February 8, 2022
Let's Talk Solutions: Infection Prevention with Erva Trotter and Luke Draper of UCHealth
Amy and Jon sit down with Erva Trotter, EVS Director at UCHealth University of Colorado Hospital, and Luke Draper, Infection Prevention Specialist at UCHealth, and discuss infection prevention, how to reduce HAI's, and keeping facilities safe.
Hey, everybody, welcome to this week's episode of Let's Talk Solutions: Candid Conversations with Healthcare leaders. I'm Jon Amos.
I'm Amy Fritzer and this week we're going to be discussing infection prevention and how the COVID-19 pandemic has impacted how hospitals and healthcare facilities fight to reduce hospital acquired infections or HAI’s, as well as infection prevention’s role in keeping patients, staff, and visitors safe.
Today we're joined by two very special guests Erva Trotter, EVS Director at the UC Health University of Colorado Hospital, and Luke Draper, Infection Prevention Specialist for UC Health. Welcome, Erva and Luke. We really appreciate both of you guys being here and bringing your expertise on this important topic. Let's get started.
All right, so Erva and Luke, thank you so much for joining us. I'd like to start just by opening the floor to both of you just to kind of explain some of your background and your experience with infection prevention. Luke, we can go ahead and start with you.
Great. Thank you guys so much. I really appreciate the chance to come to talk with you guys and talk a little bit about effective infection prevention, which is great. So, my name is Luke. I've been an Infection Prevention Specialist for UC Health for about two and a half years.
Before that, I've got a background in microbiology and public health. And in between that, I also did some work at a vaccine company. So I've been able to kind of hit a couple of different sectors related to healthcare and biomedical sciences and that sort of thing.
I did my Public Health degree in Hospital and Molecular Epidemiology, which is about as focused as a master's degree toward infection prevention as you can get, which is great. And you know, I was able to start working in infection prevention and then COVID hit and I've kind of been through the rodeo of COVID and everything, and it's been quite an experience, but it's also been really rewarding. So, happy to be here.
Awesome. So Luke, what did you say you got your degree in again?
So my degrees, I've got a Bachelor's in Microbiology and then a Master's of Public Health in Hospital and Molecular Epidemiology.
That's taken me about two years to not trip over it every single time. So I'm like, finally, to the point where it's not.
That's awesome. Erva, how about you? What's your background in infection prevention? I know you've been in EVS for a while, so won't you dive into that?
Yeah. Well, I just want to start with gratitude, thank you guys for having me on. My name is Erva Trotter, EVS Director here at UC Health. I've been with UC Health for about two and a half years.
I started with HHS in December of 2008, so time is definitely flying by. Coming up this December will be 13 years. I worked in EVS within many organizations such as ACA, Tenants, CHS and now UC Health across some of the states of Texas, Mississippi, Florida and Colorado for HHS.
So, time flys when you’re having fun.
So, obviously you guys are right in the thick of things, especially with COVID and HAI’s as they're called in the industry are major safety concern. When you say ‘HAI’s’ most people say ‘I don't really know what that means’. What exactly does that mean?
Yeah, so HAI is kind of an umbrella term. It's something that the CDC uses to define something that a patient didn't come in with, and then they get to the hospital, they pick up some variety of infection, and there's a whole bunch of subcategories that part of my job and part of the team that I work in this job. We look at cases. We determine if they meet the criteria for those different types of HAI’s, and then we put in interventions based on that to see what we can prevent.
So there's a couple of main types of HAI’s. You’ve got SSI, which is a surgical site infection. You've got CAUTI, which is catheter associated urinary tract infection. He's got CLABSI, which is central line associated bloodstream infection. And then you've got C-DIFF, which is a spore forming bacteria that causes diarrhea.
Where would that come from?
So C-DIFF is listed as spore forming, which means it creates this hard coat around the bacterium, and it makes it really, really, really hard to kill. And so maybe you have a patient who picked up C-DIFF, it does exist in the community, but maybe they picked it up, came into the hospital, they're having diarrhea and the C-DIFF is spread in that diarrhea and then it gets into the environment. It gets onto healthcare worker hands and can potentially spread from person to person. So, that's one of the metrics that I do a lot of work in and I can tell you it's it's hard to prevent, C-DIFF is really good at not getting killed and getting to the next person.
So in terms of monitoring and providing hospital surveillance of that, what does that look like within the hospital setting?
So most hospitals use what's called an EMR, which is an electronic medical record. And so at our hospital we have EPIC, which is one of the big ones. And it's a software that we use that has all the information in the hospital.
