The Importance of Collaboration between Nurses and Environmental Services

[ Music ]>>Hello, and welcome to today’s webinar,
Empowering Nurses to Protect Themselves and their Patients: The Importance
of Collaboration Between Nurses and Environmental Services. My name is Kate Wiedeman and I’m
a Health Communications Specialist at CDC’s Division of Healthcare
Quality Promotion. The mission of CDC’s Division of Healthcare
Quality Promotion is to protect patients, protect healthcare personnel, and promote
safety, quality, and value in both national and international healthcare delivery systems. This webinar is part of a series of infection
control related webinars that CDC will– is hosting with the American
Nurses Association and members of the Nursing Infection
Control Education Network. Before we get started there are a
few housekeeping items to cover. We welcome your questions. Please submit any questions or
comments you have via your chat window, located on the lower left hand side of the
webinar screen, anytime during the presentation. Questions will be addressed after
all presentations as time allows. To ask for help, please press the raise hand
button located on the top left hand side of the screen if you need to chat with a
meeting chairperson for assistance such as for technical difficulties during the webinar. Also the speaker’s slides from
today’s presentation will be provided to participants in a follow-up email. Now it is my pleasure to introduce Kathleen
Wiley from the Oncology Nursing Society who will provide opening remarks. Kathleen.>>Hi, thank you Kate. So yes my name is Kathleen Wiley
and I wanted to take the opportunity to introduce to you Dr. Hudson Garrett. Dr. Garrett is the Executive Vice President and
Chief Clinical Officer for National Association of Directors of Nursing Administration
and Long-Term Care. Dr. Garrett brings a variety of
infection prevention and control training and expertise to our topic today. He holds a dual masters in nursing and
public health, a post masters certificate as a family nurse practitioner, a post
masters certificate in infection prevention and infection control, and a PhD in
Healthcare Administration and Policy. He has completed the Johns Hopkins
Fellows Program in Hospital Epidemiology and Infection Control and the CDC
Fundamentals of Healthcare Epidemiology Program. He is board certified in family practice,
vascular access, moderate sedation, antibiotic stewardship, infection
prevention, legal nurse consulting, and as a director of nursing in long-term care. He is also a Fellow in the Academy of
the National Association of Directors of Nursing Administration and Long-Term Care,
and the American Academy of Project Management. Dr. Garrett has vast presentation experiences
on topics related to infection prevention and control, especially with
regard to how the environment of care may directly impact infection risk and
has previously served on the board of directors for the Association for Healthcare
Environment, a personal membership group of the American Hospital Association. And so with that I’d really like to thank
you Dr. Garrett for being here today and I’ll turn things over to you and look
forward to hearing your presentation.>>Perfect. Thank you very much Kathleen, and
welcome to everybody on the line today and we certainly appreciate everybody taking
the time, especially on this exciting day of the solar eclipse which seems to
have taken over everyone’s world. This webinar was developed in collaboration
with my colleagues at the American Association of Colleges of Nursing and the
Oncology Nursing Society so I want to want to first of all thank them. I do want to start with sort of a reality
check and kind of setting the ground work for what we’re going to talk about
today which is really where we are with healthcare associated infections or HAI’s. The good news is that we’re making progress. The opportunity for improvement is
that we still have a long way to go. When we look at current evidence
based recommendations specifically for infection prevention
and control, there’s many. But they really go back to some foundational
and fundamental pieces that we’re going to talk about today specific to the
healthcare environment. National compliance however is around
40-ish percent for full compliance with the known evidence-based recommendations. And one of the best websites I can
provide for you during the context of today’s program is the CDC
website which is That website again is
for healthcare associated infection. There you can really find
a plethora of information that will help us drive standardization
in practice and specifically make sure that we are aware of all of the current
evidence based tools and resources that the CDC and other partners have put out. Let’s take hand hygiene for just a second. Well we’ve got about 40% national compliance, so about 60% of the time we’re really not fully
following the evidence-based recommendations from the CDC and the World Health Organization. And then if we translate that into the topic
of today which is the healthcare environment or the clinical environment of care, whatever
you may call it, there’s a role of transmission that we’re further understanding day by day. And the last few years alone
have been very exciting to look at some of the specific resources. So let’s start with the future
of healthcare in general. And this graphic came from the
Institute for Healthcare– I’m sorry– for Healthcare Improvement, otherwise
known as IHI which was started by Dr. Don Berwick several years ago. And if you look at kind of these three elements
of how healthcare is changing and evolving, the first is really looking at
population health management. Well we’re talking today about the
healthcare environment of care. Well that impacts not only the patients that
we serve but also our healthcare providers. And so we have to include
those within our population. We can also use the clinical environment
of care as a way to, you know, positively or negatively impact the experience of care. For example, if I walk into an outpatient
clinic or I walk into a nursing ward or I walk into an ambulatory surgery center
or a long-term care facility, this is something that the patients first,
or the family members first experience, is really going to be with
cleanliness in many cases. They’re going to know are the staff friendly? Is the environment clean? I always make the analogy when I go
to a restaurant for the first time one of the first things I do is I actually walk
into that restaurant bathroom and I look and I say you know is this environment clean? Because chances are if the bathroom
is clean then there’s a good chance that the kitchen is also clean. And so that first impression around
the cleanliness of the environment in our healthcare facilities
also makes a big difference also. And last but not least is cost. Well you know that’s one of those things
that especially nurses don’t like to talk about because cost– and in many cases could
be FTE reductions, it could be staffing, it could be educational funds, but we want to make sure we can say there’s a positive
impact here because it doesn’t cost more to do the right care every single time. The other thing we need to think about is
how do we apply these knowledge based things around the environment of care to the whole
continuum of care from cradle to grave starting from the home environment, looking at
outpatient facilities, even engaging people like pharmacists, urgent care, all the
way through the acute care environment and the post acute care environment like
long-term care or rehab hospitals or hospice. This is an opportunity for us
to standardize our practices and not only our practices
but also our education. And I think this is something that really
makes a big difference when we look at how do we actually standardize our efforts
so that each single time a patient interacts with the healthcare system regardless of where
it is, they’re getting that same consistent and reliable care related
to infection prevention. So I like to start with a question of kind of
take your hat off as a healthcare provider. You know this is something that I think it’s
hard for us to do as healthcare providers, but are all infections truly preventable? And many times when I ask this question to healthcare colleagues they
say well no I don’t think so because the patient’s
co-morbidity that they may have. Well if you put your hat back on, you know and
you think about that or even think about it from a patient perspective, well the
patient’s expectation is that they’ll come in, they’ll receive care, and then they
will actually be able to go home in at least the same condition
in which they came in. And so it really depends on who you
