HCPro.com - Briefings on Infection Control

Taking a vertical and horizontal approach to MDRO prevention

Thu, 01 Dec 2011 04:00:00 GMT

Taking a vertical and horizontal approach to MDRO prevention

Creating the perfect program depends on your facility's needs

After reading this article, you will be able to:

Explain the difference between a horizontal and vertical approach to MDRO prevention
List considerations when conducting an MDRO risk assessment
Identify ways in which a successful horizontal approach can decrease MRSA colonization

Every healthcare facility has patients who are colonized with an MDRO, whether it's from the community, another hospital, or another patient.

Subsequently, preventing these patients from entering your facility is relatively impossible-unless you're willing to bolt the doors shut.

Instead, a more realistic approach involves preventing the spread of MDROs the moment those colonized patients enter your facility. Depending on the type of facility you work in and the risk factors in that environment, the backbone of your prevention efforts may follow either a vertical or horizontal path.

These expressions are used to delineate two different approaches to MDRO prevention, says Peggy Prinz-Luebbert, MS, MT(ASCP), CIC, CHSP, owner and consultant for Healthcare Interventions, Inc., in Omaha, NE. A horizontal approach is what Luebbert calls an "all for one" approach that focuses on tried-and-true prevention efforts on all patient populations. Essentially, you treat everyone the same, so you won't need to do anything special for a unique bug. A horizontal approach involves the following:

Standard precautions
Hand hygiene
Respiratory etiquette
Environmental cleaning
Aseptic technique

A vertical approach takes those same basic IC principles while adding a one-size-does-not-fit-all tactic. Each bug is treated differently and each patient has a unique infection prevention procedure. The vertical approach focuses on the following efforts:

Active surveillance
Isolation
- Level of transmissibility
- Mode of transmission
- Consequences of infection

First, do a risk assessment

Which approach you decide to take really depends on what unit you are working on, the needs of your patients, and the type of procedures that are being performed. This is where the risk assessment comes in, which will help determine what kind of approach will optimize your prevention efforts.

"You need to do a risk assessment for your environment, your patients, and your bugs," Luebbert says. "Look at which one of these works best for you. There isn't one approach that works for everyone. In some environments the horizontal approach is enough, but in others you might need to use the vertical."

For example, if you are in an outpatient setting, you may want to consider the following during your risk assessment:

Type of patients
Type of procedures
Bodily fluids that staff members may come in contact with
Pathogens that may enter the facility

An outpatient surgery center may find that standard precautions for every patient is sufficient to prevent cross-contamination of potential MDROs. However, an ICU that cares for patients who are much more critical requires many more considerations to prevent potentially deadly outcomes if an MDRO like MRSA were to spread from patient to patient.

"If you're in an ICU setting where you've got lots of tubes and IVs, the patients are on a lot of antibiotics, and there is going to be a lot of people touching and treating that patient, then you might need more than just a horizontal approach," Luebbert says.

Case study: The horizontal approach in action

Luebbert put the horizontal approach into action as an IP responsible for a large healthcare system. The IC department decided to focus its targeted screening efforts on one of the high-risk areas, a rehabilitation facility that treated hundreds of inpatients and outpatients, including quadriplegic and paraplegic patients.

For three months staff members took nasal swabs on admission, biweekly, and on discharge. On admission the IC team found that approximately 8% of patients were colonized with MRSA, a statistic that was expected considering it fell in line with the general rate of MRSA in the community. However, they also found that an additional 7% of patients were colonized upon discharge, meaning they contracted MRSA while being cared for at the facility.

"You are taught in infection prevention 101 that you never culture unless you know what you are going to do with a positive result," Luebbert says. "Well, we didn't expect that, so we brought all the stakeholders together and asked, ‘What's happening here?' "

The stakeholders took a closer look at the risk factors, especially in the large gym that was used for rehabilitation purposes, and discovered a couple of issues that may have gone unnoticed without the screening.

First, they found that employee compliance with hand hygiene and equipment disinfection was good with patients who were on isolation precautions, but with everyone else, staff members demonstrated limited compliance because they assumed they were not colonized.

Secondly, patients and visitors were not washing their hands, which further contributed to the spread of MRSA in the facility.

"A lot of family members help out in rehab," Luebbert says. "None of them were ever washing their hands. And if the patient is colonized with it, odds are their family members are too."

After identifying these key areas of concern, the rehab center instituted strict policies with both staff members and visitors. Staff members were trained to wash their hands before and after treating each patient, regardless of whether that patient was on isolation precautions. They were also trained to disinfect gym equipment between each patient, not just after patients who were under precautions. (See the sample environmental cleaning checklist on p. 4.)

"We didn't just wash our hands for those that were in isolation and we didn't just clean equipment for those that were in isolation-we did it for everyone," Luebbert says.

Additionally, visitors and patients were instructed to use hand sanitizer in between usage of equipment. Inpatients were also required to change into clean clothes before using the gym, and outpatients were asked to wear clean clothing to their rehab appointments.

Within six months of implementation the rehab center had less than 1% colonization.

"It's an example of a horizontal approach in that if we do this for everybody, whether they are in isolation or not, then we can show a decrease, and the culturing of MRSA ended up being a marker of how effective our standard precautions were," Luebbert says.

Reeducation and changing behaviors

Months later, however, the facility saw another spike in MRSA colonization. Upon further investigation, it found a simple explanation. The person who had been a big proponent of proper hand hygiene and disinfection in the gym had moved to another position. New staff members and students were filtering in and that strict adherence to standard precautions and appropriate disinfection was falling to the wayside. New staff members were quickly educated and the emphasis on standard precautions for every patient was reinforced. After the reeducation effort, the spike quickly dissipated.

But the spike reinforced the idea that hand hygiene and disinfection need to be integrated into everyday processes so they become second nature to staff members, Luebbert says. This is often echoed in procedures such as catheter insertion and removal, but the same principle applied for MRSA prevention.

"You can't say you need to change the catheter and then wash your hands; it needs to be when you change the catheter these are the steps that need to be followed to change the catheter. Hand hygiene is a big part of those steps," Luebbert says. "It's the same with standard precautions. It's part of the process; it's not a separate entity."

Implementing hand hygiene technology and improving compliance in the ED

Thu, 01 Dec 2011 04:00:00 GMT

Implementing hand hygiene technology and improving compliance in the ED

Two studies take on relevant hand hygiene issues: the Big Brother effect of surveillance technology and overcrowding in the ED

After reading this article, you will be able to:

Identify reasons why healthcare workers are apprehensive about hand hygiene technology
List the predictors of worsened hand hygiene compliance in the ED

Hand hygiene is the simplest way to prevent infections, and in nearly every hospital, someone is watching for compliance. Now that "someone" is gradually turning into "something" as more hospitals turn to automated surveillance technology in order to capture a larger sample size and improve or maintain compliance.

But as healthcare technology rapidly improves, so does the need to implement that technology appropriately. Failure to do so will only alienate healthcare workers and establish a "Big Brother" feeling throughout the hospital.

