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

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8

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12

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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

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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

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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!