
abreast of current issues that other IPs are
dealing with in a variety of healthcare set-
tings; this usually prompts me to look at my
own practices. Pursuing CIC designation is
a personally and professionally rewarding
experience. Its not easy, but it is well worth
the commitment to achieve.
5/12/15 6:09 PM
Visit SDFHC.com/sample for your free trial sample.
Briefs to keep you in-the-know

APIC honors global public health

advocate with its highest infection
prevention award
APIC will honor Cathryn Murphy, RN,
MPH, PhD, CIC, of Queensland, Australia,
with the prestigious 2015 Carole DeMille
Achievement Award.
The award, which will be presented during
the opening session at APICs 42nd Annual
Conference in Nashville, Tennessee, is given
annually to an infection preventionist (IP)
who best exemplifies the ideals of Carole
DeMille, a pioneer in the field.
We are honored to award Dr. Murphy
with the Carole DeMille Achievement
Award for her lifelong dedication to infec-
tion prevention, said APIC 2015 President
Mary Lou Manning, PhD, CRNP, CIC,
FAAN, FNAP. Caths contributions to the
field of infection prevention are expansive
and have contributed greatly to the improve-
ment of infection control practices globally.
As APICs only non-North American APIC
president in 2010, she broke down barriers,
proving that there are no borders to infection
prevention and control.
As an active APIC member for more
than 25 years, Dr. Murphy has played a
fundamental role in advancing APICs
mission. She has served on the American
Journal of Infection Control editorial board
for more than a decade, reviewed various
APIC Elimination Guides and position
papers, authored many peer-reviewed arti-
cles, and formally mentored IPs throughout
her career. Cath credits and will always be
grateful to APIC, its members, leadership,
and staff as well as previous Carole DeMille
Achievement Award winners for their collec-
tive and individual interest and investment
in her professional and personal development
and opportunities.
Dr. Murphy remains committed to build-
ing global IP capacity, ensuring that the
profession continues to grow in each of its New Zealand, Philippines, Singapore, South
facets: clinical, research, governmental, and Africa, Thailand, the United Arab Emirates,
academic. Dr. Murphy became Australias the United States, and Vietnam.
first PhD-qualified infection prevention- Currently, Dr. Murphy serves as executive
ist in 1999. As a founding member of the director of Infection Control Plus Pty Ltd.
Asia Pacific Society of Infection Control The late Carole DeMille was among the
(APSIC) and a regular consultant to the founders of APIC who later became an
World Health Organization, she has dem- internationally recognized authority in the
onstrated her dedication to globally expand- developing field of hospital infection control.
ing best practice infection prevention. She She was known for her vision and optimistic
has consulted on infection prevention issues approach to present-day infection prevention
in Australia, Canada, China, Hong Kong, methods. The award was established in her
France, Japan, Korea, Malaysia, Macau, honor in 1979, following her death.

APIC Strategic Partner: Aramark

The winter 2014 issue of Prevention Strategist featured the APIC Strategic Partner Program in the article, What makes a healthcare company an
ideal candidate to participate in APICs Strategic Partner Program. In this issue, we showcase Aramark, a long-standing APIC strategic partner.

APICs Strategic Partnership strengthens Aramarks commitment to the infec- To learn more about
tion prevention community and has helped support our mission to enrich and Aramark, visit Booth
nourish lives of those who serve.Our five-year standing relationship allows us to #630 at the APIC 2015
gather insights from infection preventionists to help us deliver innovative solutions Annual Conference or
that impact patient care.We proudly sponsor national conferences and engage visit www.aramarkuniform.
locally at chapter events to educate IPs on the importance of environmental com/healthcare.
cleaning and laundering practices as part of their overall infection prevention
program.We act as a conduit to environmental services to create collaborative
team experiences focused on hard and soft surface bacterial management.

w w w.apic.org | 19
Briefs to keep you in-the-know

New long-term care infection prevention skills pledge tool

e ... tice !
all

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ls A new long-term care (LTC) infection prevention skills tool titled Take the Pledge

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c gown m blood
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20 | Summer 2015 1| Prevention

734850_Ivera.indd 5/7/15 8:44 PM
 Chief medical officer from Florida
receives APICs 2015 Healthcare
Administrator Award
William J. Maples, MD, currently chief
medical officer for Professional Research
Consultants and executive director for The
Institute for Healthcare Excellence in Ponte
Vedra Beach, Florida, has been named
the 2015 recipient of APICs Healthcare
Administrator Award. Prior to his cur-
rent roles, Dr. Maples was the chief quality
officer and senior vice president at Mission
Health System in Asheville, North Carolina
(December 2010-March 2015).
The award, which will be presented
Dr. Maples is a at APICs 42nd Annual Conference in
Nashville, Tennessee, is given annually to
passionate advocate a member of a healthcare facilitys executive
for patient safety and team who champions infection prevention
efforts within his or her organization.
a vigorous supporter We are honored to present Dr. Maples
with this well-deserved award, said APIC
of infection prevention 2015 President Mary Lou Manning, PhD,
CRNP, CIC, FAAN, FNAP. Dr. Maples
and control. is a passionate advocate for patient safety
and a vigorous supporter of infection pre-
Mary Lou Manning, PhD, vention and control. His commitment is
CRNP, CIC, FAAN, FNAP evident through his ongoing efforts to
engage consistently with infection preven-
tion teams, push for improved processes
to protect patients from harm, and tie the
work of infection prevention to broader
quality efforts throughout the Mission
Health System.
Under his leadership at Mission Health,
the infection prevention department grew
from five infection preventionists (IPs) at
one hospital to a system-wide department
that now includes 12 IPs and spans seven
hospitals. With infection prevention and
control as part of the quality department
Dr. Maples brought a number of process
improvements to IPs, including training
in root cause analysis.
His support is also evident in the invest-
ment made in an electronic surveillance
system that minimizes infection prevention-
ists time to manually input data. During
the Ebola crisis, Dr. Maples empowered
IPs to take on leadership roles in planning,
training, and logistics, and reinforced their
recommendations with other senior lead-
ers. He made sure that the work of IPs and
the achievements in reducing healthcare-
associated infections were understood by
senior leaders as contributing to operational
goals and helping to sustain the systems
overall financial health.
Dr. Mapless colleagues agree that he was
instrumental in instilling a true culture of
safety throughout Mission Health System,
instituting weekly leadership rounds to
discuss successes and barriers in achiev-
ing the goal of harm reduction. Under his
direction, quality data included infection
prevention metrics and was posted and
reviewed on a weekly basis.
In particular, Dr. Maples committed
resources to prevention of surgical site
infections with the introduction of process
improvement teams focused on colon, spi-
nal fusion, and hysterectomy surgical site
infections. As a result, infections at Mission
Health following spinal fusion and refu-
sion surgeries dropped below the Centers for
Disease Control and Preventions National
Healthcare Safety Network weighted bench-
mark. The teams focus on reducing immedi-
ate-use steam sterilization has also paid off,
with a marked decrease in use of this process
for sterilizing surgical instruments.
w w w.apic.org | 21
 CAPITOL COMMENTS

New incentives improve

healthcare quality, cost, and
public health
BY NANCY HAILPERN, LISA TOMLINSON,
AND PATRICIA GRAY, RN, BAHSA, CIC

Statistics are people with

the tears washed away.
Victor Sidel, MD, co-founder,
Physicians for Social Responsibility

22 | Summer 2015 | Prevention

The Affordable Care Act of 2010 led
to development of the National Quality
Strategy, first developed in 2011 with the
three-pronged goal of improving health-
care quality, decreasing healthcare costs,
and creating healthier communities. All
of these goals are being addressed through
regulatory initiatives, most of which impact
Medicare. Since Medicare is the largest
payer of healthcare in the U.S., both the
carrot and the stick it uses to enforce statu-
tory regulations is payment adjustment
incentives for improved performance and
penalties for static or deteriorating perfor-
mance or for noncompliance. Performance
is evaluated through the use of measures.
Because measures are a basis of comparison
against a standard, ideally measures would
be developed and endorsed by a consensus
organization, such as the National Quality
Forum (NQF).
Quality
U.S. Secretary of Health and Human
Services (HHS) Sylvia Mathews Burwell
signaled a refocus of the way healthcare
is delivered when, in January 2015, she
announced a timeline for changing the
way Medicare pays for health services.
According to this new timeline, by 2018,
90 percent of Medicare payments will be
tied to value, rather than volume of ser-
vices provided. Because of the amount
of healthcare facility revenue that comes
from Medicare, this change will impact
all providers and receivers of healthcare.
Infection preventionists (IPs) have and will
continue to play a role in attainment of all
of these goals.
The first challenge is determining what
is meant by value. Terms like value and
quality are difficult to quantify, and can
mean different things to different stake-
holders, depending on various perspectives
as patients, providers, payers, employers,
consumers, or the government. For IPs,
this will mean continued focus on health-
care outcomes by reducing and preventing
healthcare-associated infections (HAIs).
Medicare reimbursement is determined
by compliance with measures, and whether By 2018, 90 percent of
those measures show improvement in out-
comes. The purpose of measures makes Medicare payments will
sensewe cant monitor improvement be tied to value, rather
without a baseline for comparison. But than volume of services
another challenge is the large volume of provided.
measures that are used for the variety of
programs within HHS. Measures are used
to determine compliance with electronic
health record (EHR), quality reporting,
value-based purchasing, readmissions
reduction, and hospital-acquired conditions
reduction programs. Some measures are
based on chart-abstracted coding data and
some are reported into NHSN using stan-
dardized surveillance definitions. Measures
are constantly being added or removed by
CMS, reported to CDC, adopted for use
by the Agency for Healthcare Research and
Quality (AHRQ), and re-evaluated and
updated by NQF. In addition to federal
requirements, most states require some level
of HAI reporting of measures which may
or may not correspond to federal require-
ments, adding additional responsibilities
for IPs. Although CMS has made an effort
in recent years to align measures used for
different programs within its jurisdiction,
the number of measures that currently must
be monitored presents a burden to already
under-resourced facilities and depart-
ments. In order for measures to be useful in
improving healthcare quality, they must be
aligned between programs, focused on out-
comes, and not unnecessarily tax healthcare
personnel. The good news is that current
proposed regulations are making inroads
in all of these areas.
Cost
A 2014 report by the Commonwealth
Fund found that although the U.S. has the
most expensive healthcare system in the
world, we rank 11th out of the 11 coun-
tries studied (Australia, Canada, France,
Germany, the Netherlands, New Zealand,
Norway, Sweden, Switzerland, the United
Kingdom, and the United States) in health
w w w.apic.org | 23
 CAPITOL COMMENTS
Although CMS has made
an effort in recent years
to align measures used for
different programs within its
jurisdiction, the number of
measures that currently
must be monitored presents
a burden to already
under-resourced facilities
and departments.
outcomes. Similarly, the World Health
Organization ranks the U.S. healthcare
system 37th out of 190 nations included in
its rankings of healthcare systems, despite
having among the highest per capita health-
care expenditures.
The traditional Medicare fee-for-service
payment system encourages increased care,
but more care does not necessarily mean
better care. Higher volume of procedures
has meant higher Medicare reimbursement,
regardless of whether the treatment has
good outcomes or not; however, more treat-
ment might also mean longer hospital stays,
increased use of devices, more antibiotics,
which raises both infection risk and costs.
The majority of healthcare dollars are
spent on end-of-life care. Healthcare of the
future will have to change its focus away
from sick care and more toward preven-
tive care, and hard decisions will be made
about effectiveness of treatment options.
Reducing costs will also mean provid-
ing care in the most appropriate settings,
often outside the traditional walls of the
hospital environment. This will mean
expanding infection prevention to other
types of facilitiesambulatory care, long-
term care, rehabilitation, behavioral health,
and other settings. It will also mean an
expanded focus on traditional roles of the
24 | Summer 2015 | Prevention
IP, including educating staff and patients,
developing policies and procedures geared
to non-hospital settings, and monitoring
compliance with infection prevention
practices across the continuum of care. A
necessary step will be the IPs involvement
in developing EHRs that are interoper-
able across care settings and providers, as
well as with government-based systems,
such as NHSN. It will require focus in all
facilities and at all levels on improving care
transitions.
Population health
Keeping the population healthy will
reduce healthcare costs by keeping people
out of healthcare facilities. In addition
to improved behaviors such as increas-
ing physical activity and improving diets,
preventing infections from spreading in
a population also includes compliance
with vaccine recommendations, antibiotic
stewardship from the farm to the hospi-
tal, hand hygiene, and other practices that
have long been the concentration of infec-
tion prevention and public health. Sharing
information through EHRs can ensure bet-
ter knowledge of where potential infec-
tion challenges exist in order to prevent
them. The spread of community-acquired
infections can be decreased through basic
infection prevention education of person-
nel in schools, community centers, daycare
centers, and other places where populations
congregate and knowledge about how infec-
tions are spread, and about appropriate pro-
tective practices and equipment. Expanding
partnerships with public health agencies
will be an important step in improving
and sustaining infection prevention for the
future of population health.
Summary
As healthcare continues to change in all
aspects of care delivery, IPs will need to
continue to play a key role in improving
healthcare quality in all environments, pro-
moting the use of meaningful, value-driven
infection-related measures that accurately
reflect healthcare outcomes. As always, IPs
will continue to pursue healthcare without
infection in order to create a safer world
through the prevention of infection.
Nancy Hailpern is APIC director of
Regulatory Affairs, and Lisa Tomlinson is
APIC vice president of Government Affairs
and Practice Guidance. Patricia Gray, RN,
BAHSA, CIC, is network manager, Infection
Prevention and Control, for HonorHealth in
Scottsdale, Arizona, and APIC representative
to the National Quality Forum.
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Chapter Spotlight: APIC Greater LA chapter #3
Whether we choose to be
part of the conversation on
social media in regards
to infection prevention
or not, the worlds ability
to share news and get
information instantaneously
has already left the station,
and were late to the train.
26 | Summer 2015 | Prevention
Take back your hashtags
An infection preventionists guide to Twitter
Have you ever been to Los Angeles? If you
have, you probably remember the beauti-
ful weather, the picturesque views from
the canyons to the ocean, the lean and
well-dressed people, and of all things
the traffic. It can take us Angelenos two
hours to go 10 miles during rush hour. So
as a result, weve become experts at find-
ing creative and crafty ways to get where
we need to go in a rush. We often start
off meetings and parties comparing how
attendees arrived to our new destination.
You took the 101? Seriously. Are you mad?
How long have you lived in LA? Oh, well
that explains it; youre still a new transplant.
I recommend you try the Cahuenga Pass and
then make a turn at... And so our days go,
attempting to connect with one another
in the City of Angels.
Now imagine you are a member of
the second largest APIC chapter in the
U.S.Greater Los Angeles (GLA), chap-
ter #3 and your monthly meetings are
held on Tuesdays at noon in downtown
Los Angeles. And hence, you understand
our predicament. Our chapter serves Los
Angeles County, which has more than
100 hospitals and more than 10 million
people in a 4,000 square mile radius.1 We
have more than 200 members, including
infection preventionists (IPs), epidemiolo-
gists, nurses, microbiologists, pharmacists,
doctors, and vendors.
With this in mind, our chapter uses
social media to engage members and
others in our community around the
By Angela Vassallo, MPH, MS, CIC
infection prevention conversation. Once
you get the hang of it, youll see its an
easy and beneficial way to obtain timely
infection prevention information, engage
with peers, improve communications dur-
ing disasters, and ensure IPs are represented
in the public eye.
Getting creative to
improve communications
APIC GLA is constantly looking for bet-
ter methods to communicate quickly and
efficiently with such an expansive, diverse
audience. We decided that the easiest and
cheapest way for us to promote infection
prevention in our community and engage
our members was to improve our online
presence.
By early 2014, APIC GLA was the first
APIC chapter to create Facebook and
Twitter accounts. As fate would have it,
national APIC was in the midst of improv-
ing its online presence, as well as that of
local chapters at about the same time. Thus,
we worked with national APIC to develop
our own APIC GLA website: http://com-
munity.apic.org/greaterlosangeles/home.
You dont need to love social media to use
it and benefit from it. Although I constantly
refer people to our new, shiny website, Im
not a Facebook or Instagram lover. I am,
however, a recent Twitter convert. I think
there is a major difference in the useful-
ness of these applicationsespecially with
regard to daily infection prevention work.
Facebook, Instagram, and Pinterest seem
Angelas Twitter cover photo shows her during interview with comedian Judy Greer on public restrooms for the web series, Reluctantly Healthy at
https://screen.yahoo.com/reluctantly-healthy/dirty-truth-public-restrooms-040000010.html.
to be most useful for communities to chat,
share pictures and invitations to events, and
exchange ideas. I often look at national
APICs Facebook page (www.face book.com/
APICInfectionPreventionandYou) to see whats
happening in our community. But if I have
a question that I need answered right now,
I go to Twitter. Social media applications
can be brilliant tools for staying connected
in todays world.
Twitter is an immediate and concise way
for people to get information. In a recent
CID article, Twitter was promoted as the
only platform that allows one to connect,
engage, learn, and educate oneself and oth-
ers in real-time on a global scale. 2 When
I read these words, I envisioned myself
tweeting with interesting people about
exciting infection prevention/infectious
disease topics while in my pajamas on the
sofa at nightno make-up and minimal
effort on my part. Yes, please! Sign me up
tout de suite.
Let me give you a couple of examples to
illustrate my point further. Although my
hospital is only four blocks from UCLA,
I found out about the recent CRE out-
break with ERCP duodenoscopes first on
Twitter when UCLA tweeted the infor-
mation. Several hours later when I came
home from work that day, I saw it on the
evening news. Keep in mind that by the
time I saw it on the evening news, I had
already known about it for hours and had
already communicated with my peers at
UCLA to get more information and offer
them a hand. Next case in point, during
the 2014 Ebola outbreak in West Africa,
I used Twitter to get up-to-the-minute
information. Healthcare workers, govern-
ments, news agencies, and pretty much
everyone who had a major stake in the
outbreak were tweeting information as
it happened. I remember seeing the news
on Twitter that Dr. Kent Brantley and
Marian Wrightbold were being flown to
the U.S. as they boarded the plane. And
by the time I got home that night to watch
the evening news, it was, to be frank, old
news. The Internet had already exploded
with conversations about Ebola in the U.S.
w w w.apic.org | 27
Chapter Spotlight: APIC Greater LA chapter #3
Organizations to
follow on Twitter
APIC @apic
AJIC @ajicjournal
CDC @cdcgov
WHO @who
CBIC @cbic
(They tweet CIC and SARE test
questions on a weekly basis)
APIC GLA @apicglac
APIC DFW @apicdfw
APIC Kentucky @kyapic42
I PS @ips_infection
(Infection Prevention
Society in the UK)
I PAC @ipaccanada
(Infection Prevention and
Control Association in Canada)
ID Week @idweek2015
SHEA @shea_epi
IDSA @idsainfo
28 | Summer 2015 | Prevention
before the evening news could even air
the breaking story.
Whether we choose to be part of
the conversation on social media in
regards to infection prevention or not,
the worlds ability to share news and
get information instantaneously has
already left the station, and were late
to the train. No one really reads the
newspaper anymore and most people
dont wait for the evening news to learn
what is happening in the world right
now. I understand how social media
can seem like one more thing to do in
your already overloaded life. However,
social media can enhance our work as
IPs. At work, I am constantly looking
for information and asking questions,
and I know you are, too.
The issues you are facing at work
today could be easily and quickly dis-
cussed on Twitter, in addition to APICs
IPTalkas long as you are maintain-
ing confidentiality and understanding
that all information has limitations.
Wouldnt it be helpful to quickly write
a question down and within seconds
have people respond with answers?
Imagine the immediate usefulness of
Twitter during a survey or response to
a disaster.
Top six reasons to use Twitter as an IP
1 I f used appropriately, it could be a vir-
tual listserv available 24/7. In addition
to using IPTalk (www.apic.org/MyAPIC),
all you would have to do is look at Twitter
to get your answers on hot topic infection
prevention issues at that very moment.
Warning: there is no guarantee that the
answers will be accurate. So do your own
research and check sources.
2
It could be used to improve communi-
cation during disasters. Right after the
first plane hit the World Trade Center,
I was frantically trying to call my father
who works in downtown Manhattan.
Cell phones were jammed for hours and
families like mine sat in panic waiting to
get through. It still chokes me up today.
He later got through to let me know that
he was fine. But Ill say it now because
I say it all the timeI wish our family
had been using Twitter on 9/11.
3 Viral forecasting/digital epidemiology
are changing the way we understand
how diseases move and mutate. Dr.
Nathan Wolfe presented the APIC 2013
Annual Conference closing plenary on
this very topic.
4 You can instantly network with your
peers. Ive met some really interesting
and helpful IPs in Canada and the UK

