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Infection Control Surveillance and Oversight · The SHEA Podcast

• 0:08
  SPEAKER_02: Welcome to the podcast series of Infection Control Basics brought to you by the Society for Healthcare Epidemiology of America, which promotes the prevention of healthcare infections and antibiotic predictors, and to advance the field of healthcare epidemiology and antibiotic prediction.
• 0:24
  SPEAKER_02: Today is excited to watch the final podcast of this area of infection control together.
• 0:29
  SPEAKER_02: Our four panelists are Dr.
• 0:31
  SPEAKER_02: Louisa Debry, Professor of Medicine, Infective Debatic and Epidemiology at Yale University.
• 0:36
  SPEAKER_02: Dr.
• 0:36
  SPEAKER_02: David Peter, Professor of Medicine at the Hospital of the University of Pennsylvania.
• 0:41
  SPEAKER_02: Dr.
• 0:42
  SPEAKER_02: Lisa Walder, Infection Control Prevention at Clinical Consultant Clinical Consultant.
• 0:48
  SPEAKER_02: And Christopher Beebe, Division Vice President of Medication Safety Comprehensive Pharmacy Services.
• 0:54
  SPEAKER_05: Welcome everybody to this podcast.
• 0:55
  SPEAKER_05: I'm Louise Dembry, and I want to welcome my co-moderator, David McGee, and our pharmacist Christopher Beebe and our consultant Elisa Waldalski, who are going to help us through with the questions this afternoon.
• 1:10
  SPEAKER_05: We thought we would start by talking a little bit about what your perspective is on what do we mean by oversight responsibility when we're talking about preparing for a survey and dealing with specific areas that are not under infection prevention, like the pharmacy, sterilization and disinfection, and environmental services.
• 1:29
  SPEAKER_05: Lisa, would you like to start and maybe make some comments?
• 1:33
  SPEAKER_04: Sure, thank you very much.
• 1:35
  SPEAKER_04: In regards to the oversight and what we're looking for from a regulatory perspective, infection control touches almost everything within a survey within the hospital from the moment they walk in and look at the environment and how sanitary it is.
• 1:53
  SPEAKER_04: And infection prevention and control as it pertains to very hot topic presently with pharmacy or compounding sterile preparations, high-level disinfection and sterilization, chemodialysis, and always environmental services is a partnership that, despite a lot of the findings, may be focused on being written up in an infection control chapter or under the infection control standards, that they're not to be interpreted as entirely under infection control's realm.
• 2:26
  SPEAKER_04: So this means many key stakeholders are involved in working together with infection preventionists with key oversight in central sterile processing for sterilization, for example, endoscopy for high-level disinfection of endoscopes, environmental services when it pertains to housekeeping, pharmacy leadership with some of the central compounding sterile preparation issues.
• 2:53
  SPEAKER_04: So it's it's never a siloed approach with infection prevention and control efforts.
• 2:59
  SPEAKER_04: It's typically a partnership and consultative relationship, working continuously with these areas to identify issues that they can work together on.
• 3:10
  SPEAKER_05: Thank you, Lisa.
• 3:11
  SPEAKER_05: Christopher, do you want to speak maybe specifically to some of the issues around pharmacy and particularly the pharmacy 797 and 800 standards?
• 3:21
  SPEAKER_03: Sure.
• 3:21
  SPEAKER_03: Thank you.
• 3:22
  SPEAKER_03: The USP 797 is a chapter in the United States Pharmacopoeia, which is basically a national compendium that tells standards around quality and safety of medication.
• 3:32
  SPEAKER_03: And 797 is a particular standard around sterile compounds.
• 3:41
  SPEAKER_03: But for the purposes of pharmacy, it's really going to be 99% of what we compound full of DID medications that the safety strategy.
• 3:48
  SPEAKER_03: So it outlines everything that has to do with that the physical plan, the uh work processes that the staff uses, and then a lot of quality.
• 3:56
  SPEAKER_03: And where it really affects the infective control professionals is around the environmental sampling and the environmental monitoring.
