Stephanie Mayoryk, MAS, BSN, RN, CIC, is currently the president of Mayoryk Consulting Services LLC, offering infection prevention (IP) consultation services to health care, academic, and industry partners. She has IP expertise in various settings and has a detailed understanding of IP program management in academic medical centers, community hospitals, long-term care, and specialty hospital environments.

Mayoryk has held leadership positions for the Association of Professionals in Infection Prevention and Control (APIC) at both the national and local level. She has held certification by the Certification Board of Epidemiology and Infection Control (CBIC) since 2003. She obtained her graduate degree in Health Quality and Patient Safety at the Johns Hopkins University Bloomberg School of Public Health.

Before her consulting career, Mayoryk served as the system director of infection prevention for a large urban health system in Baltimore, Maryland. She is a licensed registered nurse with clinical experience in the solid-organ transplant patient population.

Stephanie Mayoryk, MAS, BSN, RN, CIC

Despite guidance from the CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommending Enhanced Barrier Precautions (EBP) to contain the spread of multidrug-resistant organisms (MDROs), its adoption in nursing homes has been inconsistent. New research highlights key findings, challenges, and recommendations for improving infection prevention practices.

, the infection preventionist and principal consultant at Mayoryk Consulting Services, and the study's lead author, 

What was the primary motivation or research question that led you to conduct this study, and why do you believe it is important?

 This study aimed to assess the feasibility and acceptability of implementing EBP through a quality improvement (QI) initiative within 4 community-based nursing homes in Maryland. Our study objectives were to describe the elements of a quality improvement (QI) initiative for EBP implementation, assess the effectiveness of a QI initiative for EBP implementation, and assess the acceptability of EBP to health care personnel (HCP) and the barriers and facilitators of EBP for HCP.

Guidance from the CDC and HICPAC has recommended that EBP contain multidrug-resistant organism (MDRO) transmission. Yet, the full adoption of EBP by nursing homes has been variable, and EBP remains a new concept for HCP. Many facilities are beginning implementation in response to CMS requiring it in March 2024. Facilities need to have an evidence-based framework for implementation and evaluate administrative, environmental, HCP, and resident considerations before, during, and after EBP implementation.

: Can you briefly explain the methodology you used in the study and why you chose this approach?

 We randomly staggered the implementation of the QI initiative to optimize EBP implementation in 4 mixed short—and long-stay units within 4 community-based nursing homes in Maryland. The facilities belong to the same independent health care system specializing in postacute care, skilled nursing, and rehabilitation. The study timeline included a 3-month baseline period, a training period, and a 3-month intervention period.

To operationalize EBP into practice, we utilized the 4E process model (engage, educate, execute, evaluate), a Translating Research into Practice (TRiP) model component. This model was chosen because it is well-suited for larger projects that include multiple sites and has been utilized in past health care epidemiology and infection control implementation initiatives.

We performed weekly observations of HCP providing care for residents with chronic wounds, devices, and MDROs. During these observations, data was collected on the types of care performed, hand hygiene, and gown and glove use during high-contact care. We also recorded whether EBP had been correctly implemented for eligible residents and whether PPE was available if required at the point of use.

To assess the adaptive aspects of implementation, mini-interviews were conducted with willing HCPs and infection preventionists (IPs) after the 3-month intervention period. All occupational groups that care for residents on EBP, including registered nurses, nursing assistants, licensed practical nurses, and respiratory therapists, were invited to participate.

: What were the key findings of your study, and how do they contribute to the existing body of knowledge in your field?

 Overall, 1 in 3 nursing home residents met EBP indications. The most common indication (21% of 780 residents) was a history of MDRO colonization. Indwelling medical devices or chronic wounds were present in 14% and 10% of residents, respectively.

Accurate identification of residents meeting the EBP criterion improved significantly from 63% during the baseline period (with over 600 observations) to 99% during the intervention period. Among rooms with residents who met the EBP criterion, the percentage with gowns available at the point of use also increased significantly from 55% at baseline to 100% during the intervention period.