on Twitter. Shout-out to our IP peer in
Toronto, Canada (@barleychironda),
the most prolific IP tweeter in the world!
5 You would be staying up to date
even to the very minutewhen
infection prevention issues occur
around the world.
6 The more IPs join and use social media
sites, the more represented well be in
the public eye. Perhaps youve heard the
phrase the world is getting smaller.
Infectious diseases that exist in one part
of the world are everyones problems.
So why not use social media to posi-
tion ourselves as experts in our field
and showcase the great work IPs do on
the frontlines of infection prevention
to control and prevent these infections?
10-step Twitter 101
1 Create an account with a username
and password. Go to Twitter (https://
twitter.com) and think of a catchy user-
name for yourself. Its what people see
when they are reading your tweets. For
instance, @suegk0123 is much less com-
2
pelling than @suethehandwashingIP.
Create a compelling bio. It will be read
when someone looks at your account.
Heres an example of how mine has
evolved over the past year. When I
created my account last year it was, fol-
lowing interesting things and fascinat-
ing people. Then, I decided to make it
more interesting. So now it is, small but
mighty epileptic epidemiologist. Perhaps
it is a bit TMI (too much information
about me), but which person would you
rather follow?
3Follow people/organizations who
interest you and watch what they
tweet in your timeline. Find
Twitter mentors and follow them.
Ask them questions. Watch how they
engage their followers. There certainly
is an art to it.
4
Then, when you feel readysend your
first tweet. Try to say something use-
ful in a 140 characters or less. Its not
as easy as one might think, is it? Keep
in mind that when Shakespeare said,
Brevity is the soul of wit, he prob-
ably had no idea that Twitter would
one day be invented. In other words,
being concise is something weve been
grappling with for generations, and
Twitter is helping us achieve it.
5 Tweet messages with key hashtags
(This # is called a hashtag) so that
when people search a #phrase, your
messages will appear. The hashtag is
what I inaccurately referred to as the
The more IPs
join and
use social media
sites, the more
represented well be in
the public eye.
Learn more at the
APIC 2015
Annual Conference
Want to learn more about social media? Dont
miss this #APIC2015 session!
How the Los Angeles APIC Chapter Uses
Social Media: TweetingOur Way Through
LAOne Infection at a Time
Sunday, June 28, 34 p.m.
A  ngela Vassallo, MPH, MS, CIC, direc-
tor, Infection Prevention/Epidemiology,
Providence Saint Johns Health Center,
Santa Monica, California.
Jessica L. Silvaggio, MPH, CDC/CSTE
Applied Epidemiology Fellow, Los Angeles
County Department of Public Health, Los
Angeles, California.
Crystal R. Moohn, BS, associate direc-
tor, Membership & Component Relations,
Association for Professionals in Infection
Control and Epidemiology, Washington,
District of Columbia.
Visit www.apic.org/ac2015 to learn more.
w w w.apic.org | 29
 Chapter Spotlight: APIC Greater LA chapter #3
pound sign for several months until a
younger, savvier tweeter corrected me.
6 Tweet messages with meaningful
links. An example would be to put a
link in your tweet to the FDAs expla-
nation for the Olympus ERCP scope
outbreak. The characters used in a web
address do not count toward your 140
count maximum. Isnt that awesome?
Offset drain position
keeps water from
splashing directly into
drain and aerosolizing
contents of the trap.
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30 | Summer 2015
746794_Willoughby.indd 1 | Prevention
7  etweet using RT and not by
R
just clicking on the retweet but-
ton. This is a more advanced prac-
tice, but I thought you should know
nonetheless. Start your tweet with
RT: and then copy the persons
message that you want to retweet
with quotations into your new tweet.
When someone searches this topic
WILLOUGHBY WICS SERIES
W you change things up, it makes people
Infection 10
Control
Sink
'HVLJQHGVSHFLFDOO\
' of our own hashtags such as, #infectionpre-
tto minimize splashing
and reduce the spread
of infectious disease.
o now, conversations about infection preven-
Oversized backsplash Sloped rear basin wall
minimizes splashing
has coved edges and
of water stream and
helps to keep water
FUHDWHVFLUFXLWRXVRZ
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toward drain. to drain.
Black White Grey Glacier Nocturnal
Granite Granite Granite White Blue
by hashtag or looks at the original
tweeters profile, your profile will be
connected and people will get exposed
to you. Voilyou are now part of
the conversation.
8 Tweet messages directly to people
with whom you want to engage in
a conversation or who you think
might follow you/share information
with you. You do this by putting their
@username in your message.
9 Update your photo and improve your
bio from time to time to keep things
fresh and interesting. Im not sug-
gested you pose for the perfect angle and
selfie yourself into oblivion. But when
want to hear what you have to say.
Embrace the constant change!
I hope Ive convinced you to create a
Twitter or some sort of social media account
and join us in the #infectionprevention con-
versation online. We need to take ownership
vention and #handhygiene. And remember
to use the #APIC2015 hashtag this year for
the annual conference in Nashville. Right
ADA
Compliant
tion issues occur all day long with very few
IPs involved. We are the experts, yet we have
very little representation on social media. So
get out there IPs and take back your hashtags!
P.S. #thanksforlettingmerantaboutso-
cialmedia.
Angela Vassallo, MPH, MS, CIC, director of
infection prevention/epidemiology at Providence
Saint Johns Health Center in Santa Monica,
Sea
California, is president of the APIC Greater
Green
Los Angeles (GLA) Chapter #3. Under Vassallos
leadership, APIC GLA was the first APIC chap-
ter to use Twitter and Facebook. Vassallo was
nominated as Healthcare Manager of the Year
(2014) by the Los Angeles Business Journal.
References
2015 Willoughby Industries Inc.
1. L.A. County population pushes past 10 million, highest in
nation. Los Angeles Times. March 27, 2014. Available at:
http://articles.latimes.com/2014/mar/27/local/la-me-ln-la-
county-population-10-million-20140327.
2. Goff DA, Kullar R, Newland JG. Review of Twitter for Infectious
Diseases Clinicians: Useful or a Waste of Time? Clin Infect Dis.
2015 Feb 4. doi: 10.1093/cid/civ071.
12/05/15 3:15 PM
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Sue Moeslein RN, MSA, CIC
Riverside Regional Medical Center

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resulting in the deaths of nearly 75,000 people.
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1. Levin J, et al., Cooley Dickinson in AJIC 2013, 41:746-748. 2. Simmons S, et al., Cone Health
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GLOBAL INSIGHT

Perspective from Australia:

Routine culturing and surveillance
of endoscopes
By Cathryn Murphy, RN, MPH, PhD, CIC