ask but our goal is always going to be zero healthcare associated infections. We’ve got to do everything
in our power to do that. And the last piece there is that the
environment specifically makes a big difference. So when I think about contamination
I really think about the hands of the healthcare providers, and even the
patients but also the clinical environment of care, especially the things that are going
to touch the patient on a routine basis. Things like blood pressure cuffs or
pulse oximeters or anything like that. So how does transmission occur? I really like to practice the KIS
method, you know Keep it Simple. So when I think about transmission I
really think of three general buckets. The first and foremost is
that the contaminated hands. And we’ve historically focused
on us as the healthcare team. We measure compliance with the healthcare
team, but now we can expand that to look at the patients and their families as well. Right behind that though, the second source, is
really the contaminated environmental surfaces. Those things that we’re going
to call non-critical items or surfaces, environmental surfaces. And even some medical devices like glucometers. And the last is the contaminated
skin of the patient. We want to have the patient’s skin as
intact as possible because that skin serves as that most natural barrier for
infection prevention and control. And so when you insert a catheter or do any
type of procedure with a scalpel for example, we’re going to break that natural barrier. And so if you look on the kind of right
and left you’ll see that the way of course to address contaminated hands
is good thorough hand hygiene from contaminated environmental surfaces
that they’re cleaning and disinfection which is really the bulk of
what we’ll talk about today. And for contaminated skin we need to make
sure we get those indwelling catheters out and focus on the good skin and the sepsis. So one research question that I think is
important is really what role does the clinical environment of care play in the transmission
of healthcare associated infections? Well, this is more and more
understood day by day. I think 10 years ago we could’ve really
never had this webinar and been able to focus on some of these core topics. With the great work that
the CDC has done with some of their Epicenter research we’re
seeing more and more progress being made about understanding the role of the
environment but also how we play into the environment as the
healthcare provider team. Well think about a time when you’ve traveled. And I travel every week for work and so
it’s a natural phenomenon for me but I go through the airport process and I look at all
the systems, and I look at all the redundancy and I look at TSA and then I get
through and I get to my gate. And I think about the rigorousness
that is around the FAA process as well. Well, if you apply that to healthcare and you
think about healthcare associated infections, let’s just take an airplane for example. Let’s say there’s an accident and maybe a
tire blows or there’s a safety incident. Well the NTSB immediately investigates. And not only do they investigate,
but then they share those findings with all of the airline industry. It’s not a competitive situation. Well I think that’s an opportunity for
us to learn in the healthcare sector. So how do we protect those
most vulnerable patients like our infants that are pictured there? Our healthcare team as well as
our patients and their families? You know how do we come together
and share some of those learnings? And that’s really the purpose
of the NICE Network. So what’s the ideal situation? What are we trying to accomplish? I think we always need to focus,
especially in nursing, around the why. What is it that we’re trying
to make as our objective? Well we’re not trying to make a germ-free zone. We’re not trying to make a sterile environment. Even in the operating room,
everything is not sterile. While the supplies may come in
sterile, we may set up a sterile field, and try to follow sterile techniques,
the entire room is not sterile. The skin is not sterile nor
would we want it to be. And so what we’re trying to do is remove
those pathogenic sources of infection, prevent transmission, and
really inhibit their ability to become colonized on environmental surfaces. This will allow us to perform safer
procedures each and every time. So I wanted to start with a little bit of a case
study that I think is so pertinent to thinking about things through that critical thinking lens
that we all have to do as nursing professionals. Well the– let’s just take this into account– an ICU patient that was 62 years old was
admitted from the ED with severe sepsis and the total length of stay was about 42 days. And so you could kind of draw
that mental picture in your head– so the patient’s ventilated, got
multiple IV lines, has had multiple rounds of IV antibiotics and multiple surgeries. Well just in this one case example there
were 52 unique environmental surfaces and medical devices. And so that’s a lot of things
just for one patient to take care. Well if you take it a step further, look at
all of the different people that come together from that interdisciplinary care team to
deliver the safe care of this patient. They’ve got nurses and physicians and
midlevel providers and pharmacists and nursing assistants and
environmental services. One of the things that totally
gets under my skin as a healthcare provider is
sometimes our kind of silo effect. And one of the examples I think we have an
opportunity and kind of a call to action to think about today is changing and
transforming the word housekeeper to environmental services technician. I think that makes such a big difference
because when I think of the word housekeeper, I think it may be someone that comes
and professionally cleans my home, or someone who’s in a hotel that comes in
and takes care of the linens and throws out the trash and cleans the
restroom but there’s really not a lot of specialized training associated with that. In today’s complex healthcare environment,
we’re seeing more and more training required of our environmental services technicians. And certainly as professional nurses
you have tremendous amounts of training. So how do we come together and collaborate? I think the top question I get asked as it
relates to the clinical environment of care is who should clean what and
why is that the rationale? And my answer’s always pretty simple. If it’s connected to the patient,
it really is the best practice to have the clinical care provider–
whether it’s a nurse or a CNA– clean that device or clean that
surface so that we don’t interfere with anything like a ventilator or IV pumps. And anything that’s not connected to
the patient is really the responsibility of environmental services. Now that doesn’t take into account things
that happen during the middle of the day where maybe you go in to deliver care as a
nurse and you find that a surface is soiled and you can’t find environmental
services, and certainly we all want to pitch in and collaborate there. But the reason I share this example is it
talks about not only the complex nature of the surfaces and the devices,
but also the people, because I think we’ve got to look at both. Now this is a typical picture of a
regular maybe Med/Surg room here but look at all of the different surfaces. You know the wheelchair is a perfect example. I recently was in a hospital and it was
interesting to see the kind of dynamics as I was sitting there waiting
for a friend to be discharged and I’m watching these wheelchairs
come out one after one after one. And I finally walked up to one
of the transporting professionals and I said how often do you
actually clean these? And she looked at me and
she said why do you ask? And I said well I’m just curious if
these ever get cleaned between patients. And she said, well we never
really thought about that. And I thought to myself well this is an
opportunity for education and so I kind of made it a point to go speak to some of their
colleagues and said you might want to look at doing a cleaning and a
disinfection protocol around this so that we can really improve our practices. And that’s an opportunity where the
staff did want to do the right thing, they just didn’t know what the right thing was. And so when we look at nursing and
environmental services collaboration, we want to make sure that we think together. We’re not functioning in silos and
we’re addressing the complexities of the healthcare environment of care as a team. This is one of the best graphics that I can
think of, and while it’s a little bit old back from 2001, it is simply amazing to think of how the environment itself can
actually facilitate transmission. And so if you look at these contaminated
