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PSQH: Patient Safety & Quality Healthcare, March 12, 2020
Proper cleaning may help prevent the spread of coronavirus.
By William C. Shillaci
The Environmental Protection Agency has released a list of 82 registered disinfectant products that have been qualified for use against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the novel coronavirus that causes COVID-19.
Products on the list have qualified for use against COVID-19 through the Agency’s Emerging Viral Pathogen program. This program allows product manufacturers to provide the EPA with data, even in advance of an outbreak, that show their products are effective against harder-to-kill viruses than SARS-CoV-2. It also allows off-label communications intended to inform the public about the utility of these products against the emerging pathogen in the most expeditious manner.
Asymptomatic Carriers
COVID-19 is particularly dangerous because people who carry the virus, which is highly infectious, may show no symptoms and can transmit the virus for up to 24 days. Transmission is most common through droplets expelled from a symptomatic carrier through sneezing or coughing. However, COVID-19 can be transferred from any infected person to surfaces made from a variety of materials—where it can remain viable for hours to days. Cleaning of visibly dirty surfaces followed by disinfection is a best practice to prevent the spread of COVID-19 and other viral respiratory illnesses in businesses, households, healthcare facilities, and community settings.
Disinfecting Enveloped Viruses
Perhaps one of the few encouraging aspects of the COVID-19 outbreak is that the virus is enveloped. Enveloped viruses are the least resistant to inactivation by disinfection. The structure of these viruses includes a lipid envelope, which is easily compromised by most disinfectants. Once the lipid envelope is damaged, the integrity of the virus is compromised, thereby neutralizing its capacity to infect.
EPA’s Guidance
The EPA developed its Emerging Viral Pathogen Guidance in response to concerns about emerging pathogens, an increasing public health concern in the United States and globally. Because the occurrence of emerging viral pathogens is less common and predictable than established pathogens, few, if any, EPA-registered disinfectant product labels specify use against these infectious agents. Also, the pathogens are often unavailable commercially, and standard methods for laboratory testing may not exist.
The guidance was developed and finalized in 2016 to allow for a rapid response in the event of an emerging viral pathogen outbreak. It was triggered for the first time ever for COVID-19 on January 29, 2020. The guidance outlines a voluntary, preapproval process for making emerging viral pathogens claims. In the event of an outbreak, companies with preapproved products can make off-label claims (for example, in technical literature, non-label-related websites and social media) for use against the outbreak virus.
Basic Recommendations
The Centers for Disease Control and Prevention (CDC) has provided many resources to assist healthcare facilities, community sites, businesses, and households in preventing the spread of the virus. One CDC siteprovides the following recommendations:
Routinely clean all frequently touched surfaces in the workplace, such as workstations, countertops, and doorknobs, using a detergent or soap and water before disinfection.
Wear disposable gloves when cleaning and disinfecting surfaces. Gloves should be discarded after each cleaning. If reusable gloves are used, those gloves should be dedicated for cleaning and disinfection of surfaces for COVID-19 and should not be used for other purposes. Consult the manufacturer’s instructions for cleaning and disinfection products used. Clean hands immediately after gloves are removed.
For disinfection, diluted household bleach solutions, alcohol solutions with at least 70 percent alcohol, and most common EPA-registered household disinfectants should be effective.
Diluted household bleach solutions can be used if appropriate for the surface. Follow manufacturer’s instructions for application and proper ventilation. Check to ensure the product is not past its expiration date. Never mix household bleach with ammonia or any other cleanser. Unexpired household bleach will be effective against coronaviruses when properly diluted. Prepare a bleach solution by mixing 5 tablespoons (1/3 cup) bleach per gallon of water or 4 teaspoons bleach per quart of water.
The CDC’s COVID-19 guidance specific to certain industries is available here.
PSQH: Patient Safety & Quality Healthcare, February 14, 2020
Healthcare workers often come to work sick. Flexible sick leave policies may help stop that.
Editor's note: This article byJohn Palmer originally appeared on PSQH.
Do staff in long-term healthcare facilities go to work with the flu and other illnesses, even when their employer's sick policy tells them to stay home? Probably.
According to a recent study, almost 90% of staff members at one facility who had an acute respiratory illness (ARI) during five months of intense surveillance went to work when they were sick, despite the facility's policies against doing so.
"Changes in sick leave and work exclusion policies to minimize the pressure on staff to come to work while sick would protect patients and other healthcare personnel," says Hilary M. Babcock, MD, MPH, lead author of the study, professor of medicine in the infectious diseases division at Washington University School of Medicine in St. Louis, and medical director for the Infection Prevention and Epidemiology Consortium of BJC HealthCare. "Respiratory infections at this facility were more common in staff than in patients, and staff frequently worked while ill."
Working Through Illness
Researchers conducted active surveillance from December 2015 through April 2016 for respiratory viral infections among residents and healthcare providers at a 120-bed long-term care facility in the St. Louis area.