Since 1995, Australias two leading gastro-
enterological associations have recommended
routine surveillance of endoscopes, (including
duodenoscopes) and automated endoscopic
reprocessors.1 Like many infection prevention
and quality control measures in Australia, this
recommendation is not mandated by legisla-
tion, regulation, or accreditation criteria. The
extent to which various Australian states and
territories have adopted it is unmeasured and
there is no publically available repository of
data relating to endoscopic culture. Regardless,
the author is aware anecdotally that Australian
infection preventionists and gastroenterological
specialists, in general, accept and comply with
the recommendations.
In 2011, the Queensland government, in col-
laboration with the then Gastroenterological
Nurses College of Australia, developed a
web-based training module on endoscope
reprocessing.2 The module contains detailed,
practical advice regarding implementation of
the endoscope culturing quality monitoring.
It specifies recommendations for:
Standardized culturing timing, specimen
collection, and frequency according to
scope type including loan scopes;
Action in the event of positive cul-
ture of an organism of epidemiologic
significance;
Suspension of endoscopic services until
clearance;
Determination of the need for a lookback
or patient recall; and
Repeat reprocessing, repeat culturing, and
endoscope clearance.
To date, Australias long history of cultur-
ing endoscopes has been contrary to North
American practice.3 Policy makers, regulators,
and researchers have considered the increasing
trend among other countries to recommend
routine culturing. Debate has focused on the
return on investment (e.g., the likelihood that
routine endoscopic culture provides a timely
indication of faulty endoscopes, incomplete or
incorrect reprocessing, and the extent to which
culturing potentially reduces the likelihood of
iatrogenic pathogen transmission).
The debate remains unresolved with
opponents citing that in one three-year
period in New Zealand, the culture of
more than 7,000 endoscopes yielded
only one occasion of improper reprocess-
ing and nine other occasions of damaged

w w w.apic.org | 33
 GLOBAL INSIGHT
endoscopes. Additional recent debate has
considered the sensitivity and specificity
of new methods to monitor reprocessing
adequacy.4 However, recent U.S.-based
endoscopic-related outbreaks and trans-
mission of multidrug-resistant organisms
seem to have spearheaded U.S. adoption
of an endoscopic culturing regime similar
to Australias.5
Australias FDA-equivalent, the Therapeutic
Goods Administration, has also recognized
deficiencies in endoscopic reprocessing
34 | Summer 2015 | Prevention
741111_Sage.indd 1
identified by two separate and unrelated cases
of items remaining in endoscopes despite
the scopes having been subjected to multiple
cleaning and reprocessing cycles.6 Clearly, cul-
turing endoscopes is an incomplete method of
mitigating risks associated with poor quality
reprocessing. Correlating contamination of
a specific component, channel, or intricate
part of the endoscope through sampling
of flushed sterile water may be imprecise.
Rather, when coupled with standardized work
practices, staff who are knowledgeable about
5/8/15 4:40 PM
the intricacies and complexities of endoscope
reprocessing and also comply fully with best
practice recommendations can be reassured
that the quality of their work will be subject
to periodic review as measured by the act of
routine endoscopic culture.
Coordinating, over-seeing, interpreting,
and acting upon periodic endoscopic culturing
is part of the typical infection preventionists
role and function in Australia. To date, it has
served us well, although we acknowledge it
is most easily undertaken in large teaching
hospitals with onsite microbiology laboratory
services. For smaller standalone facilities such
as day-only endoscopy suites that are similar
to U.S. ambulatory care services, compliance
with the endoscope culturing recommenda-
tions may initially require provision of some
services and loan scopes by external providers.
The author welcomes questions from APIC
members seeking additional information
about Australian practices. Useful information
is also available on the Gastroenterological
Nurses College of Australia (GENCA) and
Queensland Health websites as listed in the
reference list below.
Cathryn Murphy, RN, MPH,
PhD, CIC, is executive director
of Infection Control Plus Pty Ltd
in Queensland, Australia. Dr.
Murphy served as APICs first
and only non-North American
elected president in 2010. She is an internation-
ally recognized infection prevention expert who
has worked in infection prevention continuously
since 1989 in senior positions in clinical, research,
government, and academic settings.
References
1. Gastroenterological Nurses College of Australia (GENCA). Infec-
tion Control in Endoscopy. 2010. Accessed 5 April, 2015 at www.
genca.org/public/5/files/Endoscopy_infection_control%20(low).
pdf.
2. 6.4 Microbiological Testing. Queensland Government, 2014.
Accessed 5 April, 2015 at www.health.qld.gov.au/EndoscopeRe-
processing/module_6/6_4.asp.
3. Petersen B. Commentary: Monitoring of Endoscope Reprocessing:
Accumulating Data but Best Practices Remain Undefined. Infection
Control and Hospital Epidemiology 2014;35:995-7.
4. Fernando G, Collignon P, Beckingham W. ATP bioluminescence
to validate the decontamination process of gastrointestinal endo-
scopes. Healthcare Infection 2014;19:59-64.
5. Interim Protocol for Healthcare Facilities Regarding Surveillance
for Bacterial Contamination of Duodenoscopes after Reprocessing.
Accessed 5 April, 2015 2015 at www.cdc.gov/hai/organisms/cre/
cre-duodenoscope-surveillance-protocol.html.
6. Endoscopes reprocessing procedures. Australian Government,
2014. Accessed 5 April, 2015 at www.tga.gov.au/publication-
issue/medical-devices-safety-update-volume-2-number-5-sep-
tember-2014#endoscopes.
Infection Prevention Leadership

My personal journey
By Timothy Bowers, MT(ASCP), MS, CIC

I
ve been greatly affected by those around me and owe much of my career to the right
people giving me the right focus at the right time. Im going to tell you about my start
as a medical technologist, finding infection prevention, and realizing it was more than
just a jobit has been an incredible personal and professional journey.

My start as a medical technologist
My path to finding medical technology was a complete
and utter accident. A very average student in high school, I
took an extra class in exploring medical careers. Our class
toured the lab and observed a laboratorian handling an
engorged organ when it ruptured. Blood went everywhere,
and I was immediately in love!
I went on to earn my bachelors degree in medical
technology, and for some of my elective classes I took
leadership development, which was very motivating in a
personal capacity as I hadnt had the opportunity to use
those skills professionally.
Upon completion of my clinical rotations, my first posi-
tion was in Thomas Jefferson University Hospital clinical
microbiology. I originally wanted to be in blood banking,
but Im glad I took the path I did. The lab leaders were very
supportive in allowing me to learn all of the areas includ-
ing bacteriology, virology, and serology.They were also
supportive of the development of an educational program
when the American Society for Clinical Pathologystarted
requiring us to maintain our certifications.
A firstand scary
step to work on leadership skills
I took my micro experience and some of the leader-
ship learned in undergrad and developed an educational
system for the lab so we could keep up our skills and
maintain compliance with those new regulations. It
was the first time I was able to interact with labora-
tory administration and with individuals outside of
microbiology. The previously mentioned supportive
staff played roles in preparing for the initiative. It was
petrifying. I stammered, hesitated, worried, and lost sleep
over connecting with these individuals. It lead to doing
significant research for the meetings so I couldnt be
caught off guard, which occasionally happened anyway,
but gave me the ability to educate administration on
the thought processes behind the initiative. In short, it
was one of the best learning experiences in my career at
that point. It also coincided with beginning my master
of science in health policy.
Finding my way into infection
prevention and control
I applied for my first infection prevention and control
position toward the end of my masters course work.Many
of the experiences from my program were included in the
job description.When researching what the job entailed,
it peaked my interest intellectually. I got the job, and it
meant big changes for me, and the real life transition was
scary. I was out of the lab, in a new health system, dealing
with nurses, physicians, and occasionally patients!Starting
out in infection prevention and control was rough, and for
a while it didnt look like it was going to last. Thankfully,
early on the two seasoned infection preventionists (IPs) at
the facility really helped me stay on track. They mentored

w w w.apic.org | 37
PREVENTION IN ACTION
As Mark Twain noted,
Never argue with a fool,
bystanders cannot tell
the difference. I believe
that professionalism isnt
never being yelled at; it is
never yelling back.
38 | Summer 2015 | Prevention
me on the technical aspects as well as the
soft skills (e.g., communication and inter-
personal skills) needed to be effective.Ill
never forget my first important lesson on
soft skills. My first draft email outside the
department was five paragraphs, three col-
ors, bold, underlined, and italics. Luckily,
I asked the lead IP to review it before I hit
send. The lead IP helped me get it down
to four sentences and one color (and taught
the word concise to me).
It wasnt until completing APICs EPI
101 course and applying what Id learned
at our facility that I really started becoming
engaged in the job and connecting the dots.
I was also fortunate to have an incredible
first experience with a supportive struc-
ture in place already.Nurse managers and
nurses helped fill in patient care science and
procedures; attending physicians allowed
participation in teaching rounds to absorb
the medical education given; our medical
director educated me on disease processes;
the other practitioners in the department
helped fill in the multitude of gaps that
existed, as well as keeping me focused on
the task at hand. I was finally flourishing
in my position as an IP. I then went on to
earn my board certification in infection
prevention and control (CIC).
Taking it to the next level
With a few years of experience under my
belt and my new CIC certification, I had the
audacity to apply for the ultimate test of my
development. One of the few director posi-
tions in the area, responsible for more than
one hospital, became available and I applied.
It wasnt academic medicine and it was in
a different state with a further commute. I
wasnt in infection prevention very long and
still had a lot to learn. There were so many
reasons not to apply, and yet I sent in my
resume. I thought it was a long shot, but I
got an interview.
The interview lasted all day and involved
many different individuals, including
the infectious disease/Infection Control
Committee chairman. We ended up debat-
ing every question asked for more than an
hour. It was intense. There was no yelling,
but we took opposite positions on almost
every aspect of the job. I supported my
positions with as much information as pos-
sible (e.g., NHSN definitions, CDC recom-
mendations). I left the interview thinking if
nothing else it will help me be successful in
my next interview, if it were to ever happen.
Regardless of our differing opinions, I
was offered the position because (as the
infectious disease/infection control chair-
man noted) of the way I handled differing
opinions and communicating my position
with literature. This interview was one of
the best, most terrifying, experiences of
my life. My previous experiences set me
up for a successful interview and it set the
course for many more leadership learning
opportunities I would soon experience in
my new position.
Bowers leadership tips
Gaining respect from colleagues and leadership isnt something that occurs overnight. Looking back, and asking colleagues
who know me best, there are a few things that stand out in terms of their opinion of what I do that makes me a leader and
worthy of their respect.

Tip 1 Tip 4
Learn from your mistakes. Learn from previous mistakes,
especially in communication. If your message doesnt seem to
be resonating with the intended audience and youre not getting
results, then take a hard look at what youre doing or how you could
improve the delivery of the communication. Are you providing all the
Remain calm under pressure. As Mark Twain noted,
Never argue with a fool, bystanders cannot tell the difference.
I believe that professionalism isnt never being yelled at; it is
never yelling back. People notice a calm demeanor and will
respect you for it.
relevant information? Is the mode of delivery appropriate (e.g., email
or in-person meeting)? Is he/she the correct person to receive the

Tip 5
message? Is your tone appropriate? Completely remove all ego and
concentrate on whats importanteffective communication.

Tip 2
Find great mentors. They may not search you out, but you
should search for them. Many non-traditional roles have influenced
me greatly throughout my career. Administrative assistants,
Justify everything with evidence and science. The
graduate medical education surgical residents, co-workers,
connection with leadership depends on your technical ability to
colleagues, and in my current position my staff have helped
understand the issues, as well as your ability to communicate
continue to push my development. Some gave me a goal to attain,
to those who dont understand infection prevention on the same
some showed me how to be a leader, others showed me behaviors
level. That skill will separate leaders from technical experts.
to reduce or eliminate. Some have illustrated the fall from grace. On
Always come to a meeting armed with evidence/science and
that last note, be humble (oh, the irony!).
prepare on your communication tactic ahead of time.

Tip 3 Tip 6
Dont let fear hold you back. Sometimes we are our own worst
enemies. Try to suppress the inner voices that tell you that you cant
or its not possible. Make an effort to act confident, even if you dont
feel it. Walking with nurses or nurse managers into a room to suppress
staffs fear or misconception is something Ive done on several occasions.
Constantly be a student of your skills. Keep up with
AJIC and ICHE for IP skills, but actively work on your leadership
developmentespecially those crucial soft skills.

Watching surgeries seems tame, but walking into a room with a very
unlikely rule-out Ebola case can be just as frightening if youve never done
either. Think of everything as a learning opportunity. Do something every
day that scares you. Baz Luhrmann (Mary Schmich)

Leadership is a lifelong venture that should be sharp when you need it, even if that need is not every minute of
every day.

Timothy Bowers, MT(ASCP), MS CIC, is corporate director of infection prevention & control for Inspira Health Network
in Vineland, New Jersey. He is also a member of APICs Communications Committee.

w w w.apic.org | 39
PREVENTION IN ACTION

Emergency preparedness
and infection control:
Teaming up to create meaningful
staff simulation exercises
Tips for success
By Kristine Sanger, BS, MT(ASCP)

A
s an infection preventionist (IP) turned
emergency preparedness professional, I
see many similarities within the fields
and even more opportunities to collaborate. One
of those opportunities is in the realm of disas-
ter simulation exercises. For years, emergency
preparedness professionals have been designing
disaster simulation exercises on many levels to test
the preparedness of their organizations. Most are
testing surge capacity and emergency departments
(ED). I rarely see simulation exercises go beyond
the ED, but they should. The safety of patients
relies on it. Simulation exercises should include all
departments of the hospital, clinic, or long-term
care facility. A great place to start is teaming up
with the infection prevention department.

Nursing staff initial clean up during a norovirus exercise at an outpatient surgery center.

