Infection Prevention Preparedness: Where We Go From Here

By Matt Phillion

As we, and the healthcare industry, continue to work our way toward a post-pandemic world, the lessons learned from COVID-19 remain stark and the calls to rebuild a resilient patient safety culture are loud and clear. Organizations such as the Society for Healthcare Epidemiology of America (SHEA), the CDC, and CMS are highlighting challenges, including staffing shortages and burnout, that must be addressed to better prepare for future prevention of healthcare-associated infections.

Now is the perfect time to address those challenges, as they are top of mind and the pain points resulting from them are fresh. SHEA, specifically, has been updating its education and expert guidance to incorporate lessons learned during COVID-19 for the next generation of infection prevention and antibiotic stewardship programs. They recommend an emphasis on more sustainable responses in post-pandemic healthcare.

“First and foremost, we need to reframe our thinking,” says Sharon B. Wright, MD, MPH, president of SHEA and chief infection prevention officer at Beth Israel Lahey Health. “Not necessarily post-pandemic, or post-COVID, but how do we make all care COVID-capable?” This is needed to provide safe care while protecting staff against whatever comes next, whether a new COVID-19 baseline or something else entirely.

“What was starkly pointed out when we looked at the data was how very much our practices for preventing harm to patients really depended on individual efforts and not resilient systems,” says Wright. “We need to build redundancy, resiliency, and ways to hardwire infection prevention strategies with frontline staff.”

The industry must be able to flex up and down as needs for infection prevention and control rise and recede, with expert teams who can step in. “Most of our infection prevention teams needed to add in non–infection prevention staff to help with routine tasks so we could use our experienced infection preventionists to keep some of our standard work going, as well as keep staff safe related to COVID,” says Wright.

An existing issue

Even before the pandemic, the field was dealing with an aging infection prevention workforce. “Infection preventionists were headed into retirement,” says Wright. “And there were not enough people coming into the field, so when they were, they were still fairly junior. Because of that loss of expertise, many of us, myself included, were already starting to build infection preventionist extenders into the field.”

This involved additional education for nursing students, including hands-on training, as well as looking for other infection prevention liaisons on units. Other tactics included building checklists and quality improvement projects into frontline staff’s daily work patterns so that prevention efforts didn’t fall exclusively onto the shoulders of the infection preventionist.

“Some systems were lucky enough to have funds to fill open positions and find new hires to fill out their teams, but in many cases, existing staff were being redeployed into infection prevention and employee health to provide additional support,” says Wright. “They flexed up in the moment.”

This worked when ORs were closed or other areas of the hospitals had fewer inpatients, but posed a problem in later surges—when hospitals did not cancel elective procedures or admissions and began overflowing. “We were bursting at the seams,” says Wright. “We saw a collapse of the system in places where you don’t have an infection preventionist rounding and checking on every patient with a central line or Foley catheter.”

On the whole, infection prevention during COVID-19 was more difficult because of the clinical situation and because of changes in practice designed to keep staff safe. For example, patients were placed on their stomachs to improve ventilation, which made it harder to check existing lines, and extension tubing was used for intravenous lines to reduce the number of times staff needed to enter patient rooms.

“They may not be familiar with the infection prevention strategies of a particular institution—and if your protocols can’t be learned in the middle of a crisis, there are risks for healthcare-associated infections,” says Wright.

Building it into the processes

While the industry had considered the potential for a pandemic, its focus had, understandably, been on short-lived outbreaks like H1N1 or Ebola. “We focused on care for patients with highly infectious diseases, but it wasn’t built into all of our processes—and we never imagined anything like this,” says Wright.

Even with preparedness efforts in place, certain factors complicated every aspect of pandemic response. Nursing shortages and turnover of trainees in academic centers made it hard to dedicate resources to quality projects like infection prevention. Facilities just trying to keep themselves operational—already a challenge pre-pandemic thanks to staffing shortages— found it difficult to ensure everyone was practicing at the top of their license, which is key to prevent burnout and turnover.

Going forward, there is opportunity to utilize technology and automated systems to provide reminders for common issues, such as whether the patient still needs an indwelling urinary catheter. This opens up staff time for tasks that require a trained human eye on the patient.

Beyond hospitals

The pandemic has shown the need for all staff to be further educated and trained on infection prevention. It revealed a dearth of preparedness in organizations like nursing homes, assisted living facilities, and behavioral health. “COVID showed us how much infection prevention impacts patients everywhere,” says Wright.

The CDC has been crafting video training on infection prevention for frontline staff, and SHEA has updated its compendium with strategies for preventing six of the most common healthcare-associated infections and better guidance on hand hygiene, which will be distributed over the course of 2022. SHEA is also emphasizing infection prevention across the continuum of care, leveraging the compendium for best practices across all systems and settings.

“When you don’t have universal healthcare and every organization has its own budget, there will be differences,” says Wright. Some organizations will have state-of-the-art preventive technology, and others will work within their own means. “But we can outline best practices to help staff better understand what products and processes they may come into contact with.”

Antimicrobial stewardship
Staff working in antimicrobial stewardship are some of the “unsung heroes of the pandemic,” Wright says. “Infection preventionists are getting attention because it’s an outbreak and their work is front and center, but antimicrobial stewardship has been helping design protocols for diagnostic testing and therapeutics for COVID. They’re flying under the radar, but they’re part of healthcare epidemiology, and we need to be sure to adequately resource these groups as well.”

Infectious disease pharmacists and physicians who are working to prevent spread of resistant organisms through appropriate use of antibiotics are also pulled into COVID-19 work and, like their infection prevention colleagues, they don’t have sufficient staff.

By prioritizing infection prevention, “we can do things to prepare in advance for what might lie before us,” marshaling appropriate resources and staff before the next event occurs, says Wright. “We need to look at infection prevention and antimicrobial stewardship in the same way. We need to invest in them and provide the resources and tools they need to succeed.”

Where we go from here

“One of the overarching things I’ve noticed is that when things are going well, you never hear about infection prevention,” says Wright. “That means we don’t garner resources, and there’s not a lot of attention paid to staff and an always-prepared mentality.”

When there’s a crisis, all eyes are on infection prevention, she says. And that presents an opportunity for long-term improvement. Thinking in terms of PPE, much discussion is happening around concepts like reusable respirators to help with an always-ready mentality. “Becoming less open to the fluctuations of the supply chain is going to be a long-term focus post-pandemic,” says Wright.

The question remains: How do we ensure supply chain issues and shortages do not happen again? How do we build better systems and resiliency?

“Other issues have traditionally garnered more attention than infection prevention, and we’re seeing that,” says Wright. “But I do think there’s been a shift in how people think about infection transmission. I’m not sure the public will look at flu season the same way again.”

If the industry can leverage healthcare systems and academic centers, partnering more closely with community hospitals and non-hospital-based providers, operators could share their process and best practices to improve care in all settings. “It’s about asking how we take the 100,000-foot view instead of the 10,000-foot view,” says Wright. “Who’s looking strategically to put systems in place to avoid a crisis?”

This pandemic has presented innumerable learnings and opportunities for process improvement to ensure we’re better prepared for the next crisis. “One of my mentors always told me, ‘Make lemonade out of the lemons of an outbreak. Don’t let an outbreak go by without learnings,’ ” says Wright. “They can help us prepare for the future and improve how we deliver care.”

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.