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Interventional patient hygiene (IPH): challenges and components of implementing VAP, UTI and SSI prevention programs


Interventional Patient Hygiene (IPH): APIC - June 12, 2006 Dr. Maryanne McGuckin & Robert Garcia * Interventional Patient Hygiene (IPH): APIC - June 12, 2006 Dr ... – PowerPoint PPT presentation

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Title: Interventional patient hygiene (IPH): challenges and components of implementing VAP, UTI and SSI prevention programs

(No Transcript)
  • At the end of this session, participants will
    be able to
  • Define Interventional Patient Hygiene (IPH)
  • List the components of an IPH Program
  • Develop a strategy for implementing IPH
  • Understand the importance of skin antisepsis in
    SSI prevention
  • VAP prevention progress update

What Is IPH?
Non-Clinical Providing patient care practices
that will reduce the choices of a
healthcare-acquired infection Clinical IPH is
a comprehensive evidenced based intervention and
measurement model for reducing the bioburden of
both the patient and healthcare worker.
IPH Practices/Prevention Outcomes
ICP Opportunity.?
Pressure Ulcers
A Convincing Strategy for IPH The Five Cs
The Five Cs
  • Caregiver Knowledge
  • Consumer Public Disclosure
  • Costs HAIs
  • Court Malpractice
  • Control IPH

Interventional Patient Hygiene Survey n453
  • ICP 30.9
  • CCRN 22.8
  • CCRN Mgr/Specialist 15.5
  • RN 42.2
  • 48.8 employed gt20 years
  • 67.7 Community Hospital
  • 28.3 University/Academic

Identify Components of IPH
  • Hand Hygiene 98.7
  • Oral Hygiene 94.8
  • Early Pre-op Skin Prep 69.9
  • (night before and morning of surgery)
  • Bathing/Skin Assessment 93.5
  • Incontinence Care 92.4

Healthcare-Acquired Infection Rates
VAP 67 Pressure Ulcer 43
Scientific Evidence/ IPH
  • Pressure Ulcer 72
  • SSI 66
  • VAP 86
  • UTI 75
  • LOS 74
  • MRSA/VRE 77

ICPs Questions
  • Education about IPH Components (within last 2
  • Hand Hygiene 98.6
  • Oral Hygiene 76.4
  • Early Pre-op Skin Prep 49.1 (night
  • Bathing/Skin Assessment 40.5
  • Incontinence Care 31.8

ICPs (cont)
  • ICP Involvement in Development IPH Protocol
  • YES 37.6
  • NO 63.3
  • Policy for IPH in your Institution
  • YES 39.3
  • NO 45.3
  • Dont Know 15.2

CCRN/RN Questions
  • Policy for IPH in Your Institution
  • YES 48.4
  • NO 34.7
  • Dont Know 16.8

CCRN/RN (cont)
  • Written Policy for Documentation Forms
  • Oral Care 77 81
  • Bathing/ Skin Assessment 68 86
  • Incontinence Care 54 60

IPH Discussed at Orientation/In-Service
Yes 42.2 No 40.4 Dont
Remember 17.3 Skipped Question 17
Ranking of Factors Relating to IPH
Very Important Somewhat Important Adequate/Appro
priate Supplies 94 4 Adequate Time
90 7 Standardization of Protocol
86 11 Documentation forms for
monitoring 73 25
How Do We Increase HCWs Knowledge of IPH ? How
Do We Develop and Implement a Strategy for
IPH? ?Ownership and Back to Basics
Pressure Ulcers
2. Consumer
  • 2005 - National Telephone Survey Will
    Consumers Use Public Disclosure Data When
    Choosing a Hospital?
  • 93 of respondents (9 in 10) said knowing a
    hospital infection rate would influence their
    selection of a hospital

