Jill Holdsworth, MS, CIC, FAPIC, AL-CIP, CRCST, CHL, NREMT, received her bachelor’s in biology from West Virginia Wesleyan College and her master’s in exercise physiology from Marshall University, beginning her career as a Cardiac Rehab therapist. She began working in infection prevention in 2009, became a CIC in 2010, and a fellow of APIC in 2016. 

Jill has served in multiple local APIC chapter leadership roles, including president of the Washington, DC chapter. She has also served on the APIC National Board of Directors and as cochair of the AAMI Protective Barriers Committee. Jill currently serves on the CBIC Board of Directors, HSPA Certification Council, and the Editorial Advisory Board of 

.Jill now works as the medical affairs manager for CS Medical.

Jill E. Holdsworth, MS, CIC, AL-CIP, FAPIC, CRCST, CHL, NREMT

Ultrasound examination revealing internal details, Doctor using an ultrasound probe to examine a patient's abdomen, diagnostic process

Reprocessing semi-critical medical devices is a high-risk process in healthcare that can leave patients vulnerable to infections or other complications. A critical step in the process comes before high-level disinfection (HLD): cleaning. The difference between cleaning and disinfection can often be confusing, so let’s break it down.

Cleaning occurs first, a process that physically removes soil and debris from the instrument, probe, or scope. Cleaning is traditionally performed manually by a team member or on probes using a newer automated method.

Using a probe cover or sheath should never be considered a substitute for cleaning the ultrasound transducer. The American Institute for Ultrasound in Medicine (AIUM) states that the 

ultrasound transducer should be cleaned, even when a probe cover or sheath is used

A step often skipped in the process is drying the probe after cleaning, before performing high-level disinfection. Debris, gel, and/or residual water may be left behind after the cleaning process, which can inhibit the disinfection process. It is essential that the drying cloth be selected specifically for this process, being low-linting to prevent introducing new sources of debris into the path of the disinfectant, thereby allowing it to perform its function effectively.

The final step before performing high-level disinfection is the visual inspection. Team members should visually inspect all external surfaces of the scope, probe, or item being processed for defects, debris, soil, or anything abnormal, including in the cracks and crevices of the device. Lighted magnification may be needed and should be used as appropriate.

Although cleaning scopes and probes prior to HLD can significantly reduce microbial load and soil, the process is tedious, time-consuming, and error-prone, increasing the risk of cycle failure. Failure of these processes can lead to probe damage, patient harm, and staff burnout.

Exploring options for automation can lead to increased compliance and decreased risk of human error and device contamination during patient procedures. Some clinical settings do not provide optimal environments or sufficient space to perform the necessary cleaning tasks, which can make compliance with and meeting regulatory requirements difficult. Staff turnover, shortages, and dedicated time for training and competency remain a challenge in ensuring adherence to all components of the cleaning steps.

 found that only 1.4% of endoscopes reprocessed using a manual cleaning method and an automated disinfection cycle were processed correctly at every step. This study suggests that increased training and a focus on competencies, combined with a shift toward automation, can significantly improve overall compliance with endoscope cleaning and disinfection processes.

Department leaders and infection preventionists have countless opportunities to observe, audit, and improve this process through quality improvement work, standardization, and partnerships. These tasks are often hidden work in our health care organization, yet the importance of their outcome is not lost on the overall well-being of each patient. Consistent rounding and follow-up by leaders in these areas are imperative to ensure our patients remain safe and infection-free during procedures.

Articles

Cleaning failures can undermine high-level disinfection of ultrasound probes. Learn why proper cleaning, drying, and inspection matter, and how standardization and automation can improve reprocessing outcomes and patient safety.

It Starts With Clean: The Foundation of High-Level Disinfection

I hear the familiar sound of a text message from a former colleague turned friend and look to see what he said. He is interviewing for a management position! Usually, that’s such exciting news when you have been in any profession for years, right? This infection preventionist (IP) was interviewed at a health care system, but to his dismay, they told him they only hire nurses per their job description. Kindly, they would still keep his application in consideration. A couple of days later, he was declined for not meeting their requirements.

Hearing this news, I had so many conflicting feelings. I, too, am not a nurse, but am leading a fruitful and successful career as an IP. I have not felt limited in my career because I’m not a nurse nor by not having a master’s in public health. Instead, I have learned to seek out those who have the expertise that I don’t. I have learned to become comfortable with saying “I don’t know,” or “I could use some help.” This journey my friend was embarking on was so familiar to me, and one that many others have had to endure.

Not being a nurse doesn’t mean I can’t be an effective IP. I am an IP. I am an exercise physiologist. I am an emergency medical technician. I am a certified sterile processing technician. I am board

certified in infection control and epidemiology. I am an Association for Professionals in Infection Control and Epidemiology fellow. I am not an RN, BSN, or MPH. Still, I am not just an IP.