So, it’s going to have a patient’s medical record. It's going to have all of their tests, it's going to have all of their different labs, notes that providers put in about them, the monitoring that's done, so you can get the full picture of a patient in that medical record.
The big useful component is we can then use all of those labs to get aggregated into reports. So, you know, every C-DIFF test goes on to report that says, here's all the C-DIFF tests.
Then, part of my job is reviewing those kind of determining what is going to happen with that case. Or let's say someone has a bloodstream infection. EPIC is going to tell us ‘Hey, this patient had a blood culture, take a look, see if it’s CLABSI’, and then it'll feed us all of these cases to go looking. So it's a really, really powerful tool and we have a whole swarm of people whose whole job is to improve and work with EPIC to make it serve our needs and serve the needs of frontline providers and all that stuff. So, it's really powerful and a great way for us to monitor every scene that goes on in the hospital.
On HAI's and EVS...
So then switching gears, I mean, Erva, obviously you oversee the EVS department for UC Health and working, I would imagine, hand-in-hand with Luke's team and the infection prevention team. How does EVS play a role in preventing the spread of HAI’s or containing them?
Or, you know, are there protocols that you guys follow? Are there certain cleaning procedures that you guys utilize?
Yeah. So just partnering with infection prevention, I know Luke's team every morning we get generated emails of patients in the hospital that may have C-DIFF, that may have CRE or any other known diagnosis, where housekeeping can play a part in doing certain cleaning practices and standards within those rooms.
So, just having a generated email, being able to present that to our staff on the front end prior to them starting their shifts helps them to be better prepared. You know, our team needs to know what type of isolation rooms are out there, what chemical to use, the dwell time, being able to speak to it. And they're just more confident going into patient rooms, being able to treat different surfaces, and it makes everyone feel at ease from staff to patients as well.
On COVID-19 and infection prevention...
Hmm. So I'm wondering, obviously COVID is still very prominent and you know, we've had I don't know what number of wave we're on right now, but we've had several different waves of it.
But in terms of what it's like to operate under the conditions that COVID creates within the hospital. How does that impact your approach to HAI's? Does that impact how many isolation rooms are available for patients that may have an HAI? Or what is it like fighting HAI’s and reducing those in this kind of environment?
I feel like at this point, we've kind of reached, at least on my team, we've reached an equilibrium where we've been doing all of our COVID stuff for so long that it's just part of our daily routine.
And obviously, that's different for frontline providers. You know, last season you talked with Vince and Bill about the PTSD from COVID and the burnout and just how hard it is for people to see COVID patients every day and kind of go through this so that that does that obviously makes it difficult, right? If people are really tired, they maybe would forget to do hand hygiene or, ‘Hey, I don't know if I have time to give the maximum care I can, I need to do what I can to get to each patient’, which makes it tough.
But I mean, around isolation rooms we did a lot of retrofitting with our facilities team to say,’ Hey, let's provide as many negative air pressure rooms as possible’ because that was early in the pandemic and there was still kind of discussion going back and forth of is this a droplet spread?
Is this aerosol generated spread?
So, we needed to get as many isolation rooms as possible. So, there's been so much work done by so many different people, which is, I think on one thing, it's cool to see a hospital system work the way it's intended to where we have so many different people doing so many different things and everyone is out here killing it at their job and, you know, working at the top of scope. And so that's been cool, but it's definitely been difficult. It's a lot of work. It's kind of been the people say a lot like, Oh, this is the Olympics for you now.
Or, you know, I joke before this, nobody had any idea what my job was. I'd always have to try to explain what is an infection prevention specialist, what is epidemiology, and now everybody knows both of those, which is, you know, it's different.
Yeah, and from an EVS perspective, there were many changes from the beginning, just taking COVID as an example where only clinicians were allowed to enter rooms, then all of a sudden housekeeping was able to now go in because we've got new standards from the CDC. It got to a point where I think with COVID, the average length of stay was around eight days and then you can't go with a housekeeper not entering a patient's room for eight days.
And now that we have the proper PPE, Luke's team is helping educate our staff on proper donning and doffing and ‘Hey, it's okay if you have your proper N95 mask and your PPE, you will be safe’. So, you know, we owe it to those patients that were in there during that time that ‘Hey, you'll still see your housekeeper’ because we're in a time now where you're going to always have COVID patients, that there will be those units where we're kind of working through it.
On testing and cleaning procedures...
Are there tools that you and your team use specifically to test for those HAI’s in patient rooms? Or are there specific procedures that you use that help to clean patient rooms or clean ancillary areas or clinical areas where bacteria or infection might be at a higher level?