surfaces that in this example are contaminated with VRE, they’re marked by those green x’s. And you can see how many different
sites are culture positive here. And this is, you know, a room
that’s been terminally cleaned, ready for occupation by the next patient. And this is why we see significant
risk for you know patient A to have a multidrug resistant organism
and then transmit it to the next patient after the first one is discharged. And so it’s not only an environmental
cleanliness thing that we have to think about, but it’s also how do we make sure that
staff are appropriately trained not to touch equipment, for example with gloves? Or to work in, with environmental
services collaboratively so that we’re functioning as a team? One of the things that I think helps show
success is when you walk into example for an ICU, and you see that white board
up there and it says your physician is, your nurse is, your pharmacist is, your
technician– nursing technician is– it should also say your environmental services
technician is as well because that person, while not delivering clinical care, is
certainly part of the clinical care team. And it’s an opportunity to make sure
they feel integrated into the things that we do to protect the patient. There’s been some recent analysis looking
at how much time environmental services for example spends with patients. And that opportunity could’ve been
missed for interacting with them in a way that positively impacts our HCAHPS scores. So it’s not just a patient safety
perspective but it’s also a patient engagement and satisfaction opportunity to give
us a way to work together as nursing and environmental services to improve
that patient experience in general. Well let’s think about an example
where it didn’t go so well. You know these graphics come from the
fungal meningitis outbreak that many of us may be familiar with
from several years back. And this was a terrible, I guess, example if you
will, of where contamination can come into play. Sometimes where greed can come
into play, where people are trying to mass produce different types of medications and they don’t have the right
environmental controls. And in this particular case
there was a contamination of an actual medication done
at a compounding pharmacy. That medication was then shipped out outside of
the state and unfortunately had negative impacts on many patients and unfortunately a few deaths. And so it’s an opportunity to remind us
that we need to be grounded in the science and also follow those evidence-based
recommendations regardless of the practice in which we serve. So it doesn’t matter where our environment
is, we still have to adhere to that. And the way I always think about
healthcare is it doesn’t matter, you know, where it’s delivered. It’s still healthcare. So if I’m at a bloodmobile, I have
the same expectation of safety as I would in an acute care environment. There are a few infection control imperatives that I think are pertinent
to today’s conversation. You know one of the ones that I like
to spend the majority of my time on, and I think that we all would
look at this the same, is preventing the microorganism
in the first place. One of the things that CDC
has done a tremendous job of is really improving antibiotic
resistance rates and really looking at better stewardship programs and
actually sharing some of those resources. You know that helps us reduce things like
Clostridium Difficile or C. Diff as we call it. It really gets ahead of some of the
issues that we could potentially have. The next step is really looking
at contamination. So how do we remove those organisms
from the clinical environment of care to improve overall cleanliness
of the environment? And of course we do that through
cleaning and disinfection. Then if we keep going down the spectrum,
we’re really going to get to the point where we have to stop transmission. So really the first two have
not been successful, so now we’re at the point
of preventing transmission. And that’s really where the use of
personal protective equipment comes in. if you’re not familiar with the
proper use of PPE I would refer you to the CDC isolation guidelines
which are also available on the website that I provided earlier. Each of the Healthcare Infection Control
Practices Advisory Committee guidelines that CDC publishes are available
free of charge on that website, and I would highly recommend even if you’re not
in a true infection prevention role but you know for nurses in general it’s helpful to know that. And recently released were their new
core practices that really focus on us as the healthcare team to make sure that we
can provide the best possible patient care. And last but not least is really looking at
how do we recognize more quickly the infection? There have been amazing developments
in rapid diagnostics to help us facilitate better
recognition of infection. And that is just so promising
because it allows us to have a more formal active surveillance
program, get a better idea of monitoring, and we’re going to talk about some of the
environmental specific monitoring techniques that are available at the
conclusion of today’s program. So just keep that in mind that
there’s really those four imperatives. We want to spend more time if we
can on preventing microorganisms and certainly contamination so
that we don’t have to run around and actually prevent transmission. Superbug, multidrug resistant organisms,
whatever you like to call them, they are always going to provide for a level of
surprise because they’re going to really be kind of geared towards the survival of the fittest. And you think about things like MRSA or
C. Difficile as we talked about earlier, one of the newer organism classes is CRE. But it really takes all of us in order
to reduce the risk associated with these. And I tell staff all the time,
it’s not just about the patient. It’s also about us. We also don’t want to take
home any of these superbugs. And I think of healthcare
laundered scrubs as an example. You know there’s a reason that that standard
exists from ARN because there’s a lot of evidence that suggests that, you know,
that’s a much more evidence based approach to reducing the risk for transmission for
us as well with the healthcare textiles. The same standards exist with
the healthcare environment. This is a reason that we really talk so
much about proper cleaning and disinfection. And while nobody went to nursing school to
learn how to clean a room, it is definitely part of our responsibility as
professionals to make sure that we keep that environment as clean as possible. Not only for the patient’s safety
and well being but also for us. We don’t want to contaminate ourselves either. So when you think about the prevention
of transmission versus the prevention of the pathogen we focus so much,
especially in the environment, around transmission based things
like cleaning, disinfection, the use of personal protective equipment. Even some of these new novel technologies
like UV or fogger devices that we’ll talk about a little bit later, we at least focus
on the prevention of the transmission. And so it stops transmission or
reduces transmission to a safer level. If we focus a lot more efforts on the pathogens,
like I mentioned before, and get ahead of some of the root causes of that, it really
helps us think about don’t fix the– you know or throw a product into the
mix, but really address the process. And the way I think about it just to keep it
simple is I think about a bleeding wound, right? And you apply pressure and it doesn’t stop and
maybe you elevate the wound and it doesn’t stop and you still have a bleeding wound. Well, you can either go straight to a
tourniquets or you can look at how do I stop that with maybe some new technologies and
there’s different ways to approach that. When we think about the application
to the clinical environment of care, we’re starting with those basic things
like making sure the environment’s clean, keeping the trash out of the room,
cleaning and disinfecting surfaces. And then we might move to
more objective technologies which we’ll address in today’s program as well. Another factor to consider is
colonization versus infection. Well, you know, if you think about that
iceberg effect which is detailed here, the top are the people that are infected. The folks that are symptomatic, that we actually
can physically understand are actually infected. And they have signs of infection. So these are pretty easy folks to recognize. The challenge is is that we
have patients that are colonized that actually carry these organisms within
their body and we simply don’t know. So especially for those of you
that might be dialing in today from the outpatient environments or we have