We also noted improved HCP compliance with glove and gown use during high-contact care activities. Glove use increased from 85% at baseline to 97%. Gown use increased from 27% to 78% during the intervention period. All high-contact care activities demonstrated increased glove and gown use from baseline to intervention period. The high-contact care activities with the highest level of glove compliance during the baseline period were wound and device care at 98% and 95%, respectively. The high-contact care activities with the lowest level of gown compliance during the intervention period included resident transfers and linen changes, at 66% and 80%, respectively.

Interviewed staff could identify both facilitators and barriers to EBP implementation. The 2 most frequently mentioned facilitators were the perception that EBP helps to reduce transmission of infectious diseases to other residents, staff, and families (74%) and that clear, simple, and bright signage helps to know when and where EBP can be used (69%). The 2 most frequently mentioned barriers to EBP implementation were that gowns are uncomfortable and hot (43%) and that there needs to be more clarity in knowing when a resident can be placed on EBP instead of contact precautions (34%).

These findings are significant as they demonstrate that HCP can achieve improved adherence with high-contact care activities and correctly identify residents eligible for EBP. However, the results also highlight where additional work is needed, such as improving gown and glove during resident transfers and linen changes and increasing HCP and IP knowledge of when a resident with an MDRO would require Contact Precautions instead of EBP.

: Were there any unexpected research results or challenges you encountered?

 HCPs noted additional facilitators and barriers during post-implementation interviews. These included gown comfort and providing multiple gown options, the preference for more frequent informal education on the unit, EBP signage that was visually different from traditional transmission-based precautions signage, and the need for more frequent trash removal due to increased gown waste. Ensuring these elements are assessed and mitigated may improve future implementations.

: What are your findings' potential implications or applications, and what future research directions do you suggest based on your study?

 Our findings support that the 4E implementation model can successfully be used for EBP implementations and other infection prevention and control interventions in nursing home settings. Though the recent adoption of EBP in CMS regulation may lead to hurried implementations, nursing homes may benefit from a stepwise approach to EBP implementation, including leadership training, environmental assessments, and gap analyses, and frequent HCP and resident/family education. Future EBP implementation efforts should focus on mitigating identified barriers.

Mayoryk S, O’Hara LM, Robinson GL, Lydecker AD, Jacobs Slifka K, Jones H, Roghmann MC. Optimizing the implementation of Enhanced Barrier Precautions in community-based nursing homes. 

. Published online September 20, 2024. doi:10.1016/j.ajic.2024.09.014

Articles

Research finds Enhanced Barrier Precautions reduce MDRO transmission in nursing homes, though challenges persist with gown usage, education, and comfort during high-contact care activities.

Study Highlights Successes and Challenges in Implementing Enhanced Barrier Precautions in Nursing Homes

Teaching community health care promoters about the prevention of targeted infectious diseases common to the area in Village 2 in Kenya.

According to the World Health Organization (WHO), “communicable diseases, including HIV/AIDS, tuberculosis (TB), malaria, viral hepatitis, sexually transmitted infections and neglected tropical diseases (NTDs), are among the leading causes of death and disability in low-income countries and marginalized populations.”1 Infection prevention (IP) and control in health care and community settings is essential for reducing preventable morbidity and mortality from communicable diseases globally. 

) contributor Heather Saunders, MPH, RN, CIC, and Stephanie Mayoryk, MAS, BSN, RN, CIC, were offered an opportunity to become IP consultants to a network of remote ambulatory clinics in East Africa. In this article, Saunders and Mayoryk answer questions they have been asked by other 

and other infection preventionists about their experiences, strategies, and insights from the trip.

: Explain how you got the opportunity to travel to Africa and what made you want to participate in the trip.

