Educational Webinar: The state of healthcare-associated infections & the pandemic

Good afternoon and thank you all for joining us today for a special presentation, the state of healthcare associated infections and the pandemic. A year in review and a glimpse into the future. My name is Brandon martin. I am the manager of customer engagement here at McKesson. Before we get started, I just want to share with you our latest program. This webinar is being brought to you by McKesson and you prevent our comprehensive program providing a library of resources to help you create a strong infection prevention program including educational materials regulations and guidelines from OSHA, CMS and CDC and products aligning to CDC recommendations. McKesson you prevent launches in january. So bookmark this link and be sure to look out for more from you prevent. I'm very excited to introduce you all to our speaker today. Dr j Hudson Garrett Jr President and Chief Executive Officer, Community Health Associates. LLC Dr Garrett has a faculty appointment as an adjunct assistant professor of medicine in the division of infectious diseases at the University of Louisville School of Medicine. And there's also a faculty member for the Center for Education and training and infection prevention is the president and ceo of Community Health Associates. He is a frequent international lecturer in the areas of infectious diseases, healthcare associated infections and infection prevention and control. He holds board certifications in patient safety, Healthcare quality, vascular access, antibiotic stewardship, Pre hospital emergency medical services, flexible in disco pre processing, critical care and infection prevention and control in post acute kato. He has provided testimony to federal agencies such as the Centers for Disease Control and prevention, Food and Drug Administration and Environmental Protection Agency on a variety of infection control related topics. He is also a 2021 fellow with the Institute for Healthcare Improvement and was inducted as a, as a distinguished fellow and practitioner in the national Academies of Practice. He was recently awarded fellow designation by the Society for Healthcare Epidemiology of America. We're so excited to have you with us today, dr Garrett, I will give the floor to you. Thank you very much Brandon and good afternoon and good morning to each of you. I hope everybody had a wonderful thanksgiving and is enjoying a good holiday season. As Brandon mentioned, I'm excited to be here with you this afternoon to talk about sort of the year in review. Um, I think we can all agree that 20, and frankly 2020 as well has been a pretty tumultuous uh, time for us in health care and hopefully today we can really reflect on some of the learnings that have taken place as well as some of the opportunities that we have here in the future. We'll focus in today, specifically on some of the learnings that we've experienced over the last 12 months in particular and also talk about some of the opportunities that we have in 2020 to 1 of those is really going to be to work on us as a health care team and the dynamics of our team. We're seeing multiple individuals throughout our organizations leave the field altogether, retire early or frankly just be burned out. Um And so this is a huge wake up call I think for healthcare leadership to talk about some of these unique issues that are challenging healthcare and and also many other industries that we all deal with on a daily basis just as a quick disclaimer um All of the information that's contained within today's presentation is current as of today. Um But we do encourage you to go to the various websites including the Food and Drug Administration, the CDC as well as any vaccine manufacturers websites in order to get the most up to date information following today's program. We also want to remind you that this program is not going to be construed as medical advice. And so you'd always defer to your local regulatory and public health authorities in case you have any specific questions. I do look forward to questions that you might have at the end of today's program as well. We are offering continue education for today's program. You'll be awarded one hour of C credit by the California board of registered nurses. Um In case you do you have any questions about your C credit, you're welcome to email my team at continue education at Ch A. Associates dot com. Following today's program will submit your ce. Credits and it takes about 72 business hours for those to be processed. You will receive an email from T. G. And A. Which is Terry Goodman and Associates um that will allow you to complete your online evaluation and then also claim your Ce credits online. Once you do that, it will allow you to download your sea certificate as a pdf. Since we're offering cds for today's program, you can see my financial disclosures available here for your review but also contained with them the handouts as well. So let's jump right in and really look at sort of the top lessons that we've learned specific to healthcare associated infections during the pandemic, right. And it's not just gonna be clinical lessons but frankly also some of the lessons that we've experienced with our teams care delivery and even supply chain. The second area that we're going to focus in on is how do we fix this problem? Right. We know that we've had breaks in care. We've had continuity of care issues. We've had supply chain challenges. We've certainly had a specialized care challenges in the in actually obtaining enough personnel that are actually equipped to care for our patients. And then we'll finish up with some of the future directions related to infection prevention and control. So we know that Covid has really thrown us into a pretty massive loop right? It is brought to light some issues with emergency preparedness. Certainly pandemic preparedness. Specifically supply chain management and the ability to get supplies when we need them, particularly PP. But most importantly, I think that it's actually brought light to how fragile our healthcare ecosystem can be in terms of staffing, personnel, leadership and some of the other elements that we're going to discuss here today. So I thought it would make sense to really start with. Uh some of the new things that I think are helpful for us to have as a frame of reference. Right. Part of this is that we've got a lot of exciting developments in the world. Um you know, with any pandemic comes an opportunity to learn every single outbreak I always take as what can I learn from this? How can I prevent this from happening in the future? How do I make sure that we're going to be ahead of the game the next time? Right. Because we never expect to be perfect. But we always expect to improve every single time. And that's really the core definition of quality improvement. And we've got to have that mindset. I know we're all tired and fatigued. Um I certainly every day. I thought well there's got to be more hours in the day. Um and there simply aren't but it does give us sort of that opportunity to step back and reflect on what's happened over the last year. So I thought it would make sense to sort of start with where we are now? Is is that baseline that frame of reference. Well, the good news is that we've got a large amount of diagnostics out there so that we can actually detect the disease. Right? And this is not just true for covid. Honestly this is also true for many other infectious diseases right now in my particular area, we're seeing a lot of flu particularly influenza A. As a matter of fact, one hospital has as many flu patients as they do covid patients right now, just up the street for me. But we've got to have rapid diagnostics right? The ability to detect and surveil these types of diseases to look for sort of hot hot spots right where we may have um a specific type of infectious illness that may be out there that we need to be aware of a few weeks ago we saw big outbreaks across the United States of RSV. Um and actually in adults which is fairly unusual that we see that much RSV and