many nursing faculty on the line as well, we need to think about the general population. Well, colonization does not
always equate to infection but it certainly is a risk factor
that we need to think about. This is why you see with certain
procedures there’s a decolonization process that may take place based on the surgeon’s
preference or evidence based recommendations to decolonize those patients
prior to high risk surgeries. And so this is a science that’s
continuing to be evaluated. This does not just apply,
however, to the people. We can also see colonization of organisms on
environmental surfaces where they serve as kind of reservoirs for transmission
or microbial growth. And some of the organisms that we’ve talked
about and will talk about can actually survive on environmental surfaces for
months at a time undisturbed. And so that’s why it’s so important
to make sure this collaboration between environmental services
and nursing exist. A couple of pathogens of significance that
I wanted to address in today’s program, we’re really looking at ESBL’s or
Extended Spectrum Beta Lactamases, CRE or your Carbapenem-resistant
organisms, multidrug resistant bacteria, fungal organisms like candida, and
then some of the new novel viruses that we find out there are ones of concern. And let’s use Ebola as an example. Well when Ebola hit there was a massive
response from our colleagues at CDC, right? But there was also some questions that came
up from environmental services saying well, is the product that we use in our
building actually effective against Ebola? And as you can imagine, no one wants
to test Ebola to say is it effective against a particular cleaner or disinfectant. And so what CDC did was they collaborated with
colleagues at EPA that approve these types of products, looked at the
microbiology of the organism and then made an evidence-based
recommendation for cleaning and disinfection. And so you’re not going to see these novel
pathogens that are extremely pathogenic and highly transmissible be listed on
environmental agents product labels. You’re just not going to see
that for reasons for safety. But you can always go to the EPA
and CDC for guidance on that. When we look at the CDC guidelines
for disinfection and sterilization in healthcare settings, the majority
of what we’re using in healthcare in many cases is really a noncritical item. And certainly we have other items like surgical
instruments or endoscopes or laryngoscopes that are used in different parts of healthcare, but today we’re going to
focus on non-critical items. These are the items that come in
contact with intact patient skin but do not contact a mucus
membrane or external body cavity. And so the contamination is really
by the repeated use between patients. You know perfect examples of these
include things like blood pressure cuffs or pulse oximeters or stethoscopes. Medication trays or carts are
things that can become contaminated. And what, again, we’re focusing on how do we
reduce the risk between every single patient? And the best way I can always tell people
is when in doubt, just disinfect between. And that’s always going to give us kind of that
safety zone because we’re always hitting it with our EPA registered disinfectant
in accordance with the CDC guidelines. We also want to make sure that
we visibly inspect equipment, especially as nursing professionals, that we’re
looking for signs of deterioration or corrosion or anything like that because with repeated use of disinfectants can also
come environmental breakdown. And so when you have that breakdown,
the device itself can become compromised and become a reservoir for transmission. There are different levels of disinfectant
approvals that we need to consider. And again we’re really going
to focus on two today. I’ll start at the very bottom though for
purposes of kind of giving some clarity. A sanitizer is a chemical that’s
designed to reduce bacteria down to what’s called a safe level. And so you’re going to find that these
are used in the food service industry. So you’re not going to see
sanitizers used in clinical areas. But for purposes of non-clinical items as I just
went over, you’re going to be using low level or intermediate level disinfectants. These are going to cover organisms all the way
up through the classification of microbacterium. And a perfect example of this
class of organisms is tuberculosis. And while I want to make clear that we’re
not concerned about transmission of TB on an environmental surface, it is a benchmark
organism because it’s difficult to inactivate. And so that’s why in many
cases you’ll see microbacterium as kind of a benchmark there to do that. High level disinfectants are a high– kind
of a hot area right now as we all know, especially those of us that may work in a
hospital or an ambulatory surgery center. And if you’re accredited, this
is certainly a hot button. But we’re really looking for best
practices with high level disinfection. And that not only includes the
physical task but also the training of the staff associated with that. And so again we’re really focusing today on
intermediate level and low level disinfectants. Disinfection principles that
we need to be familiar with. Well there’s a kind of a misnomer, people
throw the word cleaning and disinfection around interchangeably and cleaning
is simply the removal of bio-burden. It’s not going to actually
inactivate or kill anything. We really rely on the disinfection
process in order to do that. And again, if you think about an
intermediate level disinfectant, that’s going to be even more appropriate and
more efficacious than a low level disinfectant. But with that process we need
to have some type of monitoring. And so we’re going to talk in
just a second about opportunities for environmental monitoring programs and how
they can be really simple or really complex. And I’m going to start with the really simple
ones and the ones that are extremely effective and economical that you can
consider for your practice. I think that makes a big
difference for us to consider. So these are the– kind of a hodge podge
of different pictures but you can see on the top left you’ve got
an ultrasound machine, you’ve got electronic medical
records or computers on wheels. You’ve got a computer keyboard. You’ve got a glucometer as well. And so it makes a big difference when you think about the opportunities for
potential contamination. One of the things that you want to think about is how do you make something
that’s universally applicable for cleaning and disinfection? Well, you need to work with
biomedical engineering. You need to make sure you work
with electronic medical records. You want to work with glucometers as well. And then also look at the nursing profession
and specifically the tools that we use so that we can make sure that we
have something that’s consistent. One of the things that I see as an
opportunity for improvement for us is that in many cases we see
environmental services doing one thing and you see nursing doing another. And we need to come together
and collaborate as departments and say how do we make sure we take care of
the environment consistently so that we have that high reliability safety
net that we are all looking for? There’s a couple claims that are specific
for healthcare disinfection and I want to add a caveat to this that my expectation is
not that a regular bedside clinician is going to memorize or know this, but
we want to work collaboratively with environmental services leadership and your
infection preventionist in order to make sure that the products that you’re using to take care of the clinical environment
of care do have these claims. So let’s start with the bacteria. The first is what we call broad spectrum. So we want to make sure we have efficacy against
gram positive and gram negative bacteria, enveloped and non-enveloped viruses,
multidrug resistant organisms. One of the things that I’ll add here is kind
of a caveat of wisdom is that if you kill MRSA, then you’re already going to
take care of Staph Aureus. And so when you have that resistant
form of a particular pathogen, then you’re going to have the same non-resistant
form and so it’s not necessary to have both. Pathogen fungal organisms are becoming more of
a concern in the clinical environment of care, specifically things like Candida. And so we want to make sure
that we’re thinking about that, not only from a disinfection standpoint,
but also think about that with the impact to the patient, because we know that anti-fungal
treatment certainly comes with its own host of risk associated with treatment
for the patient. Bloodborne pathogens are
required by federal OSHA law and so you needed a minimum
HIV or Hepatitis B virus. So that’s abbreviated HBV. And preferably you want to
