get us started with part two this morning. 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 to 2013 and as APIC president in 2017. Linda 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 IP with visionary leadership and extraordinary contributions to the profession. Thank you so much for being back here with us this morning Linda for part two and we'd like for you to go ahead and get us started. Thank you so much Lindsay. I'm really excited to be back and particularly today because this is a really important issue and as I go through we'll look at some of these types of things and why it is so important. So what I'm going to do right now, if I can move my slide, my email is on right in the front here so yeah like I said yesterday if anyone wants to contact me please do so. So what are we going to do today? Well I'm going to describe the basics of cleaning, sterilization, and disinfection. For those of you who are new I think it's really really important as I think I mentioned earlier when I started infection prevention I was voluntold and I really didn't know a lot about many of these things and obviously they've changed over the years but it's really important background information. I'm going to identify the importance of manufacturer's instructions for use. I can't emphasize that enough this is a high high priority particularly with regulatory and accrediting agencies and really causes a little bit of struggle sometimes as new devices come out and what can you use on them. So we'll talk a lot about that. I'm going to discuss guidelines and recommendation and I should say it's not just equipment in devices but it's our equipment in the environment it's really medical devices. So those are very very important and I'll talk about that and then in the second portion and I combine the two sections to make it a little easier we'll just stop and then I can continue but we're going to talk about educational strategies for stakeholders and I'm going to focus primarily on EVS staff. There's a lot going on there. I'll give you some hints on things that we've done and in the meantime not only ask a question but share with us if there are things that you've done in terms of some of these educational strategies because I think it's important not only to hear from me but to hear from all of you and what you've been doing. So with that I'll get started. So I'm going to start with the Spalding classification. It was devised by a Dr. Spalding a number of years ago so it's been quite some time but really it was kind of a brilliant approach. So Dr. Spalding developed this classification to identify how an object is disinfected depending on its intended use. So he labeled them as critical, semi-critical and non-critical and critical are objects which normally enter sterile tissue or the vascular system through which blood flows and clearly if you are entering sterile tissue or you are entering the vascular system it should be sterile. A semi-critical item on the other hand is an object which touches mucous membranes or skin that's not intact and the minimum for that is what we'll call high-level disinfection. And then non-critical objects are objects that touch only intact skin. So we're talking about that in terms of what we need to do when we're cleaning or disinfecting or sterilizing and that's important. Now the potential transmission of pathogens from the environment is becoming increasingly important and I'll emphasize that for a number of reasons. First of all and you know what's very very interesting when I first started infection prevention people said well if you know how often do you clean things and we'd say well when visible soil is there and can you imagine that today but it was just not realized how long some organisms live on non-porous surfaces and active surveillance is not done on most patients for health care associated pathogens so we really don't know oftentimes what's going on with patients and we know that health care workers frequently and I should say this comes from some of the literature but I'm not sure it's frequently but we know they don't always wash their hands after contact with patients or surfaces without direct patient contact and we will we'll talk more about that. So in terms of how we break this down I think this is really a nice nice way of patient contact and you can use examples like stethoscopes here and blood pressure cuffs and we can say that we just need a low level or intermediate level disinfection because they're non-critical devices they touch intact skin but ideally they should be washed down after each use or between patients and oftentimes that isn't done it's less of a risk than our items say sterile but it's still very important. Our second example here is mucous membranes or non-intact skin and we have things on many types of things like bad speculums and scopes and I'll spend some time on that and they are considered semi-critical devices and they need a minimum of high level disinfection. Now I want to emphasize the word minimum. Ideally it would be great to sterilize them but I'll talk a little bit about that and then we need we have sterile areas of the body in the vascular system and we think of forceps and all kinds of things catheters many things like that and they're critical items and they need a minimum of sterilization. Now this sounds pretty cut and dry but we do get into some circumstances and I'll talk about those in a bit when we're challenged with these types of things. So let's talk about the case for just environmental hygiene or cleaning and we do know that previously contaminated rooms increase transmission risk. So if a patient who has a multi-drug resistant organism or a significant organism it can increase the risk of transmission and we find that many patient rooms are not well cleaned and we'll talk about what we can do particularly with environmental services. The cleaning process and I think we would all agree that the cleaning process can be improved in most organizations. We also know that improved cleaning decreases environmental contamination and it also decreases the acquisition of pathogens. Now everyone on this webinar today knows these things we've experienced it we're aware of it it differs from organization to organization but it is a hot topic and a key topic for a number of reasons. Well I love this little thing renewed respect for the role of the environment and the question is who's been in the room before you and there is a documented increased risk of acquisition of things like VRE MRSA or CDI. Now I will tell you other types of multi-drug resistant organisms when patients are admitted to a room where prior occupants had one of these or in multi-occupancy rooms. Now one of the good things about the United States is that we really have tried with new construction to have private rooms and certainly fewer hospitals that I've seen have multi-occupancy rooms although it still does occur and we know that. So this goes back obviously there's been a lot of data going back to 2010 and 2011. It's not a new thing but even last year Dr. Gita Sood who I mentioned earlier published a really nice paper in AJAC about patients acquiring C. diff and they did a study and not only were patients in the room previously but it might have even been a couple of episodes ago and they were at higher risk for C. difficile. So that brings us back to the question what are we going to do? What are the things that we can do and how important is that? And I love this little cartoon it says the patient in the next bed is highly contagious. Thank God for these curtains. So one of the things that we do know now this was published by John Otter in 2013. There's been numerous publications and they all point to the same type of thing that there is survival of pathogens on surfaces even on dry hospital surfaces. So we all know that C. difficile can live for long periods of time for more than five months and we do know that what happens with C. difficile is that it is fecal oral contamination and when the C. difficile gets into the environment it forms spores and spores are very difficult to kill and can live for long periods of time. Acinobacter can live for three days to 11 months and I know some of you think about well I really didn't think about acinobacter living in the inanimate environment. I know a number of years ago we had an outbreak of acinobacter in our surgical intensive care unit. Now most there were some patients colonized some patients infected and we really couldn't figure out where this was coming from. We were thinking of person to person and all of those types of things. Well back to good old rounding which I will always emphasize we went up actually the state department of health even came in but we went up to see what was going on. What were the practices? Was there transmission from patient to patient? What was going on? And we observed that in the intensive care unit and I know a number of you can relate to this. Oftentimes there's tons of equipment and supplies and patient areas because while you're caring for the patient nurses don't want to have to go out in the hall or or call someone and they have these little bins in the intensive care unit the surgical intensive care unit where they stored all the dressings and they stored all the equipment and things like that. But when a nurse needed something she would go through all of these probably not performing hand hygiene because she'd just been working on the patient and now I know this or that and it was very easy in these bins to contaminate it. So we did cultures from those bins and sure enough that was the source of the acinobacter. Once we really changed the process we did not allow storage of supplies like that. They were in such a manner that one couldn't contaminate them. We really resolved that issue. Now I'm not saying that there aren't other issues related to acinobacter which we know but I'm talking about all of the things that happen in the environment. Enterococcus we know lives in the environment. Also things like Pseudomonas and Klebsiella and we know that staph including MRSA can live in the environment and norovirus which we clearly realize. So these things have not changed and they do have long environmental survival. Now there's more though and in some of these studies were done before some of our big bad and ugly organisms came into play and I want to share this with you because I think it's really really important and this was really a nice major article in clinical infectious disease and it's fairly recent I think 2020 by Dr. Joseph Sexton that looked at a long-term care skilled ventilator unit and Dr. Sexton found you know we talk about candida auris. We have been lucky so far in