“the elephant in the room” dr. judy monroe indiana state health commissioner public health nurse...
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Public Health Nurses are Essential in
Indiana!
“The Elephant in the Room”
Dr. Judy MonroeIndiana State Health CommissionerPublic Health Nurse ConferenceMay 28-29, 2009
Lack of funding for Public Health Lack of knowledge and training on the part of the Public Health Workforce
Lack of key infrastructure in Public Health
Lack of understanding of the importance of Public Health
Simply NOT ENOUGH PEOPLE TO DO THE JOB!
The Elephant in the Room could be…
Did you know?◦ In the next five years 50 percent of public health
employees will be eligible to retire (Center for State and Local Government Excellence 2008)
◦ By the year 2020 more that 250,000 trained public health workers will be needed to avoid a workforce crisis (ASPH 2008)
◦ As the public health workforce retires, greater gaps in leadership and institutional knowledge will emerge in public health agencies (ASTHO 2008)
◦ More than 50 percent of states report that the lack of trained personnel is a major barrier to preparedness (ASPH 2008)
◦ Indiana has 46 public health workers per 100,000 population, while the national average is 138 per 100,000 (Center for Health Policy 2000)
The Future of the Public Health Workforce
Accreditation education efforts◦Public Health Accreditation Board (PHAB) Standards and Measures
◦Alpha and Beta testing◦Accreditation implementation in 2011
What is being done here in Indiana?
Calls to LHDs◦From the State Health Commissioner
Workforce Education and Training Plan◦A workgroup consisting of LHDs, ISDH,
and other partners◦Creation of an education and training
plan Quality Improvement Planning
◦Train-the-trainer
What is being done here in Indiana?
Remember the Beach Ball?
The Ten Essential Public Health Services
Are Public Health Nurses an important part of Essential Service #8—Assure a Competent Workforce?
Public Health Nurses are a key component in ensuring a competent workforce
Public Health Nurses LEAD Local Health Departments
Public Health Nurses have a broad knowledge base about health in Indiana
Public Health Nurses receive continuing education and advance their profession
Public Health Nurses have connections in their communities
DEFINITELY!
PHNs monitor health in their communities (ES 1)
PHNs help diagnose community health issues and investigate health issues (disease outbreaks, food borne illnesses, vaccine-preventable diseases, TB, etc.) (ES 2)
PHNs inform, educate, and empower their communities on health-related issues (ES 3)
PHNs mobilize community partnerships (PHSQIP, Collaboratives, etc.) (ES 4)
PHNs and the 10 Essential Public Health Services
PHNs help their Boards of Health and County Officials develop policies (ES 5)
PHNs help enforce public health laws (ES 6)
PHNs link people to services and provide care to people in their communities (ES 7)
PHNs help to ensure a competent workforce through their education and training (ES 8)
PHNs evaluate population health, programs, and other public-health related areas (ES 9)
PHNs use their knowledge of research for evidence-based practice (ES 10)
PHNs and the 10 Essential Public Health Services
What agencies/jurisdictions make up the public health
system in your community?
The Public Health System of the 21st Century
HMOsHome Health
Parks
Economic Developme
nt
Mass Transit
Employers
Nursing Homes
Mental Health
Drug Treatmen
t
Civic GroupsCHCs
Laboratory
Facilities
Hospitals
EMS Community Centers
Doctors
Health Departme
nt
Churches
Philanthropist
Elected Officials
Tribal Health
Schools
Police
Fire
Corrections
Environmental Health
How many nurses outside your health department do you work with in your community?◦0?◦1-5?◦6-10?◦More than 10???
PHN POLL
What community partnerships have you formed?◦With school nurses?◦With the hospitals in your area?◦With other community service agencies?
◦With other first responder agencies?◦Do you know your EMA Director?
PHN Poll
(Insert picture of elephant on beach ball)
Let’s Revisit the Elephant in the Room
An influenza pandemic?Where are we with H1N1?
What can Public Health Nurses do?
What is our current elephant?
Viral Reassortment
(2) Reassortment in swine Pandemic virus
Reassortment in humans
Pandemic virus
Reassortment/mutations in birds
Human virus
20
CDC Pandemic Severity Index
Severity Based on Case Fatality Rate
Early and prolonged closure← (4 & 5)
Short term closure← (3)
Perhaps no school closure ← (1 & 2)
…To inform, educate, and empower!
Seizing the Opportunity…
Most common mode of transmission of pathogens is via hands!
Infections acquired in healthcare Spread of antimicrobial resistance
So Why All the Fuss About Hand Hygiene?
