Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in health care facilities today. Each column explores the Bug of the Month's etiology, the infections it can cause, the modes of transmission, and ways to fight its spread. The pathogen profiles will span bacterial, viral, fungal, and parasitic species. We encourage you to use Bug of the Month as a teaching tool to help educate health care personnel and start a dialogue about microbiology-related imperatives.

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Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in health care facilities today. 

Bug of the Month: I Like to Hang Around

The COVID-19 pandemic gave the world of infection prevention and control many hard-earned gifts. These gifts include the public’s reinvigorated sense of awareness about communicable diseases and the importance of combating the spread of these diseases through contact tracing. To break the chain of infection, individuals who may have been exposed to an infected person must be contacted, tested, and treated as soon as possible. Breaking the chain of infection is increasingly essential when asymptomatic individuals can act as a reservoir, infecting others before becoming symptomatic. Although the COVID-19 virus may be the first thought for most people when the word “exposure” and its corresponding consequences are mentioned, exposure can result from many different circumstances and have varying effects on an individual’s mental, physical, and emotional well-being.

Exposures can occur almost anywhere and among anyone who is not adequately protected. Let’s consider a few predicaments that can result in exposure. First, personal protective equipment (PPE) is essential in the multifaceted approach to preventing disease transmission. However, when inadequately selected or donned and doffed inappropriately, it can leave individuals susceptible to infectious disease exposures. A health care provider involved in occupational needlestick or sharps injuries can be at risk for viral infections such as hepatitis B, hepatitis C, and HIV even if PPE is used correctly. Attending school, work, or intimate social events can render one vulnerable to the silent attack of communicable disease transmission when exposed to symptomatic or asymptomatic classmates, coworkers, family, or friends. Regardless of how an exposure occurs, the events to follow should represent a regimented physical response to the health care needs of the individual exposed to infection while encompassing compassionate and empathetic attributes.

Evoking compassion and empathy during care is particularly important because fear may be the first and most common emotion associated with the awareness of exposure to an infectious disease. There is the fear of not knowing the infectious disease(s) one has been exposed to. There is the fear of how the disease will manifest once an infection is confirmed. There is also the fear that an untimely death will be attached to the prognosis. The mind of the individual exposed to infection can easily wander into an abyss of negative thoughts, but how does the health care provider test and manage the exposure while acknowledging the trauma associated with knowing that one has been exposed? They can do so by initiating all components of compassionate care. Compassionate care “requires immersion into the pain, brokenness, fear, and anguish of another, even when that person is a stranger.”

Compassionate care is deeply rooted in the essential and fundamental elements of compassion. In health care settings, compassion is “the recognition, understanding, and emotional resonance with another’s concerns, distress, pain or suffering, coupled with relational action to ameliorate these states.”

 It is suggested that “compassion is discernible by the following 3 elements: recognizing suffering, relating to people in their suffering, and reacting to suffering.”

 These elements can easily be summed up by the moral principle known as the golden rule, which is to treat others as one would like to be treated. There is an element to postexposure patient care that not only requires being empathetic to the patient’s circumstances but also using inherent virtues to take physical action in supporting the patient’s care. Although the expression of compassion has been inhibited by various factors such as stress, time pressures, and a greater emphasis on quantity rather than quality, compassionate care is an expectation of patients and a professional obligation of health care providers.

Examples of compassionately engaging with a patient can be exercised by offering sentiments to exposed patients such as “I know you are suffering, but there are things I can do to help” or “What can I do to improve your situation?”

 Such compassionate statements act as a reflection of the health care provider’s willingness to act and promote the well-being of the patient. Ideally, compassion can be exemplified when the vulnerable moment of exposure is acknowledged by a health care provider who realizes that the exposed patient is in the hands of a health care system and its capacity to actively respond to the experience with compassion and empathy.



Empathy is “an affective response that acknowledges and attempts to understand an individual’s suffering through emotional resonance.”5 
Exercising empathy after patient exposure demands a more emotionally engaged process, allowing health care providers to potentially accommodate the patient’s emotions through personalized acknowledgment of their full experience.