adults. We've now got three different vaccines that are available including booster and additional doses. Right? And keep in mind that there is a difference between those definitions of boosters versus additional doses, those additional doses are going to be for our immuno compromised patients, those that likely did not mount that um really uh impressive immune response that we were hoping for. Whereas a booster dose is going to be for those of us that have had the regular series and are looking to simply boost the durability. Um And the sort of the duration of that vaccine's effectiveness. We've got tons of R and D. Out there in in new therapeutics, particularly some of the ones that the FDA has been talking about over the last, you know, 10 to 15 days with some of the new oral therapies that will allow us to have an antiviral that can not only reduce hospitalizations and deaths but certainly reduce over overall mortality and morbidity. These are exciting things, right? Because we also have patients that choose not to be vaccinated or we have those that have and they simply haven't mounted an immune response because maybe they're immuno suppressed. So having a bigger arsenal on our tool belt is going to be very helpful in treating many of these patients. one of the other challenges is around supply chain, right? We know that even back a year ago we were all operating in the red. Most of us were having big challenges getting supplies. Now we're going back to some of these same challenges in our grocery stores and some of our other retail markets where we're having uh unique issues with things like toilet paper and some of the other products that we rely upon. But you know, a year ago we were dealing with PPE challenges, gloves and masks and gowns and some of the other things that are necessary for the safe delivery of care. Part of what we've learned right over the last year has hopefully been a shift away from the term patient safety and really all about healthcare safety that healthcare safety includes us as the healthcare team. Right? Remember that you as a specialized healthcare provider, regardless of your role, are a force multiplier. You are somebody who is bringing unique talent, a unique skill set and perspective to the table and that matters. Um, and so we've got to do everything in our power to protect that workforce as much as we can. And then really lastly, there's some ongoing legal challenges, assisted with different mandates, not only with vaccines, but also with other regulatory things such as the OSHA, um emergency temporary standard. And a lot of this has resulted in even increased vaccine. Hesitancy and resistance to the vaccination, right? For many different reasons, we could have a whole two hour webinar just on vaccine hesitancy to sort of break those down. And the way that I think about this is that everyone's concern is legitimate, right? Whether or not it sounds crazy or is crazy, it doesn't matter, it's their concern. And so as a health care provider, we want to share sort of that empathy with those patients and take the opportunity to educate, to enlighten to bring data to the table to answer some of those questions that those personal uh folks have. Right. And that's going to give us an opportunity to really create that relationship. On dynamic part of the other challenge that we face is that we've got this second pandemic right one that we're not really freely talking about. And that was one of the reasons I was particularly excited that McKesson asked to do this presentation this month because I think it only makes sense at the end of the year that the second pandemic is really around healthcare personnel resiliency, right? We know that we have a very, very fatigued healthcare system. And with that system we know that all of the care is delivered by people. And so when we have tired personnel that are burned out that are exhausted where we've got limited resources, we've lost a lot of our specialists and in fields such as respiratory therapy. Um we know that we've got an issue and so we are not doing anywhere close to enough at a national level to reinvest in our health care system, right? Part of this is to make sure that our people are okay to ensure that they have the right staffing ratios to make sure that they have top of the line equipment that's going to allow them to deliver care, but also simply just knowing that their leadership is invested in their success and safety. Um I talked to a facility just the other day and I said, when's the last time you saw your Ceo? And they said back in 2000 and 19 and I said you're telling me you've not seen the Ceo up here in the ICU since that time frame and and the charge nurse said no, right. And that is a clear signal that leadership in that institution is not visible, they're not present. Um And so leaders and healthcare have so much power um in order to influence change and show and really help with resiliency and show the staff that they're standing behind them. So part of our learning has been about how do we protect healthcare workers. Right. And that really goes beyond just personal protective equipment. In my opinion, it is really almost about psychological PPE. Um and that is really a term that's been coined by the Institute for Healthcare Improvement. So if you're ever interested in some additional learning or just reading if you go to the ice dot org website and just sort of type in the search for psychological PPE, you'll actually see some very very interesting sort of research articles as well as some different steps that we can take to shield ourselves from some of the impacts of chronic stress. But it's not just about putting on the the gown or the gloves or the mask. It's really also about protecting us. Right. How can we make sure that we're rotating staff very similar to what you see in in airports where you see t. S. A personnel that it always seems to be when you get to the um check on the check on point there that they have to rotate and the reason they're doing that is to make sure that those people are still alert. They're still resilient and we don't do a good job of that in healthcare particularly for those that are caring for covid patients on a routine basis. We need to rotate them in and out. And some of this is going to be built back on the back of healthcare staffing and resources. Right. If we don't have the right people to deliver the specialized care that's needed, then we know that that can be a problem. Right? And so I'll just use respiratory therapy as probably the most prominent example. It's the very beginning of the pandemic. We all recall that many of these patients were activated. We saw patients that were on ventilators that certainly required the specialized touching and expertise. Excuse me of respiratory therapist but we don't have very many respiratory therapists and the ones that we do, we were completely burning them out. Um I know at least four or five that have retired retired very early. Um and actually left the field of respiratory therapy to go into other things within healthcare because they simply just got burned out with the care that they were having to provide. We also have facilities that for example we're canceling elective cases and then they laid off or furloughed there. Oh our staff. Um and I think about the anesthesia teams and all of our O. R. S. Right. Those those folks are airway experts. Why not deploy them to actually help with the management of some of these complex airway patients. Right, luckily now we've learned some things we've learned that intubation is not the best course of treatment. We've learned that we can train other people to be cross trained. Uh For example we can make every critical care nurse have specialized ventilator training. We can use other specialties like vascular access. Um Certainly our emergency department was overrun as well um in many places across the United States. And so that cross training is hugely hugely helpful. But the other thing to consider is what if. Right? And my biggest what if scenario in my brain was what if Susie R. Charge nurse or whoever