McGuckin M. American Journal of Medical Quality
2006 - In press
Less than one-half of one percent
(No Transcript)
Does IPH Play a Role in State Reporting/Public
SSI VAP UTI Hospital
Infection data low too low? Underreporting
hurts patients
Philadelphia Inquirer - May 22, 2006
3. Costs
Ref Am J Infec Control 200533542-7
Does IPH Play a Role in Costs of HAIs
Traditional Health Cost Controls
Modern Cost Care Controls Spending
Time Traditional cost controls Modern
cost controls Negotiate prices and service
fees Stop doing things that dont work Offer
fewer benefits to employees Use cost-effective
products Shift some costs to patients Improve
Reference Am J Infec Control 200533542-7
4. Court
If Science or Evidence Based Medicine Does Not
Increase Hand Hygiene Compliance Then Woe to
you lawyers also! You lay impossible burdens on
men but will not lift a finger to lighten
them. Luke 11-46-47
Guinan J, McGuckin M, et al, A descriptive
review of malpractice claims for
healthcare-acquired infections in Philadelphia.
Am J Infect Control 200533310-2.
HAIS Cases (Most Frequent)
Can IPH Reduce Malpractice Claims
  • C. difficile
  • MRSA
  • Pre-op Prep

5. Control
  • Good Medical Care? Its a coin flip The
    Philadelphia Inquirer - March 16, 2006
  • U.S. patients receive proper medical care from
    doctors and nurses 55 of time N.E.J.M. - Vol
    354, No 11, 2006

Pressure Ulcers
Control Through IPH
UTI Rate- Removal of Prepackaged Bath Product QTR
3 FY05
Is There Evidence to Support This Trend?
  • High colony count found in bath water is similar
    to the number of bacteria found in urine from
    patients with UTIs. R. Shannon et al,
    Journal of HealthCare Safety, Compliance
    Infection Control, April 1999 Vol. 3, No. 4, pg.
  • Bath water could serve as a high magnitude
    microbial reservoir of potentially antibiotic
    resistant organisms. R. Shannon et al, Journal
    of HealthCare Safety, Compliance Infection
    Control, April 1999 Vol. 3, No. 4, pg. 180-184
  • Prepackaged bathing showed lower microbial counts
    than basins
  • M. Vernon, DrPH et al, Archives of Internal
    Medicine, February 2006
  • Disposable Bed Baths are a desirable form of
    bathing Critically Ill patients.
  • E. Larson, RN, PhD. et. al, AJCC, May 2004 Vol.
    13, No. 3

Clinical Process Improvement UTI Bundle Miller
Success Story
Urinary Tract Infection Bundle (cont)
Urinary Tract Infection Bundle (cont)
VAP Rate vs. VAP Care Bundle
Role of ICP in IPH
  • Partnership with nursing
  • Protocols/policies that include patient
  • Product evaluations
  • Prospective evaluations

Dont slide into bad habits, Remember
Hand Hygiene Oral Care Catheter Site
Care Skin care
Prevention of Surgical Site Infections
  • Robert Garcia, BS, MMT(ASCP), CIC
  • Infection Control Professional Consultant

Pressure Ulcers
SSIs Magnitude of the Problem
  • 1996 28.4 million ambulatory surgery procedures
    in the U.S. (CDC, National Center for Health
  • 2003 30.8 million inpatient surgical procedures
    and 9.7 million (37) of those performed on
    patients 65 yrs and older (CDC, National Center
    for Health Statistics)
  • NNIS SSIs occur in 2.61 of all surgeries
  • 1.5 million SSIs annually2
  • SSIs are the 3rd most common HAI1
  • Attributable cost 25,546 (range 1,783 -

1. Mangram AJ, et al., Guideline for prevention
of surgical site infection, 1999. Centers for
Disease Control and Prevention, Hospital
Infection Control Practices Advisory Committee,
Atlanta GA. 2. SSI total calculated by
multiplying SSI rate from ref. 3 by surgical
procedure numbers from ref. 1 and 2. 3. Stone
PW, et al., Am J Infect Control. Nov
Relative Costs of HAIs
Risk Factors for SSI The Patient
  • Age
  • Nutritional status
  • Diabetes
  • Nicotine use
  • Obesity
  • Coexistent infection
  • Colonization
  • Altered immune response
  • Long preoperative stay

How effectively can we control these risk factors?
Risk Factors for SSI Pre- and Intraoperative
  • Inappropriate use of antimicrobial prophylaxis
  • Infection at remote site not treated prior to
  • Shaving the site vs. clipping
  • Long duration of surgery
  • Improper skin preparation
  • Improper surgical team hand antisepsis
  • Environment of the room (ventilation,
  • Surgical attire and drapes
  • Asepsis
  • Surgical technique hemostasis, sterile field

To a great extent, this is what we can control!
Goal Zero
  • The All-or-None Measurement
  • An option for calculating performance
  • Denominator No. of pts. eligible to receive at
    least 1 or more discrete elements of care
  • Numerator No. of pts. who actually received
  • No partial credit is given
  • The Centers for Medicare Medicaid (CMS) has
    moved to the all-or-none approach