 What does this look like? Emotional resonance means putting yourself in the patient’s shoes. Findings from studies have shown that patients identify empathy in their care when their full experience is acknowledged and health care providers are willing to connect to and understand the patient. This idea requires the ability to put yourself in the patient’s shoes, imagine yourself walking in those shoes, and see how you would personally react to the situation. Engaging with patients using phrases such as “Help me to understand your situation,” “I get the sense you are feeling…,” or “I feel your (perceived emotion)” are examples of exercising empathy with patients exposed to infection.

This approach differs significantly from the health care provider who displays a visceral reaction to the patient’s distressing situation through sympathy. Findings from a study suggest that patients perceive sympathy as “a pity-based response to a distressing situation characterized by a lack of relational understanding and the self-preservation of the observer.”

 Although sympathy can be appropriate for some situations when interacting with patients exposed to infection, it is essential to ensure that sympathy doesn’t make patients feel demoralized, depressed, or sorry for themselves.

 To avoid displaying a sympathetic response to the patient’s exposure experience, health care providers should reconsider the use of statements such as “I’m so sorry,” “This must be awful,” or “I can’t imagine what it must be like.”

 Sympathy may be the easiest emotion to display to a patient in moments of distress because it simply requires kind words or gestures, but in most moments of postexposure care, the last thing a patient will want to feel from the health care provider delivering medical care is a disingenuous, depersonalized, and emotionally distant and detached response to their experience.

In health care policy delivery and research, compassion and empathy are terms often used interchangeably to describe some humane qualities patients hope to see personified by their health care providers.

 Empathy and compassion are typically welcomed and valued by patients because they feel these concepts point to the health care provider’s ability to acknowledge, understand, and resonate emotionally with their experience. Compassionate care leans toward the right thing to do from a humanistic perspective. It can be the catalyst that raises the quality of care and helps improve patient safety. When health care providers work to build caring, trusting, and collaborative relationships during postexposure care, there are more appropriate health care decisions based on the patient’s expressed concerns, better patient adherence to treatment plans, and less costly outcomes. The future of health care has the opportunity to improve in the area of compassionate care, especially during postexposure care. Doing so can increase the patient’s hope for recovery, accountability in exposure circumstances, and overall satisfaction of care.

Roach MS. Caring: the human mode of being

 Caring in Nursing Classics: An Essential Resource

2. Lown BA, Rosen J, Marttila J. An agenda for improving compassionate care: a survey shows about half of patients say such care is missing. 

. 2011;30(9):1772-1778. doi:10.1377/hlthaff.2011.0539

3. Way D, Tracy SJ. Conceptualizing compassion as recognizing, relating and (re)acting: a qualitative study of compassionate communication at hospice. 

. 2012;79(3):292-315. doi:10.1080/03637751.2012.697630

4. Sinclair S, Norris JM, McConnell SJ, et al. Compassion: a scoping review of the healthcare literature. 

. 2016;15:6. doi:10.1186/s12904-016-0080-0

5. Sinclair S, Beamer K, Hack TF, et al. Sympathy, empathy, and compassion: a grounded theory study of palliative care patients’ understandings, experiences, and preferences. 

. 2017;31(5):437-447. doi:10.1177/0269216316663499

articles

Deliver compassionate and empathetic patient-centered care

Handling Exposure Cases with Compassion and Empathy


“Clean hands save lives.” “Save lives: Clean your hands.” “Washed hands are caring hands.” “The number 1 way to prevent health care–acquired infections (HAIs) is to wash your hands.” These are only a few sayings commonly heard and promoted in the medical field, but are these sayings true? The answer is an overwhelming yes. The CDC estimates that approximately 1.7 million patients acquire HAIs while hospitalized and more than 98,000 of those patients (1 in 17) die because of HAIs annually.

 Although it is difficult to quantify the number of HAIs directly linked to poor hand hygiene, per the World Health Organization, appropriate hand hygiene can prevent up to 50% of avoidable HAIs, including those affecting health care workers (HCWs).



