John Michael Weir – BBA, CHESP, REH

What is MRSA?

Methicillin-resistant Staphylococcus aureus (MRSA) is a type of bacteria that causes serious infections that are resistant to many of the strongest antibiotics, including methicillin and other more commonly used antibiotics (including penicillin and amoxicillin). (1)

MRSA occurs most frequently among patients who undergo invasive medical procedures or who have weakened immune systems and are being treated in hospitals and healthcare facilities. (2) These healthcare-associated infections (HAIs) include surgical wound infections, urinary tract infections, bloodstream infections and pneumonia. (3) People who have been hospitalized or had surgery within the past year or who are receiving treatments like dialysis are at increased risk for infections with MRSA. (4)

MRSA infections have risen sharply in recent years. In 1972, MRSA accounted for only two percent of all Staphylococcus aureus HAIs reported to the Centers for Disease Control and Prevention (CDC) in the U.S. (5) Recent data show that MRSA now accounts for 50 to 70 percent of Staphylococcus aureus infections. (6)

Staphylococcus aureus (“staph”) organisms are common bacteria that can live on the skin and are one of the most common causes of skin infections in the U.S. (7) The bacteria also live harmlessly in the nasal passages of roughly 30 percent of the U.S. population. These people are sometimes called “staph carriers” or persons who are “colonized” with staph organisms. Staph organisms can cause infection when they enter the skin through a cut or sore. Infection can also occur when the bacteria move inside the body through a catheter or breathing tube. The infection can be minor and local (for example, a pimple) or more serious. (8)

Though MRSA is generally associated with healthcare institutions, it can also occur in persons who have had no contact with a healthcare facility. These types of MRSA infections are classified as community-acquired MRSA (CA-MRSA) and are presenting to hospital emergency departments and outpatient clinics in increasing numbers. In addition, patients with CA-MRSA who are admitted to a healthcare facility can be the source for organisms that can be spread to other hospitalized patients, and such spread has been well documented. Many such infections have also occurred among athletes who share equipment or personal items (such as towels or razors) and among children in daycare facilities who are in very close contact with one another throughout the day. (9) By some estimates, more than half of all skin infections now treated in emergency rooms are caused by MRSA. (10)

How does someone contract MRSA?
MRSA is most often contracted while a patient is in the hospital. Transmission of MRSA organisms can occur from skin-to-skin contact with someone who has MRSA on their skin, by hands of healthcare personnel who pick up organisms on their hands from a colonized patient and then care for another patient without washing their hands between the tasks, by contact with items such as computer keyboards or surfaces such as bedrails that have the
organisms on them, and through insertion of devices such as catheters or breathing tubes that bypass the body’s natural defenses.

The risk for the spread of CA-MRSA is highest where people with poor hygiene are associating in close quarters such as prisons, homeless shelters, locker rooms and daycare centers.

How do we clean rooms used by MRSA infected patients?
Using a EPA registered disinfectant with a MRSA rating clean thoroughly using friction, all surfaces in the patient room, paying particular attention to high touch  surfaces. Be sure to follow contact precautions in addition to universal precautions, and wash hands thoroughly, when you finish cleaning.

References:

1 www.nlm.nih.gov/medlineplus/print/ency/article/007261.htm
2 http://www.cdc.gov/ncidod/dhqp/ar_MRSA_spotlight_2006.html
3 http://www.cdc.gov/ncidod/dhqp/ar_mrsa_ca_public.html
4http://www.nlm.nih.gov/medlineplus/print/ency/article/007261.htm
5 www.cdc.gov/od/oc/media/pressrel/r061019.htm
6 Siegel JD, Rhineheart E, Jackson M, Linda C; Healthcare Infection Control Practices Advisory Committee.
“Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006.” Available at

http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf.

7 http://www.cdc.gov/ncidod/dhqp/ar_mrsa_ca_public.html
8 http://www.nlm.nih.gov/medlineplus/print/ency/article/007261.htm
9 http://www.nlm.nih.gov/medlineplus/print/ency/article/007261.htm
10 Moran GJ, Krishnadasan A, Gorwitz RJ, Fosheim GE, McDougal LK, Carey RB, Talan DA; Emergency ID Net Study Group. (2006). Methicillin-Resistant S. aureus Infections among Patients in the Emergency Department, New England Journal of Medicine, 355,666-674.

