From Stewardship to Scopes: Infection Prevention Imperatives for 2018

By Kelly M. Pyrek

Stewardship and scopes are just two issues that are top of mind for stakeholders in infection prevention and healthcare epidemiology for the new year. Let's explore the imperatives, as suggested by leaders in the infection prevention and control community.

Stewardship
Antibiotic stewardship refers to a set of coordinated strategies to improve the use of antimicrobial medications with the goal of enhancing patient health outcomes, reducing resistance to antibiotics, and decreasing unnecessary costs. Antibiotic/antimicrobial stewardship (AS) has garnered a great deal of attention lately as a solution to multidrug-resistant organisms and a diminished pipeline of therapeutics with which to treat them. As we know, the discovery of antibiotics transformed healthcare and significantly improved physicians' ability to reduce morbidity and mortality; however, medical practitioners and researchers soon discovered that bacteria exposed to antimicrobials quickly developed a resistance to those treatments. Today, there is global consensus that resistance to antimicrobial treatment is a critical issue, contributing to rapid spread of multiple organisms for which few treatments are available.  The dramatic reduction in the development and approval of new antibacterial agents complicates this global health problem and portends a future in which many more infections have no effective treatment option, asserts the Society for Healthcare Epidemiology of America (SHEA).

"A critically important issue for 2018 is to continue to champion the clinical impact of infection prevention and control as well as  antimicrobial stewardship," confirms Keith Kaye, MD, MPH, a professor of internal medicine and infectious diseases at the University of Michigan, and incoming president of SHEA. "There's a role that everyone, from patient to provider to healthcare administrator, epidemiologists and public health officials, can play in helping to prevent infection and prevent antimicrobial resistance. And that extends from hospitals to outpatient facilities, to long-term care facilities, as well as to schools and prisons. Stewardship runs across the continuum of healthcare and community institutions."

SHEA is among many entities that support the consistent management of antimicrobials in all healthcare settings as a fundamental step in slowing resistance and improving patient health. The major objectives of antimicrobial stewardship are to achieve optimal clinical outcomes related to antimicrobial use, to minimize toxicity and other adverse events, and to limit the selection for antimicrobial resistant strains. Antimicrobial stewardship may also reduce excessive costs attributable to suboptimal antimicrobial use.

"I think we know a lot more about stewardship and infection prevention today more than we have known 10 or 15 years ago, but one of the big challenges has been implementation," Kaye continues. "Meaning we take what we know -- things like optimal hand hygiene practices or optimal environmental hygiene practices -- and implement them in a way so that there is buy-in and top-level compliance with these efficacious interventions. SHEA has been supportive of implementation science but I think coupling that with simple as well as technically more advanced aspects of infection control and stewardship is on a short list of things that we need to continue to push forward in 2018."

Addressing gaps is critical, according to Kaye, who emphasizes that many institutional infection prevention and epidemiology programs lack resources and support. "We don't bill for infection control and AS services, as these are prevention- and cost-avoidance-type ventures," he says. "Unfortunately, many times budgets for infection prevention and AS are on the chopping block among the members of the hospital C-suite. Without adequate effort and time and data management and administrative support, it is very difficult to get things done in infection prevention and AS. While resources and support decrease, I think our knowledge and the work required of us has grown significantly. For example, we know so much more about  C. difficile, what antibiotics we know are particularly risky, what types of drugs and interventions are newer and effective, like fecal transplants, but when we try to implement that knowledge -- such as which technologies and treatments to implement, how to get healthcare workers to change their behavior, not only knowing what the right thing to do is bit actually doing it, like washing hands, proper donning of gloves and gowns, or stopping antibiotic X on day seven because it's adequate treatment based on recent studies -- we encounter challenges. We must address how to cultivate healthcare professional  behavior changes that become automatic. But they also must stay mindful in order to consider these habits and why they must engage in proper practices."