So currently we use ATP testing and ATP stands for adenosine triphosphate. It's measuring the growths on surfaces within patient rooms. This is something we typically start with educating on in orientation.
With our staff, we'll have them grab the ATP monitor, they'll be able to swab door handles, the mouse that they're using, even their cell phones in orientation, letting them know that when you're cleaning patient rooms, there are contact items such as over bed tables, bed rails, door handles, toilet handles that will be swabbed in the rooms to ensure they're at a safe level.
This will help control HAI’s within an environmental service standpoint, so we're not spreading germs to other patients. As team members are cleaning, they'll notice that there's things they just can't see. So I think, you know, using the ATP monitor as a second line of defense to help ensure that we're not spreading germs to patients that may come in the hospital.
So I know that in addition to ATP testing, there's other tools, whether it's electrostatic sprayers or something like that. Are there any other tools that you're using that assist in infection prevention efforts?
Yes. Currently, we use our Clorox T-360 machine, and this is an electrostatic shock that is a quaternary disinfectant that has a negative shock into a positive environment. And everybody knows that when you have negative and positive, that's the only way you can get things to kind of stick on.
But, we use this within our waiting areas and high traffic areas to ensure that surfaces are safe for patients while staff are cleaning, I always think to myself that no one's perfect. You know, you may not wipe anything, you may get distracted, and just knowing that you have a second line of defense where someone's coming through spraying waiting areas, nightly high traffic areas, that'll just ensure that surfaces are safe.
Yeah, and I know you were obviously shooting for true cleanliness, you know, actual disinfection, but in terms of also just the reassurance that you can give staff and patients, is there something you're doing to let staff know that you're using this, that you're doing this extra measure or that patients know?
How does that impact perception? And then just the reassurance that ‘Hey, we're working and healing in a safe environment?
Yeah, so within our waiting areas today, there is signage to say, ‘Hey, this area has been disinfected.’ You know, when patients today walk into a hospital in this climate, they’re expecting a sterile environment.
So, when you see police techs rounding, wiping things down, disinfecting, we've even gone to the point now where you'll see furniture being labeled, ‘Hey, this has been sanitized’, in the past, this is something that wasn't there. Now people want to see the words written on the furniture.
But having that reassurance that signage is there, someone's rounding, letting them know what process has been taking place is definitely helpful. People that come in the hospital, I'm reminded as we, you know, visit patients, managers are rounding within patient areas just assuring them that the room is being disinfected, you will have services completed for the day. I'm always reminded when a patient came in there saying, ‘Hey, my sibling had surgery about two years ago. This is my first time here. They had an HAI with a total knee. You know, I didn't actually want services because I didn't really want someone to come into my room to minimize that. But I asked for you to kind of come up here and talk to me’.
So, just as a manager going and explaining why we're wiping contact items, why it's helpful to visit patient rooms, because nurses are in and out. I want to make sure I'm disinfecting that light switch or wiping handles because so many visitors come in and out and knowing that, you know, we can play our part in disinfecting those high touch areas.
The patient was safe. They were actually glad I came by just to talk about our services and why we were needed and no better time now than having housekeeping services.
Yeah, no kidding.
Erva, You mentioned police techs. Can you explain what those are and their role in infection prevention?
Yeah, so you think of the word ‘police techs’ or someone that's cleaning, but there's a police tech who actually floats around the hospital and their whole role is to maintain an area. So at night, areas are cleaned from top to bottom.
A police tech may not have that time in a facility that sees 300 patients a day in a lobby or 5000 patients a day within our outpatient area. So their job is to maintain the environment from a stocking standpoint to a disinfection standpoint of someone leaving a waiting area to be able to keep it straightened up from furniture, picking up debris, you know, cleaning glass, cleaning high touch items and disinfecting.
They're there just to be out there to be visible. Something as simple as a spill. They're there to respond quickly because it's high traffic, it's the entrance door of the hospital or any waiting area that's extremely busy throughout the day. But there's someone just there constantly monitoring rounding around the clock.
On an infection prevention plan...
I mean, it sounds like you have quite a robust program and probably some pretty robust policies and procedures that you're following there and which kind of naturally goes into my next thought.
Luke, I would imagine this is more for you being the infection prevention guy, but I would think that the recommendation would be or the hope would be that most hospital systems, larger facilities, even smaller facilities would have some kind of an infection prevention plan or policy in place. Maybe even a team that manages it, a team such as yours.
So if they don't, I mean, obviously, I think the last year has shown that it's probably more important than ever, right? Just a renewed focus on it. So if you're putting together an infection prevention program, what are some of the components or maybe the most important components that should be included? Or, the team leaders that should be involved?
