Evan Sweeney is an editorial assistant at HCPro. He manages and writes for Briefings on Infection Control , a monthly newsletter directed at IC compliance. He also blogs for OSHA Healthcare Advisor, a resource center for infection control and safety professionals, and regularly contributes to Medical Environment Update and OSHA Watch , which focus on healthcare employee safety and health.
Waterborne pathogens may not be first on your hospital’s list of priorities—perhaps because you haven’t seen an outbreak—but that doesn’t mean it’s not a risk in your facility, particularly if you have ornamental water structures.
“There is no structure built in America—none—that has the risk factors of a hospital building for growing and culturing legionella,” Keane says.
Furthermore, waterborne pathogens can be a significant financial burden on hospitals. Researchers at the CDC presented a study at the International Conference on Emerging Infectious Diseases, which determined waterborne illnesses—including legionella—cost the healthcare system as much as $539 million annually.
“These cost data highlight that water-related diseases pose not only a physical burden to the thousands of people sickened by them each year, but also a substantial burden in health care costs, including direct government payments through Medicare & Medicaid," says Michael Beach of the CDC.
Joint Commission requirements and legal backlash
Under EC.02.05.01, The Joint Commission requires healthcare facilities to manage risks associated with their utility systems, including “engineering controls of waterborne pathogens in potable water, cooling tower systems, and other aerosolized water systems.”
Not only can this affect compliance with Joint Commission accreditation, failure to adhere to these standards can also work against you in the court of law, particularly if an outbreak affects numerous people.
“The environment of care is not a guideline, it’s a standard—a standard that carries tremendously much more legal weight than a guideline,” Keane says.
In February 2009 and March 2010, a waterfall-type fountain in the lobby of a Wisconsin hospital caused an outbreak of Legionnaires’ disease in eight people.
The state health department released recommendations on decorative waterfalls, but the outbreak remains fresh in the minds of Joint Commission surveyors, says Peggy Prinz-Luebbert, MS, MT(ASCP), CIC, CHSP, owner of Healthcare Interventions, Inc., in Omaha, NE.
“Especially since we’ve had outbreaks now, if [a surveyor] sees a waterfall, they are going to want to see what kind of maintenance you do on it, what kind of testing you do on it, and if you’ve had problems, how you’ve responded to them,” Luebbert says.
Testing potable water
Even if you don’t have water structures in your hospital, you still need to be aware of the risks in your potable water system.
“With potable outbreaks, you don’t get a bunch of people getting sick all at the same time, so if hospitals aren’t testing for legionella—which most of them don’t do—you may not find it because legionella is a type of pneumonia,” Keane says. Hospitals are required to keep their hot water systems at 120ºF, he adds, which is a prime temperature for growing legionella.
Additionally, the guidelines for new hospitals create a much higher risk for waterborne illnesses, says Keane, who has been in hospitals with showers in every room, but the showers had never been used. Many of those showers also had shower hoses, which is a huge breeder of bacteria because of stagnant water.
“In new hospitals you have one person in a room, a sink as soon as you walk in the room for the doctor or nurse to wash their hands, and another sink in the bathroom,” Keane says. “And on top of that, you have waterless hand cleaner so nobody uses the sink. New hospitals have four times as many sinks per patient as older hospitals, and they are almost all stagnant because people are using the waterless hand cleaners.”
Every year, medical facilities plead with employees to get their annual influenza vaccinations. Some initiate campaigns as early as August, explaining the value of receiving the flu shot as well as the patient safety implications and worker safety benefits.
But despite even the most rigorous efforts, medical facilities often struggle to get flu shot rates over 50%.
A CDC report published April 2 indicated that by mid-January, nearly 62% of healthcare workers had been vaccinated against seasonal influenza, although only 37% had been vaccinated against H1N1 influenza. In previous years, rates have never been above 49%.
However, the CDC reported a 97.6% vaccination rate among facilities requiring seasonal flu shots, compared to 64.5% in facilities that only recommended the vaccine. Only 11.1% of facilities had a required policy.
Two particularly large hospital systems have taken on the challenge of implementing a mandatory flu shot policy within the past two years and have seen their compliance rates improve to as high as 98%. Although a mandatory policy eliminates the constant struggle to convince employees to get the shot, it's not without its own barriers.
In 2008, St. Louis–based BJC HealthCare, one of the largest nonprofit healthcare organizations in the United States with nearly 26,000 employees, made influenza vaccines a condition of employment. After years of voluntary vaccination programs that included incentives, leadership champions, and declination statements, BJC still could not climb above a 71% vaccination rate, according to Hilary M. Babcock, MD, MPH, assistant professor of medicine and medical director of occupational health (infectious diseases) at Barnes-Jewish and St. Louis Children's Hospitals, both in St. Louis and members of BJC HealthCare.