Staff and patients in the study were monitored throughout the surveillance period for ARI symptoms. Nasal and throat swabs were taken whenever symptoms were reported, and again at the end of the study period when participants were asked to reiterate symptoms they'd experienced.
For the study, an ARI was identified if the patient had a fever of more than 99.1°F, headache, sore throat, shortness of breath, chills, muscle and/or joint pain, coughing, wheezing, fatigue, congestion or runny nose, or change of mental status or confusion.
"This broad, symptom-based definition was designed to maximize identification of potential respiratory infections," the study says.
Of the 76 staff members and 105 patients in the study, 18 staff members and four patients were reported to have ARIs, while 16 staff members, or 89% of those who reported an illness, said they worked when they were sick.
Communicate Work Restriction Policies
The study took place in one long-term care facility, so it's unclear what the study's results mean for the rest of the healthcare industry. However, the study's authors suggest that employers need to make it easier for sick workers to take time off.
"Clearly, healthcare workers come to work sick, and I think that there are a lot of things that go into why people do that," Babcock says.
She says staffing models are not built with wiggle room, or surge capacity to cover for those employees who are sick. Also, she says there's an overarching philosophy among healthcare workers that they should avoid letting down their colleagues.
"It's an uphill battle to convince people to stay home," Babcock says. "People know when they stay home, someone who could have stayed home will get called in."
The study did have its limitations. "This was a small study conducted at one long-term care facility during one, rather mild, respiratory virus season," she adds. "This facility housed a mix of nursing home residents and shorter-stay post-hospital patients. They also have a mandatory flu vaccination policy for staff, leading to a highly vaccinated staff population. The findings may therefore not be generalizable to facilities with a different patient/resident mix or to facilities with lower staff flu vaccination rates."
Also, the study did not show direct transmission of respiratory viruses between patients and staff, and larger studies are needed to determine whether staff members who are sick transmit their illnesses to patients.
These sorts of studies are not easy to do, Babcock says. Hospitals in general don't do a great job of surveillance when it comes to respiratory infections—and those infections can come from a myriad of sources. Without isolating all patients, for example, how is it possible to determine where an infection came from?
"It would definitely be difficult and hard to control," she says, adding that data is difficult to come by, especially from healthcare workers who might not admit they're sick. "There's no real way to track it."
Despite its limitations, the published study did highlight a few important points.
"Infection prevention is paramount in healthcare settings to reduce the risk of infection among individuals," the study says. "Although there was no evidence for ARI transmission among study participants, the greater incidence of illnesses among healthcare providers suggests that paradigms of patient-centered infection prevention programs should expand to include all persons living and working in [a long-term care facility]."
"This finding suggests that facilities should consider strengthening communication and enforcement of work restriction policies and should ensure that they are feasible and ensure they are feasible for all staff members," the report says.
What the experts say
Many infection control experts say the best way to keep sick employees at home, and to avoid transmitting illnesses at work, is to have a strict, enforceable sick policy that employees can follow without fear of retribution.
"Flexible leave policies and alternate work schedules will help prevent the spread of flu at your workplace, allow employees to continue to work or function while limiting contact with others, help maintain continuity of operations, and help people manage their health and their family's needs," according to the CDC.
That's certainly not always easy advice to follow. According to Babcock, current policies in healthcare facilities, such as those that combine vacation and sick time, push people away from using sick days they would otherwise allocate toward a vacation. Also, attendance awards that reward employees for being at work don't encourage them to use sick time.
"It's about culture and philosophy, and until we can change that, it will continue to be a challenge," Babcock says.
According to the CDC, employers should review and communicate their sick leave policies and practices to employees every year before flu season begins. The CDC also offers the following general guidance:
All employees should stay home if they are sick until at least 24 hours after their fever (temperature of 100°F or higher) is gone. Temperature should be measured without the use of fever-reducing medicines, such as medicines that contain ibuprofen or acetaminophen.
Not everyone with the flu will present with a fever. Individuals with suspected or confirmed flu who do not have a fever should stay home from work at least four to five days after the onset of symptoms. Persons with the flu are most contagious during the first three days of their illness.
Workers who have symptoms upon arrival to work or become ill during the day should promptly separate themselves from other workers and go home until at least 24 hours after their fever is gone without the use of fever-reducing medications, or after symptoms have improved (at least four to five days after symptoms started).
In recognition that employees may stay home due to illness (their own or that of a family member), plan ways for essential business functions to continue despite absences. Cross-train staff so that the business can continue operating.
Babcock suggests developing policies that are more nuanced and delineate between excused and unexcused absences, for instance, or using an occupational health program to prove sickness. Another idea used by some hospitals, she says, is to allot extra sick days during flu season.
Also, good management comes into play. "Ideally, managers recognize when someone is ill, and if they sound terrible or have a fever, they should send them home," Babcock says.