have Hepatitis C virus. And of course there’s been some
exciting treatment and cures associated with Hepatitis C virus so we’re making
a lot of progress in that front. And last but not least I just wanted
to mention again the importance of knowing about emergent pathogens. Because again you’re not going to see those
reflected on your disinfectant labels. This also applies to things
like hand hygiene agents as well because they’re simply not
going to test against that. But there are a couple different ways
that we can look for the proper way to choosing a disinfectant method
related to non-critical items. One of the things I think we
have to start with is the safety. If it’s not going to be safe
for us, safe for the patient, and safe for the environment,
it’s a no– it’s a nonstarter. We’re just going to stop there and we’re going
to move on to a different type of solution. We also want to look at what specifically
are we going to clean and how often? Again, if an item is used between
patients– so if I have a DINAMAP for example and I’m pushing it down the hall and I’m going
to use it between multiple patients all day long to assess vital signs, or another example
that’s been you know heavily implicated in outbreaks is glucometers and lancing devices. That is certainly a high risk device because of
the potential exposure to blood and body fluids. And so if I’m going to clean that every single
time, what is that approved disinfectant by that manufacturer from a compatibility
standpoint is another factor we have to think about. And then, you know, what’s the ease of use? How quickly can I do it? For example if somebody, you know, I
guess commented this was a few weeks ago and he said well what if you had
something that was literally made of gold and it would inhibit bacterial
growth for a year? And I said well what’s the catch? And of course the catch was cost. And so you have to think about what’s that
tradeoff between the benefit to the patient and us and the potential cost, as
well as unintended consequences. One of the things that I
think we have to consider with these more antimicrobial
impregnated surfaces where the antimicrobial’s actually embedded in
it, is you know, what’s the potential impact to the culture of the organization? Is my environmental services team going to
continue to clean that surface if they know that that surface should in some
aspects inhibit microbial growth? And so that’s something that I don’t
really think we have enough literature on to fully understand the
unintended consequences. Another factor is really looking at the impact
of multidrug resistant organisms in general. And CDC put out an amazing study that
really kind of did a cross section of the different types of organisms, looking at all of the medical
records that they could access. And they found that over two million
infections or illnesses were attributed back to these particular superbugs
if you will, and 23,000 deaths. If you then carved out of that just C. Difficile
alone, 250,000 illnesses and 14,000 deaths. And when I saw that I was alarmed but not
surprised because we certainly know that one of the biggest risk factors for C. Difficile
infection is overuse of antibiotics. So not only do we need to address it
from a clinical environment of care to stop transmission by doing good
evidence-based recommendations with cleaning, disinfection, and personal protective equipment,
we need good rapid diagnostics to identify it. And we need a prevention strategy that starts
with prescribers as well as patients in order to really knock down this potential
resistance that can impact the community. I frequently mentioned in talks that I
give that, you know, antibiotics are one of the few classes of medications that I can
think about that truly have a community impact. You know I’ve since amended that to
say that now opoids also have an impact as well give what we’re seeing in the news
lately and just the literature in general. So there was a great graphic that
CDC put out that looks specifically at antibiotic resistant infections
in healthcare. Now when you think about today’s topic of the
environment of care, we’re really focusing in on that middle bucket, the one that’s green
that says prevent bacteria from spreading. So we’re starting with our hand hygiene agents. We’re using our personal protective equipment. And we’re also looking for outbreaks. We’re going to make sure we work
collaboratively with our infection preventionist and epidemiology staff to make sure that
we’re looking aggressively for this. On the left and the right you’ll see
additional measures like getting catheters out. Don’t use catheters unnecessarily,
especially after surgery. You know I have a friend that was undergoing a
very, very outpatient procedure that was going to be very quick– 30 minutes in and out of the
OR– and they wanted to put a Foley catheter. And it was not even indicated
and so only when we questioned that did they actually say well we don’t
really have to have it, it’s just convenient. And so we need to make sure that
patients feel empowered and safe to speak up to us and ask questions as well. That’s one of the most important aspects
we have with improving accountability with applying these evidence-based
recommendations. And last but not least is getting
better with antibiotic use. And I think that starts with us. I’ve yet to go to an audience where people
say I always take my antibiotic as indicated. It just doesn’t happen. I mean people either forget, they stop taking it because they feel better,
or worse yet, they share it. And so there is an impact
that’s associated with that. The holistic aspects of antibiotic use,
well, how do we translate the learnings here with we know we can create a
problem to the clinical environment? Well while we may not use antibiotics on
the environment, we do use antimicrobials in the form of disinfectants and cleaners. And so we need to educate all of the
associated [inaudible] so that we don’t run into that same issue as we move forward
in the next coming years where we start to see resistance with that aspect. In the very center of this graphic
you’ll find the public health department and certainly CDC really serves
as a conduit for sharing data but also helping drive evidence-based
practices and applying them to all of the kind of spectrum of healthcare delivery. No more are the days where we can focus
just on acute care because we know that these organisms can really transfer
and they can go with the patient, so if you’ve got somebody that
comes in from a nursing home, they go into the emergency department and they
go into the OR then maybe they go out for rehab and then go back to the nursing home,
well that’s multiple different sites that we need to make sure work together. And part of it starts with building a
relationship up front so that we have that more coordinated approach that’s going
to help us drive practice standardization. And environmental services and nursing, while they don’t necessarily prescribe
antibiotics, do share some drug expertise. And if you think about it
from the nursing perspective, well you’re one of the top
advocates for the patient. The most trusted profession
in the United States. Well there’s a reason for that
because the patient trusts you. And so demonstrating that
you’re thinking about the impact of unnecessary antibiotics is going to help. And having that conversation with a prescriber. If we flip the switch to the
environmental services world, while they don’t use antibiotics,
again, they use antimicrobials. And so there’s a key opportunity
there to make sure that we can actually reduce the risk associated
with the use of these chemicals or medications and use them, you know, in the right aspect. One of the best resources I stumbled upon
several years ago was this program called Partnering to Heal. I think that this program is
something that has been underutilized because honestly I literally just stumbled
upon it like I said, but it’s available on the Department of Health
and Human Services website. I’ve included the link at the
bottom so you’ll be able to click that once you get the slide
presentation from the program. But I highly, highly recommend that you use
it for both environmental services as well as nursing personnel and anybody in healthcare. Because not only does it help us actually
understand the routes of transmission and it gives, not only pictorially but also kind
of from an audio standpoint, but it truly talks about the impact of an infection
to the entire team, from the patient to their family
members to the provider team. And I have watched it hundreds of times and
I’ve used it hundreds of times for training. And I never get the same reaction from anybody. It is just amazing to see the diversity