Yeah, we have what's called our infection control plan. Right. And so it has a variety of different things in it. We have the different types of isolations that we use. That's one of the infection prevention bread and butter. Now it's something everyone is more familiar with, aerosol transmission, droplet transmission. There's also a lot of what we call fomites, which is a physical object that can transfer a bacteria or a virus to the next patient.
So we want to make sure that we have plans in place to monitor what's going on in those. That cleaning is done correctly and surveillance for the HAI’s is done right. There's plenty of organisms that we do surveillance for that don't actually cause HAI’s like tuberculosis or we have Acinetobacter or Serratia. These are organisms that can cause serious infections in patients. And even if they're not classified by CDC as an HAI, we still want to make sure that we know what's going on with them. So our infection prevention plan really covers the bases of surveillance, definitions, rounding all of this stuff like there's a lot of different things.
So another piece that we use is what's called tracer methodology, which is something that was created by the Joint Commission, which is our hospital accreditation board.
And so what we do on a tracer is we will go out with a set group of questions and survey that. And so we'll look at the unit and say, 'Are you doing this? Are you not doing this'?
So some examples are going to be. Are you storing clean and dirty things together or separately? Do you have items that are labeled with the correct expiration date? Do you have linen that's covered and put away?
And so we can take all these questions that by themselves are kind of a one off little thing and combine that into how well is this unit reaching up to our infection prevention expectations? And then also above that our regulatory standards.
And so you can take all those questions, you can aggregate them into a report of, ‘Hey, we're at 80% compliance and this gives us a really good way to track where units are at and how we're going to fare during surveys or accreditation events’. It's really what it comes down to is how do we, you know, protect patients who are at their most vulnerable, medically or just in their life stage of, ‘Hey, I'm in the hospital’, no one wants to be in the hospital and it's our job to make sure that they come out healthier than when they came in.
Yeah, I'm kind of curious, too in terms of, you know, you have this infection control plan that you have. I think it's clear that a successful execution of that plan requires collaboration between every department and every team at the hospital.
What does it look like to partner with each department? Obviously, you're partnering with EVS, with Erva there, but then also nursing and then other departments. How do you kind of build that collaboration and really have a culture?
But from everybody at the hospital that this is something we're proactively doing every day. And it's not just EVS’ responsibility, it's not just infection prevention’s responsibility, it's all of our responsibility to make sure we're fighting this.
How do you kind of take something that's a formal policy and plan and get that through to it as something we're doing every day?
Yeah, what you said, it's everybody's issue. About a year or so ago, our team went through and made it like a team motto or whatever you want to call it. And one of those pieces was, we make infection prevention everyone's business. And there's there's some formal and informal ways to do that. Formal is we have what's called the Infection Control Committee, which is a every other month committee that meets and we go over HAIs, departmental issues and it has people from all across the whole hospital.
So we have lab, we've got facilities, we've got food and nutrition, we've got radiology, we’ve got nursing, we've got front line providers.
Everybody is involved and the infection control plan actually goes through that, as being reviewed. We look at our goals that we set for each year. We look at that. And so we really want to make sure that there's an active role that all these departments are playing, officially.
Unofficially, infection prevention, I think functions kind of in a consulting role where I'm not giving direct patient care, so a patient isn't really my customer as much as the nurse or doctor or department serving them is coming to me with questions. They're coming to me with, ‘Hey, can you clarify this? Can you walk me through this process?’. My medical director told me about the three days of consulting, which is being affable, able and available.
So, we really want to make sure that we are someone who people want to go to and say, ‘Hey, we're comfortable asking this’. They might feel it's a dumb question, you know, but when it when it's something that's medical, it's never really dumb question because anything that they get wrong can be a big problem.
So, we want to make sure people are comfortable coming to us, and we want to make sure that we partner with facilities, like with the air handler stuff that I was talking about earlier, creating negative pressure, we wanted to make sure that they're able to do it before we ask and then that they're able to monitor that and make sure that it's effective. So it's, you know, it's building relationships. And I think recognizing that we're here to serve people who are giving care or we're here to serve people who are like the EVS team, even, who are cleaning rooms. I'm not the one going in and cleaning rooms, but I want to make sure that they're comfortable and safe and prepared to go in and clean those effectively.
Yeah. Erva, do you have any thoughts on how your team has specifically collaborated with other departments?
