I'd like to introduce our speaker for today's session. Ms. Linda Green has extensive infection prevention experience in acute care, long-term care, and ambulatory surgery settings. She held leadership roles in her local APIC chapter before becoming a member of the APIC Board of Directors in 2010. Linda served as Secretary of the APIC Board in 2012-2013 and as APIC President in 2017. Ms. Green was also President of the Board for APIC Consulting Services in 2015 and she continues to serve APIC and the IPC profession as an advisor and contributor to APIC position papers and implementation guides. Linda was an APIC representative on the 2020 CDC Decennial Steering Committee and she is a frequent presenter at regional, national, and international conferences. In 2020, APIC awarded Linda with the prestigious Carol DeMille Award, which is given annually to an infection preventionist with visionary leadership and extraordinary contributions to the profession. We thank you so much, Linda, for being here with us this morning. We invite you to go ahead and kick us off with part one. Thank you so much, Lindsay. Let me tell you, it is my pleasure to be here. I know that a number of you might be fairly new to the infection prevention role and some of you may be just tuning in because there's portions that you want to catch up on or you need some education. But with that, a number of my comments are going to be directed at the fairly new infection preventionists. And I think we have worked together for a total of four hours to today and to tomorrow. So it's not a long period of time, but I think we want to take a high-level overview of some of the most important things that we deal with. And clearly, you all know, no matter what your experience, is that we can't cover everything in four hours. But what I wanted to do is today to talk about the infection prevention role in general. So what is it we as infection preventionists do, important things starting with the basics, and then the second portion tomorrow, we'll focus on the environment of care. And I think that's really, really important because we know that that is really important. So let me start out. I already gave an overview, but one of the things about infection prevention myself is that I was foul and told. It wasn't something I was doing on nursing supervision and nursing quality. And one day, they came to me because the infection prevention person had left, and this is over 30 years ago, and said, well, you're going to be the infection preventionist. And that was really a difficult struggle because it wasn't really what I was interested in at the time. I love the quality department and the quality initiatives and things like that, but I came to love it. And one of the things I will tell you, for those of you who may have been violent told, or maybe brand new and don't have a good microbiology background or don't have backgrounds in some of these areas, we learn as we go on, and I think it's so important. So over that period of time, I can't think of a better profession, and I think it merges very well with quality. So those two things are really, really important. The other thing I think is important before I start is in terms of your background, when I started, we were largely nurses, and I love being a nurse. It is something important to me, but what we have learned, and I think this is important when we talk about the risk assessment, we've also learned that no one of us can do it alone. And now we have people from multiple backgrounds, from laboratory, from all kinds of backgrounds like that, master's in public health, many of those types of roles. And we find that we are richer because of the diversity and the ability to work together. So with that, just kind of a background in terms of that, and I will talk about the objectives. So we're going to start with the basic elements of an infection prevention program. Now I know for many of you who are new, and I think this happens all the time, it's like, oh, I want to get into outbreaks, you know, I want to learn about all these things. But if we don't have a good structure, if we don't have good basics, we can never, never do what we need to do. I'm going to start out with the risk assessment. And there are various types of risk assessment. Now this is not the most glamorous role, the most glamorous thing in infection prevention, but it's very important. It's very basic, and it's important that we all understand it and use the risk assessment. So I'm going to talk about how to conduct one. And I'm also going to talk about how this risk assessment is the basis for your infection prevention plan and how it drives it. I'm also going to talk about different types of risk assessments, because you'll hear the word used very widely, and yet, you know, it's kind of like, well, conduct a risk assessment. Well, is it my annual? What does it mean? And so we'll go through some of that. It's important, and I love the circle, because it is a continuous process. It does not stand alone. So it starts with your annual evaluation. So what did you do last year? What was important? How were my outcomes? What's been added? Are there new services? Those types of things. So it's all my annual evaluation. And then from the data I've collected for my annual evaluation, I'm going to start my risk assessment, and we'll talk about that and what's important. And then I am going to update or change or redo my program. So we have to realize that this process is not stagnant, but it's an ongoing process where we look at things that are going on, and we understand what needs to happen forward. So in my annual reappraisal, I want to look at my HAI data. First of all, you know, how did I do? Did I meet my goals? Did I meet the expectations of my plan? How about multidrug-resistant organisms? And I will tell you that is a hot topic right now. How about outbreaks? Did I have any outbreaks last year? Were they important? Were those things that I need to look at? How about new and unusual pathogens? What do I have? Any of the emerging pathogens? How about the ICAR risk assessments? Have any of those been done? Those are things that might also be important. So that annual reappraisal is really important. I want to look at all the data from the previous year. So from there, and this is just kind of an example of a risk assessment that starts out with the demographics, looking at the program directly, observing practices, looking at guidelines and resources that come out, perhaps even doing a gap assessment, and we'll talk about that. Now, here, for example, is a program evaluation. And it is important because oftentimes you'll say, well, you know, we've got the risks. The risks are the same. Why are we going through all this? Well, I think it's very, very important because if you look at this particular graph in this hospital, you can see that they had a target of 0.8. Now, I'm not going to get into NHSN. That's a whole different topic. But most of you, if you started infection prevention and you're in a hospital situation, I know some of you aren't. But you still have to take stock of what's happened. And you can see by this that this is an example of a hospital's CLABSI standardized infection ratio by quarter. And you can see that this has gone up extensively in 2022. As a matter of fact, when they set their goal, they said that the SIR would be below one. But the SIR is 2.034, which is statistically higher and representing 23 cases and the 91st percentile nationally. Now, with infection prevention, if you're brand new, you'll know that high numbers are not good. Low numbers are good. But 91%, that meant that 9% of the hospitals were higher. So what happened? And part of you all know what happened in this particular situation. And a lot of it is due to COVID. Quite honestly, the numbers didn't start to spike until fiscal year 22, when I think that many of the processes and practices kind of got diluted over time. So you can see that this changes. So why am I going to do a risk assessment? Well, I've given you one example with COVID. And I have to tell you, in my experience, that CLABSI rates for us in the hospital really went up. So we know that risk is inherent in the delivery of health care. In other words, you can't have health care without having some degree of risk. And I think if we look back, and we take a look back even in our personal lives, everything we do sometimes has a risk. But in infection prevention, this risk assessment assists us in focusing surveillance and other program activities. So that is really, really important. We want to begin to focus. We want to be able to look at some of these other program activities. Those things are so important. And because of the evolving nature of health care, risks must be assessed annually. So now we're talking about our annual risk assessment. I want you to keep the word annual in mind, because we'll go on to other types of risk assessment. We have to do it a minimum of annually. That does not mean that if something new comes up, that we don't do it at the time. I'll give you an example. In my experience, we had done our risk assessment after the first quarter. This is just one example. We realized, and just to give you some background, my last hospital was a mid-sized hospital associated with a university setting. I was director of infection prevention. And I still work there per diem to keep my fingers in it. But now I have kind of semi-retired. And I'm doing a lot of teaching and consulting and going into hospitals and doing assessments and working for Epic Consulting as well. So that's my new job. But I still work there. And one of the things we found was that because of the evolving nature and all of the pressure at the university setting, they were redoing the cancer unit. And having one unit at the smaller hospital have patients who were being treated, certainly not acute, like bone marrow and things like that. Well, that necessitated the fact that we do a risk assessment. We're getting a new service. And it's pretty early in the year. What does this mean? And what are we going to do? So oftentimes, we will do that risk assessment realizing that it is evolving. So as I said earlier, we have that risk assessment, which is annual. And you have to realize that if you are an accredited organization, either by joint commission or DNV, which are two accrediting agencies, you really need to look at the annual risk assessment. It is in the joint commission guidelines, the new ones again, as I know. The targeted risk assessment means that when I have new