A recent study published in the November issue of Infection Control and Hospital Epidemiology addressed this issue, conducting focus groups with frontline staff members, mid-level management, and leadership at healthcare facilities that had not yet used the technology. Almost universally, frontline staff showed reluctance to the technology and concern over the possible effects of the data that was collected, says Kate Ellingson, PhD, epidemiologist for the CDC's Division of Healthcare Quality Improvement and lead author of the study.

"Healthcare workers and the frontline weren't necessarily wary about the technology itself, but they were wary about not knowing enough about it," Ellingson says. "Many of them expressed that they would feel more confident and accepting of the technology if they knew exactly how that worked and how the data was going to be used."

The study highlighted that while technology may have positive effects on behavior, appropriate implementation will lead to a more willing workforce.

Communication and transparency

The key to this technology is open and honest communication. Of the members in the focus group, leadership was typically the most familiar with hand hygiene surveillance technology, but they were also the most willing to share the data, going so far as to release it to the public.

Healthcare workers, on the other hand, were very concerned with how the data would be used.

"There is a concern that with the oversight technology an individual healthcare worker could be fired or called out for having poor adherence," Ellingson says. "So when you're thinking about it from that perspective as the individual healthcare worker, there are a lot of concerns with accuracy."

There are also some areas where technology falters. For example, there may be instances in which a physician enters the room but does not touch the patient. Surveillance technology would track that as noncompliance, but given the context of the situation the physician would not be at fault.

"If you are talking about one hand hygiene opportunity, a single healthcare worker and a single opportunity, the direct observation is probably better because it's an observer who can see exactly what is going on and he's aware of the context of the situation," Ellingson says.

Moving past direct observation

Although direct observation does provide better context to individual instances of hand hygiene behavior, it is limited in the amount of observations that are possible.

Direct observers are also intended to be clandestine, but they are often easily recognized by healthcare workers, thus influencing compliance.

"I think where the technology brings us forward is in getting a complete sample and a better statistical proxy of hand hygiene overall, rather than that little sliver that a direct observer can give you," Ellingson says.

Improving compliance in the ED

Another study also published in the November issue of Infection Control and Hospital Epidemiology focused on hand hygiene in the emergency department (ED), a particularly challenging sector of the hospital given its high patient load and hectic environment.

The study determined that hallway or high visibility location, worker type, and glove use were all predictors of decreased hand hygiene compliance, with hallway location being the strongest indicator for noncompliance. For the first time, the study defined some of the unique issues present in the ED.

"Nobody has really looked at things that are unique in the emergency department that may not even be factors in other parts of the hospital or clinic," says Arjun Venkatesh, MD, MBA, an emergency medicine resident at Brigham and Women's Hospital in Boston and lead author of the study.

Hallway location

According to Venkatesh, when ED workers were forced to take care of a patient in a bed placed in the hallway, it elicited a couple of key points:

Hand hygiene in the hallway is much more difficult because of environmental characteristics. A hand sanitizer may not be nearby or the work flow might not easily allow access to a sink compared to a private room.
When patients are in the hallway it means that the ED is overcrowded, making it more difficult for healthcare workers to wash their hands.

Traditionally, overcrowding has been linked to other bad outcomes such as delays in antibiotics or painkillers. As a result, EDs have to take into account overcrowding and its effect on healthcare worker behaviors when planning hand hygiene campaigns.

"We're starting to show a clinical impact of crowding, especially a patient safety effect, and that will hopefully drive hospitals to new policies and delivery models," Venkatesh says.

Worker type

Most hand hygiene campaigns focus on nurses and physicians, but the dynamics of the ED should force IC departments to consider a much more comprehensive campaign that includes physician assistants, nurse practitioners, and even transport workers.

"Transport workers had very low hand hygiene compliance, almost 60%," Venkatesh says. "The reason that matters is because it only takes one missed hand hygiene opportunity to transmit an infection. If you spend all your educational efforts and resources on just physicians and nurses, you miss a whole swath of healthcare workers out there that can contribute to horizontal transmission."

Glove use

Similar to other healthcare environments, glove use contributed to worse hand hygiene.

"We've always kind of hypothesized that it's because either the time of doing both is too much of a burden or people think that because they wore gloves they don't need to wash their hands," Venkatesh says.

Thus, it's important to not only educate ED workers, but also provide immediate audits and feedback to ensure they understand the risks of cross-contamination. Given the diversity of critical patients entering the ED, and the number of deadly bugs, reminding all healthcare workers about proper hand hygiene before and after glove use is imperative to achieving higher compliance rates.

Puncture brings needlestick safety to the public eye

Thu, 01 Dec 2011 04:00:00 GMT

Puncture brings needlestick safety to the public eye

A new movie offers a mainstream medium for needlestick safety, highlighting the legal battle against medical manufacturers

After reading this article, you will be able to:

Explain how Puncture brings needlestick awareness to the general public
Analyze the importance of the U.S. Needlestick Safety and Prevention Act of 2000
Identify areas of healthcare where gaps still remain in safety needle awareness and compliance

Healthcare workers have seen it all when it comes to safety training videos. A throaty narrator exposes statistics that endanger workers if they fail to use safety needles: An estimated 800,000 needlestick injuries occur each year. Workers can be exposed to HBV, HCV, and HIV.

Although these training films routinely make their premiere in hospitals, rarely does a motion picture make its way to the big screen, highlighting the issue of needlesticks in the mainstream media.

Puncture, which opened in select cities September 23, does just that, shining a public spotlight on an issue that is generally reserved solely for the eyes of nurses, doctors, and surgeons. The legal thriller is loosely based on the true story of two lawyers, Michael Weiss (played by Chris Evans) and Paul Danziger (Mark Kassen), who battle medical manufacturing companies when an ER nurse contracts HIV after an accidental needlestick, in an effort to determine why safety needles are not being used in hospitals.

"The arc of the story is representing this event where there is the safety needle, but you can't distribute it in the majority of the hospitals," says Danziger, an executive producer of the movie, author of the screenplay, and a partner at Danziger & De Llano in Houston. "And the lawyers discover that the reason for that is there are these large group purchasing organizations [GPO] and they control significant portions-up to $100 billion-of what is purchased each year in U.S. hospitals, and they have certain deals with certain manufactures in order to get kickbacks."

Danziger says he wrote the movie for two reasons: to honor a friend, Weiss, who passed away, and to expose these issues that seem to fly under radar in the mainstream media arena.

"I just wanted to get those issues out so that people can discuss it and talk about it and understand it," Danziger says.

General public awareness

When it comes to needlesticks and needlestick safety, healthcare workers are routinely educated on dangers and subsequent safety precautions. The general public, however, is largely clueless regarding these issues.

"Most people don't understand how the purchasing system in U.S. hospitals is done," Danziger says. "They don't understand it, they don't see, they don't know, and the GPOs have done an amazing job of keeping below the radar and keeping this issue out of the public eye."

Although some newspapers, such as The San Francisco Examiner and The New York Times, have covered this issue, Puncture is really the first mainstream movie to address needlestick safety, says Ron Stoker, executive director of the International Sharps Injury Prevention Society in South Jordan, UT.