of people that just literally shut down. People that become emotional. People that say wow, I’ve never
even thought about it like that. And it’s totally free. And so I would invite you to use this resource
to supplement some of the great training that comes out from CDC so that you can
use this to actually train your staff. There are three elements for the environment of
care that I wanted to focus on as we get ready to open it up for Q & A here in a few minutes. But the first thing that we want
to do we talked about earlier. We want to look at safety. Is this going to be safe for
the clinician and the patient? And that is not a conversation that can
happen within a silo of just nursing, just environmental services, just
patient safety, or just medicine. We’ve got to do it together. We’ve got to make sure that everybody
that’s affected is engaged and understands. One of the biggest citations I
see with accreditation bodies is that staff don’t know how to use what they have. And so if someone walks up for example to
a nurse and says what’s the contact time for that disinfectant you’re using? Or what’s the contact time, how long do
you have to use that hand hygiene agent? And if they don’t know the answer
to that question, that’s a problem. Just as we’re expected to know drug information, we need to make sure we know the antimicrobial
set we’re using both on the environment as well as the skin to use them safely and according
with the manufacturer’s instructions for use. The second is efficacy. We talked about that earlier. We’re looking for how do we build
broad spectrum interventions here? Gram positive and gram negative bacteria,
your envelope, non envelope viruses, bloodborne pathogens, pathogenic
fungal organisms and the like and your multidrug resistant organisms. We want broad spectrum because it helps us
cover the gamut of things that we’re going to see on environmental surfaces. If you’re not familiar with what is
actually on environmental surfaces, there’s a couple ways to understand that. You can either culture the environment,
you can look at things like ATP measurement which we’ll talk about in a second, or you
can also look at the facility’s antibiogram and make a determination as to types of cultures that you’re actually seeing in
the facility in the patients. And then look at what you’re also finding
in the environment and do a comparison. So there’s a lot of different ways that require,
again, collaboration, not just with nursing and environmental services but also
with our infectious disease colleagues, infection preventionists, as well as
the medical laboratory and the pharmacy. And last but not least is compatibility. It’s great to have efficacy and it’s great
to have safety, but if it’s not compatible with a piece of equipment or
it’s not going to be compatible with the environment then it’s not going to
be able to move forward because we’ve got to make sure that equipment
and people are taken care of. And that way we can make sure
we don’t have any breakdown. So earlier I talked about C. Difficile
and then we talked a little bit about the proactive nature of
how we can actually address that. Well, we focus so much on antibiotic
stewardship to reduce the risk of resistance and improve overall health and there’s
some great efforts going on with that. And that really kind of covers
the class of medications. What I’d like to propose is also looking at
antimicrobial stewardship so that we can look at what are the things that we’re using? Are we using them according to
the manufacturer’s instructions? Are we monitoring the environmental cleanliness? Are we also training the staff? One of the things that I always find funny is
that people say well I’m, you know I’m educated. And I think well are you
educated or are you competent? And there’s certainly a difference
between those. So how do we make sure that we’re not only
educating people about the clinical environment of care, but we’re also making
sure they’re competent to perform the unique aspects of their role. While I don’t expect a nurse to ever get
down and clean the floor or, you know, know how to do every aspect of that role or
environmental services certainly to be able to do what nursing does, we do want to
have some basic understandings and things that we collaborate on so that we can really
focus on improving patient overall care, improving the experience, and really
maintaining a clean and sanitary environment. Now there’s two different buckets
that I like to put things in. And again I try to keep it really simple. There’s our core measures, the
things that we should do as a team– environmental services and nursing– and then there’s things that are
really more adjunctive technologies– the things that we should consider doing
especially when we don’t have success after fully implementing our basic things. So the first things we’ve talked about today. We’ve talked about cleaning. We’ve talked about disinfection. And we’ve talked about environmental
monitoring and I’ll show a specific example in just a few slides actually
that’ll address that. But what we have not talked about is
let’s say you do all of those things and you’ve got 100% compliance, well what happens when you still have ongoing
transmission lead back to the environment? Well that’s when some of these new novel
technologies might be of consideration. You can see UV light is listed there. There’s some gas and fogging solutions. Other novel technologies that will come out. And your antimicrobial environmental surfaces that actually have the antimicrobial
embedded into the surface as well. Again, I’m always going to focus on the
left side of the screen because that’s where my biggest bang for my buck is. And I, you know, my policy is don’t
address problems with a product, address it by fixing the process. What we’re looking for and what CDC
is building is sustainable tools. How do we make sure we have a sustainable
infection prevention and control program? Well a big aspect of that
is investing in our people. So it’s not just products, it’s really how do
we actually use what we have available to us and do we use it to its fullest advantage? So I think that’s something to think about. A couple special environments
that we need to think about. Well, I cannot think of the last time I went
into a NICU anywhere in the United States– and I travel all the time–
where I got into a NICU without being forcibly stopped
if I was not washing my hands. And I think that’s an amazing thing. What I’d love to get to is a world where
it’s almost like TSA where if I come into the hospital I have to go through the
metal detector or the hand hygiene station as we would call it, to actually
enter the facility. And then I’d do the same practice when I leave. And then apply that across all of healthcare. You know certain patients have higher
risks like our oncology population. You know that’s really where the
Oncology Nurses Society comes in to look at specific recommendations for taking
care of these immunocompromised patients. Our neonates are no different
because they really don’t have that robust immune system, and
these are helpless patients. They rely on us to be their total advocates. You’ve also got certain situations in the
operating room in that perioperative environment where we want to make sure that
we’re minimizing the amount of people that are coming in and out of the environment. We’re giving our environmental services
or our surgical technologist enough time to actually clean and disinfect
that room between cases and then doing a good terminal
clean at the end of the day. And then our intensive care
patients and long-term care where there’s different complexities
associated with that. In intensive care you’ve got lots of equipment. In long-term care, that’s their home. And so they’re going to have all
kinds of stuff in their environment that in many cases we cannot easily
remove because it again is their home. And so that’s something that
we need to be considerate of. Well, let’s translate that into
oncology patients as an example. You’ve got to think about the air. You’ve got to make sure that you’re focusing on environmental cleanliness
and that’s being done routinely. These patients cannot afford a single slipup. Sometimes we have the cohort patients,
and this is really where you go back to the CDC isolation guidelines to look at what
are those kind of wide routes of transmission? Maybe Norovirus and C. Difficile for
example because they’re both fecal-oral. Maybe if you have a respiratory pathogen
and you don’t have private rooms. You know certainly it would be ideal
for all facilities to have private rooms but we still have situations where you do have
to cohort and so that’s where collaborating with your infection preventionist can happen. We want to have the right staffing mix, and