procedures, new equipment, new guidelines, or some problem-oriented thing, I am going to target that. And I'm going to take perhaps what I call a deep dive. And that targeted risk assessment is so very important. And I'll give you a couple examples as we move along. So I want to realize, though, for all of us, that one of the things that happens in infection prevention is you will have days when you're exhausted, when you're working hard, you realize nothing is improving, and you want to give up. But I think it's really important that we step back and we realize what the mission is and what the vision is. So our mission is, in this particular hospital, to reduce health care infections by improving infection prevention practices across our continuum of health care. That was the infection prevention mission. And then the vision, and that's kind of where would we want to be, a safer world without infection? So we know that. So again, why bother? Well, infection preventionists assess risk day in and day out. But we want to make sure that as we assess these risks and we set our goals, it should be purposeful and it should be systematic. It's not just something that happens, but it's a systematic process. We also want to look at our risk assessment category. So how about the geographic location? Well, we know there are natural disasters and things like that. So depending on your state, many of those types of things. I am in New York State, and I don't really think, for the most part, about hurricanes and tornadoes, but we do think about snowstorms. We do think about flooding. So it's also part of our pandemic planning. How about my community? This is really important. So are there community outbreaks? You might be in a population where TB is endemic. What's my incidence of TB? Do I have a migratory population? So it's always important in your community to think about that. I remember in my early days of nursing, I worked on a pediatric unit, and we were part of an Amish population. I still remember not that I was doing infection prevention, but just kind of thinking about risk in general. We would get many Amish children who came in because of various reasons, maybe a ruptured appendix, maybe a fall, maybe all kinds of things. And we knew that they did not get vaccinations. And when we think about measles and varicella and things like that, so we would make sure that those children got private rooms and we would take precautions. So we're always doing a risk assessment. How about our organizational programs? Do we have cardiac? Do we have rehab? How about our equipment and supplies? Do we have scopes? Do we do surgery? Are there any new devices? How about environmental issues, construction? And I'll talk for a few moments about that. And then the employee things, needlesticks, TST conversions. So the components of a risk assessment then depend on the population served. And we need to identify the demographics of that population. Now, if you're a small community hospital, you may have a variety. Maybe you're at a cancer center. Maybe you're at a large urban university hospital. And we need to think of things like age, immune status, race and ethnicity, and special non-immunized populations, like I gave you an example of the Amish population. And we have to think of those things now clearly and intuitively. We also know that people on chemotherapy and many of those types of things certainly are immunosuppressed. But when I think of immune status, some of the things we need to think about is a number of diseases. The treatment relies on biologicals or types of medications, which may also suppress the immune system, whether it be high-dose prednisone or someone with rheumatoid arthritis being on some of those drugs. So we need to think about those things when we think about our populations that are at risk. And then we want to identify the care, treatment, and services. So it's based on risk. And, for example, if I have a long-term care facility as a ventilator or a rehab facility, how about inpatient and outpatient, cancer care, as I mentioned earlier, medical and surgical, and any special services I provide? So how about surgical procedures? High risk, high volume, problem-prone? Are there procedures that are going on? And one of the hot spots certainly is endoscopy. And we know there's been a lot that has come up in that area as well. And how about things like interventional radiology? What's going on there? So again, some of the outpatient or diagnostic areas. So we don't want to forget about the fact that there is a huge emphasis now on outpatient and diagnostic areas. And a lot of things are done in those areas. Bronchoscopy, for example. Lobotomy services. Do you do in-house dialysis? Another high-risk area, particularly for bloodstream infections. How about our emergency department? You know, what do we do? Are we a trauma center? Do they intubate patients, put in central lines? Radiation, oncology, all of those types of things. So it is important that we look at those. So in terms of your own checklist, you look at what ages do you see? What services do I provide? Do I have a varied population? And what procedures and treatments do I perform? How about things like endoscopy and vaginal ultrasound, minor suturing? And this is important. And we'll talk more about this. But I think it's extremely important. This sterilization and high-level disinfection. And that's a hot spot for surveyors. So demographics of the population. This might be, and that is in a particular plan. And this is one hospital that had inpatient care units. They highlighted the demographics of the population. And the population's at increased risk. And so I know it gets a little fuzzy here to look at. But it will give you an example of some of the demographics that we see. And then location, location, location. Whether it be endemic TB. Right now, I'm looking at Chicago. I'm looking at Illinois. And I was just on a call on Monday where one of the epidemiologists from Chicago is looking at high incidence of candida auris. So we need to think about those things in our own states, in our own geographical region. Because it may not now knock on wood. We do not see that in Western New York yet. I know one of our hospitals had one case of candida auris. They quickly contained it. And we've not seen others. Where for many of you, you may be seeing that. So defining the risk. For example, and I use tuberculosis. Maybe I'm a small rural hospital in Montana. And I haven't seen any cases in the past two years. Do I have a risk there? Perhaps not. And then the other things we think about when we think about a risk assessment is the threat to life or health. So when we do a risk assessment, we're going to say, if we think CLABSIs, for example, what's the threat to life or health? And we'll talk about that in a moment. What about disruption of services? Talked about hurricanes, talked about tornadoes, talked about snowstorms. What about loss of function? The other thing we have to realize, particularly with our HAI data, is there a loss of community trust. That's really important and particularly important for the C-suite. You know, if I have an increase of infections or I have an outbreak, particularly in areas where there's more than one hospital and more than one choice, how about the financial impact? And that is extremely important to your CFO and your CEO, as well as to ourselves, because we want to be good stewards of our organization. How about our legal issues? One of the things that I will tell you that I do, I love my job now. It's kind of funny because I loved being a director and I loved being full-time in acute care, but now I consult in long-term care and do a number of other things. But I'm also working with some legal issues around failure to follow high-level disinfection processes. And I can tell you that these are significant. Certainly not in a state, not in my state, not in most of your states, but it is an issue. And this is a big, big case. So there are many things that are important. And then regulatory impact and standards requirements. So under probability, you need to consider where the risk is known. Is there any historical data? And that we'll look at our annual evaluation. The other thing I want us to think about, and particularly those of you who are new to infection prevention, are there reports in the literature? Maybe I have some type of clinic where there is some recall. Maybe I have something that is really important. I haven't seen it yet, but what are the probability and what can we do about that? So you want to include observations and rounding information. Now, one of the things you are going to hear from me over the next two days is rounding and observations. I've been an infection preventionist for a long time. We have a great surveillance system at our hospital. We don't do remote surveillance, but we certainly have software that allows us to look at the chart and come up with things and not necessarily having to go to the unit for CLEBSI-CAUTI C. diff data. That does not mean, however, that we don't assess risk. And over my many years of infection prevention, and I know even some of you may work remote, which is great, but at some point we have to go to GEMBA. We have to see what's going on. We need to talk to the employees and we need to make sure that the policies and procedures that we have carefully put in place have been followed. So in terms of this picture, this is a real picture. I took it at a hospital a number of years ago. So again, I won't identify the hospital, but one of the things that they got patients in the emergency department, and oftentimes they would have to do vaginal ultrasounds. And any of you who have been involved with vag ultrasounds know the probes are expensive and they have to minimally be high-level disinfected. And we'll talk about that tomorrow, but that is minimum. And at that time they were doing chemical high-level disinfection and the emergency department decided that they could not, would not send their probes to a central place. They needed the turnover, they needed it quickly, and they were going to high-level disinfect these probes in their dirty utility room. So they competency people, they went through the competencies and the infection prevention team, including myself did not believe that this was a good use of resources internally and that the area that they had identified was really the best area to do a high-level disinfection. So one day about lunchtime, right after lunch, myself and colleagues took a visit to the emergency department. And