western New York I think we've had one case that was quickly quickly resolved but I know a number of you may have really been challenged with it and we tend to be challenged in long-term care facilities and I know some parts of the country I know particularly in the Chicago area it is a real problem. So anyways they looked at a ventilator capable skilled nursing facility but this easily could happen in hospitals as well. So what they did is they quantified the residents bilateral axillary and inguinal skin swabs and we do know that candida auris lives on skin so if you think it lives on skin it certainly can get into the environment and they did what's called a point prevalence survey. So and many of you know when we look at point prevalence we look at a point in time and environmental samples so they began to collect environmental samples and they collected them from doorknobs, from window sills, from handrails and they looked at 12 rooms and here's what they found. That candida auris was detected in 70 out of 100 tested environmental samples and 31 out of 57 resident skin swabs. This is really kind of alarming when you think about it and there was a positive correlation between the concentrations in skin swabs and associated handrail samples. So you can imagine if the patient is colonized has it on its skin and then it's on handrails and even two patients that weren't colonized had it on their bed rail swabs. So what do we know? Well this is hard to see I know it was actually 2021 that this was published but you can see on here and it is a little difficult I know to see on your screen but you can see the green is negative the red was culture and the swab positive. The purple was just culture positive and the yellow was swab positive but not culture so they they did that and that's the test that they use and here's the facility map. So what we know about the environment is very very clear not only what we talked about earlier but of these some of these new microorganisms and so we have to pay a lot of attention to the environment and I will tell you that regulatory and accrediting agencies see this is a very hot topic. So obviously what we know is that any contaminated room increases transmission risk. We talked about there I won't say frequently but periodically not well cleaned it can be improved it decreases environmental contamination and decreases acquisition of pathogens and I emphasize that earlier but I can't emphasize that enough. So now this was published by Dr. Weber in 2010 but it really stands to reason now and it's that we can there is a relationship between microbiology and surface disinfection. So what do we know? Well I've already talked about the fact that pathogens are able to survive for prolonged periods of time. Their ability to remain virulent after environmental exposure. So all pathogens contamination of the hospital environment occurs frequently. In terms of ability to colonize patients and certainly this was published before C. aureus but we've already seen that that happens is very important. We do know that there's ability to colonize the hands of caregivers and we talk about that a lot. Transmission via contaminated hands. Things like C. diff and norovirus require a very small inoculating dose. So a little bit can cause disease and there is some resistant to disinfectants. So the role of the environment has really changed and as I told you earlier the pendulum has swung and the 70s 80s and even 90s we really talked about cleanliness for appearance sake if it's not dirty and starting about 2000 so the last 24-25 years we began to look at the environment and what's even caused more focus on the environment is some of these big bad MDROs or multi-drug resistant organisms. Things like candida auris or increasing numbers of C. diff in our health care organizations. Many things like that really have caused this to happen. So we've changed our goals. You know in the past you know it was how clean are your floors and how efficacious is our disinfectants but right now we're looking at having a safer environment. So I want us to think about that because whether we have patients or residents we want to create a safe environment. So everything we do really centers around you know patient safety. It dovetails into quality and infection prevention is a huge part of that and we want to talk about hygienic practices but we also know there are many technological advances and those advances are really really important and really help us. So I love this little picture and believe it or not you can't tell but that was me a bit ago several years ago and we took this picture and I put that in oh no not shiny enough and the EBS worker is saying boy she needs to get a life. Well hopefully nowadays when we talk about how we're going to dialogue with environmental services people aren't going to look at us and say boy she needs to get a life. So with that so we know do know that the role of the hospital services in transmission of emerging health care pathogens and we talk about norovirus and c diff and asinine a vector. We know norovirus is associated with outbreaks but it happens very often in health care facilities. I know a lot of us we think of cruise ships and many things like that. The other thing about norovirus in terms of outbreaks and things it has a fairly short incubation period. So people will get ill fairly quickly. Many things like C. diff are associated with hand hygiene contamination and patients in the room and they all can be reduced by enhanced cleaning. So let's just get back to our definitions again. And I think it's important right now to look at the definition of cleaning. So what does cleaning mean? Well, it refers to the removal of visible soil and organic material. It is the physical removal of it. Cleaning is the removal of the organic material. And what we know is that if cleaning doesn't take place, and we're not only talking about the environment, we're talking about medical devices and things. If cleaning does not take place, you can't, it can't remove these types of things. And thorough cleaning is needed before disinfection or sterilization because any organic material can decrease the effectiveness of those processes. Well, when you look at low and intermediate level disinfection surfaces like floors and counters, you know, that's really important. The non-critical items, which only touch intact skin, and what it will do is it will remove or kill some types of bacteria, fungi, and viruses. So it's important for that as well. Our low and intermediate level disinfection can be used then, we talked earlier, stethoscopes, blood pressure cuffs, glucometers, and it kills most microorganisms that cause disease. It may not kill some viruses. We have to think about that. Doesn't kill some viruses. It depends on particularly if they're enveloped or non-enveloped viruses, and it does not kill spores. So we have to think about that. Anything that forms a spore. So now we move on though. So we've talked about cleaning. We know it doesn't kill spores. We know that many of the medical devices and things we use require high level disinfection. And so the goals of these medical devices include preventing transmission of microorganisms to personnel and clients, patients, and residents, to minimize damage to medical devices from foreign objects or inappropriate handling, and minimize impact on the natural environment. So a lot of our high level disinfection is liquid or chemical disinfection, and we wanna make sure that it's done appropriately. We want to make sure that our guidelines are in place, and we wanna minimize the impact on the organization. So when we talk about high level disinfection, we're talking about what we call semi-critical devices that come in contact with non-intact skin or mucus membranes. It does kill almost all microorganisms, except for some bacterial spores, but it is not sterile. Now, what I can tell you is this is one of the hottest topics. It is a very hot topic. It is a high priority to regulatory and accrediting agencies when they come in. And why is that? And part of it is that oftentimes there are numerous steps in a high level disinfection. Sterilization is still very important, but we've been doing sterilization for a long time. We have sterilizers, we have all of these types of things that we know of, that we've used, but high level disinfection oftentimes is what we call decentralized, and it's done in a number of settings. So now as an infection preventionist, we've got a role in making sure that this is done correctly. Now I'll emphasize this, and I wanna continue to emphasize because yes, the people who do the high level disinfection are not the infection preventionists, but with the new joint commission guidelines, they do talk about our responsibility, not that we have to do the competencies and things like that, but our responsibility to see that this is done correctly. Now there are safety measures in place, personal protective equipment and gowns and gloves and goggles, all of those types of things. And they will look to make sure that when you're doing high level disinfection, the types of things, particularly in decontamination areas where you're decontaminating first, you wanna make sure that personal protective equipment is in place. Now, one of the things that we know then is if we're doing disinfection, we must pre-clean. And I'll talk more about pre-cleaning when we get into some of the things like scopes. So pre-cleaning then removes visible soil from objects. If you're doing certain things, you need to manually brush it. If it's a endoscope, the purging of manual or mechanical, and I'll talk more about that in a bit. It must be done at the point of use. Pre-cleaning should be done at the point of use. So if you're doing high level disinfection, the cleaning at the point of use and following the manufacturer's instructions for use, like contact time, concentration, all of those types of things. Now, there are a number of chemicals and I'll go through those quickly, but there are liquid chemicals. We get new ones coming on all the time. But the one thing about high level disinfection is they must be FDA approved. And I'm sure none of you are using high level disinfectants that aren't FDA approved, but keep in mind FDA is approval. FDA approves anything that is human contact. So when we talk about high level disinfection, these devices are used. Antiseptics are FDA approved. Antibiotics, FDA is huge. But some of these chemicals are things like glutaraldehyde, orthophthaldehyde, and I can't say it, we call it OPA, hydrogen peroxide, and parasitic acid. Now with glutaraldehyde, it's non-corrosive, but the powder must be mixed with solution provided. There's