• 4:04
  SPEAKER_03: You know, the Joint Commission, when they come in, they are looking at the report, at the test, and uh at the results of that environmental monitoring.
• 4:13
  SPEAKER_03: And if there are issues with that, they will want to bring in the effective prevention specific.
• 4:18
  SPEAKER_03: There are two realms related to the environmental monitoring.
• 4:22
  SPEAKER_03: One is monitoring the test and their competency training.
• 4:25
  SPEAKER_03: So when they put on their gloves and put on all of their garb, their personal protective equipment for doing the compounding, they need to do two types of anti-testing.
• 4:34
  SPEAKER_03: And that would be gloved fingertip testing, where they actually press their gloved fingertips into another place to see if anything grows to judge their skill level at their garbing and gloving in an aesthetic manner.
• 4:45
  SPEAKER_03: And then the media skill test where they actually inject a test solution into a broth and see if anything grows out of that after proper incubation.
• 4:53
  SPEAKER_03: So that's more test their skills in compounding something without contaminating it.
• 4:58
  SPEAKER_03: The other part that I've seen insects and control get even more involved in is the environmental monitoring of the physical space.
• 5:06
  SPEAKER_03: There are requirements to do viable air and surface sampling both in those IV hoods where the compounding occurs and in the room that houses those IV hosts.
• 5:16
  SPEAKER_03: So there are various action levels of which remediation must take place.
• 5:20
  SPEAKER_03: So if you grow more than a certain number of CFUs from that viable air sampling, that has to be identified to the data level, and then remediation actions take place.
• 5:30
  SPEAKER_03: And same with the surface sampling.
• 5:33
  SPEAKER_03: So this is more of an evaluation of staff cleaning competency and whether they're doing all the cleaning right using the proper chemicals, which infection control should be involved in picking those chemicals.
• 5:43
  SPEAKER_03: There are examples in the chapter of what should be used for cleaning the hosts and cleaning the room.
• 5:48
  SPEAKER_03: And again, this environmental sampling is where infection control professionals may be brought in, especially if there's an experiment, because it would have to be remediated, uh, which is a whole other discussion in itself in the remediation step.
• 6:00
  SPEAKER_03: But when joint commission comes in, they will ask for at least the last test, if not a series of them, and see if there was any growth and see what action has been taken, and they'll want to ensure that infection control was involved.
• 6:12
  SPEAKER_04: Chris, this is Lisa Waldowski, and I appreciate what you just shared.
• 6:16
  SPEAKER_04: And I'd like to add to that as part of being an infection control specialist, and that is based on what you've shared, having the infection preventionist know if in that designated facility that they're working in, whether high-risk versus low, moderate risk compounding is being performed, and understanding the frequency, whether it is with the finger glove tip testing and the media field testing frequency of staff, the garbing, knowing that the staff are competent and trained.
• 6:47
  SPEAKER_04: And like you said, not only reporting when levels exceed surface and air sampling results, but that communication is continually said and relayed to infection control, even to the extent of being a mainstay in infection control committee meetings, that that information is continually reported, not to negate in real time if something exceeds that things aren't immediately being addressed, and necessary action items are implemented with retesting and leadership notification, which are all requirements in standards, as you already mentioned, with the Joint Commission.
• 7:26
  SPEAKER_04: So, again, to prevent something happening and not being notified through infection prevention and control, having that communication continually reported on a frequency that the infection control is in the loop is very important.
• 7:39
  SPEAKER_04: So thanks for bringing that up.
• 7:41
  SPEAKER_03: That's a great point, Lisa.
• 7:43
  SPEAKER_03: And the infection control professionals in the hospital should expect their pharmacy leader to be reporting the results of these tests on a regular basis.
• 7:50
  SPEAKER_04: Right.
• 7:51
  SPEAKER_03: As part of a PI, as part of a quality assurance program, even if there is no program.
• 7:56
  SPEAKER_04: Exactly.
• 7:57
  SPEAKER_03: The frequency is uh at this point a minimum of every six months.
• 8:00
  SPEAKER_03: All of this needs to be done.
