APIC-DFW Community Standards of Practice SIG

The Impact of Temperature and Humidity on the Integrity of Sterile Supplies


February 14, 2019

14:00 – 15:00

The APIC-DFW Community Standards of Practice (CSOP) Special Interest Group (SIG) held a meeting on February 14, 2019 to discuss common practices around compromised sterile supplies after exposure to extreme environmental conditions. The meeting was open to current infection prevention and public health practitioners, both members and non-members of APIC-DFW. Currently, state regulations and national guidelines require rooms storing sterile supplies to:

·         be under positive pressure relative to adjacent rooms,

·         have a minimum of 4 air changes per hour (ACH),

·         maintain temperatures between 72ºF and 78ºF, and

·         have a maximum of 70% relative humidity (RH).

These regulations and guidelines are provided by the Texas Department of State Health Services (DSHS), the Association for the Advancement of Medical Instrumentation (AAMI), the American Society of Heating, Refrigeration, and Air-Conditioning Engineers (ASHRAE), and the Centers for Disease Control and Prevention (CDC).

Prior to the meeting, a voluntary survey was administered concerning current practices for sterile supply storage and experience with a compromised supply incident. The results were used to help guide the meeting’s conversation. Seventeen facilities were represented in the survey responses, with 88.2% being acute care hospitals. All respondents that gave a quantifiable value said they store sterile supplies between 60ºF and 80ºF with a relative humidity between 20% and 70%. 82.4% of respondents stated their facility has centralized monitoring of temperature and humidity where sterile supplies are stored. 64.7% of respondents stated their facility has experienced a HVAC incident that resulted in temperature and humidity levels outside of regulation limits, with 41.2% stating their facility’s sterile supply storage areas were affected.

Participants working for a facility that experienced an event were asked to share information regarding the incident, mitigation steps, and the outcome. Representatives from two facilities, who are entities of different health systems, shared about their events. Both incidences occurred within the same week and were a result of power outages for several hours. One of the facilities reported that they sequestered all supplies that were in affected areas and, once the environmental conditions returned to normal, the areas were terminally cleaned and restocked with new supplies. The other facility did not remove all sterile supply, but described a risk assessment tool that was developed and used to remove compromised supplies.

Participants felt that further guidance was needed on how to respond when these events occur. The APIC-DFW CSOP SIG will be meeting again to further discuss this topic.


In May of 2018, DFW area infection preventionists were invited to a situation update regarding an Ebola outbreak in the Democratic Republic of Congo (DRC) by public health authorities. At the time, the cases identified in the DRC were limited to a remote area with limited international connectivity. Nonetheless, the recommendation was to remain vigilant and prepared to respond in the case a patient at risk for a high consequence infectious disease presented to one of the area facilities.

Following this guidance, our local community standards of practice (CSOP) special interest group met to discuss how area facilities prepare for emerging infectious diseases. We had turnout from three major healthcare systems in our area in addition to state and county epidemiologists. Recommendations listed below summary the decision of this meeting and guidance from public health authorities. For additional questions or concerns about this information, please contact CSOP Chair – Marie Wilson via email @ MarieWilson@mhd.com.

Disclaimer: A variety of factors impact individual facility responses and the below summarization should not be taken as a gold standard of care. Instead this information represents common interventions and resources used in our community to prepare to safeguard our public’s health.

1.    “Lack of preparation on your part, does not constitute an emergency on mine.” THINK AGAIN!
Prepare by setting policies and procedures for the below activities:

a.    Know the terminology and be prepared to answer the question of what HCIDs or EIDs are:

i.  Resource:

1.    Definition from CDC’s Emerging Infectious Diseases https://wwwnc.cdc.gov/eid/page/high-consequence-pathogens-2018

2.    Epi Case Criteria (2018) for Ebola: https://www.dshs.texas.gov/IDCU/investigation/electronic/Ebola-May-2018.pdf

a.    Additional infectious disease control unit (IDCU) information available here: https://www.dshs.texas.gov/IDCU/investigation/Investigation-Guidance/

b.    Screening

i.  What are screening expectations for EID preparedness?

