At some BILH facilities, we utilized additional staff even more during the pandemic, as “extenders” for infection prevention. For years at BIDMC, I partnered with Northeastern University’s co-op programs to embed nursing and health sciences students in teams with experienced, regular staff, which is a great learning experience for all of us and adds enormous value to our teams by freeing up infection preventionists for work requiring subject matter expertise. When the students later go out to the floors on clinical rotations or as patient care technicians, they have a good understanding of infection prevention principles and can function as our liaisons on the unit. We find our co-op students often stay on the team until graduation and can help with activities like surveillance, direct observation of infection practices on the units, staff education and participation in quality improvement projects.
Betsy Lehman Center: Can you suggest other strategies for working with a shortage of staff at a time of increased pressure on infection prevention departments? Do you attempt to improve those skills in staff working in other roles?
Dr. Wright: The Centers for Disease Control and Prevention’s national training collaborative called Project Firstline is helping to provide infection control training for staff, regardless of their previous training or educational background. A program from SHEA [Society for Health care Epidemiology of America] called Prevention CHKC provides training for frontline personnel to prevent and control health care-associated infections (HAIs).
In infection prevention and control, we are working both to simplify annual training programs, which tend to be long, and to get out on the floors more often to provide in-person education and training. Technology can help free-up infection preventionists’ time so they can do rounds, provide education and assess infection prevention practices. The pandemic has shown us how important these in-person interactions can be in helping staff to understand the reasons behind guidance and to provide opportunities to ask questions.
Some hospitals were using infection control liaisons on inpatient units prior to the pandemic to develop experts among frontline staff, in some cases with paid protected time. Such champions can work on other patient safety metrics as well, such as fall prevention. Infection prevention teams are small and cannot be everywhere in the institution at once. An investment in the development of “local experts” could expand and solidify infection prevention teams during a crisis or normal times by helping to design and disseminate education, performing device rounds to prevent HAIs and keeping day-to-day processes like hand hygiene observation going.
Health care would benefit from developing quick, infection prevention education for frontline staff. Across the U.S. during the pandemic, the lack of time to train staff had an impact on infection prevention. Health care personnel may not have time for long orientation days or online trainings and, in any event, long training sessions may not be very effective. Short videos, like those in Project Firstline and Prevention CHKC, may help fill these gaps going forward. The introduction of large numbers of travel nurses into hospitals may have compounded this problem. As there was a critical need at the bedside to assist with patient care, infection prevention practices specific to an institution, such as line insertion checklists and device rounds, may not have received enough time and attention, leading to missed opportunities to prevent HAIs.
As an alternative to travel nurses, facilities might consider training staff in blended roles to provide care where needed. This could also alleviate the problems of redeployment since the additional role would be part of their job description and been specifically selected by the employee at time of hire. Health care personnel in blended positions could work, for example, as nurses in outpatient clinics to administer monoclonal antibody treatments for COVID-19 or in highly infectious disease units. Outside of infectious emergencies, they could function as nurses on medical-surgical units or in emergency departments. While they might not be needed frequently, highly trained expert staff would be available for specialized roles when you need them most. Pre-COVID, most hospitals were already lean on staffing, which works most of the time but not when a crisis hits. These types of flexible positions could help us be better prepared for the next infectious emergency.
While we’re talking about staffing, I also want to say that antimicrobial stewardship teams are among the unsung heroes of the pandemic. We primarily think of them managing antibiotics to prevent resistant organisms and transmission, but these infectious disease pharmacists and physicians have been working tirelessly to develop guidance for the ever-changing menu of COVID-19 therapeutics and to manage shortages.
Betsy Lehman Center: The CDC has reported significant increases in health care-associated infections during the pandemic, including in Massachusetts. How do you interpret that, and could you share some thoughts on how best to refocus efforts on eliminating HAIs that cause harm to patients?
Dr. Wright: It's always been tricky for frontline staff to have enough bandwidth to focus on HAIs. Over the years, hospitals would work on reducing one HAI, like central line-associated bloodstream infections (CLABSIs), and when they reached that goal, their focus would turn to something else, like reduction of catheter-associated urinary tract infections. Sometimes when attention moved elsewhere, CLABSIs would start to increase again. When HAI prevention is not embedded in standard practice and workflows, it becomes extra work and it’s hard to keep the attention of busy health care personnel.
During the pandemic, increases in HAIs were also a consequence of the way that care was provided to COVID patients across the country. For example, proning of patients to improve clinical outcomes made it more difficult to monitor central-line exit sites and changed practices around site selection for line insertion. Similarly, attempts to reduce room entry to keep staff safe by putting windows in doors to patient rooms and use of extension tubing changed practices around device care and maintenance.
When we noted an increase in device-associated HAIs after the first surge, we had multidisciplinary discussions about how to prevent similar increases during anticipated future surges. Patients with COVID-19 would still need to be proned, for example, but perhaps processes and reminders could be put in place to maintain best infection prevention practices.
Betsy Lehman Center: As President of the Society for Healthcare Epidemiology of America, what would you say keeps you and your colleagues up most at night when it comes to patient safety?
Dr. Wright: Many of the things I’ve already mentioned have cost me sleep at different times during the pandemic. Things like PPE shortages and supply chain issues, HAIs occurring as unintended consequences of some of our interventions and certainly staffing issues, including burnout, are the top of the list. I and others in the field have been thinking a lot about how to build cross-coverage systems to give infection preventionists some rest and time to reflect on what they've been through and how we can best move forward.
Right now, some parts of health care are beginning to feel as if they’re getting back to something approaching normal, but infection prevention teams are still in the thick of it, having to do a lot of COVID-19 surveillance on top of their normal activities. This happened after Ebola and H1N1, too, but not at this scale. For many of us, the pandemic is not over yet.