[caption id="attachment_157" align="alignleft" width="150" caption="Your co-worker? "][/caption]
We have been preaching to the proverbial choir in this space about protecting frail patients from influenza, but what about immune competent coworkers? A fascinating outbreak during the first weeks of the H1N1 pandemic in 2009 reveals that health care worker-to-worker transmission may be occurring more than commonly suspected, as these infections may typically be assumed to be community acquired.
A recently published report details an H1N1 outbreak in a Chicago hospital in which the index case may have been a physician. The doctor became ill and tested positive for the virus. Other health care workers began getting ill and also tested positive. Tellingly, the hospital outbreak unfolded at a time when H1N1 was not yet widespread in the community.
The investigation revealed an interesting pattern: The transmission was occurring among co-workers, not from or to patients. Even if health care workers took precautions to protect patients, they were getting each other sick.1
In fact, two health care workers who developed H1N1 reported always wearing an N95 respirator or surgical mask when entering a patient room with a patient with respiratory illness.
Prevention of influenza transmission “is not [just] about patient to provider, it’s about transmission from person to person. You really need to take a comprehensive approach to preventing the transmission of influenza,” says David Kuhar, MD, medical officer with the Centers for Disease Control and Prevention’s Division of Healthcare Quality Promotion.
The transmission may have stemmed in part from a misguided sense of devotion to their jobs. More than half (55%) of the infected health care workers reported coming to work one or more days after developing flu-like symptoms.
“This paper serves as a reminder as to what we should be doing for infection control for influenza,” says Kuhar, who commented on the paper but is not one of the authors. “There need to be institutional strategies to prevent transmission of influenza. Showing up to work sick is not good for your coworkers and your patients.”
The study’s authors note that health care workers had “multiple exposure opportunities” to their ill co-workers. “For example, some [health care worker] cases reported traveling to a clinic together by car prior to illness onset. In addition, resident physicians attended daily morning reports and noon conferences,” the authors said.
Reference1. Magill SS, Black SR, Wise ME, et al. Investigation of an outbreak of 2009 pandemic influenza A virus (H1N1) infections among healthcare personnel in a Chicago hospital. infection control and Hospital Epidemiology 2011; 32:611-615.
–Michele MarrillSpecial update from our sister publication, Hospital Employee Health
[caption id="attachment_413" align="alignleft" width="150" caption="To Get A Flu Shot "][/caption]
I’m not going to start off by solemnly noting that the Centers for Disease Control and Prevention has had a standing recommendation to immunize health care workers against seasonal influenza for more than a quarter century. Well, there it is, a reiterated point with the dust freshly blown off.
Sorry, it’s just that I have to occasionally write it to believe it. Was there ever a public health recommendation -- as Hamlet might ask – “honored more in the breach than the observance” than this one? The relatively recent move by some hospitals to mandate the shots, does not exactly fall into the “rush to judgment” category.
After the CDC recently reported that health care worker immunization rate has now risen to a staggering 63% -- meaning more than a third of workers still could not be bothered to protect vulnerable patients from influenza – somebody at SHEA snapped. In a good way of course.
But the esteemed Society for Healthcare Epidemiology of America felt it necessary to reissue its 2010 paper calling for mandatory flu shots. All these guys do all day is think about bugs, so we ignore their advice at the patient’s peril.
The CDC also reported that rates in the 98% range are now common when flu vaccination is a condition of employment. What a novel concept, that you would have to be immunized against one of the most common and recurrent infections in history to care for that preemie baby or the soldier with no immune system to speak of because he is awaiting a bone marrow transplant. Is it unethical to be a health care provider and refuse a seasonal flu shot? Yes, it is. As someone once observed, you know it, I know it, and the American people know it.
“As healthcare providers, we are ethically obligated to take the necessary precautions to prevent the spread of viruses such as influenza and to keeping our patients, fellow workers and ourselves safe from acquiring the virus in healthcare settings,” said Steve Gordon, MD, president of SHEA. “The data from the CDC’s study demonstrates the effectiveness of policies that makes vaccination a requirement for employment.”
I’m not going to end by solemnly noting that the CDC has had a standing recommendation to immunize health care workers against seasonal influenza for more than a quarter century. Well, there it is…
[caption id="attachment_409" align="alignleft" width="150" caption="Grace Lee, MD"][/caption]
The Centers for Medicare and Medicaid Services controversial 2008 policy to cut reimbursement for certain health care associated infections (HAIs) has led to positive clincial consequences -- and some unintended ones.
Overall, the first research assessment of the impact of the CMS policy finds the glass more full than empty. For example, many infection preventionists report that catheters are being removed in a more timely manner since the CMS no longer pays for the additional costs of catheter-related urinary tract infections and other "preventable conditions" (catheter-related vascular infections, infectious complications of mediastinitis.)
This direct clinical consequence to a fiscal policy is very encouraging, but infection preventionists are also struggling with the unintended consequences of the CMS policy. As surveillance of such infections is subjected to analysis and parsing, many IPs find themselves in situations akin to a baseball umpire making an extremely close call.