Good and Bad Germs
Those working in infection control and prevention know the significance of maintaining proper and consistent hand hygiene. In case you need a refresher, here’s why it’s vital to keeping patients and staff safe. Hands are an essential body component and are used by HCWs when caring for their patients; however, they are filled with thousands of germs. Two types of bacteria live on our hands: resident and transient flora. Resident flora consists of microorganisms that can be found under the stratum corneum, the outermost layer of the epidermis, and on the surface of the hands. Common resident species include 

, and other coagulase-negative staphylococci. Resident flora has 2 essential protective functions: the competition for nutrients in the ecosystem and microbial antagonism.

 These functions serve as a body defense by inhibiting the growth of other disease-producing organisms. Although resident flora is less commonly linked with infections, it may cause infections in sterile body cavities, the eyes, or on nonintact skin.

 As the name implies, resident flora is a common and expected presence on our hands. Normal hand hygiene is not intended to eliminate resident flora.
Transient flora on the hands is removed by performing hand hygiene and has been commonly linked to HAIs. Transient flora is acquired during direct contact with contaminated individuals or surfaces and lives in the superficial layers of the skin. Typical transient flora includes 

, gram-negative bacilli, and yeast.

How Do These Bacteria Affect Health Care?
We have established that individuals have good and bad bacteria on their hands, but how do they affect health care? According to the CDC, health care providers might need to clean their hands as many as 100 times in a 12-hour shift, depending on the number of patients and intensity of care. Nevertheless, findings from studies show that health care providers clean their hands fewer than half the times that they should. This lack of hand hygiene contributes to the spread of HAIs that affects 1 in 31 hospital patients on any given day.



As we all know, an increase in HAIs affects patients, their families, and the health care system. Hospitals are affected by low patient satisfaction related to poor outcomes such as HAIs, increased risk of antibiotic resistance, and consequences including lawsuits, fines, and even loss of accreditation. The direct medical costs of HAIs for hospitals in the United States range from $28.4 to $33.8 billion annually.6 Most importantly, patients are negatively affected by increased morbidity and mortality when HAIs are acquired, adding to their illness and care.

Why Don’t HCWs Wash Their Hands?
Many factors prevent HCWs from performing hand hygiene, including the lack of access to hand sanitizers or sinks, time constraints, skin sensitivity, education, and training, and personal beliefs. These factors have been widely researched, and many techniques and instructions are available for infection control departments and organizations to address them. However, the importance of a speak-up culture should be talked about more. Nothing is more terrifying than going up to a coworker, physician, or leader and asking them, “Did you perform hand hygiene?”

Speaking up for patient safety should be an HCW’s priority. However, many
barriers may prevent an HCW from speaking up about the importance of hand hygiene to a coworker. Some of the key barriers include the following:



Some HCWs may need more confidence to speak up about hand hygiene. They may feel uncomfortable confronting their coworkers or worry about being perceived as bossy.



An HCW may hesitate to speak up because they fear their coworker may take their feedback personally or become defensive.



An HCW may not feel confident
in their knowledge or training
on the organization’s hand
hygiene practices.



Health care is a dynamic field, and employees may feel they do not have time to converse about hand hygiene.



Staff from different cultural or language backgrounds may have different beliefs and attitudes about hand hygiene or providing feedback.

What Can Medical Facilities Do What Can Medical Facilities Do
to Increase Hand Hygiene Adherence?
Organizations can incorporate multiple strategies to improve their speak-up culture. Some of these strategies may include:


Providing education and training on the importance of hand hygiene will increase awareness and understanding of hand hygiene adherence and the responsibility for speaking up. Education can include in-person sessions, online modules, posters and signage, and reminders during staff meetings or huddles.


. 
Organizational leaders serve as examples to others. Leaders who consistently practice good hand hygiene, provide feedback, and are open to ideas and suggestions will encourage others to follow suit.


Organizations will often provide just-in-time training to HCWs who have performed an adverse action; however, providing positive feedback and recognition will help reinforce good behavior and encourage their peers to do the same.


. 
Organizations can empower HCWs by creating a culture of openness and providing channels for reporting concerns. An option for anonymous reporting should be offered, and emphasis should be put on the fact that no retribution will be tolerated.


