Zero Tolerance

Infection preventionists are tireless crusaders for infection-free facilities

JHC-June16-CVRInfection preventionists: They read a lot. They worry a lot. They can be perfectionists. They enjoy detective work. They’re evangelists. They’re leaders. They think about nasty things that others would prefer to ignore. They’re direct with people, but encouraging too. They’re tough; they don’t shrink from the phrase “zero tolerance.” But most of all, they care – a lot – about the well-being of patients and medical staff.

Take Will Sistrunk, M.D., an infectious disease physician at Mercy, the Chesterfield, Mo.-based IDN with more than 40 hospitals and 700 physician practices and outpatient facilities. He’s been at Mercy 20 years, and he’s been in infection prevention for 18 of them.

“When I was in medical school and doing my fellowship, HIV and AIDS were new,” he says. “A lot of attention was being paid to them, but there was a lot of misunderstanding by the public, a lot of fear. What was so interesting was the fact that infectious disease doctors were the folks who people relied on to guide them through the process, whether that meant collaborating with public health, physicians who were not infectious disease specialists, health system leaders and others.”

Or Michael Geissler, RN, CNOR, ONC, director of perioperative services at Rothman Orthopaedic Specialty Hospital, a six-OR, 24-bed specialty hospital in Bensalem, Pa.

Initially, Geissler had some hesitation about assuming the double role of director of perioperative services as well as infection preventionist. “There’s a lot to take into consideration dealing with the infection process and trying to prevent not only surgical site infection, but communitywide infection as well, whether it be influenza, Ebola, all those things,” he says. Challenging, yes, but Geissler is proud of what he and his colleagues have accomplished in safeguarding Rothman’s patients and staff.

Or Timothy Bowers, corporate director for infection prevention, Inspira Health Network, Vineland, N.J.

“Infection prevention affects every moment of every day,” he says. “It can be difficult to grasp that. Words don’t do it justice. But the question for caregivers is, ‘How do you go through the day without hurting yourself or your patients?’” Infection preventionists try to provide the answers.

Not for the sedentary

The effective infection preventionist doesn’t sit in his or her office for long, says Sistrunk. “You collaborate with people every day.” And if H1N1 is this month’s issue, next month, it might be Zika or Ebola.

Sistrunk welcomes the fact that colleagues lean on him for his expertise. “They ask, ‘How do we take care of our patients?’ Infection prevention is a big part of that. As healthcare workers and co-workers, we have to make sure we care for patients in a safe way.

“Our communities expect us to care for patients too,” he continues. “If someone comes in with Zika, we have to understand isolation procedures, collaborate with the health department. That’s the intriguing part, and that makes it fun – and challenging.”

Payers too are increasingly turning their attention to infection prevention, going so far as to review the infection rates of their network providers and would-be providers. “And the government is saying, ‘We’re not sure we want to pay you [if your infection rates are excessive].’

“There’s a lot of education involved,” adds Sistrunk. That’s because a big part of the infection preventionist’s job is to point out all those things that can be done to make patient care as safe as possible, such as practicing good hand hygiene, implementing isolation precautions when necessary, and wearing appropriate personal protective equipment and apparel. “We have to continue teaching these things all the time, otherwise people may stop doing them.” Add to that a plethora of new products designed to address infection.

“When I was in medical school, you learned there was an acceptable, unavoidable risk of infection related to healthcare,” he says. “But with today’s focus on infection prevention, with all the new products available, and with the greater understanding of how infections spread, there no longer is an acceptable rate. Our goal is zero infections. So the pressure is on.”

Dual role
At a small specialty facility such as Rothman (with six ORs and 24 beds), Michael Geissler’s dual role as director of perioperative services and infection preventionist makes sense.

Though he had years of experience in OR management, Geissler was not formally trained in infection prevention. But he attended courses of the APIC, that is, the Association for Professionals in Infection Control and Epidemiology, which gave him a foundation and structure for his new role. And he reads everything he can get his hands on, as every infection preventionist must do.

Geissler believes that directing infection prevention activities has actually helped improve his performance as an OR director. “It keeps you focused on your staff, and [empowers] you to give them information quickly. It even affects things like changing supplies. In the director level, you might make changes for reasons of cost containment or someone’s personal preference. But [as infection preventionist], I see the potential impact of a supply on infection. So it definitely keeps that person – the OR director – grounded.”

