“The Elephant in the Room” Dr. Judy Monroe Indiana State Health Commissioner Public Health Nurse Conference May 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!

 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)

 Accreditation education efforts ◦ Public Health Accreditation Board (PHAB) Standards and Measures ◦ Alpha and Beta testing ◦ Accreditation implementation in 2011

 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

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

 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 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)

What agencies/jurisdictions make up the public health system in your community?

The Public Health System of the 21st Century

 How many nurses outside your health department do you work with in your community? ◦ 0? ◦ 1-5? ◦ 6-10? ◦ More than 10???

 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?

(Insert picture of elephant on beach ball)

 An influenza pandemic?  Where are we with H1N1?  What can Public Health Nurses do?

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!

Most common mode of transmission of pathogens is via hands!  Infections acquired in healthcare  Spread of antimicrobial resistance

 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, ’s: General Hospital of Vienna 1840’s: General Hospital of Vienna Divided into two clinics, alternating admissions every 24 hours: Divided into two clinics, alternating admissions every 24 hours: First Clinic: Doctors and medical students First Clinic: Doctors and medical students Second Clinic: Midwives Second Clinic: Midwives

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 Semmelweis’ Hand Hygiene Intervention ~ Hand antisepsis reduces the frequency of patient infections ~ Adapted from: Hosp Epidemiol Infect Control, 2 nd Edition, 1999.

Hand Hygiene Adherence in Hospitals 1. Gould D, J Hosp Infect 1994;28: Larson E, J Hosp Infect 1995;30: Slaughter S, Ann Intern Med 1996;3: Watanakunakorn C, Infect Control Hosp Epidemiol 1998;19: Pittet D, Lancet 2000:356; Year of StudyAdherence RateHospital Area 1994 (1) 29%General and ICU 1995 (2) 41%General 1996 (3) 41%ICU 1998 (4) 30%General 2000 (5) 48%General

 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:

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, 2 nd Edition, minutes log% Bacterial Reduction Alcohol-based handrub (70% Isopropanol) Antimicrobial soap (4% Chlorhexidine) Plain soap Time After Disinfection Baseline

Epidermal water contentSelf-reported skin score Dry HealthyDry 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):

 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.

 Hand 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; ~ Alcohol-based handrubs reduce time needed for hand disinfection ~

 More education on influenza  More education on an influenza pandemic  Gearing up for the coming flu season this fall  Using H1N1 as a practice run…

 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 are an Essential and a Powerful Force in Indiana!