• 8:02
  SPEAKER_05: Yeah, this is Louise.
• 8:04
  SPEAKER_05: I think you both make excellent points, and I kind of call it, I say, know what the pharmacy is doing, what their capabilities are, know the space, understand the flow, and know what the QA process is, because the last thing you really want is for the pharmacy to contact you when there's a problem and you don't really know what they're supposed to be doing.
• 8:22
  SPEAKER_05: So I think you both brought up excellent points about getting to know this ahead of time and what you need to know.
• 8:27
  SPEAKER_05: I don't know, David, if you would like to comment as a hospital epidemiologist from that perspective, if you would add anything else to what's been discussed about the pharmacy standards.
• 8:37
  SPEAKER_01: Thanks, Luis.
• 8:38
  SPEAKER_01: Chris and Lisa made several really good points about the role of infection control, infection prevention in the compounding process.
• 8:47
  SPEAKER_01: First and foremost, that location in many instances remains somewhat of a black box for infection prevention.
• 8:55
  SPEAKER_01: They need to be engaged physically, know where the space is, know where it's located, know what actually takes place in terms of what medications, where solutions are being compounded.
• 9:05
  SPEAKER_01: They also need to be familiar with the process for monitoring medication safety, the sterility of those medications, as well as the environmental disinfection and control.
• 9:15
  SPEAKER_01: Environmental care rounds are a standard process that infection prevention and other regulatory leaders typically engage in and preparedness for during commission and other regulatory surveys.
• 9:28
  SPEAKER_01: It is a perfect opportunity prospectively to continue to audit that process.
• 9:33
  SPEAKER_01: But has also been pointed out, there's a critical formalized reporting role so that the minutes actually reflect infection control's engagement in the compounding process.
• 9:43
  SPEAKER_01: So a representative of a pharmacy should be included in the infection control committee.
• 9:49
  SPEAKER_01: Our process typically, although the requirement is no more frequently than every six months, our process has typically been to have that reporting take place on a quarterly basis.
• 9:58
  SPEAKER_01: In addition to the inpatient compounding, it's important to realize that a number of health systems have large outpatient compounding pharmacies that are involved in their outpatient and fusional therapies, whether you're talking about total parental nutrition or administration, preparation of intous anti-infective agents.
• 10:19
  SPEAKER_01: Infection control has certain challenges because the frequency with which they can have boots on the ground there is limited.
• 10:26
  SPEAKER_01: But certainly a representative from the home infusion company should also be engaged in an infection control committee and report out regularly on these kinds of environmental monitoring and other culture results.
• 10:38
  SPEAKER_05: Okay.
• 10:39
  SPEAKER_05: I think we'll go on, but I thought it would be also important to spend some time talking about sterilization and high-level disinfection and the oversight because this is something that I know infection prevention is being brought into a lot.
• 10:52
  SPEAKER_05: There's a large piece of this process, and I know I'm sure Lisa's gonna go through this with us.
• 10:56
  SPEAKER_05: And also how it ties in with the OR and that whole loop about reusable medical equipment and how do we know that it's safe.
• 11:05
  SPEAKER_05: So I think maybe with that, Lisa, do you want to start in your perspective from infection prevention, how you approach this?
• 11:12
  SPEAKER_04: Of course, thank you.
• 11:14
  SPEAKER_04: So in regards to high-level disinfection and sterilization, they typically go hand in hand during a survey or audits.
• 11:23
  SPEAKER_04: And unfortunately, they have some overlapping similarities with precleaning at point of use, which is still a very frequently cited issue that right after a procedure is performed, performing pre-cleaning, whether it be a moist towel or a selected product to keep items moist during transport to minimize the risk of bio burden hardening on any instrumentation that is going to decontamination in central sterile processing.
• 11:50
  SPEAKER_04: So sterilization piece, right from pre-cleaning a point of use all the way to sterile storage, there are some pieces in that process that seem to come up time and time again during survey.
• 12:02
  SPEAKER_04: And it is so specific and detailed that it needs to be evidence-based and following products, supplies, and equipment manufacture instructions for use.