it may be was exposed to. Covid, how are we going to take care of her? How are we going to take care of her family? What if she lives with her elderly parents? And it's not wise for her to go home. Probably one of the most impressive things that I saw during the pandemic was a hospital that I worked with quite frequently. They actually rented off sort of rented out the floor of the hotel. Um And they kept that floor rented throughout the duration of the very height of the pandemic so that they have health care workers that were exposed. Um They could actually put them in the hotel. They took care of all their their food, all their incidentals. They made sure that you know if the family for example needed groceries back at home, they took care of that. Right? And so it was really a very cautious type service that allowed those individuals to know that everything would be taken care of and their employer was there standing with them and that was pretty impressive. Most people said, I can't believe the hospital is doing this. And the way that the hospital solve this was I need to take care of my frontline team. I take care of my frontline team. They will in turn will take care of my patients. And so I need to make sure that I'm getting these staff members back. Um So that there's not gonna be any particular issues with that. This really leads us nicely into the discussion about resilience, right? Resilience is not something that we talk about proactively unfortunately. And with the high rates of burnout, right? The amount of staffing that were down. Um I don't know if anybody that's fully staffed. I haven't seen a single hospital long term care facility anywhere. Um That is not um advertising for staff at a badly needed basis. Right? Even the incentives for places like Mcdonald's for example that are offering 20 to $25 an hour plus a $2000. Sign on bonus. Tell us that the need for staffing is not just a universal problem within healthcare but it's really affecting many different industries that, along with the need for specialization is a big issue. Think about a local pediatricians office if you take somebody who's an adult nurse, right and put them in a pediatric practice with no experience, no training, that's really a disaster. Um But if you have somebody who has specialized in the needs of Children um that is there to work hand in hand with the pediatrician and their staff. That makes a massive difference um in the ability to correctly deliver care. Now this is sort of a curve one that we look at on a continuum to say where's your current performance? Right. And so on the far left, you'll see sort of on the Y axis, um you'll see sort of the performance and then the arousal level on the X axis. Um The healthy tension point right, is where we actually see a lot of growth and opportunity and we're trying to get to that point of a peak which is what we refer to as the intended performance. However we see that so many in healthcare are really performing all the way over on the right, Right. And so this this sort of panic zone where we reach exhaustion is very very dicey, right? Because there's a fine line between chronic exhaustion and reaching the point of burnout. Right? And we know that individuals that approach burnout or reach that state are really going to be unlikely to be able to properly care for patients because they can't properly take care of themselves. Right? And you may be approaching this stage personally. You may know colleagues that are as well. And so part of this is to take a step back to recognize the signs and symptoms and to really get the appropriate assistance that's needed. So many of us in health care have experienced what we, you know, coin compassion fatigue where we simply can't care anymore, Right? Because it's that prolonged exposure to that repeated injury. Maybe you're an E. R. Nurse or you're an urgent care uh clinician or you work in a long term care facility just as an example and long term care, I think has experienced a different level of this than anywhere else. Just because of the nature of the vulnerability of their residents. Right? And so if you've got staff members that were scared and and and tired, you had lots of residents initially in long term care that actually contracted COVID-19. You can only take that for so long. Right? And then the body says there's no more than I can take. There's no more than I can absorb. And you but you reach that sort of breaking point. And part of this is to really look at this in terms of what we refer to as the chain of transmission, right? And if you recall from, you know, just either schooling or our exposures and see classes were thinking about how do we break sort of that chain of transmission. Things like hand hygiene, the use of PPE, making sure that we don't break the patient's skin, which is a natural barrier that were appropriately using PPE and identifying specific pathogens. But there are other ways to actually break the chain of transmission and part of that is to invest in our personnel to make sure there are individuals that are delivering the care that they matter know that they actually deliver something that is life saving, invaluable. Right? This is a massive, massive difference compared to just focusing strictly on the clinical aspects of care delivery. So there are different things that actually bring us to this point, right? Part of this is pandemics and and part of it is maybe home life, maybe there is a sort of a sense of isolationism. Uh if you were called back at the very beginning of pandemic colleagues in new york city and other places were living in their driveways in their garages because they were so afraid to bring this quote unquote new novel virus into their home. And so that that point of exhaustion has led to an increase in health care worker suicides. Alright, we've got folks that are just leaving the fields are changing to non clinical roles. Um it's been hard enough to get good nursing leaders and faculty and now we're struggling with that even on a larger scale. And so that point of trauma and fatigue is one that we can't ignore. We have to make sure that we're really moving the needle forward there and then if we have colleagues that are reaching the point of burnout and are already there, right. There are ways for us to rectify this. You know, maybe your employee assistance program is the first starting point. But simply removing them from the source of trauma makes the most sense initially. Right. If there are individuals that are drowning in a particular task or a particular project or maybe they've been on that that covid wing uh for a long period of time, I remember talking to a long term care nurse that had been working in the covid unit for over a year continuously. She'd never ever worked outside of the covid unit since she actually started there the day she started. That's where she was assigned and she never went to any other unit. So existing in a state of PPE for over a year where all you see is sort of death despair and dying right? Because their residents were very, very sick. That is going to be something that's going to take a toll on even the most resilient and highly functional healthcare providers that are able to manage that sort of exhaustion and fatigue. Well, like most anything with infection prevention and control, It all goes back to leadership, right? And leadership will make or break everything. Um, and I try to explain this to people all the time. And yet sometimes it falls on deaf ears because leaders may not be in a position to understand the value of this, but if we've learned one thing over the last few years, it's that good leadership, especially executive leadership that is visible, that is tangible, that is supportive, that is motivating is going to drive so many positive results regardless of the care setting. Right? So this doesn't hold just true for hospitals or long term care, it's the same with ambulatory surgery, certainly outpatient care as well. Leadership matters, leadership is visible not only to our staff members, but equally so too our patients, um I recently had my