while there’s no formal recommendation for this, we know that we want to minimize the route for
transmission being the staff member in general. And so if you’ve got a staff member that’s
taking care of three patients on isolation and one that’s not, that’s really not
the ideal situation so we want to try to limit the staff role in transmission as well. And part of that is educating ourselves. Educating the patients. There’s many facilities that are moving away
from contact precautions for things like MRSA. Part of it’s due to cost. Part of it is due to impact and
they’re really focusing on some of those better standard precautions. But you know each facility has to look at
this and say where are we on our journey so that we can improve overall
patient satisfaction. There are many different environmental
monitoring aspects out there that can contribute to the development of a program,
but remember the goal of our environmental monitoring
program is very simple. We want to make sure that
we’re following our process and that we’re achieving
the efficacy that we desire. So the most basic and free is
visual where we’re walking around. It’s leadership by rounding. We’re walking around watching staff clean rooms. Get in there and clean a room with them. Bring environmental services in while you’re
taking care of a patient and have a conversation and focus on what are we going
to do in this particular room? How are we going to make sure that we, you
know, keep these things clean as possible? The next is bioluminescence
which is extremely economical. You can go out and buy kits
from $10 to $50 online. They have a gel or powder and then
you use a black light that allows you to illuminate surfaces and look for not only
environmental surfaces but you can do it on the hands to specifically
look at areas missed. Again, not 100% foolproof but it really allows
us to have a basic idea of where cleanliness is. But you want to make sure you don’t tell staff
the surfaces that you’re going to actually swab so that they’re not going to make those the
cleanest and then everything else is not. And one of the newer technologies
that’s been brought over from the food service industry is actually
ATP monitoring or Adenosine Triphosphate. This is a quick barometer of
success that tells you the measure of bio-burden on an environmental surface. And so it gives you a digital
readout in about 15 seconds. The meters themselves can range from $800 to
I’ve seen them up to $1300 and a test you can do for under you know in some
cases a buck up to $2. And so it’s not extremely cost
prohibitive but it’s a great resource, not necessarily for the bedside nurse but
specifically for nursing administration and environmental services and infection
prevention and control to walk by and actually look at how
clean is the environment? And of course our goal is
to get to zero as a reading. We want to have no bio-burden present on there. The limitations with ATP though, it doesn’t
tell you what it is so you’re not going to know if it’s a bacteria or a virus. You just know if there’s
bio-burden present there. And of course we want to try to
get as close to zero as possible. And then consider some of the new novel
technologies that we talked about today which we unfortunately don’t have time
to go into detail, but it helps us look at our compliance and make
sure that we’re moving that needle towards zero
healthcare associated infections. Earlier I talked about the importance
of training and staff education and building competency and awareness. And so I’d like to finish up with a few
slides on that that focus in on what we can do to improve the people aspect which I
think is really the most important. The first is when we hire you and
annually we need to make sure we train you and provide those competencies, give you
the documentation for all of the tools that are going to be used in your practice. And when I think about kind of
core elements of required training, I want to know when to use it,
why to use it, and how to use it. And that includes things like maybe personal
protective equipment, how do I dispose of it? And God forbid, what do I do
if I have a first aid incident where maybe I get a chemical in my eye? And that’s where the safety data sheet
which is an OSHA requirement comes in there. And last but not least is that it’s not
good enough just to do this annually. I know for myself, if I don’t use something,
it is gone from my brain in 90 days. And so those periodic refreshers and making
sure that we’re testing in different aspects and different ways, modalities,
competency makes a big difference. I happen to be somebody who’s
visual so I like to see it. If you tell me in kind of an
audio format, I have no idea. It goes right out of my brain. But if I see it and I write it and I do it,
I have it and I can commit it to memory. I guess that’s why when I drive somewhere,
if I drive I can get back there without GPS. If I sit in the backseat, I
have no clue how I got there. And so that periodic refresher
makes a big difference. And then how do we build the next
wave of clinicians, both nursing and environmental services, to make sure that we actually have the right
mix for tomorrow’s clinician? Well part of that is starting
with the nursing faculty. And so that’s why we, you know, collaborated
with the American Association of Colleges of Nursing and have Dr. Garcia on
the line to really look at aspects of how do we incorporate this into curriculums? How do we make sure that faculty can serve as
clinical ambassadors for infection prevention, make sure they’re aware of the CDC core
practices for infection prevention and control which are going to be distributed at the end
of today’s webinar, and then also make use of free resources like the new
Medscape series that just came out, to not only educate themselves as
faculty experts but also the students so that we can really move the needle forward. And those core practices focus on leadership
support, making sure that the top administration of a facility understands, supports, and resources the infection
prevention and control program. We’ve got to start with education. And not just education but
translating that into competency for our healthcare associated
infection prevention efforts and the personnel associated with that. Engaging the patient, I want patients
to ask me if I’ve washed my hands. I love it. I think it’s amazing when
patients ask us these questions. It helps us hold ourselves accountable
and they help us be held accountable. And then we talked about performance monitoring. So if we use an ATP measurement or we do
bioluminescence and then I provide that feedback to you as environmental services and
nursing, that is data for action. That’s things that we can actually take and use. And it helps us look at basic things
like standard precautions or hand hygiene or our cleaning and disinfection
and something like injection and medication safety which
continues to be a problem. We also want to look at the risk assessment. That makes a big difference so that we
can be aware of the risks that we’ll face within our current role and how to protect
ourselves and that would really be driven by your infection preventionist so that we can
minimize exposures and prove outcome measures, look at our medical equipment to make sure
that we’re reducing risk for transmission. And also properly apply the
transmission based precautions so that we don’t have occupational exposure or the devices themselves actually can cause
transmission or environmental surfaces. One of the things that I wanted to mention is
that there’s a new Medscape resource available from CDC that’s out there for
infection [inaudible] control and so you can click that link there. All that’s required is a free Medscape account
and there’s six total modules out there that CDC was kind enough to sponsor with a
grant with Medscape and they’re totally free. And so you can earn contact
hours associated with that. It’s a great way to address the periodic
refresher piece that I just mentioned before. So as we conclude, you know, where are we going? Well, we’re going to continue to have superbugs. We’re going to continue to have challenges. And we’re going to continue to have
staffing challenges within healthcare. Are we ready to respond? Well my thing is focus on the positive. Focus on the back to the basics approach. Look at our center precautions. Look at our cleaning and disinfection. But also bring all the stakeholders together and
recognize the role of the clinical environment of care in transmission and incorporate
those newly published CDC core elements of HAI prevention. This will help us really move forward. So with that I’m going to turn it over to Dr.