• 12:12
  SPEAKER_04: I can't stress the importance of those two mantras enough, following evidence-based guidelines for sterilization andor high-level disinfection, and following manufacture instructions for use.
• 12:26
  SPEAKER_04: And this poses a big challenge when staff are asked about cleaning products that they're using, how long do I use it for, what is the personal protective equipment, how much time do I immerse certain supplies in?
• 12:39
  SPEAKER_04: So there is a lot of level of detail.
• 12:42
  SPEAKER_04: And again, infection control is involved, but they don't own these processes.
• 12:47
  SPEAKER_04: So working with central sterile processing technicians and central sterile processing supervisors to assure, right, from transport of these items to getting them in the right location for reprocessing to looking at endoscopy and various decentralized locations, which adds another level of complexity, all of the locations that feed into central sterile processing or in fact reprocessing their items in their own departments.
• 13:17
  SPEAKER_04: And that also with training and education and keeping not only the staff that are performing these processes safe, but also to assure that devices, whether it be a probe, vaginal ultrasound probe or endoscope, are reprocessed safely enough to reuse on a patient again, and steps have not been omitted or skipped because of time pressure, not enough devices to use on patients, or just lack of knowledge and never being trained correctly in the first place.
• 13:48
  SPEAKER_04: So there's a multi-faceted reason and challenge for some of these processes that have numerous steps involved in them for things to go in the wrong direction and ultimately lead to an instrument that still has bile burden hardened on it after sterilization because cleaning steps were not performed correctly, or a scope that missed steps because they used a contaminated brush that was supposed to be single use disposable.
• 14:18
  SPEAKER_04: So there's again stressing the elements of the process steps that are not being followed by selected evidence-based guidelines or the manufacturer's instructions for use seem to be the constant theme that I am seeing repeatedly still in large organizations and small alike, that these pose huge challenges for not only infection control, but those that oversee these departments directly.
• 14:46
  SPEAKER_01: Lisa made an excellent point when discussing the critical role of infection control in prospectively evaluating durable medical equipment that requires high-level disinfection or sterilization for its ability to be cleaned, reprocessed, and sterilized.
• 15:04
  SPEAKER_01: I certainly have been personally aware of instances where infection control was not formally engaged at the time that durable medical equipment, sometimes quite expensive, was purchased and only after-the-fact issues with regard to the ability of providers to perform high-level disinfection adequately or sterilize the instrument of only after the fact come to light.
• 15:26
  SPEAKER_01: We'd much rather be engaged prospectively before the purchase is made rather than retrospectively to both identify defects where there are divergences from the instructions for use and issues with the manufacturer's recommendations for sterilization or disinfection that may have implications about whether the device should be used in the first place.
• 15:49
  SPEAKER_05: Yeah, this is Louise.
• 15:50
  SPEAKER_05: I would agree with that, and I would make a suggestion to anyone who, whether you're preparing for a survey or not, because we should be doing the right thing every day, is to think about using like the tracer methodology.
• 16:01
  SPEAKER_05: As an infection prevention person, it was really eye-opening for me, and that means from the time the item is used, whether it's in the OR or in a clinic or an endoscopy, all the way through the reprocessing in your central serial supply and getting the item back to where it needs to go and store it.
• 16:19
  SPEAKER_05: Because you will learn a lot about that.
• 16:20
  SPEAKER_05: And Lisa, I think you touched on something also very important and to make sure that you have good documentation around all the individuals involved and they've been trained and haven't signed off on competencies to do that because people sneak into the institution.
• 16:34
  SPEAKER_05: I say that in a way, meaning new people come in all the time and we think we show them how to do it, and that's where things can fall apart.
• 16:41
  SPEAKER_05: You have anything you want to add like how people could prepare to get to understand the flow or what their processes are?
• 16:49
  SPEAKER_05: Maybe beyond a tracer, is there something else?
• 16:52
  SPEAKER_04: Well, I think that tracer methodology and having detailed checklists, like I have to say that this takes a lot of skill for the person conducting the tracer as well.