 
Coming up to a coworker and asking them directly whether they have performed hand hygiene may seem like a confrontational or accusatory way to start a conversation. Creating an organizational “phrase that saves” will prevent aggressive or accusatory feelings. A phrase that saves is an expression adopted by an organization that is given a special meaning. Everyone in the organization should know the phrase and the meaning behind it. An example of a phrase that saves is “Clean 20,” used by Santa Clara Valley Medical Center’s O’Connor Hospital in San Jose, California. To all O’Connor Hospital staff and physicians, “Clean 20” means there is an opportunity to perform hand hygiene. For example, Nurse A is outside a patient’s room charting when they notice Doctor B leaving the patient’s room without performing hand hygiene. Instead of Nurse A telling the doctor to perform hand hygiene, they gently tell Doctor B, “Clean 20.” The doctor knows the phrase that saves, so they perform hand hygiene and thank Nurse A.

The importance of hand hygiene in health care cannot be overstated because it is the most effective way to prevent HAIs. Adherence to hand hygiene practice by HCWs is far from what it should be, allowing for many improvement opportunities across health care organizations. Among those opportunities, the promotion of speak-up culture needs to be incorporated. Speak-up culture can provide an environment that supports and empowers HCWs to engage in conversations when opportunities for hand hygiene are observed. This important component of education helps to extend the reach

References
1. Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. 

2007;122(2):160-166. doi:10.1177/003335490712200205
2. Key facts and figures. World Health Organization. 2021. Accessed June 2, 2023. https://www.who.int/campaigns/world-hand-hygiene-day/2021/key-facts-and-figures
3. Kampf G, Kramer A. Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs. 

 2004;17(4):863-893. doi:10.1128/CMR.17.4.863-893.2004
4. Lark RL, VanderHyde K, Deeb GM, Dietrich S, Massey JP, Chenoweth C. An outbreak of coagulase-negative staphylococcal surgical-site infections following aortic valve replacement. 

2001;22(10):618-623. doi:10.1086/501832
5. Clean hands count for safe healthcare. CDC. February 25, 2020. Accessed May 31, 2023. https://www.cdc.gov/patientsafety/features/clean-hands-count.html
6. Scott RD II. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. CDC; 2009. March 2009. Accessed June 3, 2023. https://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf



Everyone in health care knows the importance of hand hygiene, but adherence in health care is often below 50%, and having a conversation regarding hand hygiene adherence with a coworker can be uncomfortable. What can an organization do to increase hand hygiene adherence?

The Hardest Question in Infection Control: Did You Perform Hand Hygiene?


Incorporating infection prevention and control measures throughout the entire construction process, from blueprint to ribbon cutting, can effectively reduce the incidence of infections from the outset. However, infection preventionists (IPs) are not often involved at the beginning of the construction process, or if they are, they are still determining what they should do. Here are the steps that IPs should follow to make sure infection prevention and control policies are implemented in the facility’s construction.

A typical infection prevention strategy involves the IP working with other stakeholders to establish work-related policies and procedures followed by frequent audits to confirm compliance with established policies and processes. The IP’s role is to ensure that the work is carried out to properly reduce the risk of potential infections and comply with the recommendations and policies dictated by local, state, and federal laws. It is not the IP’s responsibility to instruct a contractor on how to complete a task.



Infection Control Risk Assessment (ICRA)

 is a process to assess the impact of construction and renovation work in health care facilities on infection control programs and practices and to ensure that new construction is designed to meet the needs of the anticipated patient population.

IPs can actively participate in the design and oversight of health care construction and renovation projects by actively participating in the processes that assess and mitigate infection risks to patients, health care workers, and visitors. This article discusses infection control’s role in the construction and renovation of health care facilities. 



Policy and Procedures
The IP should include a construction and renovation policy to promote a secure care environment for patients, visitors, health care professionals, and contractors. The policy should cover all aspects of building and remodeling projects that entail infection prevention and control. The policy should also state the need for the IP to be a part of the project team from the beginning of the project to the end.