contact time at room temperature. The one thing with glutaraldehyde is that it's a strong respiratory irritant, requires exposure monitoring, and can cause allergic dermatitis. There are all kinds of regulations related to glutaraldehyde, and I don't see that used as much nowadays in my experience, but some of you might be using glutaraldehyde. OPA, on the other hand, is kind of a form of that. It's a high level disinfection and aldehyde coming from the family, but not toxic like the glutaraldehyde. It has excellent stability. It's not an irritant, and it doesn't require that exposure monitoring. And why a lot of people like OPA is it's a shorter contact time. However, there are some concerns about OPA not being used when the patient has a history of bladder cancer, and oftentimes they will not use it in urology just because, and there's supposedly some type of issue related to that. Now, in terms of accelerated hydrogen peroxide, a lot of people are using that. It's 2% accelerated hydrogen peroxide. One of the things about it is it's stable at room temperature. It doesn't irritate the eyes or nasal packages. It doesn't require exposure monitoring. It doesn't require mixing. It's got a contact time of eight minutes, a rinse time minimum of one minute fully immersed. And I'm gonna talk about that because this is another thing that certainly regulatory and accrediting agencies will talk about. Know the difference between rinsing and immersing. And when you read the manufacturer's instructions for use, think about immersing. And it is safe to discard down the drain. Now, a lot of these things, you don't really need to memorize everything about them. I think oftentimes they will look at things like, which is a respiratory irritant or things like that, which requires monitoring if you're taking a test or some type of thing, but you're not gonna have to memorize everything. The thing about these is that you should know, and we'll talk about that in a few moments, we should know what's being used. Now, there's some hospital outbreaks that are traced back to contaminated disinfectants. You know, people have used, obviously we don't use alcohol so much, but chlorhexidine, we use it more as an antiseptic. Phenolic-based, the only thing I will say about phenolics is that they should not be used in newborn nurseries. There are some guidelines. If you're using a phenolic for a disinfectant, it should not be used in newborn nurseries, primarily because it's been associated with hyperbilirubinemia. Formaldehydes, glutaraldehydes, quaternary ammonias, and there's been a number of outbreaks with quaternary ammonias. Some of the pathogens, obviously, well, caldaria, some of those types of things. The other thing we've learned over time is that disinfectants, no matter how you're dispensing of those, you should not top off the bottles. Now, it used to be years ago, you'd get a big bottle, and when your bottle was empty, you'd top it off. Well, that's a no-no nowadays because it certainly can lead to contamination, which is a huge environmental issue. So the concentration of the high-level disinfectant on manufacturer's instructions for use. You want to look at the manufacturer's instructions for use, the strip quality prior to each use. You look at the recommendations when a new container of test strips is opened, and that the documentation of the quality control test. So again, I've talked about this a lot, and we'll talk more about manufacturer's instructions for use and competency, and that is important. Now, one of the things that really has evolved are some of these devices, and that's when, years ago, we don't have these, but this device and this high-level disinfection for vag probes, and now the system also can do rectal probes. So this is great. This is one I'm certainly not pushing products, but this is a trophon that is used quite a bit in a number of organizations because you don't have the liquid disinfection, you don't have to definitely do the dilution, all of those types of things. So again, though, I have noticed, even though this is a closed system, there's a lot of electronics and things like that that go with it, you get a readout, certainly, but once those go through a high-level disinfection, I've seen some problems. So say you're doing vag probes through these, and it's really a nice system, but then you put them not inside a baggie or anything in a drawer. Well, then they can become contaminated. So remember, even things that are high-level disinfected, no matter what type of system is used, we need to think about storage, how they're stored, and are they stored in such a way that they do not get contaminated during storage? Now, worst nightmares all the time. So one of the things, and I showed you a picture yesterday of how we got rid of the liquid sterilization, and had our vag probes on ED go through the ultrasound system in the radiology department, wasn't it great? Well, one of the things, and this goes back a long time ago, was that the residents on OB decided that they wanted to do the, obviously, they were doing vaginal ultrasound on the OB unit, and they were gonna have their machine up there. And you can see from this picture that there's a mixture of clean and dirty and many things like that. Now, why do I show you these pictures? Not for sensationalism, but for you to think about things when you're making rounds. Is there separation of clean and dirty? Are things labeled appropriately, sitting in these bins? So a picture is worth a thousand words. In terms of processing logs, the clinical areas have to keep a log with information, the date and time. If you're doing a scope or any device, the serial number, the temperature, initials of the person doing the pre-cleaning, initials placing in and out of a processor, and signature and initials. And you wanna consider if you're doing a soak, what's the time of the soak? How about the water line? When you're doing these things, your manufacturer's instructions for use will talk about a water line. And I know in many sinks, it's actually ingrained into the sink. What's the time of rinse? And again, I'm gonna say, does the manufacturer's instructions for use talk about immersion or rinsing? When are things open? What's the expiration dates? And how do I document? One of the things that surveyors will pick up, this was from a long time ago, so again, from a hospital, pass or fail. Well, you can see they're marked here, but if the test results are not marked, that may be problematic. If there is a discrepancy in time in or time out, if the test strips aren't documented appropriately, and now we do know that there are temperature solutions in one of the organizations that I'm aware of that we made rounds to help them resolve issues, they weren't even doing temp monitoring. Now, how does that happen? Well, oftentimes you get new people in there, you get areas that aren't totally following all the manufacturer's instructions for use, or you get new personnel. So the idea here is you're not gonna be expected to go down and do a high level of disinfection, but what you want to do, and we've used this word a lot, but we wanna trust but verify. We want to make sure that the people in our areas, anywhere where high level disinfection is done. So instrument preparation, cleaning instruments as soon as possible. That's important, we showed a picture yesterday of biofilm, and when blood or other bioburden is allowed to dry on instruments, it can be very difficult to remove, and the effectiveness of disinfection can be compromised. So let's take a look then at GI scopes. GI lab is a hot area, we do know that. And so this really kind of, this is a schematic cross section of a flexible endoscope. And I know a lot of you do have outpatient areas, you do have GI areas. Important area, high risk area from certainly surveillance, CMS, joint commission, DNV area. So you can see that these scopes, think about cleaning things like this, you've got the bending wire, you've got the fiber optic, you've got the suction channel, you've got the outer layers, you've got air channels, and this is a schematic drawing of that. So a number of agencies, and because particularly high level disinfection is at a risk because there are so many steps in it, first of all, and oftentimes you have more people doing that. Often when we think about decentralized things in our sterile processing department, we usually have people that are key to that. Now in some organizations, they have moved all their high level disinfection to sterile processing, but it really isn't advantageous or efficacious, I should say, to do that in all areas. And so you're gonna see a lot of high level disinfection in areas. And there are certainly a lot of multi society guidelines on reprocessing, but the most recent ones come from Amy and SGNA. And I'll just spend a moment on that so you should know that. Many of you may be totally familiar, you may even know more than I do about some of these things, but I'll go through it for everyone. So Amy stands for Association for the Advancement of Medical Instrumentation. And it's made up of more than 10,000 professionals. There's people from health technology, innovators, government regulators, clinicians, educators, epidemiologists, APIC, SHEA, many of these people are in Amy, but what they do with their guidelines is they come up with consensus for best practices. SGNA, on the other hand, stands for, and I left my S out. So it says GNA, it's SGNA, stands for Society of Gastroenterology Nurses and Associates. And it's a professional organization that focuses on the safety and effective practice of endoscopy. Now, Amy came up with some new guidelines that totally SGNA did not completely support. So in other words, Amy came up with some very significant new guidelines. What regulatory and accrediting agencies are telling us is that when you write your policies, you have to determine whether you're gonna follow Amy or SGNA, and this is for endoscopy. But what I'm seeing over time is that people are gradually adopting the Amy standards simply because they are a higher level most of the time. So what did they put in their new guidelines? Well, instead of using pre-cleaning, so we know that pre-cleaning is important, but they changed it to say it should include all aspects. So they call it point of use treatment. In other words, from the point of use, you wanna clean, so you pre-clean at the bedside after the device, but you wanna talk about the handoff. You wanna make sure things are prepared correctly. So it includes all aspects of point of use treatment. It includes that handoff communication from point of use to the decontam area. And at the minimum, making sure that you have that patient