Yeah, one thing Luke and I’s teams currently do is our collaborative round, so we have biweekly, collaborative rounds with the nursing and IP representatives tagging along as well. So we always think of who cleans what a lot of time you have a regulatory agency coming it's last minute, you're like, ‘Hey, I'm not responsible for that’, and I think we just have clear lines on who's doing what because we're rounding biweekly. We're looking at things that can be improved. Talking with our team members, they're understanding dwell times of chemicals on how we can improve the unit, so I feel like just that open line of communication week in and week out definitely plays a part.
And I would imagine a huge part of all this, the whole policy and procedures and program and all that is just ongoing education. I mean, you'd have to be collaborative on that too across all the different departments throughout the facility, whether it's clinical or non-clinical.
Luke, does your team kind of manage that as well or, Erva, does your team kind of manage that? Or do you kind of work together on that? Do you guys talk about, ‘Hey, let's focus on this issue this time with the whole hospital’? Or how do you kind of approach that?
I think one thing that COVID has really highlighted is how difficult it is to change policies and practices, right? So that's one thing we've dealt with a lot is, ‘Hey, when we ran out of our normal cleaning wipes in March, April, May of last year. Okay, now we're switching to bleach everywhere’. So now we have to educate everyone on how to use raw bleach, how to mix it safely and how to use it because it has a different dwell time than bleach within a wipe.
There's just a constant need to be on top of our education. And it's, you know, it's very important and we are fortunate that we share education duties with a lot of different groups. So EVS does a lot of their own education, we do a lot of education. There are nurse educators whose entire job is to educate nurses and make sure that they're able to speak that language really well. So our team does sit in the inner circle of education, and we do want to make sure that we're providing it correctly. But we're fortunate to be able to partner with other people who also share that responsibility.
On comforting patients...
And I know you touched on this earlier Erva, but is there anything that you coach your team when it comes to communicating with patients to help them feel safe? And then if a patient has a concern, how does your team address that?
Yeah. So you know, our housekeeper that goes in the room is going to see the patient the most. First, we want to identify if the patient is there or not and explain those services that are in the room.
Knowing that we use five rags, there's a proper protocol that you'll clean the bathroom last and the room first, letting the patient know what the rags are used for within the specific zones within the room and just kind of talking through your cleaning process to ensure that there is assurance is there that I won't be mixing or double dipping my rags while I'm in the room. Because patients are in the bed and they're watching and they want to hear those sounds – that the toilet’s flushing, that the sink’s running, that you're flickering the lights, and that they smell cleanliness. The smell of clean is even a trigger that's in the room.
But just kind of talking through the process. That communication is huge because patients – they don't know what you're doing. “Why are you wiping that?” That all kind of plays a part in the education process.
Our staff also alerts us if someone's not in the room. So you'll have a “sorry I missed you” card that's left there and a patient thinking “wow, did the housekeepers ge to my room?” So they'll leave that card and they'll alert their manager and say, “Hey, you know, Mr. or Mrs. Jones was out of the room. You should go by and see them and let them know that I did come by and recognize that the tent card was actually on the table and make sure they were satisfied with the services.” And since the housekeeper wasn't there to explain the services, the manager can kind of go through and reassure that those services were completed.
I can assure you that while you're getting an x-ray or down for surgery that we didn't skip your room. I think that's huge because if you missed that moment with the patient, that can mean everything during their stay.
Yeah, I think the education of both staff and patients is really important. But I kind of want to switch gears and dive into the specific partnership that IP and EVS have and how that kind of fleshes itself out. And kind of the daily cleaning protocols and things that you do, Erva.
A part of the cleaning protocols is when a team member gets to the floor. they're able to round their unit to identify the type of patients that they have. They're looking at signage. If there's reverse isolation, we obviously want to clean those rooms first to make sure that that patient's not compromised.
Well, we'll also clean our patients who are not in isolation. We'll take care of those to provide our services. And then we're letting our staff know to clean our isolation rooms last to ensure that we're not spreading germs on the floors.
On best practices...
In terms of with COVID and how those protocols have developed and evolved, Luke, how has your team been involved in tracking that, seeing what works, providing guidance maybe on how they can implement some of their best practices? How has that kind of been over the last 18+ months?
So isolation precautions – if you want to kind of get down into the the nitty gritty — they’re based on transmission based precautions. So what we do is we look at all the research that's been done in the field and say, how does this organism transmit from one to the next?
Because something like flu — that's a droplet transmission — is going to be totally different from like Pseudomonas, which is going to get on a surface or might get in a drain and gets to the next patient. So you have to understand what type of precautions a patient is on to really understand what type of cleaning they have to do.
I think the biggest thing at the beginning of COVID was droplet versus airborne. But we also ran into stuff like should people wear hair nets or change hospital scrubs? Because people were concerned that COVID would get in their hair or was going to get into the cloth of the clothing and transmit to the next patient.