This isn't without its challenges, of course. "The managers are in the same bind because everyone has to do more [with less] coverage. Also, occupational health nurses can't walk around a 1,500-bed hospital and listen for signs of illnesses and sneezing. If we don't see them, we won't know, but we want to make it clear that we want you to stay home during those times."
John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at johnpalmer@palmereditorial.com.
The threat of the 2019 novel coronavirus spreading rapidly in the United States remains low for now but concerns in the public may be contributing to a growing shortage of personal protective equipment and other supplies.
Hospitals and other healthcare organizations should keep a close watch on their N95 respirators, which could be walking out the door with staff or others concerned about contracting the highly contagious but—so far—slow spreading virus in the United States.
And those surgical masks that physician offices, urgent care centers, hospitals, and other healthcare facilities offer patients and visitors at entrances also seem to be disappearing faster than usual, said Skip Skivington, a vice president with Kaiser Permanente Health System, during a webinar sponsored Tuesday by the CDC for hospitals and others who need to stay ahead of what has become a deadly disease in China.
The briefing, “CDC 2019 n-CoV response: Strategies for Ensuring Healthcare Systems Preparedness and Optimizing the N95 supplies,” offered guidance on how to conserve supplies now and if the pandemic becomes widespread here.
While there are 27 countries and more than 40,000 cases worldwide, with most concentrated in the origin country of China, the CDC is monitoring only 13 cases across the United States, said Anita Patel, PharmD, MS, team lead of the CDC’s Pandemic Medical Care and Countermeasures, in opening the webinar.
That said, she also noted that the U.S. public health system remains on high alert as hospitals, airports, and other key sites screen patients and incoming passengers for possible infection.
The COVID-19 virus (the name proposed by the World Health Organization Monday) is much like an ordinary cold in that the best protection is to isolate anyone who may be symptomatic and use respiratory protection, along with standard, contact and airborne precautions, said Michael Bell, MD, the CDC’s deputy director of the Division of Healthcare Quality Promotion.
If possible, patients under investigation should be given a surgical mask and moved to a negative pressure room. Healthcare workers should use appropriate PPE, including eye protection that should be goggles and not safety glasses.
Many healthcare workers think that safety glasses should be enough with respiratory protection, but coughing can spew infection into the eyes around the glasses.
While there is no evidence yet that the COVID-19 virus can remain contagious while airborne like measles, potentially infecting an entire room or building over a short period of time, Bell says the CDC recommends full airborne protection until the U.S. officials “see how bad this can be.”
Bell urged healthcare organizations to check the CDC’s healthcare professionals’ information on its websiteevery day. The CDC has teams across the world trying to learn about the virus and information is updated frequently—so much so, the CDC has begun to date when material is being updated and mark which sections are new.
The CDC specifically focused the guidance on the supply line because the agency recognizes, along with other healthcare organizations, that China is a major source of medical supplies.
Strategies for optimizing the available supplies of the N95 masks, which can filter out particulates, begin with the most effective control: Eliminating the threat. In this case, that means isolating anyone suspected of COVID-19 infection as soon as possible, hopefully before that person even enters the hospital, urgent care center, ambulatory care site, or primary care office, said Marie de Perio, MD, who works with the CDC’s National Institute for Occupational Safety and Health.
That means educating the public as well as those within your organization so you can screen potential patients over the phone or online portals before they get to the facility and keep them isolated. That could mean having them wait in their private vehicle until someone can come out to evaluate them, giving them masks and otherwise keeping them out of the main population area until they can be taken to an isolation area.
The second most effective method would involve engineering controls, said de Perio. That means using glass or plastic barriers at intake desks, using airborne intake isolation rooms (AIIR) and ventilation systems in treatment areas to restrict the infection.
Finally, de Perio said, use administrative controls to manage the supplies you do have. Among other suggestions, she said to:
Consider limiting the personnel who are not directly involved in medical care from entering the patient’s room to conserve the number of N95 or other specialized respiratory masks being used. That may mean excluding dietary or housekeeping from the room, she said.
Bundle your healthcare activities so that clinicians and nurses can limit use of PPE.
Consider video monitoring when possible and cohorting healthcare workers to limit the number of people who need to be fit-tested for N95 use as well as limit potential exposures.
Clearly define when and who will need to be using the specialized masks and emphasize that they do not need to be worn outside the healthcare setting for those patients.
In preparing for the possibility of a spread of the novel coronavirus to the U.S., Kaiser’s Skivington said his health system drew on experience from the post-911 concerns over anthrax, SARS, Ebola, measles and other contagions through the last two decades.
He and David Witt, MD, both co-chairs of Kaiser’s National Clinical Workgroup, worked with others at the health system to get guidance out to clinicians and to develop screening questions.
It was important to include doctors and other clinicians in developing those screening tools and getting them into the electronic health records system because they are on the front lines using them, said Skivington.
In addition to hospital preparation, the system created patient management guidance for its home health workers and created a medical office building strike team to deal with patients who presented outside the hospital setting.