annual physical and I was pretty impressed when the practice manager came in um after my exam and said I just want to introduce myself, make sure everything went well um and also lets you know that we appreciate your business and I was quite surprised because that had never happened to me and this is a very large healthcare system and she said, well we're approaching things differently from some learnings from the pandemic. Um and I said, well that's interesting, could you share with me what changed? And she said her employee, um I guess satisfaction scores were lower because the managers were not as visible, they were actually working from home, which was kind of interesting, but they also noted a dip in patient satisfaction scores because they felt like no one was really delivering the very best care because everything was being done, sort of hands off. Right? And so they really sort of adapted their approach, which I was glad to see. Uh for sure. Now one thing to sort of think about is to establish an internal barometer, right? Really figuring out where you currently are, Are you running hot? Are you at the point of burnout? Are you running cold? Are you at a point where you just don't care anymore? Um You know, and you've got to sort of figure out and almost like the power company says, you know, keep it sort of neutral room temperature. Um And so it's totally normal for just like our blood pressure to fluctuate up and down for us to fluctuate, sort of our emotional state to fluctuate in our our sort of clinical vulnerability that we have with their patients and how we're going to think. Um I know that for example, when I woke up this morning, I got woken up very very early by a spam caller at like five o'clock in the morning um and then have some meetings fairly soon after that. So I just stayed up and it really threw up throughout my whole day, right? It was something that I could feel my temperature changing if you will and I had to sort of reset that and we always had that opportunity to reset when needed. That's something that we can do, not only with ourselves, but also with our colleagues as well. Mhm. So let's talk now about sort of the overall impact of the pandemic. And we're going to start with sort of the most obvious and then frankly work towards the end. If you look at impacts level one, this is your direct patient care. The things that we see on a daily basis. These are going to be the physical sort of um uh you know, notifications that you're going to see uh patient mortality and morbidity. You're going to think about the impact of families. You're gonna think about that visible child that came in and is now hospitalized. Level two is really where we actually go out a level deeper and we actually focus on sort of the community stress and impact. Um One of the ones that I would call out here is the impact of public health. We have seen a massive amount of folks leave the field of public health because of the pandemic. Part of that is is really burn out. But the other part is opportunity in the private sector. You know, do you want to work a government job where you're getting paid maybe 15 to $18 an hour. Um and you're sort of board or do you want to go work a private sector job during a pandemic where you can get paid upwards of 40 to $50 an hour and actually help with Covid testing vaccine, administration etcetera. And so that has really created sort of a new field. But it means that we've lost a lot of very talented individuals within healthcare, um, particularly public health. We're now seeing some of the social impacts where individuals are having trouble paying their bills. Um, we're seeing folks that have lost their employment or maybe it's changed their hours have changed. We're seeing employers that are shutting down, resulting in that. And then when we get out to impact level three and four is when we look at sort of those long term consequences. Think about patients for example that did not seek medical care and maybe they had a growth or a lump and they didn't think anything of it or they were worried to seek care during the midst of the pandemic. And so they actually had a miss cancer diagnosis that missed opportunity for early intervention. As just an example, you've got patients that have chronic comorbidities such as morbid obesity, uh smokers, folks that have COPD and some of the other things that we know, we're going to put them in increased risk right? All of these are impacts that may or may not be directly appreciated by frontline healthcare providers because you may not see them right. You may only see the impact of the patient right before your eyes, but you're certainly seeing some of these other impacts within our localized communities. So this really begs the question, What have we learned and frankly, what have we not yet learned or appreciated from the pandemic, right part of this is to always go back to the most basic element of helping us curb the pandemic, which is how is it spread? Right. Let's just say that there's new, a new superbug, It's a new novel virus. It originates from asia and we have no idea anything about it, but we know the route in which is transmitted. Let's just hypothetically say that that is something that's going to be airborne transmitted. Right? And when I say airborne, I mean true airborne very small particle size, long survivability in the air and it requires a full respirator. Well that is a very, very different thing than something that is more of a contact pathogen that we can control with good hand hygiene. Right? I certainly would let rather have a contact pathogen than something that's truly airborne and words also matter. Um one of the things that was particularly, I think alarming and challenging for us in healthcare was when CDC released um the document to the public that essentially says covid was airborne, right? And it was a very poor choice of words in the sense that airborne to us means again that small particle size, that's you know, it's not going to be large droplets and it's gonna stay and survive in the air for very, very long periods of time. It also means that for every single interaction with that patient, I need to wear some type of respiratory protection that is Going to be in 95 or higher. Now does covid have the ability to sort of function an airborne route in some instances with the sort of forms of aerosols. Yes. Is that the most common transmission? No. Right. And if it was truly a absolutely airborne virus, then we would see many, many thousands of healthcare workers because, you know, have it because we're all wearing surgical masks with just normal delivery of care. Right? So identifying the route of transmission helps us know how to stop it, how to intervene, What the appropriate level of PP or isolation is. How should we cohort patients as an example. And I think this would have been particularly helpful for our long term care colleagues because they dealt with such a hard blow with the amount of individuals that they had under their care during the height of the pandemic. Some of the other questions that we should consider are what I refer to as the three piece right people process and product in that order. The first is people. And the reason it has to be first is because without people we can't deliver care. Right? And without good people, we can't deliver care. We've all worked with folks that were averaged and we've all worked with folks that were great. I think we can certainly agree that we'd always like to work with folks that were great. Um, you know, when I go to certain places and I'll just use Tik filets an example. Uh because I'm based here in Atlanta and I'm a little bit biased with that. But they always say it's my pleasure. Right? It's always a very pleasant experience with those individuals. Imagine if every single interaction with the patient was pleasant, right? Imagine if every patient was respectful, which we know is not always the case and every single health care provider had the necessary skills to deliver their specialty care needed for that patient. This would be a massive, massive win for us in