identifier, that you have the data procedure, the treatment was completed, all of those types of things. So it involves more, but those standards really require point of use. That is a non-negotiable issue. Transport. This is a big one. Actually, I was caught in this one a couple of joint commission times ago. After point of use treatment, transport equipment in a closed container marked biohazard. Now, we were doing that, but somehow they were using biohazard signs, and one fell off the container. And that was unfortunate, but it was one they picked up. A closed container or closed transport cart must be non-porous, leak-proof on its sides, and bottom and puncture resistant. But the other thing is, items that are returned to central processing must be kept moist. And one of the things that you will run into, particularly if you're sending items back for sterilization, so to speak, or taking something back that maybe you have, you're doing this outside, for example, in our physician offices, some of the equipment that they use that needs to go back for sterilization have to be kept moist. And I will tell you, surveyors will come in, and if you have containers that are getting ready to be returned, they'll look inside to see that they're kept moist. And that's a good suggestion. Oftentimes, people will put moist non-leaning towels. There are some things, even on the weekend, there are some things that you can get that will keep them moist. But it's an important thing, and think about that. If the blood is dried on, biofilm is going to form, so we have to remember those issues. Back to spokes, spokes, scopes, excuse me. After point of use treatment, transport equipment in closed containers, and I said it earlier, it has to be non-porous. The leak test is done in the process room prior to manual cleaning, because we want to make sure that you test the leaks. Are there any leaks or things like that? It is always performed before cleaning. What if there's a tear in the lumen? The high-level disinfectant will get into the fibers and damage them, so leak testing. Manual cleaning includes the valves, the connectors, and anything detachable. As I'm talking about this, and if you haven't been involved, or even if you are involved, you're saying to yourself, why don't we just sterilize these things? A lot of these items are heat labile, or are designed in such a way that they must be subjected to high-level disinfection. Now, I know that a number of facilities, there are disposable scopes and many things like that, and a number of facilities have gone to disposables, because they figure that it really takes away some of these high-risk things. I can't tell you. I know that some of your gastroenterologists, in particular, don't feel that they work as well or as functional as the ones that have to be high-level disinfected, so it really depends on your facility. It also definitely increases the amount of things in our landfills and those types of things, so we have to think clearly about that. I think some people are looking at things like that. The same with laryngeal scopes. Oftentimes, people will use disposable laryngeal scopes, particularly in areas like ED and things like that, so whether to use high-level disinfection, whether to go to disposables, is something that you need to look at in your own organizations. I want to talk a little bit, and I think this is a great, great study by Cori Olstad, and she's done a lot of work, a lot of work into devices, because we know that outbreaks still occur, so we have not gotten rid of them, and she's done some work on longitudinal assessment of reprocessing effectiveness. Looking at all of those things, and as I said earlier, they watched reprocessing, they interviewed people, and theoretically, high-level disinfection should work, but it almost has to be so perfect for high-level disinfection to really work 100%, 100% of the time that they say sometimes it's not attainable in the real world. Again, that transport guidelines should be documented. You need your policy, and when you're transporting things, enzymatic cleaner, wiping down things, all of those types of things, but we see a lot of gaps, particularly because of product design, because of improper cleaning, failure to follow the manufacturer's instructions for use, and things like not soaking at the right time. Most organizations, and when you make your rounds, they do have timers now, so they can time them, what product you're using, and temperatures. This is what OSTED saw, and this is some of the concern. You can see, and these are pictures, it was published in HF cracked lenses, or scratched cloudy lenses, or scratching. With these scopes, that was part of the reason that many, Amy in particular, looked at some of the additional things that they thought was important, but failure to use disinfection products or processes appropriately has repeatedly been associated with the transmission of healthcare-associated infections. If you don't do it correctly, it won't be successful. Some of the other issues with endoscopes, Amy says that we really should use magnification. You can't really see. They're looking at even using borescopes, and many organizations do that, but what the guidelines really say, if you have high-risk scopes like duodenoscopes, or bronchoscopes, or many high-risk scopes, that you really should do some type of cleaning verification. The high-level disinfectant, the time of soak is critically important, and your time starts when the last item is placed in the solution, and you don't leave them longer than the solution label time, and different products have different soak times, and then that rinse. And then in terms of drying and storage, it's really important that it doesn't touch the bottom of the floor, and one of the things I see from time to time with some of the larger scopes happens less frequently with the new cabinets. Oh, excuse me. Happens time to time with new cabinets that you can see them touching the floor. They need to be dried, pressure-regulated, so don't put them in your cabinets wet. Don't put them in your cabinets wet. There are some guidelines for HEPA-filtered cabinets, thoroughly drying the exterior, and it has to be well-ventilated, and many, many organizations are going to drying cabinets, HEPA-filtered, many of those types of things. So, in terms of CMS citations, central processing failures are going to be numerous. They include, but they're not limited to, an appropriate packaging of instruments, particularly they'll look at peel pouches, hinged instruments not opened wide enough, clean supplies stored in the same room as sterile supplies, and inadequate monitoring of the environment in the central processing department. Transporting of scopes inappropriately, monitoring of temperature and humidity, manual high-level disinfection versus soaking, they've noticed several citations in this area, and they've noticed citations without use of personal protective equipment. So I'm going to talk about this part, and then we'll take our break and I'll see if there's any questions, and then we'll move on to other things. But one of the things, and many of you, this is old news now in some ways, but some of you may have been around for a while, and many of you who maybe are new, had not realized that duodenoscopes were really considered high risk, particularly because of their design. So if you look at this picture, most endoscopes are forward viewing, duodenoscopes are side viewing, and there certainly were outbreaks related to this, and there was an FDA, and it's been almost 10 years now, so they do recommend, I know many organizations are periodically testing, culturing duodenoscopes or using ATP to assure, and part of it is the design. So you can see on this picture, there's this little elevator channel, and it is really very, very difficult to clean in there. So those are some of the designs. So Joint Commission talks about doing a high-level disinfection risk assessment, and here's a little form that they came out in their booster pack. So, you know, where are the processes after you've made rounds? And in the risk assessment, one of the things you need to do, so I gave you a lot of information, and if you're brand new and your head's spinning, don't let it spin. Know where the high points are. Go to the department, see how they're doing, keep these things in mind. One of the things that's important, and I think critically important for all of us, is to identify locations where all or part of high-level disinfection is done, and go and visit them. And your approach should not be punitive, but, you know, talking to people, getting to know them, having them go through the guidelines, having them go through things with you, it's really helpful in being more of an advocate before they get, before a CMS or Joint Commission or survey comes in. So looking at those types of things, and when we see a problem, oftentimes what I've done is say, you know, you did a really good job, but I saw this one area I'm a little concerned about. And if you really didn't have your water up to the watermark or all of those types of things, typically people will be nervous, but you being more of a resource and helping them, and having them help you, show me how you do things, really, really helps. So with that, I'm going to stop right here. We'll talk a little bit about sterilization, and then we'll go into some of the education. But at this point, I want to give you a five-minute break. I want to be conscious that you can just get a drink of water or stand up for a minute, and I'm going to turn it back and see if there are any questions, Lindsay. We do have a couple questions here. I'm going to go to the chat first, and let's see. So this first question says, do you have any thoughts, Linda, on semi-critical instruments that are sterilized in pill packs that are done for convenience rather than HLD, and then once delivered to the clinic are all opened and placed in a drawer, not in their pill packs? Well, you've got two things. Pill packs are fine. Obviously, if it can be sterilized, it should. That's important. But we've had those same problems, and once they're placed in a drawer, they don't need to necessarily stay in the pill pack. I understand that. But once you put them in the drawer and they're high-level disinfected, how do you know they're clean? How do you know someone's dirty hands haven't reached in there? Now, one of the things that I have advised some people is, you know, if it's hard with the pill packs, have a baggie. Have a bag that they're individually put in so you can see, because what I'm hearing is, we've got to go through, we've got to see about sizes and things. So, have something transparent, but