"[We] really just thought that we had pretty much exhausted all of the voluntary efforts," Babcock says. "Despite all of these many years of trying, we really hadn't gotten to where we wanted to be. So that's really what drove the decision to decide on the mandatory policy. We really felt it was an important patient safety issue to get our staff vaccinated."
BJC allowed exemptions for medical reasons (e.g., egg allergies, prior allergic reactions, and history of Guillain-Barré syndrome) and religious reasons only. The system successfully vaccinated 25,561 of its workforce members, a 98.4% vaccination rate, with only 90 religious exemptions and 321 medical exemptions.
In November 2009, the Hospital Corporation of America (HCA) in Nashville implemented a mandatory policy that required employees who could infect or become infected by a patient to get the seasonal flu vaccine or wear a surgical mask in patient care areas. Prior to the 2009 flu season, vaccination rates had varied from 20% to 74%.
HCA is one of the largest systems in the country with 163 hospitals, 112 outpatient centers, and 368 physician practices in 20 states. Under the mandatory policy, seasonal flu shots were offered to 140,599 employees, and 96% complied.
Communicating your policy
Simply making influenza vaccines mandatory does not replace the need for continued communication of the policy.
At BJC, each facility within the system was responsible for communicating the policy, answering individual questions, and continuing education about the vaccine. Most of the larger facilities established town hall meetings that included an infectious disease specialist, an occupational health professional, an infection prevention nurse, an HR representative, and someone from the legal team to answer questions and talk about the policy, says Babcock.
Babcock notes that it's probably even more important that communication of a mandatory policy is very clear and is presented to employees early in the year rather than weeks before flu season.
"As soon as you decide this is what you are going to do, [it's important] that you start talking about it and publicizing it and making it clear what the process is for an exemption, that you have people available to talk to those who have concerns about the vaccine so they can have their concerns addressed and alleviated in a timely and reasonable fashion," she says.
Ultimately, BJC terminated eight employees—two worked in information services in the corporate offices, and the other six included a patient care technician, a paramedic, a laboratory technician, a nurse, a sitter, and a physical therapist.
Using exemption forms
One of the most important aspects of the mandatory vaccination policy is ensuring that there is enough room for medical and religious exemptions.
Babcock recommends developing a form that lists medical contraindications for exemption (e.g. egg allergies, previous reactions) rather than an open letter from a doctor.
"We got a lot of letters that didn't give us enough information for us to make a decision. With forms, it's a little bit easier to have that information in front of you," she says.
Religious exemptions required a written letter from the employee that stated a religious conviction opposing the vaccination. That letter was reviewed by HR, and employees were notified within five days if they were exempt.
Timing is everything
BJC was fortuitous and perhaps a little foresightful with the implementation of its mandatory policy. Because the health system implemented the policy in 2008, before H1N1 emerged in April 2009, it easily rolled the H1N1 vaccine into the requirements once it became available.
"Again, that went pretty smoothly, but by that point we already had a mandatory program, so people had sort of wrapped their minds around that to start with," Babcock says.
However, healthcare facilities that are considering a mandatory vaccination policy for the 2010–2011 flu season won't run into the problem of forcing employees to take two shots. On February 22, the FDA decided to follow the World Health Organization's advice and fold the H1N1 vaccine into next year's seasonal vaccine, meaning there will be only one shot for both viruses.
This, coupled with increased attention to pandemic influenza and patient and worker safety, could mean mandatory vaccinations are the future.
"I think that there is increasing expectation that healthcare workers will be vaccinated, and it's becoming more and more of a patient safety issue, similar to other vaccination requirements for healthcare workers," says Babcock. "There are just certain duties that as healthcare workers we take on to protect our patients, so this is just becoming one of them."
As the initial waves of the newly passed healthcare reform law begin to ripple out, safety committee members should consider how the changes could affect environment of care and occupational health concerns.
"To the extent you believe the healthcare reform law will increase the demand for services, it could certainly have the effect in the near term of straining the resources of hospitals … [and] that would affect [managers] who are overseeing the safety and health of employees," says Bradford Hammock, partner at Jackson Lewis, LLP, a law firm in Reston, VA, where he heads the workplace safety compliance practice group.
The law will provide coverage to about 32 million uninsured people and offer tax credits to about 4 million small businesses to help cover the cost of insurance for their employees.