The reason Puncture may bring more awareness to the general public is not only because of its exposure, but also the compelling story that adds an authentic and personal touch to this issue. This is often the best way to capture the attention of both the general public and the healthcare community.

"I think that personal stories add a lot to the discussion of safety for healthcare workers and the public," Stoker says. "I am a great advocate of being transparent with information so that all people are aware of the dangers and concerns of medical devices."

The movie Puncture offers this personal account of a story that is based on real events, capturing the true horror that needlesticks can wreak on an individual. Danziger hopes this will help generate additional awareness within the public forum as more patients begin to realize the dangers healthcare workers face on a daily basis.

"You have to always be hopeful that the movie will bring it to people's attention," he says. "There is a certain movement amongst people to try and rein in healthcare costs that are unnecessary, so I think eventually it will change, but it's not going to change without coming to people's attention, and people looking at it, and people talking about it."

Exposing group purchasing organizations

One of the major themes in the movie is the battle with GPOs to sell safer medical equipment to hospitals. Many GPOs get kickbacks from device manufacturers, Danziger says, so there is often a reluctance to sell a device that isn't going to elicit the most profit. This serves as one of the primary controversies in the film, setting up a "David vs. Goliath" theme.

As a result, inventors and entrepreneurs that have developed a safer needle or device are shut out from healthcare facilities, and healthcare workers are put at risk.

"There are safe needle products that aren't being purchased by the hospitals through the GPOs because they are a couple of cents more and they don't have sweetheart deals with these independent manufacturers of safety needles, so nurses' safety is put at risk for a couple pennies per syringe," Danziger says.

In 1998 Stoker was working for a medical device manufacturer, training healthcare workers on the manufacturer's product. He lost 25% of his market share in one day after California passed a law requiring the use of safety needles, and he didn't have a single safety product in any of his offerings. Many states followed suit soon after, and in November 2000 the U.S. Needlestick Safety and Prevention Act was signed into law and OSHA quickly responded with corresponding amendments to its Bloodborne Pathogens standard.

"We are much safer now than we were then, but are we where we need to be? No," Stoker says. "I think we have much more work that still needs to be done."

Gaps in the healthcare environment

Although Puncture brings more awareness of needlestick safety to the general public, gaps still remain in the healthcare environment concerning the use of safe needles.

Stoker recently conducted a survey with Outpatient Surgery Magazine assessing compliance with the Bloodborne Pathogens standard in surgical suites. Although the results have not yet been published, the survey highlighted the fact that even though healthcare workers are aware of the requirements of the Bloodborne Pathogens standard, a vast majority still fail to comply.

"It is appalling to recognize how many operating rooms continue to use non-safety products," Stoker says. "For example, safety scalpels have been available for a few years. In fact, they have hit a second, or third, or fourth generation safety scalpel, and yet surgeons are unwilling to use them."

Furthermore, many hospitals are not using the safest needles on the market, Stoker says. For example, many clinicians are still using first-generation syringes, including active safety needles that require healthcare workers to activate the device themselves. Passive safety devices, which have been on the market for years, activate as soon as the needle touches the patient's skin. If the patient kicks, moves, or thrashes, the healthcare worker is protected by a device that has already activated.

"I believe that there's still much work to convert conventional sharps devices into passive safety products and to upgrade active safety products into passive safety products," Stoker says.

Sterile processing and its current status in the healthcare community

Thu, 01 Dec 2011 04:00:00 GMT

Sterile processing and its current status in the healthcare community

After reading this article, you will be able to:

Explain why sterile processing has received more attention in recent years
Analyze ways to conduct a thorough risk assessment
List best practices for following manufacturers' instructions

Editor's note: The following questions were answered by Michele DeMeo, an independent consultant and former sterile processing manager at Memorial Hospital in York, PA, and Pam Neiderer, RN, BS, director of surgical services at Memorial Hospital.

Q How has the focus on sterile processing shifted in the last few years? Does there seem to be more attention devoted to this area of healthcare?

A MD: There has been a shift and more attention. This has occurred on several levels for many reasons and will continue to evolve, I believe. Experts, outside of sterile processing and nursing, are realizing that the function and/or department responsible for "sterile processing" actually are the individuals responsible for whether or not an item was processed appropriately before a procedure or surgery. Previously, even many executives might look at their outcomes and believe nursing, OR, or the physicians are the ones to credit. It never crossed most of their minds that part of the successful (or unsuccessful) results might partly or wholly be attributed to this often tiny department known to "just" clean equipment.

Attention has been partly given due to this new and different realization due to an increasingly higher litigation climate. No one wants to take the blame or own the result, if it is not possible. Think of how many articles and news stories have surfaced just over the "dirty scope" topic and its ramification on several high-profile entities across the country.

Another source of attention is from the professionals in the sterile processing field itself. Technicians play a vital role and need not only the recognition and pay associated with a role thought of as complex and difficult, but also many of the naturally occurring benefits that tend to parallel this: money for continued education, and funds to have the most advanced processing equipment and supplies.

More attention means more inquiries; and with more inquiries comes information. With information comes knowledge. And only with knowledge can there be improvement and advancement. So, a wider breadth of key stakeholders are becoming introduced to the vital nature of this lesser-known field within healthcare. These key stakeholders have a lot at stake. They are shareholders, doctors, CEOs, and CFOs of hospitals; they are design manufacturers of delicate and complicated equipment; they are mothers and fathers in government agencies who may have had a relative with a bad outcome. Understanding who really performs what and how in our healthcare entities will drive better process improvement efforts when opportunities present themselves, and better designed equipment will come to the market when companies really understand who and what occurs before and after a surgical procedure with their device.

PN: The entire medical community has become increasingly aware of sterile processing in the last few years. Several incidents have occurred to force institutions to look at what really happens in their sterile processing department [SPD]. The CEOs and owners of many facilities have become aware of the vulnerability of their investment when there is a break in technique and the responsibility does not just lie in the hands of the SPD department. Healthcare has finally become part of the national headlines. This has challenged the industry to provide improved methods, products, and training for sterile processing. The industry has also contributed to improving how operations are completed in the processing arena. There have been many improvements in several resources used in processing, such as indicators, integrators, and biological vials.

Q Every department conducts some sort of annual risk assessment. What are some key areas that sterile processing departments should focus on during annual assessments to ensure their program is compliant?

A MD: My belief is that low-usage/quantity but high-risk tasks and functions should be assessed the most. These are the areas that are most likely to fail since they are either not performed often or have the most devastating result if they do fail. These tasks might include assessing your CJD procedures, internal positive biological recall practices, or even your special cycles.

PN: Risk assessments should involve incidents that seldom occur but are high-risk events. For example, staff should participate in evaluating the proper steps to take when a "wet" pack occurs. While evaluating any process, it is important to use evidence-based information to incorporate any process changes. Each member of the staff should be required to review low-incidence events to ensure they are all universally compliant. Each member of the team may have trained at different schools; this increases the chances of inconsistency of techniques.