have something that they're not just sitting in a drawer, because cross-contamination can happen, and surveyors will definitely pick up on this. Okay, and then let's see here. It looks like there's one question here in the Q&A that says, thinking of competencies, how do you have your sterile processing staff educated so that they can be the experts and train the rest of the OR staff? It's easy if you are a large facility or if you're part of a system, but for those independent and smaller hospitals, what would you suggest? It's very, very difficult, and that is a problem, but one of the things is, even in small hospitals, and I've seen that, I've made some rounds, they have at least an individual person be certified, and that person then has the competency to educate other people. The other thing you can do is make sure that you send one person there to some type of educational type of thing. Oftentimes, they get credits for doing that, so that you have an individual that is able to competency other people, and quite honestly, it's not just sterile processing. I've seen some people say, how is a non-infection preventionist able to competency an infection preventionist, like your boss or things? That is one way you can do it. The other way is that you can work with some of your professional associations and have someone come in to assess people, although that's a little difficult. I would recommend having one expert in your area to be able to do that. Okay, let's see here. Just one other comment here that says, I love for quality and infection prevention to partner and take turns auditing or observing the OR. Either can check for timeouts and watch the sterile field, and if all meds are labeled. Yeah, that's great. One of the things we do, and I don't want you to think that infection prevention is the only person. We all need to work together. We need to get all of us to work together, but I do, as an infection preventionist, and particularly those who are new, you need to know where the bodies are buried. I don't mean that, but look at your high risk areas. Now, we talked about a risk assessment. Where are the areas that things will go wrong or patients will have a high risk of something happening and know where they are and go and visit them. And you will be surprised when you do that. I can't tell you how many times in my experience, OR or endoscopy will call because they're saying, we don't know what to do about this. Would you come and look? So, become a partner. Anything else? Just one follow-up question, I think from the previous question, asking who would do that certification, through your vendors or possibly APIC? There is, I think for the central processing organization, they do do certification. I know in some states, they have made it a requirement, actually, to be certified in sterile processing. Perfect. Okay, I don't see any other questions. Do you want to take a little five-minute break and maybe come back at 10 after? Would that work? 10 after is perfect. Thanks so much. Wonderful. So, we'll just pause for about five minutes and see you all back at 10 after 11. If you have any questions, you can be typing those in, and then we'll see you back in just a few moments. Thank you. Reporting back. There we go. Okay, well, hopefully everyone got just a tiny little break. So, we'll move on. So, we've talked about organic material and why it's important, because it usually contains pathogens from infected patients. And organic material is a food source for bacteria. Yum, yum, yum. And they multiply rapidly. It dries, as we said. So, to protect the shell of the organism, hard to clean, promotes biofilms, and inactivates many disinfectants. But I want you to look at the upper right-hand corner, the picture of skin floods. We shed 10,000 per minute of skin floods. Now, that's really important for a number of reasons. One of the things we know, things like Candida auris can live on dry skin. And the other thing that someone asked me, you know, we, in terms of OR, they wanted to put some of their waterless scrub in the room. They thought, well, we could go in the room and use it. And I'm thinking, no, because of skin flakes. So, there's a lot of questions you might be asked. And this is high-level disinfection booster pack by Joint Commission. So, as I said earlier, know where your scopes are, know where your probes are, know where your devices are. We'll talk about competency, the verification training of frontline staff, and someone asked about that. So, however you can do that, it is important to have that competency. And it is something, first of all, that's important. And secondly, that certainly regulators will look at. And know where your manufacturer's instructions for use is. It is important. If you have a contract, let's assume that you are using something that looks compatible with what the manufacturer's instructions for use is. And this is where a lot of organizations get into trouble. You can write to the company, the device manufacturer, and have them put into writing that this is acceptable. But sometimes organizations assume that they can make the decision, and it can lead to problems. And then finally, thinking about documentation. And this is just an example of something that you might want to use. So, all of those things can be important there. Now, let's talk about the decontaminant area. The first thing to keep in mind if items are going to be sterilized is that it starts in surgery. If the initial decontamination does not take place in surgery, it could be impossible to properly clean instruments. And I've had that problem sometime. Your sterile processing will say, I don't know, they didn't wipe down these instruments. You want to get rid of the gross blood, anything you can before it goes to sterile processing. Spray foam and those types of things to keep the instruments moist. One of the things that we see, some organizations use what's called back basins where they put the instrument in the water. But it is important that that is done. And a nice thing to do in terms of rounds, which I've done periodically, is go down, as a matter of fact, on one of my trips, I actually gowned up in decontam when I was doing some consulting, put on the heavy rubber gloves, looked at all of those things as instruments were coming back. And it's a great wake up call because we found some things that really did not take place. And we also found some things like sharps with instruments and they're supposed to be separated. So, a good little thing for you to do. And we talked about instrument cleaning and removing of soil. Now, the other question that comes up and is really important for infection prevention is this idea of immediate use sterilization. It used to not be called immediate use. It was called flash sterilization. And we realized that it was immediate use. And what that means is that it doesn't go through everything your sterilizer cycle. It's usually a lesser cycle. But the big thing is it really doesn't have chance to dry sometimes, so there are potential difficulties. It is important that there is enough equipment. Immediate use nowadays should be limited to those situations where maybe a screw is dropped on the floor and you don't have a replacement. It should not be used just because I don't have enough instrumentation. Dr. X actually wants to do six cases right in a row, so keep that hot topic. Now, how about implants? Well, first of all, whenever you have an implant, we know that implants need to be free of all contaminants and residues, which could potentially harm a patient. That's important, and implants must have a biological in them. Any load that has an implant must have a biological, and I'll talk about that. It starts during the surgical procedure with cleaning of instruments, wiping the instruments, and I talked about the back basin. I also talked about that sterilization is removal of all material, including spores. You have to have the right sterilization cycle. You have to follow the manufacturer's instructions for use for packaging and things and all of those types of things. We have different processes of sterilization. We have heat, which the steam sterilizer is preferred. We have gas, ethylene oxide, which is really, I remember when ethylene oxide was used extensively. Now, it's usually in large organizations, most organizations themselves, a large organization where they're producing equipment. I don't really see them used particularly in individual organizations because ethylene oxide has some side effects and items have to be aerated and many of those types of things. Then there is liquid chemical sterilization, but the contact time is longer. We don't usually see that in the United States, but in certain emergency areas or other countries, they do use what we call cold sterilization. What you need to know about is the monitors is you have the physical monitors, and they monitor time and pressure. We know, we've all seen this. There's a color and it's outside the container. Now, you also have other types of monitors inside the package, and we're seeing mostly that they're using these integrating and emulating, I should say, monitors, took me a second, because they're inside and you can at least see that things took place. But the gold standard, so the monitors say, and I should say that again, the monitors tell you that the heat and the temperature inside and all of those things have reached where they need to be and that's really important. But the gold standard is the biological monitor. What is a biological monitor? Well, it is something that is one of the hardiest types of things you can imagine. If it kills that, it'll kill everything. Now, you don't need to memorize this, but I have seen this as a test question sometimes. In steam sterilizers, the biological monitor that they use is called Geobacillus Stereothymophilus, and in ethylene oxide, it's a Bacillus Atrophaeus. Those are used in monitors. What it's telling you with the biological is yes, the organism has been killed. It's placed within the process and incubated after the sterilization cycle is complete, and the indicator is evaluated for growth to indicate whether or not the sterilizer has succeeded or failed. When do you use one? A biological monitor should be used for routine load release, routine sterilizer efficacy, and periodic product quality assurance testing. It needs to be run a minimum of weekly, but daily in most organizations and whenever there is an implant. It needs a biological. We need to make sure that all organisms are killed. The other thing that's important is that you must have a recall process for biologicals. If I have a positive biological, say I had some growth, that's an important thing. Now, it