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INSIDE THE CURRENT ISSUE

May 2011

Infection Prevention

Infection Control Update

Hands-free water faucets found to hinder hospital infection control

A study of newly installed, hands-free faucets at The Johns Hopkins Hospital, all equipped with the latest electronic-eye sensors to automatically detect hands and dispense preset amounts of water, shows they were more likely to be contaminated with one of the most common and hazardous bacteria in hospitals compared to old-style fixtures with separate handles for hot and cold water.

Although the high-tech faucets cut daily water consumption by well over half, Johns Hopkins researchers identified Legionella growing in 50 percent of cultured water samples from 20 electronic-eye faucets in or near patient rooms on three different inpatient units, but in only 15 percent of water cultures from 20 traditional, manual faucets in the same patient care areas. Weekly water culture results also showed half the amount of bacterial growth of any kind in the manual faucets than in the electronic models.

While the precise reasons for the higher bacterial growth in the electronic faucets still need clarification, the researchers say it appears that standard hospital water disinfection methods, which complement treatments by public utilities, did not work well on the complex valve components of the newer faucets. They suspect that the valves simply offer additional surfaces for bacteria to become trapped and grow.

Infection control experts behind the latest study, believed to be the first detailed analysis to show how and why these new fixtures pose a problem in preventing Legionella infections in hospitals, say the electronic devices were widely introduced in patient care and public areas of hospitals across the United States, including in The Johns Hopkins Hospital, more than a decade ago. The idea was to prevent bacterial spread from people touching the faucet’s water handles with their dirty hands.

As a result of the study, conducted over a seven-week period from December 2008 to January 2009, Johns Hopkins facilities engineers removed all 20 newer faucets from patient care areas and replaced them with manual types. A hundred similar electronic faucets are also being replaced throughout the hospital, and hospital leadership elected to use traditional fixtures –The original goal of the research team, says co-investigator Gregory Bova, senior engineer at Johns Hopkins, was to test the new faucets to determine how often and for how long treated water needed to be flushed through the hospital’s taps to keep Legionella and any other bacteria at nearly undetectable levels. Study results showed Legionella bacteria levels between 0 and 3,000 bacterial colony forming units per milliliter of water from electronic faucet samples.

Researchers say their next steps are to work with manufacturers of electronic and manual faucets to help remedy their flaws and to design components that can be cleaned more easily and save water.

 
 DECEMBER 2013

IP Salary Survey reveals need for surveillance technology

by Susan Cantrell, ELS

Who wants to be average? Average is mediocre. Average is halfway to the bottom. No, average is not something to which to aspire. While there is no such thing as perfect, it is, nevertheless, an ideal to work toward. Infection control professionals (ICPs) are doing just that on a daily basis.

Using statistics gleaned from Healthcare Purchasing News’ 2011 Infection Prevention Salary Survey, we can paint a picture of the "average" ICP. However, make no mistake: there is nothing average about the average ICP. Infection control and prevention is not work for the faint of heart, it is not for those whose theme song is "it’s not fair"; it is not for those who can be content with the status quo. This is a special breed.
Salary survey history

Who she is

The 2011 Infection Prevention Salary Survey doesn’t hold big surprises this year. Again, statistics show that the average ICP is female (88.5%); Only 8.8% are male. Apparently 2.8% of respondents only reveal their gender on a need-to-know basis, because they chose not to share it with us. Her age is about 54, again similar to last year’s at 52.7 years. She holds a bachelor’s (45%), is a registered nurse (78%), and is certified by the Certification Board of Infection Control and Epidemiology (51%).

Mostly commonly, our average ICP’s title is infection preventionist. At 32%, this represents a slight rise from 2010’s 27%. The next most common title is infection control coordinator (21% in 2011 versus 20% in 2010). Our ICP most often reports to the vice president or director of quality or risk management (43%, compared to 39% in 2010).

The average ICP has worked in infection prevention between 5 to 9 years (24%, compared to 23% in 2010). She also has worked in infection prevention at her current facility between 5 and 9 years (27%, compared to 29% in 2010).

Salary vs. Job Function
Salary vs. Job Function

Our average ICP is employed, overwhelmingly so, by a nonprofit (66%) hospital (54%) that is a standalone but part of a group purchasing organization (37%) or part of an integrated delivery network (36%). The location most often is rural (41%), with suburban trailing close behind at 31%, followed by urban at 28%. Twenty-four percent of respondents work in a 100- to 199-bed hospital, which is similar to 2010’s at 23%. Her department likely includes only 1 to 2 employees (83%), which is similar to 2010 (80%).