Emergency departments (ED) are already among the top locations in medical centers for violence between patients and staff.
"You have overcrowded emergency rooms right now," says James Blair, FACHE, president and CEO at the Center for Healthcare Emergency Readiness in Nashville. "You're going to make 30 million people eligible [for insurance]. They won't be coming hat in hand."
When people believe they have a right to medical care—"and that's what the rhetoric has led everyone to believe, that everyone in America is covered," Blair says—some individuals may be difficult to physically control when they find out at the ER that they have to wait until certain provisions for covering the uninsured kick in over the next four years.
"I think a greater number of folks will show up and push for their 'entitlements,'" which will up the ante for workplace violence in medical centers," says Roll, president and principal consultant at Healthcare Security Consultants, Inc., in Frederick, CO.
Others aren't so sure about a long-term increase in ED visits. Although there may be a spike in traffic in the near future, the long-term situation may see fewer traumatized people arrive at the ED as more ill people seek treatment from primary care physicians, says Randall Snelling, CPEO, chief physical environment officer at DNV Healthcare, Inc., a hospital accrediting group based in Cincinnati.
"Once everyone gets their arms around it . . . folks won't be coming to the ER with stomachaches," he says.
A sudden increase in patients could also further stretch the supply limits of a hospital. It's already tricky enough determining just-in-time inventories of surgical masks, latex gloves, food, and other provisions. Now hospital planners and emergency managers will need to get a firmer grasp on how healthcare reform could tax the supply chain.
Although not a potential disaster in the traditional sense, healthcare reform, by potentially bringing more people into hospitals, will challenge facilities by depleting them of supplies more quickly, Blair says.
Whenever a major regulatory change occurs that affects an industry directly, implementing the changes takes away resources from other areas, such as safety and occupational health, Hammock says.
"The reality is you have X number of people to do things," he says. "When something major comes along, you'll pull resources from other areas."
An interesting note: A provision in the healthcare reform bill establishes a National Healthcare Workforce Commission, which will include among its roster healthcare workers and employers, writes John Howard, MD, director of the National Institute for Occupational Safety and Health (NIOSH), in his NIOSH Science Blog.
The workforce commission is expected to submit recommendations to federal lawmakers and agencies to improve the safety and worker protection for healthcare employees, Howard writes.
Editor's note: This article was adapted from a story that ran in the June issue of Briefings on Hospital Safety, which can be found on The Hospital Safety Center.
A perennial problem in healthcare facilities usually comes back to a very simple 30-second procedure. Ask any infection preventionist (IP) about his or her major focus on hand hygiene compliance and you'll likely hear a number of strategies, obstacles, or frustrations with getting staff members to comply with hand hygiene best practices.
Measuring compliance is just half the battle for IPs. Improving compliance is another challenge. Part of the Joint Commission's National Patient Safety Goal NPSG.07.01.01 requires facilities to set goals for improving hand hygiene rates, and it's a continued focus of Joint Commission surveyors.
Roughly two years ago, Collette Hendler, MS, RN, CIC, infection preventionist at Abington (PA) Memorial Hospital formed a team of hospital employees whose "regular workflow allows them to be in all areas of the hospital so they are not noticed." These hand hygiene "spies" remain anonymous so employees aren't aware of when they are being watched or who is watching them.
"If a nurse manager would say to me he didn't believe my data, I would tell him to do it himself and see how his data compared to ours, and in the one particular case he came down halfway through the day and said he couldn't take it anymore and believed our numbers were what they were," Hendler says.
After the spies had been dispersed to collect data, the message needed to be clear and consistent. Both facilities turned to their marketing teams to create more buzz around hand hygiene compliance and offer daily reminders to staff members.
"I actually probably have something that a lot of other hospitals don't have, and that's that I have my own PR person who is assigned to the hand hygiene project and I work very closely with him and he comes up with a lot of creative ideas," Hendler says.
One of those ideas included screensavers with humorous or provoking messages. One included a picture of a young patient that read, "You could kill him with your bare hands." Another was a spoof of the "Sham-wow" infomercial that read "Hand-wow." These approaches raised compliance rates to 88%.
"We try and do things that are funny, things that are serious, just try to shake it up so people look at the screensavers and there is some message going on," Hendler says.
Texas Children's Hospital in Houston took a similar approach two years ago, focusing on marketing its hand hygiene campaign rather than just educating employees, says Jeffrey Starke, MD, director of IC. The marketing team brought in an outside consultant who helped develop a campaign called "Hy-Five" aimed at patients and families as well as physicians and employees.