health care. So those specialized, qualified and well resourced and supported personnel to deliver that care or what we mean here, the second area of focus is processed, Right? So if I go back to, let's just use our normal infection control policies and procedures. Well, if I don't have confidence that those are being executed, things like hand hygiene, uh surface disinfection, the use of PPE that I'm getting catheters out when they're no longer medically indicated, then I really have very, very low flexibility in overcoming something as simple as a pandemic or an outbreak. Right? Because we know that those outbreaks and pandemics, they may all be the same pathogen, but the amount of individuals that will be impacted in sort of the overall mortality morbidity can be very, very high dependent upon the infectivity of that disease. So, having confidence in our basic core practices is really going to make a huge, huge difference. And then lastly, is products right without the products that we need to properly and safely care for our patients and residents. We can't keep ourselves safe. Right? And this does not in any way mean that you need that gold standard product that you've always liked and use. Um, that's always nice. Right? But it's nice to have. But let's say I can't get my purse. I preferred in 95 respirator. But I can get an alternative as long as I can fit tested and the staff still passed then that's great. It doesn't have to be that exact same brand or manufacturer. And that's one of the things that we need to consider strongly is how do we really impact supply chain? The CDC has really used sort of this red light, yellow light, green light almost like a stoplight based approach where we think about conventional capacity, right? Conventional means everything's hunky dory. We're not having supply chain issues. We're not seeing any changes in our sort of ordering process, Everything is in stock and were able to get that that yellow light or or contingency is where we have an issue. We have products that are not available. Maybe there's some that are on backorder or there's some alternative products that we can get. Um, but it really doesn't mean that we can't get products or we may have different types of formulation, maybe you were used in a ready to use disinfecting wipes and now you need to use a spray or concentrated liquid. And then lastly, is that red light or that crisis mode. Right? And while we may not be operating in crisis mode right now, in terms of personal protective equipment or some of the other supplies that we use, we are seeing this in areas like sailing. Um, and some of the other products that might be on, on sort of short supply here lately. The other piece to consider is what's going on in the commercial supply chains, right. Things that might impact our our, you know, customers or patients if you will. So one of the things to consider is that every time we get on a plane, right? It's also about self protection. And if you remember when you get on an airplane, the first thing they normally say is that we're here primarily for your safety. And then secondarily we're here for customer service. And the same is true for health care. If we don't take care of ourselves first, then it really makes us ineligible and unable to help our patients. And so pulling down that oxygen mask and placing it on your face first so that you can properly care for uh, you know, your patient or your resident is going to be a massive, massive important step, then you can help those that are around you. This is things like resiliency and taking a break and making sure if you need the time off that you take it. Um that you know, you step up and help colleagues that are in need. Um not everybody is great at that sort of influencing some of their emotions. Now, one of the nice things that I've learned over the years is that you can control your reaction. Sometimes I'm good at this. Other times I'm not just like all of us, right, We're not perfect. But the attitude is really the culmination of all of the three things that are listed here in the circle, right? Thoughts, feelings and actions and that is our show took over responsibility that we and we alone control. Right? And so if I have a bad interaction with a staff member or patient, I have the ability to let it ruin my entire day or have the ability to just sort of say that was not personal or maybe even if it was, but I have to focus on the task at hand which is caring for my my patient. Um I also have to make sure that I I sort of wipe the slate clean at the end of the day and actually make sure that I returned back in a in a good sort of mental position. Now in the infectious disease space we really refer to this iceberg impact of looking at the differences between colonized versus infected, right? Remember that colonized, you're going to be folks that carry and have the potential to develop infection, whereas those that are truly infected are going to be outwardly symptomatic, the folks that are coming in that are federal that have got that, that um, you know, symptomology that's consistent with an infectious illness and those are the ones that we see, right, that the ice that's sticking out above the water. What we don't fully appreciate is the amount of individuals that have been impacted. And so while we have fairly good numbers for those that have been vaccinated, we have a fairly good idea about the total number of cases of covid, we have no idea the overall impact. Things like PTSD Long covid hall syndrome individuals that are really experiencing a lot of challenges with recovery. Um, you know, where these individuals that were completely vaccinated, were these individuals that were not right? There's a lot of data that goes into analyzing the effectiveness of our public health measures and this gives us tremendous opportunity um to really focus in on what are the efforts that will make the most difference versus the things that really don't have a lot of route rudin science if you will. Um, and I'll just use an example like social distancing. Um, you know, we may have told the public to do social distancing, but then we didn't really do that very effectively within healthcare and really also what's the ideal distance if any, um, if I've got two parties and mask, especially in healthcare, there's really not a big need for social distancing. Um and and so I can look at the pragmatic based approaches that I take to ensure that it's going to give me my maximum return on investment from an infection prevention standpoint. Now there are ways right that we can protect ourselves as a health care team from risk. Well, the first and foremost is to not be exposed. Well that's not always possible. However right, if we are teaching facility especially we don't need to send everybody and their brother into that procedure, um let's say that we're gonna nebulizer patient as an example, I don't need to have three people in there, I want to have one person in there and preferably have that person exit while the process is being completed and then come back in. We also should evaluate our effectiveness with personal protective equipment and making sure that it actually fits correctly. You know, we've spent a ton of money um as a uh economy on sort of the different glass shields, the plexiglass shields and there's really not a lot of data that talks about any value with that now, does it make sense that it would stop some gross secretions? Yes. Um but as far as what I spend my money on that versus other things, probably not. Um and so that really impacts um the way that we deliver care and also the impression that we're giving publicly out there. One of the other things that we can do too is to figure out ways to track and sort of monitor any illness within the healthcare community, right? I want to know every single time a healthcare worker contracts an infectious illness, right? I also don't want my healthcare workers to come to work if they're actively ill, right? If you've got vomiting, diarrhea, an unexplained rash or fever, then those are sort of four double whammies that I don't want