Thirty-eight percent of respondents said they spend 100% of their time on infection prevention and control, which is up a little from last year’s 35%. From there, the numbers take a dramatic drop: 9.5% (11% in 2010) say they spend 90% to 99% of their time on infection prevention and control, and 13% say they spend 80% to 89% of their time on infection prevention and control. From that point, the numbers drop depressingly low.

Salary vs. Education
Salary vs. Education

Time not spent on infection prevention and control is spent on other duties such as employee health, 43% (2010: 42%); education, 27% (2010: 22%); disaster preparedness, 26% (2010: 24%); patient safety, 19% (2010: 13%); and quality-performance management, 15%, (2010: 15%).

The majority of respondents (79%), serve on a product-evaluation committee. Their responsibilities include the following: determine need, 65%; safety evaluation, 52% (2010: 57%); product testing, 45% (2010: 49%); education, 44% (2010: 44%); process improvement, 43% (2010: 48%); cost analysis, 36% (2010: 27%); define usage, 32% (2010: 34%).

Product areas for which supplies are purchased or specified by her department include but are not limited to hand sanitizers, 82%; needlestick/sharps safety devices, 64%; disinfectants/sterilants, 62%; masks/respirators, 61%; cleaning equipment and supplies, 55%; gloves, 55%; handwashing systems, 51%; and protective wear, 48%. The numbers deviate very little from the previous year.

Salary vs. Region
Salary vs. Region

At our average ICP’s hospital, they have stocked supplies to prepare for a possible flu pandemic (90.5%). They also are preparing procedures for mandatory reporting of infections (89.7%). Methicillin-resistant Staphylococcus aureus (MRSA) is getting attention, too, with 62% currently employing screening for MRSA at patient admission; another 7% are in the planning stages; 30% do not have such plans; and less than 1% do not know their facility’s plans for MRSA screening upon admission. None of these numbers deviate significantly from 2010’s.

This year, survey questions also included whether respondents’ facilities have instituted or plan to adopt a handwashing surveillance program: 81% answered "yes"; 9% are considering it; 8% are not; and less than 2% don’t know their facility’s plans.

How’s the money?

Our average ICP’s annual base salary in 2011 is $72,045 as compared to $69,419 in 2010. Fifty-three percent of the survey respondents indicated they received a raise, which is better than last year’s 45%. Salary remained the same for 40% of respondents (2010: 47%). A decrease affected 8%, the same as last year. For those who received an increase, it ranged from 3% to 3.99% for 27.5% of respondents (2010: 25%); 2% to 2.99% for 35.5% of respondents (2010: 37%); and 1% to 1.99% for 25% of respondents (2010: 20%).

Salary vs. Number of Beds
Salary vs. Number of Beds

Thirteen percent of respondents expect to receive a bonus as part of their 2011 compensation, which is 5.5% more than in 2010. There was a correspondent slight decrease in those who do not expect to receive a bonus this year (77%; 2010: 82%). Those who do not know if they will receive a bonus remain almost exactly the same at 10%. For those who expect a bonus or incentive based on current salary, 38% expect to receive 1% to 2% (2010: 33%), and 32% expect to receive 3% to 4% (2010: 37%).

Still good news on the job-security front: Most feel somewhat secure (48.6%; 2010: 46.5%) or very secure (41.5%; 2010: 47%). Fortunately, only a small percent (10%) feel somewhat insecure, but the percentage is slightly up from last year (2010: 6%).

What does it all mean?

How we got here

The results of the 2011 Infection Prevention Salary Survey were shared by HPN with a few working in the field to help explain things happening in the background that led to the current results and to put the results in perspective.

Vicki Brinsko
Vicki Brinsko

Vicki Brinsko, director, Infection Control and Prevention, Vanderbilt Medical Center, Nashville, TN, offered an interesting observation on the evolution of the ICP: "I think ICPs are going through a metamorphosis, much like the caterpillar changes to a butterfly. The ICP changed their title from infection control practitioners to infection preventionists (IPs) because that is the focus: prevention."

"Traditionally, ICPs have been in the shadows, behind the scenes," said Brinsko, "doing their thing to check the box for the Joint Commission. Today, they find themselves in the spotlight. More and more states are electing to become transparent in sharing infection control data with the public. More demands are also coming from internal customers as departments, department chairs, nursing units, etc, want to see their data."