Suggestions for Infection control procedures for free-standing imaging centers and hospital radiology departments

The cleanliness of free-standing imaging centers and hospital radiology departments is crucial for reducing the spread of MRSA and other acquired infections. The following are 11 simple procedures to implement that can prevent the spread of these infections.

1. Have a written infectious control policy to include MRI cleaning procedures as well as the cleaning schedule and have it posted throughout the center.

2. Implement a mandatory hand washing / hand sanitizing procedure between patient exams for technologists and any others who come into contact with patients.

3. Clean the MRI tables, inside the bore of the magnet and any other items that come into contact with a patient. Infection control experts recommend this be done between each patient.

4. Clean all pads and positioners with an approved disinfectant. Infection control experts recommend cleaning after each patient.

5. Periodically inspect the pads with a magnifying glass, particularly at the seams, to identify fraying or tearing. If present, the pads should be replaced.

6. Regularly check all padding material with an ultraviolet (black) light and make sure that any biological material detected on the pads can be removed.

7. Replace damaged or contaminated pads with new pads incorporating permanent antimicrobial agents.

8. Use pillows with a waterproof covering that is designed to be surface wiped. Replace pillows when their barrier is compromised.

9. Promptly remove body fluids, and then surface disinfect all contaminated areas.

10. If a patient has an open wound or any history of MRSA/other infection:

a. Gloves and gowns should be worn by all staff coming in contact with the patient. These barriers must be removed before touching other areas not coming in contact with the patient, i.e. door knobs, scanner console, computer terminals, etc.

b. The table and all the pads should be completely cleaned with disinfectant before the next patient is scanned, if it is not already being performed between every patient. For patients with any known infectious process add 10-15 minutes onto the scheduled scan time to assure there is enough time to thoroughly clean the room and all the pads.

11. All furniture should be periodically cleaned. Ideal surfaces are those that are waterproof and wipeable. Infection control experts recommend this be done between each patient.

By now, everyone should know that patient satisfaction data is no longer public. The Centers for Medicare & Medicaid Services (CMS) developed the Hospital Consumer Assessment of Healthcare Providers and Systems or HCAHPS for short, to increase accountability and transparency of healthcare delivery practices. It is the first public, and nationwide standardized survey that provides direct comparisons of hospital services.

Survey results are posted on the web at www.hospitalcompare.hhs.gov along with other clinical measures to give patients a fairly complete view of the quality any given hospital is providing. One idea behind this is that consumers will “shop around” for their healthcare, something like one would shop around for a restaurant or a new car.

At my, like most hospitals we use in addition to HCAHPS, another survey tool that measures many more aspects of patient care and performance. A drawback to HCAHPS is that it measures only the basic elements of patients care, excluding a lot of factors important to patients in their overall experience.

For my area of responsibility HCAHPS includes only one question: “During this stay, how often were your room and restroom kept clean?” -Never, Sometimes, Usually or Always. This can be misleading because it does not measure the level of cleanliness, only the frequency. If the housekeeper makes several visits to your room does that mean “Usually” or “Always”. If the housekeeper makes several visits to tidy or straighten up but does not clean would that influence the response”.

Regardless of the answer to that we take definite and clear steps to improve our scores and raise the patient awareness that we are cleaning, and we want their room and restroom to always be clean, really clean. Our staff are trained with scripting and hospitality programs that include greeting the patient and letting them know what we will be doing in their room. We use leave behind cards when the patient is asleep or away for a test letting them know their room was cleaned and a phone extension to call if they would like any further service.

I have no doubt that HCAHPS, in the present form or revised will remain. I work hard to help my staff be successful at delivering a quality service to our patients and guests worthy of the “Always” score. We will continue to do so regardless of this survey though. Our greatest satisfaction comes from the patient who really feels their room is very clean and safe for them.