So that's the biggest challenge of having a novel organism that comes out — we don't have this wealth of information and data as to how to combat and clean it. So we have to kind of ratchet it up as far as we can, and we need to make sure that we're safe first and then work back from there.
Fortunately, coronaviruses are not particularly hardy as compared to something like C-diff, so we don't have to use bleach. But then when we ran out of cleaner that would kill it, we did have to use bleach.
And so there's kind of this back and forth between what do we think is going to kill the organism? What do we know is going to kill the organism? What do we actually have on hand? Transmission based precautions give us a framework to start with and then we can adjust based on the needs for that specific situation.
So, Luke, obviously the last year has been pretty crazy for you guys and having a novel coronavirus. So when you were going through your training and your education and your multiple degrees, you know, did you ever train for something like that?
Did you guys ever discuss the possibilities of new organisms you might come across and how to handle that?
I'd say yes and no. So did I expect that we were going to have like a once in a 100 year outbreak six months into my career? No. But you know one thing that's great about public health and one of the reasons why it's being recognized and used a lot in hospitals is the modeling and statistical ability that our field has to project what may happen. If you look at major respiratory outbreaks that have happened in the last 40 years — round numbers — there's been about one every ten years, whether it's flu or SARS.
We've seen them with a somewhat cyclical pattern. Obviously, we can't predict when exactly there's going to be another one. But we're also not going to be surprised if there's another big respiratory outbreak.
So I think people in public health maybe weren't surprised that something was going to happen. But I don't think any of us really knew about the scale that we were going to hit. I've got a very specific memory about this. I think it was probably late February of 2020. I got called into a meeting with a group of providers and they were wondering if they needed to be worried about this. And this is when COVID was just kind of blowing up in China and hadn't hit the U.S. at all.
And I remember talking to them and saying that we have seen this type of thing before with bird flu and swine flu in SARS. So this isn't totally crazy. It's not here yet. But it might be.
We'll kind of have to see what it looks like. There are obviously different levels of population density. There are different levels of food practices and things like that that do play a role into how viruses move inside countries. But I very specifically remember being kind of like, Yeah, we'll see. We'll see what happens, you know?
And then fast forward, two months later, all of the alarms are going off. We're out of products. Everyone's losing their minds. It was kind of like, oh boy, this is not what we expected at all.
And you became the most popular guy in the room.
You know, I think we are very lucky to have a really deep pool of experience to draw on with our medical directors. And so we really had some great people working to try to figure out [our next steps].
Because we know what's going on today and we don't know what's going on tomorrow.
Having a proactive rather than reactive approach?
Yeah, definitely. So I was surprised as much as anybody else. But we did go into things like transmission precautions and preparing for a huge influx of patients.
I think our hospital has been very fortunate and very well led to be able to avoid a type of situation that people had in New York, where they were running out of beds and running out of ventilators.
There are a lot of things that play into it, but I think I'm very happy with and very pleased with how our hospitals handled it.
Erva, you've been around for a long time — you've been a director for 13 years. Did you ever anticipate this or what did you expect when you first found out?
Yeah. You know, when it first happened, you almost didn't believe it — thinking this isn’t really much and I'm sure this will go away. It's a hot topic that will last for maybe a month or two.
But it's still here today.
We're looking at over a year and a half where you just didn't expect something like this. But I will tell you, housekeeping is definitely important nowadays. Where everyone said no, they now say, yes, please come to my area. Can you disinfect? We'll give you whatever time you need. It’s become a culture of yes, now.
On the lasting impact of COVID-19...
I am curious in terms of how this changes not only standard procedures and protocols that you have, but also just contingency plans and preparation. What’s the impact COVID is going to have even after it's, you know, hopefully gone?
What's that kind of impact going to be, within the hospital specifically?
I think COVID has in some ways had some silver linings — there have been some good that's come out of it. Like our hospital stood up and took down and stood up some incident command centers, which really gave those folks involved a lot of experience.
They set up the command center. They answered questions. They got stuff done. And now we’re able to look back on that and see the things that we learned that worked and didn't work.
And it's really given us the ultimate testing ground to say, ‘Do we know how to respond to this?’ You know, can we flex our system to its breaking point and then come back stronger?
I think the good from an Environmental Services (EVS) standpoint that came out of this is, you know, things that are the second line of defense. We talked about ATP, and we talked about Clorox T360. There are some facilities that use UV lighting.
We have our hydrogen peroxide spray. That's what’s in a lot of our terminal cleans where facilities were on the fence at some point in spending money. I think now that's more so available because they know that it is creating a cleaner environment for our patients.