Nolan T, Berwick D. All-or-none measurement
raises the bar on performance. JAMA
Defining Appropriate Care in Surgery
Advantages of All-or-None Measurement
  • .all-or-none measurements more closely reflects
    the interests and likely desires of patients.
    This is especially true when process components
    interact with each other synergistically.violatio
    n of a single step in the sterile technique in
    surgery may vitiate the benefits of proper
    execution of all other steps1
  • The Take Away Message in SSI prevention, it
    makes little sense to assure that the surgeon has
    washed his hands properly if the patients skin
    has not had optimal prepping

1. Nolan T, Berwick D. JAMA 2005.
Why Should Hospitals Place Greater Emphasis on
How Skin is Prepped?
  • When we consider pathogenesis of SSI, it has been
    accepted for decades that most SSI are endogenous
    in nature
  • Surgical Infections1
  • Surgical Infections Including Burns2
  • Surgical Site Infections3
  • Surgical Antisepsis4

1. Dellinger EP, Ehrenkranz. In Hospital
Infections, Bennett Brachman, 1998 2. Kluymans
J. In Prevention and Control of Nosocomial
Infections, Wensel RP, 1997.3.Wong ES. In
Hospital Epidemiology and Infection Control,
Mayhall CG, 1999. 4.Crabtree TD, Pelletier SJ,
Pruett TL. In Disinfection, Sterilization, an
Preservation, Block SS, 2001.
Infection Rates by Wound Classes
Dellinger EP, Ehrenkranz NJ. Surgical Infections.
In Hospital Infections. Bennett JV Brachman
PS, eds., 1998
Sources of S. aureus Infection in Cardiac Surgery
  • Prospective study of 376 patients undergoing CABG
  • Pre-op nasal cultures, intra-op wound cultures of
  • Nasal cultures of all CV surgery/OR personnel
  • DNA subtyping of patients colonizing/infecting
    strains and personnel strains
  • 38 SSIs (10.1), 14 deep infections (3.3), 5
    mediastinitis (1.3)
  • Of gt30 wound infections, all except 1 from
    patient ( endogenously-derived infections)

Jakob et al. Eur J Cardiothorac Surg
200017154-60. Slide courtesy of D. Maki
CDC on Skin Preparation
  • Require patients to shower or bathe with an
    antiseptic agent on at least the night before the
    operative day. Cat IB
  • Thoroughly wash and clean at and around the
    incision site to remove gross contamination
    before performing antiseptic skin preparation.
    Cat IB
  • Use an appropriate antiseptic agent for skin
    preparation. Cat IB
  • Apply preoperative antiseptic skin preparation in
    concentric circles moving toward the periphery.
    The prepared area must be large enough to extend
    the incision or create new incisions or drain
    sites, if necessary. Cat II

Guideline for Prevention of Surgical Site
Infection, 1999. HICPAC, Centers for Disease
AORN on Skin Preparation
  • The surgical site and surrounding areas should be
  • The skin around the surgical site should be free
    of soil and debris. Removal of superficial soil,
    debris, and transient microbes before applying
    antiseptic agent(s) reduces the risk of wound
    contamination by decreasing the organic debris on
    the skin.
  • Cleansing should be accomplished by any of the
    following methods before surgical skin
  • Patient showering and/or shampooing before
    arrival in the practice setting
  • Washing the surgical site before arrival in the
    practice setting, or
  • Washing the surgical site immediately before
    applying the antiseptic agent in the practice

Standards, Recommended Practices, and Guidelines,
2005 Edition. AORN, Denver, CO.
AORN on Skin Preparation (contd)
  • When indicated, the surgical site and surrounding
    area should be prepared with an antiseptic agent
  • Antiseptic agents should be.used in accordance
    with the manufacturers written instructions.
    Antiseptic agent(s) should have a broad range of
    germicidal action.

