Heather Saunders, MPH, RN, CIC

Before the COVID-19 pandemic, hospital administrators were familiar with the purpose and vision of the infection prevention and control (IPC) department. When health care–acquired infections (HAIs) were high or outbreaks present, administrators would turn to their IPC colleagues to better understand what steps were being taken to reduce infection rates and prevent the spread of disease within the hospital. Despite their importance in the prevention and control of infections, some IPC departments have historically felt unsupported by hospital administrators.

Occasionally, these departments have received little to no support for more full-time employees and no additional funding for prevention efforts. They also have had a limited role in making hospital decisions that ultimately affect infection prevention and control.

As COVID-19 spread, hospital administrators looked to IPC experts to determine how to protect employees, patients, and visitors. IPC quickly became one of the most important departments in the hospital. Infection preventionists (IPs) were at the table for every decision and department capacity was increased to sustain prevention and control efforts. The increased attention and support are what we have needed for decades to substantially reduce HAIs in hospitals.

The pandemic has had a detrimental effect on progress in reducing HAIs.

 (See table below.) If we can harness the energy present between the IPC department and hospital administration during the pandemic, together we can become change catalysts, tackling HAIs with such gusto that the road back to zero infections will be paved in yellow bricks. But to accomplish this, we need a road map. We need defined steps that will lead hospital administrators and IPs along the path to improved patient safety with decreased HAIs.

First, to see the changes we hope for in hospital IPC, we need the full support of hospital administration. For too long, preventing and controlling infections has rested solely on the IPC department. If we want sustained improvements in our hospitals, administrators must visibly show support for IPs while investing time, resources, and hospital funding to increase the capacity of the IPC department.

As Tamasin Adams, MPH, CIC, manager of infection prevention for the Lutheran Hospital of Indiana, states, “With the combination of administrative support and IP knowledge, new processes can be supported and implemented to keep patients and staff safe.” Yet many activities, such as increased surveillance for HAIs or electronic hand hygiene monitoring, will require additional staff and funding. Currently, many IPC programs barely have the capacity to keep up with mandatory HAI surveillance and reporting requirements.

Although HAIs tied to mandatory reporting and hospital reimbursement are priorities for the hospital, many other HAIs are being neglected due to limited staffing within IPC departments. With administrative support to increase infection prevention staffing, IPs could move beyond HAIs tied to reimbursement and target those not regulated by mandatory surveillance and reporting requirements.

Visible support from hospital administration increases staff buy-in for IPC efforts. Although IPs have the tools and knowledge to decrease HAIs, hospital administrators must make those efforts visible and rally buy-in from frontline staff. Without frontline support, efforts to improve prevention practices and mitigate the spread of infections will quickly fail.

One of the most overlooked methods for gaining frontline support is having existing relationships and trust with frontline staff members. When hospital administrators and IPs show their respect, trust, and support of frontline staff, those staff members will respond in kind. When we work collaboratively, we work toward positive change. During the pandemic, everyone throughout the hospital turned to the IPC department for answers.

Relationships with frontline staff members were forged through the fires of COVID-19 prevention and response. Now that trust, respect, and collegial relationships have been established, hospital administrators and IPs must continue to collaborate with frontline team members to prevent and control HAIs.

For Sara Townsend, MS-HQS, FAPIC, CIC, manager of infection prevention for Children’s Hospital of Philadelphia, COVID-19 allowed her IPC department to develop partnerships with frontline staff in their fight against HAIs. According to Townsend, “Suddenly [individuals] I never knew existed called me their new best friend. I, like others on my team, saw the never-ending list of questions and [individuals] as an opportunity. Today, as we dive back into scary times, those who labeled us their ‘new best friends’ have become reliable partners.” When hospital administrators and IPs build relationships with staff, those individuals become collaborators in the journey toward decreased infections.