In 2008, I had the opportunity to spend 10 weeks in East Africa as an intern with an organization I hold in high regard, Missions of Hope International. That experience opened doors to future opportunities in global health and sparked my desire to pursue a career in IP and my master’s degree in international public health. Over the years, I’ve become deeply passionate about improving the global infrastructure of health care and preventing communicable diseases. When I received a call from a colleague earlier this year asking if I’d be interested in partnering with medical clinics I’d been previously acquainted with in East Africa, I jumped at the opportunity to use my expertise in IP to support ongoing efforts at the clinics.

I have always wanted to use my IP expertise globally. However, raising my 2 children and transitioning into rigorous IP program management roles made international work seem improbable. When I started my consulting business in 2018, I realized that pursuing additional learning and opportunities outside the United States would be feasible. Heather asked me in late spring 2023, whether I’d ever consider an international trip. I shared my desire but noted how life and work priorities always moved this to the back burner. She put me in touch with the team’s medical lead, and we chatted. I was thrilled to receive a formal invite!

: What were you asked to contribute, and what were your deliverables?

When we initially spoke to the clinic administrator, who had requested our visit, we were asked to provide education on IP and control. However, we knew we needed to understand the clinics’ capacity, capability, and needs better before developing an education plan. After several virtual meetings, we all agreed on a plan to assess the network’s 4 ambulatory clinic locations for opportunities to improve infection prevention. Additionally, we would provide general IP education to community health volunteers partnered with the clinics. This education would focus on the chain of infection and hand hygiene. We would also allow time for structured focus groups to better understand community health needs. Using the existing assessment tools from WHO, the United Nations, the CDC, and other organizations, we developed a tool tailored to assess low-resource health care settings. Our assessments focused on hand hygiene and standard precautions, cleaning and disinfection, instrument reprocessing, waste management, safe injection practices, and preventing specific infectious diseases.

We prepared a summary report that focused on those core components. Each section began by noting the strengths observed in overall infrastructure and work practices. Opportunities for improvement from our direct observations were described, and pictures were often included. Each section ended with supportive references and links to national and international public health guidelines and regulations.

We are also developing education tools for patient education by the community health volunteers. The volunteers highlighted the need for specific patient education material and gave us a list of their priority infectious disease concerns (eg, brucellosis, malaria, TB,
HIV/STIs, rabies etc). These tools will highlight feasible individual and community prevention strategies for the region based on their current resources.

: What were your findings and recommendations?

The basics of IP are essential no matter where you go. It’s important to remember this when conducting assessments in low-resource health care settings. Focusing on improving the basics can significantly affect IP and control. We performed numerous clinical observations of foundational infection control practices such as hand hygiene, injection safety, and personal protective equipment (PPE) use. We identified opportunities in all these areas, working with the clinic administrator to determine the next steps in addressing opportunities for improvement.

We spent significant time assessing TB prevention and control infrastructure. A lack of environmental controls and respiratory protection was observed. We discussed the feasibility of outdoor specimen collection and outdoor directly observed therapy home visits with clinic leadership. We were invited to enter village homes and quickly recognized the lack of airflow and likely high concentrations of droplet nuclei because traditional village homes are made of cow dung, and windows were uncommon.

Before sharing specific recommendations, it was essential to ensure that our primary reference source was predominantly the Ministry of Health guidance. We noted some significant differences in these guidelines compared with the US for instrument reprocessing and high-level disinfection [HLD]. We had to familiarize ourselves with a decontamination soaking step before manual cleaning and HLD. We could not assume the US guidelines would meet local regulations.

: Describe any challenges you experienced during the assessment process. Were there surprises?

When conducting assessments in low-resource settings, capacity and capability must be considered first. Availability of resources and unstable health care infrastructures are often barriers to improving infection prevention. Instead of quickly jumping to providing a solution, we tried to better understand driving factors. For example, it was noted upon assessment that access to hand hygiene products was lacking. However, before recommending to the clinics that they increase their access to hand sanitizer, we first sought to determine their capacity for expanding that access. In many regions of the world, hand sanitizer is not available as a pre-packaged product, requiring clinics to buy ingredients and make hand sanitizer on-site. In this case, we found that hand sanitizer was readily available. However, many other recommendations would require brainstorming with clinic staff to determine what was feasible given available resources.