1.    Resources to help answer this question:

a.    https://www.cdc.gov/vhf/ebola/clinicians/evd/infection-control.html – Overall IP&C considerations

b.    https://www.cdc.gov/vhf/ebola/pdf/ed-algorithm-management-patients-possible-ebola.pdf (ARCHIVED Identify, Isolate and Inform infographic from CDC)

c.     Care for the patient under investigation (PUI)

i.  Understand the role your facility plays in HCID response. Are you a frontline, assessment or treatment facility?

1.    Resources to help answer this question:  

a.    CDC differentiation of frontline, assessment and treatment facilities: https://www.cdc.gov/vhf/ebola/healthcare-us/preparing/hospitals.html

2.    Based on that designation, what is expected of your facility related to care for the PUI for an HCID?

a.    Resources to help answer this question:

                                                                                          i.    ASPR TRACIE develops resources (toolkits, templates and fact sheets) to address current and emerging infectious disease threats: https://asprtracie.hhs.gov/infectious-disease

                                                                                         ii.    Specifically, their EMS Playbook may help guide frontline facilities on what care is expected for the PUI outside of treatment facilities: https://files.asprtracie.hhs.gov/documents/aspr-tracie-transport-playbook-508.pdf

ii. Protecting employee health and wellness while caring for the PUI

d.    How to safely transfer the PUI to a higher-level of care?

i.  Resources to help answer this question:

1.    Interfacility transport of PUI from CDC https://www.cdc.gov/vhf/ebola/clinicians/emergency-services/interfacility-transport.html

2.    North Central Texas Trauma Regional Advisory Council: https://ncttrac.org/programs/healthcare-coalition-hpp/tsa-e/hcid/

2.    “Practice makes perfect!”
Measuring the effectiveness and staff comfort with interventions designed to help identify and care for the patient at risk for an HCID.

a.    Exercises – Work with your hospital’s emergency preparedness officer to plan and execute exercises

i.  Planning – Allow ample time to plan your exercise and inform those that need-to-know

ii. Implementing – Be flexible and remember, “This is only a drill!”

iii.  Reviewing – Include key stakeholders in after-action discussions and improvements

iv. Resources

1.    Mystery patient toolkit: https://asprtracie.hhs.gov/technical-resources/resource/3989/mystery-patient-drill-toolkit

b.    Personal Protective Equipment donning and doffing procedures:

i.  Resources for guiding PPE practice:

1.    Training: https://www.cdc.gov/vhf/ebola/healthcare-us/ppe/index.html

2.    PPE calculator: https://www.cdc.gov/vhf/ebola/healthcare-us/ppe/calculator.html

3.    “The only true wisdom is knowing you know nothing.” -Socrates
Many recommendations have emerged since 2014 on the topic of emerging infectious diseases and will continue to. Its imperative infection Preventionists  stay in-the-know and continue to collaborate among each other and with our public health colleagues. Only when we remain up-to-date will we be able to keep our facilities up-to-date and thus provide the highest level of care while minimizing the risk of exposure to staff and the public.

a.    Resources

i.  Sample Emergency Preparedness Plan from the University of Texas: https://preparedness.utexas.edu/sites/preparedness.utexas.edu/files/infectious-disease-plan.pdf

ii. Communication resources from the CDC:

1.    Please note, some of this information has not been updated since 2015. Carefully review information prior to dissemination as it may not all continue to be accurate. For example, as of this posting there are no known PUIs in the United States.

iii.  EVD information for clinicians (helpful guidance for IPs located here as well): https://www.cdc.gov/vhf/ebola/clinicians/index.html

iv. Ongoing training from CDC and SHEA: http://ortp.shea-online.org/online-training/

v.   National Ebola Training and Education Center: https://netec.org/training/

MDRO in NICU CSOP Meeting Notes

A survey was disseminated to APIC DFW members prior to the meeting. Results from that survey are below:

  • The majority of respondents (40%) have a Level 3 NICU
  •  Respondents also included IPs responsible for Level 1, Level 2 and Level 4 NICUs. Some respondents did not have a NICU.
  • The majority of respondents (60%) have an infection prevention policy for their NICU
  • Only some (40%) respondents described regularly screening visitors for signs/symptoms of infection. Others described screening but only during flu season. 40% of respondents didn’t have any screening for NICU visitors in place.
  • 50% of respondents have managed an MDRO in their NICU. 100% of respondents named MRSA as a common MDRO in their NICU.