Skin Prep Protocols Example I
Package directions Use sponge to prep desired
Skin Prep Protocols Example II
2 CHG Cloth Skin Prep Instructions
  • Use first cloth to prepare the skin area
    indicated for a moist or dry site, making certain
    to keep the second cloth where it will not be
    contaminated. Use second cloth to prepare larger
  • Dry surgical sites (such as abdomen or arm) use
    one cloth to cleanse each 161 cm2 area (approx 5
    x 5 inches) of skin to be prepared. Vigorously
    scrub skin back and forth for 3 minutes,
    completely wetting treatment area, then discard.
    Allow area to air dry for one (1) minute. Do not
  • Moist surgical sites (such as inguinal fold) use
    one cloth to cleanse each 65 cm2 area (2 x 5
    inches) of skin to be prepared. Vigorously rub
    skin back and forth for 3 minutes completely
    wetting treatment area, then discard. Allow to
    air dry for one (1) minute. Do not rinse.

Antiseptic Agent Characteristics
  • Significantly reduce microbial counts on intact
  • Contain a non-irritating, safe antimicrobial
    preparation that maintains the skins integrity
  • Be broad-spectrum
  • Be fast-acting and/or have residual effect
  • Clearly define time of application and time of
  • Be cost effective

Crowded and Confusing Market
Variance in protocols and practice
(No Transcript)
Chlorhexidine SSIs
  • Why are there no studies that link use of CHG and
    SSI prevention?
  • Lack of good study design
  • Inclusion of surgery types other than clean
  • Inadequate application of agent (bathing with
    agent followed by rinsing)
  • New study comparing three commercially available
    skin prep products (with CHG, iodine, triclosan)
    provides evidence that pre-op skin prepping with
    a CHG-impregnated cloth without rinsing or
    showering at 12 hrs. and 3 hrs. prior to OR skin
    prepping significantly lowers microbial

Maki DG, Paulson DS. abstract Evaluation of 6
preoperative cutaneous antiseptic regimens for
prevention of surgical site infection. SHEA
Conference, 2006.
What we commonly see in the medical record
  • The patients skin was prepped in the usual
    sterile manner

Pre-operative Shower/Bath Protocol
  • Protocol should consider the following aspects
  • An antiseptic should be selected based on certain
    characteristics as addressed by the FDA
  • How and when is the antiseptic dispensed to the
  • How often should the patient use the antiseptic
    product once or twice?
  • When are the best times to accomplish
    preoperative antiseptic shower/bath?

Nancy B. Bjerke. Preoperative skin preparation a
system approach. Infection Control
Today. http//
Pre-operative Shower/Bath Protocol
  • Is the whole body cleansed or just the incisional
  • What kind of educational materials are available
    or does the facility need to create their own?
  • Is the surgeons support necessary for this
    initiative, or does it involve only nursing?
  • Who verifies completion of this patient
    responsibility and where is this documented?

Nancy B. Bjerke. Preoperative skin preparation a
system approach. Infection Control
Today. http//
Surgical Skin Prep Protocol
  • Work Outward. Begin at the incision site and move
    out in concentric circles. Discard the sponge
    applicator when periphery is reached and do not
    return a sponge/applicator to the incision site
    once it has been applied to that area. Extend
    prep beyond the anticipated drape borders.
  • Prep problem areas last. Certain areas within the
    incision site with the potential to house excess
    bacteria need particular attention during the
    prepping process. The umbilicus typically has a
    high microbial count and needs to be cleaned with
    a Q-tip prior to prepping. Open wound, and
    perineal areas should be prepped last.
  • Be careful with drapes. When applying a drape, it
    is critical you follow the drapes individual
    product instructions. Certain preps need to
    remain in contact with the skin for a specified
    amount of time to be fully effective. Placing a
    drape before the solution dries could interfere
    with this time requirement, so check the
    products package label for special instructions.

Cynthia Spry. Outpatient Surgery Magazine.
Skin Prep Protocol
  • Avoid pooling. Applying excess amounts will cause
    the prep solution to pool under the patient.
    Pooled prep solution in contact with the skin can
    cause irritation or burn and can compromise the
    adhesive of a dispersive electrode. Be especially
    careful to prevent pooling under a tourniquet
    cuff. If a flammable agent, such as alcohol, is
    used, allow the solution to dry to reduce the
    possibility of fire. Use of an active electrode
    in the presence of a flammable agent could result
    in fire.
  • Document action. Performing a skin assessment,
    documenting the assessment, prepping and
    observing the condition of the skin after surgery
    are other key components of a successful
    infection control strategy. Look at the condition
    of the skin before the prep. Is there a rash? Do
    you notice a break in skin integrity? Written
    documentation of your assessment will create a
    baseline record and will let staff in the
    recovery unit determine if a later skin reaction
    was the result of the prep.