may be that someone set the parameters wrong on the sterilizer, it was user error, and that there's nothing wrong with your sterilizer, but you must recall everything in the load, in previous loads since the biological was used. You must re-challenge it, and oftentimes, we will find that it really was just a user error, not a problem with our sterilizer, so obviously, we would recall that load. The important thing is re-challenging that sterilizer. We talked about the environment. Cleaning is the first step, and it's vitally important to follow the manufacturer's instructions for use. That was a lot of information. What you're going to do with that information is have a high level of awareness as to what needs to be done. Know that if you're new and you have a small surgery area and you're by yourself, and they say something, a biological failed, knowing what to do and reaching out if you don't know. But one of the things we talked about, and we'll move on with this sterilization and disinfection, is how do we influence, how do we engage, and how do we educate our caregivers? We've got a whole other area that we need to think about. I just want to, first of all, just focus on education. We have evolving and emerging best practices. One of the things about education is attention to basics erode over time. One thing I will say is that infection prevention is no longer the Cinderella program. Remember, teaching can occur without learning and learning can occur without teaching. As our role, we are a contact expert. We have to develop, facilitate, evaluate teaching and learning. We want to create an environment for participation and interaction, and we want to help stimulate reflective and critical thinking to promote good practice. That's a lot. But there's a lot of opportunities for you as infection preventionists, national conferences, annual competencies, looking at special topics of interest, grand rounds, community speaking, orientation. One of the things about orientation is that you have a lot of diverse backgrounds and educational levels. How you do your orientation in your own organization may be specific to you. But one of the things that I have found is that you have a lot of diverse backgrounds and educational levels. If you've got everyone in the hospital at general orientation, you want to be careful about information overload, and you may want to have your orientation in different segments or different ways. So you want to focus on one to three key objectives. You want to provide handouts. You want to prepare questions to engage the group. And one of the things that's been very, very successful are games and contests and things like that. Since COVID, I found a number of organizations actually do some things online orientation. It is acceptable as long as there is a method to check back. And they're pre and post-test, and even some of the online things actually do games and things like that. So there's a lot of opportunities. But one of the things that we do know about learning is that it's meant to have a persistent change in performance that results from experience and interaction with the world. So that means that we really need to think about effective education. One of the things that happens is rapid change, info overload, staff turnover, or the message is not tailored to the audience. So if I'm trying to educate, and we're going to talk a little bit about environmental services, we've got to tailor our message to the audience. So one of the things I think about with education, we talk about formal things. We're in an education session now, so we know that. But we need to realize that in our roles as infection preventionists, that education is going on constantly. People are looking to us for leaders. So every infection preventionist is a leader. Now, you may not be a manager, you may not manage people, but you are a leader, and people are looking to you. One of the things that I find oftentimes is we need to think about that education that comes up sporadically. Oftentimes, a unit will call you and say, I'm having difficulty with this, or we've got this patient, or we've got a situation. The best opportunity for education is in the moment education, because that's something that people need to know and want to know. And I find that best. The other thing, and someone brought that up very beautifully yesterday, is this idea of coaching. Part of your job as a leader is not to be negative, but to be able to coach others, to be able to help them. And when you do, they see you as a resource. So a lot of learning styles, if you do have hands-on, you know, playing games, theorists, people, pragmatists are practical situations with goals. Don't pigeonhole people. One of the things I like to do sometimes is to give people scenarios. So if you're doing an online in your hospital and things like that, and it's something you've gone through, you know, give them a scenario when it's worked very, very well. And think about things like that where you can be creative because that is important. Now, we've got all kinds of different learners, you know, we got our visual learners, they sit up front, they take the notes, they need verbal instructions. We've got people who do like lectures. One of the things that is important if you're doing in-person learning is give people opportunity for group discussion. You know, there's so much learning that takes place, but whenever you can involve them. And then we've got different learners that want hands-on experience, they want to role play, they like frequent breaks, and they just want to do it. So I think for adult learners, their readiness to learn is affected by their need to know. So don't ignore those opportunities. Don't ignore those opportunities when someone needs to know and have that one-on-one with them. And they can get bored easily, so remember that. And the other thing I'll just talk about before we go into the specifics of some of our areas where we need to work with them is humor can be a tool. So it's got to be relevant to the content. It can't be sarcastic, but it relieves tension, it breaks the ice, it increases motivation, interest, comprehension, and it can bridge cultural gaps. So always think about humor as a tool. I think sometimes that sharing things that we've done ourselves that aren't particularly helpful might be a tool that you can do. And we all know we've had situations in which we've got it wrong. And so I always like to use that as a learning and sometimes as a bit of humor. Now, with hand hygiene, I think that's one of the things that there's a lot of opportunity there. We do know that, you know, I love the bear picture or some of these types of things as well. And when you're monitoring hand hygiene, it's really important that we give coaching feedback, many things like that. So I'm going to talk now, I'm going to switch gears for a moment, and I'm going to talk about environmental services. And we want to connect the dots to the ultimate goal. And our real goal is keeping patients safe. So when we talk about environmental services, they're one of our largest stakeholders. Well, they're a large stakeholder. Our largest stakeholder, I think, is nursing most of the time. But I want us to think about this. I know it's an old story before most of you were born. But having said that, during a visit to the NASA Space Center in 1962, President John F. Kennedy noticed a janitor carrying a broom. And he interrupted his tour, and he walked over to the man and said, hi, I'm Jack Kennedy. What are you doing? And he said, well, Mr. President, the janitor responded, I'm help putting a man on the moon. Now, that's an old story, and many of us have heard that. But I think it's important when we talk about how we're going to influence people. So I gave you a lot of information today and a fair amount of information yesterday. But now, as infection prevention leaders, how am I going to be able to influence people? And when other people realize that what they're doing makes a difference, when what they're doing can really change things, they become more involved. So the idea of environmental services, if nothing else, COVID kind of helped us realize that there is definitely an increased focus on the environment. And we talked about it earlier, multi-drug resistant organisms, studies supporting the role of the environment, regulatory and accrediting agencies, and also our patient and resident satisfaction. And when we look at cleaning, we talked about this earlier, the colonized or infected patient, we've got the contaminated surface. And then we've got what happens if we don't clean and disinfect. We've got colonized patients, susceptible patients, and health care worker hands. And we also know that we have environmental reservoirs. And actually, this came from Project Firstline. And I think it's really a nice, nice drawing. And it's something that I definitely would use with environmental service people. Because it says, although we can't see, germs are everywhere and they need somewhere to grow and a place where they can live. And these are called reservoirs. So talking to our environmental service staff, we may be able to use drawings like this to say, you know, what you're doing is really making a difference. You're a part of the infection prevention team. And as such, you're making a big difference in many of these types of things. Some of our challenges with EVS is that they have not traditionally been an integral part of the IP team. So if you have infection prevention committees, I know in small hospitals, they also maybe have it under a safety committee. But make sure EVS is part of your team. And the other thing is that oftentimes, institutions run at or near 100% capacity. And we have this quick room turnover, this quick discharge, and quick admission of new patients is a priority. Well, I will tell you, that is a real problem. As a matter of fact, one of my stories is that I always wanted to be a nurse. Now, we talked earlier that not all infection prevention nurses are nurses, nor should they be, because there's a lot of other backgrounds. But I always wanted to be a nurse. I was so excited. And after my first year of nursing school, I got to be a nursing tech in a small hospital. And really, I was pretty clueless. I didn't know much about microorganisms, those types of things. And I remember the unit I was on was near capacity. And they were giving me all these tasks to do. And I was running around and trying to get to where I needed to be. And there was a discharge. And at that time, we did the room cleaning and the clean bed. And the ward clerk, not even a nurse, came to me. And she goes, they are bringing this patient up from the ED right now. Have you