·         The majority (63%) of respondents routinely conduct surveillance cultures in their NICU. Frequencies ranged from on admission/transfer into the unit only to every other week.

A few themes emerged during discussion from two in-person meetings of the CSOP SIG:

1.       Participants agreed that standardization of visitation practices across hospital systems would be beneficial for infection prevention in units. A separate work group will form for further discussions on this topic   
         a.   Opportunities for standardization:
               i.    Screening of visitors
               ii.   Cleaning of personal electronic devices upon entry to unit
               iii.   Including parents as part of the infection prevention team

2.       It is unclear if unit configuration (open bays versus private rooms) has implications on MRSA transmission. Participants agreed that a multi-center study on the topic would be beneficial. Follow up to occur beyond this SIG in facilities of varying layout types.

3.       Coordination between facilities on patient transfers sometimes lacks vital infection/colonization information. Participants discussed possibly using the CDC’s Hand Off tool for neonatal transfers to facilitate information dissemination.

Overall, these CSOP sessions provided valuable information on what infection prevention practices look like in some DFW-area NICUs. We appreciate everyone’s participation and input. If you were unable to be a part of the CSOP sessions but are interested in the visitation practices and/or unit configuration follow up sessions, please email CSOP Chair, Marie Wilson at MarieWilson@mhd.com

Look for a needs assessment survey coming to you for future session ideas! We’re here to serve you, so we appreciate your input!

COMMUNITY STANDARDS OF PRACTICE APIC-DFW Special Interest Group Conference Call - 1/12/2018

In this first convening of the Community Standards of Practice (CSOP) SIG, we discussed Influenza activity in our region and facilities. We had at least 20 participants on the call from Palo Pinto to Bonham and many places in-between. Below are some findings from our call that may help you in your facility if you’re feeling the burden of this year’s flu season.

  1. Reporting requirements:
    a.  Check with your local authority on their requirement. Some may vary.
  2. Visitor restrictions/screening:
    a. Many respondents are utilizing signage at main (or all) entrances encouraging visitors to stay away if they’re experiencing flu-like symptoms
    b. Some respondents are relying upon bedside staff to watch for questionably sick visitors and encouraging them to leave for the safety of the patient.
    c. One respondent is strongly encouraging limitation of visitors to one person per patient.
    d. One respondent is currently limiting visitors to two per room in areas without single-patient rooms.
    e. Some Long-Term Care facilities have shut their doors to visitors and new residents in response to outbreaks in their facilities.
  3. Sick Healthcare Workers (HCWs):
    a. Tracking
        i. Most respondents noted that HCW Call-Ins are funneled by unit managers/house supervisors to the Employee Health or Infection Prevention department.
    b. Handling if present to work
        i. Some respondents have the ability to send sick HCWs home.
        ii. Some respondents rely upon managers to send sick HCWs home.
       iii. Some respondents explained patients are sent to Employee/Occupational Health for evaluation
       iv. Evaluation varied from screening for Influenza-like Illness (ILI) to testing for flu and treating
    c. Prophylaxis
        i. Most respondents are not providing prophylaxis at this time
       ii. Few are with documented exposure regardless of vaccination status
      iii. Below is guidance for prophylaxis at LTC facilities:


       4. Empiric Precautions:       
            a. Most respondents are not employing empiric droplet precautions at this time. It was encouraged this decision be evaluated at a physician-specific level given no known standard established in the community.

Thank you all for your participation in our SIG conference call. We hope you found the call and this information valuable if you were unable to attend. If you have any questions, please email MarieWilson@mhd.com .


From a Scholarship Recipient

From Kathy Skalkos, RN, MN, CIC

This was by far the best national conference I have attended.

The venue at Anaheim was so conducive to easy access. The triangle of having the hotels and convention center so proximal to each other facilitated attendance to the sessions. In addition the conference center rooms were also easily accessible. We did not have to walk miles between sessions.