Q Ensuring compliance with manufacturers' instructions is a huge part of sterile processing. What is the best way to approach this issue, especially if you are a large facility with many different pieces of equipment? Are there tips that can make this process easier and more organized for staff members?

A MD: There are lots of ways, but if your facility has a computer system, adding the instructions to the instrument (or equipment's) count sheet-think of a recipe-works well. Also, having prompts at different stop points in the processing to allow for instruction review is important.

Q What kind of process should be in place when a staff member has a question about manufacturers' instructions? Is it as simple as calling the manufacturer?

A MD: Mostly yes, and I want to stress to call the manufacturer directly and speak with the technical or clinical department. While sales representatives are trained, they are not processing experts. Misinterpretation can and does occur often. The most common phrase a sales representative will say to me is, "Oh, just use your standard cycle." We need pre-sterilization instructions and actual sterilization method and cycle parameter details. It is not an option.

PN: The manufacturer is the final rule. It is going back to basics. They are responsible for providing the proper guidelines for the product they manufacture.

Q What are the most common examples of noncompliance in sterile processing? Where do you see programs struggle most often?

A MD: Unfortunately, it is not following exact instructions from the very first to last step in the process. While the field of SPD is improving exponentially, it is not as well honed as one might believe in some facilities. I see/hear managers or technicians that do not have good understanding of extended or special cycles. I also see too much streamlining of cleaning, disinfection, and processing solutions being coordinated by a purchasing department without the advice or review of SPD. All solutions are not equal, regardless of what might be presented. They have different purposes for different devices and processing steps. This task of streamlining cannot be done in a purchasing or finance vacuum with the bidding companies. PVAST (purchasing value analysis standardization team) that include SPD and infection control are perfect venues.

PN: The highest incidence of noncompliance in sterile processing occurs in the cleaning and disinfecting process. It is common for employees to abbreviate this process or completely eliminate it to rush to the sterilization process. This especially occurs when you do not have properly trained or certified employees managing this process. There is a misconception that if the instruments go through the sterilization process, all of the bioburden is eliminated. There is also a great deal of pressure from the operating room to turn over instrumentation in a timely manner.

Q How should you determine how many full-time employees are needed in sterile processing? Is there a specific formula to use? What is the best way to present this to leadership to get needed resources?

A MD: Determining labor is not an easy or straightforward task, but it is crucial. In both circumstances, volume and intensity of volume must be compared and contrasted against other facility and department current norms, along with anticipated future norms or expectations. Breaking down pivotal tasks into coordinating "minutes," or rather "worked hours," is a great start. However, you cannot be misled into simply converting to just minutes. There are other departmental factors that are relevant and/or irrelevant to the equation. You can easily be stuck in the "but we are different" mind-set if you do not fully understand basic principles of benchmarking.

You will always have both highly productive employees and less productive (in terms of quantity). Taking a sampling of your highest and most complex tasks and functions and conducting a time study is important. It will give you a good and more accurate sense of where technician time is being (or not being) spent and how much you need. These numbers can be reviewed against your actual time usage. Remember, you need to be able to explain the dynamic SPD environment to administration or finance if you are not a part of a benchmarking service. This is because you will never be able to time-study everything, and good services have to normalize data to help its customers.

As for how to present this to leadership, what is likely to work best is an executive summary of tasks compared to hours worked and intensity. It should include what is needed to maintain or improve quality and should demonstrate what will be needed with forecasted new or different types of volume for the up-and-coming new fiscal years. (Often this is not handed to you. You have to ask what the executive strategic initiatives will be in the near future as surgical cases are not equal in needs or resources in SPD either.)

Q What advice do you have for someone who is new to sterile processing?

A MD: Assume you know little. Read trade magazines. Reach out to those with years of successful experience. Truly assess your department and read up on how to conduct an effective assessment. Review process improvement techniques. Read, reread, and reread technical SPD manuals. Know the basics like the back of your hand. Do not trust everything you are told. Question your new world over and over again, and don't stop.

PN: New employees must continually read to stay up to date with sterile processing changes and improvements. The Internet provides an abundance of information and resources to obtain this information. It is vital to be active in an organization that will provide continual education and networking. Networking with peers is an invaluable method of learning. In addition to education, experience provides the most valuable lessons. Someone new to the SPD workforce should have a mentor or someone they can utilize as a resource. It is important to seek the advice of someone who is experienced. Never assume you know what to do or how to do something.

Briefings on Infection Control, December 2011

Thu, 01 Dec 2011 04:00:00 GMT

Taking a vertical and horizontal approach to MDRO prevention

Creating the perfect program depends on your facility's needs

After reading this article, you will be able to:

Explain the difference between a horizontal and vertical approach to MDRO prevention
List considerations when conducting an MDRO risk assessment
Identify ways in which a successful horizontal approach can decrease MRSA colonization

Every healthcare facility has patients who are colonized with an MDRO, whether it's from the community, another hospital, or another patient.

Subsequently, preventing these patients from entering your facility is relatively impossible-unless you're willing to bolt the doors shut.

Standard precautions
Hand hygiene
Respiratory etiquette
Environmental cleaning
Aseptic technique

Active surveillance
Isolation
- Level of transmissibility
- Mode of transmission
- Consequences of infection

First, do a risk assessment

For example, if you are in an outpatient setting, you may want to consider the following during your risk assessment:

Type of patients
Type of procedures
Bodily fluids that staff members may come in contact with
Pathogens that may enter the facility

Case study: The horizontal approach in action

Secondly, patients and visitors were not washing their hands, which further contributed to the spread of MRSA in the facility.

"A lot of family members help out in rehab," Luebbert says. "None of them were ever washing their hands. And if the patient is colonized with it, odds are their family members are too."

"We didn't just wash our hands for those that were in isolation and we didn't just clean equipment for those that were in isolation-we did it for everyone," Luebbert says.

Within six months of implementation the rehab center had less than 1% colonization.

Reeducation and changing behaviors

Implementing hand hygiene technology and improving compliance in the ED

Two studies take on relevant hand hygiene issues: the Big Brother effect of surveillance technology and overcrowding in the ED

After reading this article, you will be able to:

Identify reasons why healthcare workers are apprehensive about hand hygiene technology
List the predictors of worsened hand hygiene compliance in the ED

The study highlighted that while technology may have positive effects on behavior, appropriate implementation will lead to a more willing workforce.

Communication and transparency

Healthcare workers, on the other hand, were very concerned with how the data would be used.

Moving past direct observation

Although direct observation does provide better context to individual instances of hand hygiene behavior, it is limited in the amount of observations that are possible.

Direct observers are also intended to be clandestine, but they are often easily recognized by healthcare workers, thus influencing compliance.

Improving compliance in the ED

Hallway location

According to Venkatesh, when ED workers were forced to take care of a patient in a bed placed in the hallway, it elicited a couple of key points:

Hand hygiene in the hallway is much more difficult because of environmental characteristics. A hand sanitizer may not be nearby or the work flow might not easily allow access to a sink compared to a private room.
When patients are in the hallway it means that the ED is overcrowded, making it more difficult for healthcare workers to wash their hands.