"Not being a nurse doesn’t mean I can’t be an effective IP."

As an IP, I was also a “one-er,” as our APIC President, Patricia Jackson, MA, BSN, RN, CIC, FAPIC, calls someone who is the sole IP for an entire facility. I was the only IP at the facilities I worked in for over 8 years. So even though I had an unconventional background and beginning in IP, I always felt respected, valued, and needed in my facilities.I didn’t feel like my background was a barrier, or a hinderance to my work or how competent I was in my role.My colleagues counted on me, knew I was the subject matter expert and trusted the guidance I provided—because I was the IP. However, I wasn’t oblivious to what was happening around the

country—that others were being turned away from positions because of their lack of certain certifications.

Years later, I am still confused, surprised, and disappointed that I am hearing stories of health care organizations not giving the opportunity to experienced and outstanding IPs for positions simply because their job descriptions are only for nurses. We have come too far as a

profession to limit ourselves to only 1 specific title. True, nurses are an important component of any infection prevention team, but so are all of the other professionals who are filling IP teams across the globe. As we continue to focus on diversity and inclusion, we need to include our IP team construction in this conversation and understand the benefits we gain from the differences we bring.

I shared my thoughts on LinkedIn about my friend’s rejection for not being a registered nurse, not expecting anyone to pay it much attention. The response to this post was overwhelming, and the comments and stories have been incredibly inspiring (

). The comments started pouring in from those IPs who felt the same way, who have been turned down for roles for the same reason, or who want to be an IP but are having trouble getting noticed because of their lack of degree or experience. I have been talking personally to many of these individuals who may have lost hope after not being considered for specific roles and some who have IP positions but have compared how they are being treated in the workplace as “bullying” because they come from a nonclinical background. This must stop.

How do we motivate those who feel they will not be able to enter the infection prevention field because they don’t have a certain degree, certification, or background? How do we re-energize those who have been rejected in the past for not being a nurse? How do we encourage those who feel discrimination in the workplace due to their lack of certain credentials? It is going to take all of us to make this happen, to spotlight the work we do, the significance of our work, and the incredible reach we have in our influence and responsibilities. We need to elevate the role we have as IPs, the expertise needed in this field, and the importance of having people of different backgrounds on your team. We learn from each other, we build off the expertise of our teammates, and we succeed because we function as a team with individual talents.

The time is now to highlight the importance of the IP role, the variety of areas we cover as IPs, and the span of services we offer daily. We do not belong in the background of health care when we are leading the way with patient safety, emergency management, construction, dialysis, disinfection, sterilization, and so many other areas. As a profession, as individuals, and as aspiring IPs, we are all 1 team with 1 goal—to keep our patients and our staff safe.

If you would like to let Infection Control Today know what you think the required education should be for IPs, fill out ICT's 

, open until October 15, 2023. The results will be posted on October 16, 2023. 

Infection preventionists (IP) can come from many different backgrounds. This is 1 opinion from 1 very successful IP who doesn't have an RN or a BSN and the bullying that sometimes occurs.

I’m Not Just an Infection Preventionist

A picture of infant's foot covered with wires. (Adobe Stock) 

In a world where electronic hand hygiene monitoring has become the hot topic, what do you do when you either don’t have the system or have a facility that doesn’t have the capability for the system? This is where creativity kicks in, and hand hygiene adherence can become fun. Welcome to the world of behavioral science, where you will learn how to trick the minds of your teammates to increase adherence to hand hygiene through color, images, and a sense of ownership.

Recently, the neonatal intensive care unit (NICU) at Emory University Hospital Midtown in Atlanta, Georgia, was unable to install the hand hygiene electronic monitoring system the rest of the facility was moving to. Thus, the infection prevention, quality, and nursing teams started brainstorming ideas for improving dispenser placement, monitoring, visual aids, and availability of products. With a mixture of room layouts, this made the project difficult at times because some areas had open bays, some had a variety of wall spaces, and some had curtains. The teams realized this problem would not have a singular solution.

Color Emotion Guide (Credit: The Logo Company https://thelogocompany.net/psychology-of-color-in-logo-design/ ) 

The unit team members had been monitoring hand hygiene themselves for years, which was yielding high adherence results and led them to believe there were no improvement opportunities. Although common for manual, unit-based observation programs, this belief often led to falsely high adherence numbers and low yield in terms of understanding where to focus improvement efforts. The infection prevention and quality teams sent in secret shoppers to collect observations, and the results were significantly lower than the self-observations. The teams set out to form a new plan for monitoring and increasing hand hygiene adherence in regard to the hospital’s tiniest patients.