Once we have the full support of hospital administration and the buy-in of frontline staff members, we must get back to the basics of infection prevention to reduce the rate of HAIs. We must reemphasize the focus on basicpractices such as good hand hygiene, proper use of personal protective equipment (PPE), and environmental cleaning and disinfection. These are effective strategies that will work again with support and resources provided to infection prevention teams. But how, with extreme staffing shortages and a burned-out workforce, do hospital administrators and IPs successfully improve infection prevention practices? In short, we must keep it simple. First, we must set up our staff for success in achieving best practices in all areas of basic infection prevention. Hand hygiene supplies, disinfectant products, and PPE must be kept readily available and easily accessible to support best practices. Next, we need hands-on education with return demonstration by all staff to ensure competency. Then, to ensure practices are sustained, we need appropriate auditing, monitoring, encouragement, and feedback to frontline staff. Finally, we must continue education through frequent reminders and signage about best practices for basic infection prevention.

But according to Erica Jones, BSN, RN, CIC, director of infection prevention for Mt. Washington Pediatric Hospital in Baltimore, Maryland, “Education isn’t always the answer.” Sometimes, even with the best hands-on education, we find that our efforts fall short of producing sustainable change. Jones says “it is about engaging frontline staff in processes to understand their day-to-day and how to incorporate basic prevention principles into processes that are already in place.” It comes back to collaboration. Again, for prevention efforts to succeed, we must work as a team with frontline staff, listening to their perspectives and involving them in our efforts to improve the prevention and control of infections.

But listen closely, because this is important: None of this can be accomplished without the full support of hospital administration.

The work ahead for IPs will take more administrative support and funding than ever. The COVID-19 pandemic has brought a significant rise in HAIs. The reasons are abundant but the solution is simple. We need administrative support to increase the capacity of the IPC department, we need increased funding and visible support from hospital administrators for IPC efforts, we need buy-in and involvement from frontline staff, and we need to return to the basics of infection prevention. But together, hospital administrators and IPs can stem the rising tide of HAIs in our hospitals. United, with increased support of the IPC department, we can sustain positive change in the prevention and control of infections. 

HEATHER SAUNDERS, MPH, RN, CIC, is director of infection control at Johns Hopkins Office of Population Health in Baltimore, Maryland. She is also owner of and primary consultant for Broad Street Prevention, where she guides health care and business leaders in the prevention and control of infectious diseases.

Greene MT, Gilmartin HM, Saint S. Psychological safety and infection prevention practices: results from a national survey. 

. 2020;48(1):2-6. doi:10.1016/j.ajic.2019.09.027

Weiner-Lastinger LM, Pattabiraman V, Konnor RY, 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. 

. Published online September 3, 2021. doi:10.1017/ice.2021.362

Articles

If we want to see sustained improvements in our hospitals, administrators must step in and visibly show their support of IPs while investing their time, resources, and hospital funding to increase the capacity of the IPC department.

How Hospital Administrators Can Help IPs Manage HAIs

In 1918, the world was swept by a terrifying novel influenza pandemic that killed about 50 million people.1 The primary cause of death, however, was not the influenza virus itself but the secondary bacterial pneumonia that so often followed. Antibiotics wouldn’t be discovered by Alexander Fleming until 1928, so physicians during the 1918 pandemic had nothing with which to treat bacterial pneumonia. Before antibiotics, people were at risk of dying from the same common bacterial infections we so often take for granted being able to treat today. When Fleming received his Nobel Prize for the discovery of penicillin, he warned that misuse of antibiotics could lead to resistant bacteria. True to that warning, bacteria, and now yeast, have developed ways to resist antimicrobial treatment. And if we don’t act quickly to prevent and contain antimicrobial resistance, we may see a time in which the inability to treat common infections will once again be our reality.