1. Never mix chemicals.
2. Always wear gloves.
3. Always wear protective eye wear or glasses when pouring chemicals or working overhead.
4. Always wash your hands after chemical use and before eating.
5. If a potentially harmful chemical comes in contact with your skin or eyes, flush with water immediately and call your supervisor.
6. If n doubt about proper use, always ask your lead, supervisor or manager.
7. Chemicals should always be dispensed in the safest manner possible from a flip top cap. The only exceptions are glass cleaners and deodorizers, which can be dispensed by trigger sprayers.
8. Any chemical on a cleaning cart or in a storage closet must be labeled with the correct name of the contents in the bottle, the specific hazard warnings, and the target organs affected by exposure to the chemical. In other words, a pre-printed label. Don’t just write the name on a bottle.
9. For any question concerning makeup or compounds, please refer to the MSDS or your hazard communication manual.

The most important staff related task we have in Environmental Services is training. Almost every challenge or difficulty we face can be reduced or eliminated with great training. I’m going to list steps that will help you conduct successful training. This is not meant to be a perfect or complete list, just use this as your starting point and customize it for your needs.

ACTION STEPS:

1. Organize the Approach for Training

a. Decide the amount of skill you expect the trainee to acquire and by what dates.
b. Prepare a schedule to follow

1. Have the employee ready for training.
2. Decide what area will be used for training.
3. Decide items to be covered in each training session.

2. Organize the Work

a. Decide how the area to be covered will be separated into segments that can be learned.
b. Arrange for the proper supplies.
c. Be sure the necessary equipment is available and in good condition.

3. Orient the Employee

a. Put the person at ease.  Make them feel comfortable with you.
b. Explain the task to be learned and find out how much the employee knows about it.
c. Stress the importance of the task, the reason it must be done, and the results of doing it well.  The employee must become interested in learning the work.
d. Explain and show the employee each step of the task, one step at a time.  Don’t go too fast, look for understanding.
e. Stress each step clearly, completely, and with patience to make sure the employee understands.

4. Hands on Training

a. Have the employee attempt the task, and correct any errors while he or she does the task.
b. Have the employee do the task again, and explain each step as the employee does the tasks.
c. Repeat the procedure until you are certain that the task is being done properly and the employee fully understands.

5. Follow Up

a. Allow the employee to perform the task on their own.  Be sure they know that they should contact their supervisor if assistance is needed.
b. Check on the employee frequently until they are thoroughly comfortable in the performance of their duties.  Always encourage the employee to ask questions.

6. Evaluation Employee Performance

a. What are the areas of poor performance?
b. Should they be retrained?
c. If retraining is required, when should it be started, and how long should it last?
d. Is the schedule being met?  If not, why?

Any Questions?

We know that our primary purpose is cleaning. We train our staff to recognize dirt and soil in so many forms and to remove it. We educate, coach and celebrate our successes. We also know that good strategies for combating infection and cross contamination include things such as hand washing and personal protective equipment. In fact recent studies point more often to poor hand washing practices then the environment as the primary cause of hospital acquired infections.

We in Environmental Services understand the importance of hand washing as well as the importance of a clean environment. No matter how well hospital employees adhere to hand washing policies we simply cannot keep pathogens out. Without a top quality training program focused on cleaning and disinfecting the environment, infections will continue to be a problem; germs must be killed wherever they exist within the hospital environment.

I teach my staff to focus on cleaning. Our primary purpose is cleaning, and we never stop and say good enough. We clean and disinfect so that our surfaces not only look clean, they are free of contamination also. I work closely with our infection control department to track results and the partnership has helped to develop best practices that have proven very successful.

When you think about your role in healthcare, remember that without a healthy environment, patients will get sicker, and ultimately, go somewhere else for their healthcare. Support you facility with excellent cleaning, a team relationship with your infection control department as well as your staff. And don’t ever lose focus on cleaning for success.

Employees may be more prone these days to blame others for problems they have caused themselves, said Paul Harvey, assistant professor of management at the University of New Hampshire in Durham.

Harvey, who studies behavior in the workplace, said it is “a natural human tendency to want to deflect blame for negative outcomes (especially at work where your competency is always being evaluated), and so people often subconsciously look for other people to blame when problems arise.”

If the finger-pointer is the boss, the situation becomes even more complicated, he explained. “When that happens, people usually have to stand their ground and hope that, over time, the facts help to vindicate them.”