This policy should include the following information:

 departmental responsibilities for each ICRA component, work types covered by the requirement, definitions of terms used in the ICRA, processes for confirming compliance with the ICRA, and any recordkeeping requirements associated with the ICRA process. Importantly, an IP should have authority outlined in the construction and renovation policy to halt the project immediately in case of unsafe practices.


 must at least tackle the following subjects: the quantity, location, and types of isolation rooms for airborne infection isolation and protective environments; a risk assessment for waterborne pathogens;

 the quantity, location, and types of handwashing stations and hand sanitation dispensers; any specific heating, air-conditioning, or other ventilation requirements; and mitigation measures and selections of materials for furniture and coatings. The IP should consider the regulatory requirements, local authorities, and international guidelines such as those of the Facility Guidelines Institute (FGI), CDC, and American Institute of Architects.

Infection Control Risk Mitigation Recommendations
Written infection control risk mitigation recommendation (ICRMR)

 plans created by the ICRA team are included in ICRA. At the very least, these written plans should cover the following topics: patient locations during construction and any need for patient relocation; containment barriers and other ICRMR construction phases and their impact on plumbing and ventilation systems; effect of the construction on traffic flow, access to exits, and operation of life safety systems; and any training needed for staff, construction workers, patients, or visitors. Information on the restroom and dining options should be accessible to construction employees. Installation of new materials must meet standards for cleanliness and the absence of water damage. IPs should know how the project will be monitored to verify the ICRMRs and what written processes will be used to halt work as necessary.



Construction Risks
Construction activities in or near health care facilities can increase the risk of infection because of mold spores carried by air currents, waterborne pathogens in plumbing systems that have become stagnant because of a lack of use while construction is underway, or the disruption of accumulated biofilms on existing plumbing. In addition to the danger of infection, construction activity can irritate patients and other building occupants with noise, vibration, disruption of traffic flow, and odors. These construction-related effects are a further worry in patient care locations where residents cannot be moved during construction and when there are no unoccupied after-hours periods. Additionally, materials inside and outside the construction zone might be damaged by flooding brought on by building activity. Before working on or near plumbing fixtures, project managers should ensure construction employees know where the water shutdown valves are located. Before any flooding incident, having procedures for handling flooding can ensure a quick reaction that doesn’t increase the risk of infection. A flood checklist is listed by the CDC.



Construction Containment
A barrier system may be put in place around construction work zones in health care institutions to keep any dust-produced and potentially contagious bacteria contained. These barriers include plasterboards, rigid plastic panels, or flame-resistant plastic sheets. In addition to the physical containment barrier, removing air from the enclosed construction area can result in lower air pressure than neighboring occupied spaces. Airflow from nearby clean spaces enters the enclosed workspace because of this reduced pressure, also known as negative pressure, before exiting the exhaust. The exhaust may be sent outside or, after passing through a high-efficiency particulate air (HEPA) filter, back into the building. Therefore, creating negative pressure within the contained work zone relative to adjacent spaces helps to prevent the release of airborne infectious agents in the event of a breach in the containment barrier or when opening doors to move workers and equipment in or out of the work zone.

Air Monitoring
Air sampling should be initiated with seriousness because the performance and interpretation of air cultures for fungi are relatively complex. However, the CDC does not recommend sampling for airborne microbial contaminants before, during, or after construction projects. There are several instances in which sampling may be judged necessary: when nosocomial infec¬tions are due to common environmental airborne fungi such as Aspergillus fumigatus, before initial occupancy of specially con¬trolled environments, and when procedures necessary for the cleanest air quality are being established and maintained.

Particle counts are recommended for monitoring the effectiveness of the construction containment. A significant increase in the airborne particle counts near the construction containment relative to the surrounding background levels may indicate a breach or leak. Particle counts are also used to check the functionality of HEPA filters in vacuums and negative air machines. There are no recognized safe or dangerous particle levels to use as a benchmark.