"We're starting to show a clinical impact of crowding, especially a patient safety effect, and that will hopefully drive hospitals to new policies and delivery models," Venkatesh says.

Worker type

Glove use

Similar to other healthcare environments, glove use contributed to worse hand hygiene.

Puncture brings needlestick safety to the public eye

A new movie offers a mainstream medium for needlestick safety, highlighting the legal battle against medical manufacturers

After reading this article, you will be able to:

Explain how Puncture brings needlestick awareness to the general public
Analyze the importance of the U.S. Needlestick Safety and Prevention Act of 2000
Identify areas of healthcare where gaps still remain in safety needle awareness and compliance

Although these training films routinely make their premiere in hospitals, rarely does a motion picture make its way to the big screen, highlighting the issue of needlesticks in the mainstream media.

Danziger says he wrote the movie for two reasons: to honor a friend, Weiss, who passed away, and to expose these issues that seem to fly under radar in the mainstream media arena.

"I just wanted to get those issues out so that people can discuss it and talk about it and understand it," Danziger says.

General public awareness

Exposing group purchasing organizations

As a result, inventors and entrepreneurs that have developed a safer needle or device are shut out from healthcare facilities, and healthcare workers are put at risk.

"We are much safer now than we were then, but are we where we need to be? No," Stoker says. "I think we have much more work that still needs to be done."

Gaps in the healthcare environment

Although Puncture brings more awareness of needlestick safety to the general public, gaps still remain in the healthcare environment concerning the use of safe needles.

"I believe that there's still much work to convert conventional sharps devices into passive safety products and to upgrade active safety products into passive safety products," Stoker says.

Sterile processing and its current status in the healthcare community

After reading this article, you will be able to:

Explain why sterile processing has received more attention in recent years
Analyze ways to conduct a thorough risk assessment
List best practices for following manufacturers' instructions

Q How has the focus on sterile processing shifted in the last few years? Does there seem to be more attention devoted to this area of healthcare?

PN:

AHA adds its voice to call for mandatory flu shots

Tue, 01 Nov 2011 04:00:00 GMT

AHA adds its voice to call for mandatory flu shots

How to sell mandatory flu shots to hospital staff

After reading this article, you will be able to:

Discuss why more hospitals need to adopt mandatory influenza immunization policies
Identify the process for educating staff on the importance of accepting seasonal influenza immunization
Describe the elements of a typical policy including choice to use flu mask as alternative to immunization

Add another voice to the call for mandatory influenza vaccinations for healthcare workers.

This time the voice isn't coming from the bleachers, but rather from the box seats, as the endorsement is from the American Hospital Association (AHA), a group made up of hospital and healthcare executives.

In April, the AHA's board of trustees approved a new policy urging its members to institute a mandatory flu shot policy for healthcare workers. To protect the lives and welfare of patients and employees, the AHA said it "supports mandatory patient safety policies that require either influenza vaccination or wearing a mask in the presence of patients across healthcare settings during flu season."

That's welcome news to infection preventionists, who have been battling to get healthcare workers vaccinated against influenza each season. "I can say it in one word: Hallelujah!" says Peggy Prinz Luebbert, MS, MS(ASCP), CIC, CHSP, a consultant and owner of Healthcare Interventions in Omaha, NE, who works with healthcare organizations across the country.

"It sets a standard for the nation of what hospitals should be doing," says Deborah L. Wexler, MD, executive director of the Immunization Action Coalition in Saint Paul, MN. "The AHA is another major organization that is being added to the ranks of those doing the right thing for patient safety."

In the past, the AHA had a policy encouraging flu vaccination for healthcare workers, but had not gone as far as making it mandatory, says Nancy Foster, AHA's vice president of quality and patient safety.

The organization kept an eye on the clinical evidence and decided earlier this year that it was clear the call for mandatory vaccination was a step it needed to take to protect patients, she says.

The evidence is very strong that high levels of vaccination result in reduced transmission of flu from workers to patients and also among healthcare workers, Foster says. The evidence also shows that in healthcare organizations with high rates of vaccinations, there is a decrease in the number of patient deaths from influenza, she adds.

"This really is about patient safety," Foster says.

Hospitals that want to adopt a mandatory policy don't have to reinvent the wheel since numerous facilities have already made flu shots mandatory for healthcare workers.

To share the experiences of hospitals that have already implemented mandatory policies, the AHA has hosted three conference calls for its members from July through September. Foster says 350-500 hospitals have participated in each of those calls.

The AHA also provides resources and tools to assist hospitals in establishing policies and creating campaigns to educate workers on the Hospitals in Pursuit of Excellence website at http://bit.ly/qr5HgM.

Foster says hospitals that have adopted a successful mandatory vaccination program have told her support from leadership is necessary. "It was absolutely essential they had the support of leadership, including and especially the CEO, the [chief operating officer], and the board [of trustees]," she says.

It's important that those individuals stand in line and receive their flu shot, as well as talk about the reasons for the mandatory policy, she says.

Mandatory flu shot policies are legal, Foster says.

All of the hospitals with a mandatory policy have included alternatives for healthcare workers who have medical contraindications or legitimate reasons not to receive a vaccination, she says.

One alternative, which the AHA policy endorses, is to require healthcare workers who don't receive a flu shot to wear a mask when in contact with patients to prevent flu transmission, Foster says. Some hospitals help workers find jobs in their organizations where they are not in contact with patients, she adds.

The more organizations, especially ones such as the AHA, that endorse mandatory vaccinations, the more compliance the healthcare industry will see, says Wexler.

More and more hospitals are mandating influenza vaccination, she says. "I think this is the snowball that is going to keep rolling down the hill."

Some hospitals mandate flu vaccination unless workers have a medical contraindication, she says. Some also allow workers to decline because of religious reasons.

Workers need to know why hospitals are requiring mandatory vaccination, Wexler says, so they don't feel this is something foisted upon them for no good reason. "Education is a key component of this," she says.

Adopting a mandatory influenza vaccine policy requires some intense work, she says. "This is a major undertaking in any hospital."

The good news is once it is in place, it becomes easy in future years to have a successful vaccination program with an extremely high vaccination rate, says Wexler.

Libby Chinnes, RN, BSN, CIC, an independent infection control consultant with IC Solutions, LLC, based in Mt. Pleasant, SC, who assists healthcare facilities nationwide, says she has spent 30 years trying to convince healthcare workers that flu vaccination protects patients.

"It's such an easy no-brainer thing. It's hard for me to understand we are still fighting this battle 30 years later," she says.

Chinnes applauds the AHA's stand but says individual hospitals will have to decide whether to make flu vaccinations mandatory. Some healthcare workers may never be convinced they should get a flu shot.

"I think it's going to take a true major [flu] outbreak in our country for some healthcare workers to heed the warning. They don't perceive themselves at risk. They don't see it as a patient safety issue," she says.

One way for hospitals to get healthcare workers to acknowledge the risks to patients is to have them sign a declination form, says Chinnes. The form requires healthcare workers to confirm in writing that they understand by not getting a flu shot they may be placing patients under their care at risk of contracting influenza, she says.