you anywhere near the care of a patient, nor do I want to end the building. Um I want you home recovering, but that's not always the possibility that we have because of HR policies. And so if you're in a leadership role in joining us today, that's something to really put on the homework list to make sure that there is a defined, very, very strict uh sick leave policy that allows employees to call out. Um also arranges for them to be tested if needed and get some type of occupational health follow up as necessary. We don't want folks coming to work sick and we need to make sure that it's a financially okay for them to do that. Um and so setting that expectation upfront will make a huge difference. And then lastly, it's our collaboration with public health. Uh certainly over the last two years, we've seen tremendous strides with our public health professionals and collecting data and making sure that it's publicly available, some of that data is not perfect. Um and let's just sort of call a spade a spade and realize that it is not, it is not perfect. Um and it needs to give more granularity so that we can understand the true impacts of all of our efforts and figure out what's working and what's not. I also like to remind us of the core interventions for healthcare associated infection prevention, right? This is really driven directly out of the CDC core practices that were released by the healthcare infection control practices advisory committee and and sort of the rationale behind this is if we focus in on these core efforts that we can really reduce and almost eliminate the majority of healthcare associated infections if we do this consistently. Um and make it part of our hardware process things like washing our hands, no shock there. Um not reusing single use needles and syringes. Um following the evidence based guidelines for the use of PPE um training and educating our healthcare personnel. Uh and one word that I like to draw attention to is is sort of training and education. I can train and I can educate until the cows come home, but that does not mean that that individual be competent and so it's not good enough, especially these days to only train individuals. We also want to assess for competency. That is real specific, right? That makes a massive difference when we look at improving overall safety and also other elements like leadership support. Um That is a massive, massive thing. That is a critical element right time back to the overall success of the program. And we talked about that earlier in today's program. Now I want you to imagine that you are working at an employer. Maybe it's your current employer, Maybe it's the previous one. Maybe it'll even be a future one, Right. And you've all worked with somebody that is probably not in the right position. Maybe that individual is highly qualified. Maybe they got the right credentials, but they're just not effective in that role. Now, if they're not effective in that role because they don't try, that's a little bit different. But imagine they were just placed in the wrong role for their skill set. Probably the most dramatic example I can give is let's take maybe an outpatient pediatric nurse and turn them into an adult ICU nurse, right? That's not gonna work. Um There may be some, you know, crossover and and skill set that's applicable, but it really is taking that person not only out of their element for the aged population that they're trained to treat, but it really is taking them from two different levels of acuity, Right? And so have everybody in the right seat on the bus. Um and that's going to make such a massive, massive difference in our preparedness, but also our overall response. Um as it relates to that. And this really gets us to sort of the point of cross training everybody, especially in an inpatient environment needs to have training in basic respiratory care management. We need to know some essentials of critical care. We need to know how to place some of these advanced vascular access devices like picks and central lines. And we've also got to be well trained in specimen collection. Um we've seen a ton of errors in the outpatient setting with poor specimen collection, especially for these rapid covid tests that might exist out there. And so it's important to have not only training but also regular monitoring to ensure that what we're actually expecting is actually taking place. Um that way we can ensure that everything is going to be uh functioning normally. So what if I can't order the things that I normally do? Right. This really goes back to sort of that supply chain optimization and we're gonna talk about that traffic light approach here in just a minute. But the way that I remember this in my head, I'm all about acronyms. It helps me remember things is the es si phenomenon efficacy, safety and compatibility? And you're gonna do it in that order? So think about it like a 123. The first question we have to ask is does this thing actually work, does it actually deliver upon the infection control? Promise that I was told does it kill covid, does it kill em are say does it kill influenza? for example, if the answer is yes, then we can move on to question number two, which is is it safe? Right. And this safety is is not just for the patient. It's also for us as the healthcare team as well as the environment surrounding them. Let me give you an example of that, let's say that you are somebody sells you a fogging machine and they say, hey, you can go fog the entire long term care ward with this and it will take care of Covid but they never tell you that you can't do that with the residents still in the area. Right. But they tell you that the mist is is nontoxic? Well, one might make the assumption that yes, it's efficacious. But is it safe? Right. What about if those patients are experiencing respiratory issues and now you're spraying some type of myth. Even if the myth is non toxic, it can still have impact to those respiratory sensitive residents in that particular setting. And so let's just assume that for purposes of this example that it is safe. Then we're going to move on to the final sort of step, which is number three compatibility, right. Is this going to actually be compatible with things like ultrasound probes or blood pressure cuffs or pulse ox emitters or some of the bladder scanner as an example. And so if it doesn't meet all three criteria, then it really is not the best solution that we should be using. We want to make sure that something is going to work effectively. The other aspect of this too is to work proactively with your supply chain vendors, right? You may work with the national or regional distributor or other manufacturers for specialized products, but you've got to have a plan in place that is really built around utilization. The CDC does offer a PPE calculator that allows you to put in your overall usage as well as your number of procedures and things like that and your staffing. And it does give you a fairly good accurate depiction of what your usage should be. Right. This is something that I would strongly strongly recommend that you share with your supply chain partners. Um It will give you a tremendous bang for your buck and good roo. I if you have a plan in place what sort of my primary products that I'm willing to use, what if those aren't available? What are the next things? Um and and I'll tell you one of the things that I've done that's worked very effectively is I don't really use disposable in 95. Um I frequently will use an Alaskan respirator for care of covid patients. Um It allows me controllable respiratory protection. I've been fit tested in it and then I'm not relying upon the ability for that facility to have the mass that I was tested in, right. This is a really great strategy, especially for providers that are moving amongst facilities, but also for frontline healthcare personnel to have sort of a hybrid where you've got both disposable and reusable supplies that can help you get through any type of crisis that you experience. Um Certainly that was a big thing for me as I knew I had respiratory protection