The campaign increased compliance to around 80%, and as a result, Texas Children's won the Child Health Corporation of America's National Quality Award.
"Executives love marketing, and so they know that these data are looked at by outside agencies that are looking at us and are doing rankings, and so they know that they can look people in the eye and say, ‘We really believe in quality; here is the data and the awards to back it up,' " Starke says.
Starke says that even though Texas Children's reached 80%, getting over that last hurdle to the 90th percentile took additional facility-wide motivation.
"We said we needed to do a little better, and I'm a big believer in incentives," Starke says. "I think we are all influenced by the same things as other people."
Texas Children's has an employee bonus program called P3. Previously, all incentives were based on financial numbers and volume, but Starke went to his administration and talked it into making hand hygiene part of the bonus program for employees. Then he took it one step further and made it part of the administrator's bonus program as well.
"I know this sounds trite, but we convinced them that it was the right thing to do," Starke says. "We said, 'What's good for the goose is good for the gander,' and once you agree to do this for the employees, how can you possibly exempt yourselves? [We were] sort of trying to create a 'just culture,' and I think this is a very important part of 'just culture,' that administrators be just as responsible for these things as the frontline employees are."
The facility had to meet a 95% compliance rate for employees and administrators to get that portion of their bonus, while other factors contributed to other portions of their bonus.
Since implementing this incentive, compliance rates at Texas Children's have stayed between 95% and 99%, Starke says. Simultaneously, bloodstream infection rates have plummeted. Although Starke admits there are other factors to account for this reduction, it has helped set the culture and emphasize infection prevention.
"It's not like there are administrators browbeating people," Starke says. "It's not like people are up there going, 'If you don't do this, we can't vacation this year.' It's creating the same culture and expectations at every level of the organization, and I think that's sometimes where [infection prevention] falls down, is not making executives responsible."
Now that H1N1 fears have seemingly subsided, many infection control departments are evaluating their flu prevention programs, looking for deficiencies, while also noting effective policies and procedures.
For a number of facilities, the recent two-headed flu season proved the importance of a well-rounded respiratory infection control program.
Fred Hutchinson Cancer Research Center (FHCRC) and the Seattle Cancer Center Alliance (SCCA) created an aggressive prevention program that resulted in no increase of H1N1 cases in the facility month-to-month, despite a 100-fold increase in H1N1 cases in the Seattle area. The features of the program were published in a recent issue of Blood.
"I think we were really afraid and we didn't know how pathogenic or virulent this strain really was, especially with immunocopromised patients," says Michael Boeckh, MD, infectious disease physician at FHCRC. "There was simply no knowledge, so we took a very conservative approach. We really didn't want to find out later that it was a very bad strain, so we thought we would take the approach of designing a very comprehensive way of keeping the virus out of the system."
FHCRC already had a plan in place that was designed to incorporate a "heightened sense of alertness" beginning in October when most respiratory infections surface, and then that alertness would step down in April if activity had subsided. This allowed FHCRC to unknowingly prepare for the first H1N1 outbreaks, says Corey Casper, MD, a researcher in the FHCRC's Vaccine and Infectious Disease Institute and medical director of the SCCA's IC program.
"So ironically we had heightened our sense of alertness, and we were actually thinking of backing down when H1N1 hit, but rather than backing down we were actually able to scale back up to a higher level of alertness and take our plan off the shelf and very rapidly make it specific to H1N1," Casper says.
One of the major features of FHCRC's H1N1 plan was the screening process. Every person—patient or visitor—who entered the facility would have to answer a list of questions to determine whether they carried flu-like symptoms (see the Tools page on OSHA Healthcare Advisor to download the checklist).
The layout of FHCRC made it particularly conducive to screening patients and visitors as soon as they walked in the door, Casper says. Like most facilities, there is a reception area at the main entrance, but more importantly the blood draw laboratories are located in the same area.
"So many of the patient visits start with blood draw before you get chemotherapy, or before you get your latest prognosis about your cancer, you need a blood draw," Casper says. "So that is really where you start the patient care."
In addition to the screening checklist, the IC department also instituted a policy in which everyone who was screened received a sticker. Everyone at the facility knew that if they saw someone without a sticker, they needed to say something.
A major issue of contention in medical centers is how to handle paid sick time for employees who get H1N1. CDC guidelines recommend that employees with flu-like illnesses stay home for up to seven days depending on the severity of symptoms.
