By Kelly M. Pyrek
This article originally appeared in the June 2022 issue of Healthcare Hygiene magazine.
As the Association for Professionals in Infection Control and Epidemiology (APIC) celebrates a half century of protecting patients and healthcare personnel through the efforts of infection prevention and control (IP&C) and risk management, we examine the journey of the field and the profession as it evolves and impacts the entirety of the healthcare landscape.
In 1970, the Centers for Disease Control and Prevention (CDC) established the National Nosocomial Infections Surveillance (NNIS) System, now known as the National Healthcare Safety Network (NHSN), which is used to report and track healthcare-acquired infections (HAIs). It created the bedrock upon which modern public health efforts were built. With epidemiological structures beginning to take shape, nurse epidemiologists and infection control nurses began to outline the beginnings of what would eventually become the infection preventionist (IP) profession in the early 1970s. APIC was founded in 1972 by a small group, led by pioneers such as Carol DeMille, Pat Lynch, Kay Wenzel, and other visionaries.
“The thing I'm most proud of is the persistence and the determination of not only the individuals who are members of APIC, but anyone in the profession of infection prevention and control,” says current APIC president Linda Dickey, RN, MPH, CIC, FAPIC, interim senior director for quality, patient safety and infection prevention at UCI Health in Orange County, Calif., who adds, “Especially in talking with the earlier founders of APIC and then also having some perspective of putting them in practice for almost 30 years. It's taken a lot to continue to push forward with reducing infection risks. I marveled when I learned more about the beginnings of APIC and how there was no infrastructure, there were no data definitions, there were no avenues for sharing information -- there was nothing excerpt the desire to make this a better planet by reducing the risk of infection. People who cared about doing that figured out how to stay in touch with each other, how to build a profession. I think our persistence has been key, but it hasn't been without big challenges because there are so many competing interests in healthcare. That has made it an uphill climb to move forward on reducing infection.”
Dickey points to the fact that APIC didn’t start as an IP-exclusive organization. “One thing that was surprising to me when we were talking with some of the original founders and also looking at the original first newsletter for APIC, was that it wasn’t intended to solely be an association for professionals in infection control; it wasn't specifically for what we now call infection prevention, in that it was more physicians, nurses and housekeepers, and anybody who was a professional and saw it within their scope of practice to reduce the risk of infection. I love that, because we have seen the emergence of a profession that is specifically aimed solely at preventing infections but the whole idea of also having a professional association where you could collaborate with other people who have that as part of what's in their sphere of influence is lovely.”
A former APIC president, Connie Steed, MSN, RN, CIC, FAPIC, is a veteran IP recently retired from a large healthcare enterprise who has worked in the field since 1978 and recalls the evolution of the profession. “Back in those golden days we were called infection control nurses; now the focus is on prevention and with that has come process change as we address infections caused by emerging antibiotic-resistant organisms.”
She credits APIC with giving her career a sense of direction. “As an IP, I don't know how I would have been able to proceed through my career without APIC. In the early years, not everybody knew about it, and it took me almost a year to find out about them from the CDC. I became a member and my professional growth and development escalated because I had a network, and I had a structure for education. APIC expanded and became successful in supporting the profession of infection prevention and control. Although it was a slow journey at first, we eventually got there.”
“All through our 50-year history, here have been many watershed moments and milestones,” says a former APIC president Ann Marie Pettis, RN, BSN, CIC, FAPIC, of the University of Rochester Medicine in New York. “Like HIV, when we first started seeing young men dying of an infectious disease and we had no idea what was causing it. I had just started working in infection prevention right before that, and AIDS changed everything. It truly was a watershed moment, almost like remembering where you were when (John F.) Kennedy was assassinated, for Instance. Everybody remembers where they were and what they were doing when they heard about it. So, I think the field of infection prevention has had moments like that. Many more outbreaks have followed since then, and they have all led up to the COVID-19 pandemic.”
As APIC was forming in the 1970s, and four years after the launch of what became the NHSN, a watershed report was released, essentially paving the way for the emergence of the field of infection prevention and control. The results of the Study of the Efficacy of Nosocomial Infection Control (SENIC) demonstrated that strategies such as surveillance and feedback led to significant decreases in HAIs. Essentially, the SENIC study sought to determine whether (and to what degree the implementation of infection surveillance and control programs (ISCPs) lowered the rate of HAIs (called nosocomial infections then); as well as to describe the status of ISCPs and infection rates; and demonstrate the relationships among characteristics of hospitals and patients, components of ISCPs, and changes in the infection rate.