during the pandemic because it was something that I actually bought and paid for myself. Um and so remember that the OSHA E. T. S standard does allow you to bring in your own pee pee um to healthcare facilities as long as it's fit tested. So we talked briefly about sort of these three modes of operation related to PPE that conventional which is your green light, your yellow light which is your contingency and red light which is crisis right now we again we may be focusing in on sort of conventional and contingency right now for most supply chain but I would encourage us to think about other applications of this like staffing, right? And I don't think any healthcare facility is saying yes, we're fully staffed, we're good to go. We don't need any more help. Right? I haven't seen that in years. Um and I would anticipate as many of you would as well that we will continue to see that drop off and it'll even get worse over the next few years. So sort of consider what's your mode of operation? How long can you stay in red? How long can you stay in yellow and then sort of how do you get yourself back to green? Yeah. As I mentioned before, this is just an example of one of the Alaskan respirators that's available out there um in the market. But this is something that is not just for health care workers but also has been used widely by first responders, right? And so it allows us to build sort of to this program of sustainable respiratory protection. Alright. If I know that every single clinician has something that they can use if we run out of our disposable products, then it makes it a lot easier to maintain clinical continuity of care. What we do not want to do is get to a point where we are unable to deliver care, right? That is something that just keeps me up at night. Um It's also something that leads us to sort of a different conversation which is visitation. Um I remember driving past a hospital where there was a long term care facility that I was doing a lot of work with. And every single day there was a gentleman out there outside of the window singing to his wife all day long, he was there rain shine, it didn't matter. Um and it really broke my heart right? Because the facility was not allowing visitation and I I kept thinking to myself, there's gotta be a way to do this and do this safely. Um And the reality is the cases that long term care residents got of covid they weren't coming from outsiders, they were coming from the staff. Right? So that only tells us that this quote unquote walk down a visitation was really not effective. Um you know, and it certainly had a major, major emotional, psychological and even physical, um you know, issues that were associated with the care of those residents because these people are isolated, right? They were really dependent upon sort of that interaction um with their family members and we don't want to serve the role um as well. Right, This is something that is particularly um important for us now, what about building sort of the capability for the future? Right. That's the sort of last area that I want to talk about before we get to question and answer well, this can never ever be done in a vacuum, right? It has to include all of the different players and your players, maybe even slightly different than what I have available here. Um I think that this is a very, very important conversation to have that. It does take a team based approach in order to disinfection. It also takes a team based approach to keep us safe. Right? And again, without healthcare workers, we can't deliver healthcare. Right? Healthcare is completely limited upon our ability to deliver that safe and reliable care. This is not just physicians. This is not just nurses, This is not just materials management, it's not just distribution, it really is every single person that is involved in this team now. Does that take some coordination? Absolutely it does. But does it really bring immense value when it's done in this coordinated fashion? You betcha right. It is a huge, huge thing that we have to make sure that we focus on and bring all of the respective parties to the table. We want to be more inclusive versus exclusive and over communicate, especially during times of difficulty. One of the other things to consider too is building a simulation lab. This is an area that I've got a tremendous amount of passion in because it gives us the opportunity to do small test of change in a controlled environment where there's no harm to the patients or to the staff for example. Um you know, this is one of the big things that originated with the first um sort of part of the pandemic, which what do you do if somebody is prone right? As far as positioning and they need CpR Well, many people have not been trained on how to do CPR on a prone patient or how do you intubate somebody that's prone like that? Um this is an example. And so some adaptations had to be done in simulation labs to figure out what were the real best practices associated with this, Right. What what are some ways that we can actually simulate the true care and delivery of care but to do so an environment that allows us to learn right, very similar to like mock codes or some of the other type of training, like a CLS that you might have been through. Right. But then you can analyze this together and figure out what are the right opportunities. This is also a great way to implement new products. Um if you're gonna do that where you can allow people to come in a sort of a hands on approach, maybe bring the vendor in um as well and then allow them to actually do some education and learning around this again in a controlled environment so that you don't have any issue with patient safety. There are some different things that we should be monitoring though, especially during times of difficulty like pandemics and outbreaks and that's really looking at product failures and any type of adverse events that would be unexpected. And remember that there's expected events. Um you know, and we'll talk about an example of that in a minute and then there's unexpected event. You know, if I give you any type of vaccine, I expect you to have a little bit of arm pain. I expect it to be a little bit red. I don't expect you to develop things like Bell's palsy or two certainly develop a blood clot, right? Those are not expected. Um outcomes. So this information is available in a wide variety of places. Probably most notably is the mall database which is uh taken care of by FDA. We've certainly got different clinical associations and recommendations from places like the CDC. The eCA reinstitute is an excellent, excellent resources if you cannot check that out. That looks at comparative information on health care product. Um and then lastly, is really looking at use your training validation, right? How do I make sure that I almost do a human factor study to determine whether or not a product is going to be appropriately used if it's not. Maybe the instructions for use are bad and they need to be revised just as an example. And then lastly, is what about us? How do we become a person of increase? How do we become a person who can actually move that needle forward? Right. Part of this is leadership. Part of this is development training but it really is, is deeply rooted within each of us, right? That intrinsic desire to be more to actually shed the wealth to share that knowledge and information, to bring some of those best practices to speak up and advocate for the patient. Um, and to frankly do what is right despite very difficult and adverse situations. This is the difference between good and great and so that person of increased focus can really help us move the needle as it relates to health care delivery And one of the other areas that I think is is particularly challenging for us right now is to really maintain honesty and transparency associated with care delivery and also what we know and what we don't know right part of this is going to be centered around um healthcare data, right. We want to make sure that healthcare data is transparent, that it's published, that it is, it is defendable. Um