40 | Summer 2015 | Prevention

 When planning a simulation exercise,
consider six very important things:
1
Plan for success. The Homeland Security
Exercise Evaluation Program recommends
a progressive approach to simulation exer-
cises.1 This entails beginning the process
small with a discussion-based exercise and
to gradually increase the capacity and
3 Develop clear, well-written objectives.
capabilities of the exercise as your staff
becomes more familiar with the process.
All too often, staff are put to the test with
a plan with which they are uncomfortable
and/or unfamiliar, and the exercise ends
up only frustrating staff rather than acting
as a learning opportunity.
2 Manage expectations. Sometimes when
simulation exercises are developed, the
scope of the exercise is lost during the
many hours of organizing and in the
many minds that are participating. Too
often, the functions to be tested become
more than what is manageable and the
4 Involve new people. The ED is the
5
6 Know the regulatory requirements of
number of participants is more than what
is beneficial to the entire exercise. This
is often referred to in the exercise world
as avoiding Armageddon.
Objectives need to be the full driving force
behind the development of any simulation
exercise. A good objective is clear, concise,
and focused on performance. For example,
if you want to test your plan to respond
to an outbreak of measles in your campus
childcare center, you need to determine
which tasks within the plan are to be tested
and stick to them. A good objective in
Learn
that example would be, By the end of
more about
the exercise, participants will have notified
the health department and the daycare
customers of the risks and exposure within emergency
12 hours of the initial case identification.
Again, this should be based on what is preparedness
at APIC 2015
written in the current plan.
single most tested department when
it comes to disaster simulation exer-
cises. This is appropriate because the
Abstracts
021Measles Emergency Response:
ED will likely be the one department
Lessons Learned from a Measles Exposure
that is always affected by a disaster, but
in an 800-bed Facility
they arent the only ones. In a shooting
023The Creation and Rapid Deployment of
event, the operating room will be in
a Preparedness Plan for Ebola Virus Disease:
high demand; in an Ebola outbreak,
Lessons from a Large Healthcare System
all departments will be needed. The
purpose of a simulation exercise is to Workshops
provide practice for a real event. All
3102Emergency Preparedness:
people in your facility will benefit from
The Infection Preventionist (IP) as Part of
this practice.
the Team
Get creative. Dont fall into the trap of
always doing the same familiar commu- Concurrent session
nity exercise. This leads to frustration,
3200Infection Prevention Emergencies
non-participation, and an attitude of
on Friday Afternoon at 4:30!
apathy with the exercise itself.
your audience. If your facility is regu-
lated by The Joint Commission (TJC),
know what TJC expects and requires
To learn more, visit
www.apic.org/ac2015.
for yearly compliance. If the Centers for
Medicare & Medicaid Services are the
regulators, become familiar with their
requirements. You are much more likely
to gain buy-in from staff and leadership
if your simulation exercise is going to
w w w.apic.org | 41
 PREVENTION IN ACTION
Exercise actor using oatmeal to simulate an uncontrolled vomiting episode.
contribute to compliance with the regu-
latory agencies of your organization.
Getting creative with infection
prevention simulation exercises
There are many creative ways to merge
the expertise of infection prevention in
simulation exercises. Listed below are just
a few that are quick, easy ways to engage
new groups and promote infection preven-
tion in simulation exercises. All of the ideas
listed could be done in a discussion-based
exercise or elaborated further in a full-scale
scenario.
1  harmacy: Test an infectious disease expo-
P scenario to gauge staffing rates.
sure plan by having staff pull all supplies
needed in the event of an anthrax exposure.
42 | Summer 2015 | Prevention
4 Environmental services: Test an infec-
5
2  aternity: Test your infectious disease
M
exposure plan and your media relations
plan by having staff respond to a sibling
visit with measles. Add to the scenario
that the patient had been in the hallway
visiting area with other patients and that
the sibling had been coughing at the
time. Have simulation participants col-
lect names of all patients that had been
exposed, the staff that had been exposed,
and discuss how it might affect staffing for
the immediate future. Its likely that staff
members would have children at home
who would be at risk, so another more
public exposure could also be added to the
3
Food services: Test a power outage in the
kitchen. Ask the staff to provide details
of how to know when food is not cooled
properly and potentially dangerous to
serve. Prepare menu plans for the next five
to seven days with only the supplies that
they have in house in case of prolonged
power failure and a need to shelter in
place.
tious disease exposure plan with a noro-
virus incident scenario (oatmeal makes it
very realistic). Have staff go through the
clean-up process with proper personal
protective equipment. This could be done
with other infectious diseases as well.
Operating room/maintenance: Test the
knowledge of infection control procedures
by creating a flood in the supply room,
an HVAC shutdown, a loss of steam, or
a construction barrier failure. Talking
through these procedures could help
introduce staff to the idea that infection
prevention starts with the environment.
The most important thing to consider
when planning a simulation exercise
is who you are training and what you
want them to learn. After completing
any simulation exercise, success should
be measured and documented. In addi-
tion, appropriate training should be pro-
vided in response to opportunities for
improvement. As long as the simulation
exercise is designed and followed up on
based on audience and objectives, the
success and learning of the well-planned
exercise will be undeniable. Being pre-
pared for unexpected events on all levels
creates an environment of patient safety
that your staff and patients will appreciate
and expect.
Kristine Sanger, BS, MT (ASCP),
is director of Hospital Training
and Exercise Programs, Center
for Preparedness Education at the
University of Nebraska Medical
Center in Omaha, Nebraska and associate executive
director of the Association of Healthcare Emergency
Preparedness Professionals (AHEPP). She is also
a member of APICs Emergency Preparedness
Committee.
Reference
1. Federal Emergency Management Agency. 2013.
Homeland Security Exercise and Evaluation Pro-
gram. Available at: www.fema.gov/media-library-
data/20130726-1914-25045-8890/hseep_apr13_.pdf.
Accessed March 24, 2015.
 2
1
3
4

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PREVENTION IN ACTION

Focus on long-term and behavioral health outbreaks

Identify the pathogen:

Clostridium
perfringens
By Steven J. Schweon, RN, MPH, MSN, CIC, HEM, FSHEA

H
ospital outbreaks are reported more often in the medical literature than
occurrences in the long-term care (LTC) or behavioral health setting. By
studying and learning from outbreaks in the LTC/behavioral health setting,
infection preventionists (IPs) will glean additional knowledge and apply this informa-
tion to hopefully prevent future infections, and infection clusters in their facilities.
This quarterly column will assist the IP with heightening awareness of appropriate
interventions for preventing an outbreak.

While everyone A recent Morbidity and Mortality Weekly Report
(MMWR) describes 42 residents and 12 staff
is susceptible members at a state psychiatric hospital who expe-
to Clostridium rienced vomiting, abdominal cramps, and diar-
rhea.1 Within 24 hours, three patients had died.
perfringens food The three patients who died were taking medica-
poisoning, the very tions with anti-intestinal motility side effects. An
investigation revealed that eating chicken served
young and elderly at dinner was associated with illness.
are at the greatest Based on your education and training, you
suspect the following pathogen(s):
risk for infection and Norovirus
complications, with Astrovirus
Staphylococcus aureus
illness lasting up to Clostridium perfringens
two weeks. Clostridium perfringens enterotoxin was
detected in 20 of 23 stool specimens from ill
residents and staff members. This organism was
also found in the chicken.
An investigation revealed the chicken was
cooked approximately 24 hours before serving.
It was not cooled properly, per the facility policy,
and there was a delay with the required tem-
perature checks. Additionally, the chicken was
removed from cooling at three different times for
additional preparation steps, before being served
as cold chicken sandwiches or chicken salad. The
state sanitarians inspected the hospital kitchen
and found no violations of the sanitary code.
Background on Clostridium perfringens
Clostridium perfringens is a Gram-positive,
spore forming bacterium that is found on raw
meat and poultry, environmental sources, and
in the intestines of humans and animals.2 Some
strains produce a toxin in the intestines that
causes gastroenteritis. The Centers for Disease
Control and Prevention (CDC) estimates this
organism causes nearly one million cases of food-
borne illness annually.2 Clostridium perfringens
infection usually has a sudden onset, lasts for
less than 24 hours, and results in diarrhea and
abdominal cramps.2 Fever or vomiting does not
usually occur. The infection is not transmitted
person-to-person; use of Standard Precautions is
sufficient when caring for the patient. The incu-
bation period is six to 24 hours.3 This organism
is also the causative agent for gas gangrene and

44 | Summer 2015 | Prevention


can be
used for
biological warfare.
While everyone is susceptible to Clostridium
perfringens food poisoning, the very young
and elderly are at the greatest risk for infection
and complications, with illness lasting up to
two weeks.
Diagnosis and treatment
Clostridium perfringens food poisoning is
diagnosed by either detecting the bacterial
toxin in the feces or determining the number
of spores per gram in the stool. Antibiotics are
not recommended for treating the infection.
Rehydration therapy is used to replace fluids
and electrolytes lost due to diarrhea. There is
no vaccine available to prevent illness.
How does food poisoning occur?
Common food sources containing this
organism include beef, poultry, gravies,
and dried or pre-cooked foods. Although
this organism may be part of the normal
intestinal flora, illness is due to ingesting
food contaminated with a large number
of Clostridium perfringens organisms that
PHOTO COURTESY: CDC.
This illustration depicts a photomicrographic view of a Gram-stained
culture specimen from a patient with gas gangrene, and revealed the
presence of numerous Clostridium perfringens Gram-positive bacteria.
side effects, may have impaired gastroin-
testinal motility; this will delay elimina-
tion of the toxin and may result in severe
intestinal damage and possible death.
Any food that has been left out too
long may result in illness, despite a normal
appearance.
Steven J. Schweon, RN, MPH,
MSN, CIC, HEM, FSHEA, is
an infection prevention consul-
tant with a specialized interest
in acute care/long-term care/
behavioral health/ambulatory
care infection challenges, including outbreaks.
References
1. Centers for Disease Control and Prevention. Fatal foodborne
Clostridium perfringens illness at a state psychiatric hospital-
Louisiana, 2010. MMWR. 2012;61(32). Available at: www.cdc.
gov/mmwr/pdf/wk/mm6132.pdf. Accessed March 27, 2015.
2. CDC. Clostridium perfringens. Food safety. 2014. Available at:
www.cdc.gov/foodsafety/clostridium-perfingens.html. Accessed
March 27, 2015.
3. U.S. Department of Health and Human Services. Clostridium
perfringens. 2015. Available at: www.foodsafety.gov/poisoning/
causes/bacteriaviruses/cperfringens/. Accessed March 28, 2015.
produce enough toxins in
the intestines and cause illness.2
Spores germinate between 54140 degrees
Learn
Fahrenheit; the bacteria grow very rapidly more at the
between 109117 degrees Fahrenheit. APIC 2015
To prevent illness, foods should be cooked Annual
thoroughly at the recommended tempera-
tures, then kept either warmer than 140 Conference
degrees Fahrenheit or cooler than 41 degrees
Attend Steven Schweons session at
Fahrenheit, which prevents spore growth.2
APIC 2015, June 2729 in Nashville,
Food that is reheated must also be pre-
Tennessee.
pared at the recommended temperature; oth-
erwise, live bacteria may become ingested. Outbreaks on Behavioral Health
Units: What Happens When Intensive
Take home messages for the LTC/ Inpatient Psychiatric Therapy Meets
behavioral health IP: Communicable Diseases
mended
It is critical to strictly adhere to recom-
food cooking and storage tem-
Monday, June 29, 9:3010:30 a.m.
Learning objectives:
peratures to prevent illness. Identify one reason an outbreak may
During environmental rounds in your
facilitys kitchen, review temperature logs
go undetected in a behavioral health
setting.
to ensure policy compliance.
State two evidence-based best
Include Clostridium perfringens as a
possible pathogen when suspecting food
practices to prevent outbreaks.
poisoning on the milieu or in a LTC unit. Describe one intervention to halt
an outbreak.
Patients taking psychiatric medications,
or other medications with anticholinergic
w w w.apic.org | 45
PREVENTION IN ACTION

A family-centered
care model to
reduce pediatric
CAUTI
By Vicky Uhland

W
hen the staff of Akron Childrens Hospital in Akron, Ohio, decided Between 2012
to implement a catheter-associated urinary tract infection (CAUTI) and 2013, the burn
prevention program, they knew they faced some challenges. Unlike center reduced
most adult CAUTI prevention programs, pediatric CAUTI initiatives require catheter days by
both patient and family participation. Fortunately, Akron Childrens already had
75 percent, from
a robust patient- and family-centered model of care delivery when it enacted its
618 to 245. The
CAUTI prevention program three years ago. And the team, co-led by infection
prevention staff, had the added benefit of being able to participate in the Ohio number of CAUTIs
Childrens Hospitals Solutions for Patient Safetya pioneering pediatric col- dropped from
laborative to prevent serious harm from hospital acquired conditions including seven in 2012 to
healthcare-associated infections (HAIs). two in 2013. The
burn center has
Akron Childrens is the largest pediatric health- CIC, manager of infection prevention and control,
gone more than
care system in northeast Ohio, with about 800,000 evaluated nursing sensitive quality indicators and
patient visits a year. It operates two hospitals and has found that the burn center and pediatric inten- 330 days without
about 80 locations across the region. The hospital sive care unit (PICU) had the highest CAUTI
has earned Magnet designation for excellence in numbersmainly because they served many criti- a CAUTI.
nursing care. In 2012, Akron Childrens infection cally ill patients who required catheters. Using the
prevention team, including Cheryl Christ-Libertin, Rosswurm-Larrabee model for planned change in
DNP, CPNP-PC, RN-BC, NE-BC, evidence-based practice based on evidence, the team first developed
practice coordinator, and Tina L. Bair, MSN, RN, a pilot study for the Paul and Carol David Regional

46 | Summer 2015 | Prevention


Burn Center. The surgeons and nursing staff
helped individualize the infection preven-
tion plan to the burn injured patients and
measured reliable use of the insertion and
maintenance bundles, as well as strategies
to reduce catheter days.
In 2013, they joined efforts with the Ohio
Childrens Hospitals Solutions for Patient
Safety network and spread the work to
the PICU. Key drivers to prevent CAUTI
included use of clinical criteria for catheters,
use of insertion and maintenance bundles,
and daily evaluation of the need for the
catheter. Interventions tested encompassed
everything from a catheter removal decision-
making algorithm to a patient information
handout for family members. In 2013, Bair
and an administrative intern instituted a
hand hygiene improvement program using
Lean Six Sigma methodologies.
The results have been impressive. We
were recognized as a top-five network hospi-
tal among the more than 80 hospitals in the
National Childrens Hospitals Solutions
for Patient Safety network for reduction
of catheter days, Christ-Libertin said.
Between 2012 and 2013, the burn cen-
ter reduced catheter days by 75 percent,
from 618 to 245. The number of CAUTIs
dropped from seven in 2012 to two in
2013. The burn center has gone more
than 330 days without a CAUTI. And
the 2013 CAUTI rate of 1.27 notably
outperformed the National Healthcare
Safety Networks pooled mean of 4.10.
American Burn Association (ABA) veri-
fication surgeons took note and called
the center to discuss its strategy. The suc-
cesses were shared at the ABA regional
and national conferences. The PICU
pediatric intensivists and nursing staff
reviewed progress toward established goals
monthly. The team also reduced catheter
days and established highly reliable use
of the bundles (greater than 95 percent).
They reduced CAUTI from five in 2012
to two in 2013. The PICU shared its suc-
cesses at the American Nurses Association
Quality Conference.
Akron Childrens nurse provides patient- and family-
centered care for quality outcomes.
photo courtesy: Akron Childrens Hospital.
Pros and cons of an RN-driven catheter
removal algorithm
The team implemented a decision-making
algorithm that determined when catheters
should be used or removed. The algorithm,
which Christ-Libertin said came from pub-
lished literature, focused on RN-driven cath-
eter removal.
During the trial period, the nurses com-
pleted the algorithm and recorded their
decision about catheter removal for each
patient. Then the providers recorded what
their decision would be. Christ-Libertin said
the infection prevention team was looking for
95 percent agreement, and got 90 percent.
We found that nurses wanted to keep the
catheters in more often, she said. The provid-
ers wanted to take the catheters out more often.
So the team decided to abandon the
algorithm. Unlike in the adult world, our
pediatric intensivists and acute care nurse
practitioners are onsite and round at three
scheduled times a day in the PICU. The nurs-
ing staff and providers use a shared team
decision-making approach. Christ-Libertin
w w w.apic.org | 47
PREVENTION IN ACTION

said. We found that discussion in rounds can

Read more about CAUTI in replace the algorithm.
The clinical staff added review of the number
the American Journal of of urinary catheter days to its rounding tool that
Infection Control details the topics to be discussed during rounds.