Screening questions were updated as needed, including extending the time period that patients were asked about possibly visiting China to 30 days, which at the time was beyond CDC recommendations, noted Witt.
They also reached out to all the staff at its facilities to gather concerns and address them, to get ahead of the overuse of PPE, he said.
The other benefit of that communication was dealing with a fear that cut down on possible discrimination against patients of Asian descent, said Witt.
Among the more than 100 questions posed by the webinar audience—only a fraction were answered because of time—were concerns about what precautions to send home with patients who would be cared for by family members.
Bell said simple surgical masks were enough because those family members would not be expected to perform medical tasks that could cause major airborne exposure.
When asked if home healthcare workers would then be fine working with just the surgical masks, Bell said no. Those workers might be doing more extensive care and would absolutely need the N95 type of respirators and other recommended precautions in caring for their patients. Especially if they are going from home to home, he said.
On January 15, the Occupational Safety and Health Administration (OSHA) raised its civil penalties (85 Fed. Reg. 2,292) by approximately 1.8%. The final ruleimplements annual inflation adjustments of civil monetary penalties assessed or enforced by OSHA and other agencies within the Department of Labor (DOL) in 2020, as required by the Inflation Adjustment Act (Pub. L. 114-74).
OSHA’s penalty increases for workplace safety and health violations include:
For a willful violation, in which an employer knowingly failed to comply with an OSHA standard or demonstrated a plain indifference for employee safety, the minimum penalty increases from $9,472 to $9,639 and the maximum penalty increases from $132,598 to $134,937;
For each repeated violation for an identical or substantially similar violation previously cited by the agency, the penalty ceiling rises from $132,598 to $134,937;
For each serious violation for workplace hazards that could cause an accident or illness that would most likely result in death or serious physical harm, the maximum penalty increases from $13,260 to $13,494;
For each other-than-serious violation, the maximum penalty increases from $13,260 to $13,494;
For each failure to correct violation, the maximum penalty increases from $13,260 to $13,494; and
For each posting requirement violation, the maximum penalty increases from $13,260 to $13,494.
The new penalty amounts take effect immediately, applying to any penalties assessed after January 15.
On November 2, 2015, Congress enacted the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015, the Inflation Adjustment Act, to improve the effectiveness of civil monetary penalties and maintain their deterrent effect.
On July 1, 2016, the DOL published an interim final rule establishing an initial “catch-up” adjustment for civil penalties the Department administers. The Labor Department has issued annual inflation adjustments of civil penalties in 2017, 2018, and 2019.
The department is required to calculate the annual adjustment based on the Consumer Price Index for all Urban Consumers (CPI-U). Annual inflation adjustments are based on the percent change between the October CPI-U preceding the date of the adjustment, and the prior year’s October CPI-U.
The current adjustment is based on the percent change between the October 2019 CPI-U and the October 2018 CPI-U. The cost-of-living adjustment multiplier for 2020, based on the Consumer Price Index (CPI-U) for the month of October 2019, not seasonally adjusted, is 1.01764.
Existing penalty amounts are multiplied the multiplier, 1.01764, and then rounded to the nearest dollar.
If an OSHA Compliance Safety and Health Officer (CSHO) finds a hazard or standard violation during an onsite inspection, the inspector may issue citations and penalties. Inspections begin with a presentation of agency credentials and an opening conference and include a worksite walkaround and closing conference.
If the agency issues any citations or penalties, an employer may request an informal conference with the OSHA Area Director to discuss citations, penalties, abatement dates, or any other information pertinent to the inspection. The agency and the employer may work out a settlement agreement to address hazards found during an inspection.
OSHA has stated that its primary goal is correcting workplace safety and health hazards and ensuring compliance rather than imposing citations and collecting penalties.
PSQH: Patient Safety & Quality Healthcare, January 17, 2020
The accreditation agency calls on healthcare organizations to support nurses by addressing the causes of burnout.
By John Palmer
Editor's note: This article originally appeared on PSQH.
Realizing the growing impact that stress and burnouttake on the health of nurses and their ability to do their job properly, The Joint Commission is stepping in to help battle the problem.
According to The Joint Commission, of the 2,000 healthcare providers who participated in an April 2019 national nursing engagement survey, more than 15% of all nurses reported feelings of burnout, with emergency department nurses at a higher risk. The second survey in 2019 found that burnout is among the leading patient safety and quality concerns in healthcare organizations.
Only about 5% of respondents surveyed said their organization was highly effective at helping staff deal with feelings of burnout. Only about 39% said their organization was "slightly effective" at dealing with burnout, and 56% said their facility was either slightly or highly ineffective at it.
"As the frontline caregivers in healthcare today, nurses accomplish a myriad of tasks and responsibilities, but often at high personal cost," according to The Joint Commission publication. "The need to juggle competing priorities in often high-stress situations can result in feeling overwhelmed or burnout. The negative effect of these stressors can affect the ability of health care professionals to care for others."