Spry C, Outpatient Surgery Magazine. May 2005.
Prevention of Ventilator-Associated Pneumonia
Pressure Ulcers
VAP Facts
  • Third most common HAI and most common among ICU
  • Second most costly HAI
  • Between 10 and 20 of patients receiving gt48
    hours of mechanical ventilation will develop VAP1
  • Critically ill patient who develop VAP appear to
    be twice as likely to die compared to those
    without VAP
  • Patients with VAP have significantly longer
    lengths of stay in the ICU (mean 6.10 days)2

1. Sole ML, et al., Am J Crit Care. March
200211(2)141-9 2. Rello J, et al., Chest. Dec
Current Recommendations
UI unresolved issue NA not addressed
IHI 100K Lives Campaign. Getting Started Kit VAP
How-to Guide CDC Guideline for Preventing
Healthcare-Associated Pneumonia, 2002.
Elevation of the Head of the Bed
  • Recent randomized controlled study that disputes
    study referenced by CDC to recommend use of
    semirecumbent positioning to prevent VAP
  • Study is unique in three aspects
  • Patient positioning was continuously monitored in
    first week
  • The semirecumbent position was compared to the
    standard of care
  • Data analyzed according to the intention-to-treat
  • Results
  • Patients in supine position (control) reached
    only 9.8 to 14.8 degrees (i.e., standard of care)
  • Mean backrest position in study group was 30
  • No difference in VAP rates between the groups
  • Pressure ulcers 30 in supine group, 28 in
    semirecumbent group

van Nieuwenhoven CA, et al. Feasibility and
effects of the semirecumbent position to prevent
ventilator-associated pneumonia A randomized
study. Crit Care med 200634396-402.
Stress Ulcer Prophylaxis
Flanders SA, Collard HP, Saint S. Nosocomial
pneumonia State of the Science. Am J Infect
Control 20063684-93
  • 7 meta-analyses, gt20 studies
  • 4 showed significant VAP reductions
  • 3 showed similar but non-significant VAP
  • Cook D, et al. A comparison of sucralfate and
    rantidine for the prevention of upper
    gastrointestinal bleeding in patients requiring
    mechanical ventilation. Canadian Critical Care
    Trials Group. N Eng J Med 1998338781-97.
  • Large randomized trial showed no benefit in
    either sucralfate or H2 antagonists
  • Kantorova I, et al. Stress ulcer prophylaxis in
    clinically ill patients a randomized controlled
    trial. Hepatogastroenterology, 2004200451757-61
  • randomized, placebo-controlled trial, 287 pts.
  • studied omeprazole (PPI), famotidine (H2
    antagonist), sucralfate
  • No significant differences in bleeding or
    pneumonia rates among the 4 groups

Subglottic Secretion Drainage
  • Meta-analysis of randomized trials
  • 5 trials met inclusion criteria (patients gt72
    hrs. of mechanical ventilation)
  • Results
  • shortened duration of ventilation by 2 days
  • shortened length of stay by 3 days
  • delayed onset of pneumonia by 6.8 days

Dezfulian C, et al. Subglottic secretion drainage
for preventing ventilator-associated pneumonia
a meta-analysis. Am J Med 200511811-18.
Pathogenesis Interventions
  • Strategies to prevent VAP are likely to be
    successful only if based upon a sound
    understanding of pathogenesis and epidemiology.
    The major route for acquiring endemic VAP is
    oropharyngeal colonization by endogenous flora or
    by pathogens acquired exogenously from the
    intensive care unit environment, especially the
    hands or apparel of health-care workers,
    contaminated equipment, hospital water, or air.
    The stomach represents a potential site of
    secondary colonization and reservoir of
    nosocomial gram-negative bacilli.