The SENIC project found that hospitals reduced their nosocomial infection rates by approximately one-third if their infection surveillance and control program included four components: appropriate emphases on surveillance activities and vigorous control efforts’ at least one full‐time infection‐control practitioner per 250 beds; a trained hospital epidemiologist, and, for surgical wound infections, feedback of wound infection rates to practicing surgeons.
More milestones followed in rapid succession. Structure and accountability were needed, and in 1976, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) – shortened to The Joint Commission now – enacted the very first infection control standards. Two years later, APIC released its first position paper, titled the “Statement on Infection Control Programs.” In 1981, the APIC Certification Association (APICCA) was established, to eventually become the Certification Board of Infection Control and Epidemiology, Inc (CBIC), and in 1983, it administered its first certification exam. In 1986, then-President Ronald Reagan established National Infection Control Week, which eventually became International Infection Prevention Week (IIPW), celebrated annually in October. That same year, infection control was upgraded by the Health Care Financing Administration (now known as the Centers for Medicare & Medicaid Services) from a standard under sanitary environment to a separate condition of participation.
More progress came in the 1990s. In 1994, the Association for Practitioners in Infection Control became known as its current moniker, setting the stage for an evolution of terminology in the field and the profession. For example, as we know, the emphasis was changed from mere infection control to infection prevention over the years, and the more obscure nosocomial term was changed to hospital -acquired and eventually morphed into the preferred healthcare‐associated infection and paired with the profession of healthcare epidemiology. Even staffing terminology evolved, moving from the original titles of infection control nurse and infection control officer to infection control professional/practitioner, to eventually the modern term of infection preventionist, adopted in 2008.
“They used to call us infection control officers, but in many places, such as the New York State Department of Health, this is still our title,” Pettis confirms. “The word ‘officer’ scared some people; when you showed up, they all scrambled. Nobody wanted to see you coming, and honestly, HIV changed that because then they were knocking my door down because they were scared, and they wanted to understand the disease better.”
Steed concurs. “When we transitioned from infection control to infection prevention, it was a big deal,” she says. “It was an important transition for us to make because what we've learned is that when you have a significant challenge like infections, it’s much better to try to prevent it instead of merely controlling it. And then we acknowledged that more HAIs were preventable, a concept introduced by the Institute for Healthcare Improvement (IHI). When IPs embraced that I feel like there was a huge culture change, adopting a vision and mission of healthcare without infection. We've expanded this now where our mission is a safer world through infection prevention; we’ve transitioned from just safe healthcare to a safer world, and this is appropriate, given the pandemic we have just experienced. We felt very strongly that the vision needed to change to be more encompassing because infection prevention is just not for healthcare, it’s for the community, for schools, for airlines, for so much more. Another thing that has changed over the years is that we are now being called upon across the continuum of care beyond hospitals, including long-term care facilities, physician practices, home healthcare, etc. That's a trajectory that has really impacted infection prevention and control, and we're very much in demand.”
While the terminology has evolved to fit the times and the institutional political mood, at its core, the practice of infection prevention and control encompasses a set of tenets, including leadership support; education and training of healthcare personnel on infection prevention principles; patient, family and caregiver education; performance monitoring and feedback; adherence to standard precautions and transmission‐based precautions; and occupational health. These core infection prevention and control practices should be implemented in all healthcare settings across the continuum of care.
Having a robust IP&C program is more important than ever before, and as Garcia, et al. (2022) observe, “Fifty years of evolution in infection prevention and control programs have involved significant accomplishments related to clinical practices, methodologies, and technology. However, regulatory mandates, and resource and research limitations, coupled with emerging infection threats such as the COVID-19 pandemic, present considerable challenges for infection preventionists.”
As Garcia, et al. (2022) note further, “Infection prevention programs in healthcare facilities nationwide have enhanced the culture of safety through modifications in each organization's systems of care by assessing efficacy, and revising, standardizing, and monitoring clinical and ancillary practices. Coordinated efforts at reducing HAIs have been determined to be effective to varying degrees when IP&C programs are provided with adequate resources and supported by the implementation of evidence-based strategies. Multi-faceted HAI prevention programs have been proven to be cost-effective, a finding of vital importance in the present landscape of healthcare reimbursement and therefore in the overall financial health of the institution. IP&C efforts have been facilitated by application of such fundamental tools as core components, competency models, and implementation science which assist infection preventionists (IPs) to bridge gaps between organizational barriers to change and successful outcomes.”