Changing procedures and staff buy-in

Using electronic medical records to increase the efficiency of catheter-associated urinary
tract infection surveillance for National Health and Safety Network reporting, Shepard, John After realizing that operating room (OR)
et al., American Journal of Infection Control, Volume 42, Issue 3, e33-e36. staff places more than half of all catheters used
in the hospital, the infection prevention team
Nurse-directed catheter removal protocols to prevent catheter-associated urinary tract
infection: Strategies for implementation, Hebden, Joan N., American Journal of Infection Control,
expanded its CAUTI prevention program to
Volume 42, Issue 6, 670. Surgical Services. The OR and PICU teams
began evaluating pre-connected catheter sys-
A comparison of the microbiologic profile of indwelling versus external urinary catheters, tems, which were not widely used in childrens
Grigoryan, Larissa et al., American Journal of Infection Control, Volume 42, Issue 6, 682-684. care.
Impact of catheter-associated urinary tract infection bundle on other health care-associated Because the OR has restricted space, the
infections, Cheng, Wei-YaLin, Yu-HsiuLai, Chih-ChengChao, Chien-Ming et al., American Journal of OR education coordinator led staff practice
Infection Control, Volume 43, Issue 2, 197-198. with inserting the systems on training man-
Risk factors for catheter-associated urinary tract infection in Italian elderly, Vincitorio, Daniela nequins. This had the added benefit of helping
et al., American Journal of Infection Control, Volume 42, Issue 8, 898-901. staff develop a best-practices insertion method
without interference with a surgery. In addition,
Introducing a catheter-associated urinary tract infection (CAUTI) prevention guide to patient all new nurse hires receive simulated insertion
safety (GPS), Saint, Sanjay et al., American Journal of Infection Control, Volume 42, Issue 5, 548-550.
training, and all nurses complete ongoing edu-
Emergence of extended-spectrum -lactamase-producing Escherichia coli in catheter-asso- cation on catheter insertion, maintenance, and
ciated urinary tract infection in neurogenic bladder patients, Takaba, Kei et al., American Journal CAUTI prevention best practices. The anesthe-
of Infection Control, Volume 42, Issue 3, e29-e31. sia team evaluated practices and reduced cath-
Clinician practice and the National Healthcare Safety Network definition for the diagnosis of eter days for patients with epidural catheters.
catheter-associated urinary tract infection, Al-Qas Hanna, Fadi et al., American Journal of Infection Christ-Libertin said not all nurses were com-
Control, Volume 41, Issue 12, 1173-1177. fortable with the new catheter methods. We
actually needed more buy-in from hospital staff
What we dont know may hurt us: Urinary drainage system tubing coils and CAUTIsA
prospective quality study, Kubilay, Zeynep et al., American Journal of Infection Control, Volume 41,
than from patients families, she said. The
Issue 12, 1278-1280. literature tells us that nurses and providers may
believe that CAUTI are fairly benign and dont
Trends in catheter-associated urinary tract infections among a national cohort of hospital- cause much harm. Competing priorities for care,
ized adults, 2001-2010, Daniels, Kelly R. et al., American Journal of Infection Control, Volume 42, catheter [care] can get lost.
Issue 1, 17-22.
The team also developed a patient informa-
tion handout on CAUTIs, detailing things like
the definition of a CAUTI, symptoms of a UTI,
what staff will do to prevent a CAUTI, and
Learn more at the what patients and families can do. The handout
APIC 2015 Annual Conference review process included review by the hospital
Parent Advisory Council. Christ-Libertin said
Attend these CAUTI sessions at APIC 2015, June 2729 in the handout guides staff on information to
Nashville, Tennessee. review with families on the topic of CAUTI.
3205Plastic Rounds: A Nurse-Centric Approach to At the heart of patient- and family-centered
Reducing Catheter-Associated Urinary Tract Infection (CAUTI) care is the recognition that parents are the con-
and Central Line-Associated Bloodstream Infection (CLABSI). stants in their childrens lives. They hold the
 3500NHSN CLABSI and CAUTI Surveillance 2015. most complete understanding of each childs
3002Proper Collection of Blood and Urine Cultures: Potential past, present, and future, Christ-Libertin said.
Impact on Central Line-Associated Bloodstream Infections Our biggest insight is that we may think we
(CLABSI)/Catheter-Associated Urinary Tract Infections (CAUTI) know the best thing for the patient, but unless
Surveillance. we involve them and their families, we wont
know for sure.
3103Using CUSP to Prevent CAUTI: Key Lessons Learned
from a Large National Clinical and Fellowship Project.
Vicky Uhland is a medical writer for Prevention
Strategist.
48 | Summer 2015 | Prevention
PREVENTION IN ACTION

My bugaboo

Hepatitis C
The silent epidemic
A microbiological
overview of
Hepatitis C

50 | Summer 2015 | Prevention

 Greetings fellow infection preventionists!
The science of infectious diseases involves hundreds of bacteria, viruses, fungi, and protozoa. The amount of information available about
microbial organisms poses a special problem to infection preventionists (IPs). Obviously, the impact of microbial disease cannot be overstated.
Traditionally, the teaching of microbiology has been based mostly on memorization of facts (the bug parade). Too much information makes it
difficult to tease out what is important and directly applicable to practice. This quarters My Bugaboo column features information about the human
pathogen Hepatitis C. The intention is to convey succinct information to busy IPs for common etiologic agents of healthcare-associated infections.

Please feel free to contact me with questions, suggestions, and comments at irena@case.edu.

BY IRENA KENNELEY, PhD, APRN-BC, CIC

T
he Hepatitis C virus (HCV) has been referred to as the silent epidemic because estimates
indicate that approximately four million Americans are infected with this bloodborne patho-
gen. In the USA, the incidence of HCV fell between 1992 and 2003, but no further decreases
have been documented since that time.1

Liver failure caused by HCV is one of the
most common reasons for liver transplants
in this country. Approximately 75 percent of
people infected with HCV become chroni-
cally infected and will remain infected indef-
initely. Furthermore, HCV infected persons
may not be aware of their chronic infection
because they have no signs or symptoms.
Unfortunately, these infected people serve
as a source of transmission to others.1,2
Hepatitis C is an RNA virus in the
Faviviridae family. In the past, it was known
as non-A non-B virus.1
Clinical significance and epidemiology
HCV infection shares many character-
istics of Hepatitis B virus (HBV) disease,
but is much more likely to become chronic.
Severe symptoms can occur with HCV; how-
ever, there have been reported cases in which
there was no damage to the liver. Chronic
liver disease with no overt symptoms is much
more common.1,2
Cancer may occur as the direct result of
HCV infection. Worldwide, HBV infection is
the most common cause of liver cancer; how-
ever, in the U.S. it is more likely to be HCV.1
Background
HCV occurs in all ages, although the high-
est incidence of acute HCV is found among
persons 2039 years. African Americans and
whites have similar incidence rates of acute
disease with higher rates in persons with
Hispanic ethnicity. Vertical transmission is
also possible.2
Outbreaks of HCV infection have
occurred in outpatient settings, hemo-
dialysis units, long-term care facilities,
and hospitals. Both healthcare workers
and patients are potentially at risk. This
risk has been associated with unsafe
injection practices, reuse of needles,
fingerstick devices, syringes, and lapses
in infection prevention and control
protocols.1,3
Risk factors for HCV infection
Recommendations have been devel-
oped for persons considered at higher risk
for HCV infection. These laboratory tests
include routine blood work/serum testing
for anti-HCV antibodies. Risk factors are
listed in Table 1 on the following page.1,3

The Hepatitis C virus (HCV) has been referred to as the silent epidemic because
estimates indicate that approximately four million Americans are infected with this
bloodborne pathogen.

w w w.apic.org | 51
PREVENTION IN ACTION

Table 1. Risk factors for HCV infection

Contact with a person with confirmed or suspected
Persons born between 19451965
HCV infection
Employment involving contact with human blood Persons who currently inject drugs or who have injected drugs in the past, even if once
Receipt of blood transfusion or blood products or many years ago

Dialysis or kidney transplant Recipients of clotting factor concentrates before 1987

Injecting drug use
Number of different male sex partners
Number of different female sex partners
Hospitalization and/or surgery
Intravenous infusions or injections received in an
outpatient setting
Residence in a long-term care facility
Dental work/oral surgery
Recipients of blood transfusions or donated organs before July 1992
Long-term hemodialysis patients
Persons with known exposures to HCV (e.g., healthcare workers after needlesticks,
recipients of blood or organs from a donor who later tested positive for HCV)
HIV-infected persons
Children born to infected mothers (do not test before age 18 months)
Patients with signs or symptoms of liver disease (e.g., abnormal liver
enzyme tests)

Acupuncture/tattooing/body piercing
Puncture with a needle or other object contamination Donors of blood, plasma, organs, tissues, or semen
with blood

Laboratory testing and use of standardized diagnostic hepati- HCV RNA by reverse transcription poly-
HCV is usually diagnosed with a blood test tis panels for testing symptomatic patients, merase chain reaction verifies HCV infection.1
for antibodies to the virus. The clinical signs including all serologic markers mandatory
and symptoms of acute disease caused by the by state laboratory reporting requirements. Infection prevention and control
hepatitis viruses are similar. This makes sero- Serologic markers include IgM anti-HAV, There is currently no vaccine available for
logic testing necessary to establish a diagnosis HBsAg, IgM anti HBc, and anti HCV.1,2,3 HCV. There is also no effective post-expo-
in persons with jaundice or other signs and/or Asymptomatic chronic HCV infected per- sure prophylaxis. Implementation of primary
symptoms of acute hepatitis. Persons with acute sons should be tested for infection based on prevention practices that have proven to be
HCV infection generally exhibit the follow- risk factors for infection and/or elevated liver effective to reduce the risk of HCV infection
ing: anorexia, nausea, malaise, vomiting, dark enzymes, such as ALT and AST. A positive include: standard precautions, hand washing,
urine, clay colored or light stools, and abdom- test result for HBsAg or anti-HCV by enzyme and educating of healthcare personnel about
inal pain. Centers for Disease Control and immunoassay (EIA) should be verified by a safe injection practices. Secondary preven-
Prevention (CDC) encourages implementation supplemental antibody assay. Detection of tion activities are focused on outbreak inves-
tigation and the reduction of liver disease
and other manifestations of HCV-related
chronic infections.1,3,4
Additional resources The current treatment regimen for HCV
is ribavirin plus pegylated interferon ther-
CDCViral Hepatitis: Index of information from the CDC on hepatitis viruses, including apy. These treatments are not considered
hepatitis B virus and hepatitis C virus. www.cdc.gov/hepatitis/index.htm curative, but may prevent further damage to
the liver. In 2011, two new protease inhibi-
CDCProtecting Healthcare Personnel www.cdc.gov/HAI/prevent/ppe.html tor drugs were approved for treating HCV.2
Recent advances in HCV therapy have
given those infected an improved chance for
CDCHepatitis B and the Healthcare Worker: CDC answers frequently asked questions longer lifeessentially considered a cure.
about how to protect healthcare workers www.immunize.org/catg.d/p2109.pdf Cure means the HCV is not detectable in
the blood three months after treatment ends.
A new regimen that has been approved by

52 | Summer 2015 | Prevention

the Food and Drug Administration (FDA)
includes sofosbuvir, which was the first drug Read more about Hepatitis C
that did not need to be used with interferon in the American Journal of
therapy. Protease inhibitors have also been
approved by the FDA in the treatment of
Infection Control
chronic HCV infection: simeprevir, bocepre-
vir, and telaprevir. HCV treatment in adults
is changing constantly with the advent of new Outbreak of Hepatitis C among patients admitted to the Department ofGynecology,
therapies and other developments.5,6 Obstetrics, and Oncology, Rorat, Marta et al., American Journal of Infection Control, Volume
42, Issue 1, e7-e10.
Reporting
Hepatitis C in Cardiac Patients Investigation Leads to Opportunities for Improvement in
The CDC recommends that all states Preventing the Transmission of Bloodborne Pathogens, Sturm, Lisa, et al., American Journal
and territories conduct surveillance for of Infection Control, Volume 39, Issue 5, E205.
acute viral hepatitis, including Hepatitis
A, B, C, and non-ABC. Case reports are Hepatitis C transmission due to contamination of multidose medication vials: Summary of
transmitted weekly by state health depart- an outbreak and a call to action, Branch-Elliman, Westyn et al., American Journal of Infection
ments to the CDC. However, the state- Control, Volume 41, Issue 1, 92-94.
based databases of persons reported as Evaluation of a universal vs a targeted Hepatitis C virus screening strategy among pregnant
anti-HCV positive vary considerably and women at the Vienna University Hospital, Diab-Elschahawi, Magda et al., American Journal of
have not been standardized.1,7 Infection Control, Volume 41, Issue 5, 459-460.
To date, information on cases of viral
hepatitis reported nationally has been main- Outbreak of Hepatitis C virus infection associated with narcotics diversion by an Hepatitis C
tained by the CDC in two surveillance sys- virusinfected surgical technician, Warner, Amy E. et al., American Journal of Infection Control,
tems. Information collected by the National Volume 43, Issue 1, 53-58.
Notifiable Disease Surveillance System
(NNDSS) includes diagnosis, event dates,
and basic demographic data. Additional
information is collected by the Viral
Hepatitis Surveillance Program (VHSP),
which includes clinical and serologic test
results, and risk factors for infection.1,7 Learn more at the
Irena Kenneley, PhD, APRN-BC,
APIC 2015 Annual
CIC, is associate professor at Case Conference
Western Reserve University,
Attend this special microbiology workshop at
Frances Payne Bolton School of
APIC 2015, June 2729 in Nashville, Tennessee.
Nursing in Cleveland, Ohio.
Swimming in Alphabet Soup?
KPC, CRE, IgG, IgM:
References A Cant-Miss Opportunity to Review the
1. Centers for Disease Control and Prevention. Guidelines Latest in Microbiology!
for Viral Hepatitis Surveillance and Case Management.
Atlanta, GA. 2005. Available at: www.cdc.gov/hepatitis/ Monday, June 29, 810:30 a.m.
PDFs/2005Guidlines-Surv-CaseMngmt.pdf.
2. Cowan MK. (2013). Microbiology Fundamentals: A Clinical
Learning objectives:
Approach. McGraw Hill: New York NY. Discuss the human/pathogen interaction, from
3. Centers for Disease Control and Prevention. Health Care exposure to outright infection.
Settings and Viral Hepatitis. 2011. Available at: www.cdc.
gov/hepatitis/Settings/HealthcareSettings.htm. Interpret microbiology and immunology patient
4. Centers for Disease Control and Prevention (HICPAC). Guideline reports.
for Isolation Precautions: Preventing Transmission of Infectious
Agents in Healthcare Settings. 2007. Available at: www.cdc. Apply infection control and prevention interven-
gov/hicpac/2007IP/2007isolationPrecautions.html.
5. Centers for Disease Control and Prevention (HICPAC). Guid-
tions to real-life situations common in various
ance on Public Reporting of Healthcare-Associated Infections: healthcare delivery settings.
Recommendations of the Healthcare Infection Control Practices
Advisory Committee. 2009. Available at: www.cdc.gov/hicpac/
pubReportGuide/publicReportingHAI.html.