On moving forward...
Is there any worry from either of you guys in terms of, you know, human nature drifting back to the status quo? And how do you hold on to some of the silver linings like you said, Luke, and how do you keep those going forward and not let it kind of drift back?
Hopefully one day Covid's gone and we're past it, but yet how do you keep moving forward with some of the things we've learned and not let us drift back into some bad habits?
I think that's absolutely a potential. You know, I think human nature is to have a short memory. And fortunately, policies and things that are written don't have to have a memory issue set in stone.
So I think taking the opportunity we have to [implement some of those things] — maybe it's travel screening or maybe next respiratory season we have people who get screened for symptoms instead of just letting people get around willy nilly in a hospital during flu season. Maybe people will be more used to that.
It kind of reminds me of the visitor restrictions that we have in place. So during flu season, in past years, we'd have visitor restrictions on some of our heavily immunocompromised units, like bone marrow transplant or solid organ transplant.
And having those visitor restrictions is to protect the patients who are there. And so, well, you know, a couple of years from now, people may forget about that, but if we can put in policies in place that [let people know what we’re doing for flu season] and that we're going to have temperature screening or symptom screening for anyone coming into the hospital, I think we can.
I think we do have the opportunity to learn from this and really improve our practices in kind of those minor ways that don’t have to be everyone wearing a mask all the time (that’ll go away at some point). But I do think we have the opportunity to learn and move from there.
On balancing infection prevention and patient needs...
Yeah, I guess it kind of mirrors how 9/11 changed airport security forever, right? And so I think maybe there will be a similar effect.
I am curious, though, about bringing up visitor restrictions when you consider patient care and the impact of having a loved one [with you] can have on healing and recovery, right? How do you balance staying true to the infection prevention measures you need to have while also accommodating some of those emotional needs that patients may have? How does that work, exactly?
One of the big tasks that were given as infection prevention tests is to balance the risk of an infection or risk of exposure versus risk of whatever thing you're putting in place.
So, visitor restrictions have been a tough thing to work with this year. I mean, even just just recently, we've changed \to walk our restrictions forward a little bit and make them a bit more restrictive because we're seeing higher rates of COVID in the community.
And you know, I've heard stories of patients who said, ‘Hey, I came in on the day that you changed the restrictions, and if I had known, I would have gone to this other place’, and that's tough to hear. It's really hard to hear the impact it has on people because I think we can't downplay the emotional effect that can have seeing your loved ones or getting that family support during potentially the hardest time of this patient's life.
So. You know, so it's on us to balance if we have people coming in who might have COVID and they're giving COVID to maybe the patient that they're coming to see or giving it to some person they pass in the hallway, that's a risk that we have to balance.
We do our best to say, ‘Hey, maybe for these patients, you get one patient or you get one visitor a day for one hour or for these patients, you get two visitors a day for two hours’.
And so we kind of try to set up categories of, you know an end of life situation is going to be different from a person who came in for a broken leg, which is going to be different from, you know, a mom coming in to have her baby.
So, we just try to put in place clear policies so that our frontline staff are able to rely on that and look back and say, ‘I really understand that this is tough for you to hear. I really understand that, you know, you want to have your whole family here, but just out of, you know, out of an abundance of safety and wanting to protect you and the other people in the hospital, we're going to limit you to one visitor a day or two visitors’.
Erva, is that something that your team is aware of and that you're actually coaching them? ‘Hey, visitors, you know, they're not getting as many visitors, that's a need that obviously we can't fill completely, but we can kind of be that emotional kind of connection for some patients that are here’. Is that something you talk to your team about?
Yes, we have that conversation all the time because, you know, when visitor restrictions hit, we kind of play our part in going in the room, putting a smile on the patient's face. We're the only ones that you know or one of the few that comes in for something that's not touching the patient, moving the patient, poking the patient.
But we can go in there to have a conversation while we're in there completing our job. And I think that's huge. Just to be able to put a smile on someone's face, ask them how they're doing, especially when you get to know the patient, if you've cleaned their room several days in a row. You get to know them by name, they know you by name. They're saying hi, good to see you again, glad you're here. That's huge.
And building that relationship, especially when their family can't make it or they're there talking to them through an iPad or just over the phone. But, you know, just like you build a relationship with your nurse, you're also doing that with the housekeeping staff as well.
Luke, having that balance can't be easy, especially when we talk about human nature and like you said, vulnerability in patients, being by themselves and that certainly inhibits their healing as well. I would think now that it's been so long that there's probably more of a better understanding from families and things like that.