A comprehensive infection control program consists of numerous components including evidence‐based written policies and procedures, training and education, healthcare personnel safety; and surveillance and disease reporting; as well as conducting infection control program assessments to identify program strengths and weaknesses and which can be utilized for staff education and improved patient outcomes. It’s a tall order, and one that evolves in the face of outbreaks, pandemics, and other crises.
In their AJIC pre-proof paper, Garcia, et al. (2022) documents the current state of infection prevention and control, and outlines guidance and recommendations in 14 key areas that establish a roadmap for future implementation of these interventions. Robert Garcia, BS, MT(ASCP), infection preventionist at Stony Brook University Medical Center in New York, says he collaborated with experienced IPs, epidemiologists, and other content experts to address the most significant issues currently affecting IP programs, with an emphasis on “implementation of innovative, cost-effective, and evidence-based interventions, engaging healthcare leaders and experts in clinical care in proven prevention measures, holding staff accountable, and adopting high reliability principles.”
Among the key challenges and recommendations for change cited in their paper, Garcia, et al. (2022) emphasize the importance of IP&C program standardization. They point to the 2015 APIC Mega Report which provides a look at the average percent of time spent on key areas but does not address the variability from one hospital to another. “Although reporting structure is key to the success of an IP program, there is currently wide variation regarding hierarchical reporting with some programs reporting to quality departments, some to nursing, some to patient safety, and a few directly to the C -suite or executive level,” the authors write. “…Infection prevention department staffing is also lacking standardization. A recent peer-reviewed study concludes that the actual IP staffing level in U.S. hospitals is anywhere between 31 percent to 66 percent above the current outdated benchmark of 0.5-1.0 IP per 100 occupied beds. Research is needed to define the ideal for each of these essential program components, which would together provide a reliable design for a best practice IP&C program.”
Regarding IP&C program standardization Garcia and colleagues (2022) make key recommendations for change:
• Based on outcomes based scientific research (e.g., HAI rates, process compliance, patient satisfaction), establish a standard template for IP programs to support the replication of best practices, avoid errors, and optimize processes
• Conduct research focusing on determining IPs time allocation, considering variability between healthcare facilities
• Conduct research into IP&C program reporting structure
• Establish a certification process for physicians in IP programs
• Conduct research to determine ideal IP staffing levels based on essential program components
“One of the top priorities for APIC is conducting and publishing research on what a strong, effective infection prevention program looks like,” Dickey says. “What should the resourcing look like? What is the best staffing ratio in different settings, as we have different needs? We need to examine the structure of our programs because It's not the same everywhere. In some settings you're going to need varying levels of IT support, clerical support, surveillance, etc. There is a variety of needs to have a successful program and so we want to have that information published so that when we reach out to healthcare leadership, we have benchmarking across organizations. APIC is going to be looking at that, and I think those efforts will help those who are in leadership positions further advocate for infection prevention.
When you're working without good, solid information, you can advocate more effectively.”
As APIC reaches its 50th anniversary this year, the nation is emerging from the grips of a global pandemic, and as the new normal is crafted, infection preventionists are grappling with the path forward, both personally and professionally, as well as on a national and institutional level.
“We are always going to have to advocate for infection prevention within whatever setting we're practicing because there are always competing interests,” Dickey says.
“Having said that, I think that even before COVID, but certainly COVID has helped elevate the profile of the need for strong infection prevention resources. It's taken us 50 years to get where we are in acute care, and you know long-term care is nowhere close, and we saw the unfortunate effects of that during the pandemic. People now realize there is a whole level of structure needed and which is currently missing to support long-term care safety, and it's not just for the residents, but also for the workers.”
“It's a double-edged sword because I think that although we had tremendous successes, and address incredibly diverse issues, what we don't know is the consequences of the pandemic and the impact on our IP&C departments,” says Garcia. “The pandemic has had a tremendous impact on healthcare institutions, and it is yet to be seen how that could limit program expansion, curtail resources, limit staffing or other significant impacts.”
Garcia continues, “Another concern is that so many healthcare workers have left the profession and we are just now coming to terms with whether they will be replaced. So many veteran healthcare personnel have left and taken with them their knowledge of infection prevention. So, dealing with new workers is difficult because of the need to teach them the right way to do things, which can take some time. So, what that impact is going to be remains to be seen.”
What is certain is the exodus among healthcare professionals has exacerbated the stress levels and workloads of those left behind and tasked with carrying on.