Burnout: A longstanding issue
It's not a new problem. According to a 2016 study from the Mayo Clinic, at least 15%–20% of adults in the U.S. report high levels of stress. The study, published in the Journal of Occupational and Environmental Medicine, concluded that stress and burnout in the healthcare industry is a major problem that leads to negative health behaviors. It recommended that companies look to integrate and enroll employees into wellness programs to help cut down on stress and fatigue.
A high correlation was found between the stress levels of an employee and what was called the four domains of quality of life: physical health, mental health, nutritional habits, and perceived overall health. Higher stress correlated to lower levels of all four domains.
The study found that employees who reported high-stress levels and perceived poor quality of life also reported the lowest usage of wellness programs.
What leads to stress and burnout?
Perhaps most important than recognizing the presence of stress in healthcare is knowing why it occurs. A 2017 Joint Commission study of more than 3,000 nurses worldwide found that the most common factors related to burnout are exclusion from the decision-making process, the need for greater autonomy, security risks, and staffing issues.
"Health care organizations that implement burnout interventions—such as mindfulness and resilience training—may experience increased employee retention, reduced staff turnover and performance problems, and increased patient satisfaction," The Joint Commission said. "Mindfulness refers to the practice of learning to focus attention and awareness on the moment-by-moment experience with an attitude of curiosity, openness and acceptance."
The Quick Safety report identified several areas that healthcare facilities should work on to help battle the problem of burnout, including the following goals:
Educate nurses, preceptors, and nurse leaders on how to identify behaviors caused by burnout and compassion fatigue, and to become aware of their individual stress triggers, participate in self-care activities, and discuss resiliency
Improve clinician well-being by measuring it, developing and implementing interventions, and then remeasuring
Offer nurses opportunities to reflect on and learn from their practice and from other practitioners
Work with internal teams to assess whether current EHR systems may be customized to better support nursing workflow
Conduct regular staff meetings that include discussions about new organizational policies, processes, and outcomes from leadership meetings—making sure to engage nurses in these meetings
Occupational stress, defined by the National Institute for Occupational Safety and Health (NIOSH) as "the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker," is nothing new in the healthcare workplace, and up until recently was regarded by many to be part of the job.
But as more attention is paid to the adverse effects of stress and burnout on patient safety, and with resultant costs to healthcare in the forms of lawsuits, financial losses, and reputation consequences, the need to be proactive becomes more paramount.
"Studies indicate that health care workers have higher rates of substance abuse and suicide than other professions and elevated rates of depression and anxiety linked to job stress," according to NIOSH. "In addition to psychological distress, other outcomes of job stress include burnout, absenteeism, employee intent to leave, reduced patient satisfaction, and diagnosis and treatment errors."
Among nurses specifically, NIOSH found certain factors, including the following, to be linked with higher stress:
Work overload and time pressures
Lack of social support at work (especially from supervisors, head nurses, and higher management)
Exposure to infectious diseases and needlestick injuries
Exposure to work-related violence or threats
Sleep deprivation
Role ambiguity and conflict
Understaffing
Career development issues
Dealing with difficult or seriously ill patients
"As a general rule, actions to reduce job stress should give top priority to organizational changes that improve working conditions," according to NIOSH literature. "But even the most conscientious efforts to improve working conditions are unlikely to eliminate stress completely for all workers. For this reason, a combination of organizational change and stress management is often the most successful approach for reducing stress at work."
Creating a healthy work environment
What exactly are those organizational changes? According to the Quick Safety report, there are several steps that leaders at healthcare organizations can take to help develop and foster a more resilient environment, including informing leaders in the organization about the professional factors that foster resilience, such as the following:
Feeling valued professionally
Colleague support
Use of mentors/role models
A feeling of making a difference
Team support and organizational support
Use of debriefings
Feeling competent to meet the needs of the job
Positive reappraisal, empowerment, and sense of accomplishment
In addition, the report recommends that healthcare organizations develop and practice leadership empowering behaviors (LEB), which enhance the meaningfulness of work, foster opportunities to participate in decision-making, express confidence in high performance, facilitate the attainment of organizational goals, and provide autonomy and freedom from bureaucratic restrictions. These LEBs can be developed and practiced by doing the following:
Create a safe and positive work environment. Security concerns have been identified as a risk factor for the development of staff burnout, so it's important to engage with staff around their perceived environmental threats and develop action plans to address concerns.
Enable employees to participate in decisions related to their work. The Joint Commission says that shared decision-making strengthens the voice of clinical nurses as they collaborate with leaders around optimal staffing plans.
Express confidence in employees' ability to perform at a high level and help them attain goals.
Ensure that leaders engage in discussions and have a physical presence in the department. Engaging with nurses allows for an open dialogue and exchange of ideas, as well as providing validation. Open dialogues help provide nursing leaders with a forum to foster best practices, find workable solutions for departmental issues, and teach leadership skills through mentoring sessions.
John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at johnpalmer@palmereditorial.com.