this is what we saw. So needless to say, and I think it's important with pictures sometimes that you don't identify them, that they don't get everywhere. So you don't put it on your intranet, but you do want to share maybe the picture with the director of emergency services and who's ever making decisions. In that case, our COO was very involved. And I said, here's what's going on. Well, needless to say, they found another place to high-level disinfect them, which was radiology, which was very close by. They had a hard process. All they had to do was walk over there, use theirs and all was solved because it wasn't at that time eventful to use sterile processing. So what happens when you make these rounds? They're part of your risk assessment, knowing what's going on. So when we do our risk assessment, now we are going to assign three values. We're going to assign the probability that it will occur. We're going to talk about if it does occur, the impact or the severity, and mostly important, do we have current systems in place to mitigate the risk? Now, one of the things when you do your risk assessment that I think is really important is there aren't any right or wrong answers. You can't say I'm part of a system and we're going to do the system risk assessment because quite frankly, what you do in your little hospital as part of the system may be very different. So this really is something that has to be very unique to a organization. You need to allow for discussion and you need to promote consensus. It is one of the things that should be an interdisciplinary, multidisciplinary thing. We need to bring people to the table so that they can help with their risk. Now, you're going to get your score from either multiplying or adding the three component numbers. And most of the time it will be a mathematical average. I think the group consensus comes in in whether or not systems are in place. And I think that is very important and very, very important. So, in terms of prioritization, you want to rank order the risk using scores. So each organization's priorities will be different. And it is important to realize that and begin to prioritize. Now, there are two types of risk assessment. Most people use a quantitative risk assessment, but in very, very small hospitals where you have very little data, and, you know, I was consulting with hospitals and they just don't have enough data to get a yearly serve on, you know, CAUTIs and CLABSIs and many of those things. So sometimes in some of those areas or if you're a critical access hospital, you may need some qualitative data. So, use a numeric scoring system based on the probability of an event. And it involves measuring. So, let's look at an example of a quantitative risk assessment. So, I gave you the example of the CLABSI after COVID. So the probability that it would occur in this particular hospital was three. The severity, because we know that bloodstream infections can have disastrous effects. Some people would say, well, maybe it's a two, but we agreed that it was a three. People can, certainly with a scaphoreus bacteremia, they can get endocarditis and things like that, but lack of preparedness or compliance. And this is where things changed because even though those threes were important during COVID, that lack of preparedness, there were very good policies in place, but oftentimes that lack of preparedness because it was a lack of compliance. Many of you have seen, I don't have to tell you how people had their IVACs outside the room and they were stringing, tubing and things to the floor and things like that. So, it makes sense that that would go up. The other thing about the preparedness or compliance that I think is vitally important is that sometimes you as an infection preventionist say, we got a great policy, we revised the policy, we educated people, everything's good. And you'll hear someone from the frontline say, hey, you think it's good, you should see how they cut corners. Well, that's not a good thing, but it gives us some perspective on what's really going on. Same with CAUTIs and here is a VAE. So, now you could add those numbers or you could multiply them. So, if I take three times three is nine, times three is 27. If I add them, three and three is six plus three is nine. And for VAE, six and two is eight. So, the reason why I recommend the multiplying is that it helps us distinguish. Because oftentimes your numbers will be very, very close together. That's why I recommend multiplying, but either is right. Now, some organizations take a qualitative approach. They assess risk using written descriptions. For example, they might use what we call a gap or a SWOT analysis. Now, I use the gap analysis and I have used the gap or SWOT analysis when I do a targeted risk assessment. So, not the annual one, but certain times whether you have outbreaks or new guidance policies, a gap analysis is great. But in a small hospital, you might talk about a gap analysis. So, I said, it can be two years and you don't even have a volume to do a standardized infection ratio, but you can do a gap analysis and look at your policies and procedures and see if indeed they are consistent with what best practices are. The SWOT analysis is a little different. I have seen SWOT analysis used oftentimes when particularly when you're looking at new services or things like that, where there are the strengths with this, where are opportunities, what are our weaknesses or threats? And those are often used in high-level discussions as well. So, but here's a sample gap analysis. You can look at hand hygiene. My compliance was 45%. I wanted to be 90. But what did we do? Well, we found some gaps. The gaps were primarily before going into the room, not afterwards. So, here is my action plan. I'm gonna make a leadership priority. I'm gonna evaluate the location of where my alcohol gels are. In terms of needle sticks, this is another example. Incidence has increased by 2% from 2009. I'm sorry, that should have been 2019, but you can get what I'm talking about. And in terms of CLABSIs. So, all of that is really important. So, again, here is an alternate tool. You can look at geographic locations. Many of those types of things are also important. Now, in terms of diseases and conditions in the community, you know, what's our extent of TB? I also like to look at Legionella. Now, Legionella is usually sporadic, you know, particularly in the hot months. But I think it's important to look at, particularly if you see cases in your hospital that may be community acquired. What are we doing? What are we looking at? Meningitis. Community acquired MRSA. Hep A. And things like pertussis. One of the things that I want to point out right now, and there's been a lot of discussions. I know I am on a committee with certain people from health departments, persons from CDC, representatives from APIC and SHEA. And, you know, one of the things that is vitally important is that we work with local or county health departments. And there's a lot of discussion about organizations sometimes being hesitant to report. So, it is important that you work with them and that you also understand what your local prevalence is. Now, surveillance data must be part of the risk assessment. And we know that. So again, what are my C difference? How about MRSA incidents? How about MDROs? Surgical site infections. CLABSIs and CAUTIs. And all of those things become very, very, very important as we move along. So, that's important. And new procedures or devices. And all of those types of things. I just saw a comment about the slides being available. And I think Lindsay will address that afterwards. So. Yes, absolutely. Yes, they are. Thank you so much. The slides will be available. So, don't worry about it. As a matter of fact, yes, I know they're available because she is putting them in PDF and making them on there. So, I should apologize. I knew that myself. No, you're good. They're in the chat now. So, if anybody would like them as a resource and didn't get them in advance, they're right there in the chat now. Great. Thanks, Lindsay. That's really helpful. So, steps for performing a risk assessment. And that's great. So, if you want to look at the slides while I'm talking, that's great. So, creating a risk assessment. Key staff. That's important. Environmental services. And I'm gonna talk about that tomorrow. They have become incredibly, incredibly important nowadays. I can't even begin to tell you how important they are. How about pharmacy? How about lab and nursing? And administrative and clinical leaders? And then just some people that may be opinion leaders. And by opinion leaders, you might want to put a nurse from a particular unit or something. And you want to create your timeline. You know, it may take you up to two months to review your risk assessment. Review it annually is important. And you want to beforehand gather your data. So, sometimes it's really hard to do if you're using calendar year. You might not have all your data right away. So, what is your date gonna be? How about my infection rate and trends? How about any sentinel events? How, you know, we know during COVID that many people weren't, you know, calculating their data in the early days. How about community data and trends? And literature from new trends? And I always look to areas like the World Health Organization. CDC has so much information. And APIC, and APIC has certainly been so important to me. So, steps for performing a risk assessment. Develop a systematic method. So, turn your qualitative data into quantitative when available. It's really important that we try to have quantitative data. Select your template. Decide how you're going to rank it. Convene a multidisciplinary team to determine your priorities. And perform the risk assessment by providing data, completing the template, and reaching consensus. And then use your priorities to develop your program goals. So, you want to develop a goal for each selected priority. And then create an action plan. And then one of the things that's also important is disseminating the information. Share it with stakeholders and acknowledge those that have participated. Now, remember, you want to include both your actual and potential risks. Clearly identify priority ranking. If it's numerical, identify how you calculate those points. And if you have to use qualitative data, you might want to say high, medium, or low. And also include data from rounds and observations. And identify potential risks. Now, these are some, there are a number of new literature as well, but