“We need to keep encouraging one another because it is a field that does require a lot of ‘Stick-to-it-iveness,’ and I don't think that we can underestimate the value of helping one another, encouraging one another,” Dickey says. “It’s important that we remind IPs of what they've accomplished, because so much of the time they are head down and haven’t been able to see how far they've come. Sometimes it can feel like a slow slog, so we need to constantly remind people of their value and that they make a difference.”
Dickey continues, “We also need to see more recognition of the profession. There's going to be a significant push on APIC’s part to put forward an Academic Pathway. Our is a profession that many people have stumbled into in the past, coming from many different avenues of training and a variety of degree programs.”
APIC has announced it is creating an infection prevention and control curriculum for colleges and universities. APIC’s IP Academic Pathway marks the first national effort to link undergraduate and graduate programs to the field of infection prevention and control, which is hoped to lead to certification in infection prevention and control.
“The pandemic has brought to light the tremendous need for trained infection preventionists in our nation’s healthcare facilities,” says Devin Jopp, EdD, MS, CEO of APIC. “While APIC has a robust competency model and other resources to support professionals already practicing in the field, a clear pathway into infection prevention and control careers does not currently exist for college and university students. Through IP Academic Pathway, APIC plans to create an intentional track for infection prevention certification and degree programs. This will help not only the healthcare field, but also industries like entertainment, hospitality, and travel, which are increasingly hiring infection preventionists.”
An APIC task force will develop the IP Academic Pathway core concepts, which will detail competencies needed to work successfully in infection prevention and control as outlined by the Certification Board of Infection Control and Epidemiology (CBIC). Once developed, the curriculum can be integrated into a higher education institution’s course of study through their undergraduate, graduate, and continuing education programs.
“We must also focus on professional development of the next generation of the infection prevention and control workforce,” says Steed. “APIC is doing a tremendous amount of work around promoting an academic pathway to the field. Wouldn't it be something if we could have a bachelor’s in science in infection prevention and control and epidemiology? We already have master’s programs out there, but for undergraduates, what could that degree look like? How can we do that? And then the other question is, do they need to be nurses? This is brainstorming, but can we think about having an infection control assistant? That might help expand the workforce and we would not have to worry about the cost of a nurse or certified infection preventionist. I think that that's important work to explore for the future. What does the future look like? That's a critical thing that APIC is examining. The future requires that IPs be creative, thinking through how they can support their programs so that they're not doing it alone.”
Resourcing and has been a perennial problem along with grooming and growing new talent, and with the pandemic bringing some hospitals to the brink of financial failure, IP&C programs have mirrored that of public health fiscal challenges.
“Despite the pandemic, nobody wants to fund public health, and this has been true historically as well,” Pettis says. “Another area that we've not put the resources toward is taking care of our elderly. We know this, and yet until the pandemic placed attention on these deficits, it was very challenging to draw attention to these chronic needs. Now, we've got the world’s attention, and we've got to deliver. Obviously, we don't have enough IPs. We do have a new vision and mission post-pandemic and our vision is an audacious one. But it's one that the pandemic moved us into and that's creating a safer world through infection prevention. But to achieve this, we need much more influence, more impact and we need to continue to contribute. We need more boots on the ground and so that ties into APIC’s IP academic pathway that we have been working on so diligently over the last year and a half. I would say we've made some progress, but it's a huge task to ensure that people don't just stumble into infection prevention like I did and like most of my colleagues did. We didn't go to nursing schools saying we wanted to become infection preventionists, but rather we stumbled across it, and so we must change that. It is unfortunate that the pandemic hastened those who were ready to retire, and perhaps it also put off people who may have wanted to join the profession. And maybe it has befuddled everybody who's in the middle, and so holding onto those people is critical. I'll give you an example at our institution of what gives me hope that there is such a bright future for infection prevention. One of our veteran IPs, Linda Green, retired, deciding that after the pandemic, it was time. We hired this brand-new graduate with a master’s degree in public health. She thought that because of the pandemic, she wanted to be an infection preventionist, so she shadowed us in infection prevention for a while, and she is so excited that we must pinch ourselves that we found someone who, instead of being scared off by the pandemic, was actually drawn to it. In general, nursing is taking an unbelievable hit from early retirees, and that has also impacted our profession. The good news is that we were sort of hidden under a rock, if you will, but no longer; people now know who we are, what we do, what we can offer, and they're excited by that, so there's real hope for the future. There's power in numbers, and the more that we can all sing from the same songbook, I think the more benefit there will be, and the more impact we can all have."