Kaye continues, "Implementation science is about impacting behavior, where you make systems changes, things that systemize and obviate key steps or avoid unnecessary decision-making and when you can force systems to push providers in the right direction, that's always a plus. So, various aspects of implementation science, behavior change, process change at system levels, are some examples where we have learned a great deal, but in many ways, we are still at the toddler stage of this quality improvement venture, particularly around behavior modification of healthcare workers. I think there is a lot more that can be done in terms of optimizing process in healthcare systems to prevent infection and to prevent antibiotic and antimicrobial resistance."

In 2014, the President’s Council of Advisors on Science and Technology (PCAST) released a report to the President, "Combating Antibiotic Resistance." The report was released simultaneously with a National Strategy on Combating Antibiotic Resistant Bacteria as well as with a Presidential Executive Order, emphasizing to the Nation the importance of addressing this growing challenge. In late 2017, the World Health Organization (WHO) sounded the alarm that the world is running out of antibiotics with which to combat the growing threat of antimicrobial resistance. The WHO report, "Antibacterial Agents in Clinical Development: An Analysis of the Antibacterial Clinical Development Pipeline," explains that most of the drugs currently in the clinical pipeline are modifications of existing classes of antibiotics and are only short-term solutions. The report found very few potential treatment options for those antibiotic-resistant infections identified by WHO as posing the greatest threat to health. Earlier last year, WHO identified 12 classes of priority pathogens – some of them causing common infections such as pneumonia or urinary tract infections – that are increasingly resistant to existing antibiotics and urgently in need of new treatments.

The 2017 WHO report identifies 51 new antibiotics and biologicals in clinical development to treat priority antibiotic-resistant pathogens, as well as tuberculosis and Clostridium difficile. Among all these candidate medicines, however, only eight are classed by WHO as innovative treatments that will add value to the current antibiotic treatment arsenal. There is a serious lack of treatment options for multidrug- and extensively drug-resistant M. tuberculosis and gram-negative pathogens, including Acinetobacter and Enterobacteriaceae (such as Klebsiella and E. coli) which can cause severe and often deadly infections that pose a particular threat in hospitals and nursing homes.

While much work remains to be done, Kaye emphasizes that there is a glimmer of hope: "Antimicrobial stewardship is much more in the public vernacular these days, and both consumers and lawmakers are talking about it along with healthcare professionals and public health officials," he says. "it's good news that healthcare workers, and not just infectious disease physicians or pharmacists, are aware of this critical issue. There are still a few areas in which we have limitations; No. 1 being metrics -- how can we measure stewardship in a way that is generalizable across different types of hospitals, with different types of patients, that cater to different specialties? These metrics need to be better defined. Also, it is important to align national healthcare goals with stewardship efforts, to align what we think are critical issues with public policy, and with CMS as well as with existing political infrastructures to come up with what we think are good solid stewardship goals for hospitals to follow that will attack antimicrobial resistance. We are continuing to focus on having SHEA take more and more of a leadership role and be a vanguard in public policy as it relates to stewardship issues. SHEA partners with IDSA and other organizations, and together, we promote stewardship and drive policy. Unfortunately, given the complexities of U.S. healthcare, and given the fact that many healthcare workers are overburdened and don't have a lot of extra time, progress might be slower than we would like. It also takes financial incentives, policy requirements or accreditation requirements to move the needle, so to speak, to impact change in healthcare worker behavior in hospitals and other healthcare settings. I think the Joint Commission implementing antimicrobial stewardship standards, has been a critically important landmark in the past several months. I look forward to continuing to see stewardship grow in healthcare institutions of all sizes everywhere."