Safdar N, Crnich CJ, Maki DG. The pathogenesis of
ventilator-associated pneumonia its relevance to
developing effective strategies for prevention.
Respir Care 200550725-39.
Linking Oral and Dental Colonization with
Respiratory Infection
  • A review of the published evidence linking
    oropharyngeal colonization and respiratory
    infection, including VAP (20 studies)
  • Provides suggested oral and dental interventions,
    some beyond the scope of current guidelines

Garcia R. A review of the possible role of oral
and dental colonization on the occurrence of
health care-associated pneumonia
Underappreciated risk and a call for
interventions. Am J Infect Control 200533527-41.
Suggested Oral Dental Care Interventions
(No Transcript)
VAP Bundle Success Stories
  • Rochester Medical center, Rochester, NY
  • At least 220 days without a VAP case
  • http//
  • Overlake Hospital, Bellevue, WA
  • Reduced VAP by 80 in one year
  • http//
  • Consortium of 127 ICUs in 70 hospitals
  • 68/127 ICUs eliminated VAP for at least six
  • Along with CLAB bundle, estimates are that 1,500
    lives were saved, 81,000 hospital days, and 165
  • http//
  • Owenboro Medical Health System, Owensboro, KY
  • Reduced VAP by 72 in 18 months
  • http//

Swedish Medical Center Results of VAP Bundle
VAP Bundle Comprehensive Oral Care
  • Used HMO Acronym
  • Head of Bed keep at least 30 degrees or greater
    unless contraindicated
  • Mobility Each even hour, complete or assist the
    patient in performing mobility
  • Oral Care Perform oral care every even hour on
    intubated and trached patients. Suction brush at
    0800 and 2000. Suction catheters at extubation,
    position changes, and every 6 hours or as needed.

Simmons-Trau D. ZAP VAP with a back-to-basics
approach. Nurs 2006 Crit Care128-36.
Adding Comprehensive Oral Care to the IHI VAP
Bundle Achieving Zero
  • Baptist Memorial DeSoto
  • Baptist Memorial Hospital Golden Triangle
  • Bay Regional Medical Center
  • McLeod Regional Medical Center
  • OSF Saint Francis Medical Center
  • Overlake Hospital Medical Center
  • Palmetto Health Baptist
  • Upper Chesapeake Medical Center

48-month Study on Effect of Oral-Dental Care on
VAP Brookdale University Hospital Medical
Center, NY
  • Objective to determine the effect of a
    comprehensive oral care program on rates of VAP,
    mortality, cost
  • MICU patients on mechanical ventilation gt48 hrs.
  • Pre-intervention 1/1/01-12/31/02, standard
    oral care
  • Intervention 1/1/03-12/31/04, education and use
    of a novel oral-dental care system designed to
    reduce bacterial colonization of the
    oropharyngeal tract and teeth
  • Standards of care during the entire 48-month
    study included 7d vent circuit replacement,
    24-hour HME filter replacement, 24-hour closed
    suction catheter replacement, semirecumbent
    position unless contraindicated, administration
    of stress ulcer prophylaxis, and use of a weaning

Garcia R, Jendresky L, Colbert L, Bailey A.
48-month study on reducing VAP using advanced
oral-dental care protocol compliance, rates,
mortality, and cost. Abstract presented at the
2006 APIC Conference, Tampa, FL. publication
pending, Crit Care Med
Patient Demographics Baseline Measurements
Protocol Compliance
Outcome Data
VAP Rates, MICU, 2001-2005
Near Zero!
Cost of VAP
Warren DK, et al. Outcome and attributable cost
of ventilator-associated pneumonia among
intensive care unit patients in a suburban
medical center. Crit Care Med 2003311312-3. Rell
o J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm
L, Redman R, Kollef MH. Epidemiology and outcomes
of VAP in a large US database. Chest
20021222115-2121. Cocanour et al. Cost of
ventilator-associated pneumonia in a shock trauma
intensive care unit. Surg Inf, 2005665-72. Kolll
ef MN, et al. Epidemiology and outcomes of
health-care-associatedpneumonia Results from a
large US database of culture-positive pneumonia.
Chest 20051283854-62.
Cost Avoidance BUMC VAP Project
Total product cost 59,133
  • My thanks to the Brookdale family for their
    dedication and supreme efforts in improving the
    care of our patients

Questions Answers
  • Dr. Maryanne McGuckin ScEd., MT(ASCP) Senior
    Research Investigator Adjunct Associate
    Professor Senior Fellow, Leonard Davis Institute
    for Health Economics Senior Fellow, Institute on
    Aging University of Pennsylvania School of
  • Robert Garcia BS, MMT(ASCP), CIC
  • Asst. Director of Infection Control Brookdale
    Univ. Hospital Medical Center 718.240.5924
  • President
  • Enhanced Epidemiology, LLC P.O. Box 211 Valley
    Stream, NY 11580 516.810.3093