Surveillance: In infection control, surveillance is the term used to describe the function of observing, gathering, investigating and reviewing information about the patient as it pertains to infection prevention and control.

Patient Assessment: Accurately reporting signs, symptoms, and changes in condition and initiating isolation precautions as indicated.   

Tracking and Trending: Tracking and trending information gathered from surveillance; Practicing outbreak prevention and investigation, monitoring rates of infection and communicating findings in the form of verbal and written reports.  

Orientation and Staff Education: Educating staff, patients and families to Infection Prevention. Monitoring staff compliance with basic infection control principles such as; hand washing, isolation, transmission based precautions, and use of personal protective equipment (PPE).

Monitoring Antibiotic Usage:  Reviewing and reporting antibiotic usage and trends of antibiotic resistance reported in antibiograms.   

Revising Policies and Procedures: Participates in updating policies and procedures needed to maintain compliance with current recommendations from agencies of the federal and local government such as; OSHA, the CDC, state and local departments of health. 

Conducting Environmental Rounds: Monitoring department compliance with Infection Control guidelines; conducting environmental rounds and consultation as needed.

Monitoring Employee Health: This may or may not be the direct responsibility of the Infection Preventionist. Responsibilities  include annual physicals and tuberculosis screening for new hires and employees, offering influenza and Hepatitis B. vaccines, keeping accurate employee records, initiating workplace restrictions if indicated, becoming familiar with OSHA regulations and educating staff to Infection Control and Blood Borne Pathogens standards.

Each facility will have their own policies and procedures regarding the expectations of the Infection Control Designee. Responsibilities may be shared but usually are not. Hopefully, the Infection Control Professinal will be given the support they require to do their job efficiently and with satisfaction. 

The Guidelines stress vaccination of all Healthcare Workers (HCW), which I believe will become “A Condition of Employment” in the near future. Education of staff to the underlying principles is very important. There are still many HCW’s who believe they will become sick or actually “Catch” the flu from the vaccine, which is untrue. Enlightenment is key, but it may take a mandate to finally put things into perspective. 

How vaccines prevent disease/ cdc.gov

Vaccines for Healthcare Workers

Is the physician getting an accurate picture of what is going on with the patient? When the physician does not have a clear picture of what might be going on, the Broad Spectrum Antibiotic is a tempting choice to make; It may be prophylactic but it treats multiple organisms and buys time until labs are ordered, drawn and resulted. But, misuse of Broad Spectrum Antibiotics has also caused the resistance that is now actually limiting a physician’s choice for treatment.

Communication from nursing staff to physician could be one of the most important steps toward preventing the misuse of antibiotics. Treatment of suspected infections must be supported by accurately reporting pertinent data gathered by nurses experienced in using established surveillance tools. Nurses need encouragement and education to develop familiarity with established criteria and strong nursing observation skills. Without a professional nursing assessment the physician may be left in the dark with little else to do but to choose the Broad Spectrum Antibiotic; conversely, a concise nursing assessment could prevent an order for a treatment that may not be in the best interest of the patient.  

“Observation tells how the patient is; reflection tells what is to be done; training tells how it is to be done.Training and experience are, of course, necessary to teach us too; how to observe, what to observe; how to think, what to think.” (Nightingale, 1882)

The very mention of the word incites the manifestation of a psychological phenomenon causing everyone and anyone who hears the name to immediately begin scratching, even when there is no evidence that they have developed a close relationship with the mite; health care workers often lose their perspective in the company of a patient currently diagnosed with that handy medical term.. “Cannot rule out.” Maybe this will help a little:

• The scabies mite does not hop, skip, jump or fly
• Scabies is transmitted by close, personal, skin to skin contact.  So yes, a HCW giving close, physical care to a patient with scabies, runs the risk of transmission, but only if they don’t use precautions.

Diagnosis is often difficult; to obtain a more reliable diagnosis than “Cannot rule out” a positive skin scraping can be definitive; at the same time, a diagnosis could be missed if it just so happens the mite and its waste products were not collected in the specimen.

Traditionally, in order to cover the “Cannot rule out” diagnosis and the potential for an outbreak, Elimite (Permethrin) was ordered to treat the patient along with everyone and anyone. Treatment commenced for anyone and everyone at the same time and there were frequent 2^nd and even 3^rd rounds of treatment.