Janet Haas, PhD, RN, CIC, FSHEA, FAPIC, of Lenox Hospital in New York and president-elect of the Association for Professionals in Infection Control and Epidemiology (APIC), emphasizes the role that nurses and infection preventionists can play in antibiotic stewardship across the continuum of care. "That is something that people with expertise among our membership is thinking about deeply and trying to determine the best way that we can help in this very important work," she says. "Most likely that will be serving as a bridge to frontline healthcare providers and especially nursing staff who were under-appreciated in this role until that paper by Rita Olans and colleagues (Olans R, et al. Good Nursing Is Good Antibiotic Stewardship Am J Nurs. Vol. 117, No. 8. August 2017) said, 'Hey, nurses are pivotal to all of this, as they are the ones seeing these patients daily.'

However, many staff nurses are not familiar with the concept of antibiotic stewardship and so we are socializing that message and figuring out how we can help that practice. We want to ensure the communication among healthcare personnel about antibiotics in a very clear way so that the course duration isn't misunderstood during transfers of care, such in long-term care, for example, where it may not be clear to the receiving end what day the patient is on. We also want to get the word out to ambulatory-care sites about the true indications for starting patients on antibiotics. We want to work with the public so they can understand the ramifications of getting that course of antibiotics if they don't need it; clinicians who serve people in primary care are under enormous pressure to administer antibiotics, so we are trying to help with that communication. I think we have a unique role because we are seeing a patient not just on this unit or in this place, but having more of an overarching view, and so we as IPs are trying to make sure that people know what to do in the various care settings where antibiotics are being prescribed, and then helping to see how that moves across care for that patient. And recognizing when patients come back into a facility, that if they have had antibiotics they may be at a greater risk for C. difficile -- which, of course, is another priority around which we need to better work."

Outbreak Preparedness
Late last year, the Society for Healthcare Epidemiology of America (SHEA), with the support of the Centers for Disease Control and Prevention (CDC), issued a new expert guidance document for hospitals to use in preparing for and containing outbreaks. The guide was published in the journal Infection Control and Hospital Epidemiology.

"This guidance details the role of the healthcare epidemiologist as an expert and leader supporting hospitals in preparing for, stopping, and recovering from infectious diseases crises," says David Banach, MD, co-chair of the writing panel and assistant professor of medicine at the University of Connecticut and hospital epidemiologist at UConn Health. "Armed with the resources to develop and support key activities, healthcare epidemiologists can utilize their skills and expertise in investigation and response to infectious disease outbreaks within a hospital's incident command system."

SHEA and CDC collaborated in 2016 to form the Outbreak Response Training Program to guide healthcare epidemiologists in how to maximize their facilities' preparedness and response efforts to combat outbreaks such as Ebola, Zika, pandemic influenza, and other infectious diseases. The new document, "Outbreak Response and Incident Management: SHEA Guidance and Resources for Healthcare Epidemiologists in United States Acute-Care Hospitals," leads epidemiologists through how to apply, use, and interact with emergency response structures, groups, and frameworks from the institutional to the federal levels, and provides an overview of essential resources. The principles in the guidance are intended for acute-care hospitals, but may apply to other types of healthcare facilities, such as free-standing emergency departments and long-term care facilities.
According to the guidance document, during a crisis the epidemiologist provides medical and technical expertise and leads infection prevention and control efforts, coordinates with institutional stakeholders, and provides input into internal and external communications.
"We will always be faced with new and re-emerging pathogens," said Lynn Johnston, MD, co-chair of the writing panel and professor of medicine and infectious diseases at Dalhousie University, Halifax, Canada. "This guidance is part of an ongoing effort to develop tools and strategies to prevent and manage contagious diseases to ensure patient and public safety."

The document is part of a partnership between SHEA and CDC to prepare for emerging and re-emerging infections by providing training, educational resources, and expert guidance for dealing with outbreaks in healthcare facilities. The program is designed to train U.S. healthcare epidemiologists, who oversee infection control programs, to have the skills, abilities, and tools available to implement infection control practices and provide a leadership voice in responding to infectious threats. To operationalize the guidance, SHEA will conduct an outbreak response workshop in January, develop and post toolkits based on the recommendations, and provide online training modules and webinars.
While the world waits for the next pandemic, SHEA's Kaye emphasizes that there is much that can be done at home to prepare for an outbreak, large or small, including an outbreak of insidious influenza.