Patricia Heath
Patricia Heath

Responsibilities of the ICP have evolved over the past 5 to 10 years. Patricia Heath, RN, BSN, Infection Prevention, St. Luke’s Magic Valley Medical Center, Twin Falls, ID, explained why: "ICPs are being forced to spend more of their time gathering data rather than spending time developing strategies to reduce infections. The pressure from regulatory agencies, Centers for Medicare and Medicaid Services (CMS), and other payer sources is requiring time being spent to write reports, enter data into the National Healthcare Safety Network (NHSN), and present data in multiple formats."

 

Russell Olmsted
Russell N. Olmsted

Russell N. Olmsted, MPH, CIC, 2011 Association for Professionals in Infection Control and Epidemiology Inc. (APIC), president, and epidemiologist, Infection Prevention and Control Services, Saint Joseph Mercy Health System, Ann Arbor, MI, expounded: "There has been an unprecedented level of focus and concern on the part of consumers of health care on healthcare-associated infections (HAIs). Commensurate with this scrutiny has been legislative mandates for public disclosure of facility-specific HAI data, a move toward value-based purchasing by CMS and an increasing number of third-party payers, and newly emergent regulatory and accreditation requirements. The primary source of this data is from surveillance findings collected by infection preventionists (IPs). These factors have placed increasing responsibilities and demands on IPs. Over this same time period, there is clear evidence that HAI data, when shared with direct-care personnel, can be an effective mechanism to prevent infection. The ‘engine’ that runs on this data is the collaborative model that implements prevention bundles."

ICP's Influence Purchasing

Products/supplies which are
purchased/specified by IPs

Hand Sanitizers

82%

Needlestick/Sharps Safety Devices

64%

Disinfectants & Sterilants

62%

Masks/Respirators

61%

Cleaning Equipment & Supplies

55%

Gloves

55%

Handwashing Systems

51%

Protective Wear

48%

Disposable Kits and Trays

33%

Dressings

26%

Software/Data Surveillance/Reporting

25%

Bandages/Dressings

24%

Safety Eyewear

24%

Waste Management

23%

Sterilization Supplies & Equipment

17%

Drapes

16%

Computer Equipment/
Waterproof keyboards

15%

Sterility Assurance Products

15%

Sterilization Wraps & Containers

14%

Air Purification Systems/Filters

13%

Med/Surg Supplies

13%

OR Supplies/equipment

12%

Test Kits/Bacterial Typing Products

10%

Patient Warming Equipment

5%

Pharmaceuticals

4%

Pressure Management Systems

3%

Smoke Evacuators

3%

Other:

5%

Doing more=getting more? Not so much

Unfortunately, noted Olmsted, whereas IPs’ responsibilities have expanded, "compensation of IPs has not differed significantly from other health disciplines over this time period."

Heath’s experience at her 144-bed medical center echoes Olmsted’s observation. "Salaries are not being increased and workloads are increasing. Budgets are stretched due to the need of other positions being created to meet the ever-increasing requests for explanations of actions, data collection, [and] constant chart reviews gathering information to submit to multiple agencies. There is no money available for more personnel or increased salaries. There are just more expectations of the ICP in her current hours. Everyone in healthcare is expected to do more with less. I don’t see any changes in the near future, especially with healthcare reform looming with no clear definition."

Brinsko’s experience at a much larger facility is a little different. "As more demands are placed on the traditionally tiny infection control department, these small departments have experienced growth. With growth comes an increase in budget, whether for additional personnel or increasing education, travel, etc. Our department went from 3 ICPs in 2000 to 9 ICPs in 2011. Our hospital also grew in size, and we went one step further in creating a new position for an outpatient ICP, which hopefully could become a model for other institutions."

"Mandatory reporting and CMS pay-for-performance have spotlighted infection control activity in a way that 10 years ago was unfathomable," continued Brinsko. "To imagine hospitals posting their central-line–associated bloodstream infection (CLABSI) rates on a public website, let alone on a poster on a unit in their hospital, was something beyond imagination; so, infection control and prevention departments had to, and have to, grow to accommodate the data demands. Infection control and prevention departments not only collect and analyze the data they are the content experts on strategies to reduce the infections. The Centers for Disease Control and Prevention (CDC) is leading the way with the mantra of ‘Chasing Zero’ and rightly so. Infections cause harm to patients. Prevention is what infection control and prevention departments specialize in. Along with budget increases, salaries also tend to increase, although admittedly, some areas may be slower to respond than others."