When I first saw the agenda for this years’ conference I knew it was going to be special. So many world renowned experts would be presenting and NHSN had so many sessions listed. I perceived that one could not be disappointed with any session they chose to attend.

Personally I attended most of the NHSN seminars only this time they asked for our input rather than giving instructions. I also attended early morning sessions and Dr. D. Pittet’s Hand hygiene session which was dynamic.

Most of all it was networking with all of the other IPs. This time because of the location I met so many individuals from the west coast and Alaska etc. It was comforting to know we all have similar problems and on the reverse side that I don’t have some of theirs.

APIC has always been unique in that we share amongst ourselves without politics hindering our transparency. We speak as one voice and I am happy to say we are getting louder!

I left the convention questioning what will the future hold for IPs and what role are we going to play because it will be changing as we move toward total electronic surveillance.

Finally, I wanted to thank-you all again for the support you gave me and to tell you that the process of not having ED staff draw blood cultures from the IV start but rather from separate peripheral sticks greatly if not entirely reduces blood culture contaminations. We also have switched entirely to the alcohol/CHG prep pad for skin prep and rarely use the straight alcohol prep pad.”

Why YOU Should Apply for APIC DFW National Conference Assistance Program!!

From Linda Miller, RN, CIC

“The APIC Annual Educational Conference held in Anaheim, CA in June was an exceptional experience. There were many informative and interesting sessions. Below are take-away points from four of the sessions I attended.

Infected Healthcare Workers: Practice vs. Recommendation was a point/counterpoint session based on recent recommendation for work restriction for HBV infected coworker published in the MMWR in July of 2012. Main points focused on the obligation of Employee Health to maintain employee confidentiality and the recommendation for sending infected healthcare workers to a confidential expert review panel. This would ensure that all employees are treated fairly and equitably.

 Core elements of an Antibiotic Stewardship program were defined as:

  • ·         Leadership commitment
  • ·         Program leadership including a physician champion and a Pharmacy leader
  • ·         Utilization of an antibiotic use tracking system that monitors ordering practice and identifies opportunities for improvement
  • ·         The use of facility-specific antibiotic protocols for treatment
  • ·         Reporting and education
  • ·         Interventions to improve antibiotic usage.

                Key moments of antibiotic stewardship involves improving usage at certain specific opportunities

  • C. difficile infections
  • Positive blood cultures
  • IV antibiotics at discharge
  • Drug/organism mismatches

Measuring antibiotic usage is time consuming. An NHSN antibiotic usage module was launched in 2012. There is a hope to create benchmarks for antibiotic usage and utilization rate, both of which will be risk adjusted for facility type. Data can be submitted as unit-specific or facility-wide.

HICPAC presented the 2014 Draft Guidelines for SSI Prevention.  The guidelines will be in two portions; a core section and an arthroplasty section. The draft guidelines are based on randomized controlled trials only. Since much of the recommended practices that we are used to are not necessarily supported by these types of trials, they will be classified as unresolved issues. This includes many of the measures currently required in the SCIP Core measures data set. When queried how we would be expected to continue to support the SCIP measures as evidence based practice when they were being removed from the main body of evidence that most of us rely on, the speaker indicated that the expectation is that we look to AORN for practice guidance.

A presentation on IV clean rooms outlined the expectations for UPS 797in regards to certifying rooms for IV admixture and compounding. Compounding personnel are required to wear no make, no jewelry and no artificial fingernails. Personnel are also required to submit to gloved fingertip sampling of at least 3 fingers biannually. Documentation is needed for cleaning of the room and total particle counts and surface testing is required every 6 months. Acceptable particle count levels can be on Table 2, page 15 of the USP 797 document. A contingency plan needs to be in place for when the IV cleanroom is shut down for testing failures. Hospitals are encouraged to purchase compounded medications from certified providers only.

Once again, please accept my gratitude for the APIC DFW Annual Conference Scholarship. My session was very well attended and I have been invited to present for two other APIC Chapters and to speak next year at the California APIC Consortium (CAC) at their annual conference. Thank you so much for the support and the opportunity.“