antibiotic-resistant threats, national action plan, many of those types of things. And here is an example. And I think this is very, very helpful with infection control rounds. How about how it's, is the manual there? Well, now most are electronic. So, can people access? Or is your infection prevention policies part of it? Do you just have a subject? So, no longer is it maybe a manual, but there are subject areas of infection prevention. How about personal protective equipment? Always when you're making rounds, see that the personal protective equipment is available. I know if any of you are in long-term care, this is a high priority, particularly with CMS and things like that. How about hand gel? Where's the hand gel located? How about the medication room? One of the things that I want us to think about, if there's not a medication room, there's a medication area, don't have it too close to sinks because splashing may occur. And this is a huge risk. It hasn't even been linked to some outbreaks. So, if you can't do a total renovation, you're gonna have to have splash guards or something like that. So, think about those things. How about needle boxes? And then the refrigerators. No, dear. You know, many of those types of things. Now, what's important is oftentimes now in vaccine refrigerators, we have automated checks and many things like that, but just make sure that people are doing that. So, the questions you want to keep in mind is how prepared are we to respond if the event occurs? How is our target population affected? And what is the expected frequency of the occurrence? So, I'm going to give you an example. Now, again, I just gave you one example and I talked about the CLABSI, but here's an example of how you might do that infection risk assessment. And again, there's no one best ways. There are a number, there's just a number of forms and things, but this is one example. So here you've got the explanation of a risk. We're going to give a high risk of three, a moderate risk of two, a low risk one or zero for none. And then the severity might be life-threatening, major impact, moderate harm or minimal impact. And then under preparedness, a three would get a poor, a two would get a fair and a one is a good. So now we know we can't go any higher than 27. And here you have the example that I gave you about a CLABSI. What's the impact on patient safety? COVID and sepsis, impact on financial reimbursement. So this was one right after COVID. I used the 2022. Things were easing up, but obviously the organization had not got back to following the policies and procedures. And one of the things that this risk assessment said that a lot of these CLABSIs were in the ICU where they wanted to target those. So all of those types of things, and you could see that they put in a number of interventions here. So again, what's the probability and what have we done to decrease the risk? Well, now I'm onto my plan and what's my vision and mission. And this risk assessment is going to drive my plan. And here's an example. Again, many of your plans, you should have a plan, even if you're new, take a look at it. This one is a little longer. It starts out with the mission and vision, scope of services and demographics are important, what the surveillance activities are, and then the risk assessment annual reappraisal was attached to it. So here is an example of the mission statement to prevent healthcare associated infection. Goals are consistent with the values. And there are things like this, because this particular organization looked at quality and safety. They looked at patient and family-centered care. They looked at finance, growth and infrastructure and system integration. So all of those things might be part of it. Another example of a vision statement is the hospital will be a leader in its quest to provide healthcare without infection. Now, here is another example of a way you could do your plans. Your strategies are environmental rounds. Your plan is to participate in those. Sterilizer testing, that is really important. I'm going to look at that. It's done in accordance with AORN or AIME or CDC. Those types of things. So all of those are important as well. And regulatory and accrediting agencies. Now, there is a new one, but you can look at this, and it's important. Very, very important. We're not going to focus on this in these sessions, but keep your regulatory and accrediting issues in your plan. Value-based purchasing, data, and don't forget about hand hygiene. This is really important, first of all, that you can pull your data, you look at what's coming down, that you communicate. All of those things are important. So when you write your plan, develop your outline, identify local, state, and federal requirements, base it on your risk assessment, prioritize your goals, have your measurable objectives, and outline what strategy you're going to have to meet the goals, and then establish mechanisms to measure success. So one of the things that I would also recommend is consider setting up a system to be alerted about new services. Always set up a system with whomever. So if you know someone, it isn't done purposely, but oftentimes an organization and their strategic planning or moving forward will bring something in new, or maybe it's in surgery, that you did not even know about. Well, I'll just give you an example. For example, so we had done robotic surgery for years, and it was very, you know, very effective in terms of prostate surgery. Previously, where patients had to get blood and stay for days, it became an ambulatory procedure. That was all well and good, and I'm going back about 10 years, but I want to make this example to you. So anyways, GYN thought, wow, you know, we want to bring in the robot for GYN surgery. Now, mind you, the prostate surgery was done in the main OR, those types of things, done very well, lots of space. So all of a sudden, we started getting post-op hysterectomy infections, and it was really confusing to us what was going on. And someone said, well, did you know that they put the robot up in the L&D room so they could do it, because they often did hysterectomies up there. So we went up to watch. Now talk about going in and seeing what was going on. Well, the space was not sufficient, and when I looked at what was going on, because any of you who've seen robotic surgery know they're big, and they take up a lot of room. Well, you could not hardly move without contaminating the sterile field. So make sure that you know about that. In terms of the infrastructure, you know, what invasive medical devices are you using? How about healthcare screening and immunization? Antibiotic stewardship. We're not focusing on this in this particular session, but it is important. We've done a lot of work. I know historically, we've done a course for nurses on antimicrobial stewardship, really important. And then tomorrow, we'll talk about sterilization and disinfection. How do we educate families? What about the environment of care? How about standard and transmission-based precautions? How about surgical and special procedures? And then targeted risk assessment. Targeting something that's going on. Maybe I had an outbreak of disease somewhere. Maybe I started seeing an increase in SSIs. Maybe I had an outbreak. Now I want to go and target it. So here's a risk assessment. Let's look here at endoscopy. Maybe I saw a number of patients all of a sudden with C. diff after endoscopy. This is really strange. And so, you know, one of the docs reported it to the manager, so to speak. So here's a gap analysis tool that I would use for a targeted risk assessment. And it really is important. So is pre-cleaning done? And I'll talk a little bit about that tomorrow. So at point of use, leak testing. How about the manual cleaning? How about visual inspection? How about the scope disinfection? So this is important as we look at when things come up. Now we do a targeted risk assessment. So this is just one little tool you can use. What I have seen surveyors do is they take the manufacturer's instructions for use. We'll talk about that tomorrow. What it says, they have it up in front of them, and they ask someone to go through it. Now, the other risk assessment tool that I'll talk about very briefly is the construction risk assessment. So we've talked about the annual one. We've talked about the targeted one. And now the construction one. So the infection preventionist identifies or confirms a risk group associated with the project. They identify the degree of risk. And they might have to be one of the signers. So again, we're not going to get into this in great detail, but you do need to know about the construction risk assessment. You want to know what type of construction activity is going on. And you've got them labeled here, type A, B, C, and D. And that helps you understand what the risk is. And then one thing I just wanted to mention, and I know not all facilities are doing this, but the ICRA 2.0. And what it did is it took the original risk assessment, and it added some things that are very, very helpful. For example, we talked about step one, A, B, C, and D. And these are in your handouts, what type of project is going on. And then you looked at the patient risk. Now, prior to ICRA 2.0, and even if you use the original one, as long as you're doing a risk assessment. But the thing I like about the ICRA 2.0 is it takes some of the categories and distinguishes between high risk and highest risk. And I think that is very, very, very important. And those types of things. And then the class of precautions. For example, whether you have a low risk group, whether you have a medium risk group, and you take the risk, and then you see what the project is, what type of project you have, and you can identify what types of interventions you need to take. And then in the last step, you talk about the surrounding area. Now, prior to that, we didn't have that as official, but this is really important because we have seen outbreaks related to surrounding areas or areas above or below. And so you can, you have all these on your handouts that you could see. So bottom line is, we've got this construction risk assessment. Someone thought, wondered if they're available. Certainly they can be obtained. You can see most of this right on that. I'll try to get you all of those types of things. But the important thing, and I think it's really, really important, is that we go through this and realize that what we do is really very logical. It is a logical process. We do that because we need to have that data to help us