Water System and Quality Monitoring
Because of mold growth following water damage, many issues for controlling construction aerosols have been shifted to source management. During renovation projects, the water quality management team may request routine flow of water lines not used regularly to ensure that chlorine or other disinfectants in the water remain at effective concentrations to control bacterial and biofilm growth. Additionally, with plumbing dead legs (the part of the pipe that is not in use), the water inside becomes stagnant and at risk for microbial amplification. The IP should discuss prevention and control measures such as removing plumbing dead legs encountered or created during the planned project. If the dead leg cannot be removed, a valve may be installed to isolate it from the flowing main line so the abandoned pipe may be left in place. It may be simpler to handle future shutdowns for maintenance, remodeling, or pathogen outbreak control if isolation valves, recirculating plumbing systems, and connections for injecting chlorine or other disinfectants are strategically placed. Also, the IP should consider measures to control the growth of Legionella and other waterborne pathogens in plumbing systems, procedures, and schedules used for flushing and disinfecting the system before occu¬pancy when construction is completed. Unless the institution has a history of issues with water bacteria, typically Legionella, testing is typically not consid¬ered. To ensure there has been no fecal contamination, new water systems must undergo coliform testing.



Working With the Construction Team
The IP can think about mandating formal training or competency testing for the project managers and construction personnel implementing infection prevention suggestions. Health care facilities frequently require tuberculosis testing and immunizations for staff members, including external contractors who often operate in patient care areas. Additionally, programs can detect workers who are actively coughing or have exposed skin rashes and prohibit them from working in the regions that provide patient care.

After Construction and Before Occupancy
The ICRA and contract documents should specify how the containment barriers should be taken down and how the construction area should be cleaned up when the job is over. Before returning to the location to provide service, facility workers should conduct a routine clean¬ing of the area. The IPs should verify the ventilation system’s balance and perfor-mance levels to ensure they meet design requirements. Before putting any ducts back into service, clean any improperly sealed ones that became contaminated with building dust.



Conclusions
The IP has a vital role in both the design and construction phases of health care facilities. The IP collaborates with the construction team and clinical personnel early in the design process to identify potential infection concerns and then specifies the materials and designs that will best reduce those risks. The IP should be familiar with the construction process and the expectations for infection prevention during construction using resources such as the guidelines from the FGI, CDC, and the Association for Professionals in Infection Control and Epidemiology.



References:
1.	Johnson L. Construction and renovation. December 14, 2015. Revised May 27, 2019. Accessed June 20, 2023. https://text.apic.org/toc/infection-prevention-for-support-services-and-the-care-environment/construction-and-renovation
2.	Booth RD, Kobus C, Stever R. ASHE ICRA 2.0 Process Guide. American Society for Health Care Engineering. Accessed June 20, 2023. https://www.ashe.org/icra-2-process-guide
3.	Association for Professionals in Infection Control and Epidemiology. Infection Prevention Manual for Construction & Renovation. Association for Professionals in Infection Control and Epidemiology; 2019. Accessed June 20, 2023. https://apic.org/Resource_/store/books/preview/SLS9808_Preview.pdf
4.	Facility Guidelines Institute. 2018. Accessed June 20, 2023. https://fgiguidelines.org
5.	Checklist for infection control concerns when reopening healthcare facilities closed due to extensive water and wind damage. CDC. Accessed June 20, 2023. https://www.cdc.gov/disasters/reopen_healthfacilities_checklist.html
6.	Recommendations for the cleaning and remediation of flood-contaminated HVAC systems: a guide for building owners and managers. CDC. Accessed June 20, 2023. https://www.cdc.gov/niosh/topics/emres/cleaning-flood-hvac.html
7.	

Journal of Perioperative Nursing Clinics 3

(2008). Pgs 137-142.
8.	Morris G, Kokki MH, Anderson K, Richardson MD. Sampling of Aspergillus spores in air. 

 2000;44(2):81-92. doi:10.1053/jhin.1999.0688




When constructing a health care facility of any size, it is crucial to seek the advice and expertise of an infection preventionist. This article provides guidance on how to do so effectively.

Infection Control Today, July/August 2023 (Vol. 27 No 6)

Bug of the Month: I Like to Hang Around

Handling Exposure Cases with Compassion and Empathy

The Hardest Question in Infection Control: Did You Perform Hand Hygiene?

From Blueprints to Ribbon Cutting: Infection Preventionists’ Role in Construction