"No matter what else of going on with emerging and re-emerging pathogens, I always think about flu," says Kaye. "Influenza is something that healthcare providers must think about year-round, as mentally we must always be preparing for the next flu season.  Flu is a killer, and I feel it is our duty to get vaccinated to protect our patients. We know that Zika pops up, we had Ebola a few years back, and we never know what's going to hit next, but in general, there is preparedness work that can be done year-round that will pay dividends regardless of what the pathogen is. This preparedness work includes partnering with your public health department at the state or local level, conducting drills for different types of infectious threats, or seeing to stockpiles of personal protective equipment. By preparing for contagious outbreaks with pathogen x or y or maybe something like flu, it helps shore up general preparedness. Training is critically important, as is having a good communication flow within your institution, as well as between your facility and your state and local public health departments. Preparedness never ends, and it isn't outbreak- or pathogen-specific. Preparedness can be effective for all infections and improve infection prevention and control in general by reminding providers about proper practices. We never stop preparing because the next pandemic is around the corner. Having a plan is critical for protection and safety of patients as well as healthcare workers.

Cultivating a Culture of Patient Safety
Cultivating and maintaining an institutional safety culture is a significant underpinning of patient safety, emphasizes Amber Wood, MSN, RN, CNOR, CIC, a senior perioperative practice specialist with the Association for periOperative Registered Nurses (AORN). "The top issue that we have been working on at AORN is team communication and developing that patient safety culture," she says. "This kind of culture is essential to achieve successful outcomes, including the prevention of SSIs. Part of the patient safety culture includes team communication elements, including checklists, handover communications, briefings and debriefings, specific communication tools that can be implemented during the perioperative phase that can engage the team in conversation and part of supporting that patient safety culture and it's important for teams to be involved in the development of the tools and checklists and this is part of having high-reliability teams, so teams that are successful are continually evaluating the work that they are doing and the role of each team member on that team and what they are bringing to the table. Another element of this is team training; we recommend formal team training programs to use these tools and help improve communications."

Wood continues, "This concept can help prevent surgical site infections (SSIs) because facilities have created a culture in which people are free to speak up, and they are verifying that their evidence-based practices for infection prevention are being achieved. So, one example of this is ensuring the patient received his/her antibiotic preoperatively, which would be part of a preoperative checklist. Debriefing at the end of the surgery and ensuring that if this patient is at high risk for an SSI, we need to make sure we have passed off these communications for the next phase of care. Debriefing among the team and discussing how they could have done something much more efficiently in reducing the time the surgical site was open and thereby reduce the risk for an SSI. Or witnessing a break in sterile technique and feeling comfortable enough to speak up to any member of the team and say, 'You contaminated your glove' or 'You breached the sterile field,' and that provides a safer environment in which to facilitate patient safety."

Wood says she sees two trends in the SSI prevention arena: "The first is considering the role of the microbiome and antimicrobial stewardship when selecting interventions, such as antibiotic selection, testing the patient for staph colonization, considering decolonization protocols (whether with an ointment of with an antiseptic solution), looking at patient bathing and not just preoperatively but post-operatively as well, and how clean the patient is and considering the role their microbiome plays in the development of infection." She continues, "The other SSI prevention trend is looking at the patient in a more holistic way, looking at their recovery, so not isolating one element from another. For example, making sure they have good nutrition preoperatively and post-operatively to improve wound healing, which then reduces the risk of an infection developing. And mobilizing the patient early after surgery to get them moving, prevent pneumonia, get their body healing. Teaching the patient how to care for their wound. We think that the ERAS protocol -- standing for enhanced recovery after surgery -- is advancing in healthcare these days, with detailed protocols that address how to recover patients as quickly as possible, since quicker healing is less likely to be associated with post-surgical complications."