I mean, last summer, when my mother was in the hospital, she was at end of life, so we were able to go in and be there. But had she not been, two rooms down from her with someone who was a COVID patient, and their family was not allowed in.
And I specifically remember, I don't know if there was a spouse or a brother or how the relationship was to the patient, but was talking to the staff about, ‘Well, why can't I go in? Why can't my family come in and see her’?
I was kind of within earshot and they knew the situation that my mom was in. So I was wondering, Well, maybe that's if the staff didn't say, well, because she's dying. And so, you know, it was at that point they let us in.
Yeah, I think it's really important. You know, transitions or mindsets that we have to have as infection prevention tests or really any kind of health care provider is to see patients is not just a number, you know, not just their medical record number or 56 year old male with heart disease.
You know, like there's a whole person behind there and there's a whole family that cares about them. And I think, you know, it's obviously something that we've known about, but COVID has really brought that to the front.
You know, it makes it tough, makes it really hard to have those conversations. And so we just have to come in with a, you know, a sense of understanding and try to be compassionate and really say, ‘Hey, I understand. And I want to explain to you why this is for the safety of either your loved one or someone else's loved one’.
On increase in HAI's...
Luke, I'm curious if you've seen there was a report that came out, a press release by the Society for Healthcare Epidemiology in America. It looks like there's been an increase in HAI’S in 2020 from 2019.
Did you see that report?
Yes, I'm very familiar with those. And you know, there's I think there's going to be a lot of research that comes out in the next couple of years as to what was behind that. You know, I think we have a lot of anecdotal reasons, you know, of staff or busier or you have people who are using a lot more antibiotics.
So antibiotic resistant infections cropped up more or you have people who are ventilated for a lot more. That's I mean, that's one that I don't think we need any research for, you know, to know, ‘Hey, if we have all these ventilated patients who are not doing well’. There's another subset of HAI called VAE which is a ventilator associated event, and we saw a definite up cropping in those because you have way more people using a ventilator.
I think that's a really complex issue. It's one that, with C-diff specifically, I've been digging into for a year and a half and I'm still digging.
So, healthcare is complex. It's busy, it's messy. And as much as we don't want it to be those things, and as much as that's kind of our job to make things clean and simple, it's messy. And COVID made it a little messier. And I think we are now in the position to say, ‘Hey, next time we have flu season or next time we have a staffing crisis, how do we make sure that our hand hygiene and our cleaning and our other basic infection prevention stuff doesn't get compromised’?
On what to remember with infection prevention...
What would be the most important thing to remember when it comes to HAI’s or infection prevention?
Working with IP, being transparent, like Luke said earlier, no question’s a dumb question when it relates to healthcare. But if there's something that as an EVS leader that you want to recommend as a second line of defense, whether it's at Clorox T 360 UV lighting, I say you should bring it to your administrator or leaders attention and bring the facts behind it. You know, what are the reasons why we should have it? How can it improve your numbers, especially with patients? What one in five comes in hospitals that could contract an HAI?
So when it comes to the reason behind it, I think, you know, just asking those questions, partnering, sitting down during your infection prevention committee meetings and just hash it out, I think that's really going to be what's best.
So my ending plugs are going to be, wash your hands, if you're in the hospital and you see somebody not washing their hands, tell them to wash their hands. As a patient, I think that's important to advocate for, you know, help patients feel empowered to advocate for themselves and say, ‘Hey, I didn't see you wash your hands before you're coming in to access my line. Can you wash your hands, please?’. So I think that's one plug.
Second plug is I think there is a lot of value in infection prevention. There's a lot of value in the abilities that we have with data and the abilities we have with all the products to make strides in preventing infections. You know, we always want to shoot for zero infections.
We always want to shoot for SIR, which is standardized infection ratio of zero. And obviously, that's a very lofty goal. You know, some people might say it's not achievable, you know, but that's what we want to shoot for.
And I think COVID has really highlighted the value that infection prevention brings. The strength that a good infection prevention program can have and can really say, ‘Hey, we can prevent infections and we don't have to be at the mercy of bacterial evolution’, right?
We don't have to be at the mercy of these things that we can't see. We can make changes in behavior and cleaning and really, really make a difference in people's lives.
That’s awesome. Well, Luke, it's been awesome to have you on. Erva, I know we've talked several times over the last 18+ months and it's been great to have you on as well and just appreciate both of you guys' insight, and just all the work that you guys are doing out there on the front lines. I know I get to stay kind of tucked in an office and I'm not out there, but you guys are out there fighting it every day and I really appreciate it.
I echo. Thank you. Thanks, guys.
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