“We want to see something that is more clearly defined and communicates that being an infection preventionist is a dynamic career option,” Dickey adds. “There is also additional work around defining a job code with the Department of Labor so that they know we exist. We will continue to see that whether people enter our profession through laboratory services or public health sciences or nursing services, there is an academic or clinical pathway that is built on the core competencies of what an infection preventionist is and what that individual needs to know to be successful. We need to look at the skill sets, as not all of them are epidemiology and statistics; what really makes people successful are the soft skills of collaboration and persuasion, being articulate and other skills that can help them build partnerships and teams. That’s because we're successful through lateral behavior change and influence rather than anything that's hierarchal.”
Because IPs spend so much of their day observing, coaching, and training others, it can be easy to lose themselves in the process. Dickey says that IPs must try to avoid burnout by reminding themselves it’s acceptable to acknowledge the need to take care of themselves along with their colleagues and patients.
“It’s critical for IPs to realize the importance of self-care,” she adds. “You must remember to put on your oxygen mask first before assisting others. We must take care of ourselves, figuring out how to take a breather, finding what rejuvenates us.”
“The future is very bright, but we still have our work cut out for us to describe who we are and how to get there,” Dickey continues. “The pandemic introduced the infection preventionist and the field to a degree. There are now some healthcare sectors that are now reaching out because they realize the value proposition that we represent in keeping environments healthy and keeping people free of infection. Other sectors have seen our value as well, so the job market Is going to be increasingly diverse going forward.”
In 50-plus years of practice, infection preventionists have witnessed numerous outbreaks, but none may have focused the limelight on infection prevention and public health as the SARS-CoV-2 outbreak and eventual pandemic did. More than ever before in the history of the field and the profession, the attention focused on eradication and control of infections and emerging and existing infectious public health threats must be leveraged for the benefit of the field and its practitioners.
Pettis says many have heard their true calling by entering the profession, and that vocation has been confirmed by the pandemic. “I have a very close friend from high school who has always been fascinated by what I do, because she's a germaphobe. When the pandemic struck, she said, this is what you were born for, this is what you have been preparing for your entire career. I think that is true for all of us in infection prevention. I feel badly for the people who got into the field right before or during the pandemic because they didn't have time to prepare it, but the rest of us had sort of been preparing for this. We have all thought it’s not a matter of if, but it's a matter of when. However, when the pandemic came, it was still had at the very beginning to guess how it would unfold. We know for sure this won't be the last; hopefully there won’t be another pandemic like this one for another 100 years, but that's probably unrealistic.”
Steed acknowledges the great turnover among healthcare professionals, and how it can impact preparedness for the next outbreak or pandemic.
“Part of that exodus may be due to distress associated with COVID because it was such a significant event,” she says. “I was APIC president that first year of the pandemic and I didn't sleep much because I was incident commander in one of our markets. It was clear the entire healthcare community was undergoing a great deal of stress. Our resilience was severely tested, so we developed a wellness program designed to effectively support healthcare providers on the COVID frontline. Everyone was so busy, many of us working seven days a week. It became apparent that we had to help people take care of themselves as they were taking care of others.”
Steed continues, “I'll never forget that year, ever. It had a tremendous impact on the world and on infection prevention. The question we've got now is, what is Infection prevention and control going to look like post-COVID. The CDC has appointed me to an isolation taskforce that will examine transmission-based precautions and see if they need to be simplified, and possibly modify them because there was much confusion about droplet versus aerosol and airborne transmission. I think the CDC is doing the right thing by reviewing those precautions and looking at how can we better describe the mode of transmission for respiratory infections that are transmitted through droplets and make it easier for everybody to understand. I'm privileged to be involved in that work because I think it's going to be very important and so I'm excited about what’s ahead. That's an example of how we deal with infectious diseases that require enhanced precautions; my hope is that we can articulate the issue in a clearer way. The way we practice basic infection prevention and control demands that we have the right PPE and we perform hand hygiene the right way, but we need to re-examine how this is articulated to people in the simplest way so that it is not confusing, especially during an event such as a pandemic. There were rules for the community, and then what hospitals implemented confused both the community and the healthcare world due to the differences between the two approaches. How can we improve the messaging around interventions and protocols?”
When the next outbreak or crisis hits, a well-funded, adequately resourced program has a better chance to weathering the storm. What can make or break a program is whether an IP knows how to make a successful business case for infection prevention and control, which is the shortest path to securing the necessary wherewithal provided by healthcare institution leadership.