• 17:04
  SPEAKER_04: Reason being there's so many pieces to the actual process that it should probably be done in a collaborative team approach to understand, like you brought up, the quality monitoring and understanding, following instructions for use to know that I don't really get to make a decision myself on how long I need to immerse the scope for.
• 17:26
  SPEAKER_04: It tells me, you know, it's very black and white.
• 17:30
  SPEAKER_04: And the fact that I could go and do a tracer on Friday and I could do a tracer today and happen to say what happened between the last time I was here and now, that things can change that quickly, that this is a process that needs hyper vigilance in observing and having other stakeholders continually monitoring this, particularly when you notice an area out of compliance that the staff aren't quite getting, that they're not understanding, that you're supposed to dip the test strip for one second and read it 90 seconds, that they don't have any wiggle room to make that stuff up.
• 18:09
  SPEAKER_04: Do I need to provide visual aids, visual resources?
• 18:12
  SPEAKER_04: What do I need to rectify this and do it immediately?
• 18:16
  SPEAKER_04: Um, do I need them to reprocess this item immediately?
• 18:19
  SPEAKER_04: Some of these items can't just wait till the next time I get to come once every quarter to trace.
• 18:25
  SPEAKER_04: So it does bear seeing how critical the identified issues are to justify how frequently I need to audit and be doing a tracer all the way through and what needs immediate remediation or intervention.
• 18:40
  SPEAKER_05: Yeah, I think audit periodically with immediate feedback and retraining is something that can be very helpful.
• 18:46
  SPEAKER_05: So I would definitely do that.
• 18:48
  SPEAKER_05: It reinforces the practice of the point of use, and you brought up a good point about end users also owned this process.
• 18:54
  SPEAKER_04: Right.
• 18:55
  SPEAKER_05: So I think with that we will transition to talk a little bit about infection prevention's role in materials management, and then we'll kind of finish with environmental services.
• 19:11
  SPEAKER_04: Sure.
• 19:11
  SPEAKER_04: So with materials management, I almost don't want to start at the beginning about prevention.
• 19:17
  SPEAKER_04: It seems we're often finding products that have been the perfect term you just said in a former comment was sneaking things in, finding out products, devices have already landed in your facility and are being used, and you find out after the fact.
• 19:34
  SPEAKER_04: In a perfect organization, you would be part of a committee to review products in advance to assure that you can clean them, you can store them, what risks they pose up front.
• 19:46
  SPEAKER_04: And it's not just infection control, but other key stakeholders involved with materials management before we even approve something to come into the hospital.
• 19:56
  SPEAKER_04: So ideally, committees, whatever they're called or termed, meet on a regular basis and people bring to that committee things that they want to get approved to use.
• 20:08
  SPEAKER_04: But I oftentimes unfortunately see that that's already happened, that they bypassed any review and they're already being used.
• 20:16
  SPEAKER_04: So we have this challenge of silos that departments think, oh, we want this, this sounds great, or they go down to a local Kmart or Walmart and buy a product and then it's there and you wonder how it arrived.
• 20:29
  SPEAKER_04: And again, using things off label or thinking they're saving the organization some money in resources oftentimes is the rationale or reason that this type of issue arises.
• 20:41
  SPEAKER_04: So I think that we have to step back and try to bring it back to where we need it to start at and not have to clean it up after it's already there and make it fit or make it work.
• 20:51
  SPEAKER_05: Do you want to touch also on environmental services?
• 20:55
  unknown: Sure.
• 20:58
  SPEAKER_04: Oh, definitely.
• 20:59
  SPEAKER_04: And I think environmental services and infection control need to be joined at the hip in regards to many issues, particularly high-risk areas, specialty areas like the OR, with understanding that dedicated staff are helping with cleaning those environments on a regular basis, particularly the terminal clean at the end of the day, but looking at the level of detail that that sets the tone for the entire survey.
• 21:29
  SPEAKER_04: If your OR environments are not pristine, that the rest just kind of is tainted by that impact.