Employees may not have enough sick time or may feel pressured to come back to work before they have fully recovered. The first step in developing an effective sick leave policy is getting administrative buy-in, which could do more harm than good, Casper says.
"The administrators and the executives of a healthcare organization are looking at this as either a tool for risk management or a tool to save money and they're not looking at it as a tool to improve the quality of medical care, which is delivery," Casper says. "And if you're not looking at it from that perspective, then you don't give it the appropriate resources and attention that it needs."
Often the fear is that staff members will take advantage of extra sick time, but Casper says administration was upfront about the issue, and explained that additional sick time should only be used if it was absolutely needed.
"Our administration wanted to do the right thing, and due to the uncertainty of how bad this was going to be, which nobody knew at the time, I think we had a very great buy-in," Boeckh says.
Over the past several years, MDROs have become a leading concern for medical facilities attempting to reduce their hospital's healthcare-associated infection (HAI) rate.
A study published in the January Microbiology found that certain organisms can actually become less susceptible to both disinfectants and antibiotics. Researchers grew the bacteria Pseudomonas aeruginosa in the presence of a common disinfectant—benzalkonium chloride—and found that the bacteria eventually became 12 times less susceptible to the disinfectant and, perhaps more importantly, 256 times more resistant to the drug ciprofloxacin.
Previous studies of antimicrobial resistance haven't easily translated to real world situations, says Gerard T.A. Fleming, researcher for the Department of Microbiology at the School of Natural Sciences at the National University of Ireland in Galway and lead researcher for the study. This study used a system called chemostat, or continuous culture, which allows culture parameters to remain constant, similar to the way organisms grow in their natural environment.
"The thing about chemostat is it's a wonderful selection machine," Fleming says. "It's a wonderful evolution tool because being in an environment where you are competing for nutrients, those mutants that are not fit are those that have not become resistant to the disinfectant and are lost in the system. So that means we are evolving the strains through natural selection—which happens out there in the environment—toward resistance."
In addition, researchers used bacteria and a disinfectant that had real world applications. Pseudomonas aeruginosa, which is present in hospitals; is heavily associated with people who suffer from cystic fibrosis, pneumonia, and other HAIs; and has significant implications for burn victims, says Fleming. Benzalkonium chloride is one of the most common disinfectants or component of disinfectants used in the hospital environment, says Fleming.
After a month of testing, the researchers found that the bacteria was tolerating 12 times more disinfectant than it was at the start, meaning it had become hyper-resistant to the benzalkonium chloride.
However, the experiment didn't just yield frightening results on the susceptibility of bacteria. For the first time, this study showed that bacteria could remain resistant to disinfectant for an extended period of time, even when it was tested in the chemostat with no disinfectant whatsoever.
"For example, if it was 12 times more resistant, 200 hours later it remained 12 times more resistant in the absence of disinfectant," Fleming says.
Further, the study tested the original strain of bacteria against the resistant strain to see which one survived. In the absence of disinfectant, the original, nonresistant strain won out, but in the presence of very low residual levels of disinfectant—levels often found in the hospital environment—the resistant strain survived the original bacteria, indicating that in these residual levels, the resistant bacteria could actually grow.
Even more concerning, the bacteria that was 12 times more resistant to benzalkonium chloride was also found to be 256 times more resistant to ciprofloxacin, a drug commonly used to treat GI tract and pulmonary infections, even though the bacteria had never been exposed to that antibiotic.
"We then took the strain again and grew it in the presence of the antibiotic and it became three-fold more resistant to the disinfectant than the sensitive strain," Fleming says. "That's the balancing experiment there. That kind of concludes that the two are linked. If A produces B, then B must be associated with A, and we showed that."
Using disinfectants appropriately
Although Fleming acknowledges this was an experiment conducted in a laboratory with just one disinfectant, one strain, and one antibiotic, he says the effects of this experiment are very real for healthcare facilities.
"The message I'm trying to get out is a caution, and the caution is as follows: Do what it says on the bottle," says Fleming. "If it says take a capful and add it to a liter or 10 liters, do that because this has been tested."
Fleming recommends using the right concentration of disinfectant according to the manufacturers' instructions, leaving the disinfectant on the surface for the appropriate amount of time, and rotate disinfectants so you aren't continuously using the same solution.
"A lot of people, particularly in hospital environments, may have a budget to work on," Fleming says. "If you buy 300 bottles this month, maybe you can get down to 250 bottles next month, and you have a cost savings. There's only one way you're going to get down to 250 bottles, and that's either to reduce the frequency of your disinfection regime or dilute it down more, and that's what I'm pleading people not to do."