“Infection prevention successes will depend largely on strong leadership support,” write Garcia, et al. (2022). “A recent analysis of management methods identified three practices as important facilitators in the prevention of HAIs: First involves engagement of executive staff. Establishment of IP&C goals by executive leadership emphasizes an organizational priority among managers and frontline staff and enables open communication with persons who are empowered to make change. Second addresses information sharing. Establishment of an organization-wide system to relay, display, and discuss relevant infection data with frontline staff is an important activity. Third involves management coaching. The coaching activities identified as most needed involve providing staff with feedback on how to perform clinical care processes correctly and re-educating staff on best practices for IP&C. The future success of IP programs will therefore lay in identifying and implementing cutting-edge program modifications and best practices while supported by targeted executive actions.”
An increasing number of IPs have established good relationships with members of their institution’s C-suite, paving the way for more input as to how resources are distributed.
“We must have a seat at the table at all times, and the hospital or healthcare system C-suite must acknowledge us,” Pettis says. “Many of my colleagues around the country have been given that seat, but not all of them have, and particularly IPs like in rural areas and underserved areas are out there all by themselves. They don't have an epidemiologist to fight for them. APIC just introduced a toolkit for isolated IPs, recognizing that we're not all in academic teaching centers. We must gather them closer so that they know where the resources are, they know that they can work with those of us who have been around for a while.”
She continues, “Working with the C-suite is critical, obviously, because they hold the purse strings. We must become adept at building a business case for our programs. We must get better at networking with our partners In our institutions, such as those in the finance department. You've got the data, but are you working with them to help you build that business case? We must have the data. We must have the research to make that business case. Hospitals are hurting after the pandemic, and we’re all up against so much, but it's the most exciting job there is in healthcare.”
Steed says it’s time for IPs to come into their own.
“There is a need for IPs to understand that they are leaders. The APIC competency model for infection preventionists was a big accomplishment in articulating what IPs at the novice, intermediate and advanced levels should know. When I was a young IP, I had to figure out pretty quickly that I'm not going to get anything done unless I can ensure a return on investment, create a business plan, and speak with confidence. That requires developing relationships with other leaders; our profession is not just about surveillance. You can’t just stay in your office and crunch the numbers; to truly be effective, you've got to be on the front line with the staff, being the influencer. I think that that's a huge priority for one of our Strategic Plan Initiatives of elevating infection preventionists as advocates, leaders, and experts. That’s been key forever, but it's even more so now.”
Steed continues, “Another thing that I think helped us, despite the stress it caused, is the fact that infection prevention is in the spotlight more than ever because of the pandemic. We were in the spotlight before COVID because of value-based purchasing and because everything follows the money, and so if we don't do well, we get penalized. It makes us focus on effective prevention and control, and makes healthcare leadership understand our resources needs, and elevates and enhances our processes and the way we care for patients. The new attitude of many healthcare leaders is a huge benefit for our profession, but we must do a better job of engaging with them and help to influence them as to what is considered to be best practices. That's happening, but we need to continually strengthen the influence of IPs in the healthcare leadership world. I want all IPs to be able to walk into the corporate White House, as I call it, and be able to sit down with the CEO, the CNO, the CFO, and be able to have a professional conversation and not be afraid to do that. IPs must be confident about expressing their opinions about what their organizations need to do, what it’s going to cost, and the ROI that will be achieved.”
The future is yet to be written, and IPs have an opportunity to be architects of their profession for the next 50 years of service.
“How we come out of this pandemic, which in many ways often feels like a new abnormal, but it will normalize eventually,” Pettis says. “How long it will take requires a crystal ball, but I think we've got a lot of the right Initiatives in place to get us where we need to go.”
The future hinges on several more key issues.
“A critical area is research,” Pettis emphasizes. “Infection prevention has been a bit weak on the research end of what we do. We've relied on other disciplines for research more than we should, and so that will that go along with our mission to advance the science and the practice of infection prevention. The concept of implementation science is in our wheelhouse, and nobody else does that as well as infection prevention does. I do think we have many questions from a research standpoint that other disciplines’ research doesn't always answer for us. We must conduct our own research to do that, we're strengthening our in-house research ability.”
Steed agrees, noting that, “We must continue to champion scientific advancement in infection prevention and control practice. An example of that is the desire to have – when faced with emerging pathogens that are aerosol generating, airborne droplet transmitted -- one mask that could effectively fit anyone’s face, protect the provider, and not require fit testing. One of the most frustrating experiences during the pandemic was that people would put on a surgical mask and not don it correctly. How can we develop a mask that you put it on, and you don't have to do much to it to make it fit except for just press it around your nose make sure it's in the right place. That sounds simple, but it’s not. I would love to see that so you didn't have to worry about all the complication of N95s and fit testing, and of course, during the supply chain challenges, there were shortages of PPE and protocols went out the window because no one could afford the time it took to fit test.”