This version of blaming is a form of “abusive supervision” and includes “spreading rumors about employees, insulting them, withholding information, and pretty much everything short of actual physical abuse.”

Reference:

Watch for ‘Employee Scapegoating’ as Economic Troubles Continue. (2009, March). HR Focus, 86(3), 8-9.  Retrieved March 29, 2009, from Alumni – ABI/INFORM Global database. (Document ID: 1654950911).

Perhaps you sometimes think you don’t want the responsibility of running the ES department. If so you are not alone. When I transitioned from Supervisor to Manager some years ago it was like this. In the beginning, it was a challenge of transitioning from being an employee to running an organization, of being lonely and complete work / life distortion. However it did not take long to get organized and develop personal routines that helped me be calm enough to hear God’s instructions for success.

And when I say challenge, I mean I had to change my way of thinking about everything. Even though I had different life experiences to help, I sometimes had thoughts of, “what exactly did I get myself into”? That is when I had to remember we have a lot more help then we often realize. Adversity provides the resistance necessary to develop the strength to overcome great obstacles. This strength consists of self-confidence, perseverance, and, very importantly, self-knowledge.

As I have found many things becoming easier then other challenges arise and the responsibility and possibility of it all tries to paralyze me more than I want to admit. And I have to spend more time in prayer to get through it. Really, given the opportunity to change the world, would you take it? I believe those of us in this business think we would, but it is so very hard to look in the face of what you truly want and take it. It is very hard to fight the war of what really mattes and look past the fear to what possibilities lay ahead.

As the people in our departments change, we will find that many we have hopes for are not always stepping up. And those who do often think about stepping right back, because unless you are in the fight to make change, it is difficult to know how hard it really is. Keep encouraging them and believing in them so they will work with you to make your facility and department better.

This year will probably be one of your hardest. There will be days when you don’t want to strategize, or build relationships, or be so obsessed with seeing the ER floors looking awesome. Just remember you don’t always buy a thousand rolls of toilet paper at a time. Some days you have to be normal and just buy six rolls at the supermarket. While that is ok, remember “being normal” gets you fifth place, and you know you want to be in first, and all successful people take risks that normal people would not. But it’s the follow through that’s hard, the follow through that builds your character.

You will find that as you stay with it, you will be able to muster strength from somewhere you didn’t know you had. Every setback you encounter in life contains valuable information that, if you study it carefully, will eventually lead you to success. Without adversity, you would never develop wisdom, and without wisdom, success would be short lived indeed. When you make a mistake, say, “That’s good! I’ve gotten that out of the way. I will never do that again.” You will no doubt make other mistakes, but they won’t bother you nearly as much when you treat them as learning experiences.

During it all, remember that you are not alone. You have all your staff that together make up your team and you have all your peers here at ASHES to talk with and share ideas. Stay current with the changes that are happening and keep an open mind as the challenges come your way. Don’t be afraid to try something different, to think outside the box or to challenge the status quo. Keep your head up above the negativity and you will be ok. We all have within us the potential for greatness, and when your standard of performance is based upon being the best you can be-for yourself-you will never lose. You will only improve.

Housekeeping management is often viewed as a straightforward position and can be an overlooked area for training. While everyone thinks they know how to clean, the management of housekeeping is more complex than people realize and has critical impact on guest satisfaction. To help tackle your job, cover these 10 areas:

1. Guest experience
2. Multicultural understanding
3. Staff training
4. Efficiency
5. Inspections
6. Deep cleaning
7. Preventive maintenance
8. Safety and security
9. Inventory
10. Standard operating procedures

We have been doing patient rounding where we go see the patients and ask a few questions like, was your housekeeper friendly, was your room cleaned satisfactorily, is there anything we can do for you? We get good feedback and has helped our HCAHPS and Press Ganey scores.

Recently I’ve started using workers that have restrictions to the point where I can not work them, but they can walk, talk and write come in for ES Ambassador duty. I give them some scripting, a clipboard and the rounding questions and have them spend hours going to talk with patients. We talk about our goal of having their room always clean, how the survey works, and so on. I’ve had very positive feedback on this and it helps get the staff back to work with a better attitude.