The World Health Organization lists antimicrobial resistance as one of the top 10 global public health threats.2 Regarded as serious a threat as climate change, antimicrobial resistance threatens to rob us of the antibiotics we rely upon for the treatment of infectious diseases, and of many of our modern medical advances. A review about antimicrobial resistance estimated that “globally, at least 700,000 people die each year of drug resistance from illnesses such as bacterial infections, malaria, HIV/AIDS, or tuberculosis.”3 This same report warns that, without quick and strategic action, “this toll will exceed 10 million each year by 2050 and cost the world over 100 trillion USD in lost output.”3

Because of the role antibiotics play in the development of antimicrobial resistance, much of the conversation around containing resistance revolves around the stewardship and development of antibiotics. We need antimicrobials to treat infections and must therefore be judicious in our use of those antimicrobials. However, we have learned over time that the prevention and control of infectious diseases should never rely on 1 strategy alone. Instead, a combination of strategies enables us to most effectively prevent infections. To prevent the spread of antimicrobial resistance, we must address the horizontal transmission of antimicrobial-resistant organisms in addition to addressing antimicrobial stewardship. Antimicrobial resistance is worsening, but not solely because of the inappropriate use of antimicrobials. Resistance is spreading. Drug-resistant organisms and resistance mechanisms are spreading from person to person, primarily in health care settings, through lapses in basic infection prevention and control. To prevent this horizontal spread of antimicrobial resistance, we need infection preventionists (IPs) to lead in the fight against drug-resistant organisms.

When outbreaks hit or increases in infection are seen, we sometimes mistakenly look for a rare causative event, such as a contaminated medical device. However, more commonly, outbreaks and increases in infection are linked to lapses in basic infection prevention and control. To best prevent and decrease infection, including antimicrobial resistance, we have to get back to the basics. The US Centers for Disease Control and Prevention (CDC) notes that primary prevention measures for 

 a drug-resistant fungal infection, include hand hygiene, environmental cleaning, and adherence to transmission-based precautions—strategies that are all too familiar to IPs.4 Although these strategies are the foundation of infection prevention and control, all too often, we find that adherence to these basic measures is lacking. As IPs, we have an incredible opportunity to significantly reduce the transmission of antimicrobial-resistant organisms by focusing on improving adherence to the most basic of infection prevention practices. Sometimes, prevention really is that simple.

 The cornerstone of infection prevention and control will always be surveillance. Without effective systems in place to identify infections and outbreaks, we cannot prevent and control them. Antimicrobial resistance requires unique surveillance systems and close collaboration between clinical laboratories and infection prevention and control departments. IPs need to understand what their laboratories have the capability to identify and how they communicate when resistance is confirmed. Additionally, IPs need to have their own surveillance systems for reviewing, tracking, and trending antimicrobial resistance. The IP is usually the first to notice trends in antimicrobial-resistant organisms, leading to the identification of outbreaks and resistance.

 It is still not uncommon to find a provider who has never heard of 

 or the carbapenemase New Delhi metallo-beta-lactamase. Not only do health care workers need to be educated on novel and emerging resistance, but IPs also must have a firm understanding of these organisms and how they spread. As they say, knowledge is power, and so we must empower ourselves and our health care coworkers with the knowledge needed to win the fight against antimicrobial resistance. The Centers for Disease Control and Prevention (CDC) has developed a wealth of information for IPs, public health professionals, and health care workers on drug-resistant organisms including Candida auris and CRE.5,6

 Education, surveillance, and basic infection prevention are incredibly important to our efforts in containing antimicrobial resistance. But to be really effective at preventing and containing resistance, we must understand that resistance is not just an institutional problem but a regional one. And to fight a problem outside our own walls, we must establish clear lines of communication with other health care facilities in our region. Failure to document or communicate infection status or isolation needs is the No. 1 reason for antimicrobial resistance to spread across the health care spectrum. When a health care facility does not know that a patient is colonized with a drug-resistant organism, they fail to place the patient on the appropriate transmission-based precautions or put other measures in place that can aid in containing resistance. To fight resistance, we must all work together and develop ways to ensure communication during patient transfer. IPs can encourage the use of transfer forms, such as the Inter-Facility Infection Control Transfer Form from the CDC, to help ensure that isolation and infection status is always communicated as patients travel throughout the health care network.7