understand. So when I think of rounding, I actually oftentimes think of targeted risk assessment. So make sure you do that. So in terms of my final thoughts, and we'll take a five-minute break after this, is that the risk assessment and the plan really should be a living document, and it should be updated as needed and should be used as a reference. So I'm going to stop sharing on this one and see if there's any questions in the Q&A that Lindsay may have before we take our break. Perfect. Thank you so much, Linda. I'm going to scroll up here in the chat. I don't see anything in the Q&A. So for those of you who may have missed the initial introduction, just note that as we begin part two, if you have any questions for Linda, you can type your questions into that Q&A option found at the bottom of your Zoom window. Or if you don't see that option for any reason, you can, of course, utilize the chat and type in your questions as well. And I do see a couple here in the chat. Let's see. Okay. So appreciate you reviewing programs and sharing your experiences for a new infection preventionist in a small 49-bed hospital. How much time should be spent on rounds and observations for the units and OR? Would you say one day a week or one unit a day, four hours a week, four hours a month? And what would be the best way to share the findings to partner with managers rather than call attention to failures? Wow, that's a wonderful question. I can't really tell you the time. I think that's what you're finding. What I would do is look at my schedule. For example, how best might I do my routine rounds? And maybe what I've seen, I know in my hospital, different infection preventionists are assigned and they'll decide. So if you're in a small hospital, maybe two hours a week or three hours a week. And decide on a day if you can, but if not, and sometimes there's emergencies, you're not always going to be able to do it. The other thing about your rounds is you will find the hot spots where maybe I need to go back more frequently and other areas that are really fairly pristine, but you still have to keep an eye on those. So I can't give you exact numbers, but doing the rounds is important and extremely important is when you have things come up, when you have a sentinel event or even incidents or things, be able to go to that area. From my risk assessment, I identify my high priority areas and I'd be very certain that I visit those more frequently because those are the areas that are important. So if you're doing endoscopy, if you're doing high level disinfection, it's really important to go to those areas. And we'll talk more about that in the next sessions as well, but thanks. That's a wonderful question. Absolutely. Thank you so much. And then let's see, there's just a comment here that says, just my two cents and my personal experience, it's a balance of rounding with other duties and responsibilities. The benefits of frequent rounding are greater opportunity to develop relationships with the unit staff, identify opportunities for improvement, great opportunity for staff to ask questions, opportunity to provide real-time education. Yeah, and thank you. And she did ask that question and I forgot to answer that part. Immediate feedback, feedback in the moment. And the other thing that I will say is, and I think this is so very, very important. When you give immediate feedback, now your nurse manager or whoever may want to aggregate data, but giving feedback. And one of the examples I have is you didn't see someone practice hand hygiene. Instead of saying, hey, say, you know what, Lindsay, I see that you didn't perform hand hygiene before you went in the room and I didn't catch you, but you know what, I just want to give you feedback because I sure would want someone to remind me. So you do it in a way that's coaching and learning the skills about being able to talk to people is a skill that you need in infection prevention, but it is so vitally important. And you are a leader and people will look to you. So the way you communicate, the way you address people. So for the person who answered that question as well, thank you so much. Okay. We're going to take a quick minute break. I promise I won't go over, but the next section probably won't be quite as long. So I got 1104. If we come back at 1109, I just like people to just stand up, get a drink and we will be back. Perfect. Sounds great. So we will just pause for just a moment. If you have any questions for Linda in the meantime, go ahead and be typing those in, but then we'll come back in just a few moments. We'll take just a quick break. If you have your other slides on it, we can have those. Yep. I just waiting for you to stop. Yep. You should be able to share sharing. Oh, I thought you were sharing. Oops, that's the wrong one. Let me get my next one. Good. Good. You see those? They look like they're not showing up, Lindsay. Not yet. All right. I'll try sharing again. I've got them, but somehow they didn't share. I thought they worked. Hmm. I don't know why. But then we just need to go back to your Zoom window and hit that share screen again. For some reason. Let me see here. Okay. There we go. That should go. Good. I just got to get it from the beginning. There we go. Thank you so much. Perfect. Okay. We'll just take a quick break and be back in just a few moments. All righty. Thank you so much. Were there any more chats that I need to address before we start? I don't see any at this time, so I think we should be in good shape. Okay. Well, great. Thank you again, Lindsay, and thanks for your help here. The one thing I wanted to mention to everyone, too, is hopefully you'll join in tomorrow. Tomorrow, our second session, we'll talk more about engaging stakeholders. So a lot of what we talked about, particularly with environmental services personnel. So all of you brought up some great questions and great ideas, and we'll be talking about that more tomorrow as well. So I just wanted to, because we could certainly talk a lot about all of that. So I'm going to talk about now the infection prevention role in terms of best practices, and I'm going to talk about some of these things. I'll go through them quickly, but I just want to make sure that we are all on the same page and understand that we do have a role. So I'll talk about CAUTI and CLABSI. I'll discuss some of the recent literature regarding best practices, and I'll talk a little bit more about rounding strategies, all of which are very, very important. So in terms of surveillance, as I said earlier, I'm not going to talk about NHSN, but what I will talk about is the fact that we talked about prioritizing our population at the greatest risk and looking at those types of things. Now, one of the things about surveillance that is extremely important is understanding process and outcome measures, and I think we do understand that. So an outcome measure would be healthcare-acquired infection. We know that. And a process measure, though, is patient care practices aimed at preventing HAIs. So two different things. I see oftentimes people will ask questions about that, and it is important that we look at that. So the process measures have standard definitions, and by process, I mean the process to be measured and the methodology for collection. Now, we just talked about rounding, which is very important, but there's a number of other process measures. For example, are patients given the right antibiotic prior to surgery, the recommended one? Is the antibiotic discontinued per guidelines within that first 24 hours? Actually, the recommendations say no prophylactic post-op doses. So when we develop our process measures, we want to identify the methodology for collection. And some things are pretty easily understandable with antibiotics that we're going to look at the MAR or the whatever documentation they use in the OR, but other things are a little more difficult. For example, how are we going to look at hand hygiene? And we'll talk about that as we move on. In terms of outcome measures, utilize standard definitions that are generally accepted and published like the NHSN definitions, but there might be other outcomes of care. So it's very, very important. I understand that a new CMS measure, I don't know if any of you are responsible or in long-term care, but a new CMS measure is going to be hospitalized residents for an infection that was related to long-term care. So in other words, an infection associated event linked to long-term care for which the patient had to be hospitalized. So lots of outcome measures we do see that regulatory and accrediting agencies, although they'll look at their outcome, they're really looking at your process measures. So in terms of standardized criteria, we need to look at what are we going to look at? How are we going to monitor it over time? And we want to be able when possible, although sometimes difficult with process measures, but certainly good with outcome measures is to compare rates between groups. Now, select appropriate denominator data. So for outcome measures, I want to know my denominator. So this is important if you're new. Your denominator must include the patient at risk, okay? So in terms of catheter-associated urinary tract infections, I need to know the number of urinary catheter dates because people who don't have a urinary catheter are not at risk. The same with CLABSI data, and we all know that. So if you don't have a central line, you can't have a CLABSI. So we need to think about that. And on the other hand, when we look at outcome data, we look at patient days for C. difficile because we feel that your population is at risk. It's not device-related. In terms of process measures, we can look at compliance rates. For example, hand hygiene. We can look at things like immunization rates, many of those types of things. The advantage to some of our process measures is that they really work well in long-term care and outpatient settings in particular. So if I'm looking at an outpatient setting, I want to really look at, you know, process measures many times. So infection rate versus immunization rate, as we said. So what we want in our process measures is how are we going to collect that data? Are we going to do direct observation or are we going to do chart review? This is where, in many cases, some of our quality colleagues, particularly with the chart review, will help in some of these process measures and getting that information from, you know, the chart and then feeding it back or being part of that collection when we talk about process measures. On