Garcia from the American Association of Colleges of Nursing to make a few closing comments and
then we’ll open it up for question and answer. Dr. Garcia?>>Thank you Dr. Garrett and
thank you for your insightful and informative presentation
highlighting the fundamental elements for use in the environment of care. The resources that you have presented
and shared will empower nurses nationally to enhance their knowledge on minimizing
bacterial colonization and transmission through collaborative practice and partnering
with our environmental services colleagues. I will now turn it back over to Dr.
Garrett for questions and answers.>>Perfect. Thank you very much, Rick. It does look like we have several questions. I’ll try to do my best to answer all. I will tell you if there’s any
questions we cannot answer due to timing, we will commit to getting those answers for you. The first question is, and this is a great one, is for portable blood pressure
machines, how often should you clean? This is a question that I would say let’s
even make it a little bit more broad. So shared medical equipment
in general should be cleaned and disinfected after every single patient use. There are many facilities that
also say just as a kind of measure of extra safety they’ll say
clean it before and after. Well, when I asked the question why do you
do that, people say well I don’t really know if the person before actually cleaned it. And so I will give them that. I think that it’s always better to be
safe than sorry but the general rule of thumb is shared medical equipment between
uses does need to be cleaned and disinfected. And so that will always keep you safe. One of the biggest areas that we
had mentioned before was glucometers because of the risk of blood exposure there. And that applies there as well and that’s
certainly a big hot button especially for CMS and Joint Commission so hopefully
that answers that question. The next question is do you recommend
cleaning and disinfection of non-critical, reusable equipment after every patient
versus should we move to actually disposable in the ambulatory setting as well as inpatient? So great question and I think
it’s kind of two parts. I think the first part I answered
before which was if it’s a shared piece of medical equipment you do want to clean
and disinfect it between every single use. So that takes care of that. The second which is a more
interesting question is should we move to all disposable things
like blood pressure cuffs? I think there is some strategic
value in that in the sense that you’re not going to
share it between patients. But let’s use the blood pressure
cuff as an example. Most often when I go into ICUs at least, I see that that blood pressure cuff is
actually wrapped around the patient’s bedrail. Well we know that the science shows
that that’s one of the dirtiest areas in the patient environment and so we’re
already contaminating that disposable, non-shared device through the
environment through our own practices. So I think it’s fine if that’s
something that cost-wise you can absorb. But you want to make sure that you
still store it in a way that’s going to prevent contamination and even if it’s not
going to be shared, you do want to disinfect it between uses because you don’t want
to take something from the environment and then apply it to the patient. And I would also add that it’s important to
consult the manufacturer’s instructions for use to make sure that you’re
compliant with those as well. So hopefully that answers that question. The next question is is environmental services
removes garbage without changing gloves or doing hand hygiene in between rooms. How can we get buy-in? That’s an excellent question. First and foremost is that regardless
of clinical training or clinical roles, everybody has the same– follow
the same rules is kind of my motto. Hand hygiene applies to all
whether you’re a volunteer or you’re environmental services
or the chief medical officer. So they absolutely need to be wearing gloves when they’re handling any
potentially infectious waste. That’s an OSHA requirement. But they also should be performing hand hygiene and that’s a CDC requirement
from their guidelines. And so if environmental services is going to
come in, then they need to perform hand hygiene, come in, put their gloves on, grab the trash and
then leave and go immediately to the receptacle and then of course remove those gloves
and then disinfect their hands as well with their alcohol based hand
sanitizer or soap and water. So definitely need to make
sure that you’re doing that. As far as to your point about getting buy-in,
I think that’s where the collaboration with environmental services leadership comes in. And you know if you call your environmental
services technician a housekeeper, that just totally changes the conversation versus you’re an environmental services
technician that plays a role just like my certified nursing
assistants or nursing technicians do. And so we want to try to
integrate them as much as possible. The next question is do you have any
recommendations to help with education for environmental services personnel
for whom English is a second language? Excellent question and one
that comes up all the time. I will give you kind of a two part answer. The first is that, you know, if you
think about most healthcare facilities, you want to check the job description. Most facilities do require
that all staff that work in the healthcare facility
be proficient in English. So proficiency does not mean it’s their first
language it just means they’re proficient. It would be no different than if I walked
into a hotel in the United States and I tried to be greeted by someone
and they spoke in French. I don’t speak French and so we do want to make
sure that there’s kind of the healthcare jargon that we need to make sure
everyone’s familiar with. And then also that there’s not a language
barrier that will inhibit their ability to receive instructions and
follow our safety principles. And so the other piece to
that is we need to ensure that the staff can access the safety data
sheet and read it accordingly in order to protect themselves in case
there’s some occupational exposure. I’ve seen some really cool practices
with facilities that have hired people where English is not their first language, and they’ve actually provided on-site ESL
classes to actually help them with that. I’ve seen facilities that have just not hired
people and actually done testing before as part of their pre-hire employment test. So there’s all different ways to do that
but I would certainly make sure you want to make sure– or I guess allow for different
situations that you deal with and ensure that everyone can communicate in a fair manner. The next question is is that regarding ATP,
what’s the upper limit of acceptable range? I’m sorry?>>Hi, this is Ashley Verma [assumed spelling]. Unfortunately we are out of time and I’m
going to transfer it over to Kate Wiedeman to provide the instructions
on continuing education. But thank you so much for your presentation. We have lots of questions and we’ll be
following up with the participants afterwards. Kate?>>Yes, thank you so much Dr. Garrett,
that was a really wonderful presentation. So before we end today’s webinar I just want to provide some instructions
for continuing education. So you must complete the continuing
education post-test and evaluation. Please follow the detailed instructions that
will appear on the post-meeting web page right after you close out of the webinar. You must complete and pass the post-test
activity at 75% to receive continuing education. For those on the phone who currently
aren’t logged in to ReadyTalk online, to obtain continuing education,
please go to The access code for this webinar is NES0821. A follow-up email will also be sent after
the webinar with detailed instructions about completing the continuing
education post-test and evaluation. With that I’d like to thank our speakers as well
as all of you for taking time to join us today and for your commitment to
keeping your patients safe. Thank you so much.

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