Evidence of Relationship Between Hand Hygiene
and Healthcare-Associated Infections
Substantial evidence that hand hygiene reduces the incidence of infections
Historical study: Semmelweis More recent studies: rates lower when
antiseptic handwashing was performed
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Ignaz Semmelweis, 1815-1865
1840’s: General Hospital of Vienna
Divided into two clinics, alternating admissions every 24 hours:First Clinic: Doctors
and medical studentsSecond Clinic:
Midwives
0
2
4
6
8
10
12
14
16
Mat
erna
l mor
talit
y, 1
842
First Clinic SecondClinic
The Intervention:Hand scrub with chlorinated lime
solution
Hand hygiene basin at the Lying-In Women’s Hospital in Vienna, 1847.
Hand Hygiene: Not a New Concept
Maternal Mortality due to Postpartum Infection General Hospital, Vienna, Austria, 1841-1850
0
2
4
6
8
10
12
14
16
18
1841 1842 1843 1844 1845 1946 1847 1848 1849 1850
Ma
tern
al M
ort
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y (
%)
MDs Midwives
Semmelweis’ Hand Hygiene Intervention
~ Hand antisepsis reduces the frequency of patient infections ~
Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.
Hand Hygiene Adherence in Hospitals
1. Gould D, J Hosp Infect 1994;28:15-30. 2. Larson E, J Hosp Infect 1995;30:88-106. 3. Slaughter S, Ann Intern Med 1996;3:360-365. 4. Watanakunakorn C, Infect Control Hosp Epidemiol 1998;19:858-860. 5. Pittet D, Lancet 2000:356;1307-1312.
Year of Study Adherence Rate Hospital Area
1994 (1) 29% General and ICU
1995 (2) 41% General
1996 (3) 41% ICU
1998 (4) 30% General
2000 (5) 48% General
Self-Reported Factors for Poor Adherence with Hand Hygiene
Handwashing agents cause irritation and dryness
Sinks are inconveniently located/lack of sinks
Lack of soap and paper towels Too busy/insufficient time Understaffing/overcrowding Patient needs take priority Low risk of acquiring infection from patients
Adapted from Pittet D, Infect Control Hosp Epidemiol 2000;21:381-386.
Efficacy of Hand Hygiene Preparations in
Killing Bacteria
Good Better Best
Plain Soap Antimicrobial soap
Alcohol-based handrub
Ability of Hand Hygiene Agents to Reduce Bacteria on
Hands
Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.
0.0
1.0
2.0
3.0 0 60 180 minutes
0.0
90.0
99.0
99.9log%
Ba
cte
ria
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uc
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n
Alcohol-based handrub(70% Isopropanol)
Antimicrobial soap(4% Chlorhexidine)
Plain soap
Time After Disinfection
Baseline
0
1
2
3
4
5
6
Baseline 2 weeks
Alcohol rub Soap and water
1517
192123
2527
Baseline 2 weeks
Alcohol rub Soap and water
Epidermal water contentSelf-reported skin scoreDry
Healthy Dry
Healthy
Effect of Alcohol-Based Handrubs on Skin Condition
~ Alcohol-based handrub is less damaging to the skin ~
Boyce J, Infect Control Hosp Epidemiol 2000;21(7):438-441.
Recommended Hand Hygiene Technique
Handrubs◦ Apply to palm of one hand, rub hands together
covering all surfaces until dry
◦ Volume: based on manufacturer
Handwashing ◦ Wet hands with water, apply soap, rub hands
together for at least 15 seconds
◦ Rinse and dry with disposable towel
◦ Use towel to turn off faucet
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Time Spent Cleansing Hands:
one nurse per 8 hour shiftHand washing with soap and water: 56 minutes– Based on seven (60 second) handwashing episodes
per hour
Alcohol-based handrub: 18 minutes– Based on seven (20 second) handrub episodes per
hour
Voss A and Widmer AF, Infect Control Hosp Epidemiol 1997:18;205-208.
~ Alcohol-based handrubs reduce time needed for hand disinfection ~
More education on influenzaMore education on an influenza pandemic
Gearing up for the coming flu season this fall
Using H1N1 as a practice run…
What Needs to Be Done?
Hold meetings in their communities (Town Hall, business groups, school personnel, government, and many others)
Use the lessons learned so far from the H1N1 event to improve policies, procedures, practices in public health
Help their communities get ready for all public health emergencies using an “all hazards” approach
Public Health Nurses can…
Public Health Nurses are an Essential and a Powerful
Force in Indiana!