PSQH: Patient Safety & Quality Healthcare, December 12, 2019
A new report finds antimicrobial resistance is higher in medical device-associated infections than those from surgical procedures.
Antimicrobial resistance was found to be higher in medical device-associated infections than in those resulting from surgical procedures, according to a new report from the CDC's National Healthcare Safety Network(NHSN). The report was published this week in Infection Control & Hospital Epidemiology,the journal of the Society for Healthcare Epidemiology of America.
"Combating antimicrobial resistance is a top clinical and public health priority in the United States," said Lindsey Weiner-Lastinger, MPH, an epidemiologist at the CDC, in a release. "These data show that the threat of exposure to bacteria that are resistant to antibiotics extends across the nation. The data also serve as an urgent call for healthcare facilities and public health agencies to intensify their efforts to prevent the emergence and spread of antimicrobial resistance."
The report compiled data from more than 5,600 facilities from 2015 to 2017 and found that resistance was consistently higher for device-associated healthcare-acquired infections (HAI) than for the same bacteria identified after surgical procedures. The devices studied were those used for a limited time in a hospital setting such as central lines, ventilators, and urinary catheters.
Researchers found that 48% of tested Staphylococcus aureus isolated from device-associated infections were methicillin-resistant (MRSA), compared to 41% among those isolated from surgical site infections. And 82% of tested device-associated Enterococcus faecium bacteria were vancomycin-resistant, compared to 55% among surgical site infections.
Germs in adult and pediatric facilities varied by infection type and care location, according to the study. The most common HAI bacteria among adult patients were Escherichia coli (18%), Staphylococcus aureus (12%) and Klebsiella (9%). A companion report on pediatric HAIs, with data from 2,454 facilities, found the most prevalent pathogens among pediatric patients were Staphylococcus aureus (15%), Escherichia coli (12%), and coagulase-negative staphylococci (12%).
The report also found that bacteria associated with long-term acute care hospitals are more likely to be resistant than those acquired in short-stay acute care hospitals. In addition, HAIs in adult healthcare settings are more likely to be resistant than those in pediatrics.
The #MeToo movement has encouraged a wide range of industries that once looked at sexual harassment as "part of the job" to start taking steps to improve working conditions. Healthcare is among those industries that are not only finally recognizing the extent of the problem but looking for ways to prevent this behavior in the future.
And the behavior is widespread. When Medscape surveyed 6,200 physicians and clinicians in 2018 about sexual harassment incidents over the prior three years, it found 7% of physicians and 11% of nurses, nurse practitioners, and physician assistants had experienced sexual harassment. Reported harassment ranged widely from sexual comments or leering (reported by 52%) to the offer of a promotion in exchange for sexual favors (reported by 3%). Nearly half (47%) of the perpetrators were physicians.
Perhaps most notably, more than half (55%) of those harassed did or said nothing to confront the perpetrator. Among residents, silence was even more common (78%). As Susan Strauss, EdD, RN, an expert in the topic, commented in the report, "Most places don't know how to conduct an investigation, and many HR departments don't recognize the nuances of sexual harassment issues."
Scott Cormier, vice president of emergency management, environment of care, and safety for healthcare facilities service provider Medxcel, is among those professionals ready to help healthcare organizations recognize those nuances. "What healthcare [providers] are doing and need to continue to do is to let our associates know no matter what their gender is, no matter how they identify, that [sexual harassment] is absolutely wrong and is intolerant," he says.
That starts with a sexual harassment program that includes ongoing training and awareness initiatives. According to Cormier, "Many times, sexual harassment programs are already in place because of the regulatory requirements but spin up or spin down based upon an event." That type of reactionary response means that other team members are missing out on the benefits of active promotion and training. And that's important to address. Consider that the Medscape survey found that of the 2% of physicians who reported having been accused of sexual harassment, only 2% felt the accuser was accurate in their accusation. Health systems may need more impactful education on what constitutes appropriate behavior to help bridge that disconnect.
Get an accurate handle on training
For a first step, Cormier suggests outsourcing the creation of organizational sexual harassment training.
"Engage professionals who do this for a living," he encourages. "We all try to do things internally … we want to try to save costs. That's not the right way to do something this important. Make sure that you put together a professional program."
Next, organizations must provide training to all associates and staff, as well as the people who are going to be managing the program and investigating complaints. "That training can't be just one and done. There has to be some sort of baseline training and then continuing education," Cormier insists.
That baseline training is particularly important. "When you put these programs in place, you're going to see a couple hundred percent in reported events and you're going to think, 'We're getting worse.' But you have to realize you never had a baseline and it's going to take a year or two or maybe three to develop that," Cormier notes.
With a baseline in place, organizations can more accurately begin to drive toward the goal of zero incidents. "The only acceptable number when it comes to sexual harassment is zero," Cormier points out. "If you're driving for something other than zero, then you don't have an effective program."
While Cormier notes that this approach will cost more in development and maintenance, it also may help reduce turnover and burnout by creating a safer place to work. Given recent research indicating that anywhere from 44% to 78% of American physicians suffer from burnout, training can be a valuable component in creating a better culture for your employees.