Recently, standardized treatment recommendations are based on the logical chain of events surrounding patients and those who have been in closest contact with them. For instance, someone who simply places a food tray on an overnight stand and leaves the room is not usually at risk for transmission of scabies.  See: CDC on Scabies  See Also: California Department of Public Health on Scabies

We can help to quiet the jangled nerves of co-workers hit by a scabies scare by reminding them:

• The scabies mite is not transmitted through the air or droplets and they do not hop, skip, jump or fly.
• Scabies transmission may occur when there has been close, skin to skin contact.
• The chance of picking up the scabies mite from a patient’s laundry is very small. Conversely, if you are at home and you sleep in the same bed with a family member who has scabies, you could be at risk.   
• Be mindful. If you suspect scabies, wear gloves and a gown and report your suspicion.
• Most of all use Standard Precautions at all times, on all patients.  
• Follow your State Infection Control Guidelines for the Management of Scabies in Long-term Care, or  your own facility P & P or recommendations from the CDC.  

 You can stop itching now.

According to the FDA this year’s flu vaccine contains the same combination of viral subtypes as last year’s. The 2011-2012 flu vaccine is comprised of:

• an A/California/7/2009 (H1N1)-like virus;
• an A/Perth/16/2009 (H3N2)-like virus; and
• a B/Brisbane/60/2008-like virus.

People may wonder why it is necessary to repeat the same flu vaccine again. Multiple studies have shown we develop antibodies to the flu vaccine about two weeks after receiving it but those same antibodies decline during the course of the year. For these reasons it is recommended everyone over the age of 6 months be vaccinated each year prior to flu season. October is here and flu season is expected to continue well into March of 2012, so be sure and have yourself and your family vaccinated as prescribed by your physician.

Influenza is highly infectious even before symptoms appear, so an infected person could be shedding the virus before they even know they are coming down with the flu. With this in mind, vaccination should be offered as soon as it becomes available, especially to those who are in the business of caring for people with already stressed immune systems.  APIC also recommends healthcare facilities, skilled nursing facilities, hospitals, physician’s offices, urgent care centers, and home health agencies should require immunization as a condition of employment.  APIC Position Paper on Healthcare Workers and the Influenza Vaccine 2011

• Where is your Infection Control Manual?
• Do you follow your own Policies and Procedures? Where are they located?
• Where is your Policy for Scabies?
• How long does the patient need to be on contact isolation after treatment with Elimite for Scabies?
• Who needs to be offered treatment for Scabies?
• Do you have a policy for Outbreak Management? May we see it?
• Do you have an effective hand hygiene program?
• We observed the wound care nurse removing her gloves and not washing her hands or using alcohol sanitizer.
• We observed the Nursing Assistant in the hallway with gloves on.
• We observed a Dietary Aid taking a tray into the room of a patient on Contact Isolation without using PPE.
• This patient was re-admitted from the hospital with MRSA of the Nares; why isn’t she on Isolation?

There is a good answer for every one of these queries; some depend on individual facility Policies and Procedures; most answers can be found in the CDPH Infection Control Guidelines for Long-term Care

If you are familiar with your Policies and Procedures, the answers are really not that  difficult; if not, one could become rattled and lose the ability to effectively communicate with the surveyors; what then?

Will you be able to call your consultant in time to find answers to the questions?

Will the consultant be available at the moment you need them?

Would you choose a mad, fearful last minute scramble, or would you rather plan ahead, remain calm and retain those good feelings of being in control?  The reality is the DSD, or whoever is the infection control designee, should know the answers to the questions. Now is the time to really educate ourselves.   

The truth is no one can educate us; they may offer resources and in some cases opportunity for educational experiences, but for the most part, we have to make the effort to find out as much as we can about the specialty we are in charge of, and there is much to learn. It doesn’t have to be overwhelming, to start with, don’t allow yourself to become dependent on someone else; instead, take control of your future and educate yourself.

Start by locating and reading your Infection Control Manual with every opportunity. Find out what your policies are; learn them, understand why you use them, share them and educate others to them. Lastly, insist on compliance.

Most of all don’t wait. Could you answer the questions I mentioned? Don’t depend on a consultant, another nurse, or anyone other than yourself, to find the answers. If you do, it will be too late; you need to be confident enough to answer questions related to the Infection Control Program in your facility. Educate yourself; knowledge brings confidence. Commit to understanding what you do, why you do it, and where the supporting documents for your facility Policies and Procedures are located.