and then it's easily accessible and understood by a wide variety of audiences. And so I really operate in sort of three buckets, right things that we absolutely know, which is our evidence based practices, things like the importance of hand hygiene is an example. Then there's a bucket of things that we suspect we know, but we're not 100% sure right. And this normally comes in the form of things like CDC guidance documents or expert consensus or some type of key expert opinion that comes up from a clinical society. But then there's the bucket of things we don't know and and that's okay. That is our our sort of opportunity bucket for healthcare research to improve the quality of care delivery but not talking in terms of these is really a disservice to our teams to tell people, I don't know. But here's what I think we're going to do. What do you think right and to get some solicitation of ideas and input is really going to be some sort of a big win here and this leads us into trust, right? How do we build trust within our leadership? How do we build trust within our patients, the communities that we're serving, whether you're in the inpatient or outpatient environment, it doesn't matter. The healthcare team is a team that the patient wants to trust. And particularly those of you that are joining that are nurses. You know, there's a reason nurses are the most trusted profession year after year after year. And so that is really based on the leadership role that you take at the bedside um in delivering some of that care to your patients. But there's also fear, right? And I call that false evidence appearing real. Um and so always dig ask questions if something doesn't seem right, challenges um ask the questions and look for the source, the source book for the citation. Um you know, some things that even CBC has put out have not been sighted and when I've called and said, well, what's the what's the basis for this recommendation? Well, we're not sure yet. Right. And so and then other things are very, very heavily cited based on scientific data. And so we always want to know the differences between the two. It's not to say that one is is bad and the other is good. It really just needs to be transparent and how we do that because our patient's expectation remember is safe, reliable and efficacious care that's cost effective, Right? So they're not going in asking for an infection, they're not going in and asking for an adverse event. Right. And so that makes a massive, massive difference. And we want to think outside of the box, right? We have to think differently than we did two years ago, right? I don't really like the term in new normal, um, because I think it's really an an evolution of infection prevention and control that we're focusing on. But we want to make sure that we get back to a point of autopilot right where health care can continue to sustain itself. That were much more in, in more of a smooth flight versus, you know, turbulence all the time, all day long, which is what we've all experienced over the last two years. Right. And so this leads us into some lessons learned, right? We know that people need investment. We know that we need more leadership. We certainly want to continue to see clinical development and research and development with both drugs and therapeutics, but also surveillance technologies, the ability to detect disease quickly. And then it all needs to be wrapped up into a clinical strategy that focuses on prevention, Right? And this is going to give us our biggest bang for our buck and lastly, is are we ready for the next big one? And I would venture to say that as a health care community, we're not right. It's not to say that we can't get there. I'm certainly optimistic that with effort and and many of us that are willing to engage in this process, we can get there. Um but it certainly says that there's a long way to go and it has to be a continuous and ongoing effort to always be ready for that next pandemic. So as we summarize the program today, right. First of all, I appreciate the amazing work that each of you has done over the last two years, right? You know, we're at a very special time of year where we think and reflect and for me I'm very thankful for the relationships that I have. I'm very thankful for the many, many healthcare providers like each of you that have taken everything that you have and given it at work and giving it to your patients and your clinical care team and also your families, right? But we have an opportunity before us to really evolve and to to really adapt and prepare better for these types of pandemics. We have the opportunity to step up and challenge the way that we communicate and be more transparent and also ask our public health authorities to demonstrate significant leadership so that people will build trust and this requires us to be at the front lines very visible transparently and really bring all the leadership uh fruits that we have to bear. This will allow us to prepare right to engage and to ensure that we're ready for those next possible challenges that might be faced. And this has all got to be based on data and data will help us drive our continuous quality improvement associated with this. So I've included a few select references available for you in case you're interested. Um And again you can always check out the CDC website in case you do have any additional questions as that's updated on a daily basis. I've included my contact information in case in case you have questions after today's program and at this point I'll turn it back over to the moderator for our question and answer period. Thank you so much dr carrot. We do have uh just a couple of minutes for questions. If you do have a question please put that in uh the Q. And a box in the bottom left hand of your screen. If we're not able to get to all of your questions and we will certainly follow up, I do have one about masks patty asks should procedure masks in long term care be at least in A. S. T. M. Level one. So the answer to that is absolutely. Um you know I see it I think that's a really pertinent question because too often not just in long term care but frankly everywhere um with the exception it seems of dentistry I see so many healthcare providers that are using masks that are not even rated um if you're not familiar with the STM rating, I'd encourage you to go out and google that but it really is looking at four different levels of protection. Right? And so it's not just about even level one. But the first thing is it needs to be rated. The second is it should be rated for this specific type of intended procedure and the risk associated with that. For example, if I think I'm gonna have a lot of fluid exposure um then that's a whole different ballgame. And I also should be considering things like eye protection as well. So remember that respiratory protection is important. But if you're covering your respiratory system most likely, especially if there's going to be any body fluid exposure you want to make sure you're covering your eyes as well. So I think definitely having a rated mask is the starting place to go and then look at your your average usage. I mean I think the level one would be perfectly acceptable for the majority of long term care residents, you know care delivery. Um but so many places including gowns as well, they don't actually have rated products. And so check with your manufacturer, your distribution partner to ensure that what you're actually ordering is going to be appropriate for the care setting and in your intended care delivery. Excellent. Thank you so much. Well we have reached the full hour. So uh if you did not were not able to get your question uh submitted please do uh reach out to dr Garrett and you can certainly reach out to us as well. I want to thank you all for attending today's webinar. Please do visit our website, mm S dot McKesson dot com to view our upcoming webinars and register as well. Many thanks again to Dr Garrett for sharing his expertise with us today. And thank you again all for attending. We do hope you have a great day. Thank you Dr Garrett.