Remove barriers to safe reporting
The next step is to establish a culture where employees feel safe enough to report incidents of sexual harassment. Clearly, reporting should never make employees feel as though they're at risk of compromising their jobs. But it's not enough today to simply have a system in place. The long history of sexual harassment in healthcare—something Florence Nightingale openly dealt with in the 1800s—puts the impetus on the organization to make employees feel safe in reporting incidents or concerns.
"The way we do that is to continuously remind them they're not going to be punished or feel degraded or feel demeaned for reporting it and going through this process," Cormier says. He adds that this is one reason establishing a feedback loop with supervisors is important. In other words, once an incident is reported to an individual's direct supervisor and the supervisor investigates the complaint, that supervisor has not completed the investigation until he or she has relayed the findings to the person who initiated the complaint. Cormier says this is an area many people tend to miss, but it's an important part of making victims feel heard and supported.
Safety in reporting is a critical step, but Cormier suggests that reporting must also be simple. After all, physicians and nursing staff are severely overworked as it is. Setting up hurdles to reporting is likely to deter victims of sexual harassment—who have perhaps too long viewed harassment as a part of their job—from speaking up.
"If it takes me 30 minutes of my day to report this, I'm not going to take the time," Cormier says. "In healthcare, we have dedicated people who are focused on our patients, and they're not going to take 30 minutes away from their patients to do this."
Once a report comes in, the onus must be on the system to gather information and analyze it to resolve the allegation. Speed, again, is key. As Cormier puts it, there's someone feeling vulnerable and insecure waiting upon your actions to gain some sense of closure. "To close that gap of insecurity, we want to make sure that we have a method of doing this thoroughly," he says. "We don't just want to make assumptions that it did or didn't happen. We don't want to rely on what people think about this person or that person. We want to have a thoroughly trained investigation team to take appropriate action, whether it's counseling or another form of process, to deal with the issue. Then we have to make sure to review that process and make sure it continues to be effective."
Ongoing improvement is another key, Cormier suggests. There needs to be constant accountability all the way to executive leadership to improve the investigation, review, and support processes.
Instill organizationwide accountability
Many healthcare organizations struggle with creating a program that works and driving the changes necessary to improve their culture. The first step is to understand how your staff feels about the current culture so that you know where to improve.
Working with an experienced third party can help ensure you're not missing organizational blind spots. "Look for somebody with experience," Cormier suggests. "Look at the programs that they've helped with, and look specifically to see if they're effective and have had a reduction in the amount of sexual harassment incidents."
The most critical thing, however, is to ensure the entire organization knows they have a responsibility to drive the culture forward. Everyone must understand appropriate behavior, report incidents, and investigate rapidly. Healthcare workers are tasked with doing more with less, so it's more critical than ever that their employers do more to eliminate hostile working environments.
Megan Headley is a freelance writer and owner of ClearStory Publications. She has covered healthcare safety and operations for numerous publications. Headley can be reached at megan@clearstorypublications.com
PSQH: Patient Safety & Quality Healthcare, November 15, 2019
The Centers for Disease Control and Prevention lists 18 kinds of antibiotic-resistant bacteria and fungi that pose urgent, serious, or concerning threats.
By Jay Kumar
A new report from the Centers for Disease Control and Prevention (CDC) found that antibiotic-resistant (AR) bacteria and fungi cause more than 2.8 million infections and 35,000 deaths per year in the United States. In a 2013 report, the CDC reported that at least 23,000 Americans died annually from AR infections.
In addition, when factoring in C. difficile, a bacterium that is not typically resistant but can cause deadly diarrhea and is associated with the use of antibiotics, the report expands that total to more than 3 million infections and 48,000 deaths.
Since the original report six years ago, prevention efforts have reduced deaths from AR infections by 18% overall and nearly 30% in hospitals. But the increased number of infections in this new report was found by using previously unavailable data sources.
The new report also categorizes the top AR threats based on level of concern: urgent, serious, or concerning.
"The new AR Threats Report shows us that our collective efforts to stop the spread of germs and preventing infections is saving lives," CDC Director Robert Redfield, MD, said in a release. "The 2013 report propelled the nation toward critical action and investments against antibiotic resistance. Today's report demonstrates notable progress, yet the threat is still real. Each of us has an important role in combating it. Lives here in the United States and around the world depend on it."
In the new report, the list of 18 germs includes two new urgent threats, drug-resistant Candida auris and carbapenem-resistant Acinetobactor. These were added to three urgent threats identified in 2013: carbapenem-resistant Enterobacteriaceae, Neisseria gonorrhoeae, and C. diff.
The CDC plans to take the following actions to deal with antibiotic resistance:
Make sizable investments in every U.S. state in programs such as the AR Lab Network to rapidly detect and help prevent antibiotic-resistant infections.