the other hand, observation, we know that many organizations will have someone additional helping with that. For example, they might have secret shoppers that they have. I know at our university hospital, they've had a lot of medical students who've been employed to do some hand hygiene. So any of those types of things. But when your person, when you have a person collecting process measures or observations, make sure that you orient them as to what you're going to do and how to collect that data. Because if you're going to use it for improvement, you want to standardize your methodology and make sure you're moving it. So what are the difficulty with process indicators? Well, first of all, reliability. Interrater reliability. I want to make sure that if other people are collecting the data, that they're collecting that the same way I do. For example, if I'm having people collect hand hygiene data, what is it we're collecting? Are we collecting hand hygiene in and out of the room? Because I can't really watch in the room. Is that two separate observations? Because oftentimes someone will go in the room and spend a half hour. So I'm saying if you see someone go in, it's a separate intervention or process indicator. How about difficulty with observing processes, which often happens. If you're measuring by documentation, you may not adequately reflect the care provided. The one thing I always find when we talk about that is, for example, I have a CHG BAS. And they'll say, no, we gave the CHG BAS. They just forgot to document it. So how are you getting around that? And you always say, well, if it's not documented, it's not done. If it's not documented in your automated record, it's not done. But there might be other ways that you can find out that. The problem we had with CLABSI, and we saw a decrease in the CHG BAS. But one of the things we did is because we were using actually the wipes, we developed a process where there would be a certain number of wipes on the PARs in there, and they would be restocked. And sterile processing, or the purchasing department, would log how many they gave you. And then you could look at line days to make some type of match to see whether they were done. Now that can be a little complicated, but on the other hand, it's a way to say, well, guess what? It wasn't documented, but also you didn't use enough wipes to have done enough. And then surgical prophylaxis. Regulatory and accrediting agencies, as I said earlier, frequently use process measures, whether your state health departments, your joint commission, and the Centers for Medicare and Medicaid Services. Now we're not getting into definitely talking about regulatory, but oftentimes if there are huge problems with your joint commission or DNV accrediting thing, CMS will do its own survey. Or CMS might do random surveys based on complaints or things like that. And they will definitely go to you, look at procedures, see where things are done, and it becomes very, very important. Well, again, I share things with pictures. And this is very interesting when we think of C. diff and we think of fecal oral contamination. This is just one example. Or this one, which I think, and again, I think we have to be careful where pictures are and not name the patient, but it does help. And you can't see this, but this was a urinary catheter bag on the floor behind other things. And we know the floor is dirty and microorganisms can certainly contaminate. And how about this one? This is another one that we picked up over time on those types of things. So they do help. Now, if I'm talking to environmental services and we're going to talk tomorrow more about that and how we educate, sometimes just sharing a picture saying this is what we're talking about might help. Now, in terms of best practices, this is a three-month moving average of hand hygiene rates. And it's very helpful because you can look at this and you say, wait, everybody's doing well. Why is all inpatient only 65 percent? And that's because you didn't see the rest of the graphs. But again, there's a lot of opportunity where some areas are doing exceptionally well and other areas where they're not. And then another thing, and this is really maybe helpful for those of you in small organizations. I think another practice that you can certainly employ is this thing about days since last term. And if you're in a large organization, they have combined it with some of the quality measures. But it really shows you, well, it's been 67 days since we had a bacteremia. Well, it's been over a month since we had a CLEBSI. And remember how many there were last year. Surgical site infections, those types of things, pressure ulcers, and they included falls on here as well. So those are strategies you can use. One of the things I will tell you if you are new to infection prevention is stay current with the literature. Now, there is so much to learn, but I always try to stay current with the literature. Look at CDC's latest guidance. Look at APEC. Hopefully you are members or going to be members of APEC. Look at what they come out with. And I'm talking about, and actually it says SHAE Compendium of Strategies, but it's really APEC and SHAE. APEC had representatives on this compendium of strategies. And SHAE, if you don't know, is Society for Healthcare Epidemiology. And it is important. So they have come up with a number of guidelines. There have been infection preventionists involved in all of these guidelines. And they are some of the latest guidelines that have come out. So I kind of want to review those. I'll review them at a high level. The nice thing about this, if you're not a member of SHAE, you don't get the SHAE documents, is that they are free of charge. So you can look them up. You can get them. So one of the things that I talked about, CLABSI, is APEC's guide to prevention of CLABSI. The compendium strategies to prevent HAIs, which is now complete. And CDC's HICPAC guidelines. Now when I talk about HICPAC guidelines, HICPAC is Healthcare Infection Advisory Panel, part of the CDC. And these are a group of experts that were appointed to this panel by expertise. And they are working right now. They're working on isolation and respiratory guidelines. They have worked on employee health guidelines. And it is important that when guidelines are confirmed that we begin to look at those. So I'll talk a little bit about CLABSI. This was one of the first ones that came out. And just in terms of feedback, we did have some in 2014. They were supposed to be updated in 2020. But along came COVID. So basically, they have been released over the last two years. In 2022, the first ones were central line infections. Now, in terms of the SHAE practices, one of the things that I would recommend is to look at the best practices and conduct a gap analysis. So look at the recommendations and say, do I do this? Do we have a policy? And always look at the difference between our practice and our recommended practice. So SHAE said some of their essential practices. And I was surprised at this, but the subclavian vein is still considered the preferable site for CVCs. Now, people on the front line and in ICUs will argue with you because it may be very difficult. But we do know that many times when lines are inserted in interventional radiology, that that site makes good sense. This is to prevent infection. We do know that oftentimes in emergent situations, we can't do it. But we need to think about it when we can. Previously, they recommended avoiding the femoral vein. They recommend that you avoid it, but there are some situations in emergent situations where you can't. So ultrasound guidance for catheter insertion, be careful though that you don't jeopardize the sterile technique. And the use of chlorhexidine-containing dressings is now considered an essential practice. And in the past, it was considered a special approach. And then routine replacement, if you're not giving blood, should definitely not be replaced up to seven days. So again, this is in your handouts. They're in your slides. There is a link. But again, these are the list of essential practices. So one might look at that and say, you know, the chlorhexidine bathing or in the ICU, having the checklist and performing the hand hygiene and what you do after insertion. I think it's really one of the things that's really important because this was considered an essential practice back in 2014, and they still kept that in there. Although we know oftentimes that staffing is really difficult, but they wrote, ensure appropriate nurse-to-patient ratio and limit use of float nurses in the ICU. They say there's a high quality of evidence. And sometimes that is difficult to do, we know, with agency nurses and things like that. One of the things that really there's a fair amount of evidence in terms of dressings and using the chlorhexidine-based antisepsis and clearly changing that dressing if it's soiled, loose, or damp, all of those types of things. And again, this is in your handout. But CLABSI is between 2018 and 2019. Pre-COVID had about a 7% decrease, but we know we had a slight increase going down. We do know that it increases morbidity, raises mortality, and this documentation was really from the compendium. And they estimated that the attributable cost is $48,000, although I've seen other literature. So in terms of pathogenesis, and this is really just a review for many of you who are fairly new, we see migration along external surfaces. The important thing in terms of surveillance is that migration along the external surface is more common early in less than seven days. So if I'm trying to look at what's going wrong with my CLABSI, so if it's an early onset CLABSI, I may be looking at insertion or those early practices where the hub contamination, where I get interluminal colonization, is more common when a line has been in for a longer period of time. And we know we can get seeding from another source or contaminated infusates, but that really is very rare. So we're not really, but where do we get the bacterial contamination? Well, we can get it on the patient's skin and healthcare worker's skin. So we do know, particularly coag negative staph, which lives on all of our skin, it's a normal colonizer. But when that same coag negative staph that colonizes our skin and doesn't cause infection gets into a sterile site and may cause infection, and particularly with coag negative staph, it likes to adhere to things like catheters and things like that. We could have contaminated needle devices and all of those types of things. So