“We heard this a lot in the qualitative work [that included interviewing IPs],” said Grace Lee, MD, MPH, associate medical director of infection control at Children's Hospital in Boston. “Some people said the pressure was really on the billing staff and the hospital as a whole to try and modify their coding practices to ‘game’ the best reimbursement possible. In other hospitals, I was actually surprised, the IPs were at the frontline trying to coordinate between the physicians and the coders and get this to all work out. Which actually is a huge `time sink’ when you think about it, taking you away from all of the other activities that you want to do.”
Lee and colleagues conducted a survey and accompanying research to assess the impact of the CMS policy on IPs and infectionprevention resources. Preliminary findings from the unpublished study were presented recently in Baltimore at the annual conference of the Association for Professionals in Infection Control and Epidemiology.
For more on this important story see the September issue of Hospital infection Control & prevention.
Amid recognition of all manner of excellent journalism, it is with both sincere gratitude and some surprise I report that our coverage of MRSA seemed to resonate strongly at the annual National Press Club Awards recently in Washington, DC.
“MRSA Patient Stories,” a two-part series in the Nov-Dec 2010 issues of Hospital Infection Control & Prevention, claimed top prize in the category of Best Analytical Reporting in Newsletter Journalism. While putting some pressure on the Centers for Disease Control and Prevention to adopt more aggressive measures against the pathogen, the report lent a human face to the annual toll of Methicillin-resistant Staphylococcus aureus (MRSA).
In conversations at the awards dinner, several audience members and fellow award winners recounted their own stories of health care associated infections (HAIs). It is all too clear that HAIs have touched so many lives and ended so many others. This was brought home in a rather surprising way, after I accepted the HIC award and returned to my seat beside my wife, Jenny Rose.
“My mother died of MRSA. Thank you very much for your work,” said Lara Logan, reporter for CBS News and 60 Minutes, looking out into the audience from the podium.
Having just received a standing ovation as much for her individual courage as her receipt of the NPC’s Freedom of the Press Award, Logan touched on her vicious assault in Cairo’s Tahrir Square while covering the Arab Spring uprising in Egypt. The outpouring of support from her colleagues in journalism helped her get through the traumatic aftermath, she said.
“It was like being a newborn baby – you feel that kind of vulnerable,” Logan said. “Everything my colleagues came out and said about what happened to me – personally, privately, publicly – was just like wrapping me in a blanket. I could start to rebuild and find that person that was lying in Tahrir Square somewhere. I am so grateful for that in so many ways.”
"Thus, though the plague had ended, we continued to live by its standards.”
Albert Camus, The Plague.
From time to time since the launch of this blog I have been asked about the presence in our HICprevent masthead of that strange, cloaked character wearing a beaked mask. As those familiar with the history of infectious diseases are no doubt aware, it is the iconic plague doctor: a foreboding figure last seen walking among the infected and dead, using his stick to touch and turn, when the Black Death ravaged Europe in the Middle Ages.
It is little wonder that this bizarrely garbed health care worker became more associated with the disease than a cure. As Yersinias pestis bacteria caused virtually untreatable infections that arose in discolored, swollen lymph nodes or “buboes,” it was a daunting task to attempt to help these fevered, frenzied masses. Various symptoms are described, including bleeding from the ears, but perhaps the most chilling clinical note is this: “The pain was usually caused by the decaying or decomposing of the skin while the person [was] still alive.” It is estimated that the epidemic killed some 75 million people, roughly half of the population of Europe at the time.
Thus, the image of the plague doctor is certainly an ominous reminder of our continuing vulnerability to emerging infections. However, there is something in this figure – one seemingly conjured from a Poeish masquerade – that also represents vigilance and courage in the face of an unknown infection. Here we see the rudiments of basic barrier precautions, with a robe coated or waxed for protection and even see-through glass eyes in the beaked mask, which contained aromatic herbs and plants to block out the putrid air and the smell of death. The thought was that this "miasmatic " air was contagious, though we know today that the vast majority of these cases were vector-borne via rats through fleas. This approach was closer to the mark then other interventions, which included bloodletting and other desperations.
Indeed, this prototype medical mask may have actually prevented a few infections. As some bubonic plague patients developed plague pneumonia -- aka pneumonic plague -- they could have transmitted disease by droplets and possibly through the air over a limited range. The pneumonic version of the disease is often cited as a much-feared bioterror weapon, which if effectively aerosolized would require mass antibiotic prophylaxis of exposed populations. May that day never come. But if it does there will be responders quickly in the field -- elaborately garbed and masked, determined to help -- wondering just exactly what they are dealing with.
The Centers for Disease Control and Prevention estimates that hospital workers suffer some 385,000 needlesticks and sharps-related injuries every year. In addition to costs incurred by the health care facility, the stress on the affected worker and the worker’s family can be enormous. Testing for bloodborne pathogen infections can last for months, fueling anxiety and distress for a prolonged period.
If your sharps injuries have reached a plateau and you are having a hard time making progress on needlestick prevention, it may be time for a “blitz.”