Sometimes, though, the driving factor is simple compliance. I always find it surprising how much health care worker compliance is a challenge no matter what part of the world I’m in. In one instance, during our assessment, single-use vials were observed being reused. When conducting interviews to better understand the driving factors behind this practice, a clinic pharmacist stated, “The staff 

 they’re not supposed to use these more than 1 time. They just need to be reminded.”

I was surprised at how the team was able to communicate amid language barriers and cultural differences. We had opportunities to participate in several community gatherings, which allowed us to recognize the community’s passion for song and dance. We tailored our training approach to incorporate singing and dancing into hand hygiene education and return demonstration exercises. We observed that the community’s cultural norm for health education occurs through community talks. These talks occur outside, under the canopy of large acacia trees. We decided to move our sessions with the community health volunteers to this setting. This provided a casual, familiar atmosphere and promoted honest dialogue regarding community challenges and infectious disease risks.

: How might infection preventionists interested in international health find opportunities to participate and support ongoing work?

For those interested in becoming involved in international health
and development, I recommend first networking with those already working in the field. Look to well-established, reputable organizations that align with your goals and values. Learn more about the strategic priorities of global health and development and determine what organizations are taking steps toward those goals. As with many other specialties, beginning with volunteer work and short-term assignments is a great way to gain experience in the field.

Because this was my first international experience, I defer to Heather on how best to pursue these opportunities. I am grateful she provided me with that networking connection to make my first trip possible.

However, I’ll share some key attributes and learnings that summarized my experience:

Flexibility is required. Not much happens per the itinerary. Things moved slowly, and I had to adjust to the local pace.

Spontaneity and creativity were necessary. We were asked on day 1 to perform education without performing any baseline assessments. We were able to pull it together and figure out quickly what worked well and what didn’t.

Frustration is inevitable because access to clean water and PPE was severely lacking. It was frustrating to realize that we could fly direct in 14 hours, yet supplies and technologies seem light years away from the hands of those who need them most.

Prioritization is necessary. You can help guide small, feasible learning opportunities and tests of change, but make sure they are based on leadership and community priorities.

Hope and a passion for providing excellent patient care is already alive and well among the health care professionals who live and work in the region.

Beginning in January, Saunders and Mayoryk are holding monthly meetings with the leadership for the chain of clinics they visited in October. During their meetings, they’ve been collaboratively discussing their findings and next steps toward implementing improvements in infection prevention and control. 

Currently, they're assisting the clinics with the prioritization of high-risk findings and implementation of best practice changes. They’re also currently developing educational materials for community health promoters to help address some of the ongoing educational needs identified during their visit and these follow-up meetings. 

They look forward to developing their continued partnership with the clinics, opening the door for additional opportunities in the future to join hands with others working to improve infection prevention and control in low-income communities. 

Our work: communicable and noncommunicable diseases, and mental health. World Health Organization. Accessed January 2, 2024. https://www.who.int/our-work/communicable-and-noncommunicable-diseases-and-mental-health

Infection preventionists Heather Saunders and Stephanie Mayoryk's journey to East Africa emphasizes the positive impact of infection prevention efforts in low-income countries. Despite challenges, their experience encourages IPs to engage globally, fostering hope and passion for providing excellent patient care.

Stephanie Mayoryk, MAS, BSN, RN, CIC

Articles

Study Highlights Successes and Challenges in Implementing Enhanced Barrier Precautions in Nursing Homes

Infection Prevention in Low-Resource Settings: Two Infection Preventionists Consult in East Africa

Infection Prevention in Low-Resource Settings:  Two Infection Preventionists Consult in East Africa