we know whether we're talking about CLABSIs or CAUTIs, we always have to think of biofilm. So what does that mean? I think many of you know that, but I'll just go through it briefly. So this is biofilm on a central venous catheter. So what happens, as I said earlier, the bacteria tend to attract to invasive devices. They like it, they may hang out there. They often have what I'll call a substrate or slimy, a particularly coag negative staph slimy, and they get other bacteria to attach to it. So it's, hey, come on guys, I always think of like gum. And then other bacterias attach to it and they form this biofilm. Now, biofilm is important for two reasons. First of all, antibiotics can't really penetrate the biofilm and it is related to infection. Now, if you think of biofilm, I always think of perhaps something that had something sticky on dishes or things like that. I didn't get it rinsed off and you realize how hard it is to remove it. So biofilm. So when we look at best practices related to epilepsy, we look at insertion, we look at maintenance, and we look at some of those special issues related to our population. And we know that the insertion practice is the standard prep is alcohol, recommended alcohol-based prep, a standardized tray or carb, low barrier precautions, and they do recommend the ultimate site selection as subclavia. The reason for the chlorhexidine prep is twofold. First of all, chlorhexidine is long-acting, alcohol is quick-acting. So we've got that combination and chlorhexidine usually is not made inactive in the president's subblood. So we've got that. The basic recommendations are the kit or the cart, the insertion checklist, education, credentialing those, and adding the CHG bathing. So I've put this up. Again, it's from a policy, but I think it's helpful for those of you particularly who may not be used to some of these things, looking at what can be in policies, how you remove them, how you maintain it, those types of things. So again, this is just one example, and many of you may have things similar to this. So certainly isn't reinventing the wheel, but it is helpful if you have some guidance documents. So there are other strategies. Many people are using the CHG bathing on any patient who has a central catheter. They're looking at midlines because we know a midline does not go into a great vessel and therefore might be very, very advantageous, but there are certain medications that cannot be given through midlines. And looking at high-risk populations, for example, in ICU where they tend to decolonize patients. So if you have, say, you're colonized in your nares with MRSA or things, they would decolonize you in an ICU. And many organizations are doing that house-wide. So in terms of the messages, the original dressing is important. Seeing more and more evidence that that dressing is important, we have to make sure it's intact. When they get disrupted, we need to pay attention. And that is one thing, and I will say when we talked about rounding, checking those dressings, I think is a really, really good strategy when you're making your rounds. So it's not just environment. Think about those things and having the bundles. I'm gonna move on to CAUTI. It's a common hospital infection. It occurs when a patient with a urinary catheter, indwelling catheter is in place for more than two days before the event occurs. Now, this was a late compendium. It actually didn't come out till the end of last year and its strategies to prevent catheter-associated urinary tract infections. We've got a lot of guidelines here. Some of these have been around for a while. One of the things that I can tell you about CAUTI is the fact that there haven't been a lot of new guidance documents. The compendium really goes through many things that we've known for a long time. So there's not gonna be a magic bullet. There's not gonna be, wow, we learn new things. But again, there is, this was the 2014 one, but we have the new one now. We have the HCPCS guidance document. It's still appropriate with many of their guidelines, but remember when you have a CDC document like this, it's been around for a while and they don't put interventions that don't have a very, very high degree of evidence. So it's helpful if you have some, but they've only really had a couple of recommendations in there that really have high levels of evidence, which is why we have to look to our other ones. And then there's an ANA tool, which came out a while ago, but it's still really helpful because it's got some guidance in terms of urinary retention and things like that. So what's new in the compendium then? Well, basically it really just talks about essential practices, really hard wiring how, when to use a urinary catheter. And the one thing I will say is if any of you are aware or familiar with the CDC guidance, it says that one of the indications for a urinary catheter might be I and O in critically ill patients. Now, one of the things that we need to realize is that not every patient in the intensive care unit needs a urinary catheter. So just be being critically ill now with guidance documents says you need a catheter if you're going to use the information, so the output, to either stabilize the patient or to titrate medications. We don't just put it in just because. So that's important. One of the things that it does discuss is urine culture stewardship. So in other words, when I look at that discussion, it's like oftentimes when we look at urine cultures, the patient has a temp and we just say, oh, send a pan culture everything and really looking at the necessity of urine cultures. The other thing that I have seen in my experience and I saw it just a few months ago when I was working at the hospital and I just thought, well, never gonna get away from this is the patient who had no signs, you know, no tenderness or anything like that was being treated for a pneumonia. They called the doctor because the urine was clotting and malodorous and said, well, this patient needs a urine culture. Well, we know that after a certain amount of days, and I'll talk about that, everyone has microorganisms in their urine. So they updated their performance measures and then they discuss limitations of external urinary catheters. So the compendium is really helpful. And one of the additional approaches that I will talk about is they talked about injury from urinary catheters. So when we think of harm, we need to think about the fact that a patient may have a urinary catheter and be harmed because they're confused. And many people have equated it to a one-point restraint. So I have the little old lady who's confused, trying to get out of bed. She's not gonna say, oh, I have a urinary catheter so I don't really have to go to the bathroom. She's gonna try to get out of bed and may harm herself. So things that they talked about. But what they did say in their studies is that 12 to 16% of patients may have a urinary catheter at some time during their hospitalization. And of these, up to half of them may not have a clear indication. And this is the important thing. If you put a urinary catheter in, the risk of bacteria in the urine ranges from three to 7% daily. So you can get these bacteria. Non-infectious complications are also important. And they don't really see frequent bacteremia. So when patients really die, it's usually related to confounding variables. They really feel, and again, I talked about the intensive care unit, and that this idea of diagnostic stewardship is so important that you have an appropriate reason for culturing and you collect it as appropriately. And you don't leave the urine, say, sitting on a unit. And I know many of us have labs that are remote. Now, the other thing about CAUTI is we think about medial, rectal, or vaginal. And certainly, the placement of the urinary catheter leads us to think about that. But we also have external sources, like equipment or contaminated hands, of healthcare personnel. And the specimen could also be contaminated just because it sits too long. So in terms of the pathogenesis, we know that microorganisms can colonize the catheter and create biofilm, as I spoke about. They tend to ascend early after catheter insertion. So if you get that early catheter insertion, it may certainly be related to poor asepsis or lack of asepsis. And bacteria can also ascend one to three days, and that's because of capillary action. So again, the bacteria is introduced. The microbes can ascend the urine collection bag via reflux, and the biofilm can occur. And this is a nice schematic that they had in here, and it talks about all the things related to urinary catheter harm, from immobility, to increased length of stay, to the bacteria, and to trauma and discomfort. And this is a very nice guide that is in the compendium that's been used. And they talk about the steps to avoid a urinary catheter, CAUTI. And they say that step zero is not to put it in in the first place. And then step one is the aseptic insertion, step two is maintenance, and step three is removing it appropriately. So the risk of CAUTI, as I said earlier, increases by 5% each day, and more than about 50% of patients who have a catheter in for five days will have asymptomatic bacteria. You'll get urine out, but they don't have signs and symptoms. And we can also get contamination from the drainage bag. So again, I'll just give you this reference because I thought it was important. It was published in 2019 and BMJ. They used a very large data set. They said that there was an incremental risk of CAUTI with each additional day of catheterization. And they said that we need to give special attention to patients with risk factors and females and those with mobility issues. Now, this is a pocket card that came from some work I was doing with AHRQ, and you can go through that. But I think it's really important if you're new to it, it is in your handout choosing the appropriate hand hygiene, removing it, maintaining the sterile clothes drainage, and particularly when you're working with new staff and things, making sure that they really understand that. And particularly maintaining the dreg below the level of the bladder. I remember working one day and my office was down, I could take a shortcut down the OBGYN ward. And sometimes for C-sections, they would insert a urinary catheter. And I walked down the hall and here's this lady going down the hall with her baby and she has her urinary drainage bag hooked on the bassinet. I thought, oh my goodness. Or you'll see that and make sure that you do orient your transport staff not to place