For a sample form, go to the OSHA Healthcare Advisor Tools page at www.oshahealthcareadvisor.com.

Cutbacks could mean fewer patients protected by flu vaccinations

There's one more reason why it's important for healthcare workers to receive an influenza vaccination this year.

Due to cutbacks in free flu shots, some hospitals may find that fewer of their patients are protected from influenza by an annual vaccination.

In many communities, federal and state budget cuts have halved the number of free vaccine doses available this flu season, meaning many cities and towns have had to cut back sharply on the number of people who get free flu shots at community-run clinics.

While the free clinics remain, in Massachusetts, for instance, the state has told local health departments to limit them to uninsured people and those whose health insurance does not cover the vaccine. In the past, many communities offered free shots to anyone who wanted one.

With the cuts, many people, including Medicare and Medicaid recipients, will have to get a flu shot by making an appointment with their physician or going to a pharmacy with a walk-in clinic that offers the vaccination.

That has some health officials worried about a reduction in the number of people, including seniors, who receive a flu vaccination. "I suspect strongly that people will not get vaccinated in the numbers that we have had in the past. That does not bode well for the health of the community," Larry Ramdin, health agent in Salem, MA, told The Salem News.

"Unfortunately, it's a sign of the economic times," Ramdin said.

With fewer people immunized, the influenza virus has more opportunity to spread.

While the amount of free vaccine may be limited in some communities, the vaccine itself is expected to be plentiful this year.

Requiring masks for healthcare workers

Healthcare workers either need to get an influenza vaccination or wear a mask when working with patients during flu season, according to a new American Hospital Association (AHA) policy.

That's a necessary step to protect the safety of patients, says Nancy Foster, AHA's vice president of quality and patient safety.

While a flu shot is preferable, wearing a mask is a way to minimize the transmission of droplets that can cause influenza, she says.

But is mask-wearing practical?

"I won't say it's the most comfortable option. But the risk to patients is too great [not to require it]," Foster says.

Hospitals often start vaccinating workers with flu vaccine in September, and flu season can run as late as through April.

"You're looking at months of wearing a mask," says Libby Chinnes, RN, BSN, CIC, an independent infection control consultant with IC Solutions, LLC, based in Mt. Pleasant, SC.

The requirement to wear a mask may be an incentive for some healthcare workers to get a flu vaccination, Chinnes says. "If you wear a mask for very long, it gets hot and uncomfortable," she says.

If hospitals are going to require masks for healthcare workers who decline the flu vaccine, they need to make that part of their policy, Chinnes says.

The hard part will be enforcement, she says, since workers may need to wear a mask for five or six months.

"Masking is a hassle for employees and can be problematic for hospitals to enforce," says Deborah L. Wexler, MD, executive director of the Immunization Action Coalition in Saint Paul, MN.

Monitoring healthcare workers who must wear a mask because they haven't had a flu shot is a challenge, agrees Peggy Prinz Luebbert, MS, MS(ASCP), CIC, CHSP, a consultant and owner of Healthcare Interventions in Omaha, NE, who works with healthcare organizations across the country.

Luebbert has worked with a couple of hospitals that have required masks and it does provide some motivation for workers to get a flu shot.

Healthcare workers are required to wear a mask as soon as they enter the facility, from October 1 to March 1, she says.

The healthcare workers are required to indicate on their identification badge whether they have had a flu vaccination or must wear a mask, she says. For instance, a blue dot indicates the worker has had a flu shot, while a red dot indicates they have not had it.

Luebbert admits it is like wearing a scarlet letter for those who don't get a flu shot.

The masks themselves are "awful," she says. "The employees hate it. It's uncomfortable and the patients can't see your face. And the patients hate it because they can't see the worker's expression."

It must be the responsibility of the employee's manager to monitor workers to ensure they are wearing their mask, Luebbert says. Infection preventionists cannot be everywhere in a hospital to monitor all workers.

Hospitals should be prepared for questions from patients and family members who may wonder why a worker is wearing a mask when providing care, says Chinnes.

"I think hospitals should come up with some kind of script so a healthcare worker can say, ‘This is why I'm wearing a mask,' " she says. Hospitals don't want patients to think they are allowing a worker who is sick to take care of them.

Luebbert agrees that hospitals need to communicate to patients and family members why workers are wearing a mask. One hospital put up a poster in its lobby advising people that both visitors and employees who had not been vaccinated against the flu must wear a mask during flu season, she says.

Needlestick hazards in nonhospital settings? Better believe it

Tue, 01 Nov 2011 04:00:00 GMT

Needlestick hazards in nonhospital settings? Better believe it

Healthcare safety experts show hazards are present, injuries happen, and OSHA compliance is low

After reading this article, you will be able to:

Explain why there is a disparity of safety device adoption data between hospital and nonhospital settings
Refute the five common myths associated with noncompliance with OSHA needlestick safety regulations
Identify the most frequent OSHA violations related to needlestick safety

Despite the volume and complexity of procedures, hospitals don't have a monopoly on needlestick and sharps injuries suffered by healthcare workers.

That point was made clear in "Achieving Sharps Safety Compliance in Non-Hospital Healthcare Settings," an August 8 Web conference hosted by the International Healthcare Worker Safety Center at the University of Virginia in Charlottesville.

Three experts in healthcare worker safety and facility compliance looked at why, more than 10 years after the passage of the Needlestick Safety and Prevention (NSP) Act, nonhospital settings still struggle with preventing needles and sharps injuries, and how this situation is related to misinformation about OSHA compliance and, consequently, low adoption of safety devices.

Here are the highlights of the program.

There is a disconnect in the level of safety provided in accordance with the Bloodborne Pathogens standard in hospitals compared to nonhospital settings, said Janine Jagger, MPH, PhD, director of the International Healthcare Worker Safety Center, who presented first on the program. The Center-through EPINet, which Jagger developed in 1991-provides healthcare facilities with a standardized system for tracking occupational blood exposures and is used by more than 1,000 U.S. hospitals.

But nonhospital settings, such as doctors' offices, urgent care clinics, dental facilities, long-term care facilities, dialysis centers, ambulatory surgery centers, and laboratories, are difficult to reach in terms of enforcement, documentation, and surveillance.

"They fall into the situation that we refer to as ‘no data, no problem,' " said Jagger. "While we do not have good direct data reflecting the situation in these settings, that doesn't mean there are not problems."

What EPINet does show is a dramatic increase in the use of safety devices versus conventional devices-especially in IV catheters, phlebotomy devices, and needles and syringes in hospitals. This increase comes just a few years after the November 2000 passage of the NSP Act.

Market share data on the use of safety disposable syringes, however, shows significantly lower adoption rates for alternate sites compared to hospitals, said Jagger; the adoption rate for alternate sites in 2003 was less than half that of hospitals.

Another consideration coming from EPINet data is the risk of injury and exposure attendant to procedures and the devices used in those procedures.