w w w.apic.org | 53
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54 | Summer 2015 | Prevention

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PREVENTION IN ACTION

Hand hygiene hurdles:

How can we
overcome them?
Q&A with Dr. Timothy Landers

F
or most of the last decade, Timothy Landers, PhD, RN, CNP,
CIC, has been focused on effective hand hygiene programs.
Therefore, it makes perfect sense that he would help write the
latest in the series of APIC Implementation Guides, Guide to Hand
Hygiene Programs for Infection Prevention, sponsored by GOJOa
long-standing Strategic Partner. Dr. Landers, who is an assistant
professor in The Ohio State University College of Nursing and
a Robert Wood Johnson Foundation nurse faculty scholar,
said the guide examines the historical and regulatory con-
text for hand hygiene programs, and also delves into the
latest science. Its designed as a best-practices primer
for beginning to intermediate infection preven-
tionists (IPs), their clinician colleagues, and
healthcare facility executives.

w w w.apic.org | 55
 PREVENTION IN ACTION
credit: troy Huffman, The Ohio State University
Timothy Landers, PhD, RN, CNP, CIC.
Prevention Strategist chatted
with Dr. Landers recently about
specifics of the new Guide to
Hand Hygiene Programs for
Infection Prevention, and his
thoughts on how hand hygiene
can be improved in every type of
healthcare setting.
Look for the new
Guide to Hand Hygiene
Programs for Infection
Prevention at
www.apic.org/
implementationguides.
56 | Summer 2015 | Prevention
Q:
Why do you have an
interest in hand hygiene?
My area of interest is in the pre-
vention of antibiotic-resistant bacteria, so
the more I learned about the importance of
hand hygiene in preventing these types of
bacteria, the more I wanted to focus on it and
develop effective programs. Hand hygiene is
the cornerstone of our infection prevention
activities; so as IPs, it should be the core of
what were doing.
Not to brag too much about IPs, but the
work we do to prevent infections makes many
other advancements in healthcare possible.
Clinicians are able to do highly technologi-
cal, highly invasive, lifesaving procedures
like brain surgery or chemotherapy because
were focused on preventing infections that
would otherwise kill people who are having
these procedures.
Q:
What are the key points
that IPs need to know
in order to design
and implement hand hygiene
programs?
This is the most exciting part of hand
hygiene research in generalthat is, the
idea of a multimodal program is absolutely
essential. Some of the key components of
a multimodal program are education and
training, providing effective products where
theyre needed, providing cultural and lead-
ership support for hand hygiene efforts and
monitoring, and then linking that back to
education and training. Its really the syn-
ergy of when all those components of hand
hygiene programs are working together effec-
tively that we see the biggest change.
The guide presents what the individual
components of a hand hygiene program
might look like, and also helps IPs think
about how the different modes or interven-
tions could work together. That is the biggest
take-home message.
This guide is unique in that it gives IPs
the tools to adapt national and international
hand hygiene guidelines to their local set-
tings. A majority of hand hygiene activity
depends on a supportive environment and a
culture that places patient safety at the center.
Successful hand hygiene activity also depends
on the selection of products and the monitor-
ing and training that healthcare professionals
receive; there are local variations in all of
those things.
An off-the-shelf program that anyone can
simply take and implement doesnt exist.
Having a successful hand hygiene program
requires trained, knowledgeable, and expe-
rienced IPs to examine their local settings
and study their local cultureseven things
like the humidity and temperature variations
that affect users preferences for hand hygiene
products. The guide highlights the important
role IPs have in developing these programs.
Q:
What is the future of hand
hygiene in healthcare
settings? What do you
see as the major scientific issues
related to hand hygiene that still
need to be addressed?
Practical questions need to be answered,
like what are the best practice recommenda-
tions around glove use and hand hygiene?
Work also needs to be done on designing
well-tolerated hand hygiene products that are
effective against the full range of pathogens
in our healthcare settings. This is something
industry is working on, but I think more
needs to be done there.
Understanding behavioral aspects of hand
hygiene is important, as well as what can be
done as the healthcare system evolves. With
the emphasis on being efficient and having
good patient safety and patient outcomes,
how can we leverage that interest to really
encourage hand hygiene?
Work should be done to pinpoint the
most effective monitoring strategies, includ-
ing feedback on the best formats and ways
to deliver monitoring results. The role of
the patient in hand hygiene is an important
area that has been overlooked and needs to
be addressed. We havent really developed
recommendations or products for patients
to be able to perform hand hygiene in
healthcare settings.
In our guide, weve outlined a best-prac-
tices approach, and we discuss advancements
in products, culture, behavioral change, and
monitoring. Essentially, the guide is meant
to help IPs be on the lookout for these things
as they emerge. However, it doesnt neces-
sarily make recommendations about one
thing over another, except for whats based
on solid science.
Q:
Based on your work, what
do we know about hand
hygiene and glove use?
More work must be done in this area.
The interesting facet of hand hygiene and
glove use is that, in general, we think about
hand hygiene protecting patients from the
transmission of these dangerous organisms
or pathogens, and we tend to think about
glove use as protecting ourselves as healthcare
workers. Thus, there is an intrinsic motiva-
tion for glove use and extrinsic motivation
to perform hand hygiene.
Others have called for the glove use guide-
lines to be based on more solid evidence. I
believe well see more evidence on this topic
in the next two to three years.
Q:
What are some of the
explanations for variations in
hand hygiene compliance?
Compliance varies by discipline. Training
and background sometimes emphasizes the
importance of hand hygiene in different
ways. We also may see levels and frequency
of hand hygiene differing depending on levels
of interaction with patients. Unfortunately,
infection prevention and control measures
dont have as much of an immediate effect on
a patient as giving the wrong drug or using
the wrong surgical technique. So in infection
prevention, the outcome is somewhat distant
from the intervention.
Its important for IPs to be aware of the
various ways different professionals respond
to infection prevention initiatives, and how
interventions need to be based on empirical,
validated data. Leadership also must make
a commitment to a hand hygiene program.
Leadership sets an example and provides
resources for integrating multimodal hand
hygiene programs.
Throughout the guide, we present ways
to facilitate cultural change and overcome
hand hygiene compliance variations. Three
unique ways include:
1. Positive deviance. This includes novel
ways of managing change.
2. Frontline ownership. This involves get-
ting direct caregivers to commit to hand
hygiene as their core metrics.
3. Writing a business case. This includes
learning how to converse with corpo-
rate leaders about the economics of a
well-functioning hand hygiene program. that are led by highly skilled and engaged IPs
For instance, it could mean doing chief who are able to adapt the program specifically
executive rounding to get executive buy-in. for their environment.
Overall, the guide reinforces the impor-
tance of highly skilled IPs. It takes knowl-
Q:
edgeable and engaged IPs to recognize the It seems like weve known
needs of different audiences and develop about hand hygiene for
hand hygiene strategies and approaches for so long, but there are
different groups. still issues. What barriers remain
in implementing hand hygiene
programs?
Q:
 hat does successful hand
W In the non-infection prevention world, an
hygiene implementation idea exists that hand hygiene is a simple act.
look like? But its really a complex act that has deep
Successful hand hygiene programs need motivations. We need to understand that
to be multimodal, coordinated, adequately hand hygiene is complex but is worth doing
resourced, and be an institutional priority to keep patients safe.
Read more about hand
hygiene in the American
Journal of Infection Control
Impact of sink location on hand hygiene compliance for Clostridium difficile infection, Zellmer,
Caroline et al., American Journal of Infection Control, Volume 43, Issue 4, 387-389.
Sustained increase in resident meal time hand hygiene through an interdisciplinary inter-
vention engaging long-term care facility residents and staff, ODonnell, Marguerite et al.,
American Journal of Infection Control, Volume 43, Issue 2, 162-164.
Impact of the first hand sanitizing relay world record on compliance with hand hygiene in a
hospital, Seto, Wing Hong et al., American Journal of Infection Control, Volume 43, Issue 3, 295-297.
A multifactorial action plan improves hand hygiene adherence and significantly reduces
central line-associated bloodstream infections, Johnson, Linda et al., American Journal of
Infection Control, Volume 42, Issue 11, 1146-1151.
Comparison of hand hygiene monitoring using the 5 Moments for Hand Hygiene method
versus a wash in-wash out method, Sunkesula, Venkata C.K. et al., American Journal of Infection
Control, Volume 43, Issue 1, 16-19.
Face touching: A frequent habit that has implications for hand hygiene, Kwok, Yen Lee Angela
et al., American Journal of Infection Control, Volume 43, Issue 2, 112-114.
See one, do one, teach one: Hand hygiene attitudes among medical students, interns, and
faculty, Polacco, Marc A. et al., American Journal of Infection Control, Volume 43, Issue 2, 159-161.
Impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional
hand hygiene approach in 3 cities in Brazil, Medeiros, Eduardo A. et al., American Journal of
Infection Control, Volume 43, Issue 1, 10-15.
Systematic qualitative literature review of health care workers compliance with hand
hygiene guidelines, Smiddy, Maura P. et al., American Journal of Infection Control, Volume 43,
Issue 3, 269-27.
w w w.apic.org | 57
Lessons
learned:
Questions and concerns
regarding safety of
endoscopes and validity of
manufacturer guidance

R eports of carbapenem-resistant Enterobacteriaceae (CRE)

infections related to endoscopic retrograde cholangiopancrea-
tography (ERCP) duodenoscopes raised concerns among infec-
tion prevention experts, federal agencies, and the public. In February 2015, Ronald
Reagan UCLA Medical Center notified 179 patients who underwent ERCP that
they may have been exposed to CRE from contaminated duodenoscopes. Ronald
Reagan UCLA Medical Center reported that only patients who underwent ERCP
procedures from October 3, 2014, to January 28, 2015, were at risk of CRE infec-
tion as a result of these procedures. UCLA Medical
Center noted that it processed the scopes according
MEET THE EXPERTS
to the standards stipulated by the manufacturer. As
of February 23, a total of seven UCLA patients were James Davis,
infected and two died. MSN, RN, CCRN, CIC, HEM
Senior Infection
Among infection preventionists, this incident has Prevention Analyst
raised many questions about appropriate cleaning ECRI Institute Headquarters
Centers for Disease Control Plymouth Meeting, Pennsylvania
and disinfection of endoscopes, surveillance cul-
and Prevention (CDC) James Davis represented APIC as part of the
turing process of endoscopes, and the validity of Division of Healthcare Quality Promotion working group that helped develop the CDCs
manufacturer guidance. Here, we present common Atlanta, Georgia duodenoscope surveillance protocol.
questions that have arisen about these issues and
answers from experts.

58 | Summer 2015 | Prevention

 Answers from experts

Q: How did the FDA

approve the sale
of endoscopes that are not
properly validated to be
reused without the risk of
infection when manufacturer
guidance is followed?

Frank Myers: Press reports have

stated that some of the ERCP
scopes linked to some of the
outbreaks were not approved
by the FDA in the configura-
tion used. Manufacturers are
allowed to make small changes to a design
that does not significantly change the func-
tion or cleaning of the device. In this case, the
company in 2010 felt the changes were not
significant enough to warrant a new 510(k)
approval.The FDA has since become aware
of the changes and requested a new 510(k)
application be submitted.Both the FDA and
the manufacturer have supported using the
scope in the interim despite not having 510(k)
approval.Other scopes linked to outbreaks
have been approved by the FDA.Because
of this, the FDA has reached out to APIC
and others to give input on new validation
approaches for these scopes.
Citation: www.fda.gov/NewsEvents/Newsroom/
Frank Myers, PressAnnouncements/ucm437804.htm.
MA, CIC
Infection Preventionist III
Infection Prevention
Clinical EPI
UC San Diego Health System
San Diego, California
Frank Myers represents APICs Practice
Guidance Committee and is APIC liaison to the
Association for the Advancement of Medical
Instrumentation.

w w w.apic.org | 59
PHOTO COURTESY: Dartmouth-Hitchcock/Mark Washburn
Q: Does the cleaning and disinfection
issue apply to just ERCP endoscopes
or to other items with a similar
elevator channel structure such as endoscopic
ultrasound scopes (EUS)?
CDC: All endoscopes should undergo
appropriate reprocessing in accordance
with the manufacturers instructions.
Given the complex design of duodenoscopes, spe-
cial attention should be paid to the cleaning and
disinfection of the elevator mechanism located at
the distal tip of the duodenoscope and to ensuring
complete drying of all the channels and the elevator
mechanism. Training and oversight of individuals
performing endoscope cleaning and disinfection is
an essential component of successful reprocessing.
Clusters related to transmission of bacteria from
EUS have not been reported to CDC; however, since
these scopes have similar design features to duode-
noscopes, similar challenges for transmission might
also exist with these endoscopes. CDCs interim
surveillance protocol (www.cdc.gov/hai/organisms/
cre/cre-duodenoscope-surveillance-protocol.html) is
primarily intended for duodenoscopes; however,
the measures outlined in the protocol could also be
applied to these devices.
Frank Myers: While the FDA and
other organizations guidance have
focused on the ERCP scope, many
institutions have begun to look at and
speak about elevator scopes as being
problematic. This grouping includes both ERCP
and EUS.Since elevator scopes share a number
of similar characteristics, it is being proactive to
also look at processes and cleaning issues around
these scopes.The American Gastroenterological
Association (AGA) Center for GI Innovation and
Technology convened a meeting, Getting to Zero,
in March with experts in gastroenterology, epidemi-
ology, and infectious disease; the endoscope manu-
facturers Fuji and Pentax; and representatives from
the U.S. Food and Drug Administration (FDA),
CDC, and ECRI Institute to discuss how to prevent
these infections and recommended treating all ele-
vator-channel endoscopes the same, including both
FNA echoendoscopes (EUS) and duodenoscopes.
There has been one outbreak linked to EUS, sug-
gesting their design may not be different enough to
prevent the issues seen with ERCP scopes.
Citation: www.prnewswire.com/news-releases/how-to-stop-duode-
noscope-infections-300054158.html.
60 | Summer 2015 | Prevention
Q: If a facility is considering sending their ERCP
endoscope(s) out for ethylene oxide (ETO) gas
sterilization, what things do infection preventionists and
administrators need to consider and plan for?
James Davis: Infection preventionists and administrators need to consider
and plan for:
1. The tracking and management of scopes leaving and returning to the
medical facility.
2. Performing due diligence related to cost and quality for companies that
perform such work (consider the use of a due diligence checklist).
3. Knowing who is responsible if a scope is damaged during transport or reprocessing,
how it will be replaced, and whether or not loaner equipment is available until a
replacement is purchased will be important to know up front.
4. R eviewing the contract for assignment of liability related to lapses in reprocessing/
sterilization by the contractor.
5. Knowing who provides the transport containers and how sterility is maintained
during transport.
6. Conducting a FMEA [failure mode and effects analysis] prior to initiating the
system change.
7. S imulating the process in-situ. (The best laid plans may need to change once the
process is simulated where the work happens.)
8. Contacting the endoscope manufacturer regarding warranty issues related to off-IFU
[instructions for use] reprocessing, and whether or not the manufacturer support will
change if using ETO.
Q:
ETO gas sterilization is known to degrade medical equipment after
multiple exposures. Is any data available regarding how many times
ERCP endoscopes may be treated with ETO before they degrade?
James Davis: The scope Frank Myers: I agree with
manufacturer will need to James comments. I would add
provide that answer based that some institutions switch-
on validation and testing. ing to ETO have reported sig-
One should also contact the nificant losses in the number
manufacturer regarding warranty issues of scopes because of degradation.If your
related to off-IFU reprocessing. institution is considering ETO sterilization,
it would seem prudent to query institutions
that have or are using ETO sterilization on
scope models that your institution will be
sterilizing. Asking about their experiences
with ETO sterilization, including attrition
rate, will allow your institution to plan for
all the issues around ETO sterilization.
Q:
James Davis: Refer to the
What turnaround
time should facilities answer of question three.
Simulation/FMEA of the pro-
who move to ETO
cess will be the only real way to
gas sterilization expect (e.g.,
answer the question given the
transportation, sterilization,
variability of distance transported, facility
and aeration time)? processes, and contractor load and lead time.