Once you commit to your own education,  your experience will become your expertise and you will be in the position of educating those who are asking all the questions. Good luck!

• Consider this a potential Norovirus- associated Gastroenteritis outbreak.
• First notify DON, Medical Director, resident’s Physicians, Administration and staff; the Medical Director, DON or Administrator will report to local County Health Department and DHS Licensing. An outbreak exists when there is an increase in the expected baseline level of cases in a facility; a sudden occurrence of more than the usual expected cases is the definition of outbreak; all outbreaks are reportable.
• Place symptomatic patients on contact isolation and stop social activities until symptom free for 48 hours. Use gowns, gloves and masks if there is vomiting.
• Assess all patients for similar signs and symptoms. Develop line listings/outbreak surveillance Forms for surveillance and tracking purposes; use separate tracking forms for residents and employees.
• Meet with all staff; review signs and symptoms of noroviruses; per CDC incubation period is 12-48 hours; duration 24-60 hrs and 30 % of affected patients may be asymptomatic. Transmission is by direct person to person contact, the oral/fecal route, or contamination of water or food by infected persons; the virus may also become aerosolized when patients are vomiting.
• Re-enforce strict hand washing guidelines and use of Personal Protective Equipment (PPE).
• Environmental Disinfection; the CDC recommends Chlorine Bleach solutions or EPA approved disinfection products. (http://www.cdc.gov/ncidod/dhqp/id_norovirusfs.html)
• Instruct visitors on precautions and limit visitations if necessary.
• Document signs and symptoms, notification of physicians and all new orders.
• Maintain and hold staff rotations until outbreak is resolved. Continue monitoring cases until there are no further signs and symptoms consistent with Norovirus-associated Gastroenteritis cases in your building.

Resource: CDC/Norovirus in Healthcare Settings

I’ll soon be posting some questions and answers regarding situations found in some of the Long-term Care Facilities I work with. Thank you again for your support!

Answer: In health care, policies and procedures describe protocols written, reviewed and adopted by the institution one is employed by. They are more than a guide, they define the expectations for performance and set standards that can and will be used to measure the appropriateness of the employee’s behaviors on the job. Whether documents are being created or revised, they must be accurate, consistent, compliant and based on current practice. Outdated policies must be updated at least annually and more often if warranted. 

The policies and procedures that most affect my position are those of the infection control manual. When a facility signs a contract to retain services from a lab and radiology company, they may be provided with an infection control manual that spells out policies and procedures for surveillance, tracking & trending, employee health, environmental issues, education etc.

Once a facility accepts the manual they should review it with their infection control committee; if they wish to adopt the policies and procedures, they must review, adopt, sign the Infection Control Committee Approval page, and rename the manual using the facility’s name. 

More often than not, the manual finds its way to the back of a book shelf  in some obscure office; Staff Developers and Directors of Nursing come and go, no one keeps up with the manual and eventually, many guidelines become outdated. 

Surveyors want to know facilities have an infection control program in place, that they have policies and procedures, and that they follow them. There are times when I receive an urgent call because a surveyor has surprised a facility and is asking questions they cannot answer; why? Because they are not familiar with the infection control manual and therefore, not familiar with their own policies and procedures. These facilities are at risk for being found deficient by surveyors.  

Some of the more highly infectious organisms found in healthcare facilities are the seasonal influenza viruses and noroviruses, which cause gastroenteritis; these viruses are capable of causing outbreaks due to the ease with which they are transmitted from person to person.

All one has to do is stop and think about where their hands have been today, where everyone else’s hands have been today, and what those hands have touched and will touch. Take a minute, close your eyes, and think about it. The possibilities for transmission seem endless, don’t they?

Now, think about interrupting that cycle; think about the barriers you will need to interrupt transmission. It’s really just that simple.

• Gloves if you anticipate contact with blood or body fluids.
• Gowns if you anticipate splashes being generated during patient care.
• Masks if a resident shows signs and symptoms of respiratory illness, i.e. coughing, sneezing.  
• Goggles, face shields and N-95 respirators are usually not needed in Long-term care situations but should be available.

*As always, Infection Control begins and ends with hand washing (view this visual link) 

Next: infection control related questions  I am asked on a daily basis