An additional conundrum that Steed points to is balancing increasing workloads in a shrinking workforce that may have a suboptimal infrastructure.
“The CDC recommends that healthcare organizations have an IP&C program that is sustainable,” she says. “Today, in many organizations, IP programs are insufficient and unsustainable, and when COVID was at its peak, some hospitals continued surveillance, but many others didn’t because they were overwhelmed, understaffed and under-resourced. CDC's clear message to healthcare leaders is you must examine your infection prevention and control program and figure out how to make it more robust and sustainable through things like pandemics, emerging pathogens and other challenges. Some people say the CDC is criticizing them, but remember, infection prevention is the business of the healthcare organization, but we can only do as much as we can in a 24-hour day. This is important messaging to corporate healthcare leaders -- we must wake them up.”
Many IPs maintain that without adequate staffing, they cannot continue to meet the demands which a post-COVID world are placing on their institutions, which are already stretched thin.
“There must be more research on staffing,” Steed confirms. “The problem is, staffing ratios are not regulated. However, corporate healthcare leaders won’t like regulation. That's exactly what we're doing for in long term care, where we are saying that if you've got more than 100 long-term care beds, you need a full time IP. Now, if you look at acute-care facilities, they haven't caught up. This issue needs to be prioritized and researched further.”
Stone, et al. (2009) were among the first to analyze staffing and structure of hospital-based infection prevention and control programs. They sent a Web-based survey to 441 hospitals that participate in the National Healthcare Safety Network. The response rate was 66 percent (n = 289); data were examined on 821 professionals. Infection preventionist staffing was significantly negatively related to bed size, with higher staffing in smaller hospitals. Median staffing was one IP per 167 beds. Forty-seven percent of IPs were certified, and 24 percent had less than two years of experience.
Furthermore, researchers have found that how IPs spend their “time varies significantly from hospital to hospital and is driven in part by regulations, by the priorities of hospital administration and supervisors of IP, and by the strengths and interests of the IP.”
In 1969, the CDC recommended one FTE per 250 occupied beds in acute care. APIC’s Delphi Project suggested one IP for every 100 occupied beds in acute care. Bartles, et al. (2018) found that infection prevention FTE needs of the system as a whole were under-represented by 66 percent when using the lower staffing ratio benchmark of 0.5 FTE per 100 beds‐ 37.435 versus actual 108.40; also under-represented by 31 percent when using the higher staffing ratio benchmark of 1.0 FTE per 100 beds -- 74.82 versus actual 108.40. When aggregated across the organization, the comprehensive review results yielded a new benchmark of 1.0 IPC FTE per 69 beds for the enterprise, including all care settings requiring infection prevention oversight.
While the staffing issue remains a challenge that APIC and others are attempting to address, the chronic, perennial problems that IP&C programs are tasked to solve – such as hand hygiene compliance, proper donning and doffing of PPE, etc. – remain as competing priorities.
“Those chronic issues are always there, they always need attention, time, money and effort put toward them,” Pettis confirms. “I think that is probably the main reason so many people in infection prevention are thinking about retiring. In infection prevention, you're never quite there, you're never done, and we now have lost so much ground in terms of HAI prevention because of the pandemic. We must reclaim that lost territory but there are so many plates spinning already. So as IPs, we must keep our wits about us, keep our heads on straight and constantly conduct risk assessments so we can prioritize. I think it’s easy to use the pandemic as an excuse not to do everything that we should. It’s too easy to fall back and say, ‘well, you know that's why we're not able to do that right now.’ But even if the IP can keep those plates spinning, they are likely asked to do even more, and they look at them and think, ‘You're kidding, right? Do you realize that I haven't even taken a potty break?’ So, it's a challenge and who knows what the answer is, except that we must continue to be out there and not hide out in our offices behind the computer, and that's easy to fall into. During the pandemic, some colleagues did most of their work virtually from home during most of it, while others were boots on the ground the whole time. Those who worked from home need to break that habit in a hurry, get back out there in the weeds with everybody so that they don't think you're just speaking from an ivory tower. You've got to be out there mixing it up with the staff, and yes, it's hard, but it must be done.”