Q: Should facilities that chose
to perform surveillance
cultures on endoscopes
perform these cultures on all
endoscopes or just ERCP endoscopes?
CDC: In the United States, bacte-
rial transmission associated with
endoscopes for which no obvious
reprocessing breaches were identified have
thus far been linked to only duodenoscopes.
In light of this, CDC developed an interim
protocol specifically for duodenoscopes that
can serve as a guide for facilities consider-
ing cultures of duodenoscopes to assess the
adequacy of their duodenoscope reprocessing.
Although there is no requirement to perform
duodenoscope cultures, some facilities have
elected to perform regular surveillance cul-
tures as part of their response to the issue. This
is not a replacement for ongoing training and
oversight to ensure that cleaning and disinfec-
tion steps are performed correctly; however, it
does provide facilities considering duodeno-
scope cultures with a consistent starting point
for a protocol that can be adapted for use.
Some groups outside the United States have
recommended routinely performing surveil-
lance cultures of other types of endoscopes,
in addition to duodenoscopes. However, the
benefit of this approach is not known.
Q:
Is it recommended that facilities
test each endoscope or a random
sample of endoscopes? If the
latter, what is the recommended interval?
CDC: Facilities choosing to perform
surveillance cultures of duodeno-
scopes should consider obtaining
post-reprocessing cultures of each duodenoscope
that is in service. However, the optimal frequency
of surveillance cultures has not been determined
and could range from after each duodenoscope
use (after reprocessing) to interval sampling, e.g.,
monthly or after every 60 procedures for each
duodenoscope. International guidelines have
recommended intervals ranging from every four
weeks to annually.
Q: Is the surveillance culturing process recommended by CDC validated
such that it assures endoscopes that are surveillance cultured
cannot transmit infection?
CDC: CDCs interim surveil-
lance protocol represents one
James Davis: The CDC has pro-
vided an interim protocol to help
possible approach to culturing guide facilities. Validation of a cul-
of duodenoscopes and has not yet been ture method is possible; however, to
validated, i.e., the sensitivity, specificity say that the validation of the culture
and limits on quantitation or detection method will eliminate the risk of infection from
are not established for all organisms. As a fomite is improbable. One must consider false
such, a negative culture result should not results/negatives and an individual laborato-
completely exclude the possibility of a con- rians performance of the task. Each facility
taminated duodenoscope. In the event of that will be performing screening will need
a suspected outbreak linked to duodeno- to design a system that validates their own lab
scopes, negative surveillance cultures alone processes and performance.
should not be used to exclude duodeno-
scopes as a source of cross-contamination. Frank Myers: No, the CDC has
stated explicitly that the sensitivity of
this culturing method is not known,
meaning false negatives are a distinct
Q:
possibility.Unpublished reports have
stated that some scopes implicated epidemiologi-
Who should perform cally in outbreaks have cultured negative using
the processing, this method.
culture, and Citation: www.cdc.gov/hai/settings/lab/lab-duodenoscope-
identification of resultant bacteria sampling.html
from the samples collected?
CDC: Samples should be
processed by personnel with
microbiological understanding
of culturing principles and identification of
common environmental and clinical bacteria.
Facilities should use discretion in determining
personnel best qualified and trained for these
Learn more at the
activities. A multi-disciplinary team should be
brought together to decide the best approach for APIC 2015 Annual
the individual facility. The facility can consider Conference
using an external laboratory for the laboratory
Attend these scope and CRE-
protocol (e.g., academic environmental micro-
biology laboratory associated with the hospital
related sessions at APIC 2015,
June 2729 in Nashville,
or private contract laboratory, etc.) if necessary.
Tennessee.
3006Preventing the Next
James Davis: Culturing meth-
Hospital Outbreak of Carbapenem-
odology should not deviate from
Resistant Enterobacteriaceae (CRE).
the standards currently used by a
3101Swimming in Alphabet
facility/industry. If a facility does
Soup? KPC, CRE, IgG, IgM: A Cant
not conduct environmental or
Miss Opportunity to Review the
fomite-based cultures, consider consultation
Latest in Microbiology!
with an environmental hygienist or an experi-
2306Reprocessing Endoscopes
enced contractor. As for who should culture,
in Ambulatory Care Settings: What,
if facility-based, the laboratorians (culturing
When, Why, and Where?
is what they do). If non-facility, confirm the
2306The Evidence behind New
contract stipulates the competency and training
Guidelines for Reprocessing Flexible
the culturing staff receives.
Endoscopes.
w w w.apic.org | 61
Q: Do facilities need to quarantine the endoscopes until results are known? If
not, what should the recall process be for endoscopes that culture positive
but have already been used on a patient?

CDC: Facilities could consider holding duodenoscopes out of use while surveillance
culture results are pending, especially if surveillance cultures are performed after each
use. For facilities that choose to not quarantine duodenoscopes, and a high-concern
organism (as defined in CDCs Interim Duodenoscope Surveillance Protocol) is detected through
surveillance cultures, the duodenoscope should be taken out of use until remedial actions are taken and
cultures no longer detect presence of the organism. The decision to notify exposed patients should be Read more about
made in consultation with appropriate facility staff, including infection prevention staff and hospital endoscopes in the
epidemiologists, and public health authorities. Patient notification should generally target all patients American Journal of
who underwent a procedure with the contaminated duodenoscope since the time of the last known Infection Control
negative duodenoscope culture. Facilities should routinely document the specific endoscope used for
each patient to facilitate the identification of exposed patients in the event of a patient notification. Aldehyde-resistant mycobacteria
bacteria associated with the use of

Q:
endoscope reprocessing systems,

Significant caution must be

observed when performing
surveillance cultures to
prevent contamination. What type of
Q: Is there any work being done
with the manufacturers to
change the design of ERCP
endoscopes so that they can be adequately
Fisher, Christopher W. et al., American
Journal of Infection Control, Volume 40,
Issue 9, 880-882.

Establishing a clinically relevant bio-

room or location should be used for
cleaned and disinfected?
duodenoscope sampling?
James Davis: I am unaware of any
CDC: Duodenoscopes should be design revisions being proposed.
sampled on a clean surface away However, a company may want to inves-
from traffic, obvious airflow (e.g., tigate such an option. A scope design
vents), and potential contamination with that would perform the same ERCP as
water. A sectioned-off area of a reprocessing the traditional elevator channel type scope and has
room or a separate room can be designated for been designed with reprocessing ease in mind, would
duodenoscope sampling. likely provide that company with a sales edge over the
competition.
burden benchmark: A quality indi-
cator for adequate reprocessing and
storage of flexible gastrointestinal
endoscopes, Alfa, Michelle J. et al.,
American Journal of Infection Control,
Volume 40, Issue 3, 233-236.
An Outbreak of Carbapenem-
resistant Klebsiella pneu-
moniae Infections Associated
with Endoscopic Retrograde
Cholangiopancreatography (ERCP)
Procedures at a Hospital, Sanderson,

Q:
Roger et al., American Journal of Infection
What future standards regarding endoscope cleaning do you expect we will see? Control, Volume 38, Issue 5, e141.

Validation of adenosine triphosphate

James Davis: Healthcare is a hands-on
business, always relying on humans who
need to perform tasks in order for the sys-
tem to function. ERCP scopes combined
with the CRE organism have shown a
potential weakness in high level disinfection/cleaning
methods. However, where there is weakness there are
opportunities for improvement.
1. Human factors/ergonomics: As is the case with
most instruments used by proceduralists, the
instrument is designed around the procedure. The
reprocessing of said equipment will vary in level
of difficulty as the complexity of the instrument
increases. The ERCP scope has been designed to do
a very specific job within the human body; it has
been designed to not only perform the procedure,
but aide the proceduralist in completing the tasks
related to the procedure. One may ask if the ERCP
scope design has prioritized reprocessing at the same
level as procedural performance. Industry may want
to look at future design and address all of the needs
of all of the users who come in contact with the
device. If industry does not answer the call, in my
opinion, there should be standards set forth that
ensure human factors and ergonomics are addressed
for each stage of the devices use.
2. Certification/licensure of reprocessing/steriliza-
tion staff: Medical devices that are reprocessed
range in complexity from a simple pair of hemostats
to the ERCP-type duodenoscopes being discussed.
Each device type is processed in a certain way by a
certain method. Due to the complexity and exact-
ness of the tasks reprocessing staff must perform,
several states have proposed bills that would make
certification or licensure a requirement. Currently,
I am unaware of a federal proposal for certifying or
licensure; however, the combination of ERCP and
CRE has proven to be a warning of what is pos-
sible. I would expect to see more stateand perhaps
federallegislation introduced that would require
formal validation of competency that sets standards
for reprocessing staff.
to audit manual cleaning of flexible
endoscope channels, Alfa, Michelle
J. et al., American Journal of Infection
Control, Volume 41, Issue 3, 245-248.
Early identification and control of
carbapenemase-producing Klebsiella
pneumoniae, originating from con-
taminated endoscopic equipment,
Alrabaa, Sally F. et al., American Journal
of Infection Control, Volume 41, Issue 6,
562-564.
Note from the editor: APIC thanks
Mary C. Virgallito, RN, MSN, CIC,
APIC Public Policy Committee
member, and Susan A. Dolan, RN,
MS, CIC, APIC president-elect and
senior advisor to APICs Public
Policy Committee, for developing
the questions for this article.

62 | Summer 2015 | Prevention

 Additional CRE and scope resources

Visit APICs CRE webpage (www.apic.org/Resources/Topic-specific-infection-prevention/CRE) for resources and guidance from CDC and others on preventing
infections associated with duodenoscopes. Here is a small sampling of what youll find on this page:

Government resources
Centers for Disease Control and Prevention
resources
Interim Duodenoscope Surveillance Protocol
Interim Duodenoscope Sampling Method
Interim Duodenoscope Culture Method
Stop Infections from Lethal CRE Germs Now (Vital
Signs report)
Guidance for control of Carbapenem-resistant
Enterobacteriaceae (CRE)
Tracking CRE
Management of multidrug-resistant organisms in
healthcare settings
Laboratory protocol for detection of carbapenem-
resistant or carbapenemase-producing Klebsiella
spp. and E.colifrom rectal swabs
U.S. Food and Drug Administration resources
FDA releases final guidance on reprocessing of
reusable medical devices, issued 3/12/2015
Reprocessing Medical Devices in Health Care APIC CRE reporting map
Settings: Validation Methods and Labeling, issued Summary of state CRE reporting requirements
3/12/2015 APIC Government Affairs resource
Safety communication, issued 2/19/2015
Olympus validates new reprocessing instructions APIC communications
for model TJF-Q180V duodenoscopes, issued resources
3/26/15 Key talking points for infection preventioniststo
Agency for Healthcare Research and Quality ensure effective reprocessing of ERCP duodeno-
resources scopes to reduce the risk of infection
Carbapenem-resistant Enterobacteriaceae (CRE) The APIC and Society for Healthcare Epidemiology
control and prevention toolkit of America (SHEA)press release
ERCP procedures and duodenoscopesfrequently
Other resources asked questions for consumers
ECRI Institute recommends culturing duodeno-
scopes as a key step to reducing CRE infections
ECRI Institute, March 3, 2015
How to stop duodenoscope infectionsAmerican
Gastroenterological Association, March 23, 2015
Superbug reveals challenges with high level dis-
infectionThe Joint CommissionQuick Safety
advisory,March 2015

741284_GOJO.indd 1 w5/13/15 11:30 AM | 63

w w.apic.org
 Measles
in the U.S.
Discussions with public health representatives
Photo courtesy: CDC/Amanda Mills.

64 | Summer 2015 | Prevention

LEFT: This image depicts a young boy who was receiving an injection in his right
lateral thigh muscle. This is known as an intramuscular injection, and in this case,
was delivering the requisite vaccination appropriate for his age group.

T
he United States declared measles eliminated in 2000. But less than 15 years later, U.S.
public health officials have seen cases of measles skyrocket, with a total of 23 measles
outbreaks in 2014 resulting in 668 measles cases reported from 27 states. The Centers for
Disease Control and Prevention (CDC) noted that this is the greatest number of measles cases since
measles elimination was documented nearly 15 years ago. The 2014 case count is in stark contrast
to the case count of 2013, when the U.S. reported only 58 measles cases.1
Public health officials are still grappling with increasing cases of measles in 2015. From
January 1 to May 29, 2015, 173 cases of measles have been reported from 21 states and the
District of Columbia72 percent of these cases were linked to a large multistate outbreak
associated with an amusement park in California.1 The measles case count continues to grow.

Prevention Strategist had the opportunity to interview public health officials and departments
that have been contending with measles in their regions.