Being grounded all the time isn’t necessarily easy. “The biggest challenge is being aware of all the minutiae that can lead to infection or increase the potential risk of infection,” says Geissler. “As a staff member, these are things you’re not necessarily dialed in to.”

Then there’s the detective work that must be undertaken when a call comes in about a patient with a suspected infection. “You ask, ‘What is it?’ ‘Did we have a breach in protocol?’ ‘Was the patient sick before surgery?’ ‘Could it have been caused by an implant from the manufacturer?’ ‘Did we care for the dressing properly?’

“And I’m thinking, I’m responsible for all of this.”

The trick is to raise people’s awareness of infection prevention protocol without breathing down their necks, he says. Rather than being perceived as a watchdog or overseer, Geissler has worked to establish a collaborative arrangement with front-line staff so that together, they can ensure the safety of patients and staff. At press time, he was working on a performance improvement project designed to make it “second nature” for OR nurses and techs to practice good hand hygiene prior to opening anything sterile in the field.

“We don’t have many surgical site infections,” says Geissler. “Over the last 12 months, we’ve only had two, out of 4,700 cases. Still, I think we can challenge those numbers.”

Stay informed, stay focused
While working as a medical technologist at Thomas Jefferson University Hospital after graduation, Timothy Bowers developed skills in microbiology and virology, and an interest in patient safety. At the time, infection prevention was a field of rising interest, as some states, including Pennsylvania, were just beginning to mandate that healthcare systems publicly report their incidence of healthcare-acquired infections.

So, at around the same time he received a master’s degree in health policy, he accepted a position as infection control practitioner at Penn Presbyterian Medical Center. In 2011, when the corporate director position at Inspira opened up, he gladly pursued the chance to assume a larger role in patient safety.

With so many villains to chase today – including central-line-associated bloodstream infections, catheter-associated urinary tract infections, C difficile, MRSA, surgical site infections and more – where does the infection preventionist focus his or her efforts? That depends on a lot of things, such as where you practice, and when, says Bowers, who is a member of the APIC Communications Committee. So, CAUTI-related issues might take center stage at one point, then C difficile at another, then something else. Bowers dials into the APIC listserv to find out what his colleagues are experiencing, and how they can help each other.

“As a community, we rely on each other,” he says, referring to fellow infection preventionists. “And at Inspira, we really engage front line staff,” including nursing, transport, environmental services, physicians who see patients on the floor, volunteers, etc.

Infection preventionists rely on another source of support – supply chain management.

“I have a great relationship with our supply chain management group,” says Bowers. Front line staffers attend shows and educational conferences throughout the year, and often come back with a suitcase full of product samples and literature. With the help of supply chain, Bowers and his team ask some fundamental questions: “What is this new product addressing?” “Is it something we have already addressed?” “Is this a better way of addressing it?”

A case in point were ultraviolet light “robots” that can disinfect an OR suite or patient room in a few minutes. “A few years ago, there were only a few vendors offering them,” says Bowers. “Now there are 12 or 15.” The infection prevention team studied the data and, with supply chain’s help, secured several of the systems at a reasonable price.

“We really do our due diligence,” he says. “We don’t want to discount something that could bring additional safety for people, but on the other hand, we don’t want to bring everything in.”

A good, trusting relationship with vendors helps too. “If I see a vendor in the hall and I’m not too busy, I have no problem sitting down and talking. But I need to know they are being on the level with me. And if you can’t tell where the relationship ends and the sale starts, you have a problem.”

The road ahead

Infection preventionists look to the future with anxiety and optimism.

For example, biofilm makes Geissler nervous. Microorganisms can build up on the surface of a surgical instrument that hasn’t been cleaned promptly or thoroughly. But that buildup can be invisible to the human eye; in other words, the instrument looks clean, but isn’t. Geissler believes that bleach-based products remain the gold standard for killing spores.

Despite the challenges, Geissler is optimistic about the future. “There’s a better focus on infection prevention today,” he says. Mass media and social media have helped spread the word throughout the population. The fact that healthcare facilities publish their infection rates has been helpful too. “All these things are definitely helping fuel the fire to keep people’s attention on what we can do to prevent infection.”