The recent escalation in HAIs might be impetus enough for a return to so-called shoe-leather epidemiology.
A recent paper by Weiner-Lastinger, et al. (2021) reported that significant increases in the national standardized infection ratios (SIRs) for central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), ventilator-associated events (VAE), and MRSA bacteremia were observed in 2020, during the COVID-19 pandemic. The researchers sought to determine the impact of the pandemic on HAI incidence in U.S. hospitals, and national- and state-level SIRs were calculated for each quarter in 2020 and compared to those from 2019. The largest increase was observed for CLABSI, and significant increases in VAE incidence and ventilator utilization were seen across all four quarters of 2020.
As the authors note, “The pandemic response placed burden on acute-care hospitals (ACHs), which may have altered staffing practices, increased critical care capacity, and modified use of personal protective equipment (PPE). In the early stages of the pandemic, little was known about how COVID-19 hospitalizations would affect the incidence of healthcare-associated infections (HAIs). Single-site studies observed early signs of increases in select HAIs during the spring of 2020. Others have studied the occurrence of secondary infections in COVID-19 patients Additionally, a report from the National Healthcare Safety Network (NHSN) found significant increases in central-line–associated bloodstream infections (CLABSIs) during the early months of the pandemic.”
The researchers note further, “The year 2020 marked an unprecedented time for hospitals, many of which were faced with extraordinary circumstances of increased patient caseload, staffing challenges, and other operational changes that limited the implementation and effectiveness of standard infection prevention practices. A regular review of HAI surveillance data is critical for hospitals to identify gaps in prevention and address any observed increases in HAIs. Infection prevention staff should continue to reinforce infection prevention practices in their facilities and consider the importance of building resiliency in their programs to withstand future public health emergencies.”
While IPs grapple with HAIs anew, it’s interesting to reflect on an APIC campaign from 2007-2008 called the Targeting Zero Initiative, designed to eradicate infections deemed preventable by the Centers for Medicare & Medicaid Services (CMS). The campaigns educational initiatives aimed at eliminating Clostridium difficile-associated disease, as well as CAUTIs, CLABSIs, and mediastinitis. The initiative provided a package of education, research, and guidance for IPs, and at the time sparked an energetic debate over the feasibility of reaching zero infections. The initiative spawned a number of APIC Guides, including one on the elimination of C. difficile, that sought to help IPs address new changes to the CMS regulations at the time, which eliminated or reduced payments for the aforementioned three HAIs.
At the time, then-APIC president Denise Murphy noted, “We want to prepare infection prevention and control professionals to more effectively educate and influence frontline healthcare teams about process improvements that could ensure safe patient outcomes. Leveraging the new CMS guidelines, we hope to heighten awareness among clinical and administrative leadership about the value of infection prevention. Responding to this challenge requires a blend of research, education, and practice guidance -- a combination of activities that APIC is uniquely positioned to undertake. Following our positive experience taking a very comprehensive approach to MRSA in 2007, we plan to launch an aggressive fight against these deadly infections on multiple fronts in 2008.”
Today, thinking has evolved, but the topic of zero infections is the high bar for IP&C programs, albeit a difficult one for some institutions.
“We’d all love to see that happen, as it’s a laudable endeavor,” says Dickey, “but is it realistic to hit zero? I don't think any of us believe that could ever happen unless we didn't live in a world of germs. Certainly, we want to see long, sustained periods without infection. We've seen it in high-risk populations, so it is possible to do, but I think having a goal of sustainable zero for as long as you can go is wonderful. To think that it will always be zero, I don't believe is doable, but certainly being able to sustain zero for long periods of time is attainable and that's an exciting goal.”
APIC. 50th Anniversary Timeline. Accessible at: https://apic.org/50th-anniversary-timeline/
Bartles R, et al. A systematic approach to quantifying infection prevention staffing and coverage needs. Am J Infect Control. 46 (2018) 487‐91.
Garcia R, Barnes S, Boukidjian R, Fakih MG, Edmiston CE, Levesque M, et al. Recommendations for Change in Infection Prevention Programs and Practice. Am J Infect Control. May 03, 2022. DOI: https://doi.org/10.1016/j.ajic.2022.04.007
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Stone PW, et al. Staffing and structure of infection prevention and control programs. Am J Infect Control. Feb. 8, 2009. doi: 10.1016/j.ajic.2008.11.001
Weiner-Lastinger LM, et al. The impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: A summary of data reported to the National Healthcare Safety Network. Infect Control Hosp Epidemiol. Sept. 3, 2021.