cleaned the room yet? And I said, I know I didn't get a chance. She goes, I know this was a clean patient. Just put clean sheets on there. It'll be fine. Can you imagine that nowadays? And yet, I did what she said. So time will tell. But the other thing that I think is important for you to think about that in your own organizations, have you shared outcome data with EVS staff? Have you helped them understand the importance of the role they play? Well, we had a C-DIF task force. And we would give EVS. Actually, it was even highlighted in a journal. And the Wall Street Journal actually took pictures of our EVS staff with the epidemiologists because we had had such good results. And one of the things that we did was give them C-DIF data each month or every time we produced the data. Now, we didn't give them patient names. We didn't give them standardized infection ratios. But we gave them C-DIF data. And they really seemed to appreciate that and to really say, wow, this is great. But if we're going to bring evidence to the bedside, we have to involve EVS as an integral part of infection prevention. Given what we see with the environment, it's important. We need to share outcome data. So we might give them things like even a number of new MDROs on a unit. But certainly, we give them back the number of C-DIFs. We want to enhance observations with objective data. And most important, we want to require leadership involvement and support. And that leadership involvement means going all the way to the highest levels, even the C-suite, to say, great job, people are doing a wonderful job. So the process is that health care institutions may be able to lower their rates by even improving these practices because this domain is something that really needs better designed research, reinforcing hand hygiene, strengthening the cleaning and disinfection, all of those types of things. Well, the other problem we have, it's not just EVS. But there is an assumption that environmental services cleans everything. Well, that's their job. And we need to understand what types of things are cleaned by the multidisciplinary team. So here's kind of an example, certainly, things that we have used, again, each organization has to think about that. But who does clean some of these things, especially things that are cleaned by nursing? I mean, if you have a patient who has an IVAC pump and is in the hospital for a month, who's wiping that down, not environmental services. And looking at who does what and when it's cleaned, these are things that might help. Now, one of the other approaches certainly is using pictures and saying who are they used and by whom. For instance, hand gel dispensers by EDS or blood coughs are cleaned by nursing between use or IV pumps. And thinking about our competency-based training and audit and feedback. So visual assessment can only identify gross lapses in practice. And so we need objective measures and feedback. And I love this. Well, I wish I had this every time someone didn't perform hand hygiene. But there are a lot of enhanced monitoring tools. There's looking at things. And we did go in and look at the checklist during our C-DIF thing and really watched environmental services. There are swab cultures. But the two systems that I think are easy and can be used are the fluorescent gel and the ATP. So here is the ATP. And many of you might be familiar with this. And here is the fluorescent gel. And the ATB is a, it's used in the food industry. And I can never say it. But anyways, it reads relative light units, adenoglutin, anyways. Having said that, it reads relative light units. So I always say, well, it's kind of like measuring crud. In other words, it doesn't tell you about cultures, but it does tell you that cleaning was done. And there aren't official boundaries, but usually you say you're always going to get a little bit in there, but it should be somewhere below 200 or so. What happens, it's a great teaching tool. You use these swabs and you stick it into the nanometer and it'll give you a reading. Now, if you've got, particularly with environmental services or even sometimes with nursing people and things like that, things nursing has to clean, is that as you use your swab, and if it's an area that should not have been contaminated, you can stick it in there and you get this relative light unit. If it's under 200, great job. I have come up, for example, in the OR. And you've got everything now that's computerized and it's morning. So the computer keyboards and everything that they use should be clean, correct? And so you stick your little swab in the nanometer and you get a reading of 3000 or 4000. And I've seen that happen. All of a sudden people's lights go on, like this has not been cleaned. So it's a great teaching tool or you might use it periodically. It's a hard thing to do all the time, but it's great for environmental services. It's a great teaching tool. And I'm sure many of you are familiar with it. And then the fluorescent marker system, which is like the glow germ or what have you. After cleaning, you put it in a specific spot and then see if after daily cleaning or terminal cleaning, if it's removed and if you can still see it, you know that wasn't cleaned. So the advantages of these is that you can combine with infection surveillance to identify gaps and strengths. And I guess that's what we're talking about. Because we talked about the role of infection prevention. You know, one of the things we can do because we are everywhere or can be everywhere, we can look at our data and then we can look at what we identified where our gaps are. We can monitor adherence to infection prevention standards and it should be an opportunity and not a punishment. Well, in our C-DIF collaborative, we developed some check sheets that we use. These are the different hospitals. It was a city-wide thing. And we would go in and we would watch them, you know, perform things. Now, obviously direct observation isn't the best tool, but it's really helpful sometimes when you're using that checklist and looking at what's going on. And we even encourage people, look, you can't memorize everything right away, use the checklist. So that's a great tool. And the other thing is we can use isolation practice checklists. So if we're talking about environmental services or talking about other areas, we can use isolation checklists and look at things. And I think it's important that we begin to look at these things and get aggregate data. How are our isolation practices? What are we doing? What types of things might be going on? And when you do your checklist, and some things you don't have a checklist for. So you wanna ask yourself, am I gonna be doing multidisciplinary rounds and I just want a general checklist, or am I going to be going down to endoscopy and am I going to be making rounds and seeing what's going on? Some things there aren't checklists for. So do you do routine checklists? Are there checklists that are routine? How about manufacturer's instructions for use? I have seen, I repeated that earlier. I have seen surveyors, particularly with high-level disinfection or some type of thing, take the manufacturer's instructions for use right out of the package inserts and have someone walk you through it. And then how about outbreaks? If I have an outbreak in a certain area, that's when I want to do a targeted assessment. I wanna see what's going on. I wanna go down to endo. Or someone mentioned in the chat, looking at outbreaks and things like that. What are they doing within surgery? Those types of things. And sharing that information. And the one thing to keep in mind, and I think it's hard because we all get sensitive and we think we're doing a good job, but to say to people, I'm gonna come in. I wanna watch what you're doing. I wanna learn myself, but I also wanna see if there's anything we've forgotten as new things come out and some of those types of things. So it really helps us kind of build that, I would say mutual trust, so to speak. Now, the other thing, and I think many of you are familiar with it, but I love these. This is a CDC checklist that they come out. And the reason why they use this checklist is it's called quick observation tools. And there's like 19 of these. You can go on the CDC website. You can look at the checklist. And they're just very, very quick tools, whether it be central venous catheters or ventilators, thing airborne isolation. These are great tools to use and it really helps you. So I would certainly recommend using these types of things. One of the things that we do know about checklists is it does help us, first of all, remind us of what we need to look at. And secondly, just to standardize behavior. The other thing I will recommend sometimes, let's just say that I have a problem with contaminated blood culture. So now I'm getting a number of quag negative STAT draws. One of the things you can do is go up and talk to people and have a conversation. Hey, tell me how you draw a blood culture. And I know people who do it all the time. Walk me through it if you can, just unofficially. And if you've got five people and you get five consistent answers, you know you have some content validity that your process is in place that people know what they're doing. But if you start asking people and people go, well, you know, I do it this way. I know other people don't. Yeah, or they skip steps or things like that. You might say to yourself, well, the process isn't hardwired and it's a good way, particularly with procedures or things that you do all the time or someone does. It's important to know that if our procedures are hardwired or not. Now, this is another one. And I like this one as well, because this is a great CDC tool and you can look at reprocessing high level and liquid sterilization. And, you know, just questions like this, is the pre-processing dirty area separate from the clean area? Is adequate space allotted for device inspection? Do we have that? How about the traffic flow? And that's important. Remember that we start soil. So things come in soiled, they're decontamined. You move along, look at those things. Is there readily available PPE? Eyewash stations are a high risk area that they look at and the maintenance of those things. And there are more, but I just give you an example of that. And then for our outpatient settings, I think this is great. It came out a while ago, but it is still available. Infection prevention checklists for outpatient settings. Minimum expectations. So environmental cleaning, does the facility have written policies and procedures? Who does the cleaning? Do you use, do you outsource it? Who's doing it? Looking, one of the big things in terms of rounds in our outpatient