Wood says that in 2018, AORN will be issuing one new guideline and several updated guidelines. The new guideline, Guideline for Team Communication, provides instruction on cultivating and maintaining the aforementioned safety culture. The revised guidelines include updated guidance on patient positioning, medication safety, prevention of venous thromboembolism, medical device and product evaluation, as well as manual chemical high-level disinfection. "In this last revised guideline, we are emphasizing that manual high-level disinfection is not ideal, as there are human factors involved," Wood says. "Any time we can automate or use a mechanical process, that is ideal when the manufacturer's instructions for use (IFU) allow it. And regarding the hot topic of high-level disinfection versus sterilization of flexible endoscopes, it has been recommended that when a device is validated for sterilization, that it ought to be sterilized because that gives you a greater margin of safety over high-level disinfection that would still leave some microorganisms and spores on a device. Regardless of HLD or sterilization, we continue to emphasize the importance of effective cleaning first."

Understanding that patient safety is the underpinning of everything that infection preventionists do, is part of the work ahead for the profession, says APIC's Haas. "I think 2018 is going to be very exciting and an expansion of some of the work we have already been doing for our 2020 Strategic Goals," she says. "We have conducted a workforce MegaSurvey, so we are going to be putting out a few more papers related to that, and in the coming year we will be focusing on the future role of the infection preventionist. I love the fact that our competency model grounds us at the very center of patient safety. That's important to me and to our members and to the profession. We can never forget what our purpose is, and that is keeping our patients safe from infections. The role and the places in which we find ourselves are changing, so we are going to be looking at the future role of the infection preventionist in context of long-term care, critical access hospitals, ambulatory surgery centers and hemodialysis centers, to understand how we can best meet the needs of the practitioners in those areas, and keep patients safe in the less traditional spaces that we think about for infection prevention."

Haas continues, "As our members are getting a little bit older, we must think about the next-generation IP and we will be engaging younger and newer members of our profession in the conversation about what is important to them as they come into this profession and to keep them excited and continually developing in the role. Additionally, IP certification is a key component of the strategic plan objectives, to keep that moving as a designation of competency and to be entrusted with the safety of patients."

Upholding patient safety and running an effective infection prevention and control program requires resourcing, a perennial challenge for many institutions. "It's a challenging job and it's an opportunity to be helpful across the spectrum, which is what keeps some of us excited about this profession.  To be able to perform our jobs well as IPs, we do have to make the business case to hospital leadership. Since there are financial penalties for poor performance, that message has been received, but the danger in that is if it's the only thing you are focusing on is a piece of this broad and expansive role. That is important to patients even if they don't see it. So, the best thing for the patient is to not have to worry about any of this, to not even think about infection preventionists and hospital epidemiologists and just to be able to assume with certainty that's one thing they don't have to worry about -- and that's what we strive for. Of course, it doesn't come easily and so we must continue to make the business case. I think APIC helps to raise the profile of the IP to the C-suite and what IPs and healthcare epidemiologist are contributing in their service. They know we exist but they may not know the broad scope of services we provide and assist with. It depends on your institution and how forward-thinking it is; there are some people who are well recognized and highly regarded in their hospitals for bringing value to patient safety, and there are other places where the perception is not as far along. So, APIC is working hard to raise the recognition level of the profession to our administrative colleagues and other stakeholders."

Sterile Processing and Scope-Related Outbreaks
Infection transmission by contaminated flexible endoscopes remains a top concern for the new year. The ECRI Institute's Top 10 Health Technology Hazards for 2018 report lists endoscope reprocessing failures as the No. 2 concern on the list. As the ECRI Institute report notes, " Failure to consistently and effectively reprocess flexible endoscopes-that is, failure to clean and disinfect or sterilize the instruments between uses-can lead to the spread of deadly infections. Studies highlighting the challenges of this process, along with continuing reports of patient exposures to contaminated instruments, underscore why this topic remains a critical concern." Areas that require particular attention, according to ECRI, include:
The cleaning step, which is largely manual and technique-dependent. If biologic debris and other foreign material is not cleaned from the endoscope first, residual soil can harden, making subsequent disinfection ineffective.
Instrument storage after reprocessing. Moisture trapped in the channels of an endoscope can promote the proliferation of any microbes not eradicated by reprocessing.