I’ve increased our cross training and we all know how that helps. I’ve also moved staff more frequently to play to their strengths more than I have done in the past.

I put a large communication board in our common room. This happens to be our laundry and storeroom area where we check in and out the keys and pagers. During our standup meetings I share Press Ganey positive comments and other good comments and post them on our communication board. The increased focus on the score has helped I believe.

So far my HCAHPS score for the first quarter of 2009 is running 81%. This is a 10 point improvement over last years average, and higher over just November and December of last year.

What things have you all been doing to raise your scores and your staff satisfaction?

Good old fashoned hotel guest room cleaning tips. While not hospital work it is similiar and we have to appreciate the hard working staff that take care of us away from home. Enjoy!

Today was a very busy day with major work on a new training program I am writing with help from a good friend and peer in this business. I also had the opportunity to network with several people and connect with one tonight on LinkedIn. I recommend to people that to stay in touch with others is very important and we should always make the effort to encourage each other. If you want to share your thoughts you can do so here, and if you want to connect you can find me at http://www.linkedin.com/in/johnmweir

I’m wondering how many of us who have been in Healthcare Environmental Services for ten years or more still operate in a similar manner as years past. I love this business for many reasons, and at the forefront the every changing world of healthcare creates the most enjoyment. I look for ways to keep ahead and as I reflect back over the years, today’s operation is so much different then when I started.

Even so, I feel we are coming up to the critical mass point in our operations where we are going to see a massive change in this business. Up to now, we have all been learning to adapt to doing more with less, different cleaning chemicals and processes, competition between the in-house and out-sources operations just to mention a few of the “hard” process aspects. In the “soft” or the human, labor side we have seen many laws to benefit employees, different types of time off opportunities, repetitive stress injuries and a multitude of generational issues that are present in our labor intensive business.

With hospital reimbursements shrinking, expenses expanding, and the probable change in the way health care is delivered coming with the new elected leaders, don’t be satisfied with the status quo. While the daily work must go on, take the time to consider and evaluate new ways to deliver your service. I’m open to sharing and helping anyone to brainstorm and think outside the box.

HAYWARD, CA (March 4, 2009)—In its February 2009 newsletter, “Environments of Care News,” the Joint Commission, the main entity that accredits hospitals in the United States, has published an article titled “Preventing Infections in the MRI Suite: Magnetic Environment Poses Strong Challenges.”

This landmark article quotes Peter Rothschild, M.D., author of the groundbreaking paper “Preventing Infections in MRI: Best Practices” and founder of Patient Comfort Systems. The recommendations in Dr. Rothschild’s paper resulted from his close work with the infection control arm of the Joint Commission. Now, following the publication of Dr. Rothschild’s paper, the Joint Commission, realizing the critical importance and risk to the patient from the lack of infection control in MRIs, is alerting hospitals and imaging centers, in no uncertain terms, about the importance of infection control in MRI facilities.

Dr. Rothschild explains, “The Joint Commission is clearly concerned over the lack of infection control in the MRI suite. They will, in the future, closely examine this area, and properly train their inspectors to physically enter MRI rooms for a more definitive inspections. The areas under greatest scrutiny will be: 1) existence of an infection control policy; 2) how and when the MRI was cleaned; 3) who are the individuals performing this cleaning and what is their safety training; 4) examining all the table pads and positioners to see if they are torn or frayed. Inspection may even include a black light to reveal biological material embedded in the pads, on the table or within the MRI bore itself.”

“The Joint Commission clearly cannot assure the public that an accredited hospital is safe without thoroughly evaluating the MRI suite. The lack of even basic infection control, such as hand washing or cleaning between patients, is well known by technologists operating the MRI and radiologists reading the MRIs,” adds Dr. Rothschild, who also has published an 11-step infection control policy designed for the MRI center. As Dr. Rothschild explains, “An MRI is a very complex and dangerous area to clean. It is unreasonable to think it can be cleaned safely and effectively by untrained personnel.”