Olmsted also offered insight into how CMS changes in reimbursement and mandatory reporting have affected infection control and prevention departments’ budgets and staffing. "I think changes in regulations and reimbursement have had a significant impact on awareness of the problem of HAIs and the risks these represent to patient safety. These changes have opened the door to the C-Suite, and there is increasing interest in prevention strategies. However, there has not been a notable increase in staffing levels for IPs. Krein et al1 conducted two nationwide surveys of practices aimed at prevention of HAIs in US hospitals in 2005 and again in 2009. The average level of staffing dedicated to IPs had not changed between these time periods. By contrast, the percentage of hospitals that have a hospitalist program grew from about 50% to almost 80%. Another survey by Stone et al2 found staffing levels were higher in smaller facilities. There was a median staffing of 1 IP per 167 beds."

Unfortunately, while more demands are made of ICPs, Olmsted said it has "not demonstrably" resulted in additional resources and fatter budgets. He did note, however, that "there has been some increase in support of surveillance technology. Given the increasing demands for HAI data," continued Olmsted, "there has been an increased interest in, and use of, surveillance technology to increase efficiency of surveillance of HAIs. A study by Grota3 identified this trend, albeit use of surveillance technology remained at a prevalence of just over 20% in hospitals studied."

Product Evaluation Committee Members

As a member of a Product Evaluation Team, in which of these categories do you play a role?

Determine
the need

65%

Process
improvement

43%

Safety evaluation

52%

Cost analysis

36%

Product testing

45%

Define usage

32%

Education

44%

Other:

4%

Recognition, appreciation

On the positive side, ICPs’ role in patient safety, and costs saved as a result of their efforts, is now better recognized and appreciated. Olmsted observed that prevention bundles and collaboratives have raised awareness and appreciation of the "team approach to prevention, meaning the IP is the subject matter expert but the implementation of prevention strategies comes from engaging direct-care personnel."

He cited an example: "There was a recent report, based on CDC’s NHSN published in the Morbidity and Mortality Weekly Report that described substantial reductions in frequency of CLABSIs among patients in intensive care units (ICUs) across the U.S. There has been ample success in preventing CLABSIs and ventilator-associated pneumonia in ICUs. The prevention bundles are largely the reason for these successes. There is no doubt the work of IPs and their direct-care colleagues are preventing infections and saving lives."

Brinsko related how recognition of, and appreciation for, ICPs’ role in patient safety and cost reduction affected her department. "After mandatory reporting and CMS changes, ICPs moved to the ‘big table.’ Suddenly, ICPs–in my hospital–were requested to be at more top-level meetings. The C-suite was suddenly aware of our department and actually wanted to meet with us and hear what we had to say. Infection control and prevention has been preaching the same message for years, for decades, but now the right people are hearing the message and acting on the recommendations. The C-suite has read the business case for a dedicated infection-prevention program and has listened."

Heath’s experience is a little different: "I think that the role of the ICP is being recognized, but everyone is so busy chasing the next data set or verbal reporting process that there is no time for recognition."

Important issues

When asked about the survey results on preparing for a flu pandemic, screening for MRSA, and mandatory reporting of infections, Olmsted had this to say: "These are all important potential issues, but IPs at each facility need to conduct a facility-specific risk assessment as a foundation for developing an infection prevention and control plan that makes the most sense for a particular facility. Some of this is driven by legislative mandates involving select pathogens such as MRSA and Clostridium difficile or certain types of HAIs like CLABSI. The reporting mandates are important for transparency and awareness, but reporting alone is not sufficient for driving prevention. It is use of this data by providers to change and improve safety of care that is the real ‘secret sauce.’ Emergency preparedness is important, and last year’s pandemic was a good opportunity to test our level of preparedness."

Salary by Years in IP vs. Years at Current Facility
Years

"Some of these may or may not rank as high as others. Another point of reference is the HAI prevention plan that was published by U.S. Department of Health and Human Services in 2009. This did identify MRSA and C difficile but also highlighted other important targets such as catheter-associated urinary tract infection, surgical-site infection, and Surgical Care Improvement Project measures aimed at prevention."