Jagger shared data showing that injury rates along the spectrum of devices-syringes, butterfly blood collection sets, phlebotomy devices, IV catheters, and lancets-are similar between hospitals and outpatient settings.

"The procedures and devices used are what determines risk level, so we must have the same level of safety compliance in nonhospital settings as hospitals," said Jagger. "The ‘no data, no problem' attitude is a poor defense for what we need to do to protect healthcare workers and comply with OSHA's Bloodborne Pathogens standard."

Not too far into her presentation, Elise M. Handelman, RN, MEd, an occupational and environmental health consultant who worked in OSHA for nearly 20 years, quoted from OSHA's Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens:

Where engineering controls will reduce employee exposure by removing, eliminating, or isolating the hazard, they must be used.

And that applies to nonhospital settings, period, Handelman adds.

She explained that the engineering controls section of the standard requires employers to seek input from frontline workers in identifying, evaluating, selecting, implementing, and training on safety devices.

"A needlestick is a needlestick is a needlestick, regardless of where it happens, and the goal of the standard is to reduce or eliminate those occurrences," said Handelman.

It is a common misconception that small employers are not covered. "Any private business with even one employee is still covered by the standard if there is a reasonable expectation that their employees are exposed to blood or OPIM," she said.

Another point of confusion on Bloodborne Pathogens coverage concerns recording and reporting requirements. "OSHA does say that if you have less than 10 employees, you do not have to keep OSHA logs, which includes the sharps injury log," Handelman explains. However, all other provisions apply.

For a list of frequent bloodborne pathogens violations in nonhospital settings acquired by HCPro's OSHA Healthcare Advisor, see p. 9.

Handelman next identified other costs of noncompliance:

Increased insurance rates if self-insured
Potential workers' compensation costs
Potential legal action from workers or unions
Lost employee work time due to testing or treatment
Expenses related to temporary or permanent replacement workers
Bad press

Lost work time and additional expenses for replacing workers pose particular difficulties for small healthcare facilities, she notes.

Compliance in the use of safety needles and sharps makes for a safer, more healthful work environment. Handelman lists the following example benefits:

Lower workers' compensation costs
Better CMS and Joint Commission surveys
Enhanced worker productivity with fewer days lost
Increased recruitment and retention of skilled workers, keeping facilities competitive

Recruitment and retention of workers is important in all healthcare settings, including nonhospital settings, said Handelman.

In her role as principal consultant for Healthcare Accreditation Resources, LLC, in Holliston, MA, Pamela Dembski Hart, CHSP, BS, MT(ASCP), has helped many nonhospital healthcare facilities to achieve compliance with the Bloodborne Pathogens standard.

In most cases, noncompliance is not intentional; rather, it results from a misinterpretation of the law or a lack of knowledge in its application. Dembski Hart identified the five most common myths that lead to noncompliance in nonhospital settings. (See p. 8 for more detail on those myths.)

She also shared results from an informal survey of 12 facilities whose specialties included internal medicine, OB/GYN, pain, women's health, dermatology, and adult general medicine; the survey included a hospital-associated practice, an ambulatory surgery center, and four endoscopy facilities.

The results showed that 66% of facilities reported purchasing safety devices, and 58% said those devices are routinely used, although some noted routine use was only among nurses. Fifty percent reported evaluating safety devices. This shows that compliance with the law is spotty at best, said Dembski Hart. But the dearth in compliance proved even worse when facilities were questioned about annual reviews and who did the evaluating: 75% did not conduct an annual review, and in 50% of the facilities, device selection was made only by managerial staff.

Although the survey admittedly had a small sample size, "the results correlate with data I have collected in previous years and that of other published studies," said Dembski Hart.

To avoid this type of noncompliance, she recommends safety officers focus on the following implementation guidelines:

Annually update the exposure control plan
List sharps that pose the greatest exposure risks
List safety-engineered devices that are being evaluated
Document annual consideration and implementation
Prioritize and schedule the evaluation, implementation, and final selections; and list the methods of soliciting input

The key takeaway from the guidelines is that no one should accept needlesticks as part of the job, said Dembski Hart. Your workplace may not have received any citations or fines, and your workers may be unwilling to change their habits, but neither of these things justifies noncompliance. Safety devices really do help reduce, if not eliminate, injuries, she adds.

The conference, both audio and visual presentations, is available free on-demand, but registration is required. To access a recording of the conference, go to http://bit.ly/nqUHjZ. The program is 1 hour and 6 minutes in length and includes a Q&A at the end. You can find more resources on sharps safety and EPINet on the International Healthcare Worker Safety Center website at www.healthsystem.virginia.edu/internet/epinet.

Five myths on needlestick safety noncompliance

As part of the "Achieving Sharps Safety Compliance in Non-Hospital Healthcare Settings" August 8 Web conference, Pamela Dembski Hart, CHSP, BS, MT(ASCP), principal consultant for Healthcare Accreditation Resources, LLC, in Holliston, MA, debunked the five most common myths in healthcare facilities that supposedly excuse noncompliance with the part of the Bloodborne Pathogens standard amended by the Needlestick Safety and Prevention Act. Here are the differences between myth and fact as she saw them:

Response: Isn't it just about watching a video?

Fact: Annual training must include an explanation about evaluation and use of safety devices. This usually is not possible using a generic video, said Dembski Hart. And annual really means every year. Additionally, credentials do not exempt anyone-even doctors-from the training requirement, she noted.

Response: We looked at them. The sales rep showed us some samples.

Fact: Annual documentation on evaluation must be completed, and a cross-section of staff must provide input. That doesn't mean having input only from the nurse manager, which is one of the most frequent misunderstandings, said Dembski Hart. Again, annual does mean every year.

Response: Is having a box on the shelf enough?

Fact: Having achieved consensus in selection, you now must implement and monitor compliance. Dembski Hart recommended notifying staff that the safety devices have arrived and are ready for use. Remember, it is the employer's responsibility to monitor and enforce compliance among staff members, she added.

Response: Safety devices are just too expensive.

Fact: "This is probably the biggest barrier I have found to implementation," said Dembski Hart. Yet not only have there been huge improvements in design and cost, prevention itself is cost-effective. The perceived direct and indirect cost of adopting safety devices pales in comparison to the actual cost of a sharps-related injury. "An injury with no time lost is at least $100; an injury with time lost could cost $3,000; an injury with seroconversion could go to $300,000," she explained.

Response: Staff members aren't interested in changing. What we have now is just fine.

Fact: The Needlestick Safety and Prevention Act is multifaceted, which you can use to promote individual accountability, said Dembski Hart; she recommended safety officers make sure leadership knows about and supports safety device evaluations. Remind them that adoption of safety devices can lead to a 90% decrease in sharps injuries, she said. Ultimately, you may have to assess and document noncompliance in annual performance evaluations, Dembski Hart added. Also, make sure you are evaluating the newest generation of safety devices. Many new devices include design improvements that eliminate the objections surrounding their earlier versions, she explained.