The National Institute for Occupational Safety and Health (NIOSH) has launched a new website called STOP STICKS to help health care facilities create an awareness campaign.
The concept is to create short, targeted campaigns, perhaps lasting a month or eight weeks with new messages every week or two, says Thomas Cunningham, PhD, a behavioral scientist with NIOSH’s Education and Information Division in Cincinnati.
“This is intended to saturate the environment with messages to raise awareness. Hopefully that impacts behavior,” he says.
An effective blitz would be tailored to one area, such as the emergency department or operating room, he says. “It tends to be more effective if it’s focused in a specific area rather than the entire facility all at once,” he says.
“The first major step in conducting a blitz is to understand your audience,” he says. For example, NIOSH provides pre-tests for the OR and other areas, as well as observation evaluation forms. The blitz can then be developed around weaknesses or misconceptions, he says. (See sample OR form inserted in this issue.)
Facilities also can create data displays just by plugging numbers into ready-made charts, available on the website. There are even sample articles for the hospital newsletter.
“The idea was to give the target audience some feedback about the actual conditions they’re working in, things that are much more relevant to their specific situation, and to communicate that risk,” says Cunningham. “Everything is very customizable.”
Yet if the medium is the message, the NIOSH site needed to alter its awareness, as well. The site launched with “stock” photos of a gloved hand and a needle – and it wasn’t safety engineered. The pictures of unsafe sharps were quickly removed.
–Michele MarrillSpecial update from our sister publication, Hospital Employee Health
A proposed National Quality Forum measure may standardize the way hospitals calculate their health care worker influenza immunization rates.
Currently, when hospitals report their influenza immunization rates, both the numerator and denominator may vary widely. Are they counting vaccinations among employees who have direct patient contact? Or all employees, regardless of where they work? Are they including people who worked only part of the year? Are they counting agency staff or contract workers?
The measure proposed by the Centers for Disease Control and Prevention now covers the vaccination status of three groups:
* Employees who worked at least 30 days during the flu season. Previously, the measure asked hospitals to include any employee who had worked for at least one day. “That [change] is going to miss a small proportion of health care personnel, but it’s going to provide something that is more feasible and something hospitals may feel is more fair,” says Megan C. Lindley, MPH, epidemiologist with CDC’s National Center for Immunization & Respiratory Diseases. “To try to capture somebody who is in there or one day or one part of one day is potentially extremely challenging, particularly for a very large institution where you have people coming in and out.”
* Licensed independent practitioners. The measure will count non-employee physicians, advanced practice nurses and physician assistants, but not all credentialed employees. Again, this will make it clearer and easier for hospitals and reduce variation, says Lindley. “We found that over 70% of the hospitals credentialed their physician assistants and advanced practice nurses, and 96% of them credential their physicians,” she says. By contrast, “Fewer than 20% credentialed therapists or technicians.” Counting independent practitioners who don’t require credentialing could present challenges for some hospitals, she says. “You could capture the bulk of the credentialed nonemployees by restricting it to those three defined groups,” she says. Nurses who are credentialed through an agency would not be counted, although the hospital could require the agency to provide nurses who have been vaccinated, she says.
* Non-employees. This group would be limited to students, trainees and volunteers. It would not include sales people or vendors, contract personnel, or construction workers. The previous definition of non-employees was vague and could have led to different interpretations, says Lindley.” It could potentially be very, very different from facility to facility, which is contrary to the point of having a standardized measure,” she says.
The numerators would be: health care personnel vaccinated at the institution and those vaccinated elsewhere, those with medical contraindications, and those who declined vaccination for non-medical reasons.
To win endorsement from the National Quality Forum, sponsors must provide data on the feasibility of implementation and the validity and reliability of the measure, Lindey says. “With these revised definitions, this provides an extremely standardized way of measuring,” she says.
Hospitals had expressed concerns, especially with measuring non-employee vaccinations, in online surveys that CDC conducted with 216 health care institutions, including 80 hospitals, in four states. About half of the hospitals said their ability to determine the vaccination status of those non-employees was a major barrier.
The revised measure represents a balance designed to make measurement easier but thorough, Lindley says. “It’s better to have an extremely accurate measure of 80% of personnel than it is to have an inaccurate measure that covers 100% of personnel,” she says.
One thing may not change with the definitions: The burden of collecting the information. “For hospitals, in every numerator category for the three groups, paper occupational health records were the most common data source by far,” she says.
In other words, most hospitals can’t obtain this vaccination information simply by querying a database. Still, she says, “we were heartened that 70% of hospitals only had one person working on this [data collection],” an indication that it didn’t require multiple personnel, she says.
Special update from our sister publication, Hospital Employee Health
Hospital Infection Control & Prevention has been the leading source for news and comment on health care epidemiology for 38 years. With the HICprevent blog site we extend our coverage and commentary on this dynamic field, opening a new dialogue with infection preventionists, health care epidemiologists and others seeking solutions to one of the most vexing problems in patient safety: health care associated infections. HICprevent welcomes your comments, questions, tips and strategies for infection prevention.