that urinary catheter bag on the abdomen. And if you have breaks in a septic technique or leakage, you want to make sure absolutely that you maintain that closed system. And again, below the level of the bladder. And the guidelines still say a non-aseptic technique solution, but I've heard oftentimes there are some studies that there are, this is a meta-analysis that said that they looked at some of the benefits of using a sepsis or things like CHG, and they feel there is some emerging evidence that that might be helpful. We'll talk about alternatives very briefly. I think you're all aware of them, but the one thing I will recommend for female catheters is the female urinary catheter. I know a lot of you have used them. Those that use them even in the ICU have found them to be incredibly, incredibly helpful. And then other alternatives, bedpans and commodes. Sometimes outside the ICU, you'll hear a doctor order a urinary catheter because he's not comfortable with the weights. That should never happen. You should make sure that those are. And this is the ANA tool, which I like because you can use this as a checklist. And one of the things that we find is that these checklists really do happen. This is one thing that we had at our hospital, and this is just a little guidance tool for those of you who don't have it. It's guidelines for collecting a urine culture. So you wanna have the appropriate guidelines, new fever and one other symptom, not just collecting it because it's cloudy and malodorous. And what are the non-indications for urinary catheters, like urinary catheter alone or altered mental status alone, those types of things. And what are the criteria for refluxing those cultures and then ordering it? And the other thing I certainly will point out is this mini root cause analysis tool. And many of you are doing things like that. We do those on CAUTIs and CLABSIs and SSIs, and it really helps us. It's not your formal quality tool that you would use with a sentinel event. It's not that root cause analysis, but it's a mini root cause analysis to look at those things. So I'm gonna move on really quickly to C. diff, and we know the spores are difficult to kill and it produces a toxin. And the C. diff guidance document also came out. So all of these documents are available. Those are important things. What they talked about with their essential practices was antimicrobial stewardship. It is a basic practice. People who haven't had antibiotics are highly less likely to get C. diff. And the second thing they talked about is the cleaning, and I'm gonna talk about that tomorrow. The unresolved issues are asymptote carriers, and that continues to be a problem. So in terms of core strategies, we wanna get that patient into isolation as soon as possible. If a prevent room is not available, give priority to patients with fecal incontinence. I have not experienced that, but you may be in a situation where you have. Education, and we'll talk tomorrow about that. Really, really important. Education, educating environmental services, and we'll talk about that tomorrow. And this is the thing that is really important, the cleaning of the room. And I'm gonna spend time on that tomorrow, but I wanted to point that out. Dr. Gita Sewell out of Hopkins did another study. We've heard that even if a patient is in a room that was previously occupied by a C. diff patient, 27% increased odds, but they found that it went back some period of time. And I think that's essential when we talk about those things. Now, here's some things on rounding that are important. This was a study done in 2022. They did a pilot study on the power of rounding, and we'll get back to that rounding. And what they did is that they accumulated all their data. And so once they gave feedback from rounding, I think to the prospective area, they did an organizational type of thing. So what's well-maintained, what needs new improvement, what needs long-term support, and what we couldn't observe. And now their results were really pretty good, but this is just an example of something that you might use. But checklists or audits are important. And when we talk about that, the process of conducting an objective review of specific practices. So if we audit measures of healthcare personnel's adherence to standards and processes, we want it to be designed to improve patient care. If we effectively implement these checklists, we provide valuable information for improvement. But we talked earlier in the Q&A, and we'll discuss more tomorrow, how do we effectively implement them? We want to make sure that we have consistency, that we have reliability, that if other people are collecting this information, that it is consistent. So we'll have more questions and checklists tomorrow, but I did end on time because I wanted to make sure that we addressed any questions or comments. And we do have 10 minutes left, and we're going to talk a lot more tomorrow about checklists, about engaging staff, about those types of things. But I want to stop sharing and see what we have either in the chat or for questions, because I'm really mindful of time and I do not want to go over. Thank you so much for that, Linda. I greatly appreciate that. I'm just scrolling through. I don't see any other pending questions here. Yep, I don't see any in the Q&A either. So while we do just some kind of final wrap-up comments for today's session, if you do have any questions, please go ahead and be typing those into the chat or the Q&A option as Linda mentioned. So we'll make sure to address those. And then I'm going to go ahead and post some information here for you all in the chat. Just as a reminder for today's session, and then again for tomorrow, you will receive an email. It'll be tomorrow morning around the same time that the session started today. And that email will include a link to the recording of today's session and also the slides that Linda presented. But I did go ahead and provide the link to those slides. I've seen a couple of questions in the chat asking for that. So those are provided there for you in the chat now to have as a resource as well. But it will also be included in that email tomorrow. And then just note that that email will actually come from educationnoreplyatzoom.us. And so because it comes from that Zoom email, it may get caught in your spam, quarantine, your junk folder or something of that nature. So if you don't see it in your inbox in the morning, I would encourage you to check those additional folders. And then if it's still not there and you'd like to access the recording, you can always use the same Zoom link that you used to join us for today's live presentation to also access that recording. And then just remember that the link for the recording is available for 60 days from today's date. And then that'll be the same for tomorrow as well. And we do have an additional security measure in place of manually approving each of those recording access requests. So when you do click on that link, you'll just need to type in your information. That'll prompt an email to come to us for approval. We approve those requests very quickly, typically within a few moments of receiving that request, but we ask that you just give us one business day to approve those recording access requests. Okay, saying thank you, Linda. Great part one here and just lots of other great comments throughout the chat for today's presentation. Okay, and then if you do have any questions, I know this is just part one of our two-part series, but Linda, I'm sure your contact information is included in the slides. Maybe if not today, then maybe tomorrow. And if not, we'll be happy to get that information out to the registrants as well. And if you have any questions that you just would like to have answered, maybe even before tomorrow's session, you can always send that over to education at gha.org. We'll be happy to get those over to Linda. I know that she'll be happy to answer those questions that you have as well. Sure, thanks, Lindsay. I just wanted to say I will make sure I have my contact information in there tomorrow. The one thing I would encourage people, oftentimes, particularly if you're new, and it's hard for me to believe that at one time I was new and shy and didn't want to ask a question because I was embarrassed. So please feel free to contact me directly. I'm more than happy if you have a question or something wasn't clear to you, particularly if you're new. So I will include that tomorrow and I love to get questions. I always feel that in infection prevention, we're all colleagues. And that is the thing that working together and I have reached out to people and have been so helpful. So please don't hesitate to contact me. Perfect, thank you so much, Linda. I see a couple of questions here asking about the link for tomorrow's event. And so if you are joining us as a member of the Georgia Hospital Association and you registered on gha.org for the webinar series, then you should have received a registration confirmation email that included the Zoom link to both today's session and tomorrow's session. So possibly go back and check for that email. And then we also send out what we call a how to join email for each session. So again, if you are a member of GHA, you should have received an email yesterday that provided the information for today's session. And then for tomorrow's session, you should have gotten that email this morning that includes a link for tomorrow's session. If you have not gotten that, and you need the information, please don't hesitate to reach out to us at education at gha.org. I put that email address there for you in the chat, and we'll be happy to provide that information for you. If you're joining us as a member of a partner hospital association, I would encourage you to reach out to your contact at your hospital association just to make sure that you have the appropriate information to join for tomorrow's session as well. Okay, I don't see any other questions here. So we'll go ahead and conclude for today. And we just look forward to seeing you all back with us tomorrow morning for part two. Thank you so much for joining us. And thank you so much, Linda, for your time and information that you shared with us. And we look forward to seeing you tomorrow morning. Have a great day. Thank you so much.

Linda Green

infection prevention

risk assessments

healthcare settings

multidisciplinary team

quantitative risk assessment

qualitative risk assessment

gap analysis

SWOT analysis

ICRA 2.0

construction risk assessment

CLABSI

CAUTI

C. diff