MEET THE panel Q: Measles was declared eliminated in the U.S. in

2000. Was that a premature declaration?

Demian Chicago Department of Public Health: Endemic

Christiansen, transmission of measles in the U.S. ended in 2000.
DSc, MPH However, since measles remains prevalent in other parts of the world
Cook County where MMR [measles, mumps, rubella] vaccine isnt readily available,
Department of Public Health imported cases still continue. We live in a global community, and many
Dr. Christiansen is interim director of places around the world lack access to the measles vaccine; therefore,
Communicable Disease Control for the Cook there is a continued risk of imported cases of vaccine-preventable illness.
County Department of Public Health in Forest
Park, Illinois. Demian Christiansen, DSc, MPH: With the recent out-
break associated with a California theme park that has resulted
Chicago in at least 159 cases across 18 states, it certainly makes sense
Department of to ask this question. This declaration meant that sustained
Public Health transmission ended in the United States, but we always expected to see
imported cases, which seems likely to have sparked the recent multi-
state outbreak. In fact, in the five years prior to our most recent daycare
Tammy Sylvester, RN, BSN outbreak this past February, travel history for all measles cases had
Maricopa County Department perfect positive predictive value. Unfortunately, this is no longer the case.
of Public Health
Sylvester is communicable dis- Tammy Sylvester, RN, BSN: Yes, the U.S. did achieve
ease nursing supervisor in the Office of measles eliminations in 2000.McLean defined measles elimi-
Epidemiology, Disease Control Division of the nation as interruption of year-round endemic measles trans-
Maricopa County Department of Public Health mission.2From 2002 through 2007, measles cases in the U.S.
in Phoenix, Arizona. averaged 60 reported cases per year.1 Not until 2014 did the U.S. reach
an all-time high more than 600 reported cases.1

w w w.apic.org | 65
Q: How has public health
played a role in recent
measles outbreaks?
Chicago Department of
Public Health: Public health
plays a major role in disease surveillance
and control. This includes provider educa-
tion, contract tracing, and laboratory testing
of specimens. It is important for public health
departments to maintain a high level of com-
munication with local healthcare providers to
ensure they have the resources necessary to
educate their patients on the importance of
vaccines, recognize and diagnose illnesses,
report infected individuals to public health,
and follow the proper post-exposure infection
control protocols.
Demian Christiansen, DSc,
MPH: Measles is one of the most
highly contagious diseases known,
and we are seeing what happens
when just a small number of people are not
vaccinated against this disease. To contain the
spread, each of us has a role, whether it is iden-
tifying cases and investigating them as quickly
as possible, identifying exposed individuals
and notifying them, educating parents of well
children to abide by recommended immuni-
zation schedulesall of these are required to
control outbreaks and prevent further spread.
It takes all of us, working in concert.
Tammy Sylvester, RN, BSN:
Measles is spread in communi-
ties that are missing herd immu-
nity.Herd immunity is when groups
of people are vaccinated to protect the herd
from rapid disease spread.In the cases of
reported measles, the majority of people
who got measles were unvaccinated.1 In fact
an unvaccinated child is 35 times more likely
to contract measles as compared to a vacci-
nated child.3 Public health has issued multiple
campaigns about herd immunity, the impact of
disease, and the need to vaccinate on the local,
state, national, and international level. Much
work was done in every city to notify the public
and providers about the outbreak, as well as
to provide algorithms and contact information
for consultation on suspected cases.Public
health provided fliers for healthcare facilities
that warn of the outbreak and to tell individuals
with rash not to enter a healthcare facility or
waiting room.FAQs were issued to clinicians
to give information about the outbreak.
66 | Summer 2015 | Prevention
Q:Sthehould public health have taken a more active role in educating
public about the importance of vaccines 1015 years ago
when there was an increase in the anti-vaccine movement?
Chicago Department
of Public Health:
Public health has always promoted
vaccines as a means to prevent the
transmission of vaccine preventable
illness. Parents want to do whats right
for their children; however, there have
been certain instances where misinfor-
mation influenced their decision not to
vaccinate. One of the best ways for the
public to increase its understanding of
the benefits and safety of vaccines is to
make sure healthcare providers have
the information they need to educate
their patients. Numerous studies have
shown that a healthcare provider rec-
ommendation for a vaccine increases
the likelihood of a patient accepting the
vaccine. Public health has and contin-
ues to partner with healthcare provider
organizations (e.g., American Academy
of Pediatrics, American Academy of
Family Physicians, American Nurses
Association) to make educational
opportunities and materials available
to their members. We know that the
MMR vaccine is safe and effective, so
public health officials are committed
to educating the public directly and
through healthcare providers about the
importance of vaccines and ensuring
that residents have the opportunity to
get the vaccines for themselves and
their children.
Demian Christiansen,
DSc, MPH: Public health
must lavish health education
and health literacy with the
same attention and resources it pays to
disease surveillance and control. We
can always do more to educate people
about the importance of vaccinations.
But we have an uphill climb. The stark
reduction in measles cases beginning
in the mid- to late-1960s was, in some
ways, a victim of its own success. In
our recent measles outbreak associ-
ated with a daycare, we had several
children with fever and rash illness
who were misdiagnosed. This is not to
lay blame at the feet of those healthcare
providers but rather to point out that
many had never seen a measles case
because of the past measles vaccina-
tion successes. Without their patients
having had a clear link to the California
theme park or travel to an area with
ongoing measles transmissioncou-
pled with a dearth of measles cases
in recent years in suburban Cook
Countyit may indeed be difficult for
many healthcare providers to Think
Measles. We hope this is changing
now. Our own daycare-associated out-
break of measles along with the larger
multi-state outbreak should have been
a wake-up call.
Beyond that, however, public health
needs to change with changing times.
The Internet, in general, and social
media, in particular, have revolution-
ized the ways messages are created,
how they are packaged and deliv-
ered, and how they are consumed and
assimilated. Public health knows the
message is Get Vaccinated! We just
need to find the right way to deliver
that message. We have much to learn
from our marketing brethren! In some
cases, outraged parents delivered
the message their own waytaking
to social media and blogs, angry that
their children, some extremely ill,
may have been exposed to measles
because some chose not to vaccinate.
Many such exposures could have been
easily avoided.
Tammy Sylvester, RN,
BSN: Public health took an
active role in educating the
public about the importance
of vaccines.People were very afraid
of autism because of the false reports
by Andrew Wakefield stating an asso-
ciation between autism and MMR [vac-
cines].This was a very difficult barrier
to overcome and not much more could
have been done at the time. Public
health, especially the CDC, worked very
hard to study the claims and were able
to show that no association between the
two existed.
 Q: What did the U.S. do correctly to eliminate measles in the
past and what can we use to do the same now?

Q: What are the plans to

eradicate measles?
Chicago
Department of
Public Health: Measles remains
prevalent in many parts of the world.
In order to fully eradicate measles,
the vaccine needs to be made avail-
able in places where healthcare
systems are underdeveloped or do
not have the means to obtain the
vaccine. Current global efforts to
eradicate polio are nearing success,
and those same core public health
approaches can be applied to elimi-
nating other vaccine-preventable ill-
nesses like measles.
Chicago Department
of Public Health: After
the first measles vaccine was licensed
in the 1960s, there was a dramatic
decrease in the number of cases. Prior
to that, there was a very high prevalence
of measles cases in the U.S. Furthermore,
once a second dose of vaccine was rec-
ommended in the 1980s, the number of
cases continued to drop even further to
the point that endemic transmission in
the U.S. ended in 2000.
Demian Christiansen, DSc,
MPH: Vaccinate, of course!
We have an excellent, safe, and
effective vaccine to prevent
measles. A single dose of measles vaccine,
usually given as MMR vaccine provides
93 percent protection against measles.
Getting the recommended two doses of
MMR brings that level of protection up to
97 percent. Vaccination against measles
results in lives saved and avoids perma-
nent disability. In 2014, CDC estimated that
among children born during the past 20
years, vaccinations, including MMR vac-
cine, prevented 21 million hospitalizations
and prevented 732,000 deaths.4 Thats the
equivalent of preventing a child from being
hospitalized every 30 seconds. Thats an
amazing success story.

Demian Christiansen,
DSc, MPH: No doubt,
local and state health
departments along with
CDC will bring the multistate mea-
sles outbreak under control in short
order, if they havent already. But as
everyone knows, we live in an inter-
connected world. Truly, nothing in
recent memory has demonstrated
this more clearly than the Ebola
Virus Disease epidemic affecting
West Africa. As we have seen, any
disease can be on our doorstep in
a matter of hours. It simply isnt pos-
sible to ignore what is going on else-
where in the world. Several years
ago, the theme for World TB Day was,
TB Anywhere is TB Everywhere.
This certainly applies to measles and
countless other infectious diseases.
For measles to be eradicated, we
need to ensure it is eliminated here
in the U.S.and everywhere else
around the world. Measles eradi-
cation will take a worldwide effort
and political and economic will not
dissimilar from those required to
eradicate smallpox.
Q:
Should the MMR vaccine be mandated for children to
start school?
Chicago Department of Public Health: School vaccine require-
ments contributed to the high levels of vaccine coverage that have
been achieved among school-aged children. They are regulated at the state level
and as a result, vary from state to state. Some states allow individuals to opt out of
the required vaccines if they have a personal belief or religious belief that prohibits
receipt of the vaccine. In Illinois, the MMR vaccine is required for students who attend
daycare centers, preschools, elementary, middle, and high schools, and religious
and medical exemptions are allowed. The MMR vaccine is still required for most
individuals who attend daycare or school and do not have underlying medical condi-
tions that would prevent them from receiving the vaccine. Because there is a small
percentage of individuals who cannot receive the vaccine, it is important for those
who can receive it to do so. This concept of community immunity helps protect those
who are more vulnerable to illness.
Demian Christiansen, DSc, MPH: MMR vaccine is mandated by all
states for children to start school. However, we know that there are gaps
when individuals, or groups of individuals, opt out for religious or philo-
sophical reasons. There are several states looking to tighten requirements
for parents who seek exemptions. The Illinois General Assembly voted on such a bill.
Ultimately, though, everyone must understand that when it comes to vaccinations,
what each individual does affects the groupfor better or for worse.
Tammy Sylvester, RN, BSN: It is.The problem is the ease to which
exemptions are facilitated.Some schools are passing rules to only allow
physical exemptions documented by the primary care provider.Others
are allowing religious exemptions if signed by a pastor and requiring
parent to go to corporate district office to pick up exemption forms.The thought is
that when it is more difficult to be exempt than to go get immunized, only the ones
that really need to be exempted will go through the work.

w w w.apic.org | 67
 Q:Mtheir
ost parents turn to the Internet for
information. What can be done to Q: How can infection preventionists assist in
the eradication of measles?
educate this population about the use
of credible websites?
Chicago Department of Public Health: Public
health professionals work closely with infection
Chicago Department of Public
control practitioners in healthcare settings to report commu-
Health: Healthcare providers and public
nicable diseases, identify individuals who were exposed to
health professionals rely on evidence-based guidelines
infectious patients, and implement protocols that help prevent
to educate patients and families about healthcare-related
transmission when patients with communicable diseases seek
concerns. Although there are websites that do rely on sci-
and receive care. These efforts are ongoing to ensure that indi-
ence-based medicine, many others that are easily acces-
viduals who are ill receive the proper care, but also that others
sible do not use these same evidence-based guidelines.
in healthcare settings are protected as well.
The best thing parents can do if they have questions about
a certain healthcare issue is to contact their provider. Those
Demian Christiansen, DSc, MPH: Infection pre-
who do not have a provider should reach out to their local
ventionists are the closest partners we have in com-
public health department, many of which have vaccine
municable disease control. Their everyday work is
programs for those who are uninsured or underinsured.
geared toward preventing the spread of communicable
diseases, which is obviously a goal we share. Together, we work
Demian Christiansen, DSc, MPH: This
every day to eradicate diseases. But we cannot do it alone. We
is crucial, and once again, this is an issue of
need to continue emphasizing vaccinations and being creative
health education and health literacy, impor-
in the messaging. Debunking myths about lack of vaccine safety
tant themes in communicable disease control.
and educating the public with culturally sensitive and linguisti-
Credibility is key, but for a website to be useful, it must
cally appropriate language is key.
be well-organized, quick, and it must make technical
information accessible to parents. At the end of the day,
Tammy Sylvester, RN, BSN: Quick reporting of
we tend to listen to those we trust; healthcare providers,
suspect cases (e.g., phone calls to local public health),
especially nurses, have a vital role in providing credible
protocols in place for rash illnesses, and continued
and trustworthy information to their patients. It starts with
close working relationships with local public health.It
educating ourselves first so we can direct our patients and
takes a team, and we all want the same thing: optimal community
the public to the right resources.
and patient outcomes!

Note from the editor: APIC thanks Mary L. Fornek RN, BSN, MBA, CIC, head of Kenrof IC Consulting and Prevention Strategist editorial
panel member, for developing the questions for this article.
References
1. Centers for Disease Control and Prevention (2015). Measles Cases and Outbreaks. Accessed April 24, 2015. Retrieved from: www.cdc.gov/measles/cases-outbreaks.html.
2. McLean, H. (2012). Measles United States, 2011. CDC Morbidity and Mortality Weekly Report 61(15), 253-257. Retrieved from: www.cdc.gov/mmwr/preview/mmwrhtml/mm6115a1.htm.
3. Vara, C. (2013) Explaining measles outbreaks despite high vaccination status. Shot of Prevention. Retrieved from: shotofprevention.com/2013/09/19/explaining-measles-outbreaks-despite-high-
vaccination-status.
4. Centers for Disease Control and Prevention (2014). Report shows 20-year US immunization program spares millions of children from diseases. Accessed April 10, 2015. Retrieved from: www.cdc.gov/media/
releases/2014/p0424-immunization-program.html.

Read more about measles

Learn more at the APIC in the American Journal of
Infection Control
2015 Annual Conference
Measles in health-care settings, Maltezou, Helena C. et al., American Journal of
Attend these measles-related sessions Infection Control, Volume 41, Issue 7, 661-663.
at APIC 2015, June 2729 in Nashville, Measles investigation: A moving target, Helmecke, Megan R. et al., American
Tennessee. Journal of Infection Control, Volume 42, Issue 8, 911-915.
3402California Measles Outbreak:
Impact of a Measles Exposure in an Emergency Department, ODonnell, Anna
Epidemiology and Public Health
et al., American Journal of Infection Control, Volume 38, Issue 5, e41-e42.
Response, December 2014April 2015.
021Measles Emergency Response: Measles and pertussis outbreaks: Animportant role for travel clinics, Rapose,
Lessons Learned from a Measles Alwyn, American Journal of Infection Control, Volume 41, Issue 11, 1140.
Exposure in an 800-bed Facility. Measles Outbreak Management at a Minnesota Childrens Hospital in 2011,
LeBlanc, Julie et al., American Journal of Infection Control, Volume 40, Issue 5, e67.

68 | Summer 2015 | Prevention

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