To achieve more reliable and effective endoscope reprocessing, ECRI Institute recommends that healthcare facilities establish processes for assessing the quality of the cleaning step-for example, through magnification-aided visual inspections and the use of biochemical testing-and implement measures to dry endoscope channels after reprocessing.

In mid-September last year, the Association for the Advancement of Medical Instrumentation (AAMI) held a stakeholders meeting during which 40-plus experts discussed evidence indicating that sterilization is a superior method to high-level disinfection (HLD) for the reprocessing of endoscopes. In addition to not reducing microbial contamination as effectively as sterilization, reprocessing endoscopes using HLD is overly complex and involves far greater risks to patient safety.

AAMI reports that William Rutala, MS, MPH, PhD, director of the statewide program for infection control and epidemiology and research professor of medicine at the University of North Carolina (UNC) at Chapel Hill School of Medicine, presented findings indicating a need to forego HLD in favor of sterilization when reprocessing endoscopes. For nearly 40 years, Rutala has participated in infection prevention teams and conducted research on disinfection/sterilization at UNC Hospitals and UNC School of Medicine. "During that time, every two to three years, there have been newsworthy endoscopy-related outbreaks that resulted in meeting with various professional organizations, industry, and/or government agencies to discuss the outbreaks," he said at the meeting. "Each time, we would focus on strict adherence to cleaning and endoscope reprocessing guidelines and/or a design tweak-but the outbreaks continue."

Rutala proposed that the Spaulding classification for critical items be modified/clarified from “direct contact with sterile tissue” to “direct or secondary/indirectly contact with sterile tissue.” He further noted that when the Spaulding scheme was designed 50 years ago, semicritical items rarely, if ever, penetrated sterile tissue and healthcare did not have an adequate appreciation for the infection risk associated with endoscope reprocessing, with endoscopes used primarily for diagnostic purposes. HLD of endoscopes provides "no margin of safety," said Rutala, while sterilization will provide an increased safety margin of approximately 6 log10. That is, while HLD can provide a 6 log10 reduction in microbial contamination, sterilization offers a 12 log10 reduction (or sterility assurance level of 10–6). He further noted that while HLD removes or inactivates 10 to 100 million spores, sterilization kills 1 trillion spores. AAMI reports that Rutala summarized the problems with use of HLD for reprocessing endoscopes as follows: "If the margin of safety is so small that perfection is required, then the design is too complex and the process is too unforgiving to be practical in a real-world setting."

Cori L. Ofstead, MSPH, president and CEO of Ofstead & Associates Inc., presented data from studies conducted during 2008 to 2017. Ofstead's research involves visiting healthcare facilities throughout the country and collecting real-world data on a large variety of endoscopes. Theoretically, HLD should work, said Ofstead. However, the group's research revealed that barriers to effective reprocessing include damaged scopes; use of defoaming agents and lubricants that cannot be removed from scopes (and that harbor biofilm); relying on automated endoscope reprocessors to clean dirty endoscopes; rinsing with contaminated water (which can result, for example, from poorly maintained and dirty tubing, as well as insufficient water filtration system maintenance); failing to dry endoscopes; storing endoscopes in unventilated storage cabinets; using bare hands and dirty containers to transport endoscopes; neglecting to clean, disinfect, and perform preventive maintenance on reprocessing equipment; and not performing sufficient monitoring of reprocessing effectiveness.