The ins and outs of healthcare personnel vaccinations

Tue, 01 Nov 2011 04:00:00 GMT

The ins and outs of healthcare personnel vaccinations

After reading this article, you will be able to:

Identify the five recommended immunizations needed for healthcare workers
Describe necessary documentation that meets proof of immunity

The Immunization Action Coalition (IAC) in Saint Paul, MN, supported in part by the National Center for Immunization and Respiratory Diseases at the CDC, regularly provides advice on all aspects of immunizations.

Recently, the IAC compiled an "Ask the Experts" feature focusing on vaccinations for healthcare personnel and encouraged wide distribution of the content.

Here is what IAC experts-nurse educator Donna L. Weaver, RN, MN, and medical epidemiologists Andrew T. Kroger, MD, MPH, and William L. Atkinson, MD, MPH, National Center for Immunization and Respiratory Diseases, CDC-had to say on the subject.

Q Which vaccines does the Advisory Committee on Immunization Practices (ACIP) specifically recommend that healthcare personnel (HCP) receive in order to work in a healthcare setting?

A ACIP recommends that all HCP be vaccinated with:

Two doses of MMR (measles-mumps-rubella) vaccine (or have evidence of measles, mumps, and rubella immunity)
Annual influenza vaccination
One dose of Tdap (especially to protect against pertussis)
Three doses of hepatitis B vaccine for those who might be exposed to blood or body fluids at work
Two doses of varicella vaccine (or have evidence of varicella immunity)

For definitions of evidence of immunity to MMR and varicella, please refer to "ACIP Provisional Recommendations for Measles-Mumps-Rubella (MMR) ‘Evidence of Immunity' Requirements for Healthcare Personnel" and "Varicella: Recommendations of the Advisory Committee on Immunization Practices," Morbidity and Mortality Weekly Report, June 22, 2007.

Q For which workers in healthcare settings does OSHA require that hepatitis B vaccine be provided?

A OSHA requires that hepatitis B vaccine be provided free of charge to HCP who have reasonably anticipated contact with blood or body fluids on the job. This requirement does not include HCP who would not be expected to have occupational risk, such as billing staff and general office workers.

Employers must ensure that workers who decline hepatitis B vaccination sign a declination form.

For a fact sheet about this OSHA requirement, search for "Hepatitis B Vaccination Protection" at www.osha.gov.

Q If an employee has two documented doses of MMR but has negative or equivocal titers for one or more of the antigens, what should we do? Same question if an employee has two documented doses of varicella vaccine but tests negative.

A Actually, ACIP does not recommend testing for immunity in such situations. For measles, mumps, and rubella, ACIP considers two documented doses of MMR vaccine given on or after age 1 year and at least 28 days apart to be evidence of immunity for HCP.

For varicella, ACIP considers two documented doses of vaccine to be evidence of immunity for HCP as long as doses are given no earlier than age 12 months, with at least three months between doses for children younger than age 13 years, or at least four weeks between doses for people age 13 years and older.

Because of the limitations of serologic testing, tests for even properly vaccinated individuals will often come back as negative or equivocal, putting the employee health service in the difficult position of having to do something (e.g., give additional doses, perform a follow-up titer).

If a healthcare worker does not have any documented doses of MMR and/or varicella vaccine, he or she can:

1.Be tested for immunity, or

2. Just be given two doses of MMR and/or varicella at least four weeks apart.

ACIP does not recommend serologic testing after vaccination.

Q How soon after a dose of Td can HCP receive a dose of Tdap?

A If they have not previously received Tdap, HCP in hospital, long-term care, and ambulatory care settings should receive a single dose of Tdap as soon as feasible and without regard to the dosing interval since the last Td dose. No minimum interval exists between receiving Td and Tdap.

Q Can Tdap be given to pregnant HCP?

A In June 2011, after studying new safety and efficacy data, ACIP voted to recommend that pregnant women who have never received the Tdap vaccine be vaccinated with Tdap during their third trimester or the second half of their second trimester (after 20 weeks gestation).

ACIP made this recommendation in response to the continuing pertussis outbreak, with the goal of protecting newborns with maternal antibodies and decreasing the risk of transmission from mother to infant after birth. If the vaccine is not given during pregnancy, it should be given immediately postpartum.

To view ACIP's provisional recommendation for use of Tdap in pregnant women, go to www.cdc.gov/vaccines/recs/provisional.

Q Can pregnant healthcare personnel administer live-virus vaccines?

A A pregnant staff member may administer any vaccine except smallpox vaccine.

Q Why does CDC recommend that we consider obtaining a signed declination from HCP who refuse influenza vaccination?

A Some studies have shown an increase in HCP influenza vaccine acceptance when decliners are required to sign such a statement. In addition, such statements can help a vaccination program assess the reasons for declination and plan future educational efforts.

Q Please tell me which professional associations have endorsed mandatory influenza vaccination for healthcare workers and have created policy statements.

A The following professional associations have issued policy statements supporting mandatory healthcare worker influenza vaccination:

American Academy of Pediatrics
American Medical Directors Association
American Pharmacists Association
American Public Health Association
Association for Professionals in Infection Control and Epidemiology
Infectious Diseases Society of America
Society for Healthcare Epidemiology of America

You can find additional information about mandatory influenza vaccination for HCP including a list of more than 100 healthcare settings that have implemented mandatory vaccination programs. Access IAC's Honor Roll for Patient Safety Web section at www.immunize.org/honor-roll.

For more IAC "Ask the Experts" Q&As, go to www.immunize.org/askexperts.

Patient-to-patient transmissions, new California dental IC regulations, 'Joisey' bedbug law, reacting to flu shot resisters

Tue, 01 Nov 2011 04:00:00 GMT

Infection control news briefly noted

Patient-to-patient transmissions, new California dental IC regulations, ‘Joisey' bedbug law, reacting to flu shot resisters

Dean Clinic in Madison, WI, notified 2,345 patients that they may have been exposed to bloodborne illnesses such as hepatitis and HIV during the past five years, reports the August 30 ABC News.

Those potentially exposed were patients with diabetes learning how to self-administer fingersticks and insulin.

A review found that a former clinic nurse was inappropriately reusing devices during patient visits. Although needles were changed between patients, the demonstration device was not, presenting a slight risk of patient-to-patient blood transfer, according to ABC News.

California dental practices are now required to operate under revised infection control (IC) regulations.

The California Dental Board revised regulations to Minimum Standards for Infection Control became effective August 20 and must be conspicuously posted in practices, reports DrBicuspid.com.

New Jersey isn't sleeping tight with bedbugs. The state's Senate passed a bill requiring businesses with beds, including hospitals and nursing homes, "to have agreements in place with exterminators to eradicate bedbugs if they're found," according to New Jersey On-Line, August 25.

Briefings on Infection Control, November 2011

Tue, 01 Nov 2011 04:00:00 GMT

AHA adds its voice to call for mandatory flu shots

How to sell mandatory flu shots to hospital staff

After reading this article, you will be able to:

Discuss why more hospitals need to adopt mandatory influenza immunization policies
Identify the process for educating staff on the importance of accepting seasonal influenza immunization
Describe the elements of a typical policy including choice to use flu mask as alternative to immunization