Dr. Richard Nolan, M.D., a well-respected orthopedic surgeon in the San Francisco Bay Area, states, “The MRIs I have seen in the hospitals and especially outpatient facilities have basically no effective infection control. It is all adhoc by whomever the technologist is running the MRI at the time. I have been disgusted by the total lack of cleanliness in these facilities. Rarely do I ever see a technologist even wash his/her hands between patients much less make sure that the pads are not torn and that they are cleaned properly between patients. It has always been unclear to me how a hospital could pass a Joint Commission inspection year in and year out with such a lack of infection control and in clear violation of the Center for Disease Control guidelines. Clearly the Joint Commission inspectors in the past have not looked in the MRI suite. This is unfortunate since my patients think that if a hospital is certified by the Joint Commission, the MRI is clean and safe. In the past there has been nothing farther from the truth. This is why I congratulate the Joint Commission for taking on this important health issue.”

The Joint Commission has made it clear that they are following the CDC guidelines on infection control. These guidelines specifically state that a clean sheet is not a barrier to infectious agents. However, this is usually the only thing used by imaging centers to protect their patients. The CDC guidelines also make clear that the pads on the table as well as the coils must be cleaned between patients, not merely covered with a sheet. Most importantly, the CDC states that if table positioners or pads are torn or frayed they must be replaced. Therefore, the common practice of simply placing a clean sheet over torn, contaminated pads and covering up the smell with air freshener is a clear breach of basic infection control. Another common violation of CDC standards at outpatient MRI centers is the incredibly dangerous practice of having employees take contaminated laundry home to wash in their own household washing machines in order to save money. Not only can this further the spread of infectious agents throughout the community, but since their washing machines often lack any special sanitizing capabilities, these employees risk contaminating their own family’s clothing and thus even further spreading diseases.

“This is one of the many practices that show the total lack of understanding of infection control at MRI centers, putting not only their patients at risk but also their employees, their families and ultimately the entire community. These are just a few of the reasons the Joint Commission is so concerned about lack of infection control in these MRI facilities,” explains Dr Rothschild.

Antonio Bayon, President of MagnaWand, echoes Dr. Rothschild’s concerns while focusing on the cleanliness of the MRI bore itself. “I have been involved in the MRI business for more than 20 years, half of those years as an MRI service engineer. During my years as a service engineer, I saw all kinds of biological contaminants inside the bore of the magnet. It was common to see blood, urine, and other patient’s fluids in the tube, where the patient is placed for their MRI. I have even seen vomit dripping down the insides of the bore. I can assure you that this critical area where there is very close patient contact is not being cleaned. In the only study ever to look for the superbug MRSA in an MRI, it was found colonized in the bore of the MRI.”

Dr. Rothschild adds, “I am most disappointed by the total lack of concern by the radiology community to address this clear and present danger to our patients. I hope that the Joint Commission’s new direction will encourage administrators as well as risk management departments to take this issue seriously and adopt procedures designed to protect the patients. Until this is uniformly applied, the patients and referring doctors are basically on their own to determine if an MRI center is safe. This is most concerning for patients who are immunosuppressed or have a poorly developed immune system as their risk of a Superbug infection is often life threatening.”

Louise Kuhny, RN, Senior Associate Director of Standards and Interpretation Group at the Joint Commission, has stated in the article that the Joint Commission’s infection prevention standard underscores the need for a clean MRI suite, and that every accredited organization must have a specialized infection prevention plan. She further states the need for procedures concerning the proper removal of body fluids and disinfection of contaminated areas between patients. Most importantly, Ms. Kuhny discusses that the Joint Commission inspectors expect to see compliance such as mandatory hand washing by providers between every patients.

Louise Kuhny, RN, assures that “the Joint Commission surveys include all areas of an accredited facility in this survey activity including the MRI suite.”

As emphasized by Dr. Nolan, “A hospital’s overall infection control policy can only be as strong as its weakest link. This weakest link has clearly been demonstrated to be in the MRI suite. Immediate urgent attention by the risk management department and the administration of these hospitals and clinics is needed to address this serious public health risk. The 11-step procedure for infection control in MRI, developed with the help of infection control experts at the Joint Commission, is an important first step for hospitals and imaging centers to come into compliance with infection control standards that are used throughout the health care industry.”