The project team started with a “spaghetti diagram” exercise, where the movement of team members was studied and recorded to understand where the most-used dispensers were located and where additional dispensers were needed. A spaghetti diagram is easy to do, but it does take time—a team member should stand in 1 location and observe movement, drawing a line as they watch another team member “move” around the unit during their normal day-to-day activities. The project team obtained the unit drawings from the facilities management team (FMT) to trace the movements for accuracy of the analysis afterward. Each unique layout of the NICU space was studied in the same way and discussed by the team. Next, the team included the FMT to standardize where the dispensers, paper towels, and sharps containers would be located in every patient space. This standardized placement helped the clinical team create muscle memory to increase adherence when in each space, so they weren’t searching for the hand hygiene products. Partnering with the FMT and environmental services while rounding for this portion of the project was very important, and a great tip for success during rounds in general.

Contagious: Why Things Catch On by Jonah Berger

The idea of applying findings from behavioral science is not new; however, it is not used openly nearly as often as it should be. This strategy is a psychological approach to changing behavior to gain adherence in any type of project or process. The idea originally came from an Association for Professionals in Infection Control and Epidemiology presentation observed many years ago by the project team members, which demonstrated the science behind the use of colors in company logo design and which the members found intriguing. When considering the use of color in fliers, education, and bulletin boards in health care, the team considered how they could use these concepts in their own hand hygiene campaign to draw attention to the hand hygiene dispensers and drive compliance. After reading the book 

 by Adam Alter, the infection prevention professionals began talking more about using these strategies of color, words, images, and other mechanisms to appeal to individuals’ emotions and senses.

Drunk Tank Pink: And Other Unexpected Forces that Shape How We Think, Feel, and Behave by Adam Alter

The project team talked with the NICU nursing team about adding visual management “placards” above the hand hygiene dispensers that would prompt them to cleanse their hands. The project team showed some examples being used throughout the health care system, and the comments were surprising—the NICU team felt that they were commonly put under the adult population umbrella for education, campaigns, and other marketing plans. They wanted to be seen as an area that had specific and different needs, patients, and opportunities.

An example of what the team created. (Credit: Author) 

Hearing this, the project team did 2 things:

 They worked with their own marketing department to find a diverse set of neonatal images to use on the visual management placards that would speak to the NICU team members more than adult-centered campaign materials would.

They created a survey for the NICU team to come up with and vote on a campaign slogan. This allowed the team to feel connected and have a sense of ownership because they had created the slogan and it was theirs alone. This was a strategy the project team learned from the book,

, by Jonah Berger, about making your ideas go “viral.” By coming up with ideas that other teammates want to talk about, a concept he called “social currency,” you can spread an idea without creating additional education resources.

After visual management placards were placed on all hand gel and soap dispensers throughout the NICU, secret observers measured adherence over a 4-week period. Adherence increased significantly, although not as much as the team would have liked to have seen. Therefore, they set to work brainstorming additional ideas to further provide the NICU team with additional options for behavioral modification techniques to encourage them to clean their hands.

The next phase of the project included “point-of-use” items placed throughout the department. These items consisted of various pump bottles and additional products that could be used to cleanse hands. Another round of observations was completed by the secret shopper team to monitor the effectiveness of these products; however, there was no significant difference in overall hand hygiene adherence although the products were used in the various department areas.

Another example of sign that the team created. (Credit: Author) 

The project team decided to focus on the use of color and the emotions that are connected to color. They sent out a survey to all the NICU team members asking them to associate a specific word with various colors. This idea was adapted from a study by Jonauskaite et al.1 The team took the 4 colors that most related to the emotions of happiness and joy and outlined the current placards with this color and had the back of placards be the same solid color. These placards will replace the current placards throughout the department and will be switched out/replaced to rotate the colors on a regular basis. This intervention is planned to go live in the latter part of 2022, with an additional round of adherence observations by the project team.

This hand hygiene project taught the project team to push the limits of creativity and to tailor to the department and the NICU team’s needs. Feeling a sense of ownership for this unique area was important to the NICU team, and the team members appreciated the attention to detail and helped with buy-in to the overall process. Quality improvement projects are not always straightforward and sometimes require infection preventionists to think outside of the box in ways that are uncomfortable. This project also showed hand hygiene adherence improvement from the beginning, although full implementation was delayed due to the COVID-19 pandemic. In addition, the project helped generate new ideas as it progressed and the longer the project team had to get to know the NICU clinical team.

Jonauskaite D, Abu-Akel A, Dael N, et al. Universal Patterns in Color-Emotion Associations Are Further Shaped by Linguistic and Geographic Proximity. Psychol Sci. 2020;31(10):1245-1260. doi:10.1177/0956797620948810

Using behavior modification to keep the hospitals' tiniest patients safer. 

Jill E. Holdsworth, MS, CIC, AL-CIP, FAPIC, CRCST, CHL, NREMT

Articles

It Starts With Clean: The Foundation of High-Level Disinfection

I’m Not Just an Infection Preventionist

Big Germs, Little Lives: Improving Hand Hygiene Through Behavior Modification in the NICU