Many healthcare facilities investigated by Ofstead's team placed a high value on efficiency, to the point that patient safety was compromised. This emphasis on efficiency, coupled with human factors barriers (e.g., complex designs and instructions for use make it difficult for staff to adhere to all steps in endoscope reprocessing), means that "HLD is cutting it too close," said Ofstead at the AAMI meeting, in that everything must be done perfectly every time, or "the whole enterprise comes crashing down." Other than continued use of damaged endoscopes and the use of defoaming agents and lubricants that can't be removed, sterilization addresses all other barriers listed above, noted Ofstead.

Michelle Alfa, principal investigator at St. Boniface Research Centre in Winnipeg, Canada, presented findings showing that repeated use of endoscopes leads to gradual accumulation of debris, which can lead to microbial survival following disinfection. As a result, said Alfa, better cleaning methods are needed to provide complete contact (i.e., friction) with inner-channel surfaces to ensure removal of debris after repeated reuse. The current lack of friction methods for cleaning the air/water channel is a major concern, she added. In addition to supporting the transition to sterilization for all endoscopes, Alfa emphasized the importance of sterile storage for all endoscopes that secondarily contact sterile body sites. Unless these measures are taken, survival of bacteria will occur. "Reprocessing of endoscopes needs to be treated like an operating room procedure," said Alfa, meaning that the same degree of meticulous attention to detail is needed, every time."
AAMI reports that "The stakeholders in attendance agreed that the move away from HLD to sterilization of endoscopes is a heavily nuanced issue and something that would need to happen gradually."

The topic was revisited in mid-October during AAMI's Fall Sterilization Standards Week meeting, in which Working Group 84 for Endoscope Reprocessing (AAMI ST/WG 84) met to discuss the next steps related to taking these findings into consideration for the revision of ANSI/AAMI ST91, Flexible and semi-rigid endoscope reprocessing in healthcare facilities.

Amanda Benedict, director of standards at AAMI, says that "Some of the groups are working only on American national standards and AAMI technical information reports. Others function as U.S. mirror groups to provide input to the development of international standards and guidance documents pertaining to sterilization.”

For example, ST/WG84, is working on a revision of the aforementioned ANSI/AAMI ST91, with a new draft anticipated by March 2018. Another working group, ST/WG 15, is reviewing comments on the fourth draft of a revision of ANSI/AAMI ST67, Sterilization of health care productsRequirements and guidance for selecting a sterility assurance level (SAL) for products labeled "sterile." Other groups, such as ST/WG 11 and ST/WG 16, are working on new projects that are underway at an international level and will be providing input for the development of those standards.
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Flexible endoscope contamination has been the hot issue of the last several years and I don't see that going away any time soon, and if anything, it is probably becoming more and more important," says IAHCSMM president Steven J Adams, RN, BA, CRCST, CHL, the RN manager of central sterile processing at LifeBridge Health Inc./Sinai Hospital of Baltimore. Adams says that the Joint Commission's recent focus on this issue has been a significant driver for change in institutions seeking accreditation. "We just had a Joint Commission survey at my facility and high-level disinfection, cleaning and disinfection, and sterile processing in general, are top of mind for Joint Commission surveyors these days," he says. "This is well-deserved and a long time coming. We all know that when people think of the sterile processing department, they think about 'the people in the basement.' I have never been a believer of that descriptor, but the stigma persists. Fortunately, times are changing and people know that quite obviously, any mishap or missed step along the way can lead to infection and potential death of the patient. Now with Joint Commission's focus, I think awareness of the importance of what we do will ramp up even more. I think a number of facilities around the country will have to recognize the need for major capital outlays in order to get these departments up to snuff for the Joint Commission inspections and, of course, doing their best for their patients."