 Finally, IPs must seek to understand and collaborate with the efforts of state health departments that provide enhanced surveillance and response efforts for novel and targeted antimicrobial-resistant organisms. In the event that novel or targeted resistance is identified, state health departments and state public health laboratories may assist with facility and regional containment efforts. According to Jamie Rubin, infection prevention and control program administrator for the Maryland Department of Health, “When our public health lab identifies one of these novel or targeted organisms, they activate a coordinated response from the state health department team of infection preventionists, epidemiologists, and medical experts who then work with the health care facility to investigate potential contacts.” Occasionally, the identification of antimicrobial resistance will require enhanced surveillance methods to assist with prevention and containment, which state public health departments and laboratories can also assist with. “I hope IPs know that there is support available from their public health partners and that we can work together to reduce the development and spread of antimicrobial resistance,” Rubin said. IPs should seek to understand what their state’s health care-associated infections and antimicrobial resistance programs are doing to prevent and contain resistance.8 Furthermore, IPs should learn how they can partner and participate in public health containment efforts through ensuring their understanding of public health reporting requirements, participating in containment efforts, and quickly communicating resistance when it is identified.9 It is not alone but together that we will win the battle against antimicrobial resistance.

The world is quickly moving toward a postantibiotic era in which we may no longer be able to rely upon antimicrobials to treat infections. To prevent and contain antimicrobial resistance, we need to use a multilayered approach. It will take enormous effort and involve a number of disciplines.

At the front line of the battle are IPs, armed with the knowledge and tools needed to prevent and control the spread of antimicrobial resistance. And through using best practices in basic infection prevention, implementing strong surveillance systems, collaborating with public health partners, educating about the problem of resistance, and communicating clearly across the health care spectrum, IPs can help win the war against antimicrobial resistance. p

HEATHER SAUNDERS, MPH, RN, CIC, is the director of infection control at Johns Hopkins Office of Population Health. She is also the owner and primary consultant for Broad Street Prevention, where she guides health care and business leaders in the prevention and control of infectious diseases.

1918 pandemic (H1N1 virus). Centers for Disease Control and Prevention. Updated March 20, 2019. Accessed July 16, 2021. 

https://www.cdc.gov/flu/pandemic-resources/1918-pandemic-h1n1.html

10 threats to global health in 2019. World Health Organization. Accessed July 16, 2021. 

https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019

Tackling drug-resistant infections globally: final report and recommendations. Review on Antimicrobial Resistance. May 2016. Accessed July 16, 2021. 

https://amr-review.org/sites/default/files/160525_Final%20paper_with%20cover.pdf

. Centers for Disease Control and Prevention. Reviewed July 19, 2021. Accessed July 20, 2021.https://www.cdc.gov/fungal/candida-auris/c-auris-infection-control.html

Candida auris. Centers for Disease Control and Prevention. Reviewed July 19, 2021. Accessed July 20, 2021. 

https://www.cdc.gov/fungal/candida-auris/index.html

Carbapenem-resistant Enterobacterales (CRE). Centers for Disease Control and Prevention. Reviewed November 9, 2019. Accessed July 20, 2021. 

https://www.cdc.gov/hai/organisms/cre/index.html

Inter-Facility Infection Control Transfer Form for States Establishing HAI Prevention Collaboratives. Centers for Disease Control and Prevention. Updated June 2019. Accessed July 20, 2021. 

https://www.cdc.gov/hai/pdfs/toolkits/Interfacility-IC-Transfer-Form-508.pdf

State-based HAI prevention activities. Centers for Disease Control and Prevention. Reviewed June 29, 2021. Accessed July 20, 2021. 

https://www.cdc.gov/hai/state-based/index.html

Containment strategy responding to emerging AR threats. Centers for Disease Control and Prevention. Reviewed June 27, 2019. Accessed July 20, 2021. 

https://www.cdc.gov/hai/containment/index.html

With seemingly reckless abandon, we are quickly headed toward an era in which the antibiotics we once used to treat infection will be rendered ineffective.

Heather Saunders, MPH, RN, CIC

Articles

How Hospital Administrators Can Help IPs Manage HAIs

Antimicrobial Resistance Is Futile Without IPs’ Help