areas is safe needles, needle boxes, those types of things. Environmental services, receiving job-specific training and competency. And not only in our areas as well. And then training of equipment and PPE and all of those types of things. So all of those are really, really important. I think sometimes we have to realize that the people that we're auditing, the people that we're working with, 90% of the time, probably larger than that, 99, they wanna do a good job, but sometimes they're hurried and they can't get it done. And oftentimes we can help. We certainly have the ear of administration very often of many of those types of things. So in conclusion, I know I've presented a lot of data, but there isn't a substitute when something adverse occurs. There is not a substitute. You know, it is not good enough then when you're having an outbreak or something to say, hey, is everybody following manufacturer's instructions for use and making sure and going down and looking at the policies and how they're doing things. And so I really wanna leave you with that. The second thing I wanna leave you with is that open dialogue with staff members is an aspect of rounding. Tell me what's going on. You know, one of the things I have found sometimes is that we're really quick to jump when things come out and we wanna get the policies and procedures in place, but sometimes our policies or our procedures are so complex that they really aren't realistic. So we need to talk to people on the front line and figure out what's troubling them, what's difficult to do. And then finally, of course, are our high-risk areas or our procedures that lend themselves to rounding. So if you're new, I hope I've left you with some key thoughts particularly about the environment, about cleaning, about the fact that, you know, these types of things are so very important. And most importantly, to leave you with the fact that you are a leader. People are gonna look to you for guidance. And the more you can be a coach, the more you can involve people and help them realize that they are the people on the front line, whether it be EVS or nursing or anybody else, and that everything they do really leads in the prevention of infection, leads to patient safety and improve patient outcomes. So with that, I am gonna stop, see what questions there are, but thank you for your time and attention. And the most important thing is, I'm passionate about infection prevention, and I hope you all will be as you, for those of you who are new that start on your new journey. So thank you again. Perfect, thank you so much, Linda. We do have a couple of questions here. Before we address those, if anybody has any final questions, I would encourage you to go ahead and be typing those into the Q&A option found there at the bottom of your Zoom window, or if you don't see that option, you can of course type your questions into the chat as well. So I'm gonna go over to the chat first, and this is kind of a combined question statement that says, I was informed on Tuesday that I would take over infection prevention immediately, and I have very little experience in infection prevention. Our facility is expecting a DNB survey this month. Do you have any recommendations to help me prepare for the survey? And then thanking you for all the information that you have provided today. Well, I think first of all, is ask for a copy of the last survey. DNB comes yearly, ask for a copy of the last survey, and then ask, and usually it's either your regulatory or your quality department, ask to go through what their guidance documents are. For example, I know I use joint commission and I would wanna look at the joint commission regulations. So those are the two things, but I always look at past surveys. Because they are going to wanna see that anything to do with infection prevention was definitely cleared up. That's a great suggestion. Okay, and then this question asks, what is the standard for making bags of ice for post-procedural pain? Can they be pre-made and stored in the freezer? And if so, what is the timeframe for disposal? The pre-made bags of ice, again, hopefully is going to be in some type of container or you're not just gonna take it out of the freezer and put it on the patient. In other words, there's gonna be some type of barrier there, whether you have some bags or how that it's covered. So I think that with that, we're going to make sure that the ice stays cold and it doesn't melt. So I would not think there is a timeframe unless somehow ice is directly melting or touching the patient. But if you have something that's fluid resistant between the patient and the ice, it should not be a problem. Great, and this next question asks, do you include any additional team members during rounding, nurse manager, charge nurse, et cetera? Yeah, it depends on the rounding we're doing. So there are many types of rounds. First of all, there is the safety rounds where we have the nurse manager and we have the safety manager, materials management, people like that. And we're doing high level rounds. In other words, we're looking at everything is clean, blood, all those types of things. Now, we also have some focus rounds. For example, we started urinary catheter rounds where I took the nurse manager, the nurse who was caring for the patient, and you can combine them with central line rounds. And even our medical director liked to go and we would go in and we'd look at the urinary catheter as the bag off the floor. And then we'd ask the question, what criteria does Linda Green meet for having a urinary catheter? And so it gets the nurse thinking, those types of things. So you can have focused device rounds where you take other people. I love to take the managers, and if so, if you're looking at anything focused like that, take the nurse who's caring for the patient. I know nurses are very busy, but it's a great learning objective to say, am I really following guidelines? And look at the central line dressing, is it intact? So that's something that I have done and has worked well. Great suggestion. And then it looks like this might be our last question here that says, I love that you're talking about continuing education for infection preventionists. Often when funds are limited, education budgets are cut first in a facility. Could you share any minimums that you would suggest so that the IPs can be their own best advocates when discussing education with the C-suite? Well, it's hard to talk about minimums, but it is essentially important. I would say essentially important to at least annually have some type of education, whether it be, for example, this is an educational opportunity. Look at things, look at your APIC chapters sometimes, though they will have those, but make sure you have some type. I would say, and I'm not so much talking hours, but I'm talking about need. What do I need? What are my priorities right now in my learning area? And I do recommend when you're new that you attend training programs and then annually to have some type of thing. And there's lots of things online. CDC provides some. I always want, the best thing I can think of to advocate is to say, to use any, what can I say? Any need to your advantage. We have got this problem and we don't know a lot about it. I need to go so I can find more out about multi-drug resistant organisms or our CLEBSI problem doesn't seem to go away. I think we've done a lot, but we need training. So use your negatives to never let a bad feeling not become an opportunity, so to speak. That's great, that's a great way to put that, absolutely. Okay, just make sure you have a great idea to connect your findings for your opportunities. So that's wonderful, I love that perspective as well. Okay, I don't see any other questions. We've received so many wonderful comments that this series has been extremely helpful. And so we are just so thankful to you, Linda, for your time and the information that you've shared with us yesterday and then again today. And I know at the very beginning when Linda opened us up today, she did have her contact information on that first slide. And there in the chat, I did include a link to the slides again there for you all. So I know that she would welcome you reaching out if you have maybe a more sensitive question that you just didn't feel comfortable asking in today's format that you'd like to reach out to her directly, or you can always submit your questions to us at education at gha.org. And we'll be happy to get those over to Linda and get the response back over to you as well. And I did go ahead and just provide that final reminder there for you in the chat that you will receive an email tomorrow morning. You should have also received an email this morning that included information from part one of yesterday's session. But in tomorrow's email, you will again receive a link to the recording of today's session and then a link to the slides. I did of course go ahead and provide that link there for you in the slides as well. Just note that it does come from education, noreplyatzoom.us. So possibly if you didn't see that email in your inbox this morning, then I would go ahead and check those additional folders, your junk quarantine spam folders. And if it's still not there and you'd like to go back and access the recording of yesterday or today's session, we do record these as on demand, meaning that you can use that same Zoom link to access both the live session and the recording. And then each recording is available for 60 days from the date of that live session. And then you will just need to click on that link, type in your information, that will prompt an email to come to us to approve your recording access request. And then you will receive a follow-up confirmation from Zoom letting you know that we have approved your request. And then again, you will have full access to the recording for 60 days from the date of each live session. Just seeing lots of comments here saying wonderful session, thanking you so much, it was very helpful. And so again, if we can be of any further assistance or if you think of additional questions, please don't hesitate to reach out to us at education at gha.org. And again, Linda, thank you so much for your time and all of the knowledge that you shared with us. Thank you so much. Have a good one. I hope you all have a wonderful afternoon. Thank you. Bye-bye.

Linda Green

cleaning practices

sterilization practices

disinfection practices

healthcare settings

semi-critical instruments

pill packs

manufacturer's instructions

contamination prevention

healthcare-associated infections

protocols for sterilizing

infection prevention strategies

environmental cleaning

staff training

monitoring practices