Work with federal partners such as the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality, as well as data experts and healthcare providers and veterinarians to improve the use of existing antibiotics.
CDC and the U.S. Food and Drug Administration will continue to supply samples of resistant germs from the AR Isolate Bank to drug and diagnostic test developers who can uncover new drugs and treatments.
Invest millions of dollars finding prevention strategies that can be scaled up across the nation.
Work with private industry to enhance food-product safety, medical devices, and surveillance capabilities.
Coordinate with domestic partners to expand the national response and prevention capacity, and with global partners to enhance the ability to combat the growing threat of antibiotic resistance worldwide.
The report's findings show that prevention efforts are working, but additional research and efforts are needed to contain the growing threat, according to the Society for Healthcare Epidemiology of America (SHEA).
"This data is exciting because it shows that we are not powerless against antibiotic resistance. SHEA members, which include hospital epidemiologists, infection prevention specialists, researchers, and pharmacists, are running critically important infection prevention and antibiotic stewardship programs that save lives and help protect patients, making hospitals safer for everyone," Hilary Babcock, MD, MPH, president of SHEA, said in a release.
"We must continue to fund and support effective infection prevention and antibiotic stewardship programs in every healthcare setting and use every tool we have to prevent the spread of antibiotic resistance," Babcock said.
The transaction, which is expected to close on January 2, will see ISMP become a subsidiary of ECRI Institute. Both are nonprofit organizations that promote patient safety by highlighting adverse effects, near misses, and unsafe conditions in various healthcare settings. ECRI Institute publishes data and recommendations to protect patients from unsafe practices and ineffective products, while ISMP has advocated for improvements in drug labeling, packaging, preparation, and administration.
"This agreement will strengthen our critical contributions to medication safety," said ISMP President Michael Cohen, RPh, MS, ScD (hon.), DPS (hon.), FASHP, in a release. "It allows both organizations to retain their core missions while immediately extending our ability to share lifesaving information and further a vision where safe, high-quality healthcare is more readily available. We look forward to this new chapter."
ISMP will operate as a wholly-owned subsidiary of ECRI Institute. Cohen and ISMP Executive Vice President Allen J. Vaida, PharmD, FASHP, will continue to oversee ISMP, working closely with ECRI Institute leadership. ECRI Institute President and CEO Marcus Schabacker, MD, PhD, will immediately join ISMP’s board of trustees, along with two other ECRI Institute officials.
"Two trusted organizations deeply committed to improving the safety of medical treatments are even more effective when they work together," said Schabacker in the release. “For both organizations, this agreement furthers the mission, deepens expertise, and broadens relationships. It’s a good move for both of us and for all of the organizations we serve, and ultimately for the patients worldwide."
Editor's note: This story first appeared November 14, 2019, in HCPro's PSQH.
PSQH: Patient Safety & Quality Healthcare, October 28, 2019
A new National Academy of Medicine report offers solutions to prevent caregiver burnout.
By Jay Kumar
The National Academy of Medicine offered recommendations to prevent and mitigate caregiver burnout in a new report released this week. The recommendations target changes in workplace culture, debt and financial stress, and policies, practices, and technologies that detract from patient care.
"While many health care stakeholders are initiating important actions to address the burnout problem, there is little research indicating how effective they are in reducing burnout (and even less concerning their effectiveness in improving well-being or patient care)," according to the report's summary. "The committee's systems framework emphasizes the identification of interventions aimed at tackling the critical factors contributing to burnout as a way of fostering an improved state of professional well-being while improving patient care. There is evidence that interventions focused on work organization can mitigate burnout; thus, health care organizations are a powerful determinant and have a critical role to play in reducing clinician burnout. The evidence also indicates that individual-focused strategies may be beneficial and can be an effective part of larger organizational efforts but that, on their own, they do not sufficiently address clinician burnout."
The panel found that healthcare organizations need guidelines for designing, implementing, and sustaining professional well-being systems to mitigate the multitude of factors contributing to burnout. There are a number of gaps in the existing research literature, the committee found.
To address these concerns, the committee made six recommendations:
Create positive work environments: Transform healthcare work systems by creating positive work environments that prevent and reduce burnout, foster professional well-being, and support quality care.
Create positive learning environments: Transform health professions education and training to optimize learning environments that prevent and reduce burnout and foster professional well-being.
Reduce administrative burden: Prevent and reduce the negative consequences on clinicians' professional well-being that result from laws, regulations, policies, and standards promulgated by healthcare policy, regulatory, and standards-setting entities, including government agencies (federal, state, and local), professional organizations, and accreditors.
Enable technology solutions: Optimize the use of health information technologies to support clinicians in providing high-quality patient care.
Provide support to clinicians and learners: Reduce the stigma and eliminate the barriers associated with obtaining the support and services needed to prevent and alleviate burnout symptoms, facilitate recovery from burnout, and foster professional well-being among learners and practicing clinicians.
Invest in research: Provide dedicated funding for research on clinician professional well-being.