Sistrunk worries about antibiotic resistance. “We see some bacteria that are resistant to almost all antibiotics, and if we use antibiotics more and more, we will have a real problem.” The infection prevention team at Mercy collaborates with many people to address the issue. “For example, we work with the microbiology lab to get data to caregivers quickly, so they can make sure our patients are on the correct therapy as soon as possible,” he says.

On the bright side, more attention is being paid to infection prevention today than years ago, when Sistrunk was in medical school. Patients, their families, providers and vendors are all more concerned, he says. “As a result, we’re having productive discussions that are getting us down the road to patient safety.”

What’s more, new infection prevention data tools are available to help providers identify patients at risk of infection, so precautionary measures can be put in place quickly. “We have the ability to track infection data in real time, to see what works and what doesn’t,” says Sistrunk. “That helps us understand how we can more effectively make a difference, and not do something because we think it will work, but because we know it will really help us.”

Any time people interact with each other or the environment, the potential for infection exists, says Bowers. That’s why infection preventionists need the support of administration to create a culture of safety. Bowers says he has that support at Inspira.

“And our staff is the best,” he adds. “Whether they are fresh out of the gate or been here forever, they are all in this for the right reason. When we talk about hand hygiene, they know there won’t be any sirens or screaming. We tell them, ‘We’re trying to keep you safe, so you can provide the best care for your patients.’ And they take it in that context.”

Meet the vendors

Given the product-intensiveness of infection prevention, it’s no surprise that infection prevention professionals are inundated with sales pitches from vendors and front-line staff.

Michael Geissler, RN, CNOR, ONC, director of perioperative services at Rothman Orthopaedic Specialty Hospital, a six-OR, 24-bed specialty hospital in Bensalem, Pa., expects sales reps to explain the efficacy of their products and to produce data to back up their claims. He also wants to know that when a vendor walks in the door, he or she knows the population Rothman serves. “If you’re not prepared, I’m not entertaining a visit from you,” he says.

Meanwhile, Will Sistrunk, M.D., an infectious disease physician at Mercy, the big Catholic IDN based in Chesterfield, Mo., says providers need vendors to think outside the box. (He considers himself lucky to be able to draw on the knowledge of Mercy Research, a subsidiary that performs clinical research and is coming up with new ideas in infection prevention.) “We can no longer consider products that are just OK,” he says. “Our goal is zero infections. For us to get there, we have to collaborate with industry. If we do, we will have consistently safer healthcare.”

Leadership a must in big health systems

It’s tough enough to instill a culture of safety in one hospital, given the myriad of front-line staff and patient encounters. But how about an IDN of 30 or 40 hospitals, and a bundle of outpatient facilities?

“My typical week is a blend of patient care and leadership and administration,” says Will Sistrunk, M.D., an infectious disease physician at Mercy, the 40-plus-hospital IDN based in Chesterfield, Mo.

“The most important thing you can do is make infection prevention a priority of leadership.” When leaders meet, when caregivers meet, you want them to be talking about patient safety and infection prevention, he says. “In a big health system, you have to encourage that. You have to have data that supports it. You have to be transparent with that data. And you have to continue to make it a priority. It’s not something you can quit talking about.

“There are a lot of priorities out there,” he continues. “But with infection prevention, you have to keep at it in order to get everybody to help you. You want to develop a culture of leadership where everybody – physicians, providers, vendors, everybody – is thinking about the patients and about doing the best we can for them.”

Timothy Bowers, corporate director for infection prevention, Inspira Health Network, Vineland, N.J., says that although the acute-care hospital may present the greatest risk of an infection-related event occurring, attention must also be paid to outpatient facilities, where hundreds of thousands of patient encounters take place.

The Centers for Disease Control as well as APIC have provided resources regarding infection prevention in the ambulatory care setting, he points out. “But it comes down to having somebody with a fresh set of eyes asking, ‘Can somebody get sick from our care?’

“It’s a different mindset, but you can usually find at least one person in each setting who realizes that in giving great care, you are preventing infection. It’s a great mindset, and if you nurture it, it spreads quickly.”