Olmsted talked further about the disturbing trend presented by certain pathogens and the correlating need for good stewardship of antibiotics. "C difficile continues to be a problem for many facilities, and this is increasingly involving patients in the community. Another concern is the growing problem of multidrug-resistant gram-negative bacteria. Both of these issues highlight the need for antimicrobial stewardship to improve use of antibiotics." Brinsko suggested that, for the next survey, "It would be interesting to see if multidrug-resistant organisms (MDROs), including gram-negative MDROs, are an issue in their facility."

Brinsko also highlighted the importance of each facility conducting an infection control risk assessment. "The 2009 pandemic flu experience was a lesson, a field experience so to speak. MRSA is certainly an important pathogen; however, it is not the only pathogen. C difficile is certainly an issue in acute-care facilities, long-term–care facilities, and in the community. The main areas the IP should focus their work is in areas uncovered by their own infection control risk assessment. This is where they take their own data, look at it, analyze it, and determine what areas are ‘hot spots’ for them. A giant teaching hospital will likely have different hot spots from a small, rural, community hospital."

Surveillance is surfacing as an important issue. Olmsted suspects that may account for respondents’ answers on the survey question concerning the percentage of time they spend on infection control. "I’m not sure this interpretation is quite right. I suspect the 38% is related to surveillance of HAIs. There have been other studies that found up to 45% of the IP’s time is spent on surveillance. While I don’t think it’s reached 100%, there is no doubt that the escalating venues requiring HAI data has likely increased this part of the IP’s time. As a result, there is palpable tension between need for accurate HAI data and the desire to participate with direct-care personnel at the points-of-care delivery."

Heath added: "CMS, regulatory agencies, and other payer sources are focusing on infections that occur in the healthcare setting. Many of the decreases in payment, and pressure to submit data to get full payment, force the ICP to spend more time gathering the information to ‘feed the hunger’ of these agencies. Again, because of the need to submit the data, the work needed to make lasting changes is being rushed or not being as well educated as it could be."

Olmsted commented on what he thinks are currently the greatest obstacles and challenges that ICPs face in performing their work as they would like to ideally: "Increases in the scope and breadth of HAI data and a growing number of organizations and payers who want this data. Much of this is done using manual methods, which are tedious and time-consuming. This is layered on top of a relatively static level of human resources for infection prevention and control programs. One strategy to address the burden of surveillance is use of surveillance technology. In addition, there is emerging evidence that some of the case finding can be automated by use of algorithmic detection of possible HAIs."

The survey results revealed that 59% of respondents would, in fact, like to see more on infection tracking and reporting systems in HPN. "I’d recommend adding questions on surveillance technology," said Olmsted in regard to next year’s survey. "Other metrics of possible interest would be full-time employees per number of beds, extent of services and units [for which] the IP has responsibility, and perhaps some other volume indicators."

Brinsko also weighed in on data collection as a challenge faced by ICPs. "The greatest obstacle is non-automation of data. Manual data entry is tedious and time-consuming. Data mining is an excellent way to automate, but there are also drawbacks to some of the data-mining systems as well. The ideal system would be a software program that could cull data from the lab system, apply CDC definitions and rules for the four major infections (surgical-site, CLABSI, catheter-associated urinary tract infection, ventilator-associated pneumonia), and plug demographics into one user interface ... nirvana!"

Brinsko, too, would like to see next year’s survey include questions about automated surveillance. "Ask if the IP has a data-mining system or some sort of data-extraction tool. Automation increases efficacy and moves the IP out from behind the computer and onto the floors, the ICUs, into the operating rooms as a consultant, observer, and team member."

Conclusion

Olmsted wrapped up his observations with this: "IPs have always been able to accomplish a great deal with limited resources. One reason for this is their superb use of networking with their colleagues at their facility as well as via local APIC chapters. This drive is derived from knowledge that their work does make a huge difference in the lives of patients we care for, and that’s what really matters."

References

1. Krein SL, et al. What U.S. hospitals are doing to prevent hospital-acquired infection: 2005 to 2009 [abstract # 674]. Fifth Decennial International Conference on HAIs. Atlanta, GA: March 20, 2010.

2. Stone PW, Dick A, Pogorzelska M, Horan TC, Furuya EY, Larson E. Staffing and structure of infection prevention and control programs. Am J Infect Control 2009;37:351-357. Epub 2009 Feb 8.

3. Grota PG, Stone PW, Jordan S, Pogorzelska M, Larson E. Electronic surveillance systems in infection prevention: organizational support, program characteristics, and user satisfaction. Am J Infect Control 2010;38:509-514. Epub 2010 Feb 21.