Adams emphasizes that education and training continues as a key issue for the new year. "Right now, IAHCSMM, APIC, AORN, and most of the professional associations have fairly robust educational programs and offerings, and social media is a great opportunity to share information, especially among techs first coming into the profession. I think the one thing lacking tremendously, despite these programs, is education at the facility level. I think some institutions do a stellar job, but some facilities are sorely lacking in the type and quality of education and training they provide to their techs. I've been in healthcare since 1987, in both nursing and on the CS side, and in the last 20 years, one of the first areas in hospitals that is affected by budget cuts is education, sadly. As a result, facilities pay the price down the road; they have great personnel but perhaps their education and competencies are lacking, and it hurts this workforce. Some techs are trained really well, some are trained well enough to do the job, and others are only trained in one aspect of the job -- they might be trained very well in one area but never get exposure throughout the department, which is detrimental to the operation of the department. It's not that individual technician or nurse's fault, but it's the system. It's imperative that a larger emphasis be placed on departmental educators for perioperative, OR, and central sterile. Recently my facility added a central sterile educator to the budget and filled the position, and it is making a significant difference. We can put all this information out there, but the heart of the matter is at the individual facility level -- how education and training is rolled out, sustained and supported. That's where we have a major disconnect."

IAHCSMM president-elect Damien Berg, manager of sterile processing at St. Anthony Hospital in Lakewood, Colo., echoes Adams' emphasis on elevating the profession. "I think our biggest challenge is investing in what I call' human capital,'" he says. "We need to invest in the human capital of our techs, and ensure that there is an institutional succession plan so that we don't lose continuity when people leave the department or get promoted. We can invent a better sterilizer, we can develop standards on how to use that machine or products, but if we don't give our techs the proper training, and the proper time to do the work, nothing else matters. Take the Da Vinci robot, for example. From the moment it hits decontamination area to the moment it is ready for use, it’s six hours according to the IFUs and according to the protocols I have in my facility. So, if you want to do six cases a day, that's great, but six times six is not 24 hours, it's 36 hours -- so we run into a time problem and it requires a lot of human capital to keep up. So, we need to keep on investing, keep on inventing, but don't lose sight of the fact that we need to educate, elevate and keep in mind that our human capital is the most important aspect. We are asking techs to do more and more but we are not giving them the time to do it, and/or the proper training with which to do it. That's what I see as the crux of the matter moving forward."

Berg says the profession is so much more than the reprocessing work, and reminds fellow healthcare stakeholders that there are regulatory issues, relationships with vendors, and communication with colleagues and institutional leadership. "We must be able to speak the C-suite's language, and I must be able to translate our department's needs of time and education into their language. Now, my job as IAHCSMM president is to do that on the national and international stage, as that's the only way we are going to be successful."

Berg says he is working with his fellow board members on an update to IAHCSMM's strategic plan that will be available to the public in 2018. "The executive board met last summer to determine a vision for the organization and decide on its direction for the next five to 10 years," he explains. "We don’t want each new president to totally change course, but instead, navigate a path that is aligned with the strategic plan -- a plan that helps our board and therefore our membership, move forward on key issues. The plan solidifies what are we doing as an organization to make our profession better. Every decision we make will be guided by the strategic plan, making sure those decisions match the consensus we have achieved."

Also new for IAHCSMM in 2018 is the release of the new endoscopy manual and test, according to Berg. "We have been working with SGNA and it's been an exciting collaboration," he says. "Completion and fruition of the manual and test are significant for the coming year. Also, a joint project between IAHCSMM and AAMI is the benchmarking platform that debuted several years ago. There is going to be a joint task force meeting at IAHCSMM's annual meeting in Phoenix in 2018 where we are taking feedback from the members and from the community and we are going to revise and update our benchmarking platform so it is more useful, and provides more robust data to fight the good fight against infections." Berg adds, "AAMI just related the new ST90 guidance document on quality management systems for SPDs, and I can see IAHCSMM meeting the call for more information about this standard and what it means for our membership. We are already pursuing quality in what we do, but let's firm it up and make it more understandable for everyone. Benchmarking and quality at the user level will be huge in 2018."