• 21:37
  SPEAKER_04: So having environmental services educated and trained to have a special interest and group that does the OR areas, and then looking at the other high risk areas of rooms that are isolation rooms and knowing how those rooms are being cleaned and turned over.
• 21:54
  SPEAKER_04: And even things as benign as when you see curtains that partition ER.
• 22:00
  SPEAKER_04: Bays or different areas that are just divided, not by a wall or solid partition, but a curtain, how often those are getting turned over.
• 22:09
  SPEAKER_04: This involves close connection with environmental services to make sure everyone's on the same page.
• 22:16
  SPEAKER_04: And even with our former discussion or comment on compounding sterile preparations, that too needs dedicated staff environmentally that know how to clean a pharmacy, particularly those rooms with hoods that are performing high-risk compounding.
• 22:33
  SPEAKER_04: So there are areas that environmental services, it's not just sweeping dramping the floors or turning over a patient room that, quote, did not have an infectious patient, but making sure the understanding and competency and training has been performed for those staff to know how they clean those areas and environments because they are different.
• 22:55
  SPEAKER_05: Thank you very much, Lisa.
• 22:56
  SPEAKER_05: David, would you like to add something to that?
• 22:59
  SPEAKER_01: Thank you, Louise.
• 23:00
  SPEAKER_01: I'd like to reiterate a number of things that Lisa has emphasized with respect to the critical role of on the lines between infection control and environmental services.
• 23:10
  SPEAKER_01: EDS is a critical partner in patient safety and oftentimes aren't recognized as such.
• 23:15
  SPEAKER_01: And infection control and EDS partner over many important areas, including the choice of surface disinfected agents that are used throughout the hospital, the hand hygiene products, which are used, whether it's an antimicrobial soap or an alcohol-based hand rub, evolving technologies for environmental control, and technologies to monitor the adequacy of environmental control and provide feedback with respect to special competencies.
• 23:46
  SPEAKER_01: By all means, that's a critical role of environmental control, but a partnership between infection control, the specific unit or care area, be it perioperative services, be it the pharmacy, be it on an inpatient, acute care, or intensive care unit, are really fundamental to the success of environmental control and reducing patient risk and the potential for patient harm.
• 24:10
  SPEAKER_05: So I think I'm going to just try to summarize.
• 24:12
  SPEAKER_05: I think what I've heard from Chris and Lisa, there's been kind of some overarching comments across all these areas between pharmacy, sterilization, high-level disinfection, materials management, environmental services, but the importance for strong collaboration with these various services and departments, understanding what it is they do in the space they're working in, as well as the people who are performing these services, making sure they're trained and they have competencies.
• 24:39
  SPEAKER_05: And a big piece that both of you touched on is knowing what are the required quality assurance processes or monitoring that needs to be done and to be aware of what that is.
• 24:49
  SPEAKER_05: And I think Lisa brought up some good points thinking about which of those you would want to also bring to your infection prevention committee.
• 24:56
  SPEAKER_05: I also sometimes say that I, you know, it's important, I think, infection prevention.
• 25:00
  SPEAKER_05: We have a role in pulling together all these people that we work with and collaborate with because we also can help bring things to the hospital leadership where we feel that there are gaps that need to be bridged or that there are sticky issues that we at our level have not been able to solve.
• 25:18
  SPEAKER_05: And so I think together with our colleagues, we have a much stronger voice.
• 25:22
  SPEAKER_05: So I think about that in terms of collaboration.
• 25:25
  SPEAKER_05: So on that note, David and I would like to thank all the participants.
• 25:28
  SPEAKER_05: I'd particularly like to thank Lisa Weldowski and Chris Beebe for your insight and sharing your expertise with everybody today.
• 25:36
  SPEAKER_02: Thank you to our panelists for sharing their perspectives and experiences.
• 25:39
  SPEAKER_02: Looking to expand your knowledge and infection control.
• 25:42
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• 25:44
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• 25:50
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• 25:55
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• 25:59
  SPEAKER_02: This concludes today's podcast.